Background: Subclinical hypothyroidism (SCHo) is a common biochemical diagnosis in older age. Evidence of impact is inconclusive and guidelines are inconsistent. With increasing numbers of thyroid function tests (TFTs) performed, GPs frequently have to make management decisions regarding this diagnosis. However, little is known about how SCHo is currently being managed in primary care. Aim: To explore management of SCHo in primary care and GP reported rationale for treatment of SCHo in older individuals. Design: Descriptive study using retrospective case note review and GP survey. Setting: Nineteen General Practices, Central England, UK. Methods: Follow-up of a large cohort with subsequent detailed review of individuals for whom therapy had been initiated following diagnosis of SCHo. Data on practice policies, and rationale behind treatment were collected via GP questionnaire. Results: Forty-two individuals were treated following identification of SCHo. Factors regarded as supporting instigation of therapy recorded by practitioners included symptoms, a positive antithyroid antibody test and history of radioiodine therapy. In all, 55% were registered at 3/19 practices suggesting significant between practice variation. Reasons for testing included chronic disease check-up (n 5 14), presenting 'thyroid symptoms' (n 5 5) and presenting other symptoms (n 5 9). Reasons for therapy initiation were only recorded in 26 cases and included presence of symptoms, persistently high or increasing serum thyroid stimulating hormone concentration and patient request. Only 2/15 GPs reported having practice guidelines on management. Conclusion: Results suggest that GPs are uncertain how to interpret symptoms and TFT results in older individuals. There is considerable variation in management of SCHo between GPs with some GPs treating patients outside of all guideline recommendations.

Background Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive Staphylococcus aureus (MSSA) is the most frequent organism, and the majority are endogenous. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI. Methods Our hospital prospectively collected data on our MSSA decolonisation programme since 2013, including; all MSSA carriers, treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used. Results During the study period 15,958 primary hip and knee replacements were performed. 3200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1210 neomycin and 1221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P < 0.0001). There was no difference in PJI rates (P = 0.452). Conclusions Mupirocin and neomycin are more effective than octenidine at MSSA decolonisation. There was poor correlation between the MSSA status after treatment (on day of surgery) and PJI rates. Further research is needed to compare alternative MSSA decolonisation treatments.

Background: Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis. Methods: In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon’s logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes. Results: Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection ( P = .05) and bone stimulator use ( P < .001). Among smokers, there was a trend toward slower union with heavier smoking ( P = .004). Conclusion: This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame. Level of Evidence: Level III, retrospective cohort study.

Background: There is increasing evidence that varus deformity does not negatively affect total ankle arthroplasty (TAA) outcomes, but there is a sparsity of evidence for valgus deformity. We present our outcomes using a mobile-bearing prosthesis for neutral, varus, and valgus ankles. Methods: This is a retrospective cohort study of consecutive cases identified from a local joint registry. In total, 230 cases were classified based on preoperative radiographs as neutral (152 cases), varus greater than 10 degrees (60 cases), or valgus greater than 10 degrees (18 cases). Tibiotalar angle was again measured postoperatively and at final follow-up (mean follow-up of 55.9 months). A total of 164 cases had adequate patient-reported outcome measures data (Foot and Ankle Outcome Score, Short Form–36 [SF-36] scores, and patient satisfaction) for analysis (mean follow-up of 61.6 months). The groups were similar for body mass index and length of follow-up, but neutral ankles were younger ( P = .021). Results: Baseline scores were equal except SF-36 physical health, with valgus ankles scoring lowest ( P = .045). Valgus ankles had better postoperative pain ( P = .025) and function ( P = .012) than neutral. Pre- to postoperative change did not reach statistical significance except physical health, in which valgus performed best ( P = .039). Mean final angle for all groups was less than 5 degrees. There was no significant difference in revision rates. Conclusion: Our study is consistent with previous evidence that varus deformity does not affect outcome in TAA. In addition, in our cohort, outcomes were satisfactory with valgus alignment. Postoperative coronal radiological alignment was affected by preoperative deformity but within acceptable limits. Coronal plane deformity did not negatively affect radiological or clinical outcomes in TAA. Level of Evidence: Level III, retrospective comparative study.

Category: Ankle; Ankle Arthritis; Diabetes Introduction/Purpose: Total Ankle Arthroplasty [TAR] is a recognized treatment for end stage osteoarthritis. Many of these patients also have Type 2 Diabetes. There is a lack of literature of patients undergoing TAR surgery who belong to this cohort and any available literature has shown negative outcomes in such surgery. We aim to study whether the radiological outcomes of such patients undergoing TAR is different to their non diabetic counterparts performed at our Tertiary center. Methods: We conducted a retrospective study of patients undergoing Total Ankle Replacements between 2006 and 2014. Both patients with Type 2 Diabetes and non-diabetic patients were included. Type 1 Diabetics were excluded. Pre-operative screening of patients included thorough clinical assessment including swelling, warmth, erythema and neurovascular assessment including proprioception, vibration and neuro-filament testing. True AP, lateral X-Ray weight bearing views were obtained. MRI or CT scan was carried out on all patients pre-operatively. Patients were reviewed with X-Ray at 3, 6, and 12 month post operatively. Any radiolucency was defined as gap >2mm between the implant and the bone which was not seen at 3 month post op x-ray. Painful ankle replacement implants were investigated by SPECT CT scan. Results: 9(3.9%) of the 230 patients were diabetic. Pre-operative radiographs revealed disease confined to OA, MRI and CT scans showed no evidence of bone debris, fragmentation of articular surfaces, translation of Talus or symptomatic OA in the Subtalar or Talo-navicular joint requiring treatment. Radiological analysis at 5 years demonstrated no evidence of loosening, implant subsidence, migration or periprosthetic cysts. No x-ray progression of arthritis was noted in the Subtalar, Talo-navicular or midfoot joints in Diabetic patient group. At the latest follow up, no radiological features of Charcot arthropathy was noted in the peri-prosthetic area. Conclusion: Our radiological outcome study has demonstrated that at minimum of 5 years, patients with diabetes who underwent TAR did not show any progression of arthritis in adjacent joints. Our study highlights that in the absence of diabetic neuropathy, it is safe to offer TAR in patients with Type II DM.