Golfers are physically more active and have greater health associated quality of life than non-golfers following lower limb arthroplasty

Background

The health benefits of physical activity are well recognised. This study assessed whether golfers were more physically active after lower limb arthroplasty when compared to those that did not play golf (primary outcome). In addition pre and postoperative changes in health-associated quality of life (HAQoL) and joint specific outcomes between golfers and none golfers were assessed (secondary outcomes).

Methods

There were 304 patients [THA (n = 155) or TKA (n = 149)] prospectively registered during a 4-month period undergoing lower limb arthroplasty. The mean age was 70.0 (range 37-92, standard deviation 10.2) years and included 188 (61%) females and 120 (39%) males. They completed pre and postoperative questionnaires assessing recreational activity, physical activity, HAQoL (EuroQol [EQ]), joint specific health (Oxford scores), and satisfaction.

Results

Golfers (n = 33, 10.9%) were more likely to achieve longer than 3 hours of moderate activity during a week (48.5% vs 38.0%, odds ratio (OR) 3.4, p = 0.045) and achieved their recommended activity level (96.8% vs 77.7%, OR 8.6, p = 0.015) compared to non-golfers following arthroplasty. Postoperative EQ5D (p = 0.034) and EQVAS (p = 0.019) were significantly greater in golfers. The joint specific Oxford hip score was greater in golfers compared to non-golfers (mean difference 5.6, p = 0.022), however no difference was observed in the Oxford knee score following TKA (p = 0.495).

Conclusion

Golfers were more likely to achieve their weekly recommended level of physical activity and had a greater HAQoL relative to those that did not play golf following lower limb arthroplasty. More specifically after THA golfers also had a greater postoperative joint specific outcome, but no such advantage was observed in those following TKA.

Evidence Level

Level II, diagnostic study.

Cost-utility analysis of total knee arthroplasty using 10-year data from a randomised controlled trial: Implant design influences quality-adjusted life year gain

BACKGROUND

The aim of this study was to perform a cost-utility analysis for total knee arthroplasty (TKA) over a 10-year follow up period.

METHODS

Two-hundred and twelve patients were randomised to receive either a Kinemax or a Triathlon TKA. Patients were assessed pre-operatively, and at 6 months, and 1, 3, 7 and 10 years postoperatively. The costs of the primary and revision surgery were accounted for. One-year quality-adjusted life year (QALY) gain was used to estimate 10-year gains using the established annual health gain discounts.

RESULTS

Forty-eight patients died and eight were revised during the follow up period. Overall QALY gain per patient over the 10-year period was 2.594 and the cost per patient was £6559, which resulted in a cost per QALY of £2761 at 10 years. The Triathlon group had a significantly greater QALY gain compared with the Kinemax (mean difference (MD) 0.53, 95% CI 0.03-1.03, P = 0.02), which resulted in a cost per QALY for the Triathlon group of £2521 compared with £3107 for the Kinemax group at 10 years. The 5% annual discount resulted in a significantly lower QALY gain (MD 0.135, 95% CI 0.201-0.354, P = 0.002), whereas the 3.5% annual discount resulted in non-significant difference in QALY gain compared with the actual gain (MD 0.021, 95% CI -0.084 to 0.077, P = 0.292).

CONCLUSIONS

TKA was a cost-effective intervention, and the Triathlon was associated with a greater cost effectiveness at 10 years. The 3.5% annual discounts for QALY gain would seem to be the most accurate, with an underestimation being observed with the 5% discount.

Preoperative morbidity and joint awareness while awaiting hip arthroscopy for femoroacetabular impingement

Purpose

The Forgotten Joint Score (FJS-12) is a valid tool in the evaluation of patients undergoing hip arthroscopy, assessing the unique concept of joint awareness in the setting of a patient’s hip pathology. The preoperative burden on patients’ mental wellbeing of impaired joint function or symptoms is well established. The purpose of this study was to determine patients’ awareness of their hip joint whilst awaiting hip arthroscopy for femoroacetabular impingement, to explore any association between joint awareness and mental health status, and to determine whether this relates to time spent waiting for arthroscopy preoperatively.

Methods

A prospective database of patients undergoing hip arthroscopy between January 2018 and November 2020 was analysed. All patients with a diagnosis of femoroacetabular impingement (FAI) undergoing arthroscopic treatment were included. Questionnaires included the FJS-12, twelve item international hip outcome tool (iHOT-12), EuroQol 5D-5L (EQ-5D-5L) and the Tegner activity score. Pearson’s correlation coefficient was used to assess relationships between continuous variables.

Results

Preoperative functional outcomes were completed by 81 patients (97.5%) prior to undergoing hip arthroscopy. Median preoperative FJS-12 score was 16.67 (IQR 8.33 – 29.68). Forty-four patients reported any level of anxiety/depression preoperatively (54.3%). Preoperative FJS-12 showed a significant negative correlation with worsening mental health status (r = − 0.359, p <  0.001), and a significant positive correlation with EQ-5D-5L (r = 0.445, p <  0.001). The duration of symptoms or time on the waiting list did not correlate with increased joint awareness or worsened mental health.

Conclusion

Joint awareness is high when awaiting hip arthroscopy for FAI. Increasing levels of joint awareness correlate with poorer mental health status and poorer quality of life measures, however these parameters do not seem to be associated with increased duration of symptoms prior to surgery or time on the waiting list for surgery.

The forgotten joint score-12 is a valid and responsive outcome tool for measuring success following hip arthroscopy for femoroacetabular impingement syndrome

PURPOSE

The forgotten joint score-12 (FJS-12) is an outcome questionnaire designed to evaluate joint awareness. The responsiveness and validity of the English language version of the FJS-12 in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) is not known.

METHODS

Consecutive patients undergoing hip arthroscopy for a diagnosis of FAI were prospectively followed up over a 1 year period. Patients completed preoperative and postoperative FJS-12, EuroQol 5 Dimension (EQ-5D-5L), and the 12-item international hip outcome tool (iHOT-12). We evaluated construct validity with Spearman correlation coefficients for the FJS-12, and responsiveness by way of effect size and ceiling effects.

RESULTS

Forty-six patients underwent hip arthroscopy, of which 42 (91%) completed post-operative PROMs at 1 year follow-up. Construct validity was strong with the iHOT-12 (r = 0.87) and also the EQ-5D-5L (r = 0.83). The median postoperative FJS score was 50.2 (IQR 64). The mean change in score for the FJS-12 was 31 points (SD 31) (p < 0.001), with an effect size (Cohen's d) of 1.16. Preoperatively, three patients scored the lowest possible value resulting in a floor effect of 7.1%. Similarly, only three patients (7.1%) scored the best possible score post-operatively.

CONCLUSION

This is the first evaluation of the joint awareness concept in the English language version of the FJS-12 following hip arthroscopy for FAI. The FJS-12 is a valid and responsive tool for the assessment of this cohort of patients.

LEVEL OF EVIDENCE

II.

Fracture of a BIOLOX Delta Ceramic Femoral Head: A Case Report and Update of the Literature

CASE

A 52-year-old man underwent right total hip replacement with a 32-mm BIOLOX delta ceramic head with a polyethylene liner. At 8 months, he fell onto his right hip. Radiographs at the time were unremarkable. One month later, he noticed a sharp pain and a sensation of grinding in his right hip; radiographs of the hip showed a fracture of the ceramic head.

CONCLUSIONS

This case further demonstrates that fourth-generation ceramic heads can fracture, and delays in catastrophic failure of ceramics in total hip arthroplasty (THA) following trauma may be secondary to the "slow crack growth" hypothesis.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies

AIMS

The aims of the study were to review and analyse the reported series of debridement, antibiotics and implant retention (DAIR) in the management of infected total hip arthroplasties (THAs) to establish the overall success and the influencing factors.

PATIENTS AND METHODS

Using a standardised recognised study protocol, meta-analysis of observational studies in epidemiology guidelines, a comprehensive review and analysis of the literature was performed. The primary outcome measure was the success of treatment. The search strategy and inclusion criteria which involved an assessment of quality yielded 39 articles for analysis, which included 1296 patients.

RESULTS

The proportion of success following DAIR in the management of an infected THA appeared to improve after 2004 with a pooled mean proportion of success of 72.2%. For all reported series, from 1977 onwards, there was improved success with early debridement (< 7 days; 75.7%) and exchange of modular components (77.5%). There was a statistically non-significant improvement if debridement was performed within four weeks of the initial procedure (73.0%).

CONCLUSION

The reported success following DAIR has improved since 2004. The only determinants of outcome which we found were the timing of debridement after the onset of symptoms of infection and the exchange of modular components. Cite this article: Bone Joint J 2017;99-B:1488-66.

Randomized Trial of Buffered Versus Plain Lidocaine for Local Anaesthesia in open Carpal Tunnel Decompression

We performed a randomized double-blind case–control study in 64 consecutive patients undergoing open carpal tunnel decompression under local anaesthetic to assess the pain experienced on injection of plain lidocaine (pH 6.4) compared with lidocaine buffered with sodium bicarbonate (pH 7.4). The results showed no statistical difference in the pain scores reported by patients. The mean pain scores for all patients were low, and most patients reported that they were “not at all anxious” about receiving a similar injection in the future.

Implant design influences patient outcome after total knee arthroplasty: a prospective double-blind randomised controlled trial

Total knee arthroplasty (TKA) is an established and successful procedure. However, the design of prostheses continues to be modified in an attempt to optimise the functional outcome of the patient. The aim of this study was to determine if patient outcome after TKA was influenced by the design of the prosthesis used. A total of 212 patients (mean age 69; 43 to 92; 131 female (62%), 81 male (32%)) were enrolled in a single centre double-blind trial and randomised to receive either a Kinemax (group 1) or a Triathlon (group 2) TKA. Patients were assessed pre-operatively, at six weeks, six months, one year and three years after surgery. The outcome assessments used were the Oxford Knee Score; range of movement; pain numerical rating scales; lower limb power output; timed functional assessment battery and a satisfaction survey. Data were assessed incorporating change over all assessment time points, using repeated measures analysis of variance longitudinal mixed models. Implant group 2 showed a significantly greater range of movement (p = 0.009), greater lower limb power output (p = 0.026) and reduced report of 'worst daily pain' (p = 0.003) over the three years of follow-up. Differences in Oxford Knee Score (p = 0.09), report of 'average daily pain' (p = 0.57) and timed functional performance tasks (p = 0.23) did not reach statistical significance. Satisfaction with outcome was significantly better in group 2 (p = 0.001). These results suggest that patient outcome after TKA can be influenced by the prosthesis used.

Assessing treatment outcomes using a single question: the net promoter score

Satisfaction with care is important to both patients and to those who pay for it. The Net Promoter Score (NPS), widely used in the service industries, has been introduced into the NHS as the 'friends and family test'; an overarching measure of patient satisfaction. It assesses the likelihood of the patient recommending the healthcare received to another, and is seen as a discriminator of healthcare performance. We prospectively assessed 6186 individuals undergoing primary lower limb joint replacement at a single university hospital to determine the Net Promoter Score for joint replacements and to evaluate which factors contributed to the response. Achieving pain relief (odds ratio (OR) 2.13, confidence interval (CI) 1.83 to 2.49), the meeting of pre-operative expectation (OR 2.57, CI 2.24 to 2.97), and the hospital experience (OR 2.33, CI 2.03 to 2.68) are the domains that explain whether a patient would recommend joint replacement services. These three factors, combined with the type of surgery undertaken (OR 2.31, CI 1.68 to 3.17), drove a predictive model that was able to explain 95% of the variation in the patient's recommendation response. Though intuitively similar, this 'recommendation' metric was found to be materially different to satisfaction responses. The difference between THR (NPS 71) and TKR (NPS 49) suggests that no overarching score for a department should be used without an adjustment for case mix. However, the Net Promoter Score does measure a further important dimension to our existing metrics: the patient experience of healthcare delivery.

Adverse peri-operative outcomes following elective total hip replacement in diabetes mellitus: a systematic review and meta-analysis of cohort studies

Total hip replacement (THR) has been shown to be a cost-effective procedure. However, it is not risk-free. Certain conditions, such as diabetes mellitus, are thought to increase the risk of complications. In this study we have evaluated the prevalence of diabetes mellitus in patients undergoing THR and the associated risk of adverse operative outcomes. A meta-analysis and systematic review were conducted according to the guidelines of the meta-analysis of observational studies in epidemiology. Inclusion criteria were observational studies reporting the prevalence of diabetes in the study population, accompanied by reports of at least one of the following outcomes: venous thromboembolic events; acute coronary events; infections of the urinary tract, lower respiratory tract or surgical site; or requirement for revision arthroplasty. Altman and Bland's methods were used to calculate differences in relative risks. The prevalence of diabetes mellitus was found to be 5.0% among patients undergoing THR, and was associated with an increased risk of established surgical site infection (odds ratio (OR) 2.04 (95% confidence interval (CI) 1.52 to 2.76)), urinary infection (OR 1.43 (95% CI 1.33 to 1.55)) and lower respiratory tract infections (OR 1.95 (95% CI 1.61 to 2.26)). Diabetes mellitus is a relatively common comorbidity encountered in THR. Diabetic patients have a higher rate of developing both surgical site and non-surgical site infections following THR.

Muscle 'regenerative potential' determinesphysical recovery following total knee replacement

Objectives

Lower limb muscle power is thought to influence outcome following total knee replacement (TKR). Post-operative deficits in muscle strength are commonly reported, although not explained. We hypothesised that post-operative recovery of lower limb muscle power would be influenced by the number of satellite cells in the quadriceps muscle at time of surgery.

Methods

Biopsies were obtained from 29 patients undergoing TKR. Power output was assessed pre-operatively and at six and 26 weeks post-operatively with a Leg Extensor Power Rig and data were scaled for body weight. Satellite cell content was assessed in two separate analyses, the first cohort (n = 18) using immunohistochemistry and the second (n = 11) by a new quantitative polymerase chain reaction (q-PCR) protocol for Pax-7 (generic satellite cell marker) and Neural Cell Adhesion Molecule (NCAM; marker of activated cells).

Results

A significant improvement in power output was observed post-operatively with a mean improvement of 19.7 W (95% confidence interval (CI) 14.43 to 30.07; p < 0.001) in the first cohort and 27.5 W (95% CI 13.2 to 41.9; p = 0.002) in the second. A strong correlation was noted between satellite cell number (immunohistochemistry) and improvement in patient power output (r = 0.64, p = 0.008). Strong correlation was also observed between the expression of Pax-7 and power output (r = 0.79, p = 0.004), and the expression of NCAM and power output (r = 0.84, p = 0.001). The generic marker explained 58% of the variation in power output, and the marker of activated cells 67%.

Conclusions

Muscle satellite cell content may determine improvement in lower limb power generation (and thus function) following TKR.

Is patient reporting of physical function accurate following total knee replacement?

The aim of this study was to determine the association between the Oxford knee score (OKS) and direct assessment of outcome, and to examine how this relationship varied at different time-points following total knee replacement (TKR). Prospective data consisting of the OKS, numerical rating scales for 'worst pain' and 'perceived mean daily pain', timed functional assessments (chair rising, stairs and walking ability), goniometry and lower limb power were recorded for 183 patients pre-operatively and at six, 26 and 52 weeks post-operatively. The OKS was influenced primarily by the patient's level of pain rather than objective functional assessments. The relationship between report of outcome and direct assessment changed over time: R2 = 35% pre-operatively, 44% at six weeks, 57% at 26 weeks and 62% at 52 weeks. The relationship between assessment of performance and report of performance improved as the patient's report of pain diminished, suggesting that patients' reporting of functional outcome after TKR is influenced more by their pain level than their ability to accomplish tasks.

Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis

The aim of this study was to perform a cost-utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health-utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement

OBJECTIVES

To investigate the factors which influence patient satisfaction with surgical services and to explore the relationship between overall satisfaction, satisfaction with specific facets of outcome and measured clinical outcomes (patient reported outcome measures (PROMs)).

DESIGN

Prospective cohort study.

SETTING

Single National Health Service (NHS) teaching hospital.

PARTICIPANTS

4709 individuals undergoing primary lower limb joint replacement over a 4-year period (January 2006-December 2010).

MAIN OUTCOME MEASURES

Overall patient satisfaction, clinical outcomes as measured by PROMs (Oxford Hip or Knee Score, SF-12), satisfaction with five specific aspects of surgical outcome, attitudes towards further surgery, length of hospital stay.

RESULTS

Overall patient satisfaction was predicted by: (1) meeting preoperative expectations (OR 2.62 (95% CI 2.24 to 3.07)), (2) satisfaction with pain relief (2.40 (2.00 to 2.87)), (3) satisfaction with the hospital experience (1.7 (1.45 to 1.91)), (4) 12 months (1.08 (1.05 to 1.10)) and (5) preoperative (0.95 (0.93 to 0.97)) Oxford scores. These five factors contributed to a model able to correctly predict 97% of the variation in overall patient satisfaction response. The factors having greatest effect were the degree to which patient expectations were met and satisfaction with pain relief; the Oxford scores carried little weight in the algorithm. Various factors previously reported to influence clinical outcomes such as age, gender, comorbidities and length of postoperative hospital stay did not help explain variation in overall patient satisfaction.

CONCLUSIONS

Three factors broadly determine the patient's overall satisfaction following lower limb joint arthroplasty; meeting preoperative expectations, achieving satisfactory pain relief, and a satisfactory hospital experience. Pain relief and expectations are managed by clinical teams; however, a fractured access to surgical services impacts on the patient's hospital experience which may reduce overall satisfaction. In the absence of complications, how we deliver healthcare may be of key importance along with the specifics of what we deliver, which has clear implications for units providing surgical services.

A prospective randomised double-blind study of functional outcome and range of flexion following total knee replacement with the NexGen standard and high flexion components

Modifications in the design of knee replacements have been proposed in order to maximise flexion. We performed a prospective double-blind randomised controlled trial to compare the functional outcome, including maximum knee flexion, in patients receiving either a standard or a high flexion version of the NexGen legacy posterior stabilised total knee replacement. A total of 56 patients, half of whom received each design, were assessed pre-operatively and at one year after operation using knee scores and analysis of range of movement using electrogoniometry. For both implant designs there was a significant improvement in the function component of the knee scores (p < 0.001) and the maximum range of flexion when walking on the level, ascending and descending a slope or stairs (all p < 0.001), squatting (p = 0.020) and stepping into a bath (p = 0.024). There was no significant difference in outcome, including the maximum knee flexion, between patients receiving the standard and high flexion designs of this implant.

Cyclic pneumatic soft-tissue compression accelerates the union of distal radial osteotomies in an ovine model

The aim of this randomised, controlled in vivo study in an ovine model was to investigate the effect of cyclic pneumatic pressure on fracture healing. We performed a transverse osteotomy of the right radius in 37 sheep. They were randomised to a control group or a treatment group where they received cyclic loading of the osteotomy by the application of a pressure cuff around the muscles of the proximal forelimb. Sheep from both groups were killed at four or six weeks. Radiography, ultrasonography, biomechanical testing and histomorphometry were used to assess the differences between the groups. The area of periosteal callus, peak torsional strength, fracture stiffness, energy absorbed over the first 10 degrees of torsion and histomorphometric analysis all showed that the osteotomies treated with the cyclic pneumatic pressure at four weeks were not significantly different from the control osteotomies at six weeks.

Recovery of knee function following fracture of the tibial plateau

We assessed the functional outcome following fracture of the tibial plateau in 63 consecutive patients. Fifty-one patients were treated by internal fixation, five by combined internal and external fixation and seven non-operatively. Measurements of joint movement and muscle function were made using a muscle dynamometer at three, six and 12 months following injury. Thirteen patients (21%) had a residual flexion contracture at one year. Only nine (14%) patients achieved normal quadriceps muscle strength at 12 months, while 19 (30%) achieved normal hamstring muscle strength. Recovery was significantly slower in patients older than 40 years of age. We conclude that there is significant impairment of movement and muscle function after fracture of the tibial plateau and that the majority of patients have not fully recovered one year after injury.

Survival analysis is a better estimate of recurrent disc herniation

Studies on recurrent disc herniation quote rates of recurrence without regard to the times of recurrence and the influence of longer follow-up. Our objective was to assess the use of survival analysis to measure the rate of revision after lumbar microdiscectomy. We undertook a retrospective analysis of the hospital records of 993 patients who underwent lumbar microdiscectomy over a period of ten years. After calculating the overall rate of revision for the mean length of follow-up, we carried out a survival analysis using the life-table method. During the study period 49 patients had a revision microdiscectomy. This gave an overall rate of revision of 4.9% at a mean follow-up of 5.25 years. Using survival analysis, the rate of revision was 7.9% at a follow-up of ten years when the number at risk was 84. Survival analysis gives a more accurate estimation of the true rate of recurrence for patients undergoing lumbar microdiscectomy. The method allows better comparison between different interventions for disc herniation.

Long-term sequelae of fasciotomy wounds

A retrospective study of patients admitted to an Orthopaedic Trauma Unit over an 8-year period requiring fasciotomies, of either upper or lower limb, to reduce the risk of compartment syndrome was performed. Sixty patients were studied, of which 49 had an underlying fracture. The long-term morbidity of the wounds was studied. Ongoing symptoms such as pain related to the wound occurred in six patients (10%) and altered sensation within the margins of the wound occurred in 46 patients (77%). Examination revealed 24 patients (40%) with dry scaly skin, 20 patients (33%) with pruritus, 18 patients (30%) with discoloured wounds, 15 patients (25%) with swollen limbs, 16 patients (26%) with tethered scars, eight patients (13%) with recurrent ulceration, eight patients (13%) with muscle herniation and four patients (7%) with tethered tendons. The appearance of the scars affected patients such that 14 (23%) kept the wound covered, 17 (28%) changed hobbies and seven (12%) changed occupation. This study reveals a significant morbidity associated with fasciotomy wounds. In light of these findings, further consideration should be given to techniques that reduce both the symptoms and examination findings mentioned above and the aesthetic insult to the affected limb.

Acute compartment syndrome. Who is at risk?

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.

Analysis of muscle function in the lower limb after fracture of the diaphysis of the tibia in adults

We examined the recovery of power in the muscles of the lower limb after fracture of the tibial diaphysis, using a Biodex dynamometer. Recovery in all muscle groups was rapid for 15 to 20 weeks following fracture after which it slowed. Two weeks after fracture the knee flexors and extensors have about 40% of normal power, which rises to 75% to 85% after one year. The dorsiflexors and plantar flexors of the ankle and the invertors and evertors of the subtalar joint are much weaker two weeks after injury, but at one year their mean power is more than that of the knee flexors and extensors.

Our findings showed that age, the mode of injury, fracture morphology, the presence of an open wound and the Tscherne grade of closed fractures correlated with muscle power. It is age, however, which mainly determines muscle recovery after fracture of the tibial diaphysis.

Analysis of muscle function in the lower limb after fracture of the diaphysis of the tibia in adults

We examined the recovery of power in the muscles of the lower limb after fracture of the tibial diaphysis, using a Biodex dynamometer. Recovery in all muscle groups was rapid for 15 to 20 weeks following fracture after which it slowed. Two weeks after fracture the knee flexors and extensors have about 40% of normal power, which rises to 75% to 85% after one year. The dorsiflexors and plantar flexors of the ankle and the invertors and evertors of the subtalar joint are much weaker two weeks after injury, but at one year their mean power is more than that of the knee flexors and extensors. Our findings showed that age, the mode of injury, fracture morphology, the presence of an open wound and the Tscherne grade of closed fractures correlated with muscle power. It is age, however, which mainly determines muscle recovery after fracture of the tibial diaphysis.

Acute compartment syndrome. Who is at risk?

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.

Fractures of the tibia. Can their outcome be predicted?

We have carried out a prospective study to determine whether the basic descriptive criteria and classifications of diaphyseal fractures of the tibia determine prognosis, as is widely believed. A number of systems which are readily available were used, with outcome being determined by standard measurements including fracture union, the need for secondary surgery and the incidence of infection. Many validated functional outcomes were also used. The Tscherne classification of closed fractures proved to be slightly more predictive of outcome than the others, but our findings indicate that such systems have little predictive value.

Fractures of the tibia

We have carried out a prospective study to determine whether the basic descriptive criteria and classifications of diaphyseal fractures of the tibia determine prognosis, as is widely believed. A number of systems which are readily available were used, with outcome being determined by standard measurements including fracture union, the need for secondary surgery and the incidence of infection. Many validated functional outcomes were also used. The Tscherne classification of closed fractures proved to be slightly more predictive of outcome than the others, but our findings indicate that such systems have little predictive value.

Effects of parenteral administration of vitamin E on health of periparturient dairy cows

OBJECTIVE

To determine the effect of administration of vitamin E (D-alpha-tocopherol) on the incidence of retained placenta, metritis, and clinical mastitis during early lactation and on tocopherol concentrations.

DESIGN

Prospective randomized controlled study.

ANIMALS

420 Holstein cows.

PROCEDURE

Vitamin E (3,000 mg, IM, once) was administered to 204 cows B to 14 days before expected parturition, and 216 control cows were not treated. The number of cows that had retained placenta, metritis, clinical mastitis, displaced abomasum, and clinically apparent acetonemia or hypocalcemia were recorded. Serum concentrations of tocopherol, the tocopherol:cholesterol ratio, and glutathione-peroxidase activity were determined from samples obtained before administration of vitamin E, 7 and 14 days after administration, and at 30 days after parturition from 36 treated and 36 control cows.

RESULTS

Administration of vitamin E significantly decreased the incidence of retained placenta and metritis (13/204 [6.4%] and 8/204: [3.9%], respectively, for the vitamin E-treated group; 27/216 [12.5%] and 19/ 216 [8.8%], respectively, for the untreated group) but did not affect the incidence of clinical mastitis. Serum vitamin E concentration was significantly higher in treated than in control cattle at 7 and 14 days after administration, but serum tocopherol: cholesterol ratio was significantly higher only at 7 days after administration.

CLINICAL IMPLICATIONS

Parenteral administration of a single injection of vitamin E before parturition may decrease the incidence of retained placenta and metritis in dairy cows but will increase serum concentrations for 7 to 14 days after administration.

The pulsed tuneable dye laser as an aid in the management of postburn scarring

Permanent erythematous scarring following burns is a common problem which may be disfiguring and distressing for the patient. In this case the pulsed tuneable dye laser (585 nm) was used to treat the areas of scarring and also used prophylactically on an active scar.

Distal penile lymphoedema following hypospadias repair: a case report

A patient who developed isolated distal penile lymphoedema 10 years following hypospadias repair is reported. The classification and causes of genital lymphoedema and possible reasons for its occurrence in this case are discussed.

The psychiatric symptoms of Alzheimer's disease

The authors used a semistructured interview administered to primary family caregivers to assess the prevalence and nature of psychiatric pathology in 175 well-diagnosed community-residing Alzheimer's disease patients. Symptoms that are indicative of depression in the cognitively intact were virtually ubiquitous in this demented population. A variety of psychotic features were also regularly reported. The implications of these findings for the recognition and treatment of reversible psychiatric impairment are discussed.