A novel collagenase from Vibrio Alginolyticus: experimental study for Dupuytren's disease

OBJECTIVE

Dupuytren contracture (DC) is a highly prevalent hand affection in which contracted fingers compromise hand function. It is a benign fibroproliferative condition affecting the hand palmar fascia with a deposition of excess matrix proteins in the extracellular space of the palmar aponeurosis. In particular type III over type I collagen V. Alginolyticus collagenase (CVA), is a new enzyme that is fully active on the collagen filaments and inactive on other components of the dermal extracellular matrix. The aim of this study is to evaluate the safety and effectiveness of an intra-lesional injection of CVA on an animal model of subcutaneous fibrosis mimicking the pathological anatomy of the cord of Dupuytren's disease.

MATERIALS AND METHODS

We performed an in vivo study on 27 rats that were randomized into four groups, and we evaluated macroscopic and microscopic analysis examining the inflamed cell population and the extracellular matrix.

RESULTS

In all cases, no skin necrosis, skin tears or wound dehiscence were recorded, demonstrating the safety of the CVA in contrast to group D which had full-thickness skin necrosis, and this is confirmed by the microscopic analysis of the samples treated with CVA, where no hematomas are found around the fibrotic area with the absence of leukocyte infiltrates and macrophages.

CONCLUSIONS

CVA is confirmed to be selective for collagens I and III, reducing the risk of vascular lesions or skin ulcerations.

Quantifying Soft Tissue Artefacts and Imaging Variability in Motion Capture of the Fingers

This study assessed the accuracy of marker-based kinematic analysis of the fingers, considering soft tissue artefacts (STA) and marker imaging uncertainty. We collected CT images of the hand from healthy volunteers with fingers in full extension, mid- and full-flexion, including motion capture markers. Bones and markers were segmented and meshed. The bone meshes for each volunteer's scans were aligned using the proximal phalanx to study the proximal interphalangeal joint (PIP), and using the middle phalanx to study the distal interphalangeal joint (DIP). The angle changes between positions were extracted. The HAWK protocol was used to calculate PIP and DIP joint flexion angles in each position based on the marker centroids. Finally the marker locations were 'corrected' relative to the underlying bones, and the flexion angles recalculated. Static and dynamic marker imaging uncertainty was evaluated using a wand. A strong positive correlation was observed between marker- and CT-based joint angle changes with 0.980 and 0.892 regression slopes for PIP and DIP, respectively, and Root Mean Squared Errors below 4°. Notably for the PIP joint, correlation was worsened by STA correction. The 95% imaging uncertainty interval was < ± 1° for joints, and < ± 0.25 mm for segment lengths. In summary, the HAWK marker set's accuracy was characterised for finger joint flexion angle changes in a small group of healthy individuals and static poses, and was found to benefit from skin movements during flexion.

Dupuytren's disease: my personal view

Dupuytren's disease is a heterogenous condition for which a palette of treatment options is required. Randomized control trial evidence is sparse; design challenges, such as validated outcome measures, blinding, equipoise, funding and assessment of recurrence, may limit further data accrual. Recurrence has different significance with different treatments and so rates are not directly comparable. The risk of any treatment is a function of both the chance of a complication and the clinical sequelae of that complication. The patient must be intimately involved in choosing treatment and is often trading rapid recovery for a higher chance of recurrence. Health economies are strained and as custodians of healthcare, surgeons should consider whether many patients even need treatment. To minimize the chance of complex, hazardous and expensive revision surgery, a low threshold for primary skin grafting should be applied, especially for those who are young, have dense disease or vulnerable genes.

Venous thromboembolism after total knee replacement or total hip replacement: what can be learnt from root-cause analysis?

INTRODUCTION Because of the high risk of venous thromboembolism (VTE) in total hip replacement (THR) and total knee replacement (TKR), guidelines are used widely to enhance effective (yet safe) prophylaxis. If patients develop VTEs despite use of such guidelines, then the reasons are that the guidelines were: (i) followed but the VTE occurred anyway; (ii) not implemented appropriately. All VTEs are assessed routinely by root-cause analysis (RCA). METHODS The records and subsequent RCA reports for each patient who experienced clinically significant VTE after THR or TKR were reviewed. We established adherence to the guidelines (deemed to be 'unavoidable' with scope to improve the guidelines) and non-adherence (deemed to be 'avoidable' with scope to improve implementation). RESULTS Of 2,214 patients undergoing THR (n=1,330) or TKR (n=884), 25 (1.13%) experienced VTE. Four THR patients experienced VTE (2 of which were avoidable) and 21 TKR patients experienced VTE (5 of which were avoidable). There were significantly more VTEs in TKR patients than THR patients (p<0.0001). CONCLUSIONS A proportion of patients will experience VTE even if guidelines are followed (a baseline effect). Administration of chemical prophylaxis earlier might reduce this baseline effect further. This approach should be taken cautiously with due respect for the alternative risk of bleeding. Improvement in hospital routine may reduce the risk of VTE yet further.

The treatment of arthritis of the wrist

Arthritis of the wrist is a painful disabling condition that has various causes and presentations. The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment which allow the preservation of movement are now preferred. Modern arthroplasties of the wrist are still not sufficiently robust to meet the demands of many patients, nor do they restore normal kinematics of the wrist. A preferable compromise may be selective excision and partial fusion of the wrist using knowledge of the aetiology and pattern of degenerative change to identify which joints can be sacrificed and which can be preserved. This article provides an overview of the treatment options available for patients with arthritis of the wrist and an algorithm for selecting an appropriate surgical strategy.

A multicentre, randomized, double-blind trial of the safety and efficacy of mannose-6-phosphate in patients having Zone II flexor tendon repairs

The safety, tolerability and preliminary efficacy of mannose 6-phosphate in enhancing the outcome in Zone II flexor tendon repair was studied in a multicentre parallel double-blinded randomized controlled trial. Eight UK teaching hospitals were involved in treating repaired flexor tendons with a single intraoperative intrathecal dose of 600 mM mannose 6-phosphate, with follow-up over 26 weeks. A total of 39 patients (mannose 6-phosphate, n = 20; standard care, n = 19) were randomized. Seven were excluded from the safety and tolerability analysis because of intraoperative findings and eight were excluded due to early dropout (n = 4) or tendon rupture (n = 4), leaving 24 (mannose 6-phosphate, n = 13; standard care, n = 11) for assessment of total active motion. The safety, tolerability and other side effects were comparable between the groups. There was no significant difference between the two groups in the total active motion at Week 26. We concluded that mannose 6-phosphate, although safe and tolerable, had no beneficial effect on finger range of motion after Zone II tendon division.Level of evidence 1b.

Microcirculation in the foot is augmented by neuromuscular stimulation via the common peroneal nerve in different lower limb postures: a potential treatment for leg ulcers

AIM

Aim of the study was to examine the effects of the geko™ device (a portable electical nerve stimulator) on microcirculatory flow on the dorsum of the foot, and whether this is influenced by lower limb postures and application of a plaster cast.

METHODS

This was a cross-sectional, healthy cohort, open label, physiological response study. In 10 healthy volunteers, aged 19 to 24 years, laser Doppler fluxmetry measurements were made on the dorsum of the foot in four postures: standing (weight bearing and non-weight bearing) and supine lying (with the lower limb horizontal and then elevated). Measurements of flux were made both at rest and during stimulation with the geko™ device applied over the common peroneal nerve, at 1 Hz for 5 minutes in each posture. Repeat measurement were made after the application of a below knee plaster cast. Measures of flux were compared to basal levels assumed to be in supine with limb horizontal, with no cast and an inactive geko™ device.

RESULTS

The geko™ device was effective in increasing microcirculation on the dorsum of the foot in all four postures (mean difference =141%, 95% CI 70%-212%, P=0.001). This effect was more pronounced than that of using a plaster alone (Mean increase in flux of 73%, 95% CI 22%-125%, P=0.01) or variances due to the hydrostatic effects of different postures (mean difference 17-27.6%, P>0.05). There was a 2 to 3 fold increase in flux when stimulation was delivered in combination with the plaster cast.

CONCLUSION

Stimulation using the geko™ device augments microcirculation in the foot. The response is greater in lying and non-weight bearing than weight bearing standing but the most striking effect is when stimulation is combined with a plaster cast. The geko™ offers a potential means of promoting conditions favourable for wound healing, where treatment using compression may be contraindicated, such as arterial/mixed aetiology ulcers.

Collagenase clostridium histolyticum in patients with Dupuytren's contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes

In POINT X, a study designed to reflect clinical practice and patient treatment choices, 254 European patients received open-label collagenase for Dupuytren's contracture. The most severely affected joint was treated first in 74% of patients. In total, 52%, 41%, 7%, and 1% of patients selected the little, ring, middle, and index finger, respectively; 79% had one or two joints treated. Only 9% of patients (n = 24) received 4 or 5 injections. The mean improvement in total passive extension deficit (TPED) was 34° on day 1, improving further by day 7 to 42°. This secondary improvement was maintained by day 90 and month 6. The mean number of injections/joint was 1.2 for the metacarpophalangeal joint and 1.25 for the proximal interphalangeal joint. Median time to recovery was 4 days; the mean improvement in hand function was clinically relevant as measured by the Unité Rhumatologique des Affections de la Main (URAM) score. In total, 87% and 86% of patients and physicians, respectively, were very satisfied or satisfied with treatment at month 6, although correlation between TPED and patient satisfaction was weak (Spearman -0.18, 95% CI -0.32 to -0.06). Collagenase was well tolerated, with 10 (3.9%) patients experiencing severe adverse events. As a real-world study, the POINT X findings can be generalized to the at-large population.

Indications and early to mid-term results of ulnar head replacement

INTRODUCTION

The aim of this study was to explore the indications and show the early to mid-term results of ulnar head replacement for the treatment of pathological conditions of the distal radioulnar joint.

METHODS

Our study group comprised 52 patients with a mean age of 64 years who had 56 ulnar head replacements. Seven were implanted to salvage an unstable deletive procedure; the rest were for primary treatment of osteoarthritis, rheumatoid arthritis and trauma. Concomitant procedures along with the ulnar head replacement included wrist arthrodesis, joint replacement and tendon transfers.

RESULTS

The follow-up duration ranged from 1 year to 11 years (mean: 60 months, median: 60 months). In almost all of the patients, pain improved with a median visual analogue scale score of 2 (mean: 2.2, range: 0-8) and a median DASH (Disabilities of the Arm, Shoulder and Hand) score of 12.5 (mean: 17.9, range: 0-56). Of the 52 patients, 47 reported they would have the same procedure again.

CONCLUSIONS

Ulnar head replacement appears to be a reliable and effective procedure solving several pathological problems of the distal radioulnar joint. We present a large patient group with a short to medium-term follow-up duration.

Ultrasound case report of a palmar lipoma causing carpal tunnel syndrome

Ultrasound as an imaging technique is well established for the assessment of patients presenting with a palpable lump. Lipomata of the hand are relatively rare and are rarely the cause of neuropathy. Previous case reports of these rare types of lipomata have primarily involved imaging with magnetic resonance imaging in order to provide diagnostic information. This case report of a deep-seated lipoma of the flexor digitorum superficialis tendon sheath causing carpal tunnel syndrome and trigger wrist demonstrates that ultrasound can play a key role in the diagnosis and can provide vital diagnostic information for ongoing management and surgical resection without the need for further imaging.

Intermittent pneumatic compression. A comparison of femoral vein velocity with five different devices

AIM

Different mechanical devices for thromboprophylaxis have different flow characteristics. A new device (Vadoplex) has been developed to provide a short impulse around the calf, a concept derived from the efficacy of foot impulse technology. New devices should be compared with existing devices to establish whether it has a comparable ability to augment venous velocity. Objectives of the study were to compare the venous velocity induced by the Vadoplex with established intermittent pneumatic calf and leg compressors (Covidien and Huntleigh).

METHODS

The venous velocity was established in ten healthy volunteers with standardised Duplex ultraonography of the common femoral vein. Measurements were taken at rest and on standing, with each device inactive and active.

RESULTS

The Vadoplex induced an increased femoral venous velocity at least as enhanced as established calf and full leg sleeves.

CONCLUSION

Calf impulse technology is an alternative to other systems in enhancing femoral vein blood flow, itself a surrogate for assumed thromboprophylactic effect.

Prevention and treatment of venous thromboembolism--International Consensus Statement

The aim of this document is to provide a clear and concise account of the evidence regarding efficacy or harm for various methods available to prevent and manage venous thromboembolism (VTE).

Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery

We performed a systematic review and meta-analysis to compare the efficacy of intermittent mechanical compression combined with pharmacological thromboprophylaxis, against either mechanical compression or pharmacological prophylaxis in preventing deep-vein thrombosis (DVT) and pulmonary embolism in patients undergoing hip or knee replacement. A total of six randomised controlled trials, evaluating a total of 1399 patients, were identified. In knee arthroplasty, the rate of DVT was reduced from 18.7% with anticoagulation alone to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03; number needed to treat: seven). There was moderate, albeit non-significant, heterogeneity (I2 = 42%). In hip replacement, there was a non-significant reduction in DVT from 8.7% with mechanical compression alone to 7.2% with additional pharmacological prophylaxis (RR 0.84) and a significant reduction in DVT from 9.7% with anticoagulation alone to 0.9% with additional mechanical compression (RR 0.17, p < 0.001; number needed to treat: 12), with no heterogeneity (I2 = 0%). The included studies had insufficient power to demonstrate an effect on pulmonary embolism.

We conclude that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted.

Orthopaedic thromboprophylaxis

Thromboprophylaxis remains a controversial subject. A vast amount of epidemiological and trial data about venous thromboembolism has been published over the past 40 years. These data have been distilled and synthesised into guidelines designed to help the practitioner translate this extensive research into ‘evidence-based’ advice.

Guidelines should, in theory, benefit patient care by ensuring that every patient routinely receives the best prophylaxis; without guidelines, it is argued, patients may fail to receive treatment or be exposed to protocols which are ineffective, dangerous or expensive.

Guidelines, however, have not been welcomed or applied universally. In the United States, orthopaedic surgeons have published their concerns about the thromboprophylaxis guidelines prepared by the American College of Chest Physicians. In Britain, controversy persists with many surgeons unconvinced of the risk/benefit, cost/benefit or practicality of thromboprophylaxis. The extended remit of the recent National Institute of Clinical Excellence thromboprophylaxis guidelines has been challenged.

The reasons for this disquiet are addressed in this paper and particular emphasis is placed on how clinically-acceptable guidelines could be developed and applied.

Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared with the time course of thromboembolic events: findings from the Global Orthopaedic Registry

Patients who have undergone total hip or knee replacement (THR and TKR, respectively) are at high risk of venous thromboembolism. We aimed to determine the time courses of both the incidence of venous thromboembolism and effective prophylaxis. Patients with elective primary THR and TKR were enrolled in the multi-national Global Orthopaedic Registry. Data on the incidence of venous thromboembolism and prophylaxis were collected from 6639 THR and 8326 TKR patients. The cumulative incidence of venous thromboembolism within three months of surgery was 1.7% in the THR and 2.3% in the TKR patients. The mean times to venous thromboembolism were 21.5 days (sd 22.5) for THR, and 9.7 days (sd 14.1) for TKR. It occurred after the median time to discharge in 75% of the THR and 57% of the TKA patients who developed venous thromboembolism. Of those who received recommended forms of prophylaxis, approximately one-quarter (26% of THR and 27% of TKR patients) were not receiving it seven days after surgery, the minimum duration recommended at the time of the study. The risk of venous thromboembolism extends beyond the usual period of hospitalisation, while the duration of prophylaxis is often shorter than this. Practices should be re-assessed to ensure that patients receive appropriate durations of prophylaxis.

The use of graduated compression stockings in association with fondaparinux in surgery of the hip

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit.

The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49).

The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism.

The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient.

The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone.

A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement

Patients who undergo total knee replacement (TKR)are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative.

We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group.

We conclude that the neither method provides superior prophylaxis.

A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement

Patients who undergo total knee replacement (TKR) are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative. We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group. We conclude that the neither method provides superior prophylaxis.

Baseline factors predicting early resumption of driving after life-threatening arrhythmias in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial

BACKGROUND

In the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial, patients with ventricular fibrillation or hemodynamically unstable ventricular tachycardia were randomly assigned to receive either an implantable cardioverter-defibrillator (ICD) or antiarrhythmic drug therapy. As part of the trial, patients were asked to participate in a prospective driving survey. The purpose of the survey was to determine what baseline factors and patient characteristics specifically predicted resumption of driving earlier than advised by current guidelines.

METHODS

Patients were surveyed anonymously as to their driving habits in the initial period after random assignment and every 6 months thereafter. AVID study coordinators were independently asked to assess their patients' driving status as well. The relation between baseline factors and time to resumption of driving was explored by means of Kaplan-Meier estimates for univariate analyses and the stepwise Cox proportional hazards regression model for multivariate analyses.

RESULTS

There were 802 patients who were eligible for assessment of driving status. The majority of patients (58%) resumed driving an automobile within 6 months of their index arrhythmia regardless of whether they received drug therapy or an ICD. By multivariate analysis, patients who were younger than 65 years of age, male, and college educated were more likely to drive early, as were patients whose index arrhythmia was ventricular tachycardia.

CONCLUSIONS

Younger, college-educated men and those whose index arrhythmia is ventricular tachycardia are most likely to resume driving <6 months after the initiation of therapy for a potentially life-threatening ventricular arrhythmia. Patients with an ICD did not appear to resume driving later than those who were discharged on antiarrhythmic drugs alone.

Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial

We conducted a prospective, randomized trial to compare the safety and effectiveness of the A-V Impulse System foot pump with that of low-molecular-weight heparin for reducing the prevalence of deep-vein thrombosis after total hip replacement. Of 290 patients who were to have a primary total hip replacement, 143 were randomized to receive enoxaparin (forty milligrams daily) for seven days after the operation and 147, to use the foot pump for seven days. The primary outcome measure was the prevalence of deep-vein thrombosis, as determined by venography on the sixth, seventh, or eighth postoperative day. Secondary outcome measures included transfusion requirements, intraoperative blood loss, postoperative drainage, blood-loss index, appearance of the site of the wound according to a subjective visual-analog scale, and swelling of the thigh. The patients' compliance with the regimen for use of the foot pump was monitored with an internal timing device, and their acceptance of the device was assessed with a questionnaire. Symptoms consistent with pulmonary embolism were investigated with ventilation-perfusion scanning. The patients were contacted later for detection of symptoms of venous thromboembolism that may have occurred during the first three months after discharge from the hospital. Venography was performed on 274 patients: 136 who used the foot pump and 138 who received enoxaparin. Deep-vein thrombosis was detected in twenty-four (18 per cent) of the patients who used the foot pump compared with eighteen patients (13 per cent) who received enoxaparin (95 per cent confidence interval for the difference in proportions, -3.9 to +13.0 per cent). Thrombosis in the calf was found in seven patients (5 per cent) in the former group compared with six patients (4 per cent) in the latter (95 per cent confidence interval for the difference, -4.2 to +5.8 per cent), and proximal thrombosis was observed in seventeen patients (13 per cent) in the former group compared with twelve patients (9 per cent) in the latter (95 per cent confidence interval for the difference, -3.5 to +11.1 per cent). None of these differences was significant. No patient in either group had major proximal deep-vein thrombosis; all proximal thrombi were isolated entities involving the femoral valve cusp and were of unknown importance. One patient who used the foot pump had a non-fatal pulmonary embolism. One patient who received enoxaparin had a symptomatic deep-vein thrombosis during hospitalization. Two patients (one from each group [0.7 per cent]) were readmitted to the hospital because of a symptomatic deep-vein thrombosis despite normal venographic findings at the time of discharge. There was no difference in the transfusion requirements or the intraoperative blood loss between the two groups. There were more soft-tissue side effects in the patients who received enoxaparin than in those who used the foot pump: there was more bruising of the thigh and oozing of the wound (p < 0.001 for each), postoperative drainage (578 compared with 492 milliliters; p = 0.014), and swelling of the thigh (twenty compared with ten millimeters; p = 0.03). Of 124 patients who used the foot pump and were asked about the acceptability of the device, fourteen (11 per cent) said that it was uncomfortable, twenty-one (17 per cent) reported sleep disturbance, and four (3 per cent) stated that they had stopped using the device. Conversely, ten (8 per cent) found it relaxing. We concluded that the foot pump is a suitable alternative to low-molecular-weight heparin for prophylaxis against thromboembolism after total hip replacement and that it produces fewer soft-tissue side effects. Tolerance of the device is a problem for some patients.

Revision of failed hemiarthroplasty for fractures at the hip

The records of 56 patients in whom a hemiarthroplasty, carried out for a femoral neck fracture, had been revised to a total hip replacement, were reviewed. The mode of failure was femoral loosening in 21, acetabular erosion in 26 and both in 5. Loosening tended to occur earlier than acetabular erosion. The median time to the onset of symptoms was 12 months and to revision 33 months. There were 38 major operative or postoperative complications at revision in 27 of the patients (48%).

Incidence of fatal pulmonary embolism after 1,390 knee arthroplasties without routine prophylactic anticoagulation, except in high-risk cases

A consecutive series of 1,390 primary total knee arthroplasty (TKA) procedures (1,201 patients, 1,600 arthroplasties) performed between January 1980 and July 1994 were reviewed to establish the incidence of death from pulmonary embolism (PE). Nine hundred twenty-three bi- or tricompartment TKAs and 467 unicompartment TKAs were performed as one-stage procedures. Chemical thromboprophylaxis was used only in high-risk cases in which there was a history of previous thromboembolism or obesity. There were no deaths from PE after unicompartment arthroplasty procedures. Autopsy confirmed PE as the cause of death in 2 patients following bi- and tricompartment TKAs (0.22%; 95% confidence interval [CI], 0.03-0.8%). The incidence was higher for one-stage bilateral TKA as 1 of the autopsy-confirmed deaths occurred in this group 0.7% (95% CI, 0.02-3.78%). Two other deaths were certified without postmortem examination (pneumonia and myocardial infarction in each case). As PE could not be ruled out as the cause of death in the latter 2 cases, these were considered as possible PE deaths to provide the maximum possible death rate that could result. Thus, the maximum possible incidence of fatal PE after TKA without routine use of chemical anticoagulation was 0.4% (95% CI 0.1-1.1%). It is concluded that the risk of fatal PE after unilateral TKA and unicompartment knee arthroplasty is low. The risk of clinical, nonfatal thromboembolic events, which might themselves warrant prophylaxis, was not quantified in this article.

Is manipulation of moderately displaced Colles' fracture worthwhile? A prospective randomized trial

Thirty elderly patients with moderately displaced Colles' fractures were randomly assigned to manipulation under Bier's block or plaster immobilization alone. Moderately displaced was defined as 10 degrees to 30 degrees of dorsal angulation and less than 5 mm of radial shortening compared with the uninjured side. The groups were well matched for age, sex, fracture type and displacement; immobilization time and rehabilitation were standardized. The outcome measures were: radiological position at union, the functional score of Gartland and Werley, grip strength, cosmesis and algodystrophy assessment. There was no detectable difference between the groups in any of the outcome measures. Two-thirds of the correction of dorsal angulation achieved by manipulation was lost by 5 weeks. We conclude that up to 30 degrees of dorsal angulation and 5 mm of radial shortening may be accepted in selected elderly patients.

Barrier methods in the operating room: surgical habits die hard

Transmission of viral infection, such as human immunodeficiency virus or hepatitis B and C, is a concern for both surgeon and patient. Published guidelines advise the regular use of barrier preventive measures in order to minimise the occupational exposure of surgeons. A telephone survey was conducted of 92 orthopaedic, cardiothoracic and general surgeons in the South West Region of England, regarding their use of barrier methods. This survey shows that only a minority of surgeons regularly use protective measures, although they are readily available.