Aims

There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse.

The aim was to assess the long-term impact of humeral and forearm rodding on functional ability, grip strength, joint range of motion and angular deformity in children with osteogenesis imperfecta.

A retrospective chart review was conducted on 57 children with osteogenesis imperfecta who underwent humeral rodding or forearm rodding at our institution between 1996 and 2013. Functional ability was assessed using the self-care and mobility domains of the Pediatric Evaluation and Disability Inventory (PEDI). Grip strength was measured using a dynamometer and joint range of motion with a goniometer. Deformity was measured on radiographs of the humerus or forearm. Outcomes were assessed pre-operatively and every year post-operatively. Differences between pre-operative and 1-year post-operative outcomes were compared using paired T-tests. In 44 patients with a minimum of 2 years follow-up, outcome measures at 1-year post-surgery were compared to those at the latest clinic visit (mean follow-up = 8.0 years).

Humeral and forearm rodding resulted in a significant improvement in PEDI self-care score (mean change =5.75, p=0.028 for the humerus, mean change = 6.77, p=0.0017 for the forearm) and mobility score (mean change =3.59, p=0.008 for the humerus, mean change =7.21, p=0.020 for the forearm) at 1 year post-surgery. Grip strength improved following forearm rodding (mean change = +6.13N, p=0.015) but not humeral rodding. Joint range of movement improved following humeral rodding but not forearm rodding. There was a significant improvement in radiographic angular deformity of the forearm and humerus following surgery (p<0.0001). Over 80% of improvements were maintained in the long-term.

Humeral and forearm rodding in children with osteogenesis imperfecta leads to long-term improvement in functional ability and angular deformity.

Introduction

Wound surveillance has been reported to result in a significant fall in the incidence of wound sepsis in total knee arthroplasty (TKA). However, there is currently little guidance on the definition of surgical wound infection that is best to be used for surveillance. The purpose of this study was to assess the agreement between three common definitions of surgical wound infection as a performance indicator in TKA; (a) the CDC 1992 definition, (b) the NINSS modification of the CDC definition and (c) the ASEPSIS scoring method applied to the same series of surgical wounds.

There is mixed evidence in the literature regarding increasing age, ASA and BMI as risk factors for surgical site infection in orthopaedic surgery. To investigate the matter further, we examined 1055 wounds in 1008 patients in the Department of Trauma and Orthopaedic Surgery at University College London Hospital between 2000 and 2006. All patients with a minimum two-night stay were included. Data was collected by four designated research nurses. The age, height, weight and ASA status of each patient was recorded. All wounds were classified using ASEPSIS. This is a quantitative wound scoring method which is a summation of scores calculated from visual wound characteristics and the clinical consequences of infection.

Our results showed a strong linear association between age and ASEPSIS scores. Single variable regression analysis showed a t value of 3.32 and p value of 0.001. A similar linear association was seen between ASA grading and ASEPSIS scores. Single variable regression analysis showed a t value of 2.75 and p value of 0.006. The association between BMI and ASEPSIS scores was markedly different from that seen with age and ASA. The graph was U-shaped with patients with a BMI of 25-30 having the lowest average ASEPSIS scores. Patients with a lower and a higher BMI had higher average ASEPSIS scores. Single variable regression analysis was not significant since the relationship between BMI and ASEPSIS scores is not linear.

In conclusion, there are clearly defined patient groups who are at increased risk of developing a surgical site infection: older patients, patients with a higher ASA, and patients with both a low and high BMI. These patients should be targeted to reduce overall infection rates. This can be achieved by ensuring adequate antibiotic prophylaxis, having a low threshold to treat suspected infection and arranging regular follow-up.

Aim

The aim of our study was to assess lateral tracking of the patella with differing designs of Total Knee Arthroplasty (TKA) and compare to that of the native patella.

Purpose

To determine the impact of sonographic information on surgeons' diagnostic thinking and decision-making in the management of infants with clinically suspicious hip dysplasia.

Four experienced consultant surgeons examined 66 hips referred for possible hip dysplasia and reported for each hip (i) the confidence level (visual analogue scale 0-100) about the diagnosis of this hip, and (ii) how they would manage the hip. Each infant was referred to ultrasound and the same surgeon repeated the rating with the sonographic information available. We determined the efficiency in diagnostic thinking and calculated the mean gain in diagnostic confidence that was provided by the sonographic information. We also determined the therapeutic efficacy, ie the impact of ultrasound information on surgeons’ management plans.

The ultrasound led to a change in diagnosis in 34/66 (52%) hips. However, the management plan only changed in 21/66 (32%) hips. The mean gain in reported diagnostic confidence was 19.37 (95% CI = 17.27, 21.47). If the treatment plan did not change, there still was a gain in diagnostic confidence but this gain was small with a mean value of 8 (95% CI = 5.29, 10.70). However, if the ultrasound led to a change of the treatment plan, the mean gain in diagnostic confidence was much higher with 46 (95% CI = 30.53, 60.79). The difference was -37.67 (P < 0.0001). Ultrasound was most useful (mean gain >30) in hips demonstrating limited abduction or a positive Galeazzi sign.

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection.

If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading.

Studies have shown that the normal patella tracks laterally with flexion of the knee joint, consistent with the findings of Eckhoff et al. that the femoral sulcus is lateral to the mid-plane between the 2 femoral condyles. Patellar pain and instability is a known complication of Total Knee Arthroplasty (TKA). To date, several studies have identified the effect of femoral and tibial components on complication after TKA. However, there is very little work on how the design of the implant affects patellar tracking. Our study compares lateralization of the patella in two different AP stabilized knee implants.

A modified caliper was used to measure the width and position of the patella relative to the femur at different degrees of knee flexion. The relationship of the patella midpoint to that of the femur was subsequently assessed. Group 1 consisted of 25 native knees. Group 2 consisted of 25 patients with antero-posterior stabilized knee implant with a spherical medial condyle and a deep lateralized patellar groove (MRK, Finsbury Orthopaedics, UK). And Group 3 consisted of 25 patients with traditional cam-and-post posterior cruciate-substituting implant with a symmetrical patellar groove (PFC-Sigma, DePuy, UK). The mean follow-up for the 50 TKAs was 28 months.

Lateral tracking corresponded well in all groups, but the mean lateral displacement of the patella in group 2 correlated more closely to that of group 1. At 90 degrees of flexion, the patella was displaced a mean of 7mm laterally in both groups 1 and 2, but a mean of 4mm in group 3. Two-tailed Mann-Whitney U test (95% confidence interval) showed that the difference in lateral patellar displacement between groups 1 and 3, and that between groups 2 and 3 were statistically significant (p< 0.05). However, the patellar displacement between groups 1 and 2 was not statistically different.

Our results indicate that lateral patellar displacement in group 2 is similar to that of native knees (group 1). The effect of the underlying lateralized deep patellar groove of the femoral component in group 2 is more able to mimic that of the native femoral sulcus. This intrinsic implant design accommodates the natural tracking of the patella.

Aims: To determine the rate of orthopaedic wound infection using ASEPSIS and compare this to the rate of infection as defined by the US Centres for Disease Control (CDC) and the UK Surgical Site Infection Surveillance Service (SSISS).

Background: It is a common misconception that reported rates of orthopaedic wound infection are accurate, reliable and reproducible. Most definitions of infection, including CDC and SSISS, are subjective and depend on the interpretation of the surgeon. ASEPSIS1 is a method of wound scoring which grades wounds as uninfected, disturbed healing, minor infection, moderate infection and severe infection. ASEPSIS scoring has been proven to be both objective and repeatable2.

Method: Over 4 years, 1113 orthopaedic wounds were prospectively evaluated using the CDC definition for surgical site infections, the SSISS definition and the ASEPSIS scoring method. Patients were seen pre-operatively and at 3 and 5 days post-operatively. They also completed a wound surveillance questionnaire at 2 months post-discharge.

Results: The overall infection rates were 8% as defined by CDC, 4% as defined by SSISS and 3% as defined by ASEPSIS. Further classification of the wounds as defined by ASEPSIS revealed that 91% of wounds showed no evidence of infection (score < 10), 6.6% showed a disturbance of healing (score 11–20), 2.3% had a minor infection (score 21–30), 0.4% had a moderate infection (score 31–40) and 0.3% had severe infection (score > 40).

Conclusion: This study illustrates that accurate wound surveillance is not simple. Different wound infection definitions give very different rates of infection and make comparisons between surgeons and hospitals impossible.

We propose that ASEPSIS provides the most accurate and reproducible results and also provides more information with the grading of wound infection. The overall rate of orthopaedic wound infection using the ASEPSIS method is 3%. If all hospitals used this scoring method, more accurate comparisons of infection rates could be made.

Orthopaedic outcome measures are used to evaluate the effect of operative interventions. They are used for audit and research. Knowledge of these measures is becoming increasingly important with league tables comparing surgeons and hospitals being made accessible to the profession and the general public.

Several types of tool are available to describe outcome after hip surgery such as generic quality-of-life questionnaires, disease-specific quality-of-life questionnaires, hip-specific outcome measures and general short-term clinical measures. We provide an overview of the outcome measures commonly used to evaluate hip interventions.

Due to economic constraints, it has been suggested that joint replacement patients can be followed up in primary care. There are clinical, ethical and academic reasons why we must ensure that our joint replacements are appropriately clinically and radiologically followed up to minimise complications. This Editorial discusses this.