Cruciate Retaining compared with Posterior Stabilised Nexgen total knee arthroplasty: results at 10 years in a matched cohort.

INTRODUCTION Debate has persisted for many years about whether to sacrifice or replace the posterior cruciate ligament when performing total knee arthroplasty. A paucity of long-term follow-up studies comparing outcomes between cruciate-retaining and posterior-stabilised knees exist. We aimed to compare results at ten-year follow-up. METHODS A matched paired study comparing a cohort of 107 Zimmer Nexgen® Cruciate Retaining (CR) patients with a cohort of 107 Nexgen Posterior-Stabilised (PS) knees matched for age, sex, body mass index and preoperative American Knee Society score was undertaken. All patients underwent independent clinical assessment and knee society scoring preoperatively and at 1, 3, 5, 7 and 10 years postoperatively. RESULTS Fifty-three patients (49.5%) in the CR group and 44 patients (41.1%) in the PS group were alive at 10-year follow-up. There were no significant differences between the CR and PS groups with regards to functional assessment (P = 0.95), overall range of movement (P = 0.46) or patient satisfaction (P = 1.0) at 10 years. However, there was a significantly better score improvement in range of movement in PS knees compared with CR knees (P = 0.027). There were six revisions (5.6%) in the PS group and 1 (0.93%) in the CR group (P = 0.12). Both CR and PS knees showed excellent survivorship with no significant difference at 10 years (P = 0.068). CONCLUSIONS There were no significant differences in functional score, overall range of motion or patient satisfaction between the Nexgen cruciate retaining and posterior stabilised total knee arthroplasty at 10-year follow-up. However, PS knees had a greater score improvement in range of motion compared with CR knees.

Total hip replacement for neck of femur fracture: Comparing outcomes with matched elective cohort.

INTRODUCTION: Current literature suggests that total hip replacement (THR) is superior to hemiarthroplasty (HA) for neck of femur fracture in selected group of patients. The outcomes of THR undertaken for trauma setting remain unclear when comparing with elective THR. We compared the outcomes of THR trauma cohort with best-matched elective cohort. METHODS: We retrospectively reviewed 102 patients that underwent THR due to trauma from 2011 to 2013. We had access to 90 cases with complete records. Another 90 matched elective cases were obtained from local arthroplasty database. The elective cases were matched for gender, surgical approaches, surgeon's grade, types of implant, patient's age at operation date of ±5 years and operation date of ±60days. Subsequently, the selection criteria were relaxed to patient's age at operation date of ±10 years and operation date of ±60days. Unmatched cases were excluded. Complications and death rate were compared. RESULTS: The average age for both cohorts was 70 years. The trauma cohort had statistically significant lower BMI and longer hospital stay (p=0.001). The Functional Comorbidity Index (FCI) and Charlson Age Comorbidity Index (CACI) were the same for both cohorts, reflecting an active patient selection for THR in our centre. The trauma cohort had higher surgical complication rate (9% vs 4%), particularly higher dislocation rate (7% vs 1%); and higher medical complication rate (32% vs 6%). These were consistent with the literature. Contrary to literature, the trauma cohort had six dislocations that five of them were done via anterolateral approach. Among the eight trauma cases with surgical complications, six cases were performed by trainees. The cause of surgical complications remains unclear due to the nature of retrospective study. The trauma cohort had higher death rate than the elective cohort (14% vs 4%), with one post-operative cardiac arrest in the trauma cohort. The rest were non-orthopaedic related deaths, ranging between four months to four years. CONCLUSION: A more robust way of selecting trauma patients for THR is warranted to reduce morbidity and mortality. Follow-up for the trauma cohort is warranted, as the patients are likely to outlive the implants.

Outcome analysis of cubital tunnel decompression.

BACKGROUND: Cubital tunnel decompression is a commonly undertaken upper limb procedure. Most studies compare the different techniques of decompression; however, only a few have specifically investigated the outcome of ulnar nerve decompression. AIM: The aim of this study was to investigate the outcome of ulnar nerve decompression following cubital tunnel syndrome. METHODS AND RESULTS: A total of 174 ulnar nerve decompression cases were identified from the upper limb surgery database with complete data available for 136 cases. Simple decompression was performed in 110 (80.88%) cases, and in 26 (19.12%), anterior subcutaneous transposition was also supplemented. These operations were performed at three different hospitals by surgeons of different levels of experience. The most common cause of cubital tunnel syndrome was idiopathic. The outcome was satisfactory in 86% of cases. No obvious association was demonstrated between the outcome of surgery and duration of symptoms, presence of co-morbidities or the type of surgery performed. CONCLUSION: This is the largest outcome analysis of the results of ulnar nerve decompression at the elbow. Good results following nerve decompression were attained in 86% of cases without any significant effect of duration of symptoms or co-morbidities on the outcome of surgery. It is hoped that the findings of the current study will help general practitioners, junior doctors and surgeons in their management and pre-operative consultation with patients having cubital tunnel syndrome.

Assessing the variability of injectate distribution following carpal tunnel injection--a cadaveric study.

This anatomical study was designed to assess the distribution of a solution (injectate) made up using local anesthetic, steroid and dye into the carpal tunnel using a commonly used injection technique. Dissections were undertaken in 29 embalmed cadaveric wrists. The cadaveric specimens were dissected 24 hours after injection to observe the effect of time on diffusion patterns in both superficial and deep planes. Eighteen of the 29 specimens showed the presence of the injectate in the superficial plane and three preferential patterns of distribution were noted in the deep plane: free in the carpal tunnel, exclusively in the tendon sheath and mixed. This is the first study investigating the delayed diffusion pattern of injectate in the carpal tunnel and illustrates its variability. The findings of variable degree of superficial diffusion and different patterns of intracarpal spread help to offer some explanation regarding the variability of the response following carpal tunnel injection.

Cozen's phenomenon: a reminder.

A four-year-old child attended Accident and Emergency following a fall from a slide with a displaced and angulated proximal tibial metaphyseal fracture. Treatment included closed manipulation under anaesthesia and an above knee cast for seven weeks. Serial radiographs over the following few months were satisfactory demonstrating good alignment and evidence of healing. However, at four-months review new-onset genu valgum with mechanical axis deviation was noted. No evidence of spontaneous resolution was noted over the following 12 months and hence a corrective hemi-epiphysiodesis was performed. At 12-months post-operatively, there was marked clinical and radiographical improvement in alignment. Classically Cozen's phenomenon is described as the late-onset post-traumatic valgus deformity associated with proximal tibial metaphyseal fractures in children. We want to reemphasise the early recognition of children at risk of this unique complication. In addition, we wish to highlight the progression of the late-onset valgus and its subsequent management.

Exploring the anatomy of dorsal radiocarpal ligament of the wrist and its ulnar part: a cadaveric study.

The current study aimed to explore the anatomy of the dorsal radio-carpal ligament (DRC ligament) and to investigate the presence and histological structure of ulnar part of the DRC ligament. Twenty cadaveric wrist joints were dissected and attachments of the DRC ligament and the newly described ulnar part of the DRC ligament were identified and noted. Samples of both ligaments were sent for histological examination. The DRC ligament was identified in all 20 specimens with type I Mizuseki arrangement of fibres seen in 60% of wrists. The ulnar part of the DRC ligament was successfully identified in 18 of the 20 wrists. The histological observation of the ulnar part of the DRC ligament showed the highly uniform arrangement of collagen bundles typical of ligaments. This study explores the anatomy of the DRC ligament and confirms the presence of the ulnar part of DRC ligament through histological analysis not undertaken in previous studies.

Expression, immunogenicity, histopathology, and potency of a mosquito-based malaria transmission-blocking recombinant vaccine.

Vaccines have been at the forefront of global research efforts to combat malaria, yet despite several vaccine candidates, this goal has yet to be realized. A potentially effective approach to disrupting the spread of malaria is the use of transmission-blocking vaccines (TBV), which prevent the development of malarial parasites within their mosquito vector, thereby abrogating the cascade of secondary infections in humans. Since malaria is transmitted to human hosts by the bite of an obligate insect vector, mosquito species in the genus Anopheles, targeting mosquito midgut antigens that serve as ligands for Plasmodium parasites represents a promising approach to breaking the transmission cycle. The midgut-specific anopheline alanyl aminopeptidase N (AnAPN1) is highly conserved across Anopheles vectors and is a putative ligand for Plasmodium ookinete invasion. We have developed a scalable, high-yield Escherichia coli expression and purification platform for the recombinant AnAPN1 TBV antigen and report on its marked vaccine potency and immunogenicity, its capacity for eliciting transmission-blocking antibodies, and its apparent lack of immunization-associated histopathologies in a small-animal model.

Assessing the accuracy of bone resection by cutting blocks in patient-specific total knee replacements.

Introduction. The key to a successful total knee arthroplasty (TKA) is the restoration of the mechanical axis with balanced flexion and extension gaps. Patient-specific cutting block technique has been the latest development in total knee arthroplasty. This technique uses a magnetic resonance image (MRI) of the patient's symptomatic knee to create bone models and cutting jigs. This study was designed to evaluate the intraoperative accuracy of the patient-specific cutting block as compared to the preoperative template. Methods. Visionaire (Smith and Nephew, Genesis 2 Knee Arthroplasty) patient-specific TKA was used in all patients. An independent research officer was responsible for measuring all the resected articular surfaces of femur and tibia during surgery and compared it to the cutting block manufactured according to the preoperative template. Seven different measurements from each patient were obtained; four different measurements from the femur and three from the tibia were recorded. The differences between the actual resections made intraoperatively, as compared to the original pre-operative templates, were noted as the error. The surgical team was blinded to the measurements of the resections and the calculations of the errors. Results. Twenty-six Visionaire patient-specific TKA were included in the study. A total of 182 readings of bone resections made intraoperatively (seven for each patient). Eighty five percent of all collected readings were below the error margin of ≤1.5 mm. Size of resection had no effect on the error margin. All patients had satisfactory post-operative alignment, and at discharge all 26 patients achieved more than 90° of knee flexion. Conclusion. This observational study provides evidence that patient-specific TKA is comparable to other forms of TKA and may have some distinct advantages. In addition, we have shown that the cutting blocks are able to consistently deliver accurate cuts that are reproducible. We recommend intra-operative measurement of the bone resection and its comparison with the cutting block as a routine surgical step to confirm the MRI scan data, block placement, and instant validation of the bony resection before implant placement.

Objective assessment of the alterations in wrist mobility with the fastrak(®) system following dorsal capsulodesis.

The treatment for scapholunate dissociation is challenging and its management is varied depending on type, severity and duration of injury, and surgeon's preferred technique. This study aimed to objectively assess the variations in the range and patterns of wrist movements using the Fastrak(®) system in patients having undergone Blatt's dorsal capsulodesis (BDC). The wrist movements were successively measured between the operated and unoperated wrists, while the patients performed set tasks. Seventeen patients agreed to participate in the study. Following BDC the mean flexion loss was 23° (range 10°-38°). However, functional tasks revealed that the BDC did not adversely affect the function of the operated wrist. This novel study demonstrates objectively the functional restrictions that patients are likely to experience postoperatively following BDC. It would be interesting to note the pattern of wrist motion using the Fastrak(®) system in various other clinical settings.

Not all stubbed toes are innocuous--A case report of rare malignant eccrine spiradenoma (spiradenocarcinoma) of the toe.

Malignant eccrine spiradenoma (MES) is a rare adnexal tumour derived from cutaneous sweat glands. We describe a case of MES arising on the tip of the right middle toe. The lesion had been managed as a non-specific chronic ulcer for 4 years. The lesion was treated by elective amputation. We wish to emphasise through this case report the importance of keeping this rare but potentially lethal tumour in mind when managing chronic non-healing ulcers in extremities.

Adapting the Fastrak system for three-dimensional measurement of the motion of the wrist.

The Polhemus Fastrak short-range miniature transmitter and mini-receivers allow wrist motion to be measured continually in three dimensions, registering patterns of motion, which until now were difficult to quantify. The current study aimed to determine the applicability and repeatability of the Fastrak system when assessing wrist movements during a set protocol of activities. The device was found to be easy to use and repeatable; the Fastrak system showed a mean error of up to 3 degrees in all movements tested. Its assessment of range of motion correlated with the results in the literature. The Fastrakv system was suitable for continuous registration of movements during the performance of set tasks in either of the wrists. It has the potential to be used for documentation of wrist motion in clinics for various pathologies and for assessing outcomes in wrist surgeries.

Prescribing a website.

AIM: To assess the value of directing the attention of patients to sources of medical information on the internet. DESIGN: Prospective qualitative study in an orthopaedic outpatient clinic. PARTICIPANTS: 253 patients agreed to complete electronic questionnaires before and after reviewing information relevant to their conditions on the internet. Patients were allocated randomly into two groups; one group was given indications of general sites and the other recommended specific non-commercial sites. Completed questionnaires were received from 44 patients. RESULTS: 95% of the patients found the internet information easy to understand and 84% said that it was helpful for coping. 86% of the patients were satisfied that their current treatment was appropriate in the light of what they had learned from the internet. Ten patients out of the 36 who expressed a view thought that the internet information contradicted that provided by the doctor. Despite these results most patients still said that the doctor represented the best source of patient education. CONCLUSIONS: Increasing numbers of patients are familiar with the internet. Most of our patients felt that the internet was, on balance, helpful in providing information. The main difficulties with the internet are the sheer volume of information, the potential for misleading and the danger of misunderstanding. We feel that there is a real place for the specific prescription of an internet site by a clinician who has personally reviewed it to a patient thought to be able to benefit from it.

Patients and the Internet: a demographic study of a cohort of orthopaedic out-patients.

The Internet is a rich source of medical information but relatively few studies have evaluated its use by patients who seek medical information. The purpose of this study is to assess the demographics of Internet access and attitudes towards the Internet in a cohort of orthopaedic out-patients. Four hundred and three patients attending the orthopaedic outpatient fracture clinic completed a questionnaire consisting of six divisions including personal information, facility to access the Internet and their attitudes towards the information retrieved. Fifty per cent of the patients accessed the Internet, either from home or office and the maximum usage being in the younger age group. Twenty-nine per cent of the patients were aware of the medical information available through the Internet. 19% patients would like to have a consultation through the Internet, the maximum being in the middle-aged group. 70% of those patients who accessed the medical information reported that the Internet information was different than that obtained at consultation with the doctor at the out-patient clinic. This study reveals that the Internet use by patients is still limited. If an increased percentage of medical conditions is to be addressed through the Internet, involving patient information, on-line consultations, prescriptions and referrals, then a substantial amount of patient education and training is required