Retrospective evaluation of leflunomide as an adjunctive therapy in dogs with non-associative immune-mediated thrombocytopenia: 20 cases (2008-2021).

OBJECTIVE: To describe leflunomide as an adjunctive therapy in the treatment of non-associative immune-mediated thrombocytopenia. MATERIALS AND METHODS: A retrospective study of dogs with a diagnosis of non-associative immune-mediated thrombocytopenia treated with leflunomide March 2008 to September 2021 was conducted. Data collected included signalment, clinical signs, physical examination findings and diagnostic testing performed. Medications administered, duration of hospital stay, time to platelet concentration >150×109/L and adverse events during leflunomide therapy were recorded. Relapses within a year of diagnosis were reported. RESULTS: A total of 20 client-owned dogs met inclusion criteria. Nineteen of 20 dogs (95%) achieved a platelet concentration >150×109/L with leflunomide and prednisone combination therapy and four dogs (21.1%) relapsed during treatment or shortly after treatment. Adverse effects included diarrhoea (n=5), mild lymphopenia (n=9) and mild intermittent anaemia (n=1). A single dog developed hepatotoxicity presumed to be secondary to leflunomide therapy that resolved after drug discontinuation. One dog was treated for aspiration pneumonia during treatment. Two dogs were euthanased while receiving leflunomide. CLINICAL SIGNIFICANCE: Length of hospitalisation, time to platelet recovery, treatment response and relapse rate were comparable with alternative treatment protocols. Most adverse effects did not require leflunomide dose adjustment; however, two dogs died while undergoing leflunomide treatment and there is compelling evidence that one of these dogs experienced fatal infection secondary to immune-suppression. Hepatotoxicity remains a known complication of leflunomide treatment and serial biochemistry testing is recommended.

Establishing Baseline Radiological Metrics of the Talus and Calcaneus: A Retrospective Analysis of Computed Tomography Imaging in an Irish Cohort.

Introduction The subtalar joint anatomy is complex and heterogeneity in its morphology creates unique challenges for foot and ankle surgeons. Anatomical metrics used for prosthesis design are well established. However, there is a paucity of literature quantifying foot and ankle measurement techniques and metrics used for prosthesis design. The aim of this study was to document reproducible measurement techniques and quantify talar and calcaneal metrics in a sample of Irish patients on computed tomography imaging to aid in the design of a novel hindfoot plate. Methods A retrospective analysis of consecutive foot and ankle computed tomography images performed at our institution was undertaken. Five measurements were performed on each foot and ankle image. Statistical analysis was performed to identify if a correlation existed between measurements. Results Sixty-four CTs met the inclusion criteria. Talar body height 27.1 mm (SD 2.17 mm), talar neck width 32.7 mm (3.16 mm), talar head height 25.41 (SD 2.16 mm), lateral process to posterior talus 23.6 (2.64 mm), calcaneal height 43.8 mm (SD 3.9 mm). A positive correlation was identified between all measurements. Conclusion This study identified that there was a low degree of heterogeneity in talar and calcaneal measurements in an Irish cohort. Furthermore, the metrics used in this study will provide valuable information for the preliminary design of a novel hindfoot plate.

Ten Inventions That Shaped Modern Orthopedics.

The current field of orthopedics is the result of many decades of minor and major advancements. The evolution of orthopedics has culminated into the modern field seen today. This article presents 10 inventions that played a key role in shaping modern orthopedics.

A growing challenge: The rise of femoral periprosthetic fractures - An 11-year observational study.

INTRODUCTION: The demand for joint arthroplasty has risen as our elderly population increases and ages. With this so to has the number of patients suffering periprosthetic fractures (PPF). The aim of our study was to quantify the burden of PPF and provide an up to date reference of the epidemiology of PPF in Ireland. We also sought to assess length of stay (LOS), resource utilisation and mortality associated with this cohort of patients. METHODS: An eleven-year retrospective observational study was conducted of a consecutive series of patients treated for a femoral PPF. Costs were obtained from activity based tariffs provided by the hospital inpatient enquiry system and mortality was confirmed using the national death events publication system. RESULTS: Over the 11-year study period 174 procedures for a femoral PPF were performed. Mean age of patients was 77.6 years (SD 11.1 years) with 44.7% male. Median ASA grade was 3 (range 1-4) and mean LOS was 19 days. There was a 700% increase in patients undergoing surgery for a PPF over the study period. The mean cost of care was €24,413 in 2017. Thirty-day mortality was 2.9% while one-year mortality was 12.4%. CONCLUSIONS: PPF occur in an elderly comorbid cohort of patients. Care of these patients now makes up a considerable part of the orthopaedic workload and consumes a significant portion of healthcare resources. Patients should be treated in tertiary referral centres with surgeons skilled in their management. Better access to rehabilitation is needed.

The Role of Circular Frames in the Management of Tibial Fractures.

Introduction The purpose of this study is to evaluate the factors that impact the clinical and radiographic outcomes in a patient cohort undergoing external fixation for tibial fractures. We also aim to investigate the use of autograft, allograft, and synthetic bone graft in varying combinations in the setting of tibial bone loss with respect to optimal times to union. Methods This was a retrospective study, including 46 patients treated with a circular external fixator for the management of acute tibial fractures. The study was carried out over a 10-year period, between 2007 and 2017, at our institution. The mean follow-up at the time of review was 4.6 years. Primary outcome measures were 'time to union,' 'delayed union' (> 6 months), 'infection,' and 'duration of external fixation.' Secondary outcomes included 'length of hospital stay' and functional scores using the 'Short Form-12 (SF-12).' The statistical analysis included both univariate and multivariate analyses to control for confounding variables when assessing predictors of delayed union and infection. Results Forty-six patients fulfilled the study criteria. Fifteen fractures were classified as open. The mean number of procedures per patient was 3.8 and the mean length of stay per patient was 33 days. The mean time to union was 8.6 months overall. Significant predictors of prolonged time to union were the 'number of interventions' (p<0.01) the patient underwent and the 'bone graft type' (p<0.01) used. The time to union in the presence of either autograft or allograft was lengthened by the addition of synthetic graft. Five patients developed a deep tissue infection. The use of synthetic bone graft was significantly associated with infection (p<0.05). On subgroup analysis, it was found that the use of synthetic graft in any combination leads to significantly higher rates of deep tissue infection (p<0.05). The mean time to full weight bearing was 10.6 months (s=9.78, 3-36). The majority (57%) were using walking aids and 67% reported that the injury was still affecting their lifestyle. Conclusion Tibial fractures with bone loss are a complex group of injuries that often require multiple surgical interventions, prolonged hospital inpatient stay, and suboptimal functional outcomes in many cases. The best times to union are achieved when autograft is used alone without any other combination of bone graft type. The use of synthetic bone graft also significantly increases the rate of deep tissue infection in this cohort. We recommend the use of autograft alone when treating bone defects in tibial fractures with external fixators.

Fracture Patients' Attitudes towards Online Health Information & a 'Prescribed' Fracture Website

Introduction Following musculoskeletal injury patient education is essential to help patients understand their treatment. Many attend the orthopaedic fracture clinic with multiple questions related to their diagnosis and treatment. Aim To assess trauma patients' attitudes towards online health information and a specific orthopaedic patient information website. Methods A validated questionnaire was distributed over 5 consecutive clinics, with questions based on previous online experiences & www.myorthoclinic.com. Results One hundred six patients completed the survey. Seventy-one percent trusted the internet whereas 83% trusted the information provided by the website. Eighty-three percent felt encouraged to take action to benefit their health. Eighty-seven percent felt that there was a wide range of information provided. Seventy-two percent agreed that they learnt something new. Discussion Patients attending the trauma clinic have benefited from the 'prescribing' of a dedicated orthopaedic trauma website. This low-cost concept utilises minimal resources, requires little effort to implement and is applicable to all specialties.

Osteochondral lesions of the ankle: The current evidence supporting scaffold-based techniques and biological adjuncts.

BACKGROUND: Talar osteochondral lesions are more common than has been previously recognized. Optimal treatment remains unclear and the subject of much debate in the literature. Although reparative techniques such as microfracture have produced initial good results and remain the gold standard in the management of these lesions, the literature is deficient in long-term data. Recently, techniques focused on enhancing the local biological environment have been developed which have demonstrated promising outcomes. METHODS: We reviewed the available evidence concerning scaffold-based techniques and biological adjuncts in the management of talar osteochondral lesions published in the English language on PubMed. RESULTS: An update is provided on the current evidence concerning the role of biological adjuncts in the management of osteochondral lesions of the talus. CONCLUSIONS: There has been an explosion of interest among the orthopaedic community in the role of biologics in the management of complex talar osteochondral lesions. A number of exciting new techniques have been developed which show promise. Robust randomized control trials are required to identify the optimal surgical strategy.

An Unusual Presentation of Osteochondroma in a Sexagenarian.

Osteochondroma is the most commonly-found benign bone tumour. It is a benign, cartilaginous-capped bony projection. They are usually present on the bony surfaces of the long bones in adolescents and young adults. The risk of malignant transformation is <1% with solitary osteochondroma. We present a rare case of an osteochondroma in a patient with advanced age and an unusual location.

Flexor digitorum accessorius causing tarsal tunnel syndrome in a paediatric patient: A case report and review of the literature.

The flexor digitorium accessorius muscle is an unusual anatomical variant found in the posteromedial aspect of the hindfoot and ankle. As previously described, its location predisposes patients to developing tarsal tunnel syndrome. This case illustrates the diagnosis, treatment and resolution of tarsal tunnel syndrome in a paediatric patient, secondary to the presence of flexor digitorium accessorius muscle.

The past, present and future in scaffold-based tendon treatments.

Tendon injuries represent a significant clinical burden on healthcare systems worldwide. As the human population ages and the life expectancy increases, tendon injuries will become more prevalent, especially among young individuals with long life ahead of them. Advancements in engineering, chemistry and biology have made available an array of three-dimensional scaffold-based intervention strategies, natural or synthetic in origin. Further, functionalisation strategies, based on biophysical, biochemical and biological cues, offer control over cellular functions; localisation and sustained release of therapeutics/biologics; and the ability to positively interact with the host to promote repair and regeneration. Herein, we critically discuss current therapies and emerging technologies that aim to transform tendon treatments in the years to come.

A novel modification of the Stainsby procedure: surgical technique and clinical outcome.

BACKGROUND: The 'Stainsby procedure' is an effective salvage procedure for correction of fixed claw toe deformity. A novel approach is described involving the extensor tenotomy step of the procedure, which is easier, faster and safer to perform. METHODS: A retrospective single surgeon review was performed to assess this modification. 37 patients (92 lesser toes in 42 feet) underwent the modified Stainsby procedure. Mean follow-up was 17 months. Patients were interviewed and examined at a dedicated review clinic. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores and Foot and Ankle Outcome (FAO) scores were calculated. RESULTS: Significant improvements in end-points including metatarsalgia, callosity and requirement for insoles or chiropody were noted. Median AOFAS and FAOS scores following the modified Stainsby procedure are reported and compare favourably to previously reported scores. Median FAOS scores were as follows: 92 for the category of pain, 84 for symptoms and stiffness, 96 for activities of daily living, 100 for sports and recreation and 81 for quality of life. Median AOFAS forefoot score was 80. There was a low rate of wound infection of 2.7% (n=1). CONCLUSION: We describe a novel technical modification to the Stainsby procedure and our results support the use of this modification, following assessment of patient outcome. However, limitations to this study were noted in terms of the length of follow-up, the absence of pre-operative clinical scores for comparative purposes, and the variety of surgical procedures performed concomitantly on the 1st ray.

Arthroscopic debridement for soft tissue ankle impingement.

AIM: To assess the response to treatment in patients with soft tissue impingement of the ankle managed with arthroscopic debridement. METHODS: Forty-one ankle arthroscopies were performed for soft tissue impingement between April 2007 and April 2009. There were 26 men and 15 women and the mean age was 30.1 years. Arthroscopy was performed on an average of 21 months after injury. The Visual-Analogue-Scale Foot and Ankle (VASFA) score and Meislin's criteria were used to assess the response to treatment. RESULTS: The mean pre-operative VASFA score was 44.5. This increased to 78.3 postoperatively (p < 0.0001). According to Meislin's criteria, there were 34 good or excellent results, five fair and two poor results. Pre-operative magnetic resonance imaging was useful in detecting tears of the anterior talofibular ligament and excluding osteochondral defects; however, synovitis and soft tissue impingement was under-reported. CONCLUSIONS: Arthroscopy is an effective method for the diagnoses and treatment of soft tissue impingement of the ankle joint. This condition is under-reported on MRI.

Effects of zinc and fluoride on the remineralisation of artificial carious lesions under simulated plaque fluid conditions.

The aim was to study the effects of zinc (Zn) and fluoride (F) on remineralisation at plaque fluid concentrations. Artificial carious lesions were created in 2 acid-gel demineralising systems (initially infinitely undersaturated and partially saturated with respect to enamel) giving lesions with different mineral distribution characteristics (high and low R values, respectively) but similar integrated mineral loss values. Lesions of both types were assigned to 1 of 4 groups and remineralised for 5 days at 37°C. Zn and F were added, based on plaque fluid concentrations 1 h after application, to give 4 treatments: 231 µmol/l Zn, 10.5 µmol/l F, Zn/F combined and an unmodified control solution (non-F/non-Zn). Subsequently remineralisation was measured using microradiography. High-R lesions were analysed for calcium, phosphorus, F and Zn using electron probe micro-analysis. All lesions underwent statistically significant remineralisation. For low-R lesions, remineralisation was in the order F(a) < non-F/non-Zn(a) < Zn(a, b) < Zn/F(b), and for high-R lesions F(a) < non-F/non-Zn(b) < Zn(b) < Zn/F(c) (treatments with the same superscript letter not significantly different, at p < 0.05). Qualitatively, remineralisation occurred throughout non-F/non-Zn and Zn groups, predominantly at the surface zone (F) and within the lesion body (Zn/F). Electron probe micro-analysis revealed Zn in relatively large amounts in the outer regions (Zn, Zn/F). F was abundant not only at the surface (F), but also in the lesion body (Zn/F). Calcium:phosphate ratios were similar to hydroxyapatite (all). To conclude, under static remineralising conditions simulating plaque fluid, Zn/F treatment gave significantly greater remineralisation than did F treatment, possibly because Zn in the Zn/F group maintained greater surface zone porosity compared with F, facilitating greater lesion body remineralisation.

"S" Quattro external fixation for complex intra-articular thumb fractures.

PURPOSE: To report outcomes in 10 patients who underwent dynamic "S" Quattro external fixation for complex fractures of the base of the thumb. METHODS: Nine men and one woman aged 18 to 69 (mean, 31) years underwent "S" Quattro external fixation for complex fractures of the base of the thumb. The dominant hand was involved in 8 patients. Three patients had Bennett fractures, 5 had Rolando fractures, one had an open multi-fragmented fracture, and one had a fracture-subluxation. Four of them had had prior (failed) treatment with splints and/or Kirschner wires. The "S" Quattro external fixator was applied for a mean of 4.9 weeks. Patients were followed up in an out-patient setting for a mean of 10.7 months until bone union and removal of the external fixator. Finger flexor function was assessed based on total active movement (TAM). Functional outcomes were assessed using the Disability of Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: No pin-site infection, malunion, or non-union was encountered. Mean loss of TAM was 7.5 degrees. Five patients lost 10 degrees or more, 2 of whom lost 20 degrees (one with an open comminuted fracture and one was elderly). Four patients regained full TAM and 6 attained more than 75% TAM compared to the contralateral thumb. At the 3-year follow-up, the mean DASH score was 3.4. Four patients reported no functional disability. Poorer outcomes were reported in the 2 patients who once had lost 20 degrees of TAM. CONCLUSION: The "S" Quattro external fixator is recommended as a primary and definitive treatment modality for complex intra-articular thumb fractures when conservative and other surgical interventions have failed.

Diathermy versus scalpel incisions for hemiarthroplasty for hip fracture: a randomised prospective trial.

As the age profile of our population expands, we can expect subsequent increase in patients presenting with intracapsular fracture. The onus remains on the surgeon to make all reasonable efforts to find new and innovative means of reducing associated morbidity and mortality of the treatment of these injuries. This challenge is particularly relevant in the elderly and in patients with multiple co-morbidities. In this study, 100 patients were randomly allocated into two groups. One group had dissection to the level of the hip joint under direct diathermy control; the other group had dissection using a scalpel with supplementary electrocautery. Intraoperative total blood loss prior to dissection of the abductors was measured by collecting blood using wound swabs using a local protocol and results were statistically analysed using PROC GLM SAS. We demonstrate a clear advantage in the use of diathermy to create a hip incision showing a significant reduction in wound-related blood loss and a reduction, whilst not statistically significant, in total operative blood loss using diathermy incision. Larger randomised prospective trials are necessary to study the effects of this intervention in a larger patient population so that these end-points can be adequately assessed.

Factors affecting survival of uncemented total hip arthroplasty in patients 50 years or younger.

Providing a long-lasting total hip arthroplasty for patients younger than 50 years remains one of the greatest challenges for modern arthroplasty surgery. We retrospectively reviewed 221 patients younger than 50 years who underwent 299 uncemented total hip arthroplasties from 1983 to 2000. We assessed 5- to 15-year survival with revision as the endpoint. Femoral stem survival was 99.3% (range, 98.4-100%), 98.9% (range, 97.7-100%), and 96.8% (92.5-100%) at 5, 10, and 15 years, respectively. Including all component designs acetabular survival was 98.7% (range, 97.4-100%), 84.6% (78.8-90.4%), and 52.5% (40.7-64.3%) at 5, 10, and 15 years, respectively. Overall survival was 46.8% (33.5-58.1%) at 15 years. Total hip arthroplasties performed for hip dysplasia had lower 10-year and 15-year survival. Zirconium-on-polyethylene articulations had lower acetabular revision rates compared with cobalt-chrome-on-polyethylene. Sixty-nine revisions were performed, most commonly for polyethylene wear. Uncemented femoral stems resulted in 90% survival at 15 years followup in patients younger than 50 years at index operation. Contemporary bearing surfaces in association with such stems may provide long-lasting total hip arthroplasties, even in young, active patients.

Posterior compartment syndrome associated with clopidogrel therapy following trivial trauma.

Haematomata caused by blunt trauma may potentially induce a compartment syndrome by raising intra-compartmental pressure. We report a case of acute posterior compartment syndrome following minimal trauma to the leg of an elderly patient on the antiplatelet agent clopidogrel. This case highlights the high index of clinical suspicion required to detect compartment syndrome in those on long term antiplatelet therapy and prompt surgical decompression is recommended.

Oral vitamin C reduces the injury to skeletal muscle caused by compartment syndrome.

Compartment syndrome is a unique form of ischaemia of skeletal muscle which occurs despite patency of the large vessels. Decompression allows the influx of activated leucocytes which cause further injury. Vitamin C is a powerful antioxidant which concentrates preferentially in leucocytes and attenuates reperfusion-induced muscle injury. We have evaluated the use of pretreatment with oral vitamin C in the prevention of injury caused by compartment syndrome in a rat cremasteric muscle model. Acute and delayed effects of pretreatment with vitamin C were assessed at one and 24 hours after decompression of compartment syndrome. Muscle function was assessed electrophysiologically. Vascular, cellular and tissue inflammation was assessed by staining of intercellular adhesion molecule-1 (ICAM-1) and by determination of the activity of myeloperoxidase (MPO) in neutrophils and tissue oedema. Compartment syndrome impaired skeletal muscle function and increased the expression of ICAM-1, activity of MPO and muscle weight increased significantly. Pretreatment with vitamin C preserved muscle function and reduced the expression of ICAM-1, infiltration of the neutrophils and oedema.

Staphylococcal diaphyseal subacute osteomyelitis of the ulna in a child: an unusual cause of post-traumatic forearm swelling.

Paediatric subacute osteomyelitis (SAO) presents a diagnostic and therapeutic challenge to clinicians. Typically located in the metaphysis of long bones, diaphyseal SAO of the upper limb is rare. We present the case of a three-year-old girl referred to our fracture clinic as an occult fracture following trauma to her forearm with normal initial radiographs. Follow-up radiographs one week later showed cortical erosion of the distal ulna, while a subsequent MRI scan showed soft tissue swelling with an area of high signal in the distal ulna. A limited biopsy diagnosed staphylococcal subacute osteomyelitis of the ulna. The patient responded to high dose antibiotic therapy and made a full recovery. We present this case to highlight the high index of suspicion required to diagnose and appropriately manage this insidious condition, which may easily be confused with any number of benign and malignant bony lesions and provide a review of the relevant literature.