Continuing professional development for surgeons.

With the introduction of revalidation, continuing professional development (CPD) is becoming an increasingly important part of a surgeon's professional life. There is minimal existing information describing the CPD practices and attitudes of surgeons to CPD. This review describes the current CPD expectations of the General Medical Council and the current CPD activities and attitudes of surgeons, based around the results of an on-line study performed by the Royal College of Surgeons of Edinburgh.

Biomechanical testing of the fractured distal radius treated with a new bone cement--is it strong enough?

This study evaluates the in vitro ability of CAP, a bone graft substitute with osteointegration and osteoconductive properties, to restore the anatomy and strength of fractured distal radii. Ten pairs of cadaveric radii were imaged and tested to failure, simulating a fracture. The radii were reconstructed using CAP and were re-fractured and sequentially imaged. The deformities of the bones were determined through computerised evaluation of the radiographs. Radiographic analysis showed that CAP is capable of restoring the anatomy of the distal radius. The load and work required to fracture intact radii were compared to those required to fracture the reconstructed radii. The load to fracture was similar in the two situations. The work to fracture, however, was higher with reconstructed radii, suggesting that these are stronger than the original bones. Our study supports the hypothesis that CAP is capable of restoring the original anatomy and dimensions of the distal radius and re-establishing its mechanical strength.

A study of telephone screening and direct observation of surgical wound infections after discharge from hospital.

Post-discharge surveillance of surgical site infection is necessary if accurate rates of infection following surgery are to be available. We undertook a prospective study of 376 knee and hip replacements in 366 patients in order to estimate the rate of orthopaedic surgical site infection in the community. The inpatient infection was 3.1% and the post-discharge infection rate was 2.1%. We concluded that the use of telephone interviews of patients to identify the group at highest risk of having a surgical site infection (those who think they have an infection) with rapid follow-up by a professional trained to diagnose infection according to agreed criteria is an effective method of identifying infection after discharge from hospital.

Subspecies discrimination of staphylococci from revision arthroplasties by ribotyping.

Sixty-six cultures of Staphylococcus spp. were obtained from bone and tissue samples collected from 37 patients during revision arthroplasties and were speciated and ribotyped to assess strain diversity in each species. There were 10 ribotypes among 51 isolates of S. epidermidis, three among three isolates of S. capitis, two among four isolates of S. aureus and two among two isolates of S. simulans. One ribotype was found among each of: two isolates of S. warneri; two isolates of S. haemolyticus and single isolates of S. cohnii and S. saprophyticus. Low molecular weight bands of ribotype patterns characterized one or two related species whereas high molecular weight bands were useful for distinguishing types within species. Specimens from 17 patients yielded more than one isolate of Staphylococcus spp. In 13 of these patients the isolates were representatives of a single species but in only eight did ribotyping show the isolates to be identical. The findings of multiple species and ribotypes from samples taken from the same patient may have implications for understanding the nature of infection in revision arthroplasty and for antibiotic therapy.

Role of an accident flying squad in medical emergencies.

A retrospective study of medical cases attended by the Derbyshire Royal Infirmary Accident Flying Squad demonstrates that of 17 cases only two patients survived to leave hospital. Nine cases of cardiac arrest have been studied in further detail. In all of these cases it was found that diagnosis of arrest had been made before the Flying Squad was called and that the situation had become extreme before the arrival of the medical team. In every case the Flying Squad team took more than 3 min to arrive, irrespective of distance. Review of the literature appears to support the conclusion that medical teams have been of little value when called to cardiac arrest at any distance from the hospital because of the time lag. It is suggested that more sophisticated primary care should be available immediately, preferably by highly trained ambulance personnel. Medical teams would give appropriate support to such primary care.

Effects of joint motion constraints on the gait of normal subjects and their implications on the further development of hybrid FES orthosis for paraplegic persons.

In this study the effects of angular motion constraints of the lower limbs on the gait of normal subjects were investigated. An assessment orthosis was developed with a new hip coupling mechanism which allows its ratio of reciprocal flexion to extension to be altered. The knee and ankle joints of the orthosis could also be set to be free or locked in specific directions of angular motion in the sagittal plane. A total of 12 different orthosis configurations was tested on three normal subjects. The kinematic, kinetic and electromyographic (EMG) data were collected using the VICON system, two Kistler forceplates, foot switches and an eight channel EMG system. The physiological cost index of walking was assessed by measuring the heart rate and walking speed. It was found that (1) a higher hip flexion-extension ratio was associated with lower energy cost and faster walking; (2) allowing the knee to flex significantly reduced the energy cost and increased the walking speed; (3) allowing the ankle to plantarflex during early stance phase reduced the knee flexing moment. The implications of these effects on the further development of hybrid functional electrical stimulation orthotic systems are discussed.

The influence of external knee moments on the outcome of total meniscectomy. A comparison of radiological and 3-D gait analysis measurements.

Twenty one individuals who had undergone unilateral total meniscectomy, and had no significant antero-posterior (AP) laxity underwent three dimensional (3-D) gait analysis, bilateral radiological assessment of varus/valgus alignment and tibio-femoral osteoarthritis (TFOA). Average foot progression angle during the stance phase of gait was not related to knee adduction moment. The findings support the previously noted correlation between varus/valgus alignment and TFOA. The dynamic gait parameter of the adduction moment in early stance did not correlate with either hip-knee-ankle angle or TFOA, thus the expected influence of external moments on outcome after meniscectomy was not found. Thus the correlation between varus/valgus alignment and TFOA can not be explained by a simple loading algorithm.

The management of war wounds involving bone.

Over 200 high-velocity missile injuries treated in a low-technology environment were audited under the aegis of the International Committee of the Red Cross Hospitals in Afghanistan and Northern Kenya. Femoral fractures were treated either by traction or external fixation using a uniaxial frame. The results showed that patients treated by external fixation remained in hospital longer than those treated on traction. The positional outcome was identical in both groups. In tibial fractures the external fixator was only of extra benefit in those of the lower third when compared with simple plaster slabs unless more complex procedures such as flaps or vascular repair were to be performed. In complex humeral fractures, external fixation resulted in long stays in hospital and a large number of interventions when compared with simple treatment in a sling. We conclude therefore that in an environment where facilities are limited and surgeons have only general experience very careful initial wound excision is the most important factor determining outcome. The application of complex holding techniques was generally inappropriate.

A seven-year experience of data collection on the Insall-Burstein II total knee arthroplasty. A prospective study.

We describe a method of audit of a type of total knee replacement, including some details of the organisational difficulties of administering multicentre studies, and draw attention to how this can be done using industrial funding without prejudicing the study. This is a prospective record of 1439 patients who had an Insall-Burstein II (IBII) prosthesis implanted between 1990 and 1994. The data were collected using the American Knee Society scoring system. A method of storing radiographs digitally at low cost is also described. The results emphasise the need for the long-term collection of data on commonly used devices implanted by a cross-section of surgeons. We conclude that for most patients the IBII cemented, posteriorly stabilised, cruciate-substituting prosthesis will relieve pain and give excellent functional results throughout the patients' remaining years with a very small incidence of revision, except in cases of infection.

Treatment of Freiberg's disease. A new operative technique.

A method of treating Freiberg's disease of the metatarsal head by shortening the metatarsal bone is described. This operation has been performed in 15 patients (16 feet). Excellent relief of pain was obtained, although most patients had persistent stiffness of the metatarsophalangeal joint.

A prospective trial comparing operative and manipulative treatment of ankle fractures.

A series of 42 ankle fractures have been randomised into two groups respectively undergoing either open reduction and internal fixation or manipulative reduction and plaster. Their progress after removal of all external splintage has been followed using simple gait analysis techniques. There appears to be no difference in the outcome of treatment of the two groups in the early recovery period (up to 20 weeks).

Computerised measurement of tibiofemoral alignment.

Tibiofemoral alignment has a direct correlation with the survival of total knee arthroplasty. Traditionally, it has been measured using a goniometer on radiographs. We describe new software which measures this alignment on scanned radiographs by automatically detecting bones in the image. Two surgeons used conventional methods and two clerical officers used the computerised routine to assess 58 radiographs of the knee on two occasions. There were no significant differences between any of the paired comparisons. The largest mean difference detected was 1.19 degrees. Across all comparisons, the mean correlation was 0.755. A standardised routine for measuring tibiofemoral alignment was the greatest factor in reducing error in our study. These results show that non-medical staff can reliably use the software to measure tibiofemoral alignment. It has the potential to measure all the parameters recommended by the Knee Society.

Peripheral bone mineral density in patients with distal radial fractures.

Fractures of the distal forearm are widely regarded as the result of "fragility". We have examined the extent to which patients with Colles' fractures have osteopenia. We measured the bone mineral density (BMD) in the contralateral radius of 235 women presenting with Colles' fractures over a period of two years. While women of all ages had low values for ultra-distal BMD, the values, in age-matched terms, were particularly low among premenopausal women aged less than 45 years. This result was not due to the presence of women with an early menopause. This large survey confirms and extends the findings from earlier small studies. We consider that it is particularly important to investigate young patients with fractures of the distal forearm to identify those with osteoporosis, to seek an underlying cause and to consider treatment.

Bone mineral density of the radius in patients with Colles' fracture.

To ascertain whether patients with Colles' fracture should be investigated for osteoporosis and the risk of future fractures, we measured the bone mineral density of the distal radius of the other arm in 31 women patients and compared the results with those of a control group of 289 normal women. We divided the patients into two groups, those younger than 66 years and those older. In 25 patients we found values for bone mineral density which were lower than one standard deviation below the mean value for their age. Younger patients had a deficit greater than that expected for their ages. We believe that women with Colles' fracture should be evaluated routinely for osteoporosis, particularly if they are under 66 years of age.

The importance of the valgus hindfoot in forefoot surgery in rheumatoid arthritis.

The relationship between hindfoot deformity and forefoot pressure was assessed in 28 rheumatoid patients who had undergone forefoot reconstruction four years previously. Patients with valgus hindfoot deformities tended to have high forefoot pressures whereas those with a normal hindfoot recorded normal pressures on the dynamic pedobarograph. All patients with residual forefoot pain recorded abnormal forefoot pressures. We believe that orthotic control of hindfoot deformities should be considered for those patients who require forefoot surgery as a combination of surgical and orthotic management may offer the best chance of success.

Total meniscectomy in adolescence. A thirty-year follow-up.

We have carried out a prospective, longitudinal 30-year review of 95 adolescents who underwent total meniscectomy in one knee, and have compared the results with those observed 13 years earlier. All the medical records were scrutinised. Of the 63 patients reviewed clinically, 47 reported decreased sporting activity, although subjective satisfaction rose by 3% to 71%. The scores on the WOMAC osteoarthritis index differed significantly between patients grouped by subjective global assessment. Satisfactory function scores increased from 48% to 60%. In the 53 patients consenting to bilateral radiography of the knee, the incidence of narrowing of the articular cartilage in the operated knee increased significantly between the reviews (19% to 36%). Progression of degenerative change paralleled reduction in activity. Outcome measures were best after medial, intermediate after lateral and worst after double meniscectomy.

Below-knee cast design and the energy cost of ambulation.

The influence of various aspects of the design of below-knee walking casts on the energy required for ambulation has been examined using a technique based on heart rate measurements. It was found that the effects of the weight of the cast and the shape of the sole applied were small compared with the effects of changing ankle angle or of increasing the overall thickness of the cast sole.

The development of a new femoral brace hinge.

Mechanical and clinical trials have been performed on a new design of femoral fracture brace-the Protectair hinge system. The hinge, constructed from polythene, aluminium, stainless steel and nylon, incorporates some novel features; pre-bent hinge arms, detachable headplates and a unique knee joint mechanism. Mechanical tests under various stress states have shown the hinge to be of sufficient strength. Biomechanical tests on volunteer subjects have indicated that the unique combination of good knee flexion and prevention of knee hyperextension will be of clinical value.

Pull-out strengths for a range of screws inserted into the calcaneus: a preliminary study.

The holding strengths of AO screws in the calcaneus were tested with a view to incorporating them into a new design of ankle prosthesis aimed at reducing the incidence of loosening. Comparative studies were performed to determine the optimal type and number of screws and their optimal location and thread length. Pull-out tests with 4.5-mm cortical and 6.5-mm cancellous screws were performed on screws inserted into the posterior and middle facets of the calcaneus, these being the two most suitable places for screw fixation. The cancellous screws showed much higher holding strength than the cortical screws. There is room for only a single screw in each facet. The results indicated that a screw of 16-mm thread length should be inserted into the middle facet and a screw of 60-mm thread length into and through the posterior facet. The high holding strengths suggest that screw fixation could be a viable alternative to commonly used methods for anchoring the lower prosthetic component. Further tests are to be conducted which simulate the different types of loads occurring during gait and other activities. These will allow decisions to be made about the benefits of the proposed screw fixation method. This work is part of a long-term project which aims to produce a new ankle prosthesis that does not suffer the problems of loosening associated with present current designs. A strong screw fixation of the talar component may help to improve stability. The results show that a good fixation into the calcaneus can be achieved, and suggest that further work based on this approach is worthwhile.

Lower limb muscle dysfunction may contribute to foot ulceration in diabetic patients.

OBJECTIVES: To investigate the relationship between in-shoe plantar foot pressure and the co-ordinated activity of five lower limb muscles of diabetic patients, who are known to have a higher risk of foot morbidity. DESIGN: A portable six channel electromyographic system has been designed, developed and synchronised in real time with a 16 channel piezoelectric transducer in-shoe pressure measuring device, Gaitscan. BACKGROUND: So far, no one has tried to establish a relationship between in-shoe foot pressure distribution and muscle activity of the lower limb in diabetes. The measurement of phasic muscle activity has been related to foot pressure and compared to a control group of normal volunteers. METHODS: Twenty nine diabetic subjects and 22 healthy non-diabetic volunteers have been studied by recording electromyography of lower leg muscles and in-shoe foot pressure measurements simultaneously. RESULTS: In diabetic subjects, the period of contact pressure was greater than in normal control subjects (P<0.003). The initial forefoot time to contact with the ground was shorter in diabetics when compared to controls, indicating a faster forefoot contact. Of the dorsiflexor muscles, the Anterior Tibialis, normally contracting eccentrically at heel strike, was subject to a measurable delay in the initiation of contraction, of mean difference of 180 ms (P<0.001), in diabetic subjects when compared to the normal controls. CONCLUSIONS: The late firing of Tibialis Anterior means that its normal modulating role in lowering the foot to the ground after heel strike through eccentric contraction is disturbed. The result is that the foot reaches the foot flat stage in a less ordered manner, subjecting it to high plantar pressures. RELEVANCE: The results obtained may assist in planning realignment procedures of the foot and help prevent development of ulcers on the sole of the foot in high risk diabetic subjects.