Delayed postoperative inoculation of orthopaedic implants with persistent wound drainage or bacterial seeding of a haematoma can result in periprosthetic joint infection (PJI). The aim of this in vivo study was to compare the efficacy of vancomycin powder with vancomycin-eluting calcium sulphate beads in preventing PJI due to delayed inoculation. A mouse model of PJI of the knee was used. Mice were randomized into groups with intervention at the time of surgery (postoperative day (POD) 0): a sterile control (SC; n = 6); infected control (IC; n = 15); systemic vancomycin (SV; n = 9); vancomycin powder (VP; n = 21); and vancomycin bead (VB; n = 19) groups. Delayed inoculation was introduced during an arthrotomy on POD 7 with 1 × 105 colony-forming units (CFUs) of a bioluminescent strain of Aims
Methods
Aims. Informed patient consent is a legal prerequisite endorsed by
multiple regulatory institutions including the Royal College of
Surgeons and the General Medical Council. It is also recommended
that the provision of written information is available and may take
the form of a Patient Information Leaflet (PIL) with multiple PILs
available from leading orthopaedic institutions. PILs may empower
the patient, improve compliance, and improve the patient experience.
The national reading age in the United Kingdom is less than 12 years
and therefore PILs should be written at a readability level not
exceeding 12 years old. We aim to assess the readability of PILs
currently provided by United Kingdom orthopaedic institutions. Patients and Methods. The readability of PILs on 58 common conditions provided by seven
leading orthopaedic associations in January 2017, including the
British Orthopaedic Association, British Hip Society, and the British
Association of
An extensive review of the
The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting. A total of 421 patients from the Cohort Hip and Cohort Knee (CHECK) database, a population-based observational cohort, with hip and knee complaints < 6 months, aged between 45 and 65 years old, and with lateral lumbar, hip, and knee radiographs available, were included. Sagittal spinopelvic parameters and pathologies (spondylolisthesis and degenerative disc disease (DDD)) were measured at eight-year follow-up and characteristics of hip and knee osteoarthritis (OA) at baseline and eight-year follow-up. Epidemiology of the degenerative disorders and clinical outcome scores (hip and knee pain and Western Ontario and McMaster Universities Osteoarthritis Index) were compared between low PI (< 50°), normal PI (50° to 60°), and high PI (> 60°) using generalized estimating equations.Aims
Methods
The aim of this study was to examine the association between
postoperative glycaemic variability and adverse outcomes following
orthopaedic surgery. This retrospective study analyzed data on 12 978 patients (1361
with two operations) who underwent orthopaedic surgery at a single
institution between 2001 and 2017. Patients with a minimum of either
two postoperative measurements of blood glucose levels per day,
or more than three measurements overall, were included in the study.
Glycaemic variability was assessed using a coefficient of variation
(CV). The length of stay (LOS), in-hospital complications, and 90-day
readmission and mortality rates were examined. Data were analyzed
with linear and generalized linear mixed models for linear and binary
outcomes, adjusting for various covariates.Aims
Patients and Methods
The aim of this paper was to present the clinical features of
patients with musculoskeletal sources of methicillin-sensitive A total of 137 patients presented with MSSA septicaemia between
2012 and 2015. The primary source of infection was musculoskeletal
in 48 patients (35%). Musculoskeletal infection was considered the
primary source of septicaemia when endocarditis and other obvious
sources were excluded. All patients with an arthroplasty at the time
were evaluated for any prosthetic involvement. Aims
Patients and Methods
Tuberculosis (TB) infection of bones and joints accounts for
6.7% of TB cases in England, and is associated with significant
morbidity and disability. Public Health England reports that patients
with TB experience delays in diagnosis and treatment. Our aims were
to determine the demographics, presentation and investigation of
patients with a TB infection of bones and joints, to help doctors
assessing potential cases and to identify avoidable delays. This was a retrospective observational study of all adults with
positive TB cultures on specimens taken at a tertiary orthopaedic
centre between June 2012 and May 2014. A laboratory information
system search identified the patients. The demographics, clinical presentation,
radiology, histopathology and key clinical dates were obtained from
medical records.Aims
Patients and Methods
The use of robots in orthopaedic surgery is an
emerging field that is gaining momentum. It has the potential for significant
improvements in surgical planning, accuracy of component implantation
and patient safety. Advocates of robot-assisted systems describe
better patient outcomes through improved pre-operative planning
and enhanced execution of surgery. However, costs, limited availability,
a lack of evidence regarding the efficiency and safety of such systems
and an absence of long-term high-impact studies have restricted
the widespread implementation of these systems. We have reviewed
the literature on the efficacy, safety and current understanding of
the use of robotics in orthopaedics. Cite this article:
Currently, there is no animal model in which
to evaluate the underlying physiological processes leading to the heterotopic
ossification (HO) which forms in most combat-related and blast wounds.
We sought to reproduce the ossification that forms under these circumstances
in a rat by emulating patterns of injury seen in patients with severe
injuries resulting from blasts. We investigated whether exposure
to blast overpressure increased the prevalence of HO after transfemoral
amputation performed within the zone of injury. We exposed rats
to a blast overpressure alone (BOP-CTL), crush injury and femoral
fracture followed by amputation through the zone of injury (AMP-CTL)
or a combination of these (BOP-AMP). The presence of HO was evaluated
using radiographs, micro-CT and histology. HO developed in none
of nine BOP-CTL, six of nine AMP-CTL, and in all 20 BOP-AMP rats.
Exposure to blast overpressure increased the prevalence of HO. This model may thus be used to elucidate cellular and molecular
pathways of HO, the effect of varying intensities of blast overpressure,
and to evaluate new means of prophylaxis and treatment of heterotopic
ossification. Cite this article:
Recent recommendations by the National Institute
for Health and Care Excellence (NICE) suggest that all patients undergoing
elective orthopaedic surgery should be assessed for the risk of
venous thromboembolism (VTE). Little is known about the incidence of symptomatic VTE after
elective external fixation. We studied a consecutive series of adult
patients who had undergone elective Ilizarov surgery without routine
pharmacological prophylaxis to establish the incidence of symptomatic
VTE. A review of a prospectively maintained database of consecutive
patients who were treated between October 1998 and February 2011
identified 457 frames in 442 adults whose mean age was 42.6 years
(16.0 to 84.6). There were 425 lower limb and 32 upper limb frames.
The mean duration of treatment was 25.7 weeks (1.6 to 85.3). According to NICE guidelines all the patients had at least one
risk factor for VTE, 246 had two, 172 had three and 31 had four
or more. One patient (0.23%) developed a pulmonary embolus after surgery
and was later found to have an inherited thrombophilia. There were
27 deaths, all unrelated to VTE. The cost of providing VTE prophylaxis according to NICE guidelines
in this group of patients would be £89 493.40 (£195.80 per patient)
even if the cheapest recommended medication was used. The rate of symptomatic VTE after Ilizarov surgery was low despite
using no pharmacological prophylaxis. This study leads us to question
whether NICE guidelines are applicable to these patients. Cite this article:
Drug therapy forms an integral part of the management
of many orthopaedic conditions. However, many medicines can produce
serious adverse reactions if prescribed inappropriately, either
alone or in combination with other drugs. Often these hazards are
not appreciated. In response to this, the European Union recently
issued legislation regarding safety measures which member states
must adopt to minimise the risk of errors of medication. In March 2014 the Medicines and Healthcare products Regulatory
Agency and NHS England released a Patient Safety Alert initiative
focussed on errors of medication. There have been similar initiatives
in the United States under the auspices of The National Coordinating
Council for Medication Error and The Joint Commission on the Accreditation
of Healthcare Organizations. These initiatives have highlighted
the importance of informing and educating clinicians. Here, we discuss common drug interactions and contra-indications
in orthopaedic practice. This is germane to safe and effective clinical
care. Cite this article:
We report 79 cases of bone and joint tuberculosis between 1988 and 2005, eight of which were in the Caucasian population and 71 in the non-white population. The diagnosis was made in the majority (73.4%) by positive bacteriology and/or histology. The mean age at the time of diagnosis was higher in the Caucasian group at 51.5 years (28 to 66) than in the South Asian group at 36.85 years (12 to 93). Only one patient had previous BCG immunisation. The spine was the site most commonly affected (44.3%). Surgical stabilisation and/or decompression was performed in 23% of these cases because of cord compression on imaging or the presence of neurological signs. A six-month course of chemotherapy comprising of an initial two months of rifampicin, isoniazide, pyrazinamide and sometimes ethambutol followed by four months treatment with rifampicin and isoniazide, was successful in all cases without proven drug resistance.
Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.
Osteoporosis is common and the health and financial
cost of fragility fractures is considerable. The burden of cardiovascular
disease has been reduced dramatically by identifying and targeting
those most at risk. A similar approach is potentially possible in
the context of fragility fractures. The World Health Organization
created and endorsed the use of FRAX, a fracture risk assessment
tool, which uses selected risk factors to calculate a quantitative,
patient-specific, ten-year risk of sustaining a fragility fracture.
Treatment can thus be based on this as well as on measured bone
mineral density. It may also be used to determine at-risk individuals,
who should undergo bone densitometry. FRAX has been incorporated
into the national osteoporosis guidelines of countries in the Americas,
Europe, the Far East and Australasia. The United Kingdom National
Institute for Health and Clinical Excellence also advocates its
use in their guidance on the assessment of the risk of fragility
fracture, and it may become an important tool to combat the health
challenges posed by fragility fractures.
We reviewed 234 benign solitary schwannomas treated between 1984 and 2004. The mean age of the patients was 45.2 years (11 to 82). There were 170 tumours (73%) in the upper limb, of which 94 (40%) arose from the brachial plexus or other nerves within the posterior triangle of the neck. Six (2.6%) were located within muscle or bone. Four patients (1.7%) presented with tetraparesis due to an intraspinal extension. There were 198 primary referrals (19 of whom had a needle biopsy in the referring unit) and in these patients the tumour was excised. After having surgery or an open biopsy at another hospital, a further 36 patients were seen because of increased neurological deficit, pain or incomplete excision. In these, a nerve repair was performed in 18 and treatment for pain or paralysis was offered to another 14. A tender mass was found in 194 (98%) of the primary referrals. A Tinel-like sign was recorded in 155 (81%). Persistent spontaneous pain occurred in 60 (31%) of the 194 with tender mass, impairment of cutaneous sensibility in 39 (20%), and muscle weakness in 24 (12%). After apparently adequate excision, two tumours recurred. No case of malignant transformation was seen.
This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons. Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications. A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left
A total of 38 patients with leprosy and localised nerve damage (11 median at the wrist and 37 posterior tibial at the ankle) were treated by 48 freeze-thawed skeletal muscle autografts ranging between 2.5 cm and 14 cm in length. Sensory recovery was noted in 34 patients (89%) and was maintained during a mean period of follow-up of 12.6 years (4 to 14). After grafting the median nerve all patients remained free of ulcers and blisters, ten demonstrated perception of texture and eight recognised weighted pins. In the posterior tibial nerve group, 24 of 30 repairs (80%) resulted in improved healing of the ulcers and 26 (87%) demonstrated discrimination of texture. Quality of life and hand and foot questionnaires showed improvement; the activities of daily living scores improved in six of seven after operations on the hand, and in 14 of 22 after procedures on the foot. Another benefit was subjective improvement in the opposite limb, probably because of the protective effect of better function in the operated side. This study demonstrates that nerve/muscle interposition grafting in leprosy results in consistent sensory recovery and high levels of patient satisfaction. Ten of 11 patients with hand operations and 22 of 25 with procedures to the foot showed sensory recovery in at least one modality.
The aim of this study was to re-assess whether the use of a ‘one-knife technique’ can be considered as safe as the alternative practice of using separate skin and inside knives for elective orthopaedic surgery. A total of 609 knife blades from 203 elective orthopaedic operations, with equal numbers of skin, inside and control blades, were cultured using direct and enrichment media. We found 31 skin blades (15.3%), 22 inside blades (10.8%), and 13 control blades (6.4%) gave bacterial growth. Of the 31 contaminated skin blades only three (9.7%) had growth of the same organism as found on the corresponding inside blade. It is not known whether contamination of deeper layers in the remaining 90% was prevented by changing the knife after the skin incision. The organisms cultured were predominantly coagulase-negative staphylococci and proprionibacterium species; both are known to be the major culprits in peri-prosthetic infection. Our study suggests that the use of separate skin and inside knives should be maintained as good medical practice, since the cost of a single deep infection in human and financial terms can be considerable.
Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries. Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome. At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years.