Osteochondral fractures of the knee in skeletally immature patients: short term results of operative fixation using Omnitech screws.

PURPOSE: Osteochondral fractures in skeletally immature patients are rare. A retrospective case series is reported looking at the use of Omnitech compression screws for these injuries. METHOD: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Eastbourne Miami-J Protocol: a Pilot Study for the Care of Cervical Injuries in the Community.

UNLABELLED: PURPOSE OF THE STUDY The aim of this pilot study was to develop The Eastbourne Miami-J Protocol for care of cervical injuries within the community. Led by orthopaedic senior practitioners, a multidisciplinary approach was developed to provide education and collar care for patients on a weekly basis. MATERIALS AND METHODS A total of 51 patients (17 male and 33 female), mean age 74 years (21 to 95) with CT confirmed cervical injuries during November 2010 and May 2014 followed the Eastbourne Miami-J Protocol. RESULTS Patients required collar care on average for 7.25 weeks. Thirty-two patients had single level cervical injuries with C2 the commonest. Complications included: 6 patients with psychosocial issues; 10 patients with skin erythema due to ill-fitting collars and 2 patients with skin breakdown requiring dressings. CONCLUSION The Eastbourne Miami-J protocol demonstrates that a multidisciplinary approach, championed by the casting department, can provide care for patients with cervical injuries within the community. KEY WORDS: cervical spine, C-spine, cervical collar, community, rehabilitation.

The Eastbourne Trauma Assisted Discharge Scheme (TADS) Reduces Length of Stay in Hip Fracture Patients.

UNLABELLED: PURPOSE OF THE STUDY The aim of this prospective study; The Trauma Assisted Discharge Scheme (TADS), was to set up a new model of postoperative care for patients following a fractured hip, addressing the need for efficiency, cost effectiveness and meeting local demand. MATERIAL AND METHODS All patients with hip fractures between December 2010 and December 2011, meeting the TADS inclusion criteria were enrolled in the study. Innovative use of staff within existing budgets helped create a TAD team who with the use of defined patient goals and a link nurse provided a seamless transition from acute to community services. RESULTS One hundred and sixteen patients followed the TADS pathway; the majority aged 80-89 years and independent prior to falling. A total of 35 patients underwent dynamic hip screw fixation; 55 hemiarthroplasty, 11 total hip replacement and 11 cannulated screw fixation. The average length of in-hospital stay was 8.6 nights. The TADS reduced the average length of stay by 4.78 days. CONCLUSION TADS has the potential to be used as a model of care in other specialities and is easily transferable to the wider NHS. KEY WORDS: continuous quality improvement, quality improvement, surgery, cost-effectiveness, ambulatory care.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws.

PURPOSE OF THE STUDY: Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients. MATERIAL AND METHODS: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

The risk of neurovascular injury in minimally invasive plate osteosynthesis (MIPO) when using a distal tibia anterolateral plate: a cadaver study.

PURPOSE OF THE STUDY: Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. The aim of this study was to analyze structures that are at risk during this approach. MATERIAL AND METHODS: Thirteen unpaired adult lower limbs were used for this study. Thirteen, 15-hole LCP anterolateral distal tibial plates were percutaneously inserted according to the recommended technique. Dissection was performed to examine the relation of the superficial and deep peroneal nerves and anterior tibial artery relative to the plate. RESULTS: The superficial peroneal nerve was found to cross the vertical limb of the LCP plate at a mean distance of 63 mm (screw hole five) but with a wide range of 21 to 105 mm. The neurovascular bundle (deep peroneal nerve and anterior tibial artery) crossed the plate at a mean of 76 mm (screw hole six) but also with a wide range of 38 to 138 mm. The zone of danger of the neurovascular structures ranges from 21 to 138 mm from the tibial plafond. In one specimen, a significant branch of the deep peroneal nerve was found to be entrapped under the plate. CONCLUSION: Caution is advised when using anterolateral minimally invasive technique for plate insertion and screw placement in the distal tibia due to great variability in the neurovascular structures that course distally in the lower leg and cross the ankle.

Bilateral hip fractures associated with transient osteoporosis of pregnancy.

A case of transient osteoporosis of pregnancy complicated by bilateral neck of femur fractures is reported. We discuss the condition and review the literature, provide information to aid in the diagnostic dilemma clinicians may face when considering imaging techniques and the potential for foetal harm during radiation exposure. We discuss management strategies in such patients.

Acute spinal epidural haematoma causing cord compression after chiropractic neck manipulation: an under-recognised serious hazard?

Spinal manipulative therapy performed by chiropractors is increasingly common in the United Kingdom. Spinal epidural haematoma is a rare complication of such physical therapy but when identified represents a neurological emergency. We describe the case of a 64 year-old man who presented with a dense hemiplegia due to a spinal epidural haematoma following cervical spine manipulation performed for acute neck pain. The clinical features and surgical management of the case are discussed and we stress the importance of recognition of chiropractic manipulation as a potential cause of neurological sequelae and discuss the potential pitfalls of such therapy as it becomes more widespread.

An analysis comparing open surgical and endovascular treatment of atherosclerotic renal artery stenosis.

OBJECTIVE: Endovascular revascularization in atherosclerotic renal artery stenosis (ARAS) has dominated during the last 15 years with surgery relegated mostly to back-up for failed endovascular procedures. This study examines the available outcome evidence to determine what role open surgery should have in comparison to endovascular treatment in the management of ARAS. METHOD: Of 183 papers listed in PubMed, the USNLM and the Cochrane library, (1975-2004) 47, dealing with outcomes of surgical and endovascular treatments (evidence levels 2b and 3) were selected. Endovascular included 1750 patients in 16 prospective non-randomised (PNRT) and 5 retrospective (RET) studies. Surgical included 2314 patients in 4 PNRTs and 17 RETs. Outcome data were subjected to meta-regression analysis weighted according to the inverse variance method. RESULTS: Mean maximum ages were 79.4 yrs (SD 6.9) for surgical and 83.6 yrs (SD 3.8) for endovascular studies. Primary technical success was similar. Endovascular patency declined by 0.26%/month (95% CI: 0.04-0.48, p=0.03). Surgical studies showed greater improvement for hypertension control by 21% (95% CI: 9-33%, p=0.001) and for renal function by 34% (95% CI: 18-54%, p<0.001), as well as a higher creatinine reduction by 32 micromol/L (95% CI: 7-57 micromol/L, p<0.014). A higher excess surgical mortality, 3.1% (95% CI: 1.8-4.4%, p<0.001) became insignificant, 0.18% (95% CI: 0.7-1.1, p=0.70) when concomitant aortic surgery was excluded. CONCLUSION: This data shows a marked and durable clinical benefit for surgery. These findings question the endovascular predominance in intervention in ARAS and highlight the need for a carefully designed prospective randomised comparison to define the roles of endovascular and surgical renal revascularization.

A systematic review of short metaphyseal loading cementless stems in hip arthroplasty.

AIMS: Short-stemmed femoral implants have been used for total hip arthroplasty (THA) in young and active patients to conserve bone, provide physiological loading, and reduce the incidence of thigh pain. Only short- to mid-term results have been presented and there have been concerns regarding component malalignment, incorrect sizing, and subsidence. This systematic review reports clinical and radiological outcomes, complications, revision rates, and implant survival in THA using short-stemmed femoral components. MATERIALS AND METHODS: A literature review was performed using the EMBASE, Medline, and Cochrane databases. Strict inclusion and exclusion criteria were used to identify studies reporting clinical and radiological follow-up for short-stemmed hip arthroplasties. RESULTS: A total of 28 studies were eligible for inclusion. This included 5322 hips in 4657 patients with a mean age of 59 years (13 to 94). The mean follow-up was 6.1 years (0.5 to 20). The mean Harris Hip Score improved from 46 (0 to 100) to 92 (39 to 100). The mean Oxford Hip Score improved from 25 (2 to 42.5) to 35 (12.4 to 48). The mean Western Ontario & McMaster Universities Osteoarthritis Index improved from 54 (2 to 95) to 22 (0 to 98). Components were aligned in a neutral coronal alignment in up to 90.9% of cases. A total of 15 studies reported component survivorship, which was 98.6% (92% to 100%) at a mean follow-up of 12.1 years. CONCLUSION: Short-stemmed femoral implants show similar improvement in clinical and radiological outcomes compared with conventional length implants. Only mid-term survivorship, however, is known. An abundance of short components have been developed and used commercially without staged clinical trials. Long-term survival is still unknown for many of these components. There remains tension between innovation and the moral duty to ensure that the introduction of new implants is controlled until safety and patient benefit are demonstrated. Implant innovation and subsequent use should be driven by proven clinical outcomes, rather than market and financial forces, and ethical practice must be ensured. Cite this article: Bone Joint J 2019;101-B:502-511.

Doctors' knowledge of the appropriate use and route of administration of antidotes in the management of recreational drug toxicity.

BACKGROUND: Specific antidotes (eg, naloxone, flumazenil, cyproheptadine and benzodiazepines) are available for the management of certain recreational drug-induced toxicities. Some controversies surround the use of some of these antidotes, especially flumazenil in benzodiazepine toxicity. There are no previously published data on doctors' knowledge of the use of these specific antidotes. METHODS: A questionnaire survey was designed to determine internal/emergency medicine doctors' knowledge of the appropriate use of antidotes in the management of clinical scenarios of acutely poisoned patients. For nine simulated clinical scenarios of acute toxicity from recreational drugs (benzodiazepines, cocaine, N-methyl-L-(3,4-methylene-dioxyphenyl)-2-aminopropane (MDMA)-induced serotonin toxicity and opioids), they were asked to indicate whether the suggested antidote and route of administration were correct. RESULTS: 42 physicians of all grades completed the questionnaire. The mean correct score was 5.4 (SD 1.1) (median 6, interquartile range 5-7). The percentages correct for the various clinical scenarios were 68.3% for opioid toxicity, 81% for benzodiazepine toxicity, 28.6% for MDMA-induced serotonin toxicity and 70.2% for cocaine toxicity. Doctors were more likely to record an answer of "unsure" for the use of cyproheptadine in ST serotonin toxicity (28.6%) compared with the use of the other antidotes (1.4%; p<0.001). CONCLUSION: Knowledge of the appropriate use of antidotes in recreational drug toxicity is not consistent, with poorer knowledge on the use of newer antidotes such as cyproheptadine in serotonin toxicity. Education is required both to increase overall knowledge on the use of specific antidotes in the management of recreational drug-induced toxicity, as well as focusing on newer antidotes such as cyproheptadine.

Hepatocyte Growth Factor/scatter factor-induces phosphorylation of cortactin in A431 cells in a Src kinase-independent manner.

The Hepatocyte Growth Factor receptor transduces proliferating and scattering signals in epithelial and endothelial cells. We have explored potential interactions of the HGF/SF receptor beta-subunit (p145(beta MET)) with F-actin binding partners aiming to identify novel downstream effectors implicated in HGF/SF pluripotent signalling. Cortactin, a p80/85 F-actin binding protein, was found phosphorylated on tyrosine in response to HGF-SF in A431 human epidermoid carcinoma cells, expressing the HGF/SF receptor (c-MET). The HGF/SF receptor was enriched in the detergent-insoluble fraction and was found to co-precipitate with cortactin and to associate in vitro with cortactin. The Grb2 small adapter protein known to associate via its Src homology 2 domain (SH2) with the MET C-terminus, was also associated with cortactin. Transient transfection of A431 cells with dominant-negative Grb2 constructs has revealed that the Grb2-C-SH3 domain possesses a central role in cortactin phosphorylation in response to HGF/SF. Finally, tyrosine phosphorylation of cortactin was found uncoupled of endogenous c-Src kinase activity, thus further supporting the hypothesis that cortactin is a direct target of the MET kinase. We propose that cortactin may constitute a docking site for MET-derived signals within the cytoskeleton.

The expression of renin-binding protein and renin in the kidneys of rats with two-kidney one-clip hypertension.

OBJECTIVE: To test the hypothesis that renin-binding protein (RnBP) is involved in modulating the intracellular processing or release of renin, we examined the expression of RnBP in clipped and contralateral kidneys of rats with two-kidney one-clip hypertension, and in left and right kidneys from sham-operated control rats. DESIGN AND METHODS: Kidneys from rats with two-kidney one-clip hypertension and from control rats were either snap-frozen for extraction of mRNA or fixed for in-situ hybridization and immunochemistry. Reverse-transcription polymerase chain reaction on renal mRNA was performed using primers for renin, RnBP, glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and angiotensin-converting enzyme (ACE). In addition, renal total RNA was analysed by Northern blotting for RnBP, GAPDH and angiotensin II type 1A (AT1A) receptor mRNA, and the intensity of the bands was measured by laser densitometry. In situ hybridization for renin mRNA was carried out using digoxygenin-labelled antisense oligonucleotides and for RnBP using labelled antisense oligonucleotides and an antisense riboprobe. Controls included sections treated with RNase and sections stained with sense oligonucleotides. RESULTS: The level of expression of mRNA for RnBP is similar in clipped and contralateral kidneys of renal hypertensive rats; in contrast, renin mRNA expression is upregulated in the clipped kidney. Renin-binding protein is expressed mainly in renal tubules and collecting ducts unlike renin, which is expressed in the glomerular afferent arteriole. We did not detect lateralization of expression for ACE or the AT1A receptor between clipped and contralateral kidneys. CONCLUSION: Renin-binding protein expression is unchanged between clipped and contralateral kidneys. Therefore, a physiological stimulus that upregulates renin gene expression in clipped kidneys does not affect RnBP expression. The main sites of RnBP expression are the renal tubules and collecting ducts; in contast renin is expressed at the glomerular pole. The results show that RnBP is not colocalized or coregulated with renin in this model of hypertension.

Impaction femoral allografting at revision hip arthroplasty: uncemented versus cemented technique using a Freeman femoral component.

We report the long-term results of revision total hip replacement using femoral impaction allografting with both uncemented and cemented Freeman femoral components. A standard design of component was used in both groups, with additional proximal hydroxyapatite coating in the uncemented group. A total of 33 hips in 30 patients received an uncemented component and 31 hips in 30 patients a cemented component. The mean follow-up was 9.8 years (2 to 17) in the uncemented group and 6.2 years (1 to 11) in the cemented group. Revision procedures (for all causes) were required in four patients (four hips) in the uncemented group and in five patients (five hips) in the cemented group. Harris hip scores improved significantly in both groups and were maintained independently of the extent of any migration of the femoral component within the graft or graft-cement mantle.

Basal cell carcinoma of the penis.

Basal cell carcinoma (BCC) is the most common malignant tumour found in humans. It appears in the genital and perianal region in less than one percent of cases. Discovery of lesions around the genitalia may often be delayed due to neglect, hesitation of patients to visit the clinic or unawareness on the part of both the patients and physicians. We report a case of delayed presentation of BCC of the penis in a middle-aged man, which was successfully managed with wide local excision under the care of plastic surgeons.

Rapidly evolving giant dermatofibroma.

Dermatofibroma, also known as "fibrous histiocytoma", is a benign dermal or subcutaneous poorly circumscribed proliferation of spindle-shaped fibroblasts and macrophages in the dermis. Although it is commonly present as a brownish nodule the legs of females, it may also arise on the upper extremities, trunk, and rarely on the head. The exact pathogenesis is unclear. However, it is widely believed that the originating insult to the dermis is a folliculitis, an arthropod bite, or an unspecified initial inflammatory condition. Giant dermatofibromas of greater than 5 cm in diameter are rare, with only 22 cases reported in the literature. We present a case of a rapidly evolving pedunculated mass in the groin of a male patient. Histological examination confirmed this to be a giant dermatofibroma. Though this specimen cannot is not confirmed as such, the cellular subtype is sometimes present as a larger lesion with anecdotal reports of local recurrence and distant metastases. The clinical and radiological features which were somewhat suspicious of malignancy are considered in the context of the definitive pathological diagnosis of a benign lesion.

Anal fissure: a review.

Patients often present to general and colorectal clinics with symptoms of anal fissures and can even present acutely to hospital. Conservative remedies have healing rates of up to 85% and have largely replaced surgery as first-line management. This review highlights the cardinal points in the aetiology, pathogenesis and treatment of anal fissures.

Cholecystocutaneous fistula secondary to chronic calculous cholecystitis.

Spontaneous cholecystocutaneous fistula is an exceptionally unusual complication of chronic calculous cholecystitis now. The remarkable drop in incidence is probably associated with the introduction of antimicrobial therapy and early surgical management of biliary tract disease. We report a case of spontaneous cholecystocutaneous fistula in a patient who presented with an abscess in the right upper quadrant.

The beta-subunit of the hepatocyte growth factor/scatter factor (HGF/SF) receptor phosphorylates and associates with CrkII: expression of CrkII enhances HGF/SF-induced mitogenesis.

CrkII, a 40 kDa adaptor possessing a Src homology (SH)2 domain followed by two SH3 domains, although not endowed with catalytic activity, participates in intracellular signalling, presumably by activating the Ras pathway. CrkII was found to be phosphorylated in response to hepatocyte growth factor/scatter factor (HGF/SF) and to associate with the beta-subunit of the HGF receptor (MET). CrkII associated with p(145betaMET) via its SH2 domain. Growth-factor-receptor-bound protein 2 (Grb2) co-immunoprecipitated with CrkII species. By transient transfection of A431 human epidermoid carcinoma cells with wild-type and dominant-negative Grb2 expression constructs lacking either the SH2 or SH3 domains, we have concluded that Grb2 does not contribute to the 'presentation' of CrkII to p(145betaMET). Overexpression of wild-type CrkII in A431 cells enhanced HGF/SF-induced proliferation, while a CrkII dominant-negative mutant lacking the SH2 domain prevented a similar proliferating response to HGF/SF. The effect of CrkII on HGF/SF-induced proliferation was also abolished in cells co-expressing CrkII and Son-of-sevenless lacking the guanine exchange domain, suggesting that CrkII is likely to induce cell proliferation partly via the Ras/mitogen-activated protein kinase route.