Revision knee arthroplasty: Can good outcomes be achieved at lower volumes?

BACKGROUND: The National Joint Registry (NJR) demonstrates a re-revision rate for primary knee arthroplasty of 14.2% at 7 years. The 2015 Getting it Right First Time (GIRFT) report highlighted that 58% of surgeons undertaking revision knee arthroplasty (RKA) performed fewer than five cases per year. It has been suggested that revision cases be centralised in specialist centres with a multidisciplinary team (MDT) approach. Such a hub and spoke or cluster models may still require revision surgery to be performed at relatively low volume units. METHODS: An analysis of RKA surgery performed in a four surgeon, lower volume revision knee unit over 10 years to December 2016 was undertaken. The effect of the introduction of a MDT was reviewed. The minimum follow up was two years. The primary outcome measure was re-revision. Hospital data as well as individual surgeon NJR reports were used to ensure all re-revisions were accounted for. Outcome scores were available for 68% of cases. RESULTS: There were 192 RKAs performed in 187 patients at a mean (stdev) of 6.3 (5.4) years from the index procedure. The mean age at surgery was 68.2 (10.9) years. Twenty nine (15.5%) patients had died at the time of final review. Twelve (6.3%) cases required a further revision procedure. The commonest complication was stiffness requiring MUA. The overall 7 year survivorship was 94.9% (95% CI 90.2-97.3). The mean Oxford score at 5.4 years was 30.4 (10.4). CONCLUSIONS: RKA can be reliably performed at lower volume centres with appropriate MDT systems in place.

The occurrence of cardiac abnormalities in canine steroid-responsive meningitis arteritis.

OBJECTIVES: To document the prevalence of cardiac abnormalities in dogs with steroid-responsive meningitis arteritis and to assess resolution of these abnormalities following corticosteroid therapy. MATERIALS AND METHODS: Steroid-responsive meningitis arteritis was diagnosed based on signalment, physical examination findings, complete blood count, biochemistry and CSF analysis. Echocardiography, C-reactive protein and cardiac troponin I were measured in all cases before and 10 to 14 days after commencing corticosteroid therapy. Fibrinogen was also measured in a proportion of dogs. RESULTS: Fourteen dogs were prospectively enrolled. Increased cardiac troponin I was identified in five of 14 dogs and echocardiographic abnormalities were detected in 12 of 14 dogs, including spontaneous echo contrast (12 of 14), mild pericardial effusion (five of 14) and mildly decreased fractional shortening (five of 14). All dogs had increased C-reactive protein and fibrinogen was increased in 11 of 12. Corticosteroid treatment was associated with clinical improvement and normalisation of C-reactive protein in all dogs. The cardiac troponin I levels normalised in four of five and fibrinogen had normalised in all five dogs which were retested. Spontaneous echo contrast improved or completely resolved in 12 of 12 and pericardial effusion resolved in five of five dogs. Fractional shortening normalised in two of five dogs. CLINICAL SIGNIFICANCE: Cardiac changes are common in dogs with steroid-responsive meningitis arteritis and most resolve with therapy. Further investigation into the cause and significance of these changes is necessary in determining whether antithrombotic therapy or positive inotropic therapy is indicated.

The incidence and impact of arthroscopy in the year prior to total knee arthroplasty.

BACKGROUND: Prior knee surgery and arthroscopy is known to increase complications and re-operations in subsequent total knee arthroplasty (TKA). We set out to examine the time dependant effect of arthroscopy on Patient Reported Outcome Measures following subsequent TKA. METHODS: A retrospective review of theatre and clinical records identified 186 patients who underwent TKA within a year of arthroscopy (2009-2013). Oxford knee score (OKS) data was compared with a published cohort from the same department (1708 patients). RESULTS: One hundred and eighty six patients were identified who underwent TKA within a year of arthroscopy; 112 females, 74 males; mean age 64 (SD 10); mean BMI 31.4 (SD 4.6). There was no significant difference between groups with respect to sex, age, BMI, or pre-operative OKS. One hundred and three patients underwent TKA within six months of arthroscopy. This group had a significant reduction in OKS compared to the previously published cohort (32.8 vs 36.3, p<0.005). There was no significant difference in OKS when TKA was performed more than six months after arthroscopy (35.3). The re-operation rate was 14% in the arthroscopy group, with a revision rate of 3.8% vs 1.6% in a previously published large cohort from the same institution. CONCLUSIONS: There appears to be a negative impact of arthroscopy in relation to subsequent TKA which seems to be time dependent. TKA should not routinely be performed within six months of arthroscopy. This should inform guidelines on the management knee osteoarthritis.

The challenge of teaching undergraduates evidence-based veterinary medicine.

The Royal College of Veterinary Surgeons now lists 'How to evaluate evidence' as a day one competence for newly qualified vets. In this article, representatives from each of the veterinary schools in the UK discuss how the challenge of delivering and assessing the concepts of evidence-based veterinary medicine in a crowded undergraduate curriculum can be met.

Diagnostic value of neutrophil-lymphocyte and albumin-globulin ratios in canine soft tissue sarcoma.

OBJECTIVE: To investigate the ability of neutrophil-to-lymphocyte ratio and albumin-to-globulin ratio to differentiate soft tissue sarcoma from benign soft tissue tumours. METHODS: A retrospective study of pretreatment haematology and biochemistry in dogs diagnosed with soft tissue sarcoma or benign soft tissue tumours. The neutrophil-to-lymphocyte ratio and albumin-to-globulin ratio were compared between the two groups. In dogs diagnosed with soft tissue sarcoma, the relationship of neutrophil-to-lymphocyte ratio and albumin-to-globulin ratio to histological tumour grade (I to III) was assessed. RESULTS: In the dogs with soft tissue sarcoma (n=22), the neutrophil-to-lymphocyte ratio was significantly increased and the albumin-to-globulin ratio decreased compared to those with benign soft tissue tumours (n=14). The neutrophil-to-lymphocyte ratio and albumin-to globulin ratio were not useful as predictors of tumour grade in dogs diagnosed with soft tissue sarcoma. CLINICAL SIGNIFICANCE: Pretreatment neutrophil-to-lymphocyte ratio and albumin-to globulin ratio may aid with diagnosis and optimal treatment planning. Further investigation into their prognostic implications is warranted.

Pancreatic surgical biopsy in 24 dogs and 19 cats: postoperative complications and clinical relevance of histological findings.

OBJECTIVE: To assess the immediate postoperative complications associated with pancreatic biopsy in dogs and cats and review the clinical relevance of biopsy findings. METHODS: Retrospective review of clinical records from two referral institutions for cases undergoing pancreatic biopsy between 2000 and 2013. RESULTS: Twenty-four dogs and 19 cats that had surgical pancreatic biopsy had sufficient detail in their clinical records and fulfilled the inclusion criteria. Postoperative complications were seen in 10 cases of which 5 were suggestive of post-surgical pancreatitis. Two patients were euthanased within 10 days of surgery because of the underlying disease; neither suffered postoperative complications. Pancreatic pathology was found in 19 cases, 7 cases showed no change other than benign pancreatic nodular hyperplasia, and no abnormalities were seen in 18 cases. CLINICAL SIGNIFICANCE: Complications may be encountered following surgical pancreatic biopsy, although the risk should be minimal with good surgical technique. Pancreatic biopsy may provide a useful contribution to case management but it is not clear whether a negative pancreatic biopsy should be used to rule out pancreatic disease. Dogs were more likely to have no significant pathology found on pancreatic biopsy than cats, where chronic pancreatitis was the most common finding.

Predicting Outcome in dogs with Primary Immune-Mediated Hemolytic Anemia: Results of a Multicenter Case Registry.

BACKGROUND: Outcome prediction in dogs with immune-mediated hemolytic anemia (IMHA) is challenging and few prognostic indicators have been consistently identified. OBJECTIVES: An online case registry was initiated to: prospectively survey canine IMHA presentation and management in the British Isles; evaluate 2 previously reported illness severity scores, Canine Hemolytic Anemia Score (CHAOS) and Tokyo and to identify independent prognostic markers. ANIMALS: Data from 276 dogs with primary IMHA across 10 referral centers were collected between 2008 and 2012. METHODS: Outcome prediction by previously reported illness-severity scores was tested using univariate logistic regression. Independent predictors of death in hospital or by 30-days after admission were identified using multivariable logistic regression. RESULTS: Purebreds represented 89.1% dogs (n = 246). Immunosuppressive medications were administered to 88.4% dogs (n = 244), 76.1% (n = 210) received antithrombotics and 74.3% (n = 205) received packed red blood cells. Seventy-four per cent of dogs (n = 205) were discharged from hospital and 67.7% (n = 187) were alive 30-days after admission. Two dogs were lost to follow-up at 30-days. In univariate analyses CHAOS was associated with death in hospital and death within 30-days. Tokyo score was not associated with either outcome measure. A model containing SIRS-classification, ASA classification, ALT, bilirubin, urea and creatinine predicting outcome at discharge was accurate in 82% of cases. ASA classification, bilirubin, urea and creatinine were independently associated with death in hospital or by 30-days. CONCLUSIONS AND CLINICAL IMPORTANCE: Markers of kidney function, bilirubin concentration and ASA classification are independently associated with outcome in dogs with IMHA. Validation of this score in an unrelated population is now warranted.

Effect of low-dose omeprazole on gastric acid secretion in duodenal ulcer patients.

The effect of 7 days of oral dosing with 5 mg day-1 and 20 mg day-1 omeprazole on basal and pentagastrin-stimulated gastric acid output was studied in nine duodenal ulcer patients. Basal acid output measured 5-6 h post-dosing was decreased by a mean of 75% on 5 mg omeprazole and by 90% on 20 mg omeprazole (P less than 0.05 and P less than 0.01, respectively). Peak acid output measured 6-7 h post-dosing was decreased by a mean of 75% on 5 mg omeprazole and 97% on 20 mg omeprazole (P less than 0.01 for each). There was a wide interindividual variation in response to the 5 mg dose, with five of the nine patients having more than 90% inhibition of peak acid output, but two patients having less than 40% inhibition. This unpredictable response to daily low-dose omeprazole therapy makes it unsuitable for maintenance treatment.

Interventions for treating acute and chronic Achilles tendinitis.

BACKGROUND: Achilles tendinitis is one of the most common of all sports injuries. There is no consensus on treatment. OBJECTIVES: To assess the effectiveness of various treatment interventions for acute and chronic Achilles tendinitis in adults. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group specialised register (December 2000), Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE (1966 to December 2000), EMBASE (1980 to 2001 wk 04), CINAHL (1982 to December 2000), and reference lists of identified trials were searched. SELECTION CRITERIA: Randomised or quasi-randomised trials of treatment interventions for acute and chronic Achilles tendinitis in adults. Studies focusing on pathological tendinitis were excluded. Excluded were those trials that compared different dosages of the same drug or drugs within the same class of drugs, for example different non-steroidal anti-inflammatory drugs (NSAIDs). DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality, by use of a ten item check list, and extracted data. Requests were sent for separate data for Achilles tendinitis patients in studies within trials of mixed patient populations. Where possible, quantitative analysis and limited pooling of data were undertaken. MAIN RESULTS: Nine trials, involving 697 patients, met the inclusion criteria of the review. Methodological quality was adequate in most of the trials with regards to blinding but the assessment of outcome was incomplete and short-term. There was weak but not robust evidence from three trials of a modest benefit of NSAIDs for the alleviation of acute symptoms. There was some weak evidence of no difference compared with no treatment of low dose heparin, heel pads, topical laser therapy and peritendonous steroid injection, but this could not be fully evaluated from the reports of four trials. The results of an experimental preparation of a calf-derived deproteinized haemodialysate, Actovegin, were promising but the severity of patient symptoms was questionable in the single small trial testing this comparison. The results of a comparison of glycosaminoglycan sulfate with a NSAID were inconclusive. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis. Further research is warranted.

Epidemiology of fractures in 15,000 adults: the influence of age and gender.

We report a prospective study of the incidence of fractures in the adult population of Edinburgh, related to age and gender. Over a two-year period, 15,293 adults, 7428 males and 7865 females, sustained a fracture, and 5208 (34.0%) required admission. Between 15 and 49 years of age, males were 2.9 times more likely to sustain a fracture than females (95% CI 2.7 to 3.1). Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4). There were three main peaks of fracture distribution: the first was in young adult males, the second was in elderly patients of both genders, mainly in metaphyseal bone such as the proximal femur, although diaphyseal fractures also showed an increase in incidence. The third increase in the incidence of fractures, especially of the wrist, was seen to start at 40 years of age in women. Our study has also shown that 'osteoporotic' fractures became evident in women earlier than expected, and that they were not entirely a postmenopausal phenomenon.

Management of completely displaced metaphyseal fractures of the distal radius in children. A prospective, randomised controlled trial.

In a prospective, randomised controlled trial, 68 children who had a completely displaced metaphyseal fracture of the distal radius were treated either by manipulation (MUA) and application of an above-elbow cast alone or by the additional insertion of a percutaneous Kirschner (K-) wire. Full radiological follow-up to union was obtained in 65 children and 56 returned for clinical evaluation three months after injury. Maintenance of reduction was significantly better in the K-wire group and fewer follow-up radiographs were required. There was no significant difference in the clinical outcome measured three months after injury. Seven of 33 patients in the MUA group had to undergo a second procedure because of an unacceptable position compared with none of the 35 in the K-wire group (chi-squared test, p < 0.01). One patient in the K-wire group required exploration for recovery of a migrated wire. We conclude that the use of a percutaneous K-wire to augment the reduction of the fracture in children who have a completely displaced metaphyseal fracture of the distal radius is a safe and reliable way of maintaining alignment of the fracture.

Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing.

We reviewed 63 patients with fractures of the distal tibial metaphysis, with or without minimally displaced extension into the ankle joint. The fractures had been caused by two distinct mechanisms, either a direct bending force or a twisting injury. This influenced the pattern of the fracture and its time to union. All fractures were managed by statically locked intramedullary nailing, with some modifications of the procedure used for diaphyseal fractures. There were few intra-operative complications. At a mean of 46 months, all but five patients had a satisfactory functional outcome. The poor outcomes were associated with either technical error or the presence of other injuries. We conclude that closed intramedullary nailing is a safe and effective method of managing these fractures.

Tibial fractures with bone loss treated by primary reamed intramedullary nailing.

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

Extension of the elbow and supracondylar fractures in children.

We tested the hypothesis that children who sustain a supracondylar fracture have a greater range of elbow hyperextension than those with a fracture of the distal radius. Three observers made 358 measurements in 183 children (114 boys and 69 girls). There were 119 fractures of the distal radius and 64 supracondylar fractures. Initially, the group with a supracondylar fracture appeared to have extension 1.7 degrees greater than that of the group with fracture of the distal radius. On average, there was a maximum variation of 3 degrees between observers. After allowing for age, gender and observer, there was no significant difference between the groups. Our study had greater than 80% power to detect a difference in hyperextension of 2 degrees at the 5% level with the above observer variability. When age and gender are taken into account, any variation in the amount of hyperextension at the elbow is not sufficient to explain the occurrence of a supracondylar fracture.

Results of an operative policy in the treatment of periprosthetic femoral fracture.

OBJECTIVE: To determine the clinical outcome of patients with periprosthetic femoral fractures treated operatively. DESIGN: Retrospective analysis from 1986 to 1993. SETTING: Edinburgh Orthopaedic Trauma Unit, Edinburgh, Scotland. PATIENTS: Forty-five patients identified from a computer database as being admitted to the Edinburgh Orthopaedic Trauma Unit with periprosthetic femoral fractures. MAIN OUTCOME MEASURES: Clinical outcome grade (good, fair, poor) dependent on integrity of fixation, refracture rate, and ability to perform activities of daily living analyzed against age, type of fracture, prosthetic alignment, loosening, and method of fixation. RESULTS: Type I fractures were more common in uncemented or loosely cemented prostheses, whereas type II fractures occurred predominantly in securely cemented prostheses. Type I fractures treated by revision had the poorest results. Outcome in type II fractures was equally good whether treated by internal fixation or by revision. Age, loosening, and prosthetic alignment did not influence outcome. The mortality rate in this series was 20%. CONCLUSIONS: If a prosthesis is loose, it should be revised, or treatment varies with fracture and prosthetic type. In type I fractures, an uncemented stem may be revised to a cemented one; however, a securely cemented prosthesis probably is better when fixed internally. Type II fractures should be fixed internally because there is less operative insult. Type III fractures probably are not related to the prosthesis and should be fixed internally according to normal practice. The results of an operative policy compare well with the results of conservative management and avoid the problems of long-term immobilization.

Inferior outcomes of total knee replacement in early radiological stages of osteoarthritis.

BACKGROUND: Total knee replacement (TKR) for osteoarthritis (OA) is a common and successful operation; the severity of radiographic changes plays a key role as to when it should be performed. This study investigates whether an early radiological grade of OA has an adverse effect on the outcome of TKR in patients with arthroscopically confirmed OA. METHODS: Between January 2006 and January 2011 data was collected prospectively on all patients undergoing a primary TKR for OA. We included all patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph who had had an arthroscopy to confirm significant OA. Our primary outcomes were the Oxford Knee Score (OKS) and a satisfaction rating. RESULTS: Over the study period 1708 primary TKRs were performed in 1381 patients. We identified 44 TKRs in 43 patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph. In this group the mean age was 63 years, 66% were female and the mean BMI was 31.7 kg/m(2). At a mean follow-up of 37 months the mean OKS was only 30 points compared to 36 in all TKRs performed over the same period (p=0.0004). Only 68% were either satisfied or very satisfied. Eight knees (18%) underwent further surgery, three (6.8%) of which were revision procedures, compared to a revision rate of 1.6% in all patients. CONCLUSION: The outcomes of TKR in patients with early radiological changes of OA are inferior to those with significant radiological changes and should be performed with caution. LEVEL OF EVIDENCE: Level IV case-series.

Minimum 6year results of an uncemented trabecular metal tibial component in total knee arthroplasty.

INTRODUCTION: There are theoretical advantages of using a trabecular metal tibial component in total knee replacement (TKR) for long-term survival. We have previously reported outcomes at 3 years. We now report the clinical and radiological outcome of an unselected series of 109 knees at a minimum of 6 years follow up. METHODS: Patient function was assessed in a research clinic using Oxford Knee Score (OKS), Clinical and Functional Knee Society Score (KSS) and SF-12 physical score. Up to date weight bearing radiographs were obtained. RESULTS: Seventy-six knees in 72 patients were available for assessment. OKS scores were maintained from the 3-year assessment with a mean of 36.1 (8.6). KSS and SF-12 scores declined slightly but only to a degree previously reported as normal age related change. The mean KSS at follow up was 87.2 (17.7). There was no radiographic evidence of loosening in any implant. There has been 1 revision for unexplained pain at 27 months. CONCLUSION: The uncemented TMT in an unselected group is performing as well as any TKR implant at this stage. Future follow up is required to ensure this is maintained. The theoretical advantages may make this the prosthesis of choice in younger patients. LEVEL OF EVIDENCE: IV. Case series.

Acute phase protein levels in dogs with mast cell tumours and sarcomas.

The acute phase proteins (APP) form part of a non-specific host response to inflammation. They may be induced by a range of different causes, including infection, inflammation, cancer and trauma. As they form part of the earliest response to such insults, they have potential for early identification of disease. In people, APP levels have been shown to correlate both with the extent of disease and also the prognosis in several forms of neoplasia, including prostate, oesophageal and colorectal cancer. As such, they can be used as prognostic and monitoring tools. To date, similar studies in veterinary patients have been limited, largely retrospective in nature and many are non-specific for tumour type. The purpose of this study was to evaluate a panel of four APPs in dogs with naturally occurring mast cell tumours (MCTs) and sarcomas to identify in the first instance whether increased levels of individual APPs, or identifiable combinations of APPs, was linked with the presence of disease. In the patients with MCTs, C-reactive protein (CRP) and α-1 acid glycoprotein levels increased, with a concurrent drop in serum amyloid A levels. In the sarcoma patients, CRP, α-1 acid glycoprotein and haptoglobin were increased. These findings suggest that specific solid tumour types in dogs may be associated with specific changes in APP profiles.

A comparison of factors that influence survival in dogs with adrenal-dependent hyperadrenocorticism treated with mitotane or trilostane.

BACKGROUND: Trilostane is a recognized treatment for canine pituitary-dependent hyperadrenocorticism (PDH); however, its efficacy in dogs with adrenal-dependent hyperadrenocorticism (ADH) is unknown. OBJECTIVES: To examine factors that might influence survival in the medical management of ADH, with particular emphasis on treatment selection. ANIMALS: Thirty-seven animals referred to 4 centers over a period of 12 years that had been diagnosed with ADH and treated with either trilostane (22/37), mitotane (13/37), or both (2/37). METHODS: Retrospective analysis of clinical records. RESULTS: There was no statistically significant difference between the survival times of 13 dogs treated only with mitotane when compared with 22 dogs treated only with trilostane. The median survival time for animals treated with trilostane was 353 days (95% confidence interval [CI] 95-528 days), whereas it was 102 days (95% CI 43-277 days) for mitotane. Metastatic disease was detected in 8 of 37 dogs. There was a significantly lower probability of survival for dogs with metastatic disease when compared with those without metastatic disease (P < .001). CONCLUSIONS AND CLINICAL IMPORTANCE: The choice of medical treatment for ADH may not have a major effect on survival times. However, the presence of metastatic disease considerably decreases survival time regardless of the choice of medical treatment.

Retrospective evaluation of the effect of trilostane on insulin requirement and fructosamine concentration in eight diabetic dogs with hyperadrenocorticism.

OBJECTIVES: To describe the effect of trilostane on insulin requirements and serum fructosamine in dogs with diabetes mellitus (DM) and hyperadrenocorticism (HAC). METHODS: Observational retrospective study of eight dogs. RESULTS: Median fructosamine concentration at presentation was 401 µmol/L (range 244 to 554 µmol/L). Median insulin dose at presentation was 1·1 IU/kg/dose (0·4 to 2·1 IU/kg/dose) administered twice daily in five animals and once in three. Four dogs had their insulin dose prospectively reduced at the start of trilostane therapy. The HAC was controlled within 28 days in seven dogs. The remaining case was controlled by 17 weeks. Two dogs died within 40 days of starting trilostane. The median fructosamine concentration was 438 µmol/L (range 325 to 600 µmol/L) after stabilisation of the HAC. One case had a consistent reduction in serum fructosamine concentration over the first four months. The median insulin dose after stabilisation of HAC was 1·5 IU/kg dose (range 0·25 to 3·0 IU/kg/dose). Insulin requirements were reduced in two cases after treatment with trilostane. Four dogs required increased insulin doses. CLINICAL SIGNIFICANCE: Insulin requirements and fructosamine concentrations do not consistently reduce during trilostane treatment for HAC. Prospective studies are required to provide recommendations regarding reductions in insulin doses with trilostane treatment.