It has been shown that a cognitive function (CF) loss can occur after hip or knee arthroplasty procedures, with an incidence of 40 to 70%. The pathogenesis remains unclear but studies suggest some form of brain emboli; although both trans-cranial doppler and trans-oesophageal doppler have both shown emboli per-operatively a correlation has never been shown with CF loss post-operatively. In contrast, in the cardiothoracic literature an embolic cause is widely accepted for detectable post-operative CF drop. The purpose of this study was to ascertain whether MRI could show evidence of embolic phenomena in patients undergoing hip or knee arthroplasty. Twenty-five patients presenting for hip or knee arthroplasty procedures were consented for this study. Brain MRI scans and MR angiograms were performed 1 week pre-operatively and within 1 week post-operatively using a Phillips 1.5Tesla MRI unit. All scans recorded were independently reviewed by 2 radiologists. A series of tests to examine several modes of cognitive function were carried out by a clinical psychologist pre-operatively, and at 1 week post-operatively. The CF tests showed a clinically significant drop following surgery in 64% of cases – this is in keeping with other recently published data. None of the post-operative scans or angiograms showed overt evidence of new lesions. Three Scans had equivocal tiny brainstem hypodensities on a single slice with no correlating abnormality on diffusion images to support the presence of new ischaemia. We conclude that either the aetiology of post-operative CF drop following arthroplasty is not embolic in nature, or that with current technology MRI brain scans even with angiograms are not sensitive enough to show the corresponding abnormality. With currently available equipment there appears to be no benefit from using MRI as a tool to evaluate post-operative CF loss in this group of patients

Acute pain is one of the most common symptoms shared among patients who have suffered from an orthopedic trauma such as an isolated upper limb fracture (IULF). Development of interventions with limited side effects aiming to prevent the installation of chronic pain is critical as persistent pain is associated with an increased risk of opioid dependence, medical complications, staggering financial burdens and diminished quality of life. Theta burst stimulation (TBS), a non-invasive magnetic brain stimulation technique with minimal side effects, has shown promising results in patients experiencing various types of chronic pain conditions as it precisely targets brain regions involved in pain processing. Surprisingly, its impact on acute pain has never been investigated. This study aims to assess longitudinal effects of a 10-day continuous TBS (cTBS) protocol applied in the acute phase of an IULF on key functional outcomes. Patients with an IULF aged between 18 to 60 years old were recruited within 7 days post-accident at a Level I Trauma Center. Exclusion criteria included a history of brain injury, neurological disorders, musculoskeletal complications, and open fractures. In order to assess longitudinal changes, questionnaires measuring intensity and characteristics of pain (Numerical Rating Scale, NRS; McGill Pain Questionnaire, MPQ) as well as functional disability (DASH) were completed by all patients at three time points, namely prior to the start of the TBS program as well as 72 hours and 3 months post-intervention. Patients were randomly attributed to the active TBS protocol (active group) or to the placebo protocol (sham group). The stimulation site for each participant corresponded to the contralateral motor cortex of the injured arm. Fifty patients were recruited (female: 24; age: 40.38 years old), of which 25 were in the active group and 25 were in the sham group. Both groups were equivalent based on age, sex, type of injury, and surgical procedures (p>0.05). The intervention protocol was introduced on average 6.18 days post-accident. In comparison to the sham group, the active group showed a significant decrease in pain intensity (NRS) at 72h (F=6.02; p=0.02) and 3-month (F=6.37; p=0.02) post-intervention. No group difference was found early-on (72h post) in regard to pain characteristics (MPQ; F=3.90; p=0.06) and functional disabilities (DASH; F=0.48; p= 0.49). At three-month post-intervention, the active group showed statistically significant improvement on the MPQ (F=5.02; p=0.04) and the DASH (F=5.88; p=0.02) compared to the placebo group. No complications related to the treatment were reported. Results from this study show that patients who underwent active cTBS reported less pain and better functional states shortly after the end of the TBS protocol compared to sham patients and treatment effects were maintained at three months post-intervention. Given that acute pain intensity is an excellent predictor of chronic pain development, this safe technique available in numerous centers in Canada may help prevent chronic pain development when administered during the acute post-injury phase. Future studies should continue to investigate mechanisms involved to optimize this technique among the orthopedic trauma population and to reduce opioid consumption

Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit. A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed. Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%). Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition

Persistent post-surgical pain (PPSP) remains a problem after knee replacement with some studies reporting up to 20% incidence. Pain is usually felt by those who do not operate to be a monolithic entity. All orthopaedic surgeons know that this is not the case. At its most basic level, pain can be divided into two categories, mechanical and non-mechanical. Mechanical pain is like the pain of a fresh fracture. If the patient does not move, the pain is less. This type of pain is relieved by opiates. Mechanical pain is seen following knee replacement, but is becoming less frequent. It is caused by a combination of malrotations and maltranslations, often minor, which on their own would not produce problems. The combination of them, however, may produce a knee in which there is overload of the extensor mechanism or of the medial stabilizing structures. If these minor mechanical problems can be identified, then corrective surgery will help. Non-mechanical pain is present on a constant basis. It is not significantly worsened by activities. Opiates may make the patient feel better, but they do not change the essential nature of the pain. Non-mechanical pain falls into three broad groups, infection, neuropathic and perceived pain. Infection pain is usually relieved by opiates. Since some of this pain is probably due to pressure, its inclusion in the non-mechanical pain group is questionable, but it is better left there so that the surgeon always considers it. Low grade chronic infection can be extremely difficult to diagnose. Loosening of noncemented knee components is so rare that when it is noted radiologically, infection should be very high on the list of suspicions. The name neuropathic pain suggests that we know much more about it than we do in reality. Causalgia or CRPS-type two is rare following knee replacement. CRPS-type one or reflex sympathetic dystrophy probably does exist, but it is probably over-diagnosed. The optimum treatment I have found is lumbar sympathetic blocks. Lyrica, Gabapentin and Cymbalta may also help. Perceived pain is the largest group. It does not matter what you tell the patient, some believe a new knee should be like a new car, i.e. you step into it and drive away. The fact that they have to work to make it work is horrifying. Perceived pain is widespread. The classic treatise, Dr. Ian McNabb's book “Backache”, should be studied by all who wish to understand pain complaints. Any experienced knee surgeon will have his list of red flags or caveats. I will list only a few. If the patient comes in with a form asking for a disability pension on the first visit. If the patient's mother answers the questions. If the patient comes in taking massive doses of opiates. If the patient is referred to you by a surgeon who does more knee replacements than you do. There are other issues such as good old fibromyalgia, which appears to have gone the way of the dodo. It has been replaced by something equally silly called central sensitization. The theory of central sensitization is that if one has pain somewhere or other for three months or six months or whatever, there are going to be changes in the brain and spinal cord. It then does not matter what happens to the original pain, i.e. whether or not it goes away, the pain will persist because of the changes in the brain, hence, the title of the pain in the brain syndrome. If this theory was correct, we might as well all go home because we have all been wasting our time for the last 30 years because none of our patients would get any better. After all, all of our patients have had pain for a lot longer than three months, many of them have been involved in trauma and sometimes, compensation is at issue. The pain in the brain theory, therefore, sounds about as realistic as the flat earth society or the treatment of Galileo

Persistent post-surgical pain (PPSP) remains a problem after knee replacement with some studies reporting up to 20% incidence. At its most basic level, pain can be divided into two categories, mechanical and non-mechanical. Mechanical pain is like the pain of a fresh fracture. If the patient does not move, the pain is less. This type of pain is relieved by opiates. Mechanical pain is seen following knee replacement, but is fortunately becoming less frequent. It is caused by a combination of malrotations and maltranslations, often minor, which on their own would not produce problems. The combination of them, however, may produce a knee in which there is overload of the extensor mechanism or of the medial stabilizing structures. If these minor mechanical problems can be identified, then corrective surgery will help. Non-mechanical pain is present on a constant basis. It is not significantly worsened by activities. Opiates may make the patient feel better, but they do not change the essential nature of the pain. Non-mechanical pain falls into three broad groups, infection, neuropathic and perceived pain. Infection pain is usually relieved by opiates. Since some of this pain is probably due to pressure, its inclusion in the non-mechanical pain group is questionable, but it is better left there so that the surgeon always considers it. Low grade chronic infection can be extremely difficult to diagnose. Loosening of noncemented knee components is so rare that when it is noted radiologically, infection should be very high on the list of suspicions. The name neurogenic pain suggests that we know much more about it than we do in reality. Causalgia or CRPS-type two is rare following knee replacement. CRPS type one or reflex sympathetic dystrophy probably does exist, but it is probably over-diagnosed especially by the author of this abstract. The optimum treatment I have found is lumbar sympathetic blocks. Lyrica, Gabapentin and Cymbalta may also help. Perceived pain is the largest group. It does not matter what you tell patient, some believe a new knee should be like a new car, i.e. you step into it and drive away. The fact that they have to work to make it work is horrifying. Some of this pain is actually mechanical, especially in those with no benefits such as hairstylists. Perceived pain is widespread. The classic treatment on this is Dr. Ian McNabb's book “Backache”. It should be studied by all orthopaedic surgeons, who wish to understand pain complaints. There are other issues such as good old fibromyalgia, which appears to have gone the way of the dodo. It has been replaced by something equally silly called central sensitization. The theory of central sensitization is that if one has pain somewhere or other for three months or six months or whatever, there are going to be changes in the brain and spinal cord. It then does not matter what happens to the original pain, i.e. whether or not it goes away, the pain will persist because of the changes in the brain, hence, the title of the pain in the brain syndrome. If this theory was correct, we might as well all go home because we have all been wasting our time for the last 30 years because none of our patients would get any better. After all, all of our patients have had pain for a lot longer than three months, many of them have been involved in trauma and sometimes, compensation is at issue. The pain in the brain theory, therefore, sounds about as realistic as the flat earth society or the treatment of Galileo

Aim. Silver is known for its excellent antimicrobial activity, including activity against multiresistant strains. The aim of the current study was to analyze the biocompatibility and potential influence on the fracture healing process a silver-coating technology for locking plates compared to silver-free locking plates in a rabbit model. Methods. The implants used in this study were 7-hole titanium locking plates, and plasma electrolytic oxidation (PEO) silver coated equivalents. A total of 24 rabbits were used in this study (12 coated, 12 non-coated). An osteotomy of the midshaft of the humerus was created with an oscillating saw and the humerus stabilized with the 7 hole locking plates with a total of 6 screws. X-rays were taken on day 0, week 2, 4, 6, 8, and 10 for continuous radiographical evaluation of the fracture healing. All animals were euthanized after 10 weeks and further assessment was performed using X-rays, micro-CT, non-destructive four-point bending biomechanical testing and histology. Furthermore, silver concentration was measured in the kidney, liver, spleen and brain. Results. X-rays showed normal undisturbed healing of the osteotomy in all animals without any differences between the two groups over the entire X-ray analysis over 10 weeks (Figure 1). Callus formation was observed up to week 4 to 5 followed by callus remodeling after 6 weeks indicating physiological fracture healing pattern in both the silver and in the silver free group. Micro CT analysis revealed overall tissue (callus and cortical bone) volume as well as tissue density to be comparable between the two groups. Mechanical testing showed comparable stiffness with an average stiffness relative to contralateral bones of 75.7 ± 16.1% in the silver free control group compared to 69.7 ± 18.5% (p-value: 0.46). Histology showed no remarkable difference in the analysis of the healed osteotomy gap or in the surrounding soft tissue area. Silver content was found to be close to baseline values without differences between the two groups. Conclusions. This study shows that the presented antimicrobial silver surface modification for locking plates has a good biocompatibility without any negative influence on the fracture healing processes compared to the silver free control group. This allows for further clinical investigation of this silver technology for locking plates in fracture patients with an elevated infection risk, e.g. in patients with open fractures. For any figures or tables, please contact the authors directly

There are two types of pain, mechanical and non-mechanical. Mechanical pain hurts with movement/use, is not constant and is helped by morphine-type products. Non-mechanical pain is different. It is present 24 hours a day, often worse at night, and except for the pain of infection, is not relieved by morphine-type products. If the cause of mechanical pain can be determined, it can be corrected by an operation. The usual cause of postoperative mechanical knee pain nowadays is multifactorial, i.e. a combination of minor errors, none of which on their own would require revision. Non-mechanical pain, other than infection, is much more difficult to handle. The commonest cause is not really a pain complaint, it is disappointment due to a failure of expectation. It does not matter how often you tell patients, some patients still think they should step in a drive away. A lot of these failures of expectations become much more realistic by the end of year one. There are several other categories. Incipient osteoarthritis or sensitive people (The Princess and the Pea). If the pain complaints were severe with minimal arthritis, an operation is not likely to help. The patient on disability for no clear reason is unlikely to get a good result and Workmen's Compensation Board and motor vehicle accident patients are also a very bad prognostic sign and will often produce the postoperative painful knee. Preoperative use of large doses of morphine is also a very bad sign. It is not clear if it is the morphine, which influences the patient or the patient, who influences the morphine. There are several pain syndromes, some of which are purely psychiatric such as Conversion Disorders and Somatoform Pain Disorders. Treatment of purely psychiatric conditions should be a referral to a psychiatrist is in order. Complex regional pain syndrome is an organic pain disorder. Type 2 is causalgia or an actual nerve injury. This is unusual following knee replacement other than the odd drop foot, which even after recovery, leaves an area of dysaethesia on the dorsum of the foot. Type 1 used to be called reflex sympathetic dystrophy. This is not uncommon after total knee replacement. I managed to collect more than 40 cases. One problem is that the diagnosis to some extent is a diagnosis of exclusion. If the diagnosis can be made, then treatment is available including Cymbalta, Lyrica or Gabapentin. I have found most success with lumbar sympathetic blocks, but it is difficult to find someone, who can do these. Some patients have been treated with implantable electrical spinal stimulators with variable results. The current flavour of the month pain syndrome is called central sensitization. The theory is that if someone has pain for more than six months, then there will be changes in the brain, which will remain after the original pain goes away, hence, the title the pain in the brain syndrome. If this theory were correct, then we as arthroplasty surgeons have been collectively wasting our time for the last 40 years as no patient would have recovered. The likelihood, therefore, of this theory having any basis in reality is pretty remote. Fortunately, by the end of year one, the vast majority of our knee replacement patients are reasonably content with the procedure

Aim. To compare the performance of sonication and chemical methods (EDTA and DTT) for biofilm removal from artificial surface. Method. In vitro a mature biofilms of Staphylococcus epidermidis (ATCC 35984) and P. aeruginosa ATCC®53278) were grown on porous glass beads for 3 days in inoculated brain heart infusion broth (BHI). After biofilm formation, beads were exposed to 0.9% NaCl (control), sonication (40 kHz, 1 min, 0.2 W/cm. 2. ), EDTA (25 mM/15 min) and DTT (1 g/L/15 min). Quantitative and qualitative biofilm analysis were performed with viable counts (CFU/ml) and microcalorimetry using time to detection (TTD), defined as the time from insertion of the ampoule into the calorimeter until the exponentially rising of heat flow signal exceeded 100 μW, which is inversely proportional to the amount of remaining bacterial biofilm on the beads. All experiments were performed in triplicate. Results. Mean colony counts obtained after treatment S. epidermidis biofilms with EDTA and DTT was similar to those after 0.9% NaCl (control) – 6.3, 6.1 and 6.0 log CFU/mL, respectively. Sonication detected significantly higher CFU counts with 7.5 log (p<0.05). Concordant results were detected with microcalorimetry: significantly less (p<0.05) biofilm after treatment with sonication compared to EDTA and DTT (12 h vs 6h and 6h, respectively). The same results were observed when P. aeruginosa biofilms were treated. Mean colony counts dislodged after treatment with EDTA and DTT was similar to those after 0.9% NaCl (control) – 5.2, 5.3 and 5.0 log CFU/mL, respectively. Sonication detected significantly higher CFU counts with 6.5 log (p<0.05). Microcalorimetry reviled concordant results: significantly less (p<0.05) biofilm after treatment with sonication in comparison with EDTA and DTT (11 h vs 6h and 6h, respectively). Conclusions. Chemical methods showed no difference in biofilm dislodging compared to normal saline. Sonication is superior to chemical methods (DTT or EDTA) for biofilm detection. Sonication may be improved by combination of two or more chemical dislodgement methods

Introduction. Support of appositional bone ingrowth and resistance to bacterial adhesion and biofilm formation are preferred properties for biomaterials used in spinal fusion surgery. Although polyetheretherketone (PEEK) is a widely used interbody spacer material, it exhibits poor osteoconductive and bacteriostatic properties. In contrast, monolithic silicon nitride (Si. 3. N. 4. ) has shown enhanced osteogenic and antimicrobial behavior. Therefore, it was hypothesized that incorporation of Si. 3. N. 4. into a PEEK matrix might improve upon PEEK's inherently poor ability to bond with bone and also impart resistance to biofilm formation. Methods. A PEEK polymer was melted and compounded with three different silicon nitride powders at 15% (by volume, vol.%), including: (i) α-Si. 3. N. 4. ; (ii) a liquid phase sintered (LPS) ß-Si. 3. N. 4. ; and (iii) a melt-derived SiYAlON mixture. These three ceramic powders exhibited different solubilities, polymorphic structures, and/or chemical compositions. Osteoconductivity was assessed by seeding specimens with 5 × 10. 5. /ml of SaOS-2 osteosarcoma cells within an osteogenic media for 7 days. Antibacterial behavior was determined by inoculating samples with 1 × 10. 7. CFU/ml of Staphylococcus epidermidis (S. epi.) in a 1 × 10. 8. /ml brain heart infusion (BHI) agar culture for 24 h. After staining with PureBlu™ Hoechst 33342 or with DAPI and CFDA for SaOS-2 cell adhesion or bacterial presence, respectively, samples were examined with a confocal fluorescence microscope using a 488 nm Krypton/Argon laser source. Images were also acquired using a FEG-SEM in secondary and backscattered modes on gold sputter-coated specimens (∼20–30Å). Hydroxyapatite (HAp) deposition was measured using a laser microscope. Raman spectra were collected for samples in backscattering mode using a triple monochromator using a 532 nm excitation source (Nd:YVO. 4. diode-pumped solid-state laser). Results. PEEK composites with 15 vol.% α-Si. 3. N. 4. , LPS ß-Si. 3. N. 4. , or the SiYAlON mixture showed significantly greater SaOS-2 cell proliferation (>600%, p<0.003, cf., Fig. 1(a)) and HAp deposition (>100%, p<0.003, cf., Fig. 1(b)) relative to monolithic PEEK. The largest increase in cell proliferation was observed with the SiYAlON composite, while the greatest amount of HAp was found on the LPS ß-Si. 3. N. 4. composite. Following exposure to S. epidermidis, the composite containing the LPS β-Si. 3. N. 4. powder showed one order of magnitude reduction in adherent live bacteria (p<0.003, cf., Fig. 1(c)) as compared to the PEEK monolith. It is interesting to note that the composite containing α-Si. 3. N. 4. exhibited the worst bacterial resistance (i.e., ∼100% higher than monolithic PEEK), suggesting that the bacteriostatic effectiveness of Si. 3. N. 4. bioceramics is apparently dependent upon the presence of selective sintering additives, viz. yttria and alumina. Conclusions. The addition of 15 wt.% of specific Si. 3. N. 4. powders to PEEK showed enhanced SaOS-2 cell adhesion, proliferation, and HAp deposition when compared to monolithic PEEK. These same composites also showed resistance to S. epi. adhesion and biofilm formation.. Although improvements in osteoconductivity have been previously observed by compounding or coating PEEK with HAp, titanium, or tantalum, these approaches did not provide anti-microbial properties. Compounding PEEK with Si. 3. N. 4. represents a significant advancement due to its ability to provide both improved bone apposition and resistance to biofilm formation. For any figures or tables, please contact the authors directly

To examine the effect of lateral spine curvature on somatosensory evoked potentials (SSEP) in patients with adolescent idiopathic scoliosis (AIS) compared to normal controls. We hypothesise that patients with AIS will show increased latency in their SSEPs when bending into their curve suggesting that their spinal cord is more sensitive to this increased lateral curvature. Patients were recruited from the paediatric scoliosis clinic in a single centre. Inclusion criteria were: diagnosis of AIS, age 10–18 years, major thoracic curve measuring greater than 10 degrees on Cobb measurement, and undergoing nonoperative management. Exclusion criteria were: any detectable neurologic deficit, and previous surgery on the brain or spine. SSEP recordings were obtained via stimulation of the posterior tibial nerve with surface electrode and measurement of the cortical response over the scalp. All recordings were performed three times: with the patient in neutral standing and maximum right and left side bending. SSEP recordings show that when AIS subjects bend into their curve, latency slows by an average of 0.5ms. However there was a bimodal distribution with most subjects showing minimal change (3ms). This subset was statistically different from both a control group, and the larger AIS group. There appears to be a subset of patients with AIS who have subclinical spinal cord dysfunction demonstrated by abnormal SSEPs. This may place these patients at slightly higher risk of neurologic injury at the time of surgery

Aims

Disorders of bone integrity carry a high global disease burden, frequently requiring intervention, but there is a paucity of methods capable of noninvasive real-time assessment. Here we show that miniaturized handheld near-infrared spectroscopy (NIRS) scans, operated via a smartphone, can assess structural human bone properties in under three seconds.

Aims

Bacterial infection activates neutrophils to release neutrophil extracellular traps (NETs) in bacterial biofilms of periprosthetic joint infections (PJIs). The aim of this study was to evaluate the increase in NET activation and release (NETosis) and haemostasis markers in the plasma of patients with PJI, to evaluate whether such plasma induces the activation of neutrophils, to ascertain whether increased NETosis is also mediated by reduced DNaseI activity, to explore novel therapeutic interventions for NETosis in PJI in vitro, and to evaluate the potential diagnostic use of these markers.

Introduction. Large variations in knee kinematics existed after conventional TKA. Different design of TKA showed different intra-operative kinematics with navigation system. Purpose. The purpose of this study was to compare the kinematics of the three different types of prosthesis in navigation-based in vivo simulation. (Material and Method) Studies were carried out on 15 osteoarthritis Knees using the CT-free navigation system (Kolibri Knee, Brain LAB). Fourteen patients were female and one patient was male with mean age of 72 years. Five knees were implanted with the CR knee, 5 knees were implanted with the PS knee and 5 knees were implanted with PS mobile knee by navigated measured resection technique (PFC-sigma knee system, DePuy, Warsaw, IN). Intra-operative knee kinematics during passive range of motion from full extension to 130 degrees of knee flexion was measured after implantation while patella reduced and tourniquet released. While supporting the foot with one hand, the surgeon used his opposite hand to gently lift the thigh, flexing the hip and knee. Three types of prosthesis were compared for following factors: Presence of condylar lift-off (the gap difference greater than 1mm between medial gap and lateral gap) and anterior-posterior (AP) displacement of the center of femur relative to the tibia. Results. Lateral condylar lift-off was found in patients with the PS implant between 120° and 130° of flexion. Remaining two types of implant did not show the condyar lift-off (Fig. 1). The pattern of AP displacement showed the same manner in three implants. Femur moved anterior side form extension to 50∼55° of flexion, after that, femur moved posterior side to full flexion. The mean maximum anterior movement and angle in CR implant was 14mm @ 55°, PS implant was 17mm ï¼ 50° and PS-mobile implant was 17mm @ 55°. The mean maximum posterior movement @ 130°, CR implant was −10.5mm, PS implant was −8.3mm and PS-mobile implant was −6.9mm. There was no significant difference among three groups. Discussion. In CR implant, the function of PCL could influence to prevent the condyar lift-off. In PS-mobile implant, the mechanism of rotation platform might have contributed to prevent the condylar lift-off. The paradoxical anterior slide of the femoral condyles during mid flexion was observed in all types of implant. We could not find any difference in AP displacement of these 3 types of prosthesis

An interesting case with excellent accompanying images, highlighting the significance of tourniquets in controlling exsanguination, whilst also raising the issue of amputation versus reconstruction in severely injured limbs. A 39 year old male motorcyclist was BIBA to the Midland Regional Hospital in Tullamore, following a head-on collision with a bus at high velocity. On arrival, he was assessed via ATLS guidelines; A- intubated, B- respiratory rate 32, C - heart rate 140bpm, blood-pressure 55/15 and D- GCS 7/15. Injuries included partial traumatic amputation of the right lower limb with clearly visible posterior femoral condyles, a heavily comminuted distal tibial fracture and almost complete avulsion of the skin and fat at the popliteal fossa. Obvious massive blood loss at the scene had been tempered by a passer-by who applied a beach towel as a makeshift tourniquet. CT Brain demonstrated extra-dural and subarachnoid haemorrhages with gross midline shift. Unfortunately, the neurosurgical team in Beaumont concluded that surgical intervention would be inappropriate. However, his kidneys had not sustained ATN and were made available for donation. Two vital surgical issues were featured in this case. Firstly, it highlighted the importance of tourniquets in controlling exsanguination in a trauma situation. 1. Secondly, it raised the critical issue of amputation versus reconstruction in severely injured limbs. 2,3. . Without prompt placement of a make-shift tourniquet by a passer-by, this patient would have almost certainly died at the scene of the accident. Two kidneys were successfully donated as a result. The importance of appropriate tourniquet use cannot be overstated. This case highlights its potential life or limb-saving capabilities in emergency trauma situations. It also raises the critical issue of amputation versus reconstruction in acute emergency situations

Background and Aims:. In 2009 a combined clinic was formed by the orthopaedic Surgeons and Developmental Paediatricians in our hospital. The aim was to help improve the assessment and management of patients with Cerebral Palsy. Included in the assessment team, are the paediatric orthopaedic surgeons, the developmental paediatricians, physiotherapists and occupational therapists. Our aim was to audit the patients presenting to this clinic over a 15 month period to look at the demographic data, clinical severity and decisions taken for these patients. Methods:. We looked at patients seen in the clinic from January 2013 to March 2014. We recorded the age, gender and primary caregiver. We also recorded the reason for referral. Clinically we wanted to know the type and distribution of the CP, GMFCS score, attainment of milestones and type of schooling. We recorded underlying aetiologies and HIV status of the patients. Finally the access the patients had to physiotherapy and Occupational therapy. Results:. We saw 41 patients in total with 18 males and 23 females. The ages ranged from 5 months to 9 years (mean 4.9 years). 36 of 41 (88%) had spastic CP, 2 (5%) dystonic, 1 (2%) mixed and 2 (5%) were not recorded. Diplegic and hemiplegic predominated with 15 (37%) and 14 (34%) respectively, there were 6 (15%) quadriplegics, 1 double hemiplegic and 5 were not recorded. 13 (31%) of patients had birth asphyxia as an aetiology, 13 (31%) had brain anomalies, 9 (22%) were premature babies, the remaining 16% comprised HIV, post natal sepsis and injury. 38 (93%) were cared for by at least one parent and the remaining 3 (7%) were cared for by a grandparent. 39 (95%) had access to physiotherapy and 30 (73%) had access to occupational therapy. 21 (51%) had no access to appropriate schooling. 9 (22%) were known to be HIV positive. The recommended orthopaedic interventions were continued physiotherapy for 17 (41%) and botox in 22(54%). Discussion:. The combined clinic has highlighted the diverse nature of cerebral palsy and the challenges facing our patients. It is an invaluable tool in the goal directed management of complex cases

Introduction and aims. Solitary fibrous tumours (SFT) are rare soft tissue sarcomas. Challenges in management include the variation in anatomical location and uncertain malignant potential. We retrospectively reviewed our experience with the aim of formulating guidelines on appropriate treatment. Methods. An electronic database identified patients with SFT presenting between 2003–2011. Clinical records were reviewed. Results. 23 patients were identified. Mean age was 50.6 years (12–77 years). The anatomic location was lower limb in 8, upper limb 4, intrathoracic 3, retroperitoneal 3, buttock and perianal regions 2, pelvis 1, thoracic spine 1 and brain 1. 10 cases were histologically benign, 5 had malignant potential and 8 were malignant. In 12 cases there was a complete surgical resection. In 6 cases there was a positive margin or piecemeal excision. There were 4 local recurrences and 5 patients with metastases. Completeness of record keeping varied with times and surgical speciality. Conclusions. SFT occur infrequently, are difficult to diagnose, have an unpredictable course and present to a variety of surgical specialists. In order to improve outcomes, we recommend surgical and histological margins are accurately recorded and audited whatever surgical specialty leads the surgery, ideally within a sarcoma MDT. Complete resection at first attempt by specialists with an understanding of the need for complete resection is the goal

Purpose. Severe osteo-articular infection can be a devastating disease causing local complications, multiple organ failure and death. The aim of this study is to highlight the potential severity and subsequent sequelae of osteo-articular infections in children and to determine causative factors leading to this devastating condition. Methods. We retrospectively report on six cases treated at two academic hospitals. We included all patients with osteo-articular infections who had multi-organ involvement. All patients had more than one joint as well as another organ involved as a direct result of the bacteraemia. All patients with single organ involvement were excluded. The patient files were recorded as part of a previously published study. Data capture included X-rays, serology for blood culture, FBC, ESR, CRP and HIV. Ultrasound of involved joints, technetium bone scans, echocardiograms and computed tomography of the brain were performed when indicated. Results. There was a delay in the diagnosis and subsequent treatment of all of these patients, mean duration 4.8 days(1 to 10) Twenty-two osteo-articular sites were involved mean 3,7 sites (2 to 6)and seventeen other organs mean 2,8 (2 to 5). The mean number of debridements or joint washouts for each patient was 4,5 (3 to 6). Four of the six cases cultured organisms: One Staphylococcus aureus, one Haemophilus influenzae and one Candida spp on tissue. Local complications included chronic osteomyelitis, physeal separation, pathological fractures and hip dislocation. There was one death in a nine year old HIV positive patient with severe multiple organ failure. Conclusion. A delay in the diagnosis and treatment of osteo-articular infection was identified as the causative factor leading to severe infection with life threatening complications. NO DISCLOSURES

Introduction. Patellofemoral (PF) complications are among the most frequently observed adverse events after total knee arthroplasty (TKA). It has been reported that PF complications after TKA include decreasing knee range of motion, anterior knee pain, quadriceps and patellar-tendon rupture, patellar subluxation, and partial abrasion and loosening of the patellar component. Although recent improvements in surgical technique and prosthetic design have decreased these complications, the percentage of patients who have a revision TKA for PF complications still ranged up to 6.6% to 12%. For the present study, we hypothesized that the alignment of the femoral component is correlated with PF contact stress. The purpose of this study was to investigate the relationship between femoral component alignment and PF contact stress in vivo, using a pressure sensor in patients who had favorable extension-flexion gap balance during TKA. Methods. Thirty knees with medial compartment osteoarthritis that underwent posterior stabilized mobile-bearing TKA using identical prostheses (PFC Sigma RPF; Depuy, Warsaw, IN, USA) by a single surgeon (TM) with modified gap technique under a computed tomography (CT)-based navigation system (Vector Vision 1.61; Brain Lab, Heimstetten, Germany) were evaluated. PF contact stress was measured intraoperatively and compared with the alignment of the femoral component including intraoperative navigation data concerning medial shift of the patella and lateral tilt of the patella, postoperative coronal femoral component angle (alpha angle), postoperative sagittal femoral component angle (gamma angle), postoperative condylar twist angle (CTA), postoperative lateral condylar lift-off angle, and postoperative mechanical femoral component angle (mFCA). In addition, postoperative Insall-Salvati ratio (I-S ratio) was measured by dividing the length of patellar tendon by the greatest diagonal length of the patella. Results. Maximum PF stress was 2.4 ± 1.9 MPa, medial shift of the patella was 2.6 ± 1.5 mm, and lateral tilt of the patella was 8.5 ± 4.2 degrees. The PF contact stress was not correlated sagittal and coronal alignment of the femoral component and patella tracking, whereas rotational alignment of the femoral component was negatively correlated with the PF contact stress (r = −0.718, p < 0.01). Discussion and conclusion. Multiple regression analysis shows that PF contact stress correlates with CTA, I-S ratio positively correlates with PF contact stress in Spearman correlation analysis. The results of the present study showed a negative correlation between maximum stress in the PF joint and CTA. It has been reported that excessive external rotation increases the medial flexion gap, leading to symptomatic flexion instability of the femoral component. In addition, external rotation of the femoral component can cause relative medialization of the trochlear groove during flexion, resulting in anterior knee pain. Therefore, we should carefully decide the proper rotational alignment of the femoral component. It has been reported that PF contact stress in a normal knee was from 2.1 to 2.9 MPa in a cadaveric study. In the present study, patients with rotational alignment of the femoral component after TKA between 1.2° and 2.2° internally rotated from CEA had PF contact stress in this normal range

It is widely accepted that navigation system for TKA improves precision in component alignment. Furthermore, some of the system can measure knee kinematics during surgery. On the other hand, the measurements of kinematics during surgery have limitations because of anesthesia and usage of air tourniquet. The purpose of the present study is to compare the knee kinematics during surgery using navigation system and that after surgery using 2D/3D Registration Technique. Our final goal of the study is to improve clinical outcome by performing feedback of good clinical results to operating theater by means of kinematic analysis. Kinematics of ten TKA knees for female (average age 71 years old) medial compartmental osteoarthritic knees concerning axial rotation and anterior-posterior translation were measured twice, the time during surgery and 4 weeks after surgery. During surgery, measurement was performed using CT based navigation system (Vector Vision 1.6, Brain LAB, Heimstetten, Germany). Four weeks after surgery, knee kinematics was measured again using a 2-dimensional to 3-dimensional registration technique, which used computer-assisted design models to reproduce the position of metallic implants from single-view fluoroscopic images. Surgery was performed by single surgeon using subvastus approach to eliminate the influence of approach to muscle balance. Implant using the present study was P.F.C. Sigma RP-F (DePuy, Warsaw, USA). Axial rotation in navigation and 2D/3D are 12.3+/−2.3, and 12.6+/−3.8, respectively. Axial rotations in both of the measurement have the same pattern. A-P translations also have the same pattern between measurement in navigation and that in 2D/3D technique. These results suggested that intraoperative kinematic measurement links to postoperative kinematics. Studies of correlations between kinematics and good clinical results are ongoing

Introduction:. Periprosthetic infections that accompany the use of total joint replacement devices cause unwanted and catastrophic outcomes for patients and clinicians. These infections become particularly problematic in the event that bacterial biofilms form on an implant surface. Previous reports have suggested that the addition of Vitamin E to ultra-high-molecular-weight polyethylene (UHMWPE) may prevent the adhesion of bacteria to its surface and thus reduce the risk of biofilm formation and subsequent infection. 1–3. In this study, Vitamin E was blended with two types of UHMWPE material. It was hypothesized that the Vitamin E blended UHMWPE would resist the adhesion and formation of clinically relevant methicillin-resistant Staphylococcus aureus (MRSA) biofilms. Methods and Materials:. Five sample types were manufactured, machined and sterilized (Table 1). To determine if MRSA biofilms would be reduced or prevented on the surface of the Vitamin E (VE) loaded samples (HXL VE 150 kGy and HXL VE 75 kGy) in comparison to the other three clinically relevant material types, each was tested for biofilm formation using a flow cell system. 4. Direct Bacterial Quantification – An n = 7 samples of each material type were placed individually into a chamber of the flow cell. A solution of 10% modified brain heart infusion (BHI) broth containing 10. 5. MRSA cells/mL was flowed through each chamber. Using previously established protocols,. 4–7. after 48 hours of growth, each sample was removed, and the number of colony forming units (CFU) determined using a 10-fold dilution series. SEM Imaging – Using the same protocol as above, after the 48-hour incubation period, an n = 7 of each material type were fixed in 2.5% glutaraldehyde, dehydrated in ascending concentrations of ethanol, coated with carbon and imaged using scanning electron microscopy (SEM). Results:. Results indicated that the Vitamin E blended materials did not resist the attachment/formation of MRSA biofilms to any greater degree than the other three material types. All materials had greater than 10. 7. CFU/cm. 2. (Figure 1). SEM images corroborated with the quantification data (Figure 2). Discussion:. In contrast to previously published results,. 1–3. these data indicated that Vitamin E blended UHMWPE may not have the ability to prevent biofilm formation of a clinical MRSA isolate from occurring