The Nuffield Orthopaedic Centre (NOC) is an internationally renowned orthopaedic hospital, with strong affiliations to the University of Oxford. It provides routine and specialist orthopaedic surgery, plastic surgery and rheumatology services to the people of Oxfordshire. Specialist services, such as the treatment of osteomyelitis and bone tumours, and the rehabilitation of those with limb amputation, congenital deficiency and neurological disabilities, are provided for patients from across the UK and abroad. It is managed by the Oxford University Hospitals NHS Foundation Trust.
Aims:Total talus replacement (TTR) is an innovative technology with increasing availability. The aim of this study was to present the largest series to date of TTRs performed in the UK describing the outcomes, expected function, and complications. Methods:A total of 27 consecutive TTRs, which were undertaken between June 2019 and Decemeber 2024 in four tertiary centres, were included in the study. Prospectively collected patient-reported outcome measures (PROMs) including the Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D) scores, and the Tegner Activity Scale (TAS), at various timepoints were recorded and compared. Results:Of the 27 TTRs, eight were combined with a total ankle replacement (TATTR). Of the remaining 19 TTRs, 15 were fully articulating and four were constrained by intended bone-metal incorporation at one or more joint surface. The most common indication was idiopathic or post-traumatic avascular necrosis (AVN) of the talus (18/27). At a mean follow-up of 22 months (7 to 68), the mean MOXFQ improved significantly from 80.8% (95% CI 75.1 to 86.4) preoperatively to 43.2% (95% CI 32.1 to 54.3) (p < 0.001). The mean VAS score increased significantly from 44.5 (95% CI 33.8 to 55.2) preoperatively to 76.2 (95% CI 69.7 to 82.7) (p < 0.001). The mean EQ-5D improved significantly from 10.7 (SD 2.141 preoperatively to 7.4 (SD 2.8; p < 0.001). The mean TAS increased by 1.8 (0 to 6). Three patients (11%) underwent revision, two requiring increased constraint and another for deep infection. Conclusion:TTR can be used for patients with destruction of the talus to relieve pain and to improve both function and activity. Patients having surgery for an elective indication appear to improve more than those whose replacement follows trauma. Constrained implants produced similar results to fully articulating implants. It is a technically difficult procedure and as the numbers which are undertaken increases, standardized terminology must be used in further prospective follow-up.
PURPOSE:This study aimed to identify and synthesize published algorithms for identifying the initiation of a new line of therapy (LOT) for metastatic lung, breast, and colorectal cancer in real-world data (RWD). METHODS:We conducted a scoping review of published, English-language studies describing algorithms for identifying any LOTs with systemic anti-cancer therapy (SACT) for either non-metastatic or metastatic lung, breast, or colorectal cancer in RWD between January 1, 2014, and April 29, 2024. Dual reviewers independently screened titles, abstracts, and full-text articles, with disagreements resolved by a third reviewer. Data were extracted, categorized, synthesized, and summarized in narrative and tabular formats. RESULTS:The review identified 25 studies, mainly (64%) from the United States. Electronic health/medical records (EHRs) were the most frequently utilized (72%) RWD source. Twenty-four studies (96%) described RWD algorithms for identifying the initiation of a new LOT for metastatic lung, breast, or colorectal cancer. In 23 studies, algorithms required observing a new, adjuvant, SACT after an "incident" metastatic diagnosis code, which had been preceded by a metastasis-free lookback period of varied duration. Three studies' algorithms required observation of the completion of non-metastatic LOTs before initiation of a new LOT for metastatic cancer. Three studies validated their algorithms. CONCLUSIONS:Different algorithms are being used to identify LOT initiation for metastatic cancer. Most algorithms require an incident diagnosis of metastasis before considering subsequent SACT as newly initiated LOT for metastatic cancer. However, definitions of metastasis onset and gap duration to therapy initiation vary.
A flatfoot deformity in skeletally mature patients, now commonly described as a progressive collapsing foot deformity (PCFD), is a complex, multifactorial condition. Subtalar arthroereisis is a joint-preserving procedure designed to limit pathological subtalar pronation. While previously primarily used in paediatric patients, it has been increasingly used in adult PCFD reconstruction. The aim of this review was to evaluate the current evidence regarding the types of implants, the biomechanics, indications, complications, and clinical outcomes of the use of subtalar arthroereisis in adults. It has been suggested in biomechanical studies that the use of a subtalar arthroereisis can reduce medial column load and improve multiplanar correction. However, clinical outcomes depend on the correct sizing and positioning of the implant. Although subtalar arthroereises have been reported as a standalone procedure in a few studies, there remains too little information to allow guidance as to the correct indications for their use. It has more commonly been used as an adjunct in PCFD reconstruction, and improvements in radiological abduction of the mid and forefoot have been reported in these studies without necessarily improving patient reported outcomes. Comparative studies in which subtalar arthroereisis has been used as an alternative to lateral column lengthening in patients with significant forefoot abduction suggest similar radiological and clinical improvements. Sinus tarsi pain is the most frequent complication of subtalar arthroereisis, with rates of implant removal of between 6% and 48%. Most studies report that the correction of the deformity is maintained after removal of the implant. Thus, its role seems mainly to allow adjunctive bony and soft-tissue procedures to heal in the early postoperative period. Removal of the implant results in symptomatic improvement in between 62% and 100% of patients, suggesting that sinus tarsi pain may not be solely due to irritation associated with the implant. Overall, it appears that the use of a subtalar arthroereisis can further improve the correction of forefoot and midfoot abduction when used as an adjunct to other froms of surgery, and may have a role in the treatment of the class B component of flexible PCFD or as an alternative to lateral column lengthening. The evidence for its use in patients who undergo surgery for PCFD, however, remains of low quality, lacking a standardized PCFD-based classification; future prospective comparative trials are needed to clarify the indications, cost-effectiveness, and long-term outcomes.--
Abstract Background/Aims A 66-year-old man with eosinophilic granulomatosis with polyangiitis (EGPA) developed life-threatening neurological and cardiac involvement despite benralizumab therapy. Methods Initially diagnosed 2.5 years earlier after recurrent chest infections, asthma and pericardial effusion, he responded to mepolizumab but was switched to benralizumab for persistent eosinophilia, maintaining control for 10 months. He presented unable to walk, with rapidly progressive weakness and numbness following antibiotic-related diarrhoea. Further history revealed 2.5 kg weight loss, mild epistaxis and sinus symptoms over the last few months. Examination showed lower limb and hand sensory loss, power 2-3/5 and absent ankle jerks. Though initially thought to have Guillain-Barré syndrome (GBS), findings suggested an EGPA flare. Eosinophils were 3.04 × 109/L, CRP 167 mg/L, CK 2000 U/L. Rheumatoid factor became positive at 50 IU/ml. CXR showed a right-lower-zone cavitating lesion. Nerve conduction confirmed confluent mononeuritis multiplex. He was treated with cyclophosphamide (12.5 mg/kg) and prednisolone 60 mg; rising eosinophils (9.77 × 109/L), troponin (5652 ng/L) and BNP (2802 pg/mL) prompted 500 mg methylprednisolone, resulting in rapid recovery. He was discharged ambulant with mild residual sensory symptoms. Maintenance therapy is planned with either methotrexate or azathioprine in addition to benralizumab. Results EGPA can cause a range of cardiac and neurological symptoms. Cardiac involvement may be coronary, myocardial, pericardial or intramural. Neurological involvement may be central or peripheral. Aetiology involves eosinophil-mediated vascular inflammation causing thrombosis or ischaemia. In peripheral neuropathy, eosinophil migration can directly damage nervous tissue. High eosinophil counts correlate with disease severity. Benralizumab is an IL-5 receptor inhibitor with real-world data showing 86% patients respond to treatment. Pulmonary relapses tend to occur from week 24, though can appear as early as week 16 and may be related to drug-antibody development. However, extra-pulmonary relapses while on benralizumab are rare. Our patient developed mild nasal symptoms around week 24 but attributed them to hayfever and weight loss to increased activity. Eosinophils stayed normal until acute neurological deterioration. This case highlights that clinical relapse may occur independently of circulating eosinophil levels, suggesting tissue-level eosinophil activation or IL-5-independent pathways. Rheumatoid factor positivity in ANCA-associated vasculitis may predict worse prognosis and warrants close monitoring. Conclusion Benralizumab is an effective treatment in EGPA but secondary failure can emerge around weeks 16-24, possibly related to waning receptor occupancy or anti-drug antibody formation. Clinicians should maintain vigilance for subtle early signs such as sinus symptoms, fatigue, or weight loss — even when blood eosinophils appear suppressed. Extra-pulmonary relapses are rare but can present with both cardiac and neurological involvement, which can mimic GBS or spinal pathology. Rapid deterioration may necessitate escalation to cytotoxic induction such as cyclophosphamide. Disclosure M. Iftikhar: None. U. Ahmed: None. K. Sharma: None. A. Ahmed: None.
