A financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff

Revision arthroplasty of the hip is expensive owing to the increased cost of pre-operative investigations, surgical implants and instrumentation, protracted hospital stay and drugs. We compared the costs of performing this surgery for aseptic loosening, dislocation, deep infection and peri-prosthetic fracture. Clinical, demographic and economic data were obtained for 305 consecutive revision total hip replacements in 286 patients performed at a tertiary referral centre between 1999 and 2008. The mean total costs for revision surgery in aseptic cases (n = 194) were £11 897 (sd 4629), for septic revision (n = 76) £21 937 (sd 10 965), for peri-prosthetic fracture (n = 24) £18 185 (sd 9124), and for dislocation (n = 11) £10 893 (sd 5476). Surgery for deep infection and peri-prosthetic fracture was associated with longer operating times, increased blood loss and an increase in complications compared to revisions for aseptic loosening. Total inpatient stay was also significantly longer on average (p < 0.001). Financial costs vary significantly by indication, which is not reflected in current National Health Service tariffs.

Efficacy of CPP-ACP and CPP-ACPF on enamel remineralization - an in vitro study using scanning electron microscope and DIAGNOdent

INTRODUCTION

Remineralization as a treatment procedure has received a lot of attention both from clinicians as well researchers. The objective of this in vitro study was to find out the efficacy of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-ACPF) in remineralizing enamel surface on which artificial caries lesion had been created. The changes were analyzed using DIAGNOdent (KaVo) and scanning electron microscope (SEM).

MATERIALS AND METHODS

Ninety maxillary premolars were selected and divided into three groups of 30 teeth each: A (artificial saliva), B (CPP-ACP), and C (CPP-ACPF). All the samples were assessed using DIAGNOdent at the baseline and after demineralization and remineralization. Three samples were randomly selected from each group after remineralization for surface evaluation using SEM.

RESULTS

Statistical analysis showed that group B {CPP-ACP (4.1 ± 1.8)} and group C {CPP-ACPF (4.8 ± 1.2)} had a significantly higher amount of remineralization than group A (1.7 ± 0.7).

CONCLUSION

All the three groups showed a statistically significant amount of remineralization. However, because of the added benefit of fluoride (NaF 0.2%), CPP-ACPF (Tooth Mousse-Plus) showed marginally more amount of remineralization than CPP-ACP (Tooth Mousse).

Osteoblasts in bone tissue engineering

Osteoblasts are integral to the development, growth, function, repair and maintenance of bone. The osteoblast forms organic, non-mineralized bone matrix and is involved in complex interactions with a variety of factors, mediators and cell types. Degeneration, pathology, and trauma cause disruption and destruction of the normal skeletal environment and may lead to bone loss.

There is a rise in active populations involved in trauma, elderly patients with fragility fractures and an overall increase in primary, revision and reconstructive bone and joint surgery. Despite the rapid evolution of implant technologies and bone grafting techniques, there is still a great demand for novel bone replacement strategies.

Bone tissue engineering is the state of the art science with the potential to regenerate bone with natural form and function. This review presents the biology of osteoblasts and their current applications in bone tissue engineering biotechnologies and role in stem cell, bioactive factor, recombinant signalling molecule and gene therapy research.

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.

Tissue-resident macrophages are productively infected ex vivo by primary X4 isolates of human immunodeficiency virus type 1

Infection of macrophages has been implicated as a critical event in the transmission and persistence of human immunodeficiency virus type 1 (HIV-1). Here, we explore whether primary X4 HIV-1 isolates can productively infect tissue macrophages that have terminally differentiated in vivo. Using immunohistochemistry, HIV-1 RNA in situ hybridization, and confocal immunofluorescence microscopy, we demonstrate that macrophages residing in human tonsil blocks can be productively infected ex vivo by primary X4 HIV-1 isolates. This challenges the model in which macrophage tropism is a key determinant of the selective transmission of R5 HIV-1 strains. Infection of tissue macrophages by X4 HIV-1 may be highly relevant in vivo and contribute to key events in HIV-1 pathogenesis.

Coreceptor phenotype of natural human immunodeficiency virus with nef deleted evolves in vivo, leading to increased virulence

The Sydney Blood Bank Cohort is a group of patients with slowly progressive infection by a human immunodeficiency virus strain containing spontaneous deletions within the nef long terminal repeat region. In 1999, 18 years after the initial infection, one of the members (D36) developed AIDS. In this work, we used an ex vivo human lymphoid cell culture system to analyze two viral isolates obtained from this patient, one prior to the onset of AIDS in 1995 and one after disease progression in 1999. Both D36 isolates were less potent in depleting CD4(+) T cells than a reference dualtropic, nef-bearing viral isolate. However, the 1999 isolate was measurably more cytotoxic to CD4(+) T cells than the 1995 isolate. Interestingly, although both isolates were nearly equally potent in depleting CCR5(+) CD4(+) T cells, the cytotoxic effect of the 1999 isolate toward CCR5(-) CD4(+) T cells was significantly higher. Furthermore, GHOST cell infection assays and blocking experiments with the CXCR4 inhibitor AMD3100 showed that the later D36 1999 isolate could infect both CCR5(+) and CCR5(-) CXCR4(+) cells efficiently, while infection by the 1995 isolate was nearly completely restricted to CCR5(+) cells. Sequence analysis of the V1/V2 and V3 regions of the viral envelope protein gp120 revealed that the more efficient CXCR4 usage of the later isolate might be caused by an additional potential N-glycosylation site in the V1/V2 loop. In conclusion, these data show that an in vivo evolution of the tropism of this nef-deleted strain toward an X4 phenotype was associated with a higher cytopathic potential and progression to AIDS.

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.

Characterization of cauliflower mosaic virus (CaMV) resistance in virus-resistant ecotypes of Arabidopsis

Two Arabidopsis ecotypes are resistant to systemic infection by cauliflower mosaic virus (CaMV), a plant para-retrovirus. Arabidopsis ecotype Enkheim-2 (En-2) is highly resistant to CaMV infection while Bla-14 is more weakly resistant. CaMV resistance in En-2 can be largely attributed to the action of a single semidominant gene called cauliflower mosaic virus resistance1 (CAR1), located at a locus on chromosome 1. Resistance in Bla-14 is tightly linked to CAR1 and may be due to a weak allele at the same locus or another gene in a gene cluster. A quantitative polymerase chain reaction assay in conjunction with replication- and movement-incompetent viral mutants was used to determine whether virus replication or movement is affected in the resistant ecotypes. The pattern of accumulation of the wild-type virus in the resistant ecotype, En-2, was similar to that of a movement-incompetent CaMV mutant, suggesting that CAR1 interferes with or fails to support CaMV movement. CaMV-inoculated En-2 plants do not show visible signs of a hypersensitive response. However, indicators of an induced defense response do appear in CaMV-infected En-2 plants, such as the activation of pathogenesis-related protein gene expression and the production of camalexin, an Arabidopsis phytoalexin. Defense responses induced chemically or by mutation in the susceptible ecotypes delayed and reduced the severity of a CaMV infection. These findings suggest that CAR1 acts either in the susceptible ecotype to support virus movement or in the resistant ecotype to signal a defense response.

Factors associated with the magnitude of limitations during recovery from a fracture of the proximal humerus

Aims

The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury.

Patients and Methods

We enrolled 177 adult patients who sustained an isolated proximal humeral fracture into the study and invited them to complete PROMs at their initial outpatient visit within one week of injury, between two and four weeks, and between six to nine months after injury. There were 128 women and 49 men; the mean age was 66 years (sd 16; 18 to 95). In all, 173 patients completed the final assessment. Bivariate analysis was performed followed by multivariable regression analysis accounting for multicollinearity using partial R2, correlation matrices, and variable inflation factor.

Results

Many variables within a week of injury and between two and four weeks after injury correlated with six- to nine-month PROMs in bivariate analysis. Kinesiophobia measured within a week of injury (Tampa Scale for Kinesiophobia-11: partial R2 = 0.14; p = 0.000) and self-efficacy measured between two and four weeks (Pain Self-efficacy Questionnaire-2: partial R2 = 0.266; p < 0.001) were the strongest predictors of limitations (measured by Patient Reported Outcome Measurement Information System Upper Extremity Physical Function Computer Adaptive Test (PROMIS UE)) at six to nine months in multivariable analysis. Similar findings were observed with other types of PROM. Regression models accounted for a substantial amount of variance in all PROMs at both timepoints (e.g. 66% of the overall variance within one week, and 70% within two to four weeks for PROMIS UE at six to nine months).

Conclusion

Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy (developing resilience and more effective coping strategies) within a month. Such factors are modifiable using enhanced communication skills and cognitive behavioural treatments. These findings could be a catalyst for the routine assessment and treatment of psychological and social factors in the management of patients with fractures. Cite this article: Bone Joint J 2019;101-B:715–723.

Evaluation of anti-inflammatory effect of statins in chronic periodontitis

Objectives:

Statins are the group of lipid-lowering drugs commonly used to control cardiovascular and cerebrovascular diseases. Statins have potential anti-inflammatory effect by blocking the intermediate metabolites of the mevalonate pathway. The objective of this study was to evaluate the anti-inflammatory effect of statin medication in chronic periodontitis patients.

Materials and Methods:

Thirty patients of age group between 40 and 60 years were selected from the outpatient pool of Department of Periodontics, Thaimoogambigai Dental College and Hospital, Chennai. Thirty patients selected were grouped into two groups, Group-I consists of patients with generalized chronic periodontitis and on statin medication and Group-II consists of patients with generalized chronic periodontitis. Clinical parameters were recorded and gingival crevicular fluid (GCF) samples were analyzed for interleukin (IL)-1β using commercially available enzyme-linked immunosorbent assay.

Results:

The mean GCF IL-1β levels in generalized chronic periodontitis patients who are on statin medication (Group-I) were lower than the generalized chronic periodontitis patients without statin medication (Group-II).

Conclusion:

Reduction of GCF IL-1β levels in statin users indicate that statins have anti-inflammatory effect on periodontal disease.

The use of computer adaptive tests in outcome assessments following upper limb trauma: a systematic review

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

Materials and Methods

A search of multiple electronic databases was undertaken on 1 January 2017 with terms related to "CATs", "orthopaedics", "trauma", and "anatomical regions". Studies involving adults suffering trauma to the upper limb, and undergoing any intervention, were eligible. Those involving the measurement of outcome with any CATs were included. Identification, screening, and eligibility were undertaken, followed by the extraction of data and quality assessment using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and reg istered (PROSPERO: CRD42016053886).

Results

A total of 31 studies reported trauma conditions alone, or in combination with non-traumatic conditions using CATs. Most were cross-sectional with varying level of evidence, number of patients, type of study, range of conditions and methodological quality. CATs correlated well with fixed scales and had minimal or no floor-ceiling effects. They required significantly fewer questions and/or less time for completion. Patient-Reported Outcomes Measurement Information System (PROMIS) CATs were the most frequently used, and the use of CATs is increasing.

Conclusion

Early studies show valid and reliable outcome measurement with CATs performing as well as, if not better than, established fixed scales. Superior properties such as floor-ceiling effects and ease of use support their use in the assessment of outcome after trauma. As CATs are being increasingly used in patient outcomes research, further psychometric evaluation, especially involving longitudinal studies and groups of patients with specific injuries are required to inform clinical practice using these contemporary measures. Cite this article: Bone Joint J 2018;100-B:693-702.

The usefulness of CT perfusion in differentiation between neoplastic and tuberculous disease of the spine

INTRODUCTION

Routine diagnostic techniques are not sufficient to confidently differentiate diseases of the axial skeleton. Purpose of study was to determine whether CT perfusion (CTP) can differentiate inflammatory diseases like tuberculosis from neoplastic diseases of spine.

METHODS

Fifty-one patients with vertebrdraft%freshal body lesions associated with paraspinal mass underwent CT guided bone biopsy and histopathological evaluation. CTP was done before doing bone biopsy. Perfusion parameters like blood volume (BV), blood flow (BF), and time to peak (TTP) were calculated. Values are correlated with histopathological report of bone biopsy. Statistical analysis was done using Mann-Whitney test. P value < .05 was considered significant.

RESULTS

Of 51, 32 had infective osteomyelitis and 19 neoplastic disease (9 metastasis, 5 plasmacytoma, 4 lymphoma and 1 chordoma. Mean rBF was [inflammatory lesions, 1.79 and neoplastic lesions, 9.42 (P < .000)]. Mean rBV was [inflammatory disease, 1.63 and neoplastic lesions, 9.37 (P < .000)].

CONCLUSION

CTP technique has potential for differentiating inflammatory from neoplastic lesions affecting spine associated with paraspinal mass noninvasively.

A rare case of right ventricular myxoma causing recurrent stroke

We present a 62-year-old lady admitted in our hospital with two episodes of acute ischemic stroke about 2 weeks apart. She was evaluated for acute ischemic stroke and was thrombolysed for recent stroke in right MCA territory first time. On further evaluation, she was found to have a RVOT mass. A transthoracic and transesophageal echocardiogram revealed a PFO and a large, 5.1 cm × 2.3 cm, ovoid, well circumscribed, echogenic mass in the right ventricle outflow tract attached by small pedicle to the ventricular side of anterior tricuspid leaflet, partly obstructing the right ventricular outflow tract and protruding through the pulmonic valve during systole. She was scheduled for surgery (right ventricular mass excision and PFO closure) after 3 weeks due to the risk of secondary hemorrhage in the infarcted area following thrombolysis and anticoagulation and so was discharged with medications after full neurologic recovery after about a week of hospital stay.

She was readmitted 7 days after discharge, before the scheduled date of surgery with history of weakness of right upper limb, slurred speech and mild breathing difficulty lasting for about 20 min following which she improved slowly (transient ischemic attack). The tumor was completely removed with the stalk using cardiopulmonary bypass support. The histopathological findings confirmed the diagnosis of myxoma.

Leukemoid like reaction in a post CABG patient

The presentation of leukemoid reaction in patients post-cardiac surgery is rare with limited prior reports in the English language literature. We report a case of raised leukocyte count with no evidence of infection in a patient post coronary artery bypass graft surgery. The exaggerated inflammatory response by the patient to extra-corporeal circulation was drastically elevated, but fell short of the leukaemoid reaction definition – so we have defined it as a leukaemoid like reaction. A clear correlation between the extra-corporeal circulation and inflammatory response is documented.

Unusual complication of toxic megacolon in typhoid colitis

Colitis is a rare manifestation of enteric fever in children. Toxic megacolon complicating typhoid colitis is even rarer and requires early recognition and aggressive management due to the high mortality associated with this condition. The authors report a rare case of Toxic megacolon secondary to typhoid colitis in a seven-year-old girl.

Gastric outlet obstruction caused by prepyloric web in a case of Down's syndrome

The authors describe an infant with Down's syndrome who had a prepyloric web complicated by severe gastric outlet obstruction. The delay in diagnosis was responsible for malnutrition and the early postoperative complications of hypothermia and hypoglycemia. Awareness of the association of gastrointestinal abnormalities with Down's syndrome will enable appropriate evaluation for early diagnosis of this surgically correctable malformation.

Mass survey of leprosy in Lalitpur district, Nepal

An intense mass survey of leprosy in Lalitpur District, Nepal, was carried for the period 1986 to 1990. This was the first such large scale survey in Nepal; 85% of the total population was examined. The 5-year case detection rate was 13 per 10,000; the 5-year child detection rate was 4 per 10,000. By the end of the survey the prevalence rate was 6.8 per 10,000; at the end of 1992 this had dropped to 2.2 per 10,000. In 1989, after a 3-year interval, a re-survey was done in three village development committees (VDCs) and 4 new cases were detected, bringing the 3-year case detection rate to 3.3 per 10,000; 36% of the old cases, 20% of the new adult cases, and 3% of the new child cases were classified as multibacillary. Overall, 62.7% of the patients had no disability, 18.8% had disability grade 1, and 12.7% had disability grade 2 while for 5.8% the data were incomplete. By the end of the survey 91% of the patients needing medical treatment were on multidrug therapy (MDT). At present this has increased to 100%. The regularity rate was 86%; at the end of 1992 this had increased to 96%. The cost for detecting one new patient was US$298. Because of the high cost, it is recommended that intense mass surveys not be performed when the estimated prevalence rate is less than 10 per 10,000 inhabitants. From the data collected conclusions were drawn and recommendations were formulated for developing new strategies for the National Leprosy Control Programme of the Government of Nepal.