Usage of unicompartmental knee arthroplasty.

Unicompartmental knee arthroplasty (UKA) has numerous advantages over total knee arthroplasty (TKA) and one disadvantage, the higher revision rate. The best way to minimize the revision rate is for surgeons to use UKA for at least 20% of their knee arthroplasties. To achieve this, they need to learn and apply the appropriate indications and techniques. This would decrease the revision rate and increase the number of UKAs which were implanted, which would save money and patients would benefit from improved outcomes over their lifetime. Cite this article: Bone Joint J 2018;100-B:432-5.

Comparison of scars and resulting hypoaesthesia between the medial parapatellar and midline skin incisions in total knee arthroplasty.

The two most common skin incisions in total knee arthroplasty (TKA) are the medial parapatellar and midline. As the medial parapatellar incision is predominantly parallel to the Langer's lines of the knee, this may give a better cosmetic appearance. The aim of this study was to assess patient satisfaction of the surgical scar and resulting hypoaesthesia following TKA. Two groups of patients who underwent primary TKA were reviewed. Group 1 consisted of 91 patients who underwent primary TKA using a medial parapatellar incision and trivector arthrotomy with a mean follow up of 2.8 years. Group 2 consisted of 76 patients who underwent primary TKA using a midline incision and medial parapatellar arthrotomy with a mean follow up of 2.7 years. The scars were assessed using the validated Manchester Scar Proforma (MSP) and Visual Analogue Scales (VAS). The resulting hypoaesthesia was assessed using VAS. The mean MSP for Group 1 and Group 2 was 11.7 and 11.9 respectively. The mean area of hypoaesthesia for Group 1 and Group 2 was 28.9 cm(2) and 23.8 cm(2) respectively. There was no statistical significance in any of the parameters measured. The mean length of the incision scar was 19.5 cm for Group 1 and 19.4 cm for Group 2. Both produced equal and excellent cosmetic results. Patients in both groups had hypoaesthesia around the knee at 7 years following their TKA. Hypoaesthesia was not found to be of significant concern to patients. This information may be useful when consenting patients for TKA.

Universal precaution compliance by orthopaedic trauma team members in a major trauma resuscitation scenario.

INTRODUCTION: We determined the compliance rates of orthopaedic trauma team members in applying universal precautions in major trauma resuscitation scenarios and the availability of universal precautions in accident and emergency (A&E) departments throughout England. MATERIALS AND METHODS: A national telephone survey was implemented contacting the first on-call orthopaedic surgeon and A&E departments in hospital trusts accepting major trauma throughout England. A questionnaire was employed to ascertain current practice, experience and availability of universal precautions when managing a major trauma patient. RESULTS: Overall, 112 first on-call orthopaedic surgeons and 99 A&E departments responded. There was good compliance for using gloves (99%) and aprons (86%). There was poor compliance in using eye protectors (21%), face masks (18%), shoe covers (4%) and head caps (4%). Trainees applied universal precautions according to the level of risk they subjectively perceived. All A&E departments had gloves and aprons but the availability of the other universal precautions was less. Of trainees, 76 reported that all universal precautions were not readily available in the A&E department. CONCLUSION: Orthopaedic trauma team members are very compliant in using gloves and aprons, but should be more compliant in using eye protectors. It is questionable whether face masks, head caps and shoe covers need to be used in all trauma scenarios. In general, universal precautions should be more available in the A&E departments. There should be better communication between A&E departments and the trauma team regarding the availability of universal precautions.

Closed suction drains do not increase the blood transfusion rates in patients undergoing total knee arthroplasty.

We aim to determine whether the presence of a drain increases the actual blood transfusion rates in patients undergoing primary total knee arthroplasty (TKA). A retrospective review was performed on two consecutive groups of patients who underwent primary TKA: group 1 including 100 patients who underwent TKA and had one deep closed suction drain; group 2 including 100 patients who underwent TKA and had no drain. Blood transfusions were given post-operatively on the basis of clinical need without a pre-determined haemoglobin trigger factor. Group 1 drained a mean of 692 ml (range 150-1500) of blood in 48 h. The mean fall in haemoglobin at 48 h post-operatively was 3.26 g/dl in group 1 and 3.33 g/dl in group 2. Nine patients in group 1 and seven patients in group 2 required a blood transfusion; this was not statistically significant (P=0.79). Transfusion of primary TKA patients on the basis of clinical need can result in post-operative transfusion rates of 8%. The presence of a drain does not increase the transfusion rates of patients undergoing primary TKA.

Management of subtrochanteric femoral fractures and metastases using long proximal femoral nail.

We report our initial experience with a new reconstruction nail, the long proximal femoral nail (L.PFN), in the treatment of subtrochanteric femoral fractures and metastases. We performed 52 L.PFN in 49 patients over a period of 18 months with an average follow-up period of 47.7 weeks. Group I consisted of 24 patients, who had L.PFN for traumatic subtrochanteric femoral fractures. Group II consisted of 25 patients, who had L.PFN for femoral metastases and pathological fractures. (Three bilateral.) In nine patients in group I, the fracture was extending to the intertrochnateric region with involvement of the piriformis fossa. Eight patients in group I had open reduction and cerclage cabling of the fracture prior to L.PFN. All the traumatic fractures in group I had united with an average time to union of 19.4 weeks. In eight operations there were technical difficulties with the insertion of proximal locking screws. Five patients in our series had complications but we had no mechanical failures of the implant. L.PFN is a reliable implant for subtrochanteric femoral fractures and metastases. We also showed that open reduction and cerclage cabling of unstable subtrochanteric fractures prior to nailing was not detrimental to fracture healing in our series.

Early patient outcomes after primary and revision total knee arthroplasty. A prospective study.

There has been speculation as to how the outcome of revision total knee arthroplasty (TKA) compares with that of primary TKA. We have collected data prospectively from patients operated on by one surgeon using one prosthesis in each group. One hundred patients underwent primary TKA and 60 revision TKA. They completed SF-12 and WOMAC questionnaires before and at six and 12 months after operation. The improvements in the SF-12 physical scores and WOMAC pain, stiffness and function scores in both primary and revision TKA patients were highly statistically significant at six months. There was no statistically significant difference in the size of the improvement in the SF-12 physical and WOMAC pain, stiffness and function scores between the primary and revision patients at six months after surgery. The SF-12 mental scores of patients in both groups showed no statistically significant difference after surgery at the six- and 12-month assessments. Our findings show that primary and revision TKA lead to a comparable improvement in patient-perceived outcomes of physical variables in both generic and disease-specific health measures at follow-up at one year.

A study of tissue interface membranes from revision accord knee arthroplasty: the role of T lymphocytes.

Despite four decades of advances in the design of orthopaedic devices aseptic loosening remains a major cause for the revision of total joint arthroplasty. This study used the techniques of immunohistochemistry and reverse transcription polymerase chain reaction to identify the inflammatory cell types, cytokines and chemokines within the interface tissue surrounding failed Accord Knee prostheses. Many T cells were identified within the tissue: however, the classical marker of activation, CD25 was expressed on very few cells. Molecular analysis failed to detect the synthesis of either Th1 or Th2 cytokines. These results suggest that the T cells are being actively recruited to the site of inflammation along the chemokine gradients but are not participating in a classical immune response.

Long-term outcome of the 'Beefburger' procedure in patients unsuitable for two-stage revision following infected total knee replacement.

A 5-year review of a group of 13 patients with infected total knee replacements deemed unsuitable for two-stage revision is presented. The 'Beefburger' procedure was initially performed in all the patients as a 'definitive' procedure. Eight patients had no further procedure performed, three patients were deemed suitable for a subsequent arthrodesis, and two went on to above-knee amputation. Three patients died within the first 6 weeks, but infection was successfully eradicated in eight of the remaining 10 patients (80%) at the time of death or latest review. At follow-up, all traceable subjects had Hospital for Special Surgery Knee Scores and SF-36 scores of below average. No significant difference was found between the 'Beefburger' or arthrodesis groups. In conclusion, the 'Beefburger' procedure gives results similar to arthrodesis and amputation in patients deemed unsuitable for two-stage revision surgery and should perhaps be considered as an option in these medically compromised patients.

Dermatitis of the feet.

Most rashes that occur on the feet are due to eczema, infections, or shoe dermatitis. But which are which? Fortunately, distinguishing among these common skin diseases requires just a little basic knowledge of dermatology and familiarity with two simple diagnostic tests. Two case reports illustrate the authors' approach to diagnosis, treatment, and patient education.

Eyelid dermatitis. A common, often confounding rash.

Five common conditions and several less common ones cause eyelid dermatitis. Diagnosis and treatment depend on recognizing their characteristics, obtaining a good history, performing a careful skin examination, administering and interpreting patch tests, prescribing the proper medications at the right time, and teaching the patient how to avoid trouble in the future. A case report illustrates the importance of integration and progression of diagnostic and therapeutic steps in resolving the management challenges of eyelid dermatitis.

Hair loss in women. What to say and do to ease these patients' distress.

Few things in life are as disconcerting to a woman as losing her hair. Yet thinning hair, usually from age or a genetic predisposition to male-pattern balding, is a common problem. In this article, Dr Parkinson discusses causes of thinning hair, how to differentiate them, and how to treat them.

The diagnostic potential of synovial effusion in meniscal pathology.

During a 20-month period, 382 arthroscopies were performed and the type of washout fluid obtained was noted. When a torn meniscus was found, the fluid was macroscopically abnormal in 97.4% of cases. A crystal clear washout was associated with no demonstrable pathology in over half the cases, the remainder having mainly patellofemoral joint pathology and other articular lesions. Only 6.3% of those with a clear fluid washout had meniscal pathology. Of those with abnormal fluid, 68% had meniscal pathology, with a normal arthroscopic examination being found in only 8.5%. In addition, when the fluid from traumatic effusions was examined microscopically, a typical droplet containing lipid crystals was found to be present and to account for an oily macroscopic appearance. These data support the use of fluid irrigation of the knee as a screening test for intraarticular pathology, especially of the menisci, that may allow a reduction in the number of negative arthroscopies.

Carpometacarpal dislocation: an aid to diagnosis.

Although the 'true' lateral radiograph of the hand has improved diagnosis of carpometacarpal dislocation, cases can still be missed if only the carpometacarpal joint area is inspected, as overlap of the adjoining joints can make interpretation difficult. Measurement of the angle between the long axis of the second and fifth metacarpal bones on a true lateral radiograph, in cases of fifth carpometacarpal dislocation is advocated, as the carpometacarpal angle is increased compared with controls (38.5 degrees compared with 9.8 degrees). A lesser increase in the carpometacarpal angle is suggestive of subluxation of this joint and this should be examined under anaesthesia.