Stepping Hill Hospital,Stockport NHS Foundation Trust

Aims: This retrospective multicentre study, involving 38 UK hospital trusts, aimed to characterise the demographic features, inpatient management, and referral patterns of patients with prosthetic hip dislocations. The primary focus was to identify factors influencing a definitive management plan following acute total hip arthroplasty (THA) dislocation, and to assess differences in the management of primary versus revision THA dislocations. Methods: Data from 645 patients who sustained acute prosthetic hip dislocations between 01 January 2019 and 31 July 2019, were collected from electronic medical records. Patients were divided into Primary and Revision THA groups. Statistical analyses were used to explore demographic patterns, comparative analyses, and factors influencing referral decisions, with significance set at p < 0.05. Results: The mean age of patients was 76.2 years, with a predominance of females (65.7%) and posterior dislocations (72.7%). Of the patients, 37.8% underwent reduction in the Emergency Department (ED), with a success rate of 69.7%, while 72.9% required reduction in theatre, achieving a success rate of 90.6%. Inpatient mortality was 1.2%. Only 32.5% of patients had a definitive management plan following their dislocation. Primary THA patients (n = 504) were predominantly female (69.6%) compared to Revision THA patients (n = 141, 48.9%, p < 0.001). Anterior dislocations were more common in the Revision THA group (26.2% vs. 17.3%, p = 0.017). The primary THA group had a higher success rate in closed reduction (92.9% vs. 82.9%, p = 0.002). Revision THA patients were more likely to have a definitive management plan (52.9% vs. 26.9%, p < 0.001). Conclusions: This study highlights significant variability in the management of THA dislocations, particularly in the lack of standardised protocols for inpatient management and onward referral to revision arthroplasty surgeons. Standardisation of care pathways is needed to optimise outcomes for patients with prosthetic hip dislocations.

Acute Achilles tendon ruptures (AATRs), an extremely prevalent injury amongst adults who remain active, have been treated with surgical intervention for decades. This choice was made due to several decades-old studies demonstrating reduced re-rupture rates as opposed to nonsurgical interventions utilizing casts; however, numerous surgeons and researchers acknowledged potential complications such as wound problems and nerve damage. Functional braces and early weight-bearing now challenge this 'surgical by default' model. An evidence-based, focused review of randomized clinical trials, conventional and network meta-analysis, and large cohorts was conducted for the comparison of operative and nonoperative treatment for AATRs or the evaluation of various rehabilitation approaches. Operative management provides a lower rate of re-rupture in comparison to traditional cast-based nonoperative treatment; however, operative management also results in increased wound complications and sural nerve injuries. Nonoperative management employing functional bracing and early weight-bearing provides re-rupture rates approaching those of operative management, and the long-term functional outcome data are generally comparable. Differences in structural changes continue to exist between the two management groups, with longer tendon length and atrophy of the soleus muscle seen after conservative treatment, although for the majority of patients, the resultant strength and endurance deficits will be minimal. Both treatment options may provide optimal results if implemented through structured rehabilitation pathways. Treatment should be individualized based on the patient's specific factors, injury characteristics, and available resources. The use of current comparative effectiveness research to assist in making decisions regarding treatment with the patient is recommended.

Empathy is often described as a desirable attribute in medical practice, yet it is rarely examined as a core clinical competency, particularly in surgery. This reflective article describes a formative encounter early in a surgical career, in which a distressed postoperative patient spat at the author during a ward round. Rather than responding with anger or reprimand, the situation was met with calmness and compassion, transforming a potentially confrontational moment into one of human connection and healing. Revisited years later through contemplative practice, the incident highlights the role of emotional regulation, empathy, and perspective-taking in managing challenging clinical interactions. This reflection argues that technical expertise alone is insufficient for high-quality surgical care and that empathy should be actively taught, practiced, and valued as an essential component of surgical professionalism. Compassion, when consciously applied, can heal psychological suffering and strengthen trust between patients and clinicians.

Chronic spontaneous urticaria (CSU) is marked by repeated episodes of wheals and/or angioedema lasting more than six weeks and occasionally coexists with autoimmune thyroid disease. Autoimmune thyroid disease may contribute to CSU in a subset of patients, and symptoms can be refractory to conventional antihistamine and corticosteroid therapy. A 33-year-old woman with a history of asthma presented with recurrent widespread urticaria and periorbital angioedema, often triggered by food, resulting in repeated acute care visits. Symptoms were minimally responsive to high-dose antihistamines and systemic corticosteroids. She underwent evaluation for mast cell disorders and neuroendocrine tumors, which were excluded through normal serum tryptase, urinary 5-hydroxyindoleacetic acid, and plasma metanephrine levels. Biochemical testing revealed suppressed thyroid-stimulating hormone (TSH) and elevated free thyroid hormones, with positive TSH receptor antibodies, consistent with autoimmune thyroid disease. Medical management with antithyroid therapy, beta-blockers, and antihistamines achieved biochemical control of hyperthyroidism but did not improve urticaria. Thyroid ultrasound demonstrated diffuse hypervascular enlargement. Given persistent severe CSU and refractory hyperthyroidism, the patient underwent total thyroidectomy. Histopathological examination confirmed autoimmune thyroid disease. Following surgery, urticaria and angioedema resolved completely, with no recurrence at follow-up. This case illustrates a severe autoimmune CSU phenotype likely mediated by overlapping IgE- and IgG-driven mechanisms sustained by active thyroid autoimmunity. The complete resolution of urticaria following thyroidectomy suggests a direct causal relationship. Early recognition of thyroid dysfunction in patients with recurrent or refractory CSU can guide targeted management, prevent repeated hospital visits, and, in select cases, may enable definitive thyroid ablation as a curative approach. Multidisciplinary evaluation and individualized treatment planning are essential for patients presenting with severe autoimmune CSU unresponsive to conventional therapy.

Guillain-Barré syndrome (GBS) is an acute immune-mediated polyradiculoneuropathy typically presenting with symmetrical ascending limb weakness and areflexia. Cranial nerve involvement is recognized, most commonly affecting the facial nerves bilaterally. Unilateral facial nerve palsy, particularly in association with severe radicular lower back pain, is an atypical presentation and may lead to diagnostic uncertainty. We report the case of a 40-year-old woman with a background of papillary thyroid cancer who presented with severe lower back pain, progressive bilateral lower limb weakness, and acute left-sided lower motor neuron facial nerve palsy following a flu-like illness with diarrheal symptoms. Initial assessment focused on stroke and malignancy recurrence. Rapid neurological deterioration with bulbar symptoms and respiratory compromise prompted further investigation. Cerebrospinal fluid analysis demonstrated albuminocytological dissociation, and nerve conduction studies confirmed GBS. The patient required intensive care admission and was treated with intravenous immunoglobulin, resulting in significant clinical improvement. This case highlights a rare and atypical presentation of GBS and emphasizes the importance of recognizing asymmetrical cranial nerve involvement to facilitate early diagnosis and timely treatment.