--Eleven tips for operational researchers working with health programmes: our experience based on implementing differentiated tuberculosis care in south India

Due to the workload and lack of a critical mass of trained operational researchers within their ranks, health systems and programmes may not be able to dedicate sufficient time to conducting operational research (OR). Hence, they may need the technical support of operational researchers from research/academic organisations. Additionally, there is a knowledge gap regarding implementing differentiated tuberculosis (TB) care in programme settings. In this 'how we did it' paper, we share our experience of implementing a differentiated TB care model along with an inbuilt OR component in Tamil Nadu, a southern state in India. This was a health system initiative through a collaboration of the State TB cell with the Indian Council of Medical Research institutes and the World Health Organisation country office in India. The learnings are in the form of eleven tips: four broad principles (OR on priority areas and make it a health system initiative, implement simple and holistic ideas, embed OR within routine programme settings, aim for long-term engagement), four related to strategic planning (big team of investigators, joint leadership, decentralised decision-making, working in advance) and three about implementation planning (conducting pilots, smart use of e-tools and operational research publications at frequent intervals). These may act as a guide for other Indian states, high TB burden countries that want to implement differentiated care, and for operational researchers in providing technical assistance for strengthening implementation and conducting OR in health systems and programmes (TB or other health programmes). Following these tips may increase the chances of i) an enriching engagement, ii) policy/practice change, and iii) sustainable implementation.

The First Differentiated TB Care Model From India: Delays and Predictors of Losses in the Care Cascade

To reduce TB deaths in resource-limited settings, a differentiated care strategy can be used to triage patients with high risk of severe illness (i.e., those with very severe undernutrition, respiratory insufficiency, or inability to stand without support) at diagnosis and refer them for comprehensive assessment and inpatient care. Globally, there are few examples of implementing this type of strategy in routine program settings. Beginning in April 2022, the Indian state of Tamil Nadu implemented a differentiated care strategy called Tamil Nadu-Kasanoi Erappila Thittam (TN-KET) for all adults aged 15 years and older with drug-susceptible TB notified by public facilities. Before evaluating the impact on TB deaths, we sought to understand the retention and delays in the care cascade as well as predictors of losses. During April-June 2022, 14,961 TB patients were notified and 11,599 (78%) were triaged. Of those triaged, 1,509 (13%) were at high risk of severe illness; of these, 1,128 (75%) were comprehensively assessed at a nodal inpatient care facility. Of 993 confirmed as severely ill, 909 (92%) were admitted, with 8% unfavorable admission outcomes (4% deaths). Median admission duration was 4 days. From diagnosis, the median delay in triaging and admission of severely ill patients was 1 day each. Likelihood of triaging decreased for people with extrapulmonary TB, those diagnosed in high-notification districts or teaching hospitals, and those transferred out of district. Predictors of not being comprehensively assessed included: aged 25-34 years, able to stand without support, and diagnosis at a primary or secondary-level facility. Inability to stand without support was a predictor of unfavorable admission outcomes. To conclude, the first quarter of implementation suggests that TN-KET was feasible to implement but could be improved by addressing predictors of losses in the care cascade and increasing admission duration.

A Review on Various Biofuels and its Applications

Biofuels derived from biofuels, plant or algae or animal wastes. Unlike fossil fuels such as petroleum, coal and natural gas, refilled immediately. Biofuels are fuels made from recently harvested plants. They act like fossil fuels: they burn when ignited, releasing energy that can be converted into kinetic energy in a car, or heat a home. Biofuels can be obtained from a variety of crops and from a wide range of plant products from other industries. Not only is biodiesel stable, it is also a highly environmentally friendly, clean burning option that can be used without modification in diesel engines. In fact, biodiesel reduces greenhouse gas emissions by 56% to 86%, which means that the use of biodiesel has already reduced carbon emissions by 75.5 million metric tons. Many countries promote the use of biodiesel. In 2001, global biodiesel consumption was approximately 0.3 billion gallons. Based on the raw material, biofuels are divided into four groups: third, fourth (FGBs), first biodiesel, which is the only is a locally produced, clean-burning, renewable alternative to petroleum diesel. The use of biodiesel as a vehicle fuel enhances energy conservation, improves air quality and the environment, and provides safety benefits. Biofuels are transport fuels such as ethanol and biomass based diesel fuels. These fuels are usually blended with petroleum fuels (petrol and distillation / diesel fuel and heating oil), but can also be used on their own. Scientists have found that, in practice, biofuels produced from agricultural crops cause less pollution and greenhouse gas emissions than conventional fossil fuels, causing some environmental problems. Biofuels can also affect the poor. Various problems arise due to high prices for crops. It can go from improved water quality to creating new jobs in economically backward areas. Some applications of bioenergy require a feed based on residues from dedicated field production (such as energy crops) or agricultural production. However, many plant species grown for biofuels release higher levels of the ozone precursor isoprene than conventional crops and plants. Excess ozone poses a well-documented risk to human health, with 22,000 premature deaths each year linked to ground ozone exposure in Europe.

Upshot of Concentration of Zirconium (IV) Oxynitrate Hexa Hydrate on Preparation and Analyses of Zirconium Oxide (ZrO₂) Nanoparticles by Modified Co-Precipitation Method

In the present work, pure nanocrystalline monoclinic Zirconia (ZrO₂) has been successfully synthesized and optimized by the modified co-precipitation method. The concentration of raw material has been optimized with the fixed amount of precipitation agent (Potassium hydroxide KOH). The thermal history of the precursor has been examined through TG/DTA analysis. All the samples are subjected to study the structure, fingerprints of the molecular vibrations, and morphology analyses. The representative sample has been analyzed through Transmission Electron Microscope (TEM) and X-ray Photo Electron Spectroscopy (XPS) analyses. The as-prepared sample exhibits the better crystallinity and surface morphology with lesser particle size (190 nm) when the raw material concentration is 0.2 M. The as-prepared ZrO₂ filler (0, 3, 6, 9, and 12 wt.%) is spread through the enhanced polymer electrolyte P(S-MMA) (27 Wt.%)-LiClO₄ (8 wt.%)-EC + PC (1;1 of 65 wt.%) complex system via solution casting method. The as-synthesized electrolyte films are examined via complex impedance analysis. P(S-MMA) (27 wt.%)-LiCIO₄ (8 wt.%)-EC + PC (1 ;1 of 65 wt.%)-6 wt.% of ZrO₂ shows the high ionic conductivity 2.35 × 10^-3 Scm^-1. Temperature-dependent ionic conductivity studies obey the non-linear behavior. The enhanced ZrO₂ has been expected to enhance the other electrochemical properties of the lithium secondary battery.

Two-year clinical results of a novel load redistribution device for the treatment of medial knee OA

PURPOSE

A potential method to relieve the pain from medial osteoarthritis of the knee is to offload the medial compartment. The Latella^™ Knee Implant is a novel device designed to offload the medial compartment. The objective of the Cotera-1 study was to evaluate the preliminary safety and feasibility of the Latella implant to treat patients with medial OA of the knee, by a 2-year follow-up of a prospective multicenter feasibility study (Cotera-1) performed in the Netherlands and UK METHODS: In this first-in-man study, 11 participants received the Latella implant and were followed for 2 years, documenting physician assessment, Patient-Reported Outcome (PRO) scoring (KOOS, IKDC, Kujala, SF-36); Patient Global Assessment (PGA), radiographic analysis and MRI analysis, complications, reoperation rate and hip-knee-ankle axis.

RESULTS

The Latella Knee Implant system proved to be well tolerated and demonstrated a low-risk safety profile up to 24 months post-treatment. A responder analysis was performed of the subjects who still had the Latella implanted at 24-month time point (n = 9). Based on a MCID of eight for KOOS pain sub-scale, 78% of the subjects at the 24 month time point would be considered as responders. Similarly, based on improvement in the medial knee pain compared to baseline using the NRS scale of 1-10, 89% of the subjects at the 24-month time point would be considered as responders. Two patients were revised during follow-up: one for arthrofibrosis and one converted to TKA for progression of OA.

CONCLUSIONS

The early clinical experience with the Latella Knee Implant in this pilot feasibility study has been encouraging. It appears to be a safe implant with possible effect on medial OA. Additional studies need to be performed to assess the safety and efficacy of the procedure in a larger patient population.

LEVEL OF EVIDENCE

II.

Appropriateness of metformin prescription for type 2 diabetes mellitus patients with chronic kidney disease (Stages 3-5)

INTRODUCTION

Metformin is the first-line pharmacological therapy for type 2 diabetes mellitus (T2DM). Guidelines recommend metformin to be given at reduced dosages for those with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m² and omitted in those with eGFR<30 mL/min/1.73m². Lactic acidosis is a known complication of those on metformin. This study aimed to determine the appropriateness of metformin prescription in T2DM patients with chronic kidney disease (CKD) stages 3-5 in a tertiary centre in Malaysia.

MATERIALS AND METHODS

A cross-sectional design using retrospective secondary data of T2DM patients on metformin attending nephrology and diabetic clinics in the year 2017. eGFR calculated using the CKD-EPI formula identified those in CKD stage 3-5 defined using the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative criteria. Metformin prescription was considered appropriate when the metformin maximum daily dosage does not exceed 1500 mg in CKD stage 3a and 1000 mg in CKD stage 3b and metformin stopped in CKD stages 4 and 5.

RESULTS

A total of 143 patients were included. Majority were in the elderly age group (62.9%), male (60.8%) and had concurrent hypertension (85.3%). Median HbA1c was 8.3% (67 mmol/mol) with most patients (88.8%) having HbA1c above 6.5% (48 mmol/ mol). Majority (92.3%) were categorised as stage 3 CKD. Eleven (7.7%) subjects had inappropriate metformin prescription. Seven of nine (78%) subjects in CKD stage 4 were on metformin with a maximum daily dose of 500 mg to1000 mg. Three patients had serum lactate measured.

CONCLUSION

The majority of CKD patients had appropriate metformin prescription. However, a considerable number of CKD stage 4 patients continued to be on metformin. The many benefits of metformin may be a reason why it is still continued against recommendations. Only three patients had lactate measured which, although may suggest that lactic acidosis is not a common occurrence, the potential for metformin-associated lactic acidosis especially in those at risk should be considered.

Facile Synthesis and Characterization of ZrO₂ Nanoparticles via Modified Co-Precipitation Method

The crystalline Zirconium oxide (ZrO2) nano particles were synthesized using optimized content of Zirconium nitrate (Zr(NO3)2·3H2O) with varying KOH concentration (0.5, 1 and 1.5 M) by co-precipitation method. The thermal history of the precursor was carefully analyzed through Thermogravimetric (TG/DTA) measurement. The as prepared samples were characterized to ensure structural, functional, morphological, compositional, chemical composition and band gap by X-ray diffractometer (XRD), Fourier transform infrared spectroscopy (FTIR), Laser Raman, scanning electron microscopy (SEM), High resolution Transverse Electron Microscopy (HR-TEM), X-ray photo electron spectroscopy (XPS), EDX, Photo luminescence spectroscopy (PL). The monoclinic structure with space group P21/c has been confirmed from XRD (JCPDS 89-9066). The Zr-O stretching vibration and Zr-O2-Zr bending vibrations were confirmed through FTIR analysis. The well dispersed particles with spherical morphology were confirmed through SEM and TEM analysis. The oxidation states of Zr, O and C were confirmed through XPS analysis. The oxygen vacancies and band gap of the particles were investigated through PL analysis.

C-type natriuretic peptide signalling drives homeostatic effects in human chondrocytes

Signals induced by mechanical loading and C-type natriuretic peptide (CNP) represent chondroprotective routes that may potentially prevent osteoarthritis (OA). We examined whether CNP will reduce hyaluronan production and export via members of the multidrug resistance protein (MRP) and diminish pro-inflammatory effects in human chondrocytes. The presence of interleukin-1β (IL-1β) increased HA production and export via MRP5 that was reduced with CNP and/or loading. Treatment with IL-1β conditioned medium increased production of catabolic mediators and the response was reduced with the hyaluronan inhibitor, Pep-1. The induction of pro-inflammatory cytokines by the conditioned medium was reduced by CNP and/or Pep-1, αCD44 or αTLR4 in a cytokine-dependent manner, suggesting that the CNP pathway is protective and should be exploited further.

Antibacterial activity of various leaf extracts of Merremia emarginata

OBJECTIVE

To investigate the antibacterial activity and phytochemical screening of the aqueous, methanol and petroleum ether leaf extracts of Merremia emarginata (M. emarginata).

METHODS

The antibacterial activity of leaf extracts of M. emarginata were evaluated by agar well diffusion method against four selected bacterial species.

RESULTS

The presence of tannins, flavonoids, amino acids, starch, glycosides and carbohydrates in the different leaf extracts was established. The methanol extract was more effective against Bacillus cereus and Escherichia coli, whereas aqueous extract was more effective against Staphylococcus aureus and Pseudomonas aeruginosa.

CONCLUSIONS

: The results in the present study suggest that M. emarginata leaf can be used in treating diseases caused by the tested organisms.

Reverse Ponseti-type treatment for children with congenital vertical talus: comparison between idiopathic and teratological patients

Children with congenital vertical talus (CVT) have been treated with extensive soft-tissue releases, with a high rate of complications. Recently, reverse Ponseti-type casting followed by percutaneous reduction and fixation has been described, with excellent results in separate cohorts of children with CVT, of either idiopathic or teratological aetiology. There are currently no studies that compare the outcome in these two types. We present a prospective cohort of 13 children (21 feet) with CVT of both idiopathic and teratological aetiology, in which this technique has been used. Clinical, radiological and parent-reported outcomes were obtained at a mean follow-up of 36 months (8 to 57). Six children (nine feet) had associated neuromuscular conditions or syndromes; the condition was idiopathic in seven children (12 feet). Initial correction was achieved in all children, with significant improvement in all radiological parameters. Recurrence was seen in ten feet. Modification of the technique to include limited capsulotomy at the initial operation may reduce the risk of recurrence. The reverse Ponseti-type technique is effective in the initial correction of CVT of both idiopathic and teratological aetiology. Recurrence is a problem in both these groups, with higher rates than first reported in the original paper. However, these rates are less than those reported after open surgical release.

Strategic approach to breakdown maintenance on construction plant – UAE perspective

Purpose

– The purpose of this paper is to develop a systematic strategic approach to handle corrective maintenance onto the failures/breakdowns of construction equipment. For the maintenance crew/team, a breakdown code management is proposed, which will provide focused and unambiguous approach to manage any kind of breakdowns in construction equipments.

Design/methodology/approach

– The past breakdown records of a construction organization in the UAE are considered for analysis. From the failure data, through cause effect analysis (CEA) tools, the components and the breakdown codes namely breakdown main codes (BMC) and breakdown sub-codes (BSC) are formulated. With Pareto analysis, the critical codes are identified and validated through failure modes and effects analyses (FMEA) tools for the critical effect on the affected components. From this identified BSC's further closer failure identification codes namely breakdown symptom codes (BSyC) and breakdown reason codes (BRC) are identified through fault tree analysis (FTA) tools. The approach to modified breakdown maintenance management (MB2M) with breakdown maintenance protocol (BMP) is envisaged.

Findings

– The study was conducted on four different types of heavy lifting/earth moving/material handling system of equipment and further focused with two earth moving equipment namely dumpers and wheel loaders. Failure analysis is performed and the failure ratio and the component contribution to the failures are identified. Based on the information, the preliminary codes namely BMC and BSC are identified through CEA tools and the BMC and BSC are identified to find the most contributing codes to the maximum number of failures through Pareto analysis. Further the critical sub-codes are further verified through FMEA tools on the severity levels of the sub components due to these codes. The FTA methods are used to identify the closer reasoning and relations of these codes and the further codes namely BSyC and BRC are identified which are the exact cause of the failures. The management of breakdowns is further proposed through MB2M which includes BMP which provides all resources for the breakdowns.

Research limitations/implications

– The failure data collected are only pertaining to the Middle East region and applicable to similar regions for similar plant mix in construction companies. The sample equipment is only part representative of the construction equipment. A more robust model can be suggested in the future covering all aspects and for other regions as well.

Practical implications

– The proposed methodology and model approach is highly adaptable to similar industries operating in the Middle East countries.

Originality/value

– Many authors have studied the preventive maintenance models and procedures and proposals have been proposed. On the breakdown maintenance management of construction equipment, very few studies have been proposed mostly on the cost analysis. This model attempts to provide a code management solution to manage the unpredictable failures in construction equipment through failure data analysis on a construction organization.

Management of developmental dysplasia of the hip in young adults

The term developmental dysplasia of the hip (DDH) describes a spectrum of disorders that results in abnormal development of the hip joint. If not treated successfully in childhood, these patients may go on to develop hip symptoms and/or secondary osteoarthritis in adulthood. In this review we describe the altered anatomy encountered in adults with DDH along with the management options, and the challenges associated with hip arthroscopy, osteotomies and arthroplasty for the treatment of DDH in young adults.

Cite this article: Bone Joint J 2013;95-B:732–7.

Surgical treatment of femoroacetabular impingement in patients with slipped capital femoral epiphysis: A review of current surgical techniques

Slipped capital femoral epiphysis (SCFE) is relatively common in adolescents and results in a complex deformity of the hip that can lead to femoroacetabular impingement (FAI). FAI may be symptomatic and lead to the premature development of osteoarthritis (OA) of the hip. Current techniques for managing the deformity include arthroscopic femoral neck osteochondroplasty, an arthroscopically assisted limited anterior approach to the hip, surgical dislocation, and proximal femoral osteotomy. Although not a routine procedure to treat FAI secondary to SCFE deformity, peri-acetabular osteotomy has been successfully used to treat FAI caused by acetabular over-coverage. These procedures should be considered for patients with symptoms due to a deformity of the hip secondary to SCFE.

Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature

A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations. Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.

The World Health Organization '5 moments of hand hygiene': the scientific foundation

The World Health Organization (WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the '5 moments of hand hygiene' in 2009 in an attempt to reduce the burden of health care associated infections. Many NHS trusts in England adopted this model of hand hygiene, which prompts health care workers to clean their hands at five distinct stages of caring for the patient. Our review analyses the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. We found no strong scientific support for this regime of hand hygiene as a means of reducing health care associated infections. Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively. We recommend caution in the universal adoption of the WHO '5 moments of hand hygiene' by orthopaedic surgeons and other health care workers and emphasise the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.

Arthroscopy of the hip for paediatric and adolescent disorders

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’ disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes.

This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions.

Management of congenital talipes equinovarus using the Ponseti method: a systematic review

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.

Elastic intramedullary nailing of paediatric fractures of the forearm

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

Orthopaedic aspects of paediatric non-accidental injury

Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures.

Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death.

Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.

The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved.

The management of septic arthritis in children

We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children.

Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.

Delaying treatment of supracondylar fractures in children

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure.

This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.

Patient expectations for hallux valgus surgery

PURPOSE

To determine preoperative patient expectations and their relative importance for hallux valgus surgery using a patient-derived questionnaire, and whether such expectations are influenced by age, gender, or occupation.

METHODS

Two patient-derived questionnaires were developed using open-ended interviews. The 19 most commonly stated expectations were included in the Patient Expectation Questionnaire: 2 related to improvement in appearance, 2 to pain reduction, and 15 to functional improvements in performing daily and recreational activities. The top 9 expectations were included in the Patient Priority Questionnaire for prioritising.

RESULTS

153 eligible patients aged 16 to 79 (mean, 47) years completed the questionnaires; 29 (19%) aged less than 40 years, 84 (55%) aged 40 to 60 years, and 40 (26%) aged more than 60 years. 86% were women and 81% were Caucasian. 62% were housewives or retired pensioners. Overall, the most important expectation was improved walking, followed by reduced pain over the bunion and wearing daily shoes. These expectations varied according to age and gender but not occupation.

CONCLUSION

Patient expectations differ from those of surgeons, and vary according to patient age and gender. Understanding preoperative patient expectations is crucial to achieve better clinical outcomes and satisfaction by selecting the most appropriate operation for each patient.

The deformity index as a predictor of final radiological outcome in Perthes’ disease

The deformity index is a new radiological measurement of the degree of deformity of the femoral head in unilateral Perthes’ disease. Its values represent a continuous outcome measure of deformity incorporating changes in femoral epiphyseal height and width compared with the unaffected side. The sphericity of the femoral head in 30 radiographs (ten normal and 20 from patients with Perthes’ disease) were rated blindly as normal, mild, moderate or severe by three observers. Further blinded measurements of the deformity index were made on two further occasions with intervals of one month.

There was good agreement between the deformity index score and the subjective grading of deformity. Intra- and interobserver agreement for the deformity index was high. The intraobserver intraclass correlation coefficient for each observer was 0.98, 0.99 and 0.97, respectively, while the interobserver intraclass correlation coefficient was 0.98 for the first and 0.97 for the second set of calculations.

We also reviewed retrospectively 96 radiographs of children with Perthes’ disease, who were part of a multicentre trial which followed them to skeletal maturity. We found that the deformity index at two years correlated well with the Stulberg grading at skeletal maturity. A deformity index value above 0.3 was associated with the development of an aspherical femoral head. Using a deformity index value of 0.3 to divide groups for risk gives a sensitivity of 80% and specificity of 81% for predicting a Stulberg grade of III or IV.

We conclude that the deformity index at two years is a valid and reliable radiological outcome measure in unilateral Perthes’ disease.

The anabolic and catabolic responses in bone repair

The literature on fracture repair has been reviewed. The traditional concepts of delayed and nonunion have been examined in terms of the phased and balanced anabolic and catabolic responses in bone repair. The role of medical manipulation of these inter-related responses in the fracture healing have been considered.

Adsorptive removal of tannin from aqueous solutions by cationic surfactant-modified bentonite clay

The removal of tannin from aqueous media by cationic surfactant-modified bentonite clay was studied in a batch system. The surfactant used was hexadecyltrimethylammonium chloride. Adsorbent characterizations were investigated using X-ray diffraction, infrared spectroscopy, surface area analysis, and potentiometric titration. The effects of pH, contact time, initial solute concentration, adsorbent dose, ionic strength, and temperature on the adsorption of tannin onto modified clay were investigated. The adsorbent exhibited higher tannin removal efficiency (>99.0%) from an initial concentration of 10.0 micromol/L at pH 3.0. Adsorption capacity decreased from 90.1 to 51.8% with an increase in temperature from 10 to 40 degrees C at an initial concentration of 25.0 micromol/L. The adsorption process was found to follow pseudo-first-order kinetics. Film diffusion was found to be the rate-limiting step. Tannin adsorption was found to decrease with increase in ionic strength. The tannin equilibrium adsorption data were fitted to Langmuir and Freundlich isotherm models, the former being found to provide the best fit of the experimental data. The maximum monolayer adsorption capacity for tannin was 69.80 micromol/g at 30 degrees C. Comparison of adsorption capacity of the modified clay with reported adsorbents in the literature was also presented. Adsorbed tannin on modified clay can be recovered by treatment with 0.1 M NaOH solution. Regeneration experiments were tried for four cycles and results indicate a capacity loss of <10.0%. From the results it can be concluded that the surfactant-modified clay could be a good adsorbent for treating tannin-contaminated waters.

Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children: the experience of a specialist referral centre

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.

Management of suspected scaphoid fractures in accident and emergency departments--time for new guidelines

INTRODUCTION

The objectives of this work were to assess the clinical knowledge of clinicians in the accident and emergency (A&E) departments in England & Wales and evaluate the current trend for the acute management of radiologically normal, but clinically suspected, fractures of the scaphoid.

SUBJECTS AND METHODS

We conducted a telephone survey on 146 A&E senior house officers (SHOs) in 50 different hospitals. This survey assessed the clinicians' experience, their clinical and radiological diagnostic methods, and their initial treatment of suspected scaphoid fractures.

RESULTS

The majority (55.8%) of SHOs performed only one clinical test to diagnose suspected scaphoid fractures. Overall, 41% were unable to cite the number of the radiographic views taken and only 10% of departments have direct access to further radiological investigation. There is wide variation in the early treatment of this injury, with the scaphoid cast used most commonly (46%). The majority of SHOs (89%) were unable to describe the features of immobilisation. The mean follow-up period was 10 days, and 53% of cases were followed-up by the senior staff in A&E. Of SHOs, 54% were not aware of any local guidelines for the management of suspected scaphoid fractures in their departments, and 92% were not aware of the existence of the 1992 British Association for Accident and Emergency Medicine (BAEM) guidelines.

CONCLUSIONS

The clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory. We, therefore, suggest that the dissemination of up-to-date guidelines could help to educate clinicians to provide better care to the patients.

Impacted knife injury of the orbit, maxilla and oropharynx

Injuries in the maxillofacial region with knife in situ are not common. We report a rare case with knife impacted in the orbit, maxilla and soft palate. Removal was possible only by surgical intervention. Despite the deep penetration, the knife had not injured major structures and hence there was no untoward complication in the outcome.

Rotational osteotomies for congenital radioulnar synostosis

In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna.

There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68° (40° to 80°) to a pre-planned position of 10° of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.