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Dupuytren’s disease (DD) is a common fibro-proliferative disorder of the palm. We estimated the risk of serious local and systemic complications and re-operation after DD surgery. We queried England’s Hospital Episode Statistics database and included all adult DD patients who were surgically treated. A longitudinal cohort study and self-controlled case series were conducted. Between 1 April 2007 and 31 March 2017, 121,488 adults underwent 158,119 operations for DD. The cumulative incidence of 90-day serious local complications was low at 1.2% (95% CI 1.1–1.2). However, the amputation rate for re-operation by limited fasciectomy following dermofasciectomy was 8%. 90-day systemic complications were also uncommon at 0.78% (95% CI 0.74–0.83), however operations routinely performed under general or regional anaesthesia carried an increased risk of serious systemic complications such as myocardial infarction. Re-operation was lower than previous reports (33.7% for percutaneous needle fasciotomy, 19.5% for limited fasciectomy, and 18.2% for dermofasciectomy). Overall, DD surgery performed in England was safe; however, re-operation by after dermofasciectomy carries a high risk of amputation. Furthermore, whilst serious systemic complications were unusual, the data suggest that high-risk patients should undergo treatment under local anaesthesia. These data will inform better shared decision-making regarding this common condition.

AbstractObjectivesTo provide accurate risk estimates of serious adverse events after elective shoulder replacement surgery for arthritis, including age and sex specific estimates of the lifetime risk of revision surgery.DesignPopulation based cohort study.SettingHospital episode statistics for NHS England, including civil registration mortality data.Participants58 054 elective shoulder replacements in 51 895 adults (aged ≥50 years) between April 1998 and April 2017.Main outcome measuresThe lifetime risk of revision surgery, calculated using an actuarial life table approach and the cumulative probability method. Rates of serious adverse events at 30 and 90 days post-surgery: pulmonary embolism, myocardial infarction, lower respiratory tract infection, acute kidney injury, urinary tract infection, cerebrovascular events, and all cause death. Secondary outcome measures were the number of surgeries performed each year and Kaplan-Meier estimates of revision risk at 3, 5, 10, and 15 years.ResultsThe number of shoulder replacements performed each year increased 5.6-fold between 1998 and 2017. Lifetime risks of revision surgery ranged from 1 in 37 (2.7%, 95% confidence interval 2.6% to 2.8%) in women aged 85 years and older to 1 in 4 (23.6%, 23.2% to 24.0%) in men aged 55-59 years. The risks of revision were highest during the first five years after surgery. The risk of any serious adverse event at 30 days post-surgery was 1 in 28 (3.5%, 3.4% to 3.7%), and at 90 days post-surgery was 1 in 22 (4.6%, 4.4% to 4.8%). At 30 days, the relative risk of pulmonary embolism compared with baseline population risk was 61 (95% confidence interval 50 to 73) for women aged 50-64. Serious adverse events were associated with increasing age, comorbidity, and male sex. 1 in 5 (21.2%, 17.9% to 25.1%) men aged 85 years and older experienced at least one serious adverse event within 90 days.ConclusionsYounger patients, particularly men, need to be aware of a higher likelihood of early failure of shoulder replacement and the need for further and more complex revision replacement surgery. All patients should be counselled about the risks of serious adverse events. These risks are higher than previously considered, and for some could outweigh any potential benefits. Our findings caution against unchecked expansion of shoulder replacement surgery in both younger and older patients. The more accurate age and sex specific estimates of risk from this study are long overdue and should improve shared decision making between patients and clinicians.Study registrationClinicalTrials.gov NCT03573765.

AbstractObjectiveTo provide clinicians and patients with accurate risk estimates of serious adverse events after common elective shoulder arthroscopic procedures, including reoperation within one year.DesignPopulation based cohort study.SettingHospital Episode Statistics for NHS England, including civil registration mortality data from the Office for National Statistics.Participants288 250 arthroscopic shoulder procedures performed in 261 248 patients aged ≥16 years between 1 April 2009 and 31 March 2017. Elective procedures were grouped into subacromial decompression, rotator cuff repair, acromioclavicular joint excision, glenohumeral stabilisation, and frozen shoulder release.Main outcome measuresThe primary outcomes were rates of serious adverse events (mortality, pulmonary embolism, pneumonia, myocardial infarction, acute kidney injury, stroke, and urinary tract infection) requiring inpatient care within 90 days post-surgery. Secondary outcomes were specific adverse event rates at 90 days, and reoperations (including for deep infection) within one year.ResultsThe overall rate of complications within 90 days after arthroscopic shoulder surgery (including reoperation) was low at 1.2% (95% confidence interval 1.2% to 1.3%), with one in 81 patients at risk, and varied according to type of procedure, from 0.6% (0.5% to 0.8%) for glenohumeral stabilisation to 1.7% (1.5% to 1.8%) for frozen shoulder release. After adjustment for age, comorbidities, and sex, no effect of procedure type was observed. Pneumonia was the most common adverse event (0.3%, 0.3% to 0.4%), with one in 303 patients at risk. Pulmonary embolic events were rare, at 0.1% (0.1% to 0.1%), with one in 1428 patients at risk. At one year, the overall rate for reoperation was 3.8% (3.8% to 3.9%), with one in 26 patients at risk, ranging from 2.7% (2.5% to 3.0%) for glenohumeral stabilisation to 5.7% (5.4% to 6.1%) for frozen shoulder release. The overall rate of further surgery for deep infection was low, at 0.1% (0.1% to 0.1%), with one in 1111 patients at risk, but was higher after rotator cuff repair (0.2%, 0.2% to 0.2%), with one in 526 patients at risk. Over the study period the number of arthroscopic shoulder procedures increased, except for subacromial decompression, which decreased.ConclusionsThe findings of this study suggest that risks of serious adverse events associated with common shoulder arthroscopy procedures are low. Nevertheless, serious complications do occur, and include the risk of reoperation in one in 26 patients within one year.Study registrationClinical.Trials.gov NCT03573765.

Neutrinos were assumed to be massless particles until the discovery of the neutrino oscillation process. This phenomenon indicates that the neutrinos have non-zero masses and the mass eigenstates (ν1, ν2, ν3) are mixtures of their flavour eigenstates (νe, νμ, ντ). The oscillations between different flavour eigenstates are described by three mixing angles (θ12, θ23, θ13), two differences of the squared neutrino masses of the ν2/ν1 and ν3/ν1 pairs and a charge conjugation parity symmetry violating phase δCP. The Double Chooz experiment, located near the Chooz Electricité de France reactors, measures the oscillation parameter θ13 using reactor neutrinos. Here, the Double Chooz collaboration reports the measurement of the mixing angle θ13 with the new total neutron capture detection technique from the full data set, yielding sin2(2θ13) = 0.105 ± 0.014. This measurement exploits the multidetector configuration, the isoflux baseline and data recorded when the reactors were switched off. In addition to the neutrino mixing angle measurement, Double Chooz provides a precise measurement of the reactor neutrino flux, given by the mean cross-section per fission 〈σf〉 = (5.71 ± 0.06) × 10−43 cm2 per fission, and reports an empirical model of the distortion in the reactor neutrino spectrum.

Background Proximal humeral fractures (PHFs) are common injuries, but their management has remained controversial. Recent high-level evidence from randomized clinical trials has shown that for many PHFs, surgical treatment is not superior to non-surgical treatment. Our primary aim was to conduct a multi-nation assessment of temporal trends and changes in surgical treatment of isolated PHF in Denmark, England, and Sweden. A secondary aim was to estimate the incidence of serious adverse events (SAEs) within 30 days (and death within 90 days) of primary surgery. Methods This population-based cohort study presents routinely collected data from Danish, English, and Swedish patient registries and electronic health records from 1998 to 2018. All adult patients with isolated PHFs combined with predefined surgical procedure codes were included. Age- and sex-specific incidence rates (IRs) of surgery and each surgical procedure per calendar year were calculated. Kaplan–Meier plots displayed patient survival for the study period. Incidence proportions of SAEs within 30 days (and death within 90 days) of surgery were computed. Results A total of 54,077 primary surgical procedures, performed in 53,852 patients with isolated PHF, were included. Denmark and Sweden had the highest IR of surgery, with Denmark peaking at 17.4/100,000 person-years in 2011 and Sweden peaking at 18/100,000 person-years in 2013, while England peaked at 5/100,000 person-years in 2010. From 2004, plate fixation was the leading surgical procedure in Denmark and Sweden, while arthroplasty was the most frequent in England. The IR of surgery in Denmark and Sweden was 8–10 times higher for women aged 80 years than that observed in England. The 30-day incidence of SAEs varied between countries, ranging from 0.03% to 3.51%. Conclusions Variations in surgical practice for isolated PHF exist between Denmark, England, and Sweden, with differences in overall IRs of surgery and preferred procedures. A complex interplay between hospitals, surgeons, healthcare systems, and evidence-based factors is likely to explain such variations. However, in all three countries, the IR of surgery, particularly for the use of locking plates, demonstrated a decline from 2013, coinciding with high-quality trials and meta-analyses suggesting that evidence-based factors are becoming more prominent in orthopaedic treatment decisions.

Progressive hand interphalangeal joint (IPJ) osteoarthritis is associated with pain, reduced function and impaired quality of life. However, the evidence surrounding risk factors for IPJ osteoarthritis progression is unclear. Identifying risk factors for IPJ osteoarthritis progression may inform preventative strategies and early interventions to improve long-term outcomes for individuals at risk of IPJ osteoarthritis progression. The objectives of the study were to describe methods used to measure the progression of IPJ osteoarthritis and identify risk factors for IPJ osteoarthritis progression. MEDLINE, EMBASE, Scopus, and The Cochrane Library were searched from inception to 19th February 2020 (PROSPERO CRD42019121034). Eligible studies assessed potential risk factor/s associated with IPJ osteoarthritis progression. Risk of bias was assessed using a modified QUIPS Tool, and a best evidence synthesis was performed. Of eight eligible studies, all measured osteoarthritis progression radiographically, and none considered symptoms. Eighteen potential risk factors were assessed. Diabetes (adjusted mean difference between 2.06 and 7.78), and larger finger epiphyseal index in males (regression coefficient β = 0.202) and females (β = 0.325) were identified as risk factors (limited evidence). Older age in men and women showed mixed results; 13 variables were not risk factors (all limited evidence). Patients with diabetes and larger finger epiphyseal index might be at higher risk of radiographic IPJ osteoarthritis progression, though evidence is limited and studies are biased. Studies assessing symptomatic IPJ osteoarthritis progression are lacking.

ObjectivesTo determine the incidence of further procedures and serious adverse events (SAEs) requiring admission to hospital following elective surgery for base of thumb osteoarthritis (BTOA), and the patient factors associated with these outcomes.DesignPopulation based cohort study.SettingNational Health Service using the national Hospital Episode Statistics data set linked to mortality records over a 19-year period (01 April 1998–31 March 2017).Participants43 076 primary surgeries were followed longitudinally in secondary care until death or migration on 37 329 patients over 18 years of age.Main outcome measuresIncidence of further thumb base procedures (including revision surgery or intra-articular steroid injection) at any time postoperatively, and local wound complications and systemic events (myocardial infarction, stroke, respiratory tract infection, venous thromboembolic events, urinary tract infection or renal failure) within 30 and 90 days. To identify patient factors associated with outcome, Fine and Gray model regression analysis was used to adjust for the competing risk of mortality in addition to age, overall comorbidity and socioeconomic status.ResultsOver the 19 years, there was an increasing trend in surgeries undertaken. The rate of further thumb base procedures after any surgery was 1.39%; the lowest rates after simple trapeziectomy (1.12%), the highest rates after arthroplasty (3.84%) and arthrodesis (3.5%). When matched for age, comorbidity and socioeconomic status, those undergoing arthroplasty and arthrodesis were 2.5 times more likely to undergo a further procedure (subHR 2.51 (95% CI 1.81 to 3.48) and 2.55 (1.91 to 3.40)) than those undergoing simple trapeziectomy. Overall complication rates following surgery were 0.22% for serious local complications and 0.58% for systemic events within 90 days of surgery.ConclusionsThe number of patients proceeding to BTOA surgery has increased over the last 19 years, with a low rate of further thumb base procedures and SAEs after surgery overall registered. Arthrodesis and arthroplasty had a significantly higher revision rate.Trial registration numberNCT03573765.

Background Flexor tendon injuries are common and lead to over 3200 admissions for specialist surgical repair annually in England and Wales. Surgery to repair complete division of both flexor tendons in zone 2 of the hand is technically challenging. There is variation in surgical repair techniques with no high-quality evidence to support decision-making. In particular, the decision to repair both tendons or just one is contested. Surgery is followed by specialist rehabilitation, which takes at least 12 weeks. The resulting hand function can impact the patient’s income, life satisfaction, well-being, self-worth, and mental health. The FLARE trial aims to determine the clinical and cost-effectiveness of repairing the flexor digitorum profundus (FDP) alone (intervention) versus the repair of both FDP and flexor digitorum superficialis (FDS) (control) for the treatment of complete zone 2, single-digit flexor tendon injuries in adults. Methods A multi-centre, two-arm, blinded, non-inferiority, parallel group, randomised controlled trial with an internal pilot, economic evaluation, and nested qualitative study. Participants will be randomised 1:1 to receive either repair of FDP alone or repair of both FDP and FDS. A total of 310 adults will be recruited from NHS Trusts within the UK, randomised at surgery, and followed up within 7 days, 6 weeks, 3 months, and 6 months post-randomisation. The primary outcome measure is the patient evaluation measure (PEM) administered 6 months post-randomisation. Secondary outcomes include the PEM at other timepoints, Patient Related Wrist/Hand Evaluation (PRWHE), EuroQol 5 Dimensions Score (EQ-5D-5L), complications, total range of motion, grip strength, adherence to splint and therapy regimens, work outcomes, treatment and outcome satisfaction, and healthcare resource use. Discussion FLARE is designed with sufficient power and rigour to provide evidence on the clinical and cost-effectiveness of two surgical repair methods for single-digit, complete zone 2 flexor tendon injuries in adults. If the repair of FDP alone is as beneficial to the patient as the repair of FDP and FDS, this could save the NHS £1.8 million annually through reduced time and material costs. Furthermore, the trial findings will facilitate better shared decision-making discussions between clinicians and patients. Trial registration ISRCTN 10918157. Prospectively registered: 12.01.2023.

Background The aim of this study was to assess the inter observer and intra observer reliability of acute scaphoid fracture classification methods including a novel ‘long axis’ measurement, a simple method which we have developed with the aim of improving agreement when describing acute fractures. Methods We identified sixty patients with acute scaphoid fractures at two centres who had been investigated with both plain radiographs and a CT (Computed Tomography) scan within 4 weeks of injury. The fractures were assessed by three observers at each centre using three commonly used classification systems and the ‘long axis’ method. Results Inter observer reliability: based on X-rays the ‘long axis’ measurement demonstrated substantial agreement (Intraclass Correlation Coefficient (ICC) =0.76) and was significantly more reliable than the Mayo ( p  < 0.01), the most reliable of the established classification systems with moderate levels of agreement (kappa = 0.56). Intra observer reliability: the long axis measurement demonstrated almost perfect agreement whether based on X-ray (ICC = 0.905) or CT (ICC = 0.900). Conclusions This study describes a novel pragmatic ‘long axis’ method for the assessment of acute scaphoid fractures which demonstrates substantial inter and intra observer reliability. The ‘long axis’ measurement has clear potential benefits over traditional classification systems which should be explored in future clinical research.

The senior author was fortunate in 1996 to dive on the remote Houtman Abrolhos Islands of Western Australia and view in situ the stunning \" Asteromenia peltata \" that is so strikingly illustrated by John Huisman (viewable on AlgaeBase). Five years later, during excursions to Bermuda and Lord Howe Island (tropical eastern Australia), he observed and collected specimens referable to this species in both these localities. Based on their respective appearances in the field, it seemed unlikely that these entities from geographically remote regions represented the same species. Our molecular results not only confirm this suspicion, but further indicate that A. peltata sensu lato constitutes a complex of at least five distinct species. We restrict A. peltata to one of two species found in the western (sub)tropical North Atlantic, the second described herein as A. bermudensis sp. nov. Samples from Western Australia represent an undescribed species, A. exanimans sp. nov., while two entities collected from Lord Howe Island ( A. anastomosans (Weber-van Bosse) comb. nov. and A. pseudocoalescens sp. nov.) conform to records variously reported as Asteromenia peltata and Drouetia coalescens . Specimens of D. coalescens from South Africa are also not representative of the genus Drouetia , but form a novel lineage within the Rhodymeniaceae. We included two species of Halichrysis in our molecular analyses and, in combination with observations of salient anatomical features, provide arguments for maintaining Asteromenia, Drouetia, and Halichrysis as distinct genera.