The August 2013 Research Roundup. 360 . looks at: passive smoking and bone substitutes; platelet-rich plasma and osteogenesis; plantar fasciitis and platelet-rich plasma: a match made in heaven?; MRSA decolonisation decreases infection rates; gums, bisphosphonates and orthopaedics; PRAISE and partner violence; blunt impact and post-traumatic OA; and IDEAL research and implants

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm. The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient. A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.

The June 2013 Hip & Pelvis Roundup. 360 . looks at: failure in metal-on-metal arthroplasty; minimal hip approaches; whether bisphosphonates improve femoral bone stock following arthroplasty; whether more fat means more operative time; surgical infection; vascularised fibular graft for osteonecrosis; subclinical SUFE; and dentists, hips and antibiotics

We report our experience of the use of callus distraction with a monolateral fixator for the treatment of acquired radial club-hand deformity after osteomyelitis. Between 1994 and 2004, 13 patients with a mean age of eight years (4 to 15) were treated by callus distraction with a monolateral fixator after a preliminary period of at least four weeks in a corrective short-arm cast. All patients achieved bony union and were satisfied with the functional and cosmetic outcome. There were no major complications, but three patients required cancellous bone grafting at the docking site for delayed union. Local treatment and oral antibiotics were required for pin-site infection in six patients. There were no deep infection or recurrence of osteomyelitis

Aims

Failure of healing is a well-known problem after repair of the rotator cuff. This study aimed to investigate if early repair of trauma-related full-thickness rotator cuff tears (FTRCTs) could prevent this failure.

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42° (0° to 140°) to 89° (0° to 165°), mean external rotation from 30° (0° to 90°) to 43° (0° to 90°), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate

The June 2013 Shoulder & Elbow Roundup. 360 . looks at: whether suture anchors are still the gold standard; infection and revision elbow arthroplasty; the variable success of elbow replacements; sliding knots; neurologic cuff pain and the suprascapular nerve; lies, damn lies and statistics; osteoarthritis; and one- or two-stage treatment for the infected shoulder revision

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

We report our early experience with the use of a new prosthesis, the Modular Hemipelvic Prosthesis II, for reconstruction of the hemipelvis after resection of a primary malignant peri-acetabular tumour involving the sacroiliac joint. . We retrospectively reviewed the outcome of 17 patients who had undergone resection of a pelvic tumour and reconstruction with this prosthesis between July 2002 and July 2010. One patient had a type I+II+III+IV resection (ilium + peri-acetabulum + pubis/ischium + sacrum) and 16 had a type I+II+IV resection (ilium + acetabulum + sacrum). The outcome was assessed at a mean follow-up of 33 months (15 to 59). One patient was alive with disease, 11 were alive without disease and five had died of disease. The overall five-year survival rate was 62.4%. Six patients had a local recurrence. The mean Musculoskeletal Tumour Society score was 58% (33 to 77). Deep infection occurred in two patients, problems with wound healing in five and dislocation in one. For patients with a primary malignant peri-acetabular sarcoma involving the sacroiliac joint, we believe that this new prosthesis is a viable option for reconstruction of the bony defect left following resection of the tumour. It results in a satisfactory functional outcome with an acceptable rate of complications. . Cite this article: Bone Joint J 2014;96-B:399–405

The June 2013 Foot & Ankle Roundup. 360 . looks at: soft-tissue pain following arthroplasty; pigmented villonodular synovitis of the foot and ankle; ankles, allograft and arthritis; open calcaneal fracture; osteochondral lesions in the longer term; severe infections in diabetic feet; absorbable first ray fixation; and showering after foot surgery

In 1999, we developed a technique for biological reconstruction after excision of a bone tumour, which involved using autografts of the bone containing the tumour treated with liquid nitrogen. We have previously reported the use of this technique in 28 patients at a mean follow up of 27 months (10 to 54). In this study, we included 72 patients who underwent reconstruction using this technique. A total of 33 patients died and three were lost to follow-up, at a mean of 23 months (2 to 56) post-operatively, leaving 36 patients available for a assessment at a mean of 101 months 16 to 163) post-operatively. The methods of reconstruction included an osteo-articular graft in 16, an intercalary in 13 and, a composite graft with prosthesis in seven. Post-operative function was excellent in 26 patients (72.2%), good in seven (19.4%), and fair in three (8.3%) according to the functional evaluation system of Enneking. No recurrent tumour occurred within the grafts. The autografts survived in 29 patients (80.6%), and the rates of survival at five and ten years were 86.1% and 80.6 %, respectively. Seven of 16 osteo-articular grafts (44%) failed because of fracture or infection, but all the composite and intercalary grafts survived. The long-term outcomes of frozen autografting, particularly using composite and intercalary grafts, are satisfactory and thus represent a good method of treatment for patients with a sarcoma of bone or soft tissue. Cite this article: Bone Joint J 2014;96-B:555–61

We have performed a prospective double-blind, randomised controlled trial over two years to evaluate the efficacy and safety of an intra-operative peri-articular injection of triamcinolone acetonide in patients undergoing medial unicondylar knee replacement. We randomised 90 patients into two equal groups. The study group received an injection of triamcinolone acetonide, bupivacaine, and epinephrine into the peri-articular tissues at the end of the operation. The control group received the same injection mixture but without the addition of triamcinolone. The peri-operative analgesic regimen was standardised. The study group reported a significant reduction in pain (p = 0.014 at 12 hours, p = 0.031 at 18 hours and p = 0.031 at 24 hours) and had a better range of movement (p = 0.023 at three months). There was no significant difference in the rate of infection and no incidence of tendon rupture in either group. The addition of corticosteroid to the peri-articular injection after unicondylar knee replacement had both immediate and short-term benefits in terms of relief from pain, and rehabilitation with no increased risk of infection

Bone loss in the proximal tibia and distal femur is frequently encountered in revision knee replacement surgery. The various options for dealing with this depend on the extent of any bone loss. We present our results with the use of cementless metaphyseal metal sleeves in 103 patients (104 knees) with a mean follow-up of 43 months (30 to 65). At final follow-up, sleeves in 102 knees had good osseointegration. Two tibial sleeves were revised for loosening, possibly due to infection. The average pre-operative Oxford Knee Score was 23 (11 to 36) and this improved to 32 (15 to 46) post-operatively. These early results encourage us to continue with the technique and monitor the outcomes in the long term. . Cite this article: Bone Joint J 2013;95-B:1640–4

The June 2013 Spine Roundup. 360 . looks at: the benefit of MRI in the follow-up of lumbar disc prolapse; gunshot injury to the spinal cord; the link between depression and back pain; floating dural sack sign; short segment fixation at ten years; whether early return to play is safer than previously thought; infection in diabetic spinal patients; and dynesis

Intra-articular injections of steroid into the hip are used for a variety of reasons in current orthopaedic practice. Recently their safety prior to ipsilateral total hip replacement has been called into question owing to concerns about deep joint infection. We undertook a retrospective analysis of all patients who had undergone local anaesthetic and steroid injections followed by ipsilateral total hip replacement over a five-year period. Members of the surgical team, using a lateral approach to the hip, performed all the injections in the operating theatre using a strict aseptic technique. The mean time between injection and total hip replacement was 18 months (4 to 50). The mean follow-up after hip replacement was 25.8 months (9 to 78), during which time no case of deep joint sepsis was found. In our series, ipsilateral local anaesthetic and steroid injections have not conferred an increased risk of infection in total hip replacement. We believe that the practice of intra-articular local anaesthetic and steroid injections to the hip followed by total hip replacement is safer than previously reported

Aims

We retrospectively report our experience of managing 30 patients with a primary malignant tumour of the distal tibia; 25 were treated by limb salvage surgery and five by amputation. We compared the clinical outcomes of following the use of different methods of reconstruction.

Conventional amputation prostheses rely on the attachment of the socket to the stump, which may lead to soft-tissue complications. Intraosseous transcutaneous amputation prostheses (ITAPs) allow direct loading of the skeleton, but their success is limited by infection resulting from breaching of the skin at the interface with the implant. Keratinocytes provide the skin’s primary barrier function, while hemidesmosomes mediate their attachment to natural ITAP analogues. Keratinocytes must attach directly to the surface of the implant. We have assessed the proliferation, morphology and attachment of keratinocytes to four titaniumalloy surfaces in order to determine the optimal topography in vitro. We used immunolocalisation of adhesion complex components, scanning electron microscopy and transmission electron microscopy to assess cell parameters. We have shown that the proliferation, morphology and attachment of keratinocytes are affected by the surface topography of the biomaterials used to support their growth. Smoother surfaces improved adhesion. We postulate that a smooth topography at the point of epithelium-ITAP contact could increase attachment in vivo, producing an effective barrier of infection