Symptomatic malunion after midshaft clavicle fracture in an adolescent patient: a case report of surgical deformity correction using a 3D printed model.

A 14-year-old boy underwent surgery for symptomatic malunion of the clavicle. This complication, which is uncommon in adults and adolescents, occurred after a displaced midshaft clavicle fracture that had been treated conservatively. Surgery may be considered if functional impairment, pain, weakness, fatigability and neurological symptoms persist in the presence of significant clavicular deformity. Our case was unusual because the patient had a symptomatic malunion and lost range of movement of his shoulder despite a minor degree of clavicular shortening. We adopted an approach used in lower limb deformity correction but not described for the clavicle in which corrective osteotomy was planned and practised using a three-dimensional printed model of the malunited clavicle. A three-dimensional printed model of the mirror image of the opposite clavicle served as a template of normal. Three-dimensional models were printed from the computed tomography data. The patient's symptoms resolved and he recovered full range of movement and shoulder function following the corrective osteotomy.

Outcomes of total hip arthroplasty, as a salvage procedure, following failed internal fixation of intracapsular fractures of the femoral neck: a systematic review and meta-analysis.

AIMS: The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck. PATIENTS AND METHODS: We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant systematic review, using the PubMed, EMBASE and Cochrane libraries databases. A meta-analysis was performed where possible, and a narrative synthesis when a meta-analysis was not possible. RESULTS: Our analyses revealed a significantly increased risk of complications including deep infection, early dislocation and peri-prosthetic fracture with salvage THA when compared with primary THA for an intracapsular fracture of the femoral neck (overall risk ratio of 3.15). Functional outcomes assessment using EuroQoL (EQ)-5D were not significantly different (p = 0.3). CONCLUSION: Salvage THA carries a significantly higher risk of complications than primary THA for intracapsular fractured neck of femur. Current literature is still lacking well designed studies to provide a full answer to the question. TAKE HOME MESSAGE: Salvage THA is associated with more complications than primary THA for intracapsular neck of femur fractures.

Projecting subacute inpatient activity in New South Wales.

We describe the development of a method for estimating and modelling future demand for sub- and non-acute inpatient activity across New South Wales, Australia to 2016. A time series linear regression equation was used, which is consistent with projection models found in the literature. Results of the modelling indicated an increase in rehabilitation, palliative care and maintenance episodes and bed-days. Projections for other categories of care are problematic due to smaller levels of activity and data quality issues. This project indicated a need for ongoing monitoring of type-changing by facilities and management of data quality. Local planners will need to consider a range of factors when considering the applicability activity projections at a local level, particularly within the specific age and clinical groupings.

Estimating and projecting subacute care demand: findings from a review of international methods.

A review of projection methodologies used to project sub-acute inpatient activity in various international health care jurisdictions was undertaken as part of a project to develop subacute inpatient activity projections for the state with the largest population in Australia. The literature search identified nearly 200 articles and found three main groups of projection methodologies: projections with a focus on subacute care; projections with a focus on acute care, but which often included subacute activity in the overall projections; and projections of specific diseases/conditions influencing the demand for subacute care. In terms of the examples in the literature specifically regarding subacute care, the most common method of estimating current or future need was the use of normative benchmark ratios of beds to population. This was mainly to provide a policy basis to encourage development of subacute services, but also because of convenience. In the literature regarding acute activity projection methodologies, many incorporated subacute activity in the overall activity measures of the acute hospital unit. The most common method of acute care activity projection was use of current or trended utilisation rates applied to population projections. It appears that a significant amount of planning and demand projection being undertaken internationally on subacute care takes place within acute care methodologies. In regard to the potential use of specific diseases/conditions that drive demand for subacute care, such as stroke or cancer, it is suggested that the best use of these disease-specific projections is in reality testing the results of other modelling. A number of conclusions are made and issues highlighted regarding projections of subacute inpatient activity.

Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism.

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement. Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively. In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors.

The extended scope physiotherapist in orthopaedic out-patients - an audit.

INTRODUCTION: We undertook an audit of the activity of the extended scope physiotherapists (ESPs) in our unit. We assessed their activity against three benchmark data: (i) independent assessment and management by the ESP of 85% of patients seen by them; (ii) no patient to be re-referred to a surgeon with the same problem; and (iii) patient satisfaction rate of 89%. PATIENTS AND METHODS: All new referrals seen by the ESPs over the 6-month period between July 2002 and December 2002 were included in the audit. Patient medical records were reviewed retrospectively. Patients were contacted by telephone 12 months after their initial clinic appointment to obtain patient satisfaction scores. RESULTS: In the 6-month period, 150 patients (75 male, 75 female) were seen. Their median age was 43.5 years (range, 17-85 years). Their main complaints related to the spine (42%), knee (33%), shoulder (18%), or other site (7%). The ESPs saw and managed 82/150 patients (55%) independently. Consultant review was required for 81% of shoulder cases, 34% of knee cases and 11% of back cases. GPs re-referred 4/150 patients (3%). We successfully contacted 126 patients by telephone: 97 (77%) were satisfied with their management by ESPs. Of patients who were dissatisfied, 76% did not see a consultant at any stage in their management. CONCLUSIONS: ESPs fulfilled a useful role in our orthopaedic out-patient clinic particularly in the back clinic. The percentage of independently managed patients was much lower than the figure quoted in the literature. We suspect that the published literature does not reflect modern referral patterns and recommend that time for review of new patients seen by ESPs should be factored into consultant's clinic time. Patients' expectations may be a barrier to achieving greater levels of patient satisfaction.

Stanmore total knee replacement versus internal fixation for supracondylar fractures of the distal femur in elderly patients.

BACKGROUND: Supracondylar fractures of the femur in the elderly are difficult to treat. Total knee replacement is often not considered. The aim of this study was to compare the short to medium term outcome of fixation and total knee replacement in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be an alternative to internal fixation. PATIENTS AND METHODS: In this retrospective study, we included patients who were aged 75 or over with an ASA grade of two or less, walked independently before their injury, and sustained a type A or C supracondylar fracture. Four were treated with internal fixation and six with a cemented Stanmore knee replacement. Patients were reviewed clinically and radiographically a minimum of 6 months after surgery. RESULTS: The advantages of total knee replacement were a greater proportion of patients returned to independent walking, rehabilitation was more rapid, and knee flexion was better. The advantages of internal fixation were a decreased need of blood transfusion, a smaller proportion of patients reported knee pain at follow up, and a better mean Oxford knee score at follow up. Anaesthetic time and level of patient satisfaction at follow up were similar. There were no peri-operative deaths. CONCLUSION: In this preliminary study, total knee replacement was a reasonable alternative to internal fixation for the treatment of supracondylar fractures of the distal femur in elderly.

Outcome following a second hip fracture.

Hip fracture has a significant impact on medical resources and patient morbidity and mortality. Few patients admitted with a hip fracture are considered for prophylactic measures aimed at the reduction of further fracture risk. Currently, 10-13% of patients will later sustain a second hip fracture. In considering the possible role of prophylactic measures in the prevention of second hip fracture, we investigated whether second hip fracture has a significant further impact on patients' mobility and social independence. We also sought to identify a pattern to second hip fracture that may allow targeting of those patients who are most likely to benefit from currently available prophylactic measures. We undertook a retrospective review of 49 consecutive patients admitted with a second hip fracture between August 1999 and September 2000. Fewer patients maintained their ability to walk independently after the second fracture than did so after the first (53 and 91% respectively, P<0.0005). Following second hip fracture, patients' level of mobility determined their future social independence. Older patients and those with a history of multiple falls had a shorter time interval between fractures. Second hip fracture has a significant further impact on patients' mobility and social independence. Younger patients and those without a history of multiple falls are most likely to benefit from medical prophylaxis.

Whither the World Health Organization?

The outgoing Director-General of the World Health Organization, Gro Harlem Brundtland, has successfully returned health issues to the international arena. The new Director-General will have to cope with reduced control over funding, debate over WHO's mandate, and the relationships between WHO and other organisations. Despite the broad role described in WHO's constitution, many groups see WHO's mandate as narrowly directed at disease eradication. The method of choice for funding health programs has become public-private partnerships. These have the advantages of bringing private money, management expertise and research knowledge to bear on health problems, but rarely consider the health system as a whole, focusing instead on specific diseases. This has the potential to distort resource allocation and priorities. The international community needs to work to strengthen WHO and maintain its broad mandate to achieve the highest possible level of health for all people.

Fine needle aspiration cytology and exfoliative biliary cytology in the diagnosis of hilar cholangiocarcinoma.

Nineteen patients with suspected malignant obstruction at the confluence of the bile ducts had exfoliative biliary cytology and fine needle aspiration cytology performed. Of these patients 14 cases were histologically proven to be cholangiocarcinoma, and 3 others followed a clinical course which was clearly malignant. Fine needle aspiration cytology gave a true positive result in 14 patients (87.5%), whereas exfoliative cytology was positive in 11 (73%). There were no false positive results and no complications from either procedure. Both the cytological procedures are rapid and safe and are useful for preoperative planning of surgical and intraoperative diagnosis.

Malignant melanoma of the sympathetic chain: with a consideration of pigmented nerve sheath tumours.

A case of malignant melanoma of the posterior mediastinum, arising from the sympathetic chain is reported. The structural features and the presence of long-spaced collagen on electron microscopic examination suggest schwannian derivation of the tumour. Similar tumours are reviewed and the histogenesis of pigmented nerve sheath tumours in general is discussed. The term 'malignant melanotic schwannoma' is probably the most appropriate for the tumour entity described here.

Combined bipedal lymphangiography, CT scanning and transabdominal lymph node aspiration cytology for node staging in carcinoma of the prostate.

Forty-two patients with carcinoma of the prostate have been studied by bipedal lymphangiography, abdominal CT scanning and percutaneous transabdominal lymph node aspiration cytology to try to increase the accuracy of lymph node staging. The use of two independent radiologists to report the lymphangiograms did not improve the accuracy of reporting. CT scanning was of value only in patients in whom the lymph nodes were not opacified on lymphangiography. Aspiration cytology was positive in 8 of the 40 patients who were studied. There was no morbidity. Six of these 8 patients had MO disease, three had TO tumours and were not on treatment. A poor correlation was found between the presence of lymph node metastases and the Gleason score. Percutaneous transabdominal lymph node aspiration cytology is a safe procedure. When positive, it avoids the need for a staging lymphadenectomy and so helps to identify those patients for whom local treatment is not applicable.

Simultaneous combined pancreatic test.

A simultaneous combined pancreatic test can be performed in one morning with only one intubation of the duodenum. The test includes the measurement of exocrine pancreatic secretion of bicarbonate, enzymes, and radioactive selenium, pancreatic scanning, hypotonic duodenography, and cytology of the duodenal aspirate. In the first 70 patients it was found that a single secretion test was of only limited value in detecting pancreatic disease; cytology was the most reliable and scanning the least reliable single test; and that the combined test provided near-complete discrimination between patients with no pancreatic disease, with chronic pancreatitis, and with carcinoma of the pancreas.