Actinomycosis complicating sigmoid diverticular disease: a case report

A 63-year-old Caucasian woman was admitted to hospital as hypotensive with abdominal tenderness and vaginal discharge. Laboratory investigations showed microcytic anaemia, low albumin and high white cell count. Computerised tomography scans revealed small bowel dilatation, sigmoid diverticula, ascites and pelvic fluid. The endometrial pipelle was positive and vaginal swab was negative for actinomyces. Post mortem examination revealed widespread sigmoid diverticular disease and bowel perforation with an intense inflammation. Actinomycotic granules were noted in the diverticular inflammatory debris, pelvic abscess and lung sections. Clinical course and histomorphological findings favour the perforating sigmoid diverticular actinomycosis as an origin of the systemic infection

Radiomics for Precision Diagnosis of FAI: How Close Are We to Clinical Translation? A Multi-Center Validation of a Single-Center Trained Model

Background: Femoroacetabular impingement (FAI) is a complex hip disorder characterized by abnormal contact between the femoral head and acetabulum, often leading to joint damage, chronic pain, and early-onset osteoarthritis. Despite MRI being the imaging modality of choice, diagnosis remains challenging due to subjective interpretation, lack of standardized imaging criteria, and difficulty differentiating symptomatic from asymptomatic cases. This study aimed to develop and externally validate radiomics-based machine learning (ML) models capable of classifying healthy, asymptomatic, and symptomatic FAI cases with high diagnostic accuracy and generalizability. Methods: A total of 82 hip MRI datasets (31 symptomatic, 31 asymptomatic, 20 healthy) from a single center were used for training and cross-validation. Radiomic features were extracted from four segmented anatomical regions (femur, acetabulum, gluteus medius, gluteus maximus). A four-step feature selection pipeline was implemented, followed by training 16 ML classifiers. External validation was conducted on a separate multi-center cohort of 185 symptomatic FAI cases acquired with heterogeneous MRI protocols. Results: The best-performing models achieved a cross-validation accuracy of up to 90.9% in distinguishing among healthy, asymptomatic, and symptomatic hips. External validation on the independent multi-center cohort demonstrated 100% accuracy in identifying symptomatic FAI cases. Since this metric reflects performance on symptomatic cases only, it should be interpreted as a detection rate (true positive rate) rather than overall multi-class accuracy. Gini index-based feature selection consistently outperformed F-statistic-based methods across all the models. Conclusions: This is the first study to systematically integrate radiomics and multiple ML models for FAI classification for these three phenotypes, trained on a single-center dataset and externally validated on multi-institutional MRI data. The demonstrated robustness and generalizability of radiomic features support their use in clinical workflows and future large-scale studies targeting standardized, data-driven FAI diagnosis

A Delphi consensus statement for digital surgery

The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term 'digital surgery'. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and <30% unimportant. A final online meeting was held to discuss consensus statements. The definition of digital surgery as the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support, or training, to improve outcomes and reduce harm achieved 100% consensus agreement. We highlight key ethical issues concerning data, privacy, confidentiality and public trust, consent, law, litigation and liability, and commercial partnerships within digital surgery and identify barriers and research goals for future practice. Developers and users of digital surgery must not only have an awareness of the ethical issues surrounding digital applications in healthcare, but also the ethical considerations unique to digital surgery. Future research into these issues must involve all digital surgery stakeholders including patients

IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit. Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

AIMS: This international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients. METHODS: A multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1(st) March-31(st) May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded. RESULTS: A total of 7090 patients were included, with a mean age of 82.2 (range 50-104) years and 4959 (70%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) became positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p=0.001), residential care (OR 2.15, p<0.001), inpatient fall (OR 2.23, p=0.003), cancer (OR 0.63, p=0.009), ASA grade 4-5 (OR 1.59, p=0.008; OR 8.28, p<0.001), and longer admission (OR 1.06 for each increasing day, p<0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p<0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p<0.001). Increasing age (HR 1.03, p=0.028), male sex (HR 2.35, p<0.001), renal disease (HR 1.53, p=0.017), and pulmonary disease (HR 1.45, p=0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders. CONCLUSION: The prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher mortality risk

Technology and hip arthroplasty: acquiring skills and improving outcomes

The goals of modern total hip arthroplasty (THA) are an early return to activity with maximal stability and no functional limitations. Several surgical approaches have been developed to provide access to the hip joint to perform THA; compared to the posterior approach (PA), the anterior approach (AA) is purported to reduce the risk of dislocation and enable early return to function. The steep learning curve of this approach is well-described, so methods are required to enable surgeons to consistently deliver precise surgery without complications. The broad aims of this thesis were to 1) determine if the anterior approach hip arthroplasty confers a biomechanical advantage, and 2) identify novel technologies to improve the training and performance of this procedure. A cadaveric study assessed the stable range of motion conferred after conventional THA, dual- mobility total hip arthroplasty (DM-THA) and hip resurfacing arthroplasty (HRA), when performed through an anterior or posterior approach, before and after capsular repair. Of the twelve functional positions tested, conventional AA-THA with capsular closure dislocated in 0% while PA-THA dislocated in 17%. DM-THA and HRA did not dislocate with capsular closure, irrespective of approach. This study showed that the hip capsule is an important stabiliser in the early post-operative period. It functions as a wrapping leash around the prosthetic femoral head in flexion. The anterior approach and larger femoral implant sizes better preserve this function in positions of typical in vivo dislocation. While the attraction of AA hip arthroplasty was evident, cognitive task analysis (CTA) and the Delphi methodology was employed with an international group of expert hip surgeons to understand the technical steps, pitfalls, and steps to mitigate or address common complications. These data were also used to create a task-specific checklist (TSC) and to develop a cognitive training tool (CTT). Additionally, CTA data was used to create an immersive Virtual Reality (iVR) platform using information centric engineering (ICE) and agile development principles. CTA identified acetabular implant orientation as a critical, technical skill and a source of error for surgeons converting from PA to AA. An augmented reality (AR) software was thus designed and integrated with the Microsoft HololensTM headset to enable cup orientation to be tracked precisely to patient-specific targets on a drybone pelvis. The CTT was validated in an international multicentre RCT of 36 surgical trainees, comparing it to conventional training materials. CTT-trained surgeons performed simulated THA 35% more quickly with 69% fewer errors in instrument selection; required 92% fewer prompts; and were more accurate in cup orientation. The ability and feasibility of iVR training for AA-THA was ascertained in a 6-week curriculum of 32 surgical trainees. Their performance was compared to expert-derived benchmarks. Trainees progressively developed technical skills in iVR on a learning curve, on average plateauing after four sessions. Compared to baseline tests, their errors were reduced by 79%, assistive prompts by 70%, and procedural duration by 28%. A sawbone assessment demonstrated transfer of acetabular and femoral bone preparation skills between iVR and the real world. An RCT of 24 surgical trainees then compared a 6-week iVR program to conventional preparatory methods. The primary outcome measure was cadaveric AA-THA performance measured by two expert, blinded surgeons using a THA-specific Procedure Based Assessment. iVR-trained surgeons performed at a higher level than controls, on average completing AA-THA ‘with minimal guidance or intervention’. On average, surgeons required guidance for most or all the procedure. iVR-trained surgeons completed 80% more steps than controls, were 12° more accurate in cup orientation, and were 18% faster. Lastly, an RCT of 24 students compared AR headset-based training to coaching from a hip surgeon for learning acetabular cup orientation. It showed that AR was more accurate at providing guidance (1° vs. 6°error), and equivalent to the surgeon for delivering training to novices. However further improvements in hardware are needed before the AR prototype can be recommended for routine use, and AR may be more appropriate as an intra-operative navigation tool. It is concluded that the anterior approach for hip arthroplasty may confer greater immediate postoperative stability than the posterior approach, by preserving the function of the hip capsule, which may explain lower dislocation rates in retrospective clinical studies. However, cognitive task analysis showed that this approach is beset with unique technical surgical challenges, which reflect its well-reported complication profile. Training for AA-THA can be enhanced using cognitive training and immersive virtual reality, to shorten the learning curve and improve psychomotor skills. Future research should focus on ensuring that these technologies can be integrated into routine clinical training for the surgical team, and that they can deliver real clinical improvements.Open Acces

Dopamine receptor agonists and sleep disturbances in Parkinson's disease

Non-ergot dopamine receptor agonists, such as ropinirole, pramipexole, rotigotine and apomorphine, may alleviate some non-motor symptoms in Parkinson's disease (PD) while others may be precipitated. In this review, we discuss how dopamine receptor agonists can both ameliorate and aggravate the sleep problems in PD, a key non-motor symptom of this disease.</p

Parkinson’s disease

Parkinson's disease was first described by the London physician, James Parkinson, in 1817 and later named after him by Charcot. Parkinson's disease is one of the most important disabling illnesses of later life. The characteristic tremor, posture and clinical course were first depicted by James Parkinson in his essay The Shaking Palsy in 1817; our description today has added rigidity and bradykinesia to the list of primary symptoms. The modern concept of Parkinson's disease also includes a range of nonmotor symptoms (NMS), some of which (eg, olfactory deficit) could pre-date the motor diagnosis by 1-5 years [1]. </p

Virtual reality training improves trainee performance in total hip arthroplasty: a randomized controlled trial

Aims Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). Patients and Methods A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration. Results VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (sd 3) vs 12 (sd 3)), were 12° more accurate in component orientation (mean error 4° (sd 6°) vs 16° (sd 17°)), and were 18% faster (mean 42 minutes (sd 7) vs 51 minutes (sd 9)). Conclusion Procedural knowledge and psychomotor skills for THA learned in VR were transferred to cadaveric performance. Basic preparatory materials had limited value for trainees learning a new technique. VR training advanced trainees further up the learning curve, enabling highly precise component orientation and more efficient surgery. VR could augment traditional surgical training to improve how surgeons learn complex open procedures. Cite this article: Bone Joint J 2019;101-B:1585–1592 </jats:sec