The ROSA robotic-arm system reliably restores joint line height, patella height and posterior condylar offset in total knee arthroplasty

INTRODUCTION

There is growing interest in the use of robotic TKA to improve accuracy of component positioning in Total Knee Arthroplasty (TKA). The aim of this study was to investigate the accuracy of implant component position using the ROSA® knee system with specific reference to Joint Line Height, Patella Height and Posterior Condylar Offset (PCO).

METHODS

This was a retrospective review of a prospectively-maintained database of the initial 100 consecutive TKAs performed by a high volume surgeon using the ROSA® knee system. Both the image-based and imageless workflow were used and two prosthesis types were implanted. To determine the accuracy of component positioning, the immediate post-operative radiograph was reviewed and compared with the immediate pre-operative radiograph with regards to Joint Line Height, Patella Height and Posterior Condylar Offset.

RESULTS

100 consecutive patients undergoing TKA using the ROSA system were included; mean age 70 years (range 49-95 years). Mean change in joint line height was 0.2 mm, patella height (Insall-Salvati ratio) 0.01 and posterior condylar offset 0.02 mm; there was no statistically significant difference between the pre and post-operative values. No difference was demonstrated between image-based or imageless workflows, or between implant design (Persona versus Vanguard) regarding joint line height, patella height and PCO.

CONCLUSION

This study validates the use of the ROSA® knee system in accurately restoring Joint Line Height, Patella Height and Posterior Condylar Offset in TKA surgery. No significant differences were found between imageless and image-based groups, or between implant designs (Persona versus Vanguard).

Mako versus ROSA: comparing surgical accuracy in robotic total knee arthroplasty

There is increasing adoption of robotic surgical technology in Total Knee Arthroplasty. The ROSA® knee system can be used in either image-based mode (using pre-operative calibrated radiographs) or imageless modes (using intra-operative bony registration). The Mako knee system is an image-based system (using a pre-operative CT scan). This study aimed to compare surgical accuracy between the ROSA and Mako systems with specific reference to joint line height, patella height, posterior condylar offset and tibial slope. This was a retrospective review of a prospectively collected data of the initial 50 consecutive ROSA TKAs and the initial 50 consecutive Mako TKAs performed by two high-volume surgeons. To determine the accuracy of component positioning, the immediate post-operative radiograph was reviewed and compared with the immediate pre-operative radiograph with regards to joint line height (JLH), patella height (PH), tibial slope (TS) and posterior condylar offset (PCO). Mean difference between pre- and post-operative radiographs using the ROSA knee system of joint line height was 0.47 mm (SD 0.95) posterior condylar offset 0.16 mm (SD 0.76), tibial slope 0.9 degrees (SD 1.6) and patella height 0.01 (SD 0.05). Mean difference using the MAKO knee system of joint line height was 0.26 (SD 1.08), posterior condylar offset -0.26 mm (SD 0.78), tibial slope 1.8 degrees and patella height 0.03. No significant difference was demonstrated between the accuracy of component positioning of the ROSA or MAKO knee systems. Our study is the first study to compare the accuracy of the ROSA and MAKO knee systems in total knee arthroplasty. Both systems are highly accurate in restoring native posterior condylar offset, joint line height, tibial slope and patella height in TKA with no significant difference demonstrated between the two groups.

The Environmental Impact and Sustainability of Total Hip and Knee Arthroplasty

Background

Operating room waste is disposed of in landfill sites, recycled, or undergoes costly, energy-intensive incineration processes. By assessing the quantity and recyclability of waste in primary hip (THA) and knee arthroplasty (TKA), we aim to identify strategies to improve sustainability.

Methods

A prospective waste audit of 15 primary THA and 16 primary TKA cases was conducted at a tertiary orthopedic hospital between April and July 2022. Waste was categorized into nonhazardous, hazardous, recycling, sharps, and linens. Each category was weighed. Items disposed as nonhazardous waste were cataloged for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined using packaging.

Results

Average total waste generated for THA and TKA was 14.46 kg and 17.16 kg, respectively. TKA generated significantly greater waste (P < .05). Of all waste, 5.4% was recycled in TKA and just 2.9% in THA cases. The mean amount of recycled waste was significantly greater in TKA cases than that in THA cases, 0.93 kg and 0.42 kg, respectively.Hazardous waste made up the largest proportion for both TKA (69.2%) and THA (73.4%). Nonhazardous waste made up 15.1% and 11.3% of total waste for TKA and THA, respectively. In the nonhazardous waste, only 2 items (scrub-brush packaging and towel packaging) were recyclable.

Conclusions

We estimate hip and knee arthroplasty generates over 2.7 million kg of waste in the United Kingdom annually. Currently, only a small percentage of waste is recycled in hip and knee arthroplasty, which could improve through increased use of recyclable plastics and clear labeling of items as recyclable by medical suppliers.

The Linear Coronal Knee Offset (LCKO)-Preliminary Study of New Method of Measuring Knee Varus/Valgus Malalignment

Introduction  Considerable attention is focused on preoperative templating of radiological images in patients undergoing total knee arthroplasty to obtain optimal alignment and outcome. Several radiological measurements have been described. Purpose  In this study, we illustrate a new linear measurement: The linear coronal knee offset (LCKO) that can be used to analyze the coronal configuration on long leg alignment radiographs commonly undertaken during preoperative templating. Methods  A retrospective search was performed of our Picture Archiving and Communication System and Radiology Information System to identify 100 lower limbs anteroposterior, weight bearing, long leg alignment view radiographs of patients referred to knee clinics over 1 year with knee pain. Demographic details, clinical indication, standard radiological measurement of the anatomical tibiofemoral angle, and the LCKO were measured and data were analyzed using Student's t -test. In addition, intraclass correlation coefficient was used to analyze for intraclass reliability. Results  The average age of patients was 36.3 years (range: 12-80 years) with a male predominance. The LCKO was statistically significant between the three cohorts of patients. The mean LCKO in normal cohorts was 0.24 cm, varus was -0.6 cm, and valgus was 1.72cm. There was good inter and interobserver reliability (Kappa of 0.8 and 0.8, respectively). Conclusion  The novel LCKO measurement provides a simpler method in assessing coronal lower limb malalignment and can easily identify a normal, varus, or valgus knee deformity.

Robotic technology in total knee arthroplasty

Key factors for successful total knee arthroplasty include accurate implant positioning with precise tibial and femoral resection, combined with appropriate soft tissue balancing to achieve the desired alignment. Robotic-assisted total knee arthroplasty allows surgeons to execute pre-planned strategies with precision, with growing evidence suggesting that robotic-assisted-total knee arthroplasty reduces radiological outliers. This has yet to be proven to translate into long-term improvements in patient-reported outcomes and implant survivorship. Robotic-assisted-total knee arthroplasty systems can be divided into fully autonomous and semi-autonomous systems. While fully autonomous systems showed initial promise, semi-autonomous systems are gaining popularity with encouraging early outcomes suggesting improved radiological and clinical outcomes, although concerns remain regarding a significant learning curve, installation costs, radiation exposure and cost associated with preoperative imaging. The future of total knee arthroplasty seems certain to involve robotic technology, although to what degree and in what capacity will depend on further high-quality studies assessing long-term outcomes, complications, survivorship and cost-benefit analyses.

Outcomes of distally un-threaded screw fixation of slipped capital femoral epiphysis at skeletal maturity: a matched cohort study

The most common treatment for slipped capital femoral epiphysis worldwide is in situ fixation with a threaded screw. Un-threaded screws are designed to prevent slip progression without hindering residual growth of the proximal femur. This study aimed to compare growth, remodelling and long-term outcomes after fixation with un-threaded screws and a matched cohort of patients treated with a standard screw. Six patients (nine hips) treated with un-threaded screws and 16 patients (21 hips) treated with standard screws matched for age, skeletal maturity, sex and Southwick angle were recruited. Clinical records were reviewed for patient demographics, medical history and complications. Radiographs were reviewed for residual growth and time to physeal closure. Growth velocity was calculated. Absence of cam deformity signified complete remodelling. Clinical assessment was graded from excellent to poor and patient-reported outcomes were recorded. There was significantly more growth recorded in the un-threaded screw group in femoral neck length (7.6 mm, P = 0.003), articulo-lesser trochanter distance (5.3 mm, P = 0.028), pin-joint ratio (7.439%, P = 0.006) and pin-physis ratio (8.244%, P = 0.001). The probability of revision operations due to ongoing growth was higher in this group (risk ratio: 6.57, P = 0.0008). Time to physeal closure was not significantly different, but growth velocity was significantly higher in the un-threaded group. The lower probability of cam deformity was not significant. Functional and clinical results were not significantly different at average 11.2 years' follow-up. Un-threaded screws allow for significantly more growth than standard threaded screws. The un-threaded screw could not be recommended due to the higher re-operation rates, without any proven benefit.

Deep infection after hip hemiarthroplasty: risk factors for infection and outcome of treatments

AIMS

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

METHODS

Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year.

RESULTS

A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection.

CONCLUSION

Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958-965.

Thirty-Day Mortality for Proximal Femoral Fractures Treated at a U.K. Elective Center with a Site-Streaming Policy During the COVID-19 Pandemic

COVID-19 led to the reconfiguration of U.K. orthopaedic trauma services because surgical capacity was threatened in acute centers. We report the 30-day mortality of proximal femoral fractures in older adults treated at an elective orthopaedic center.

Review of total hip arthroplasty in patients younger than 30 years: mid- to long-term results

BACKGROUND

Data on the outcome of THA in patients under the age of 30 years is sparse. There is a perceived reluctance to offer surgery to young patients on the basis of potential early failure of the implant. The aim of this study was to review clinical and radiological outcomes of THA in patients under the age of 30 years in a high-volume specialist arthroplasty unit.

METHODS

A retrospective review of patients between 1989 and 2009 was undertaken. 95 patients (118 THAs) were identified but 17 patients were excluded for lack of clinical records or for follow-up under 5 years. Clinical records were reviewed for demographics, underlying pathology, details of operation and failures. Radiographs were reviewed for evidence of loosening and wear of the components. Functional assessment was carried out using the modified Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score and EQ-5D-5L.

RESULTS

Mean age was 25 (16-30) years and 65% patients were females. The most common underlying pathologies were development dysplasia of the hip (29%) and juvenile rheumatoid arthritis (25%). Mean follow-up was 12.6 (5-24) years, during which 19 patients (25%) were revised. The majority of the revisions were for aseptic loosening of the acetabular component.

CONCLUSIONS

Surgeons are cautious when considering THA in very young patients despite the significant documented improvement in function and quality of life after THA. This study reports on the mid- to long-term results of THA which will be valuable when advising young patients on the prospects of revision surgery at the time of primary THA.

Morbidity and mortality in patients undergoing lower limb arthroplasty surgery during the initial surge of the COVID-19 pandemic in the UK at a single-speciality orthopaedic hospital

Aims

The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic.

Methods

Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months.

Results

There were 167 elective procedures performed in the first three weeks of the study period, prior to the first national lockdown, and 57 emergency procedures thereafter. Three patients (1.3%) were readmitted within 30 days of discharge. There was one death (0.45%) due to SARS-CoV-2 infection after an emergency procedure. None of the patients developed complications of SARS-CoV-2 infection after elective arthroplasty. There was no observed spike in complications during in-hospital stay or in the early postoperative period. There was no statistically significant difference in survival between pre-COVID-19 and peri-COVID-19 groups (p = 0.624). We observed a higher number of emergency procedures performed during the pandemic within our institute.

Conclusion

An international cohort has reported 30-day mortality as 28.8% following orthopaedic procedures during the pandemic. There are currently no reports on clinical outcomes of patients treated with lower limb reconstructive surgery during the same period. While an effective vaccine is developed and widely accepted, it is very likely that SARS-CoV2 infection remains endemic. We believe that this report will help guide future restoration planning here in the UK and abroad.

Cite this article: Bone Jt Open 2021;2(5):323–329.

Association between vestibular function and rotational spatial orientation perception in older adults

BACKGROUND

Spatial orientation is a complex process involving vestibular sensory input and possibly cognitive ability. Previous research demonstrated that rotational spatial orientation was worse for individuals with profound bilateral vestibular dysfunction.

OBJECTIVE

Determine whether rotational and linear vestibular function were independently associated with large amplitude rotational spatial orientation perception in healthy aging.

METHODS

Tests of rotational spatial orientation accuracy and vestibular function [vestibulo-ocular reflex (VOR), ocular and cervical vestibular evoked myogenic potentials (VEMP)] were administered to 272 healthy community-dwelling adults participating in the Baltimore Longitudinal Study of Aging. Using a mixed model multiple linear regression we regressed spatial orientation errors on lateral semicircular canal function, utricular function (ocular VEMP), and saccular function (cervical VEMP) in a single model controlling for rotation size, age, and sex.

RESULTS

After adjusting for age, and sex, individuals with bilaterally low VOR gain (β= 20.9, p = 0.014) and those with bilaterally absent utricular function (β= 9.32, p = 0.017) made significantly larger spatial orientation errors relative to individuals with normal vestibular function.

CONCLUSIONS

The current results demonstrate for the first time that either bilateral lateral semicircular canal dysfunction or bilateral utricular dysfunction are associated with worse rotational spatial orientation. We also demonstrated in a healthy aging cohort that increased age also contributes to spatial orientation ability.

Methicillin-resistant Staphylococcus aureus in hip fracture

AIMS

Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization and surgical site infection (SSI). This paper reports the impact of routine MRSA screening and the "cleanyourhands" campaign on rates of MRSA SSI and patient outcome.

METHODS

A total of 13,503 patients who presented with a hip fracture over 17 years formed the study population. Multivariable logistic regression was performed to determine risk factors for MRSA and SSI. Autoregressive integrated moving average (ARIMA) modelling adjusted for temporal trends in rates of MRSA. Kaplan-Meier estimators were generated to assess for changes in mortality.

RESULTS

In all, 6,189 patients were identified before the introduction of screening and 7,314 in the post-screening cohort. MRSA infection fell from 69 cases to 15 in the post-screening cohort (p < 0.001). The ARIMA confirmed a significant reduction in MRSA SSI post-screening (p = 0.043) but no significant impact after hand hygiene alone (p = 0.121). Overall SSI fell (2.4% to 1.5%), however deep infection increased slightly (0.89% to 1.06%). ARIMA showed neither intervention affected overall SSI ("cleanyourhands" -0.172% (95% confidence interval (CI) -0.39% to 0.21); p = 0.122, screening -0.113% per year, (95% CI -0.34 to 0.12); p = 0.373). One-year mortality after deep SSI was unchanged after screening (50% vs 45%; p = 0.415). Only warfarinization (OR 3.616 (95% CI 1.366 to 9.569); p = 0.010) and screening (OR 0.189 (95% CI 0.086 to 0.414); p < 0.001) were significant covariables for developing MRSA SSI.

CONCLUSION

While screening and decolonization may reduce MRSA-associated SSI, the benefit to patient outcome remains unclear. Overall deep SSI remains an unsolved problem that has seen little improvement over time. Preventing other hospital-associated infections should not be forgotten in the fight against MRSA. Cite this article: Bone Joint J 2021;103-B(1):170-177.

Dyschromatosis Universalis Hereditaria

Dyschromatosis universalis hereditaria (DUH) is a rare pigmentary genodermatosis usually inherited in autosomal dominant fashion characterized by multiple pinpoint to pea-sized hypo- and hyper-pigmented macules arranged in reticulate pattern that develops within the first few years of life. An 11 years old boy presented with multiple gradually progressive asymptomatic hypopigmented macules on hyperpigmented background on trunk, extremities and face since 2 years of age. Family history was absent. Punch biopsies revealed increased number of melanocytes in the epidermis with basal cell vacuolar alteration and pigmentary incontinence and perivascular infiltration by lymphocytes and melanophages in the dermis. We herein present a sporadic case of dyschromatosis universalis hereditaria.

Vestibular impairment, cognitive decline and Alzheimer's disease: balancing the evidence

The vestibular (inner ear balance) system senses head movement and orientation in space. Vestibular sensory input plays a critical role in spatial cognitive abilities such as spatial memory and spatial navigation. Vestibular function declines with age, and recent studies have shown that age-related vestibular impairment is associated with poorer spatial cognitive skills in healthy older adults. Moreover, vestibular impairment is disproportionately prevalent among individuals with mild cognitive impairment and Alzheimer's disease, and specifically in cognitively-impaired individuals who have spatial deficits such as disorientation and difficulty driving. Indeed, emerging evidence suggests that age-related vestibular impairment contributes to a 'spatial' subtype of Alzheimer's disease, characterized by highly morbid symptoms such as wandering and falls. Given that vestibular impairment can be treated through simple, physical-therapy based exercises, identifying and treating vestibular deficits in older adults with and without cognitive impairment may offer substantial benefit in preventing, mitigating and forestalling cognitive decline.

Saccular function is associated with both angular and distance errors on the triangle completion test

OBJECTIVE

The present study was designed to determine whether healthy older adults with age-related vestibular loss have deficits in spatial navigation.

METHODS

154 adults participating in the Baltimore Longitudinal Study of Aging were tested for semicircular canal, saccular, and utricular function and spatial navigation ability using the blindfolded Triangle Completion Test (TCT). Multiple linear regression was used to investigate the relationships between each measure of vestibular function and performance on the TCT (angular error, end point error, and distance walked) while controlling for age and sex.

RESULTS

Individuals with abnormal saccular function made larger angular errors (β = 4.2°, p < 0.05) and larger end point errors (β = 13.6 cm, p < 0.05). Independent of vestibular function, older age was associated with larger angular (β's = 2.2-2.8°, p's < 0.005) and end point errors (β's = 7.5-9.0 cm, p's < 0.005) for each decade increment in age.

CONCLUSIONS

Saccular function appears to play a prominent role in accurate spatial navigation during a blindfolded navigation task.

SIGNIFICANCE

We hypothesize that gravitational cues detected by the saccule may be integrated into estimation of place as well as heading direction.

Reduced vestibular function is associated with longer, slower steps in healthy adults during normal speed walking

BACKGROUND

Vestibular signals contribute to balance and walking. With aging, vestibular function declines and gait speed decreases. Vestibular loss contributes to decreasing gait speed, but this influence could be linked to spatial and/or temporal aspects of gait. We investigated the relationship between vestibular function (semicircular canal and otolith function) and spatial and temporal gait parameters in a cohort of adults.

METHODS

113 community-dwelling healthy adults (mean age 72.2 (14.6) years) participating in the Baltimore Longitudinal Study of Aging were tested. Horizontal semicircular canal (SCC) function was evaluated using quantitative vestibulo-ocular reflex gain. Otolith function was measured with cervical and ocular vestibular evoked myogenic potentials. Gait kinematics were collected during normal speed walking. Multiple linear regressions examined the association between spatial and temporal gait parameters and SCC and otolith function separately, controlling for age, gender, height, and either cadence (for spatial gait outcomes) or stride length (for temporal gait outcomes) to account for gait speed effects.

RESULTS

Vestibular SCC function was significantly associated with both spatial and temporal gait parameters. Every 0.1 decrease in SCC function resulted in longer stride length (β = -.04 m, p = 0.004), longer stance time (β = 15.8 ms, p < 0.003), and a slower cadence (β = -2.1 steps/minute, p < 0.001). Otolith function was not associated with any gait parameter.

CONCLUSIONS

Reduced horizontal SCC function was associated with longer, slower steps in a cohort of healthy adults. These results indicate that vestibular signals contribute to specific spatial and temporal aspects of gait thought to contribute to upright balance.

Landmark Technique for a Wrist Block

Effective anesthesia of the hand and wrist has many uses inside and outside the operating room. In the emergency department or fracture clinic, a wrist block may be used for closed reductions of dislocations and fractures or for effective inspection and treatment of wounds. In the operating room, surgery may be carried out under a wrist block alone or a wrist block may be used as an adjunct to general anesthesia as the block is an opiate-sparing option to facilitate outpatient surgery and to provide many hours of postoperative analgesia, particularly if administered prior to the commencement of surgery. The landmark technique for distal peripheral nerve blocks at the wrist is a well-recognized method and is described for the median nerve, ulnar nerve, superficial branch of the radial nerve, and dorsal branch of the ulnar nerve at the wrist. To make this technique more effective for carpal surgery, blocks of the posterior interosseous and anterior interosseous nerves are added.Step 1: The patient is counseled about the procedure and the expected outcomes.Step 2: Drug allergies are checked.Step 3: The maximum safe dose of the chosen local anesthetic agent is calculated using the weight of the patient.Step 4: The drug ampules are checked for the name and concentration of the drug as well as the expiration date.Step 5: The drug is drawn up into a 10-mL syringe, and a needle is fitted for injection.Step 6: For each of the 6 nerves to be blocked, the anatomical landmarks are identified along with surrounding structures at risk.Step 7: The skin is prepared with an antiseptic agent.Step 8: The nerve block injections are administered using the techniques in the accompanying video, while checking that there are no signs of intraneural or intravascular injection. The landmark technique for wrist block is an effective method in the situations described above. However, there are occasional failures to provide sufficient analgesia as with all peripheral nerve block techniques. There is a possibility of intraneural injection, which must be avoided. There is also a risk of direct nerve fascicular injury with the needle, which therefore requires a thoughtful technique. There is little if any motor block, which makes the technique particularly suitable when intraoperative active motion is required or when physiotherapy is started directly postoperatively. The technique is very rapid to administer, and it does not require any equipment other than a syringe and needle, making it very inexpensive and suitable for austere environments.

Outcome following use of the Achillon jig for the repair of acutely ruptured Achilles tendons

We report a series of 143 patients who underwent limited open Achilles tendon repair using the Achillon device at a mean follow-up of 25 months. All patients attending our institution with a diagnosis of acute Achilles tendon rupture were considered for operative repair using the Achillon jig unless they declined surgery or met the exclusion criteria. Following surgery patients were contacted and asked to complete an Achilles Tendon Rupture Score (ATRS). The clinical records were reviewed for evidence of complications, demographic information and evidence of re-rupture. Statistical analysis of subgroups including age at presentation, delay to surgery and patients with complications was carried out using the Kruskal Wallis non-parametric test. We report no re-ruptures at a mean of 25 months (minimum 12 months) following surgery. The mean ATRS score was 84/100 (range 15-100). There was no statistical significance between any of the subgroups analyzed. In conclusion, acute Achilles repair using the Achillon jig is safe, with a low re-rupture rate, excellent ATRS scores at a minimum of 12 months post-operatively and low complications. The incidence of sural nerve injury is much lower than published series of percutaneous Achilles tendon repair without the use of a jig.

The Distribution of Bone Islands and Juxta-Articular Bone Cysts in the Growing Hand

Bone islands and juxta-articular bone cysts are relatively common incidental findings when X-rays are taken for other purposes. We have identified that the incidence of bone islands in the hands of asymptomatic children between the ages of 5 and 13 years is 3.8% and the incidence of cysts in the same population is 2.8%. Bone islands were most common in the scaphoid, whilst juxta-articular bone cysts were most common in the capitate. The age at which they appear has not been reported previously. This study first identifies their presence in the hands of children of age 10 years and 2 months (bone islands) and 10 years 0 months (juxta-articular bone cysts). Most of the lesions were already present on the first radiograph taken. New bone islands appeared in five cases between the ages of 13 years and 1 month and 15 years and 3 months. New juxta-articular bone cysts were observed to appear in five cases between the ages of 10 years 10 months and 15 years 0 months. No island or cyst changed in size during the review period.

Intra-articular and portal infiltration versus wrist block for analgesia after arthroscopy of the wrist: a prospective RCT

Wrist block has been used to provide pain relief for many procedures on the hand and wrist but its role in arthroscopy of the wrist remains unexplored. Chondrotoxicity has been a concern with the intra-articular infiltration of local anaesthetic. We aimed to evaluate and compare the analgesic effect of portal and wrist joint infiltration with a wrist block on the pain experienced by patients after arthroscopy of the wrist. A prospective, randomised, double-blind trial was designed and patients undergoing arthroscopy of the wrist under general anaesthesia as a day case were recruited for the study. Levo-bupivacaine was used for both techniques. The effects were evaluated using a ten-point visual analogue scale, and the use of analgesic agents was also compared. The primary outcomes for statistical analyses were the mean pain scores and the use of analgesia post-operatively. A total of 34 patients (63% females) were recruited to the portal and joint infiltration group and 32 patients (59% males) to the wrist block group. Mean age was 40.8 years in the first group and 39.7 years in the second group (p > 0.05). Both techniques provided effective pain relief in the first hour and 24 hours post-operatively but wrist block gave better pain scores at bedtime on the day of surgery (p = 0.007) and at 24 hours post-operatively (p = 0.006). Wrist block provides better and more reliable analgesia in patients undergoing arthroscopy of the wrist without exposing patients to the risk of chondrotoxicity.

A unique orthogeriatric model: a step forward in improving the quality of care for hip fracture patients

BACKGROUND

In August 2010, a unique model of shared care for hip fracture patients was implemented in our hospital. In this model, patients are allocated to an orthogeriatric team within 48 h of surgery, who review patients daily to manage medical complications and coordinate multidisciplinary rehabilitation, with orthopaedic input if necessary.

AIM

To compare the new model to the previous model of care as perceived by members of staff and compare clinical outcomes.

METHODS

Prospective data were collected using questionnaires given to medical, nursing and allied health professionals. Their opinions were rated using the Likert scaling system and analysed with the Mann Whitney U-test. Clinical outcomes were obtained from the hip fracture database and subsequently analysed.

RESULTS

59 responses (100%); 21 doctors and 38 allied health professionals. The majority of staff believed that quality of patient care was better in the newer model and preferred to work in this model. The median length of stay in the previous model (274 patients) was 25 days compared to 19.5 days in the new model (249 patients) (p = 0.22). 56.8% patients returned to their source of admission in the previous model compared to 72.7% in the new model (p = 0.00007). The inpatient mortality rates improved from 12.4% in the previous model to 8.4% in the new model (p = 0.26).

CONCLUSION

This unique model improved care for hip fracture patients and was cost effective. Furthermore, it highlighted excellent staff satisfaction. This can pioneer a change in the management of hip fracture patients nationally and internationally.

Impact of metabolic syndrome on re-stenosis development: role of drug-eluting stents

Metabolic syndrome (MetS) is defined as a cluster of numerous cardiovascular risk factors, which encompasses obesity, dyslipidaemia, insulin resistance and hypertension. Patients with MetS are more prone to developing cardiovascular events than other patients. To date, several approaches such as physical exercise, dietary control and invasive and non-invasive therapeutic interventions for dyslipidaemia, hypertension and insulin resistance have been used to manage MetS. However, there is a progressive elevation in the incidence of fatal and non-fatal cardiovascular events due to the increased prevalence of obesity and diabetes. Percutaneous coronary intervention has emerged over the last few years as an effective revascularisation strategy for those with coronary artery disease, in parallel with the development of effective anti-platelet medications and newer drug-eluting stents. In recent years, considerable research efforts have been undertaken to elucidate the pathophysiology of re-stenosis and develop strategies to prevent re-stenosis following percutaneous transluminal coronary angioplasty and stent implantation. Although the rate of stent re-stenosis and target-lesion revascularisation has been reduced, there is little information in the literature on the outcome of MetS in the pathophysiology of re-stenosis. In this review article, we summarise the recent development and progress on re-stenosis and the role of drug-eluting stents, particularly in MetS.

Changing pattern of femoral fractures in osteogenesis imperfecta with prolonged use of bisphosphonates

PURPOSE

Osteogenesis imperfecta (OI) has been treated with bisphosphonates for many years, with some clear clinical benefits. In adults, there are reports of a new pattern of atraumatic subtrochanteric fractures with bisphosphonate treatment. This study assesses if bisphosphonate treatment leads to an altered pattern of femoral fractures.

METHODS

Retrospective review of imaging for a cohort of 176 bisphosphonate-treated OI patients to identify the locations of femoral fractures over a two-year period, as compared to a historical control group managed pre-bisphosphonates.

RESULTS

Sixteen femoral fractures were identified in this time period in the bisphosphonate-treated group. All but two were within the subtrochanteric region. In comparison, the historical group-composed of 26 femoral fractures-had a more widespread fracture pattern, with the most frequent location being the mid-diaphysis. Many of the subtrochanteric fractures in the treatment group occurred with minimal trauma.

CONCLUSIONS

It appears that concerns over the treatment of the adult osteoporotic population with bisphosphonates are amplified and mirrored in OI. It is possible that the high bending moments in the proximal femur together with altered mechanical properties of cortical bone secondary to the use of this group of drugs increase the risk of this type of injury, which warrants further modification of surgical management of the femur.

Lateral sesamoid position in hallux valgus: correlation with the conventional radiological assessment

BACKGROUND

We aimed to quantify the severity of the hallux valgus based on the lateral sesamoid position and to establish a correlation of our simple assessment method with the conventional radiological assessments.

METHODS

We reviewed one hundred and twenty two dorso-plantar weight bearing radiographs of feet. The intermetatarsal and hallux valgus angles were measured by the conventional methods; and the position of lateral sesamoid in relation to first metatarsal neck was assessed by our new and simple method.

RESULTS

Significant correlation was noted between intermetatarsal angle and lateral sesamoid position (Rho 0.74, p < 0.0001); lateral sesamoid position and hallux valgus angle (Rho 0.56, p < 0.0001). Similar trends were noted in different grades of severity of hallux valgus in all the three methods of assessment.

CONCLUSIONS

Our method of assessing hallux valgus deformity based on the lateral sesamoid position is simple, less time consuming and has statistically significant correlation with that of the established conventional radiological measurements.

Traction splint: to use or not to use

Traction splints are widely used for immobilisation of fractures of the lower limb. There is brevity of evidence-based research on their efficacy. We present a case of skin complication following traction splint for spiral fracture of femur. It is prudent to identify patients at higher risk of developing complications of immobilisation. In circumstances where delays are inevitable, the indication and appropriateness of continuation of traction splint should be re-evaluated.

Medial and lateral rotatory dislocations of the ankle after trivial trauma--pathomechanics and management of two cases

Pure frontal plane rotatory dislocation of the ankle joint without an associated fracture is an extremely rare injury. We report one such case of an eversion rotatory dislocation and one case of an inversion rotatory dislocation. To our knowledge, this is the first report of an eversion injury resulting in dislocation of the ankle without fracture. Both patients had low energy trauma, predisposing ligamentous injuries, and recurrent sprains. In the patient with lateral rotatory dislocation, medial malleolar hypoplasia was also a contributing factor. Both patients healed the presenting index injury with nonoperative treatment, whereas the lateral rotatory dislocation had a lateral ankle stabilization to prevent subsequent injury.

Electron microscopic study of the secretion process in bovine reproductive organs

The origin and mechanism of the secretion of membrane-bound particles in bovine seminal plasma were studied with transmission (TEM) and scanning (SEM) electron microscopy of the epididymis, vas deferens, ampulla, and seminal vesicle of adult bulls. In the SEM study, all these organs were found to contain apical protrusions in the lining of the epithelial cells. Eventually the protrusions became detached and formed secretory bodies within the lumina of these organs. In the epididymis, the TEM study disclosed a granular and rather homogeneous content in the protrusions and bodies, whereas in the vas deferens they contained dilated cisternae of smooth endoplasmic reticulum. In the ampulla and seminal vesicle, the formation of the apical protrusions was associated with an accumulation of membrane-bound vesicles. These vesicles were found to be released from the storage bodies into the secretory fluid of the lumen. Both could be harvested from isolated seminal vesicle secretions by Percoll gradient centrifugation. It was concluded that various parts of the bovine reproductive organs discharge their secretory products at least partly by an apocrine mechanism. The membrane-bound particles in the seminal plasma, however, appear to be mainly derived from the ampulla and seminal vesicle.

Effect of secretory particles in bovine seminal vesicle secretion on sperm motility and acrosome reaction

Particles found in bovine seminal vesicle secretion were enriched by centrifugation. They varied in size and morphology and contained Mg2+,Ca2+-activated ATPase, aminopeptidase A, alanyl aminopeptidase, gamma-glutamyl transpeptidase and dipeptidyl peptidase IV activities. Hyperactivation of sperm motility and the acrosome reaction were induced by these particles in epididymal spermatozoa suspended in a modified Ringer medium. The hyperactivation, analysed with a microscopic slide test, started within minutes of exposure to membrane particles and continued for 3-4 h, during which time spermatozoa underwent the acrosome reaction. Acrosome staining, phase-contrast microscopy and transmission electron microscopy revealed that the acrosome reaction started within 60 min at 37 degrees C and affected up to 80% of spermatozoa in 4 h. These membrane particles differed from those reported previously in other species in enzyme composition, function and organ of origin.

Dipeptidyl peptidases in bovine reproductive organs and secretions

Dipeptidyl peptidases (DPP) I-IV were analysed in homogenates of bovine reproductive organs as well as in seminal vesicle secretions and seminal plasma. The presence of various molecular forms of these enzymes was studied by fractionation using gel filtration, anion exchange chromatography and chromatofocusing. The eluting enzymes were pooled, and their biochemical properties were briefly characterized. The histochemical localization of DPP II and IV was carried out with the most active tissues. DPP I and III were absent from seminal plasma, but their highest activity was found in the epididymis and increased during sexual maturation. DPP II was found mainly in a single molecular form and displayed a wide distribution in the reproductive organs. Its activity in seminal plasma may be derived from various organs, although the major sources are probably the apical activity in the epididymis, ampulla and seminal vesicle. DPP IV activity was high in the cauda epididymis, and ampulla, and in the seminal vesicles and their secretions. The high activity of DPP IV in seminal plasma appeared to derive from these organs, which showed a strong apical reaction of the epithelial lining. In seminal vesicles the enzyme was mainly secreted attached to membrane particles called vesiculosomes.

Studies on the multiple forms of aminopeptidase A in bovine seminal vesicle secretion

After gel filtration, anion exchange chromatography and chromatofocusing aminopeptidase A (AP-A) of bovine seminal vesicle secretion (VS-S) was found to exist in multiple forms. Depending on the pH used (pH 6.5-8.5) gel filtration of VS-S revealed 1-3 forms of AP-A. At pH 8.5 two dissimilar low-molecular-weight forms of AP-A converted into aggregated high-molecular-weight form. The aggregated AP-A was dissociated into an intermediate form with Triton X-100 and/or sodium deoxycholate and further into two low-molecular-weight forms with thiol compounds and neuraminidase. The aggregated, intermediate and low-molecular-weight forms of AP-A displayed some differences in catalytic properties, modifier characteristics and thermal inhibition.

Alanyl aminopeptidase of bovine seminal vesicle secretion

Multiple forms of an aminopeptidase hydrolysing L-alanine- and various other amino acid-beta-naphthylamides in bovine seminal vesicle secretion were studied after fractionation on gel filtration, anion exchange chromatography and chromatofocusing. Two forms of the enzyme were found in all these fractionations: one with a high molecular weight was aggregated or particle-bound and the other had a molecular weight of about 237,000. The high-molecular-weight form dissociated with Triton X-100 via an intermediate into the basic enzyme form with concurrent change in the pI and anionic sites. The basic form of the enzyme differed from the high-molecular-weight forms in substrate preference, response to some modifiers, thermal stability and kinetic constants.

Variable distribution of aminopeptidase A in male reproductive organs of mammals

Aminopeptidase A (AP-A) was analysed in the reproductive organs of the boar, bull, gerbil and man. High hydrolysis of alpha-L-glutamyl-beta-naphthylamide (GluNA) and alpha-L-aspartyl-beta-naphthylamide (AspNA) with activation by alkaline earth metals was detected in the ampulla, seminal vesicles, and seminal vesicle secretions of the bull and in the cauda epididymis of the boar and gerbil. In man, weak AP-A activity was found in all reproductive tissues. Histochemically, AP-A was localized in the epithelial cells of tissues having a high specific activity for the enzyme. AP-A was absent from human seminal fluid, whilst bovine seminal fluid had strong, and boar seminal fluid weaker, AP-A activity. Gel filtration of bull seminal vesicle secretions and seminal fluid, boar seminal fluid or an homogenate of boar and gerbil epididymal cauda and human epididymis and seminal vesicles on Sephacryl S-300 resulted in a major high-molecular-weight activity peak A at Ve/Vo = 1.17 and another low-molecular-weight peak B at Ve/Vo = 1.51 (man), 1.62 (boar, bull) or 1.75 (gerbil). This fractionation was not in all cases able to separate AP-A from aminopeptidase(s), which were active on L-alanine-beta-naphthylamide (AlaNA) but showed no activation by alkaline earth metals. Homogenates of bovine epididymis showed only the low-molecular-weight GluNA peak B, but two areas of activity for AlaNA hydrolysis. In bovine seminal vesicles and porcine epididymis, AP-A activity appeared to be linked with the functional maturity of these organs. The high-molecular-weight AP-A (peak A) appeared to be the predominant form in seminal fluid.

Aminopeptidase A in reproductive organs of the male rat: evidence for high activity in the posterior lobe of the prostate

Of the reproductive organs of the male rat a high level of hydrolysis of alpha-L-glutamyl-beta-napthylamide (GluNA) and alpha-L-aspartyl-beta-naphthylamide (AspNA) in the presence of Ca2+ (5mM) (aminopeptidase A) was found in the posterior lobe of the prostate. Histochemically, this enzyme was localized in the epithelial cells of acini, which were grouped in the dorsal part and sharply separated from non-active acini in the anterior part of the lobe. A single peak of Ca2+-activated GluNA and AspNA hydrolysis was obtained after chromatofocusing at pI 4.9 and on anion exchange chromatography this activity eluted at 0.09 M NaCl. After gel filtration on Sepharose 6B a major peak of activity was found at the elution volume (Ve/Vo = 2.28). In all of these fractionation procedures aminopeptidase A was partially or totally overlapped by other aminopeptidases hydrolysing various amino acid-beta-naphthylamides. A pooled enzyme preparation gave an optimum at pH 7.3. The hydrolysis of GluNA was markedly enhanced in the presence of Ba2+, Ca2+ and Sr2+, but the hydrolysis of AspNA was activated only by Ca2+ and Sr2+. Castration caused a significant decrease in the hydrolysis of GluNA by the posterior lobe, but did not influence the low levels of activity in other parts of the prostate or in the seminal vesicles.