Editorial: Oral Health: luxury or a fundamental human right? The necessity of introducing a dedicated oral health budget and Proportionate Universalism in Greece

Oral health is an integral part of overall health and critically affects quality of life as well as personal and social well-being. Poor oral health negatively influences general health and creates medical, financial and social burdens for individuals, families and health systems. The US Office of Disease Prevention and Health Promotion (2021) sees use of the oral health care system as a leading health indicator. Oral health improvement is an important step to reduce socioeconomic inequalities and promote the UN Sustainable Development Strategy (Wang et al., 2020, Huang and Chang 2022). Moreover, "achieving the highest attainable standard of oral health is a fundamental human right of every human being" (WHO 2022a).

Urinary tract infection is associated with 2.4-fold increased risk of surgical site infection in hip fracture surgery: systematic review and meta-analysis

BACKGROUND

There is no consensus regarding whether urinary tract infection (UTI) should be screened for or treated in hip fracture patients.

AIM

To assess the relationship between perioperative UTI and surgical site infection (SSI) in hip fracture patients, and the relationship between urinary catheterization and SSI in these patients.

METHODS

PubMed, Embase, CINAHL and Cochrane Library were searched to identify studies that evaluated the relationship between perioperative UTI and SSI and/or between urinary catheterization and SSI. Articles were included if they used the term UTI or specified UTI as symptomatic bacteriuria.

FINDINGS

A total of 4139 records were identified, with eight studies included. Meta-analysis of seven studies which evaluated perioperative UTI and SSI showed an SSI rate of 7.1% (95% confidence interval (CI): 3.8-13.2) among 1217 patients with UTI vs 2.4% (95% CI: 1.0-5.7) in 36,514 patients without UTI (OR: 2.41; 95% CI: 1.67-3.46; P < 0.001). In three studies which specifically defined UTI as symptomatic bacteriuria, the SSI rate among UTI patients was 5.7% (95% CI: 4.0-8.1) vs 1.1% (95% CI: 0.2-5.2) in those without UTI (OR: 3.00; 95% CI: 0.55-16.26; P = 0.20). One study evaluated urinary catheterization and SSI.

CONCLUSION

Perioperative UTI is associated with a higher risk of SSI among hip fracture patients but the evidence is limited by the heterogeneity in the definition of UTI. We recommend considering the possibility of perioperative UTI in hip fracture patients, with treatment administered as necessary to reduce SSI rates.

Bleeding complications in patients on warfarin undergoing joint injection/aspiration: systematic review and meta-analysis

Steroid injections in joints are commonly administered for the management of inflammatory or degenerative conditions. There is substantial controversy as to whether to continue warfarin when undertaking joint injection or aspiration. To assess the rate of bleeding complications in patients on warfarin undergoing joint injection/aspiration. Systematic review and meta-analysis. A literature search of 3 online databases was conducted by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study that reported bleeding complication rates in adult patients on warfarin undergoing a joint injection/aspiration whilst taking warfarin anticoagulation. Studies reporting on less than 5 patients were excluded. Meta-analysis was conducted using a random effects model. The search of databases resulted in a total of 1547 articles. After screening, 8 articles were deemed suitable for inclusion in the analysis, involving 871 injection/aspiration procedures. There were only 5 reported cases of bleeding. On meta-analysis the estimated bleeding complication rate was 1.5% (95% CI 0.5-4.5%). This meta-analysis shows that it is safe to perform joint injection and aspiration in patients on warfarin without routine prior testing of INR. Level of evidence: Level 4.

Surface waves and crustal structure on Mars

We detected surface waves from two meteorite impacts on Mars. By measuring group velocity dispersion along the impact-lander path, we obtained a direct constraint on crustal structure away from the InSight lander. The crust north of the equatorial dichotomy had a shear wave velocity of approximately 3.2 kilometers per second in the 5- to 30-kilometer depth range, with little depth variation. This implies a higher crustal density than inferred beneath the lander, suggesting either compositional differences or reduced porosity in the volcanic areas traversed by the surface waves. The lower velocities and the crustal layering observed beneath the landing site down to a 10-kilometer depth are not a global feature. Structural variations revealed by surface waves hold implications for models of the formation and thickness of the martian crust.

Largest recent impact craters on Mars: Orbital imaging and surface seismic co-investigation

Two >130-meter-diameter impact craters formed on Mars during the later half of 2021. These are the two largest fresh impact craters discovered by the Mars Reconnaissance Orbiter since operations started 16 years ago. The impacts created two of the largest seismic events (magnitudes greater than 4) recorded by InSight during its 3-year mission. The combination of orbital imagery and seismic ground motion enables the investigation of subsurface and atmospheric energy partitioning of the impact process on a planet with a thin atmosphere and the first direct test of martian deep-interior seismic models with known event distances. The impact at 35°N excavated blocks of water ice, which is the lowest latitude at which ice has been directly observed on Mars.

Complications following Suture Button Use for Femoral Graft Fixation in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Systematic Review

Understanding any potential complications that may occur in relation to the use of a suture button for femoral graft fixation in arthroscopic anterior cruciate ligament reconstruction can help raise awareness among surgeons and improve safety when using such implants. This is a systematic review of suture button related complications. A literature search was conducted using the PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases from their year of inception until January 3, 2019. We included studies reporting on suture button related complications in their outcomes of femoral graft suture button fixation in anterior cruciate ligament reconstruction. Our search identified 479 articles, of which 19 met our inclusion criteria. Suture button misplacement (initial or subsequent migration) was the most commonly reported complication. Although, in most cases, button misplacement is minimal and does not adversely affect clinical outcomes, in some cases it may lead to graft failure or local soft tissue irritation and require further surgery. Intraoperative screening or arthroscopic evaluation of the deployed suture button may reduce this complication.

Limited implementation of measures to reduce nosocomial spread of COVID-19 in hip-fracture patients in the North West of England

Hip-fracture patients are vulnerable to the outcomes of COVID-19. We performed a cross-sectional survey to determine measures employed to limit nosocomial spread of COVID-19 in 23 orthopaedic trauma departments in the North-West of England. Nineteen (87%) hospitals admitted patients to a ward prior to a negative swab, and only 9 (39%) patients were barrier nursed. Hip-fracture patients were operated in non-COVID-19-free theatres in 21 (91%) hospitals. Regular screening of doctors working in trauma and elective areas for COVID-19 was undertaken in three (13%) and five (22%) hospitals, respectively. Doctors moved freely between trauma and elective areas in 22 (96%) hospitals.

Assessment of InSight Landing Site Predictions

Comprehensive analysis of remote sensing data used to select the Interior Exploration using Seismic Investigations, Geodesy and Heat Transport (InSight) landing site correctly predicted the atmospheric temperature and pressure profile during entry and descent, the safe landing surface, and the geologic setting of the site. The smooth plains upon which the InSight landing site is located were accurately predicted to be generally similar to the Mars Exploration Rover Spirit landing site with relatively low rock abundance, low slopes, and a moderately dusty surface with a 3-10 m impact fragmented regolith over Hesperian to Early Amazonian basaltic lava flows. The deceleration profile and surface pressure encountered by the spacecraft during entry, descent, and landing compared well (within 1σ) of the envelope of modeled temperature profiles and the expected surface pressure. Orbital estimates of thermal inertia are similar to surface radiometer measurements, and materials at the surface are dominated by poorly consolidated sand as expected. Thin coatings of bright atmospheric dust on the surface were as indicated by orbital albedo and dust cover index measurements. Orbital estimates of rock abundance from shadow measurements in high-resolution images and thermal differencing indicated very low rock abundance and surface counts show 1-4% area covered by rocks. Slopes at 100 to 5 m length scale measured from orbital topographic and radar data correctly indicated a surface comparably smooth and flat as the two smoothest landing sites (Opportunity and Phoenix). Thermal inertia and radar data indicated the surface would be load bearing as found.

A new strategy for the treatment of atherothrombosis - inhibition of inflammation

Improvement in the prognosis of patients at risk of atherothrombotic events is based on three pillars - slowing down the process of atherogenesis (i.e. the development of atherosclerotic plaque), stabilizing the current atherosclerotic plaque, and reducing the risk of thrombotic occlusion in cases with unstable atherosclerotic plaque. The current prophylaxis has so far taken into consideration the adjustment of several risk factors, including dyslipidemia, arterial hypertension, smoking, and diabetes through lifestyle changes or pharmacological therapies. An essential part of prophylaxis is the anti-thrombotic strategy, especially anti-platelet therapy. Recently, a new pathway has been developed, based on reducing the activity of the inflammatory process with NLRP3 inflammasome, specifically a monoclonal antibody against interleukin 1beta (canakinumab). The efficacy and safety of this treatment, in secondary prevention, were documented in the CANTOS study. Other therapeutic procedures, including suppression of the inflammatory component of atherogenesis, are at the stage of clinical assessment.

SEIS: Insight's Seismic Experiment for Internal Structure of Mars

By the end of 2018, 42 years after the landing of the two Viking seismometers on Mars, InSight will deploy onto Mars' surface the SEIS (Seismic Experiment for Internal Structure) instrument; a six-axes seismometer equipped with both a long-period three-axes Very Broad Band (VBB) instrument and a three-axes short-period (SP) instrument. These six sensors will cover a broad range of the seismic bandwidth, from 0.01 Hz to 50 Hz, with possible extension to longer periods. Data will be transmitted in the form of three continuous VBB components at 2 sample per second (sps), an estimation of the short period energy content from the SP at 1 sps and a continuous compound VBB/SP vertical axis at 10 sps. The continuous streams will be augmented by requested event data with sample rates from 20 to 100 sps. SEIS will improve upon the existing resolution of Viking's Mars seismic monitoring by a factor of ∼ 2500 at 1 Hz and ∼ 200 000 at 0.1 Hz. An additional major improvement is that, contrary to Viking, the seismometers will be deployed via a robotic arm directly onto Mars' surface and will be protected against temperature and wind by highly efficient thermal and wind shielding. Based on existing knowledge of Mars, it is reasonable to infer a moment magnitude detection threshold of M w ∼ 3 at 40 ∘ epicentral distance and a potential to detect several tens of quakes and about five impacts per year. In this paper, we first describe the science goals of the experiment and the rationale used to define its requirements. We then provide a detailed description of the hardware, from the sensors to the deployment system and associated performance, including transfer functions of the seismic sensors and temperature sensors. We conclude by describing the experiment ground segment, including data processing services, outreach and education networks and provide a description of the format to be used for future data distribution.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s11214-018-0574-6) contains supplementary material, which is available to authorized users.

Fast and selective separation of carbon dioxide from dilute streams by pressure swing adsorption using solid ionic liquids

The need to create a new approach to carbon capture processes that are economically viable has led to the design and synthesis of sorbents that selectively capture carbon dioxide by physisorption. Solid Ionic Liquids (SoILs) were targeted because of their tunable properties and solid form under operational conditions. Molecular modelling was used to identify candidate SoILs and a number of materials based on the low cost, environmentally friendly acetate anion were selected. The materials showed excellent selectivity for carbon dioxide over nitrogen and oxygen and moderate sorption capacity. However, the rate of capture was extremely fast, in the order of a few seconds for a complete adsorb-desorb cycle, under pressure swing conditions from 1 to 10 bar. This showed the importance of rate of sorption cycling over capacity and demonstrates that smaller inventories of sorbents and smaller process equipment are required to capture low concentration CO₂ streams. Concentrated CO₂ was isolated by releasing the pressure back to atmospheric. The low volatility and thermal stability of SoILs mean that both plant costs and materials costs can be reduced and plant size considerably reduced.

Transient subdiffusion from an Ising environment

We introduce a model in which a particle performs a continuous-time random walk (CTRW) coupled to an environment with Ising dynamics. The particle shows locally varying diffusivity determined by the geometrical properties of the underlying Ising environment, that is, the diffusivity depends on the size of the connected area of spins pointing in the same direction. The model shows anomalous diffusion when the Ising environment is at critical temperature. We show that any finite scale introduced by a temperature different from the critical one, or a finite size of the environment, cause subdiffusion only during a transient time. The characteristic time, at which the system returns to normal diffusion after the subdiffusive plateau depends on the limiting scale and on how close the temperature is to criticality. The system also displays apparent ergodicity breaking at intermediate time, while ergodicity breaking at longer time occurs only under the idealized infinite environment at the critical temperature.

Loss of motivation and frustration for visitor surgeons in provincial health centers or psychiatric hospitals in Greece

Introduction

The core workplace for a surgeon is the operating theatre. Secondary duties may include visits to small health centers for outpatient examinations and visitor work to psychiatric hospitals.

Objective

The objective of our study is to highlight the mistakes of management that lead to half-empty provincial health centers and psychiatric hospitals.

Methods

Presentation of the 2-year-experience of a surgeon visitor in provincial health centers and in a large psychiatric hospital in Greece.

Results

The provincial health center of Lagada needs at least 4 surgeons to serve; too many patients to be examined or/and operated in 2–3 hours only. Subsequently problems arise, as simultaneously in the emergencies department a surgical eye for an abdominal pain or a bad looking leg is needed every 15 minutes. The health center of Koufalia needs 3 hours of driving per day for 3–8 surgical patients only. The psychiatric hospital offered work for 3 surgeons 5 days a week for a long period of time. During 2012–2014, only one surgeon visited the hospital once a week. The work needed to be done may kill the surgeon or force him to receive antidepressants in order to keep his functions alive.

Conclusions

Not a hint of scientific motivation for two years is a strong reason for a surgeon to avoid the duty to provincial health centers and psychiatric hospitals which is obligatory according to our national health system Laws until two years are completed for newly appointed surgeons. Managers might encourage surgeons if some balancing convenience was offered.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Nonergodic subdiffusion from transient interactions with heterogeneous partners

Spatiotemporal disorder has been recently associated to the occurrence of anomalous nonergodic diffusion of molecular components in biological systems, but the underlying microscopic mechanism is still unclear. We introduce a model in which a particle performs continuous Brownian motion with changes of diffusion coefficients induced by transient molecular interactions with diffusive binding partners. In spite of the exponential distribution of waiting times, the model shows subdiffusion and nonergodicity similar to the heavy-tailed continuous time random walk. The dependence of these properties on the density of binding partners is analyzed and discussed. Our work provides an experimentally testable microscopic model to investigate the nature of nonergodicity in disordered media.

Optimal selection policies for a sequence of candidate drugs

Pharmaceutical companies have to face huge risks and enormous costs of production before they can produce a drug. Efficient allocation of resources is essential to help in maximizing profits. Yu and Gittins (2007) described a model and associated software for determining efficient allocations for a preclinical research project. This is the starting point for this paper. We provide explicit optimal policies for the selection of successive candidate drugs for two restricted versions of the Yu and Gittins (2007) model. To some extent these policies are likely to be applicable to the unrestricted model.

Accessory bands of the hamstring tendons: A clinical anatomical study

Gracilis and semitendinosus tendons are commonly used as grafts in ligamentous reconstruction. Awareness of accessory bands of these tendons is essential in preventing inadvertent diversion of the tendon harvester into the main tendon resulting in premature tendon amputation and inadequate tendon graft. The aim of this study was to describe the characteristics of these accessory bands. Twenty five patients undergoing arthroscopic anterior cruciate ligament reconstruction using hamstring tendons were included. The number of accessory bands and distance of the most proximal band from the distal periosteal insertion point on the tibial crest was recorded for both gracilis and semitendinosus. In most cases gracilis had two accessory bands; the average distance of the most proximal band from the tibial crest insertion being 5.1 cm. Semitendinosus had three bands in most cases, the average distance of the most proximal band from the tibial crest insertion being 8.1 cm. Five (20%) semitendinosus but no gracilis tendons had an accessory band originating greater than 10 cm from the tibial crest insertion. Semitendinosus had more accessory bands compared to gracilis. A significant proportion (20%) of semitendinosus and none of the gracilis tendons had bands originating greater than 10 cm proximal to the tibial crest insertion. This knowledge about the accessory bands of the hamstrings can guide toward safe harvesting of these tendons.

Same day discharge following inter-scalene block administration for arthroscopic shoulder surgery: implementing a change in practice

Patients who had arthroscopic shoulder surgery with the provision of an inter-scalene nerve block (ISB) at Blackpool Teaching Hospitals, were previously required to remain in hospital overnight. We introduced a new protocol that allowed same day discharge following arthroscopic shoulder surgery under general anaesthesia and ISB. The aim of this study was to review the outcome of this change in practice. Our results indicated that providing a discharge protocol for patients having arthroscopic shoulder surgery with the inclusion of ISB can avoid unnecessary overnight stay and enable significant cost savings, without detriment to patient safety or satisfaction.

Reducing same day cancellations due to patient related factors in elective orthopaedic surgery: experience of a centre in the UK

Cancellations on the day of surgery represent a major wastage of resources and can impose significant distress on patients. Minimising same day cancellations can improve cost effectiveness of operating theatre running. The aim of the study was to determine the impact of administering a questionnaire, by phone to elective orthopaedic patients, the week prior to surgery. This questionnaire was aimed at identifying factors that could lead to same day cancellation for patient related reasons. The questionnaire was administered to elective orthopaedic patients over a nine month period. The rate of same day cancellations due to patient related reasons in this cohort (Phase 2) was compared with a previous cohort assessed over a five month period when the questionnaire was not in place (Phase 1). Administering the questionnaire reduced the same day cancellations due to patient reasons from 11 out of 110 (10%) to 2 out of 118 (1.60%) (p = 0.01). Theatre wastage in terms of national tariff lost due to cancellations was reduced from 25,881 sterling pounds to 1,650 sterling pounds (p<0.001). The study concludes that administering a questionnaire aimed at addressing patient related reasons can significantly reduce same day cancellations.

Double-bundle medial patellofemoral ligament reconstruction with hamstring tendon autograft and mediolateral patellar tunnel fixation: a meta-analysis of outcomes and complications

Medial patellofemoral ligament (MPFL) reconstruction is used to treat patellar instability and recurrent patellar dislocation. Anatomical studies have found the MPFL to be a double-bundle structure. We carried out a meta-analysis of studies reporting outcomes of patellofemoral reconstruction using hamstring tendon autograft in a double-bundle configuration and patellar fixation via mediolateral patellar tunnels. A literature search was undertaken with no language restriction in various databases from their year of inception to July 2012. The primary outcome examined was the post-operative Kujala score. We identified 320 MPFL reconstructions in nine relevant articles. The combined mean post-operative Kujala score was 92.02 (standard error (se) 1.4, p = 0.001) using a fixed effects model and 89.45 (se 37.9, p = 0.02) using random effect modelling. The reported rate of complications with MPFL reconstruction was 12.5% (40 of 320) with stiffness of the knee being the most common. High-quality evidence in assessing double-bundle MPFL reconstruction is lacking. The current literature consists of a mixture of prospective and retrospective case series. High-quality randomised trials evaluating this procedure are still awaited.

Theatre time utilisation in elective orthopaedic surgery

A prospective review of theatre time utilisation of the senior author's elective orthopaedic lists was carried out over a period of 10 weeks. A total of 41 cases were included. Only 54.0% of theatre time was utilised for operating. The anaesthetic time was 12.0%, and 9.3% of theatre time was used for positioning and draping. Delays in starting the list and turnover time accounted for the remaining 25%.

Is there a need for early post-operative x-rays in primary total knee replacements? Experience of a centre in the UK

INTRODUCTION

Early post-operative x-rays are often taken in total knee replacements (TKRs). Patient mobilisation may be delayed until these x-rays are obtained and this may prolong discharge. The aim of this study was to assess the value of such early x-rays and whether they influenced the early post-operative management of these patients.

METHODS

A total of 624 consecutive TKRs performed at the Blackpool Victoria Hospital over a 34-month period were evaluated. Plain anteroposterior and lateral x-rays were examined.

RESULTS

Two patients were found to have significant abnormalities: an undisplaced periprosthetic tibial fracture and a partial inferior pole patellar avulsion. Neither of these required further treatment or influenced mobility. No other complications were noted that changed routine post-operative management.

CONCLUSIONS

These results question the need for immediate x-rays in primary TKRs.

SUPERFICIAL BRANCH OF THE RADIAL NERVE PIERCING THE BRACHIORADIALIS TENDON TO BECOME SUBCUTANEOUS: AN ANATOMICAL VARIATION WITH CLINICAL RELEVANCE

We dissected 20 preserved Caucasian cadaveric upper limbs looking at the relation of the superficial branch of the radial nerve (SBRN) to the brachioradialis tendon. SBRN emerged from deep to superficial position by piercing the brachioradialis tendon near its dorsal border in four limbs. The resulting dorsal tendinous band compressed the nerve and prevented longitudinal gliding movement during ulnar flexion. This is likely to increase the risk of chronic compression neuropathy (Wartenberg's syndrome). In two of these four limbs, there was a communication between the SBRN and lateral cutaneous nerve of the forearm. No such communication was found in the remaining 16 forearms. This communication could contribute to the minimal area of sensory loss observed in Wartenberg's syndrome. We recommend that this anatomical anomaly is looked for and if present dealt with during surgical treatment of Wartenberg's syndrome, as it is likely to predispose to chronic compression neuropathy.

Reoperation for metalwork complications following the use of volar locking plates for distal radius fractures: a United Kingdom experience

Volar locking plates are increasingly used in the management of distal radius fractures. As with any new implant, understanding the rate and type of potential metalwork related complications is important. In this study, we reviewed 114 distal radius fractures treated with volar locking plating. Our aim was to determine the type and rate of metalwork complications requiring reoperation. In our series, 12 cases (10%) underwent further surgery for metalwork related complications mainly for screw protrusion into the radiocarpal joint following fracture collapse. Our results suggest that volar locking plates are associated with a high rate of metal work related complications requiring further surgery. Technical aspects to reduce such complications are discussed.

Bone-cement interface strength in distal radii using two medullary canal preparation techniques: carbon dioxide jet cleaning versus syringed saline

PURPOSE

Loosening is an important cause of failure of upper limb arthroplasty and improvement in cementation techniques may limit this. The currently accepted medullary canal preparation techniques use saline washing and gauze drying. Another method of bone preparation uses carbon dioxide compression gas jet which blows debris from the canal, whilst simultaneously drying the bone. We compared the push out strengths of cement plugs in sections of human cadaveric radii that had been prepared using either syringed saline or carbon dioxide jet cleaning.

METHODS

Following bone preparation, four radii in each group, were cemented in a standardised fashion, and cut into 1 cm sections. An Instron materials testing machine was used to measure the force needed to push the cement plug out of the bone section.

RESULTS

The force needed to push out the cement plug was significantly higher in the carbon dioxide jet (median 580.61, IQR 429.10-650.05) as compared to the saline group (median 366.57N, IQR 271.05-502.23), P = 0.009. The mechanism of failure of the bone-cement interface also differed between the two groups, with 100% of the sectioned cortices fracturing prior to cement extrusion in the carbon dioxide jet group, but only 23% of the sectioned cortices doing so in the saline group.

CONCLUSION

Our results suggest that there is a statistically stronger macro-interlock at the bone-cement interface after preparation of the medullary canals of radii using a carbon dioxide compression gas jet as compared to saline irrigation.

Distal radial and ulnar landmarks used in percutaneous pin fixation: anatomical relationship to the superficial radial and ulnar nerves

BACKGROUND

The radial and ulnar styloids as well as Lister's tubercle are important surgical landmarks in the surgical treatment of distal forearm fractures. There have been limited studies assessing their relative safety in terms of their distance from superficial nerves which are in danger during surgical procedures. The aim of this cadaveric study was to assess and compare the distance of superficial nerves to these important surgical landmarks.

METHODS

Twenty embalmed cadaveric upper limbs were dissected exposing the nerves and tendons around the wrist. The radial styloid, Lister's tubercle, ulnar styloid and nerve branches were marked with pins. The distance of the nearest nerve branch to each landmark was measured with a digital calliper. Statistical analysis of the data was performed using SPSS for Windows 11.5 (SPSS Inc., Chicago, IL) using Friedman Tests and Wilcoxon Signed Ranks tests.

RESULTS

The median distance of the nearest nerve branch to the radial styloid was 5.42 mm, to the Lister's tubercle was 16.68 mm and to the ulnar styloid was 13.56 mm. There was unequal safety for these three surgical landmarks regarding proximity to nerve branches (p < 0.00001). Paired comparison using Wilcoxon Signed Ranks Test showed that the Lister's tubercle was safer than the radial styloid (p < 0.0001) and ulnar styloid (p = 0.04). In addition, the ulnar styloid was safer than the radial styloid (p < 0.001).

CONCLUSIONS

There is a higher risk of injury to superficial nerves when operating near the radial styloid as it is significantly closer to nerve branches as compared to Lister's tubercle and ulnar styloid.

Gradual distraction using an external fixator followed by open reduction in the treatment of chronic lunate dislocation

Chronic lunate dislocation is a difficult problem to deal with. We describe a surgical technique whereby gradual wrist distraction is applied using an external fixator followed by open repositioning of the lunate. We have successfully used this technique in a rugby player with an undiagnosed chronic lunate dislocation. Our case was able to return to competitive rugby playing.

Improving osteoporosis assessment in the fracture clinic

INTRODUCTION

The aim of this study was to compare the effectiveness of different ways of referring patients to an osteoporosis assessment service at an orthopaedic fracture clinic of a hospital in the UK.

PATIENTS AND METHODS

Three methods of identifying and referring to an osteoporosis assessment service were evaluated.

RESULTS

Relying on doctors for such a referral gave a catchment rate of only 1.6%. Involving patients themselves, asking them to self-refer, increased the catchment rate to 63% (P < 0.0001). Having a specialist osteoporosis and fracture liaison nurse present in clinic and reviewing the notes of patients checking in, to see if they match criteria for osteoporosis assessment, further increased catchment to 77% (P = 0.036).

CONCLUSIONS

Simply having an osteoporosis assessment service and strict criteria to identify which patients should be referred to such a service will not necessarily increase catchment rate for osteoporosis patients. A nurse physically present in the clinic provided the best result, and supports the need of investing in an osteoporosis and fracture liaison nurse.

A modification of the McLaughlin procedure for persistent posterior shoulder instability: technical note

We describe a modification of the McLaughlin procedure for persistent posterior shoulder instability following posterior glenohumeral dislocation with a large antero-medial reverse Hill-Sachs lesion. In the original McLaughlin description, the subscapularis was divided close to its insertion to the lesser tuberosity and sutured into the reverse Hill-Sachs lesion using bone drill holes. In our newly described technique, the subscapularis tendon is not divided but is instead plicated into the reverse Hill-Sachs lesion using suture anchors inserted in the humeral head defect. We present the case of a patient with persistent posterior instability following traumatic posterior glenohumeral dislocation, successfully treated with our new technique.

Hamstring tendon harvesting--Effect of harvester on tendon characteristics and soft tissue disruption; cadaver study

The purpose of this study was to determine whether the type of hamstring tendon harvester used can influence harvested tendon characteristics and soft tissue disruption. We compared two different types of tendon harvesters with regard to the length of tendon obtained and soft tissue disruption during hamstring tendon harvesting. Thirty six semitendinosus and gracilis tendons were harvested using either a closed stripper or a blade harvester in 18 paired knees from nine human fresh cadavers. Use of the blade harvester gave longer lengths of usable tendon whilst minimising the stripping of muscle and of any non-usable tendon. Our results suggest that the type of harvester per se can influence the length of tendon harvested as well as soft tissue disruption. Requesting such data from the industry prior to deciding which harvester to use seems desirable.

Placement of a palpable marker adjacent to the mid-inguinal point: assessment of a clinical method for detecting the femoral head centre during knee arthroplasty

Localization of the centre of the femoral head is vital when using extra-medullary femoral alignment systems in knee arthroplasty. This study investigated the accuracy of a palpable marker placed in the groin for detecting the centre of the femoral head. A table tennis ball, 38 mm in diameter, was taped 2.5 cm perpendicular to the mid-inguinal point in patients having a plain radiograph of the pelvis. The mean horizontal distance between the centre of the table tennis ball and a vertical line passing through the centre of the femoral head was 8.62 mm (range 0-28.6, SD 6.76). In 100% of cases the horizontal distance between the centre of the table tennis ball and a vertical line passing through the centre of the femoral head was less than one diameter of the table tennis ball. Using a theoretical mechanical axis model our clinical method would confer an error equal to or less than 2 degrees from the weight-bearing axis of the knee in up to 98% of cases. In conclusion, our results suggest that the clinical method reported here provides a simple and reliable way of localizing the centre of the femoral head in knee arthroplasty.

Outcome of stemmed shoulder hemi-arthroplasty revision

INTRODUCTION

We report our experience of revision of failed stemmed shoulder hemi-arthroplasty for causes other than infection.

MATERIAL/METHOD

Seventeen revisions were followed for a minimum of 2 years. Fifteen cases were revised for symptomatic glenoid erosion. Sixteen were revised to a total shoulder arthroplasty and one to a cuff tear arthropathy head.

RESULT

The mean visual analogue pain score following revision surgery was reduced from 6.7 to 3.2 (P = 0.008). However the Constant-Murley and the Association of Shoulder and Elbow Surgeons scores failed to improve significantly.

CONCLUSION

We conclude that revision surgery for failed stemmed shoulder hemi-arthroplasty improves pain but not function.

Posterolateral rotatory laxity following surgery to the head of the radius: biomechanical comparison of two surgical approaches

The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach.

Hybrid monolateral-ring fixator for bone transport in post-traumatic femoral segmental defect: a technical note

Bone transport for large femoral segmental bone defects is a technically challenging task. We describe a patient with a 14 cm bone loss at the metaphyseal/diaphyseal junction of the distal femur, treated with a monolateral/ring fixator hybrid. We propose that such combination can provide sufficient stability for bone tranport to be successfully completed.

Posterolateral rotatory instability of the elbow

Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, causing posterior subluxation or dislocation of the radial head. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. The diagnosis relies on a high index of clinical suspicion, active and passive apprehension tests, and examination under anaesthesia. Surgical treatment has given consistently successful results. Open reconstruction of the lateral ligaments with a tendon graft has been the procedure of choice, with arthroscopic techniques emerging as a potential alternative.

Inter- and intra-observer variation of the Schatzker and AO/OTA classifications of tibial plateau fractures and a proposal of a new classification system

INTRODUCTION

The aim of this study was to evaluate the intra- and inter-observer variation of the Schatzker and AO/OTA classifications in assessing tibial plateau fractures, using plain radiographs.

PATIENTS AND METHODS

Fifty tibial plateau fractures were classified independently by six observers as per the Schatzker and AO/OTA classifications, using antero-posterior and lateral plain radiographs. Assessment was done on two occasions, 8 weeks apart.

RESULTS

We found that both the Schatzker and AO/OTA classifications have a high intra-observer (kappa = 0.57 and 0.53, respectively), and inter-observer (kappa = 0.41 and 0.43, respectively) variation. Classification of tibial plateau fractures into unicondylar versus bicondylar and pure splits versus articular depression +/- split conferred improved inter- and intra-observer variation.

CONCLUSIONS

The high inter-observer variation found for the Schatzker and AO/OTA classifications must be taken into consideration when these are used as a guidance of treatment and when used in evaluating patients' outcome. Simply classifying tibial plateau fractures into unicondylar versus bicondylar and pure splits versus articular depression +/- split may be more reliable.