Unusual mechanical complications of unicompartmental low contact stress mobile bearing patellofemoral arthroplasty: a cause for concern?

The Low Contact Stress Patellofemoral Arthroplasty (LCS PFA) is a newer design belonging to the second generation of inlay type implants, addressing the problems encountered in the first generation models (Lubinus & Richard's). The cemented mobile bearing metal backed patellar component in this system is "modular"; allowing interchangeable usage with either the trochlear component in a PFA or the femoral component of a total knee arthroplasty, thus obviating the need for patellar revision during conversion of PFA to TKA. The younger active patient with a PFA may exert extreme joint reaction forces on their patellar implant, rendering early loosening of the patellar implant. The endurance of this implant with repeated flexion beyond 90 degrees is also a concern. We describe a series of three unusual mechanical failures associated with this particular design of metal backed patellar component of the unicompartmental LCS patellofemoral arthroplasty.

Inter- and intra-observer variation of the Schatzker and AO/OTA classifications of tibial plateau fractures and a proposal of a new classification system.

INTRODUCTION: The aim of this study was to evaluate the intra- and inter-observer variation of the Schatzker and AO/OTA classifications in assessing tibial plateau fractures, using plain radiographs. PATIENTS AND METHODS: Fifty tibial plateau fractures were classified independently by six observers as per the Schatzker and AO/OTA classifications, using antero-posterior and lateral plain radiographs. Assessment was done on two occasions, 8 weeks apart. RESULTS: We found that both the Schatzker and AO/OTA classifications have a high intra-observer (kappa = 0.57 and 0.53, respectively), and inter-observer (kappa = 0.41 and 0.43, respectively) variation. Classification of tibial plateau fractures into unicondylar versus bicondylar and pure splits versus articular depression +/- split conferred improved inter- and intra-observer variation. CONCLUSIONS: The high inter-observer variation found for the Schatzker and AO/OTA classifications must be taken into consideration when these are used as a guidance of treatment and when used in evaluating patients' outcome. Simply classifying tibial plateau fractures into unicondylar versus bicondylar and pure splits versus articular depression +/- split may be more reliable.

Availability of orthopaedic trauma lists in the United Kingdom.

National guidelines recommend that hospitals dealing with acute orthopaedic trauma should have daily, consultant led trauma lists, performed in dedicated trauma theatres. This study examined the availability and organisation of orthopaedic trauma lists in the United Kingdom using a postal survey. Of 228 responding hospitals, only 29% had daily trauma lists. In 17%, elective cases were cancelled to accommodate trauma whilst up to 20% of hospitals had a high proportion of their trauma lists not being consultant led. Twenty-one percent of responding hospitals did not have a dedicated trauma theatre. Our results suggest that most units have a long way to go in meeting national standards regarding the availability of orthopaedic trauma lists.

Operating out of hours in acute orthopaedics: variations amongst surgeons and regions in the United Kingdom.

It is recommended that out of hours, surgery should be confined to emergency cases. What constitutes an emergency in orthopaedic surgery is not well defined. This study presents the results of a postal survey sent to orthopaedic surgeons practicing in the United Kingdom, asking them what is the time frame they would recommend operating upon, and whether they would operate out of hours for common acute orthopaedic presentations. Our results demonstrate variability both amongst individual surgeons as well as amongst different regions in the United Kingdom.

Casting versus surgical fixation for grade IIIA open tibial diaphysial fractures in children: effect on the rate of infection and the need for secondary surgical procedures to promote bone union.

We evaluated 39 grade IIIA open tibial fractures presenting in children younger than 13 years of age, to determine if the mode of fracture stabilization (casting vs. surgical fixation) was related to the rate of infection or the need for secondary surgical procedures to promote bone union. All fractures had wound debridement in the operating room. Thirty patients had manipulation and casting, and nine surgical internal or external fixation. There were two cases of infection in the cast-treated group and two in the surgical fixation group (P=0.17). None of the fractures required a secondary surgical procedure to promote bone union. Three of the fractures treated by manipulation and casting displaced; two required re-manipulation and casting and one was converted to external fixation. In two cases the applied external fixator had to be re-aligned. Our results suggest that manipulation and casting is a reliable treatment for open tibial fractures in children.

Early versus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union.

The purpose of this study was to evaluate whether there was any significant difference in the rates of infection and of secondary surgical procedures to promote bone union, between early(6 h or less after arrival to hospital) and delayed(more than 6 h) surgical treatment of open tibial fractures. Three hundred and eighty-three open tibial fractures were evaluated. 184 fractures had early and 199 had delayed surgical treatment. The rates of infection and secondary surgical procedures to promote bone union of the two groups were compared with univariate and multivariate statistical methods. There was no statistically significant difference between early and delayed treatment groups with respect to overall infection (53/184 versus 51/199 infection rates, P = 0.96), deep infection (8/184 versus 8/199 infection rates, P = 1.0), and rates of secondary surgical procedures to promote bone union (24/184 versus 20/198, P = 0.77). We were unable to demonstrate any significant difference in infection rates or need of secondary procedures to promote bone union, between early and delayed surgical treatment of open tibial fractures.

Success of cannulated screw fixation of subcapital neck of femur fractures.

In this study we retrospectively reviewed 251 patients who had internal fixation for neck of femur fracture using cannulated screws. Twenty were lost to follow-up or died soon after surgery. The fracture was displaced in 114 (49.9%) and undisplaced in 117 (50.6%) patients. There were 65 males and 171 females with an average age of 75.7 years. Average follow-up was 12 months. Of the 117 patients with undisplaced fractures 75 (64.1%) healed uneventfully. Further surgery was performed in 21 (17.9%) patients. In the 114 patients with displaced fractures, satisfactory reduction was achieved in 74 patients and of these 54 had good screw placement. Fifty-one (44.7%) patients healed uneventfully. Twenty-two (20%) of the 114 displaced fracture patients required further surgery. Forty (35%) had an unsatisfactory reduction and, of these, 26 (65%) had poor screw placement. Re-operation rates were 17.9% and 20% respectively. The rate of AVN was similar in both fracture types (10.3%-11%), but the rate of non-union was four times higher (2.6%-11.5%) in displaced subcapital fractures. The most important factors within the control of the surgeon that influence the rate of healing are adequate reduction and correct placement of the screws. In this series the reduction was unsatisfactory in 40 (35%) cases of the displaced NOF fractures, and the screws were incorrectly positioned in 46 (40.4%) of the 114 displaced fractures compared with 11 (9.4%) of the 117 undisplaced fractures. This highlights the importance of adequate reduction to enable correct screw placement in displaced fractures. (Hip International 2004; 14: 244-8).

Septic arthritis following intra-articular steroid injection of the knee--a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee.

Septic arthritis is a potential catastrophic complication of intra-articular steroid injection. There is lack of evidence regarding the precautions that should be taken to avoid such a complication, as well as how often it is encountered. The aim of this study was to evaluate the antiseptic precautions taken during intra-articular steroid injection of the knee in the United Kingdom (UK), and estimate how often septic arthritis is encountered by health professionals in the UK following steroid injection of the knee. A questionnaire was posted to 100 orthopaedic surgeons, 100 rheumatologists and 50 general practitioners (GPs), asking them about the cases of septic arthritis following intra-articular steroid injection of the knee that they encountered during their practice and the precautions they take when injecting knees. The response rate was 76.4%; 57.6% of the respondents used alcohol swabs to clean the skin, and the remaining 42.4% used chlorhexidine or Betadine. Only 16.3% used sterile towels to isolate the injection site. There were 32.5% of respondents who routinely used sterile gloves when injecting, and a total of 46.6% used either sterile or non-sterile gloves. Also, 91.1% changed needles between drawing the steroid and injecting it into the joint. Only 24 respondents (12.6%) had encountered septic arthritis after steroid injection of the knee (18 once, 3 twice, 2 three times, 1 several times). We concluded that septic arthritis post intra-articular steroid injection of the knee is probably rare. There is a wide variation in the precautions taken to avoid such a complication. However, the trend seems to be towards minimal use of antiseptic techniques. Further large prospective studies are needed to determine how frequently septic arthritis of the knee is encountered post steroid injection, and the exact precautions that should be taken to avoid it.

Reduced delays in A&E for elderly patients with hip fractures.

Published guidelines recommend early transfer of patients with hip fractures to hospital wards and avoidance of unnecessary delays in A&E. We describe a protocol whereby the liaison of an orthopaedic trauma co-ordinator with A&E reduced A&E-to-ward transfer times by 43%. Following introduction of the new protocol, 39% of hip fracture patients were in a ward bed within 3 h of admission to A&E compared to 4% previously. The new protocol also reduces administrative workload for the on-call orthopaedic SHOs.

Case report: managing fractures in non-compliant alcoholic patients--a challenging task.

AIMS: To investigate whether there are extractable conclusions for limb fracture management in dependent alcoholics. METHODS: We discuss four cases of dependent alcoholics who presented in our department over a 12-month period, and who developed significant complications owing to non-compliance with treatment. RESULTS: Initial treatment, although appropriate, failed because of non-compliance. This led to further admissions, wound infections and surgery to enable cure. CONCLUSIONS: Our case reports indicate that for upper limb fractures of the middle third of the humerus, non-operative treatment or internal fixation with out-patient detoxification is appropriate. Lower limb fractures, on the other hand, should be dealt with by external fixation and in-patient detoxification. It is imperative that the alcohol dependence is addressed if we are to decrease non-compliance.

Factors delaying surgical treatment of hip fractures in elderly patients.

BACKGROUND: Published guidelines recommend early surgical treatment of hip fractures in elderly patients. Understanding the factors that delay surgical intervention is essential in order to introduce changes that will facilitate early treatment. AIM: To determine the factors delaying surgical treatment of hip fractures in elderly patients for more than 24 h. PATIENTS AND METHODS: Assessment of 163 consecutive patients undergoing surgery for hip fractures at the trauma unit of Manchester Royal Infirmary. RESULTS: Only 72/163 (44.2%) patients had their operation within 24 h of presenting to hospital. The remaining 91 patients had a total of 239 days delay (in excess of the initial 24 h) for surgical treatment. Active medical problems (56.5%) and a wait for medical investigations (19.7%) caused most delays. Lack of operating theatre time and Sunday trauma lists caused 23.8% of delays. CONCLUSIONS: Medical problems account for most delays of surgical treatment of hip fractures. A multidisciplinary approach, with early input by medical and anaesthetic teams, is essential in managing such patients. Established protocols may reduce waiting times for essential investigations.

Soft tissue infections of the extremities in an orthopaedic centre in the UK.

OBJECTIVES: To determine the spectrum, and clinical impact of acute extremity soft tissue infections, encountered in the Orthopaedic service of an inner city hospital in UK. METHODS: Patients requiring admission for an acute limb soft tissue infection to the Orthopaedic unit of the Manchester Royal Infirmary, UK, between July 1996 and 2001 were identified from our database. Infections involving the groin and axilla, those developing within 30 days of a surgical procedure, and patients with chronic soft tissue ulcers or infections were not considered. RESULTS: Of 142 infections the majority were cellulitis (50%) and superficial abscesses (34.5%). Most were secondary to trauma (31.6%), human or animal bites (20%) and intravenous drug abuse (17.6%). Although most patients were young and otherwise healthy, ten developed significant complications: myonecrosis requiring below knee amputation (1), acute carpal tunnel syndrome (1), osteomyelitis (6), extensive skin loss requiring reconstruction (1), deep vein thrombosis (1). Seven hundred and eighty four hospital inpatient days and 143 operative interventions were devoted to these patients. The estimated cost for each episode of soft tissue infection was pound 1011. In 25% of cases earlier referral to a surgical service would have been more appropriate. CONCLUSIONS: Soft tissue infections of the extremities confer significant morbidity and impose an important burden on medical resources.

The development of a protocol in using day surgery for minor orthopaedic trauma patients.

We examined all minor orthopaedic trauma patients requiring surgical intervention at Manchester Royal Infirmary over a 6-month period to determine whether minor trauma patients meet the day surgery requirements in terms of medical fitness, analgesia requirements and postoperative complications. A total of 83 patients had surgery for minor orthopaedic trauma in the defined period. Of these patients, 79 (95.2%) were medically fit, 45 (70%) were admitted to a hospital ward and 19 (30%) were brought back to day surgery. None of the patients attending day surgery developed postoperative complications or required return to hospital. The majority of patients admitted to a ward required simple or no analgesia pre- (95.5%) and postoperatively (100%), and most were discharged on the same (55.6%) or next (35.6%) day of their operation. We suggest a protocol whereby patients with minor trauma are brought back to day surgery. This could potentially reduce pressures on bed availability.

Management of osteoporosis in an orthopaedic department: audit improves practice.

Patients presenting with an osteoporosis-related fracture are at increased risk of further fractures. We performed a retrospective survey to determine if elderly patients presenting to the orthopaedic unit at Manchester Royal Infirmary with low energy hip or distal radius fractures were being managed appropriately with regards to assessment, investigation and treatment for possible osteoporosis. The initial survey demonstrated that only 16% of elderly female patients with low energy hip fractures and none of those (0%) with distal radius fractures were started on treatment or referred for further investigations for possible osteoporosis. After changes in our practice, 76% (p < 0.00001) of patients with hip fractures and 81% (p < 0.00001) of those with distal radius fractures were investigated, started on treatment or referred to a consultant physician for the management of osteoporosis.

Weight bearing following intra-articular steroid injection of the knee: survey of current practice and review of the available evidence.

INTRODUCTION: Intra-articular steroid therapy is one of the most common clinical procedures performed by rheumatologists. There is wide variation in the postoperative instructions given to patients following such injections. AIM: The aim of this study was to determine what advice is given with regards to non-weight-bearing following steroid injections of the knee by rheumatologists, orthopaedic surgeons, and general practitioners (GPs). METHOD: A questionnaire examining advice on non-weight-bearing following knee steroid injections was posted to 100 rheumatologists, 100 orthopaedic surgeons, and 50 GPs. RESULTS: A significant proportion of respondents advised patients to avoid weight bearing after injection (42.4%). Most of these advised patients to do so for one (16.3%) or two (25.1%) days. As compared to 57.1% of general practitioners and 2.8% of orthopaedic surgeons, 70.7% of rheumatologists advised patients to avoid weight bearing (P < 0.05). CONCLUSION: A significant proportion of rheumatologists and general practitioners performing steroid injections of the knee advise patients not to weight-bear postinjection. Examination of the available literature fails to reveal strong evidence to support such a practice, which has potentially significant implications with regards to loss of working days, costs of mobility aids, and patient inconvenience.

Patellar instability following total knee replacement -- the dangers of constant design evolution.

Patellar instability following total knee replacement although infrequent can cause disabling symptoms. We report a case of symptomatic patellar instability caused by insertion of left femoral component into a right knee. We highlight that all members of the surgical and theatre team need to be familiar both with the implant equipment and of any recent design modifications, particularly if they have been used to using one system for a long time, in order to prevent surgical errors. In addition this possibility should be born in mind by surgeons looking for causes of post-operative patellar instability.

Frozen autografts: an alternative to graft disposal.

The use of fresh frozen tendon allografts is a well-documented surgical technique. We present a case where a harvested semitendinosus autograft was preserved by deep-freezing, having abandoned the initial procedure due to infection. After treatment of the infection the graft was subsequently used to reconstruct the postero-lateral corner complex with no deleterious effect at 1 year.

A brief history of gamma scintigraphy.

Gamma scintigraphy involves the radiolabeling of inhaled drug formulations, followed by in vivo imaging of deposition in two dimensions. This permits whole lung deposition to be quantified as mass of drug or percentage of the dose, and regional deposition patterns to be assessed. Gamma scintigraphy is the method by which the majority of inhaled drug deposition data have been obtained, and scintigraphic studies have become viewed as milestone assessments in the development of new pulmonary drug products. Lung deposition data are used to show "proof of concept" in vivo for these products, and act as a bridge between in vitro laboratory testing and a clinical trials program. Gamma scintigraphy is likely to remain the method of choice for assessing inhaled drug deposition for some time to come.

Deposition and pharmacokinetics of an HFA formulation of triamcinolone acetonide delivered by pressurized metered dose inhaler.

Novel formulations of asthma drugs contained in pressurized metered dose inhalers (pMDIs) are being developed containing hydrofluoroalkane (HFA) propellants. The objectives of this study were to assess the deposition in the lungs and oropharynx of triamcinolone acetonide (TAA; Azmacort, Aventis Pharma, Collegeville, PA) delivered by pMDI formulated with HFA-134a, together with the pharmacokinetic profile of TAA, and to determine the extent to which the Azmacort spacer improves targeting of TAA to the lungs. The deposition of TAA, labelled with 99mTc, was assessed by gamma scintigraphy in 10 patients with mild to moderate asthma (mean forced expiratory volume in one second [FEV1] 76% predicted), who received in randomized order three delivered (ex-device) doses of 75 microg TAA via pMDI coupled to an Azmacort spacer (TAA-spacer), and three delivered doses of 230 microg TAA via the same device, but with the spacer removed (TAA-no spacer). Mean lung deposition expressed as mass of drug was similar for each regimen (TAA-no spacer 175 microg; TAA-spacer 188 microg), but when expressed as percentage delivered dose, lung deposition was higher for TAA-spacer (53.8%) versus TAA-no spacer (26.0%), indicating superior drug targeting for TAA-spacer. The spacer reduced oropharyngeal deposition. The pharmacokinetic data showed higher plasma levels of drug for TAA-no spacer, resulting from higher oropharyngeal deposition. "Pharmacoscintigraphic" data showed proof of concept for a novel HFA delivery system for an inhaled corticosteroid based on pulmonary targeting of drug.