The use of a synthetic shoulder patch for large and massive rotator cuff tears - a feasibility study.

BACKGROUND: The aim of this study was to explore the feasibility of using a non-absorbable biocompatible polyester patch to augment open repair of massive rotator cuff tears (Patch group) and compare outcomes with other treatment options (Non-patch group). METHODS: Participants referred to orthopaedic clinics for rotator cuff surgery were recruited. Choice of intervention (Patch or Non-patch) was based on patient preference and intra-operative findings. Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), and Constant score were completed at baseline and 6 months. Shoulder MRI was performed at baseline and 6 months to assess fat fraction and Goutallier classification pre- and post- treatment. Feasibility outcomes (including retention, consent and missing data) were assessed. RESULTS: Sixty-eight participants (29 in the Patch group, 39 in Non-patch group) were included (mean age 65.3 years). Conversion to consent (92.6%), missing data (0% at baseline), and attrition rate (16%) were deemed successful feasibility endpoints. There was significant improvement in the Patch group compared to Non-patch at 6 months in OSS (difference in medians 9.76 (95% CI 2.25, 17.29) and SPADI: 22.97 (95% CI 3.02, 42.92), with no substantive differences in Constant score. The patch group had a higher proportion of participants improving greater than MCID for OSS (78% vs 62%) and SPADI (63% vs 50%) respectively. Analysis of the 48 paired MRIs demonstrated a slight increase in the fat fraction for supraspinatus (53 to 55%), and infraspinatus (26 to 29%) at 6 months. These differences were similar and in the same direction when the participants were analysed by treatment group. The Goutallier score remained the same or worsened one grade in both groups equally. CONCLUSIONS: This study indicates that a definitive clinical trial investigating the use of a non-absorbable patch to augment repair of massive rotator cuff tears is feasible. In such patients, the patch has the potential to improve shoulder symptoms at 6 months. TRIAL REGISTRATION: ISRCTN, ISRCTN79844053, Registered 15th October 2014 (retrospectively registered).

Incidence of osteoarthritis in the scapho-trapezial joint after Herbert screw fixation of the scaphoid.

Twenty patients treated with a Herbert screw for scaphoid fractures (acute or non-union) were reviewed and X-rayed 5-10 years later to assess whether there were degenerative changes in the scapho-trapezial joint due to insertion of the screw. Six had some irregularity in the lateral part of that joint, three of which followed backing-out of the screw. Two others were described as showing irregularity all round the scaphoid but, apart from these, no radiological abnormalities were seen in the central or ulnar part of the scapho-trapezial joint, or on the proximal tip of the scaphoid.

Operative shortening of the elongated defunctioned tendoachillies following previous rupture.

Healing of the tendoachilles (TA) following rupture may result in lengthening over a long segment rather than discrete scar interposition. We describe our experience and results of a direct TA shortening technique of dysfunctionally long TAs. Five patients presented with impairment of their sporting level. Four patients had TA injuries that were managed by physiotherapy alone and 1 had been cast immobilised for 6 weeks. At open operation the TAs were found to be confluent but with evidence of scarring over a long segment. A 'Z' shortening was performed. The patients were reviewed up to a mean of 30 months post op. The overall scores were excellent in 1, good in 3 and fair in 1. All returned to their chosen level of sporting activity. The technique described is relatively straightforward and gives predictable improvement in function. It is therefore a useful technique in this often-unrecognised condition

Expression of transforming growth factor-beta isoforms and their receptors in chronic tendinosis.

Chronic tendon lesions are degenerative conditions and may represent a failure to repair or remodel the extracellular matrix after repeated micro-injury. Since TGF-beta is strongly associated with tissue repair, we investigated the expression of TGF-beta isoforms (beta1, beta2 and beta3) and their 2 signalling receptors (TGF-betaRI and TGF-betaRII) in normal and pathological Achilles tendons. In all tissues, all 3 TGF-beta isoforms and the 2 receptors were present at sites of blood vessels. Cells in the matrix showed no staining for TGF-beta1 or beta3, while TGF-beta2 was associated with cells throughout the normal cadaver tendon. Tissue from tendons with pathological lesions showed an increase in cell numbers and percentage TGF-beta2 expression. TGF-betaRII showed a wide distribution in cells throughout the tissue sections. As with TGF-beta2, there was an increase in the number of cells expressing TGF-betaRII in pathological tissue. TGF-betaRI was restricted to blood vessels and was absent from the fibrillar matrix. We conclude that despite the presence and upregulation of TGF-beta2, TGF-beta signalling is not propagated due to the lack of TGF-betaRI. This might explain why chronic tendon lesions fail to resolve and suggests that the addition of exogenous TGF-beta will have little effect on chronic tendinopathy.

Multiple changes in gene expression in chronic human Achilles tendinopathy.

Atlas cDNA cell interaction arrays (CLONTECH) were used to examine degenerate tissue from four patients with Achilles tendon disorders, in order to identify changes in expression of genes important in cell-cell and cell-matrix interactions. The greatest difference between normal (post-mortem) and degenerate tissue samples was in the level of MMP-3 (stromelysin) mRNA, which was down-regulated in all the degenerate samples. Quantitative RT-PCR assay of RNA extracted from paired 'normal' and degenerate Achilles tendon tissue samples taken from tendons during surgery mirrored the results of the arrays. Levels of MMP-3 mRNA were lower, whereas levels of type-I and type-III collagen mRNAs were significantly higher, in the degenerate compared to the 'normal' samples. Immunoblotting of proteins extracted from the same tendon samples showed that three of four normal tissue samples taken from individuals without apparent tendon disorder had much higher levels of MMP-3 protein than 'normal' or degenerate samples from patients with tendinosis. We suggest that MMP-3 may play an important role in the regulation of tendon extracellular matrix degradation and tissue remodelling.

Anterior tibiotalar impingement associated with chronic ankle instability.

The authors describe the surgical treatment of 13 cases of chronic ankle instability and concomitant anterior bony impingement of the ankle in professional and recreational athletes. All patients had symptoms and signs of lateral instability and a painful block to dorsiflexion. Two patients presented with recurrence of impingement after a previous debridement alone without an ankle stabilization. The anterior osteophytes were debrided arthroscopically and a Brostrom-Gould open stabilization was performed. After a mean follow-up period of 12 months (range 4-23 months), all 13 patients had mechanically and functionally stable ankles. The mean improvement in range of dorsiflexion was 12.4 degrees and all but one had improvement with respect to a subjective and functional outcome assessment. There have been no recurrences of impingement to date. These results suggest that ankle stabilization performed in conjunction with debridement of osteophytes may reduce the recurrence of exostoses as well as improving the outcome.

IS/IT market support systems: augmenting UK primary health care groups.

The election of the Labour government in May 1997 has seen the continuation of advanced market reforms intended to modernize the UK National Health Service (NHS). The planning and implementation of information systems and technology (IS/IT) following these structural changes is both widespread and significant. An information strategy for the NHS, published recently, is intended to provide an initial seven-year program of life-long electronic health records for everyone in the United Kingdom. This article explores the potential role of these systems in the specific provision of the new primary health care groups. It argues that, if primary care physicians adopt appropriate delivery channels and service packages and are proactive in the use of IS/IT, then the outcome will produce more patient choice, less nonattendance, and consequently improved primary health care provision.

Using a biological indicator to detect potential sources of cross-contamination in the dental operatory.

The authors conducted a study using surveillance monitoring methodology to identify operatory contamination and to evaluate the effectiveness of infection control procedures. Viridans streptococci were evaluated as biological indicators of oral contamination. Viridans streptococci, abundant in human saliva, were detected on operatory surfaces after dental treatments were finished and surfaces were disinfected. The findings validate current concepts of infection control as demonstrated in barrier methods.

Developing a clinical information system: an interpretive case analysis within a UK hospital.

This paper seeks to adopt an interpretive case analysis for the study of the development of a clinical information system within a UK hospital. An initial literature review is outlined, which draws attention to the distinction between formal-rational and interpretive perspectives on information technology impacts. A case study is presented where a number of issues are identified which suggest that formal systems analysis techniques do not reflect the organizational realities within the hospital. The paper concludes with a brief discussion of the concerns for systems development, and notes the value of an interpretive perspective in this respect.

Drug use management and IT-based medical thesauri: issues of semantics and linguistics.

Argues that by interpreting the semantic content of different actions, it will be possible to draw boundaries between those aspects of a system that can be computerized and those that will best serve the purpose if left alone. This will dissuade systems developers from being caught in the technology trap. The argument is conducted in the context of developing IT-based medical thesauri for drug use management.

Designing matrix models for fluorescence energy transfer between moving donors and acceptors.

A recipe is given for designing theoretical models for donor-acceptor systems in which fluorescence energy transfer and motion takes place simultaneously. This recipe is based on the idea that a system exhibiting both motion and fluorescence energy transfer can be modeled by specifying a number of "states" and the rates of transitions between them. A state in this context is a set of specific coordinates and conditions that describe the system at a certain moment in time. As time goes on, the coordinates and conditions for the system change, and this evolution can be described as a series of transitions from one state to the next. The recipe is applied to a number of example systems in which the donors and/or acceptors undergo either rotational or translational motion. In each example, fluorescence intensities and anisotropies for the donor and acceptor are calculated from solutions of eigensystems. The proposed method allows for analyzing time-resolved fluorescence energy transfer data without restrictive assumptions for motional averaging regimes and the orientation factor. It is shown that the fluorescence quantities depend on the size of the motional step (i.e., on the number of states), only if fluorescence energy transfer occurs. This finding indicates that fluorescence energy transfer studies may reveal whether the dynamics of a system (e.g., a protein) is better described in terms of transitions between a relatively small number of discrete states (jumping) or a large number of dense states (diffusion).

The sports hernia: a cause of chronic groin pain.

The management of chronic pain in sportsmen and women requires consideration of a wide differential diagnosis. A syndrome caused by a distension of the posterior inguinal wall is described, effectively an early direct inguinal hernia. The diagnosis can be made from certain aspects of the history and examination, which are described. The results of surgical repair to the posterior inguinal wall are excellent. The procedure was carried out on 14 sportsmen and one woman. There is an 87% return to full sporting activity, with a follow-up of 18 months to 5 years. The remaining 13% were improved by the repair. Many of the athletes had received other treatments without success. The sports hernia should be high on the list of differential diagnoses in chronic groin pain.

Trauma on the Isle of Man.

The Isle of Man Tourist Trophy motorcycle races remain one of the most popular venues for motorcycle races. This is despite the reduced status of the event. The reason for the loss of world championship and formula one status is the nature of the road racing circuit itself. The twisting narrow roads are only closed to the public at certain times during the practice and race weeks. Motorcycling visitors to the event attempt to emulate their heroes on machines capable of high speeds. Casualties from both visitors and racers are dealt with efficiently by an expanded medical service. This includes the use of an aeromedical evacuation helicopter. Casualties from the visitors exceeded those from the racers themselves during the period reported.