Inpatient consultations to an orthopaedic service: the hidden workload.

BACKGROUND: While the quality and efficiency of out-patient orthopaedic referrals are well documented in the literature, there is little on the standard and appropriateness of inpatient orthopaedic consultations. AIM: To prospectively audit the pattern of inpatient consultations to an orthopaedic service. METHODS: Data were prospectively collected on all inpatients referred to the orthopaedic service over a 4-month period. RESULTS: Sixty-eight consultations were received in the study period. The average age was 68 years (range 20-86 years). Seventy-two percent of consultations were from medical services, 25% from other surgical specialties and the remainder (3%) from the psychiatric department. Eight (12%) patients required surgical intervention. Twenty patients (29%) had previously been seen in the outpatient department. CONCLUSIONS: Inpatient orthopaedic consultations generate a significant workload and the majority of such patients could be seen as outpatients. Clear and explicit guidelines on appropriate referral pathways, as well as enhanced education in the management of musculoskeletal disorders and available services may optimise delivery of patient care in the inpatient setting.

Cost induced by hip fractures.

Hip fracture is the most common fracture in the elderly population. Treating hip fractures is a major burden on the Irish Health system. There is no recent Republic of Ireland study detailing hospital costs for such injuries. A comprehensive analysis of 143 patients admitted with a hip fracture was performed to determine current medical expenditure incurred during acute hospitalization for hip fractures during 2005 in a major university hospital. Costs associated with surgery (implant & theatre costs), laboratory, radiology, physiotherapy and ward were calculated on individual basis. All the hip fractures were above 60 years of age (mean 82 years); average stay in the hospital was 11 days. The mean total hospital expenditure per patient was Euro 9236.01 of which ward costs contributed 55.33%, operative costs 39.82% and investigations 4.83%. The result clearly show that hip fractures have a major economic impact arising from the inpatient treatment, most of which relate to length of hospital stay.

Isolated proximal tibiofibular joint dislocation in an elite rugby union player.

The case is presented of a professional international rugby union player who sustained an isolated proximal tibiofibular dislocation in a training ground injury. Diagnosis was made based on clinical details, plain radiography and magnetic resonance imaging. An initial attempt at closed reduction failed. Open reduction and internal fixation were subsequently carried out. Following early rehabilitation, the patient made a successful try-scoring return to international rugby union.

Outcome following deep wound contamination in cemented arthroplasty.

Infection remains a devastating complication of joint replacement surgery causing a significant burden to both patient and surgeon. However, despite exhaustive prophylactic measures, intraoperative contamination still occurs during cemented arthroplasty with current infection rates of 1-2%. A study was undertaken to determine the incidence of perioperative contamination in cemented arthroplasty patients, to identify contaminating organisms, to identify contaminated regions within the operative wound, to identify factors associated with increased contamination, and finally to assess the medium-term clinical outcome in patients with confirmed intraoperative wound contamination. Eighty consecutive patients undergoing hip and knee cemented arthroplasty were prospectively enrolled over a 6-month period. All scrubbed personnel wore total body exhaust isolation suits and procedures were carried out in ultra-clean air theatres. Of 441 samples, contamination was identified at 21 sites (4.8%) representing a cohort of 18 patients (22.5%). Longer duration of surgery predisposed to higher contamination rates while lower contamination rates were significantly related to fewer gowned personnel within the ultra-clean system, and fewer total personnel in theatre during the procedure. None of the patients developed clinical evidence of deep prosthetic infection at follow-up. We noted a high incidence of intraoperative contamination despite standard prophylaxis. However, this was not reflected by a similar rate of postoperative infection. This may be due to a small bacterial inoculum in each case or may be due to the therapeutic effect of perioperative intravenous antibiotic prophylaxis.

Revision of the Sheehan total knee arthroplasty.

The use of the Sheehan knee prosthesis extended from 1971 to 2002. It incorporated a semi-constrained hinge with intra-medullary stems cemented into the femur and tibia. While some authors have reported excellent short-term results, others have reported revision rates of up to 31% at 5--10 years. The aim of this study was to review the senior author's experience in revising these arthroplasties. We review 54 Sheehan total knee replacements and discuss the difficulties encountered during first and subsequent revisions and the often-complex reconstruction techniques used to overcome these.

Quinolone-associated tendonitis: a potential problem in COPD?

BACKGROUND: Quinolones have traditionally had limited application in the area of community-acquired respiratory tract infections due to poor cover against Streptococcus pneumoniae. This trend is changing with the broader spectrum of newer fluoroquinolones. A rare serious side effect of fluoroquinolones is tendinopathy. AIMS: This study describes two cases of levofloxacin-associated tendinopathy in patients with severe chronic obstructive pulmonary disease (COPD) and the implications and mechanisms involved are discussed. CONCLUSIONS: The finding of two cases of levofloxacin-induced tendinopathy in our patients suggests that the problem may be more frequent than previously considered. Patients with COPD treated with fluoroquinolones may have other risk factors for tendinopathy such as advanced age, corticosteroid use and renal impairment and merit vigilance for signs of tendonitis.

Palmar lunate trans-scaphoid, trans-triquetral fracture-dislocation.

A palmar lunate dislocation associated with fractures of the scaphoid and triquetrum and an avulsion fracture of the radial styloid is described. The injury resulted from a high energy dorsiflexion/axial compression force. Open reduction of the dislocated lunate and internal fixation of the scaphoid were done as an emergency procedure. A second operation was required to internally fix the displaced triquetral fracture and reduce the lunotriquetral dissociation. A good result was documented at 6 months.

Occupational noise levels in orthopaedic surgery.

Prolonged exposure to potentially damaging noise levels in the workplace has been the subject of much recent litigation. The occupational risk of noise induced hearing loss among orthopaedic surgeons is unknown. Continuous readings of air-powered instruments routinely used in orthopaedic surgery were made in a regional trauma unit at standard distance from the noise source. All instruments generated noise levels greater than the threshold for routine monitoring of hearing loss under health and safety legislation.

Pseudoaneurysm of the profunda femoris artery due to intertrochanteric fracture of the hip.

Arterial injury caused by hip fracture is a rare event. We report a case of pseudoaneurysm of the profunda femoris artery that presented 4 weeks after correction of an intertrochanteric hip fracture with a dynamic hip screw. The diagnosis was confirmed by Duplex ultrasound scanning, and it was treated by ligation of the profunda femoris artery at the level of the pseudoaneurysm.

L- and P-selectin and CD11/CD18 in intracapillary neutrophil sequestration in rabbit lungs.

Infusion of complement fragments induces rapid sequestration of neutrophils within pulmonary capillaries. This study examined the mechanisms through which this sequestration occurs, as well as the effect of complement fragments on the expression of L-selectin and CD11/CD18 using ultrastructural immunohistochemistry. Studies using anti-P-selectin antibodies, fucoidin, L-selectin-depleted neutrophils, and anti-CD18 antibodies showed that selectins and CD18 were not required for neutrophil sequestration. However, maintaining the sequestered neutrophils within the pulmonary capillaries required both L-selectin and CD11/CD18. Neutrophils in the pulmonary capillaries of rabbits given complement fragments expressed 72% less L-selectin and 98% more CD11/CD18 than did those in rabbits given saline. Shedding of L-selectin occurred preferentially from the microvillar processes of the plasma membrane rather than from the flat intervening regions. About 28% of L-selectin still remained on intracapillary neutrophil membranes after 15 min and was likely available for binding. Shedding of L-selectin appeared slower in vivo than in vitro. These studies indicate that neutrophil sequestration induced by complement fragments requires at least two sequential steps, one that does not require recognized adhesion molecules followed by a second that requires L-selectin and CD11/ CD18.

Combinatorial requirements for adhesion molecules in mediating neutrophil emigration during bacterial peritonitis in mice.

To investigate the requirements for adhesion molecules in neutrophil emigration during peritonitis, mice received intraperitoneal injections of Streptococcus pneumoniae while the functions of multiple adhesion molecules were blocked. Emigration after 4 h was compromised by antibodies against ICAM-1 or genetic deficiency of ICAM-1. Anti-CD11a/CD18 antibodies decreased emigration in ICAM-1 mutant mice, suggesting that ICAM-1 independent emigration requires CD11/CD18 complexes. In contrast, mice mutant in ICAM-1 plus E-selectin showed no defect in emigration, suggesting that E-selectin commits neutrophils to an ICAM-1-dependent pathway during streptococcal peritonitis. However, in mutant mice lacking the three endothelial adhesion molecules E-selectin, P-selectin, and ICAM-1, emigration after 4 h was significantly compromised. Thus, P-selectin is essential to ICAM-1- and E-selectin-independent acute peritoneal inflammation. After 24 h of peritonitis, there were no differences between WT and E-selectin/P-selectin/ICAM-1 mutant mice, demonstrating that these endothelial adhesion molecules are not essential to neutrophil emigration during later stages of peritonitis.

Complement fragment-induced release of neutrophils from bone marrow and sequestration within pulmonary capillaries in rabbits.

Infusion of complement fragments induces rapid sequestration of neutrophils within the pulmonary capillaries. This study examined the contributions of the bone marrow (BM) and the liver to the accumulation of neutrophils within the lungs. Complement fragments induced the release of neutrophils from the BM within 7 minutes of infusion, and these neutrophils sequestered in the lungs immediately upon reaching the pulmonary capillaries. Neutrophils expressing high levels of L-selectin were preferentially retained within the pulmonary microvasculature. By 30 minutes after the infusion was stopped, the circulating neutrophil counts had increased, primarily because of release from the BM. The number of neutrophils sequestered in the lung had decreased by only 27%, and the number of neutrophils in the liver increased by 223%. These studies indicate that complement fragments induce the release of neutrophils from the BM far more rapidly than previously described. These newly released neutrophils immediately sequester within the lung, increasing the number of neutrophils available to injure the lung many fold beyond the number that were circulating before infusion. The preferential retention of L-selectin-expressing neutrophils likely reflects the requirement for L-selectin-mediated adhesion in maintaining sequestered neutrophils within the pulmonary microvasculature. The number of circulating neutrophils reflects a balance between pulmonary sequestration, rapid release from the BM, and uptake by the liver and other organs.

Interprosthetic fracture of the femoral shaft.

Experience in the management of a complication of ipsilateral hip and knee arthroplasty is described. The cases of four female patients who sustained a femoral shaft fracture after ipsilateral hip and knee arthroplasty are reported. All fractures were treated operatively, and in all cases internal fixation devices failed. This complication of multiple joint arthroplasty presents a difficult management problem. Rigid fixation has a high failure rate for this type of fracture. Surface knee arthroplasty provides a better opportunity for internal fixation than a knee arthroplasty with a stemmed femoral component.

Role of CD11b in focal acid-induced pneumonia and contralateral lung injury in rats.

Neutrophil emigration in response to acid aspiration does not require the adhesion complex, CD11/ CD18. This study examined the role of CD11b/CD18 using the anti-CD11b F(ab')2, 1B6, in focal HCI-induced intracapillary neutrophil sequestration and edema formation within rat lungs, as well as the effect of pretreatment with endotoxin on this injury. The results show that at the site of aspiration pneumonia, anti-CD11b F(ab')2 did not inhibit neutrophil sequestration or edema formation, either with or without endotoxin pretreatment. In the contralateral lung, focal HCI aspiration induced neutrophil sequestration that was inhibited by the anti-CD11b F(ab')2, but no edema formation. The combined effect of endotoxin pretreatment and HCI aspiration induced CD11b/CD18-independent edema formation in the contralateral lung. These data indicate that CD11b/CD18-independent pathways mediate neutrophil sequestration and edema formation at that pneumonic site with or without pretreatment with endotoxin. CD11b/CD18 mediates neutrophil sequestration at distant sites when no endotoxin is present, although this CD11b/CD18-dependent sequestration is not association with edema formation. The combined effects of endotoxin and HCI aspiration induce edema formation at distant sites that could not be prevented by inhibiting the function of the CD11b/CD18 prior to aspiration.

Femoral cementing techniques in total hip replacement.

Clinical studies have shown that second-generation femoral cementing techniques at total hip replacement result in a superior fixation of the femoral stem. In an effort to determine what benefits further developments in cementing techniques would provide, we compared the morphology of the cement mantles produced by traditional finger-packing and gun-insertion techniques. The porosity of the cement mantles was quantified using computerised image analysis. The finger-packing technique caused large air inclusions that resulted in large pores in the substance of the cement mantle, whereas the cement-gun technique did not result in any individual pore with an equivalent diameter greater than 3 mm. The mean porosity of cement mantles prepared using the finger-insertion technique was 8.3%, whereas the mean porosity in gun-prepared mantles was 1.7%. The use of a cement gun significantly reduced the porosity of femoral cement mantles (P = 0.02). Reduction of defects in the substance of the cement mantle may account for the increased survival of femoral prostheses inserted when second-generation techniques were used. Further reduction of the porosity of the cement mantle could not be expected to produce as dramatic a clinical improvement in prosthesis fixation.

16- to 25-year follow-up study of cemented arthroplasty of the hip in patients aged 50 years or younger.

The clinical outcome of the cemented Charnley hip arthroplasty at follow-up periods of 16-25 years was evaluated retrospectively in patients aged 50 years or younger. One hundred thirty-two of a total of 167 hip arthroplasties were studied. The overall probability of survival of the implant at 20 years was 75% Survival of those with rheumatoid disease was 80% compared with 64% for those with osteoarthritis. Female sex was associated with a better prognosis. Accelerated wear was associated with decreased survival of the prosthesis. Varus orientation of the femoral component significantly influenced failure (P < .01). Radiographic loosening of the acetabular component was well tolerated, but loosening of the femoral component was significantly associated with pain (P = .01).

Risk of pelvic injury from femoral neck guidewires.

Many of the devices used in the internal fixation of femoral neck fractures are cannulated and require the initial placement of one or more guidewires for accurate positioning. These wires are occasionally advanced inadvertently through the hip joint and the acetabulum. Pelvic visceral damage may follow. To assess this risk, we inserted three guidewires to a depth of 16 cm into each femoral neck of ten cadavers and explored the pelvis during autopsy. Thirty-two of the 60 guidewires had penetrated a pelvic organ. The literature on intrapelvic injuries associated with hip surgery is reviewed, and suggestions are offered on the avoidance of pelvic penetration during hip fracture fixation.

Neutrophil emigration in the lungs.

Neutrophil emigration into the lung occurs in response to inflammatory mediators in the interstitium and the airspace. Emigration through the pulmonary microvasculature occurs through two pathways, one that requires CD11/CD18 and ICAM-1 and one that does not: Which pathway is utilized is determined by the stimulus. The ability of a stimulus to upregulate ICAM-1 by inducing the production of pro-inflammatory cytokines including TNF-alpha appears to determine the selection of the CD11/CD18, ICAM-1, ICAM-1-dependent pathway Recently, a third pathway has been identified that requires CD11/CD18 but not ICAM-1. The ligand for this pathway, as well as the ligands for CD11/CD18, ICAM-1-independent adhesion have not been identified. During recurrent pneumonia, the adhesion molecules required for emigration are different than those utilize during acute inflammation in previously normal lung tissue. For example, studies investigating the role of CD11/CD18 in recurrent pneumonia induced by P. aeruginosa, a stimulus which elicits CD11/CD18-dependent emigration initially, showed that when the organisms are instilled at the same site 7 days after the initial instillation, most emigration occurs through CD11/CD18-independent mechanisms. These studies suggest that when an acute stimulus is placed at a site of resolving inflammation, new pathways of adhesion are recruited. Whether these molecules are the same ones mediating acute CD11/CD18-independent adhesion remains to be determined. In summary, neutrophil emigration in the lung can occur through several adhesion pathways, which pathway is utilized can change during the inflammatory process, and cytokines participate in the selection of the pathway.