Saving the foot: Simple orthopaedic surgical intervention demonstrates improved outcomes and reduced costs.

BACKGROUND: Forefoot ulceration in diabetes requires significant resources, with high cost and low rates of success. The authors present the results of tendon procedures (percutaneous toe tenotomy and percutaneous tendo-achilles lengthening) under local anaesthetic to adjust mechanics in patients with diabetic neuropathic forefoot ulceration. METHODS: Retrospective review of electronic patient record of 19 patients (22 feet) undergoing local anaesthetic tendon procedures between April 2019 and April 2021 with a 12 month follow up period. Size of ulcer, rate of ulcer healing, complication rates and ulcer recurrence were recorded and compared to a population of conservatively-managed patients (14 patients, 15 feet) treated prior to the introduction of tendon procedures. All clinical information obtained from electronic patient records. RESULTS: All patients undergoing tendon procedures achieved complete ulcer healing at a mean time of 3.3 weeks for toe tip ulcers (after toe tenotomy) and 4.5 weeks for metatarsal head ulcers (after Achilles lengthening). There were no admissions for diabetic foot sepsis, reduced recurrence, reduced amputation rates and no mortality. Of the conservatively managed cohort, only 3 of the 15 achieved ulcer resolution without recurrence within the 12 month study period. The cohort managed conservatively had an average cost of £ 9902 per patient, per annum. The intervention cost was £ 1211 per patient, saving an average of £ 8691 per patient, per annum with ulcer resolution (88 % reduction in costs). CONCLUSION: Significant patient benefit, reduction in resource use and cost saving was seen with this simple intervention, which merits full evaluation in a clinical trial. LEVEL OF EVIDENCE: Level-IV.

Pitfalls preventing bone union with EXOGEN Low-Intensity Pulsed Ultrasound.

OBJECTIVES: To evaluate the efficacy of EXOGEN in achieving union and common pitfalls in its use within the Manchester Foundation Trust (MFT) and Salford Royal Foundation Trust (SRFT). METHOD: Patients receiving EXOGEN therapy between 01/01/2017 and 31/12/2019 at hospitals within MFT and SRFT were identified using EXOGEN logbooks and hospital IT systems. An equal number of patients were included from both sites. Data were retrospectively collected from clinical documents detailing clinical presentation comorbidities, and radiographic images, determining the radiological union post EXOGEN therapy. In addition, local practices were observed and compared to EXOGEN's standardized guidance for clinicians. RESULTS: Fifty-eight patients were included in the primary review, with 9 subsequently excluded based on insufficient clinical data. 47% of patients achieved radiological union following completion of EXOGEN therapy. Outcomes of the 23 patients with persistent non-union were as follows - 18 were referred for revision surgery, 5 were prescribed further EXOGEN therapy, 2 refused or were unfit for further intervention, and 1 did not have a plan documented. No significant baseline differences were present in both outcome groups. However, at MFT and SRFT, rates of union with EXOGEN are below that previously published in the literature. CONCLUSION: EXOGEN has proven successful in facilitating union in established cases of non-union without the risk and cost associated with revision surgery. Centre outcome differences may be explained by failure to educate clinicians and patients on the correct use of the EXOGEN device, failure to standardize follow-up or monitor compliance, and must be addressed to improve current services.

Non-cardiac Manifestations in Adult Patients With Mucopolysaccharidosis.

Mucopolysaccharidoses (MPS) are a heterogeneous group of disorders that results in the absence or deficiency of lysosomal enzymes, leading to an inappropriate storage of glycosaminoglycans (GAGs) in various tissues of the body such as bones, cartilage, heart valves, arteries, upper airways, cornea, teeth, liver and nervous system. Clinical manifestations can become progressively exacerbated with age and affect their quality of life. Developments in advanced supportive treatment options such as enzyme replacement therapy (ERT), hematopoietic stem cell transplantation (HSCT) may have improved patients' life span. Adult MPS patients require specialist clinical surveillance long-term. In many cases, in addition to the MPS-related health problems, they may develop age-related complications. Considering the complexity of their clinical manifestations and lack of guidelines on the management of adult MPS disorders, multispecialty and multidisciplinary teams' care is essential to diagnose and treat health problems that are likely to be encountered. This review presents non-cardiac clinical manifestations, their pathophysiology, management and long-term outcomes in adult MPS patients.

The influence of tantalum on human cell lineages important for healing in soft-tissue reattachment surgery: an in-vitro analysis.

BACKGROUND: Porous tantalum is currently used in orthopaedic surgery for a variety of indications including soft tissue re-attachment. However, the clinical results have been variable and a previous laboratory study has suggested that tantalum may actually inhibit chick tendon fibroblasts. The influence of tantalum on human cell-types involved in soft tissue re-attachment has not been defined. METHODS: Human fibroblasts, human osteoblasts and human mesenchymal stem cells were plated on glass cover slips, half of which were coated with tantalum. Cell numbers were assessed at 1, 2, 7 and 14 days using Cyquant® assay. Cell adhesion and morphology were assessed using light microscopy at 7, 14 and 28 days. To reduce the effect of an expected rate of error, n = 4 was utilised for each cell type and the experiment was repeated twice. RESULTS: Statistically similar numbers of human osteoblasts and human mesenchymal stem cells were present at 14 days on tantalum-coated and uncoated glass cover slips, revealing no inhibitory effect on cell proliferation. More than double the number of human fibroblasts was seen on tantalum-coated cover slips at that time point (compared to controls), which was statistically significant (p < 0.0001). Morphological assessment revealed normal cell spreading and adhesion on both substrates at all time points. CONCLUSIONS: In vitro study demonstrates that Tantalum causes a significant increase in the proliferation of human fibroblasts with no quantifiable negative effects seen on fibroblast behaviour after 28 days culture. Furthermore, tantalum does not exert any inhibitory effects on the proliferation or behaviour of human osteoblasts or human mesenchymal stem cells. Tantalum could be an appropriate biomaterial for use in situations where soft tissue requires direct reattachment to implants and may stimulate soft tissue healing.

Current evidence and future directions for research into the use of tantalum in soft tissue re-attachment surgery.

The use of tantalum is well established in orthopaedic surgery. It has a modulus of elasticity that is close to bone and a high yield and ultimate strength allowing it to be used to form large, weight-bearing constructs with a high volumetric porosity conducive to osseointegration. However, its role in soft tissue re-attachment remains undefined due to variable clinical outcomes. Successful re-attachment of tendons to tantalum mega-prostheses, in tumour and revision surgery, has been reported but several authors report almost universal failure of long term soft tissue re-attachment with tantalum patella augments when no residual bone stock is present. It is postulated that these failures are due to a lack of stability of the implants and an inhibitory effect of tantalum on soft tissue integration. Tantalum has previously been considered an excellent biomaterial for soft tissue integration based on animal studies where implants were retrieved and subjected to mechanical testing. However, clinical studies suggest that this soft tissue in-growth does not reliably tolerate the high mechanical loads that are generated in the clinical setting. Furthermore, recent laboratory evidence suggests that tantalum may in fact directly inhibit fibroblasts, limiting the potential for mature collagen fibrillogenesis. This review collates the evidence from laboratory, animal and clinical studies to inform and guide future directions in biomaterial research and to drive improved outcomes for soft tissue re-attachment surgery.

Reverse Shoulder Arthroplasty in Rheumatoid Arthritis: A Systematic Review.

BACKGROUND: Anatomical shoulder replacement for rheumatoid arthritis (RA) is complicated by a high incidence of rotator cuff tears and glenoid erosion. This can lead to poor function and early failure. Reverse shoulder arthroplasty (RSA) has gained popularity as an alternative. This systematic review attempts to further define the role of RSA in RA. METHODS: A systematic review identified seven studies reporting outcomes of RSA in RA patients. Studies were critically appraised, and data on outcomes, complications and technical considerations were extracted and analysed. RESULTS: One hundred and twenty one shoulders were included (mean follow up 46.9 months). Consistent improvements in the main outcome measures were noted between studies. Ninety five percent of patients described excellent to satisfactory outcomes. The minimum mean forward elevation reported in each study was 115 degrees. Symptomatic glenoid loosening (1.7%), deep infection (3.3%) and revision surgery (5%) rates were no higher than for a population of mixed aetiologies. DISCUSSION: Previous concerns regarding high pre- and peri-operative complication and revision rates in RA patients were not shown to be valid by the results of this review. Although associated cuff tears are common and glenoid bone loss can increase the technical complexity of surgery, RSA provides consistent and predictable improvements in key outcome measures and the revision and complication rates do not appear to be higher than reported in a large population of mixed aetiologies. CONCLUSION: The contemporary literature shows that RSA is a safe, effective and reliable treatment option in RA patients.

Management of glenohumeral synovitis secondary to influenza vaccination.

Glenohumeral synovitis is a rare complication of vaccination that can lead to shoulder dysfunction and prolonged pain. We report a case of florid glenohumeral synovitis after routine influenza vaccination, which we consider to have occurred because of the unintentional injection of antigenic material into synovial tissues, resulting in an immune-mediated inflammatory reaction. We provide a review of the literature for this condition and describe an invasive management approach, providing, for the first time, an arthroscopic evaluation and histopathological analysis.

Treatment of deformational plagiocephaly and torticollis using a weight distribution ring: a report of three cases.

Plagiocephaly, from the Greek 'plagios' (slanting) and 'kephale' (head), refers to a condition of an infant's head deformation by forces acting upon a malleable cranium. Marked plagiocephaly causes distress and stigma towards the baby and their family and has knock-on effects with craniofacial abnormalities, visual-field defects and delay in motor skills, and may also cause developmental difficulties. Current treatment methods have multiple drawbacks. This small, illustrated case series presents a novel, cost-effective, practical first-line treatment using a horseshoe-shaped gel head ring to redistribute pressure, allowing uniform growth and reshaping. Our early experience suggests that this method represents an effective treatment option with promising results so far.