Systemic inflammatory conditions frequently affect both the small joints of the hand and the eye. Uveitis and scleritis is common in this group and patients are required to apply regular eye drops. Ophthalmic conditions are also common in patients with Osteoarthritis of the thumb CMCJ who have weakness and pain on pinch grip. Poor compliance with therapy due to difficulties in administering eye drops can cause permanent ocular and visual morbidity. A laboratory based biomechanical study was performed to replicate the pinch forces applied to the 20 most frequently used eye drops. The minimum force required to disperse a drop from a full bottle held in the inverted vertical position was assessed on three occasions by placing the eye drop bottles between a finger and thumb simulator attached to a load cell. Recordings of two bottle types were repeated using 2 different ergonomic ‘aids’ produced by the pharmaceutical companies. The data was compared to published data for pinch strength of general ophthalmology patients and to collected data for patients with thumb base CMCJ osteoarthritis. Compressive forces varied significantly between different eye drop types from 6.4 newtons (Systane) to 20.8 newtons (Minims). The highest values were found in minims which is the most frequently used eye drop. The use of the Xalatan aid appeared to increase the force required from 7.7(+/−0.64) to 12.9 (+/−3.93) but this difference did not reach significance, p=0.08, the results for Allegan aid showed no significant difference 11.3(+/−0.91) to 9.9 (+/−1.18)p=0.17. The forces required to disperse a drop increased as the bottles became less full. Forces required to disperse eye drops from bottles varies considerably and can be greater than the maximum pinch pressure of some patient groups which may be a cause of poor compliance. Some ergonomic aids designed to help with the application of drops do not appear to reduce the forces required.
Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain. This impedes early mobilization and delays hospital discharge. A prospective audit of 1081 patients undergoing primary TKA during 2008 was completed. All patients followed a programme including preoperative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, postoperative high volume ropivacaine boluses with an intra-articular catheter and early mobilization. Primary outcome measure was length of stay. Secondary outcomes were verbal analogue pain scores on movement, time to mobilization, nausea and vomiting scores, urinary catheterization for retention, need for rescue analgesia, range of motion at discharge and six weeks postoperatively. The median day of discharge was postoperative day four. Median pain score on mobilization was three for first postoperative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterization rate was 6.9%. Rescue analgesia was required in 5% of cases. The median day of discharge was postoperative day four. Median range of motion was 85° on discharge and 93° at six weeks postoperatively. This comprehensive care plan provides satisfactory postoperative analgesia allowing early safe ambulation and discharge.
We have reviewed the complication rate over a ten year period for removal of screws placed for slipped capital femoral epiphysis (SCFE) and have surveyed the views of orthopaedic surgeons with an adult hip practice in Scotland on leaving the metalwork in situ. Whilst screw removal is favoured by many orthopaedic surgeons, a recent review of the literature reported that the complication rate for removal of implants placed for SCFE was 34%. Between 1998 and 2007 84 patients had insertion of screws for SCFE. Of these 54 patients had screws removed, 51 of these records were available. The median duration between insertion and removal of screws was 2 yrs 7 months. Of the 51 children, overall five (9.8%) had complications - three (5.9%) major and two (3.9%) minor. Two screws could not be removed; one patient sustained a fracture after screw removal and two developed an infection. We assessed the attitudes of adult hip surgeons on this topic using an electronic questionnaire which was completed by 29 out of 40 recipients. 78.6% of respondents support routine removal and 21.4% favour leaving the screw permanently in place. 82.2% had needed to remove metalwork from a hip requiring arthroplasty in a patient whose metalwork was inserted during childhood; and described their experience of this including the complications encountered. We have identified a lower complication rate following screw removal inserted for SCFE than in published series. Most adult hip surgeons support routine removal once the physis is closed but studies regarding the long-term outcome of retained orthopaedic implants are needed since even with this lower complication rate the question of routine removal remains unclear.
There is limited literature regarding the outcome of hip and knee arthroplasty (THR and TKR) in the Super-Elderly (≥80yrs). The aim is to compare the outcome of THR and TKR in the Super-Elderly with a standard-age cohort of patients. From January 2006 to August 2008; 1290 TKR and 1344 THR were performed at the study institute. Comorbidity, length of stay, patient satisfaction, Oxford knee or hip scores, and SF12 scores were recorded prospectively. The Oxford Score and SF12 were recorded at one year. The mode age range was 65-74yrs for TKR (n=492) and THR (n=495), deemed the standard cohort. 185 TKR and 171 THR were performed in the Super-Elderly. Outcome in this cohort was compared to the standard. The standard cohort had a greater absolute improvement in Oxford knee scores (15.8 and 14.7.p=0.2). Improvement of absolute Oxford hip scores revealed no difference (20.0 and 20.2.p=0.8), but the Super-Elderly had a greater improvement in pain components (11.0 vs.12.0.p=0.05) with a lesser improvement of the functional components (9.0.vs.8.2.p=0.05). There was a greater improvement in the physical component of the SF-12 score in the standard cohort for both TKR and THR (10.6.vs.7.9.p=0.05 and 14.4.vs.10.4.p=<0.01, respectively). No significant difference was seen in comorbidities, but the Super-Elderly patients had a longer hospital stay for TKR (6.2.vs.8.3.p=0.01) and THR (5.9.vs.9.0.p=0.01). The Super-Elderly were more satisfied with their surgery (p=0.05). Super-Elderly patients have comparable outcomes to their younger counterparts and are more satisfied with their surgery, but they may require a longer length of stay.
Infection of total hip replacement is a disaster, with a quoted incidence of 1-2%. Anecdotal evidence has led many to believe that aggressive management of early infection following hip replacement can prevent failure. As yet, there is no firm evidence. We have reviewed 20 consecutive cases of early infection (<6 weeks post-op) treated by open debridement and washout. The cases were 19 total hip replacements and 1 hemiarthroplasty. All had prolonged wound I discharge and elevated inflammatory parameters. No differentiation was made between superficial and deep infections because at this stage the deep fascia had not yet healed. 13 cases had positive cultures (6 staphylococcus, 5 coagulase negative staphylococcus, 1 coliform, 1 streptococcus). 7 cases had either negative cultures or mixed growth, but were clinically infected. Intravenous antibiotics were given after debridement until the wound healed. Thirteen (65%) were clinically and radiologically free of infection at a minimum of 1 year follow-up. Failure to eradicate infection was treated by revision surgery and this was performed in 4 patients. Of the remaining 3 patients, one underwent excision arthroplasty, one was infected but refused surgery and one was infected but medically unfit for surgery. There is no control group, but it would be ethically very difficult to organise. As expected, we had small numbers and a mixed collection of organisms, so statistical comparisons are limited. In conclusion, these patients represent a very high risk of ongoing infection. 13 hips (65%) had no evidence of ongoing infection at a minimum of 1 year follow up. This study supports aggressive surgical management of early infection following hip replacements. Eradication of early infection can be achieved without removal of the implant.
We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel. In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries. Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01). In older patients local complications are relatively common and clinical vigilance must be maintained in order to allow appropriate intervention during their post-operative course. Despite the incidence of radiological post-traumatic arthrosis, none of the patients progressed to ankle fusion.Conclusion/Significance
We aimed to quantify the health related quality of life in a series of patients suffering a variety of different tibial injuries. Patients with previous tibial injury, randomly selected from our trauma database, who successfully completed their entire course of treatment at our institution, were recalled for final assessment. Mean time to final follow-up was 37.4 months. Statistical analysis was performed using SPSS computer software. Overall, 130 patients were evaluated. There was no significant difference in the self-care dimension between the groups. Psychological problems were common in patients with IIIb and IIIc fractures, as well as amputees, with the highest incidence in those with IIIc fractures. Patients who had undergone amputation and those with IIIb open fractures reported problems with mobility significantly more frequently than those who had IIIc type injuries. However, this could be partially attributed to the significant difference in mean age between groups, with patients sustaining IIIc injuries being younger (31.9 vs 46.9). Patients with IIIb and IIIc type fractures reported significantly more problems with pain compared with those who had undergone amputation. Interestingly, patients who had undergone fasciotomy reported pain as frequently as amputees. Regarding the VAS, only patients with closed fractures reported significantly different scores from the mean of all the other groups. These data represent the health related quality of life of patients having suffered the full spectrum of tibial injury and should be considered when determining the treatment options for these patients.
Computer-assisted surgical techniques in knee replacement procedures have been shown to increase the accuracy of implant positioning and reduce the incidence of alignment and soft-tissue balancing “outliers”. The use of this technology as a training tool is less widely reported. However, the recent implementation of the EWTD 48-hour working week for junior doctors has focussed attention on the issues of surgical training and experience. Recent evidence from trainee logbooks has shown a significant downward trend in operative exposure and this is forcing changes in the principles of how training should be delivered. Trainees are actively required to demonstrate operative competence in order to progress but are increasingly faced with limited opportunities to acquire these skills. On the other hand, trainers also face difficulties with the prospect of supervising less accomplished trainees which raises ethical issues of patient protection. We present a trainee’s perspective of experience gained in a unit routinely using computer-assisted technology and highlight the potential to enhance the learning process. Navigation systems provide constant visual and numerical feedback via a computer simulated interpretation. Initially this displays relevant functional anatomy, helps in the identification of anatomical landmarks and demonstrates sagittal and coronal plane deformities which can be difficult to accurately assess “by eye”. Computer-assisted systems have the benefit of displaying only bony anatomy which improves visualisation. This can then be compared to the palpable, clinical deformity on the table. The geometry of the native knee is also made clear with the navigation system leading to a better understand of the objectives of TKR. There are some aspects of the biomechanics of the knee which are difficult to appreciate, such as the changes in varus-valgus alignment during flexion and extension. This may be very subtle and difficult to pick up manually but can look quite dramatic on the computer. The position of cutting jigs which are held to the bone by pins can be altered by inadvertently lifting or hanging on them with the saw, when making the bone cuts. Additionally the cut can be altered by advancing the cutting block closer to the bone, for example if cutting the tibia with a posterior slope. Both these effects can be quantified by using the navigation tools to confirm the cut that has been made. Trainers can have the benefit of seeing the alignment and confirming the cuts made by a trainee without having to get closely involved with the operation. Cementation technique is also open to scrutiny with the ability to compare pre and post cementation alignment. The positive feedback obtained from computer assisted surgery is educational to the trainee, by giving an undisputable computer generated graphic of what they are doing during the different stages of total knee arthroplasty. It also shows what has been achieved at the end of the procedure. This can give both the trainer and trainee more confidence in the procedure and ensures patient safety.
Infection following hip arthroplasty although uncommon can have devastating outcomes. Obesity, defined as a BMI of ≥ 30, is a risk factor for infection in this population. Coagulase negative staphylococcus aureus (CNS) is the commonest causative organism isolated from infected arthroplasties. This study was performed to determine if there has been a change in the causative organisms isolated from infected hip arthroplasties and to see if there is a difference in obese patients. Data on all deep infection following primary and revision hips was obtained from the surgical site infection register from April 1998 to Nov 2007. Case notes were reviewed retrospectively. There were 49 patients with 51 infected arthroplasties; 25 infected Primary THAs and 26 infected Revision THAs. We found a female preponderance in the infected primary and revision THAs (n=30). 63.2% of all patients had a BMI of ≥ 30, compared to only 34.7% of the non infected population (p<
0.0001). Over the period studied, CNS was the most common organism isolated (56.8%) followed by mixed organisms (37.2%) and staphylococcus aureus (25.4%). Multiple organisms were found exclusively in obese patients. In more than half of cases the causative organisms were resistant to more than two antibiotics. This study shows that over the last 10 years, CNS continues to be the most frequently isolated organism in infected hip arthroplasties. Multiple organisms with multiple antibiotic resistances are common in obese patients. On this basis we recommend that combination antibiotic therapy should be considered in obese patients.
Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at presenting characteristics or the differential diagnosis of such lesions. We report our experience of foot lumps treated surgically looking at the patient demographics, presenting characteristics, diagnoses encountered and the diagnostic accuracy of the surgeon. All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied; 101 patients were identified. Average age was 47.3 years (range 14–79); there was a significant female preponderance with 73 females and 28 males (p<
0.0001). Pain was the single most common presenting complaint followed by footwear problems. Only three patients attended because of cosmetic reasons and neurological symptoms were very rare with only one patient complaining of paraesthesia. Certain lesions were more commonly encountered in specific zones of the foot. 32 different histological types were identified, ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the l01 lumps were correctly diagnosed prior to surgery. We have shown that there are a wide variety of potential diagnoses, which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and therefore surgical excision and histological diagnosis should be sought if there is any uncertainty.
In-vitro evidence suggests that wear debris can alter osteoblast function resulting in decreased bone matrix production and negative remodelling balance. FRZB encodes for Secreted Frizzled-Related Protein 3 which may play a role in bone formation and osteoarthritis. This study was undertaken to investigate whether the recently described single nucleotide polymorphisms (SNPs) at positions [+6] and [+109] of the FRZB gene are associated with osteolysis after THA. Genomic DNA was extracted from 481 North European Caucasians at a mean of 12 years following cemented THA for idiopathic osteoarthritis. The control group consisted of 267 subjects and the osteolysis group 214 subjects. The [+6] and [+109] FRZB SNPs were genotyped using standard techniques. For the FRZB [+6] SNP, the rare T allele was significantly over-represented in control versus the osteolysis group (χ2 test for trend, p=0.02,). The odds ratio for osteolysis associated with carriage of the [+6] T-allele versus the [+6] C-allele was 0.58 (95%CI 0.36 to 0.94), p=0.03. The odds ratio for osteolysis associated with carriage of the [+109] G-allele versus the [+109] C-allele was 0.66 (0.38 to 1.12), p=0.15. A number of covariates have previously been described in this cohort and after adjustment for the effects of these covariates, the odds ratio for osteolysis with carriage of the [+6] T-allele was 0.69 (0.42–1.16). We found that the FRZB [+6] T-allele is less common in subjects with osteolysis after THA versus controls, suggesting that allelic variants of genes associated with bone formation pathways may have a role in modulating the risk of osteolysis. However its loss of significance after correction for other factors suggests an interaction between this allele and other risk factors in osteolysis.
We performed a prospective audit to assess radiological and clinical sequelae of using injectable calcium sulphate in the management of distal radial fractures. All patients in a 4-month period who were treated with injectable calcium sulphate for distal radial fracture were included in the audit. Initial data was collected on demographics; AO classification and degree of deformity; method of fixation and surgical complications. Follow up consisted of clinical and radiological assessment of fracture healing at standard fracture clinic intervals with a final assessment of subjective functional recovery. 16 patients were included in the audit, all of whom were followed up for a minimum of 8 weeks. We observed a low incidence of secondary displacement, and did not observe the problem of increased pain and erythema that has been observed with other bone graft substitutes. We conclude that injectable calcium sulphate is a useful adjunct to conventional management of these fractures that is safe, helps maintain fracture reduction and is not associated with product specific complications.
The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union. 14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Seven fractures were originally open (grade IIIb). All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. Following initial stabilisation, all the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. The average length of follow-up was 24 months following exchange nailing. There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5/14 (35.7%) cases. 4 patients required further soft tissue debridement and a free flap to secure union. Of the remaining 5 patients, 1 required dynamisation, another required incision and drainage of peri-fracture abscess, the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24). In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis.