Do Biologic Agents Increase the Risk of Infection in Patients Undergoing Lower Limb Arthroplasty Surgery?

BACKGROUND: Biologic agents have contributed significantly to the management of patients with in rheumatoid arthritis (RA). A significant proportion of patients with RA still require arthroplasty procedures however. It is unclear whether these agents increase the risk of post operative infection after lower limb arthroplasty. METHOD: A literature search was performed for articles published over the last 10 years in the English language examining the association between anti-tumour necrosis factor inhibitors and the incidence of post operative infection in patients with RA undergoing hip and knee arthroplasty procedures. RESULTS: One large meta-analysis has been published suggesting a 2-fold increase in infection rates following orthopaedic surgery in patients receiving biological agents. When subgroup analysis of arthroplasty cases alone was performed the finding failed to reach significance. However, several further studies have demonstrated both an increased risk for surgical site infection with the use of biological agents and several conflicting articles argue the opposite. CONCLUSION: There is no current consensus on this topic. The safety of continuation of perioperative anti-TNF-α therapy in patients undergoing lower limb arthroplasty procedures is unclear. There is also little robust guidance from specialist rheumatologic societies. There is need for large scale multicentre randomised controlled trials to address this issue.

Bizarre parosteal osteochondromatous proliferation of bone: clinical management of a series of 22 cases.

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora's lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.

Biomechanical testing of a concept of posterior pelvic reconstruction in rotationally and vertically unstable fractures.

The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°. The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.

Failure of conventional retrograde cystography to detect bladder ruptures in pelvic trauma.

Conventional retrograde cystography is often used to investigate patients with suspected bladder ruptures in pelvic trauma. Clinical indicators suggestive of a rupture include haematuria and suprapubic tenderness and should increase the suspicion of bladder and urinary tract injury and prompt the clinician to undertake further investigations. Two patients with high-energy pelvic fractures had bladder ruptures detected intraoperatively despite normal preoperative retrograde cystogram. Both patients had significant clinical indicators suggestive of underlying bladder and urinary tract injury. In both cases, a routine conventional retrograde cystogram was performed but failed to identify the full extent of the bladder injury. A possible reason for misdiagnosis in these cases is the delay between injury and investigation due to tertiary referral of care.

'Verto-sign': an indicator of increased operative complexity in pelvic trauma surgery.

We demonstrate an important, newly defined, radiographic sign present in three acetabular trauma cases, named the 'Verto-sign' which, if present, indicates a particularly complex both column fracture pattern. The 'Verto-sign' is visible on the anteroposterior pelvic radiograph in a rare subtype of both column fractures and is created by the greater sciatic notch fracture fragment rotating internally or externally. The 'Verto-sign' appears, as its name suggests, like a V-shape present above the acetabulum.

Pseudarthrosis of the tibia: emergency department presentation of neurofibromatosis type 1 in a 4-month-old infant.

Congenital pseudarthrosis of the tibia is a complex and rare condition of infancy. Long bone pseudarthrosis is strongly linked to neurofibromatosis, a common genetic disorder in which pseudarthrosis tends to occur early. This report describes a similar emergency department presentation in a 4-month-old infant with subsequent diagnosis of neurofibromatosis type 1.