Return to work following revision knee arthroplasty in patients under 65 years of age: A retrospective study.

Background: Little is known about employment following revision total knee arthroplasty (RTKA). This study aims to describe factors associated with returning to employment in patients of working age who underwent RTKA surgery. Methods: We performed a retrospective assessment of all patients aged ≤65 who underwent RTKA at our NHS institution between 2006 and 2020. All indications and revision procedures were included. Pre-operative demographics, indication for surgery and Oxford Knee Scores (OKS) were recorded. Postal questionnaires were sent to patients including patient reported outcome measures and a departmental questionnaire asking patients about employment status pre- and post-operatively. Results: 132 procedures were performed in 113 patients. Median follow up was 5.5 years (2.4-9.0). Mean age was 58 (5.8) and 50% (57) were men. 62 patients undergoing 74 procedures responded to postal questionnaires and were included in the study. 53% (33) were employed prior to surgery and 61% (38) returned to work at a median of 12 weeks (3-150). Of the 24 who did not return to work, 7 reported intending to return to work. Those patients who returned to work had increased pre-operative OKS (16.9 vs 13.6) and mean improvement (16.5 vs 12.4). Conclusion: This study is limited by small numbers and its observational nature. In this population the majority of patients who wished to return to work after RTKA were able to do so. This provides some reassurance when counselling patients. Prospective studies to better understand the factors that predict return to work will be important with increasing demands from surgery.

Mechanical Alignment in Total Knee Arthroplasty for Varus Knee Osteoarthritis Leads to Significant Tibial Bone Loss.

Background Obtaining a neutral postoperative alignment is said to be a guiding principle for performing a successful total knee arthroplasty (TKA). There are many different alignment philosophies and surgical techniques to attain the goal of proper alignment. This study aimed to radiologically measure the difference in the amount of tibial bony resection required to perform a mechanical alignment versus an anatomic alignment TKA. Methods Two observers retrospectively reviewed the long leg radiographs of 100 patients (61 females and 39 males) listed for TKA between 2015 and 2018, measuring the amount of tibial bony resection required to achieve mechanical or anatomic alignment TKA. Results These radiographs' overall lower limb mechanical axis ranged between 16° varus and 17.6° valgus (mean 4.4° varus, standard deviation (SD) 6.64). By referencing 4 mm from the worn side, the mean resection needed from the normal side of the tibial plateau is 7.6 mm in the mechanical alignment measurement and 5.2 mm in the anatomical alignment measurement (p<0.0001). Therefore, 17% of mechanical alignment cuts require a tibial cut of more than 10 mm (mean 12.382 mm). No anatomical alignment measurements exceed 10 mm. When a virtual tibial cut >10 mm is required, the medial proximal tibial angle (MPTA) is a stronger predictor of deformity than the mechanical axis. Conclusion This radiological study shows that an anatomical alignment tibial cut is more bone conserving on the tibia than a mechanical alignment tibial cut and may lead to less asymmetry of the bony cuts and greater bony preservation, but clinical correlation is needed.

Does vitamin E highly-crosslinked polyethylene convey an advantage in primary total hip replacement? A systematic review and meta-analysis.

BACKGROUND: Vitamin E highly cross-linked polyethylene (HXLPE) was developed to reduce wear in total hip replacement (THR). This formal systematic review and meta-analysis aimed to provide independent synthesis of wear characteristics of Vitamin E treated HXLPE compared to HXPLE/UHMWPE. Secondary outcome measures were differences in revision rates and functional scores. METHODS: We performed a formal systematic review as per PRISMA guidelines; literature searches were conducted on 14 November 2017 (MEDLINE, Embase on Ovid, and the Cochrane Library). We included randomised controlled trials, analyses of joint registries, and case-controlled studies of primary THR comparing cups with a vitamin E HXLPE bearing with bearing surfaces made from other types of polyethylene. Initial screening was performed by 2 independent assessors; disagreement resolved in discussion with a third reviewer. Studies were evaluated using the Cochrane risk of bias tool. Data extraction permitted meta-analysis. RESULTS: 372 studies were identified on initial screening, 5 studies met the eligibility criteria. There was no significant heterogeneity between studies. There was variable risk of bias. At a mean of 35 (range 20-60) months, Vitamin E HXLPE had significant advantages over highly cross-linked polyethylene with regards total femoral head penetration (p = 0.004). Given the RSA measurement errors this may not be clinically significant.There were neither significant differences in revision rates nor Harris Hip Scores (p = 0.06). CONCLUSION: At a minimum of 3 years follow-up there was reduced total femoral head penetration for vitamin E HXLPE over HXLPE. This bearing surface does not, as yet, have clinically significant advantages in terms of revision rates or patient function over HXLPE.

The use of silver coating in hip megaprostheses: a systematic review.

Retrospective studies of silver-coated hip implants have demonstrated promising results and safety profile, however, the potential benefits are so far unproven in prospective studies. Silver-coated implants may have a role in patients undergoing revision or primary surgery with a high risk of infection but as yet there are no human studies investigating silver in primary hip arthroplasty. Adequately powered robust prospective studies are needed in this area to determine if silver-coated implants would be efficacious and cost-effective. The purpose of this systematic review article is to review the current literature regarding the use of silver in hip arthroplasty. Our review showed that there is some encouraging evidence that silver coatings can reduce infection.

A comparison of energy consumption between the use of a walking frame, crutches and a Stride-on rehabilitation scooter.

BACKGROUND: Following foot and ankle surgery, patients may be required to mobilise non-weight bearing, requiring a walking aid such as crutches, walking frame or a Stride-on rehabilitation scooter, which aims to reduce the amount of work required. The energy consumption of mobilising using a Stride-on scooter has not previously been investigated, and we aim to establish this. METHODS: Ten healthy volunteers (5 males:5 females) aged 20-40 years mobilised independently, then with each mobility device for 3min at 1km/h on a treadmill, with rest periods, whilst undergoing Cardio-Pulmonary Exercise Testing (CPET). Oxygen consumption (VO2), carbon dioxide excretion (VCO2), minute ventilation (MV), respiratory rate (RR) and pulse (HR) were measured at baseline, and after 3min of walking, without and with all 3 devices. Wilcoxon signed rank test was carried out to calculate significance with non-parametric values with Bonferroni correction. RESULTS: Three-point crutch mobilisation demonstrated significant increases in VO2 (0.7L), VCO2 (0.7L), MV (16.7L/min), pulse (24.8bpm) and RR (11.4breaths/min) compared to walking (p<0.05). Mobilisation with a frame produced significant (p<0.05) increases compared to walking; VO2 (0.7L), VCO2 (0.7L), MV (18.3L/min), pulse (35.9bpm), and RR (11.7breaths/min). Tests using the Stride-on demonstrated no significant increase compared to walking with regards to VO2 (0.1L; p=0.959), VCO2 (0.2L; p=0.332), pulse (10.1bpm; p=0.575), and RR (4.7breaths/min; p=0.633). The MV was significantly higher compared to walking (4.3L/min; p<0.05). DISCUSSION: Energy required for unit distance ambulation with a Stride-on device is similar to walking, and significantly lower than with a walking frame in single legged stance and three-point crutch mobilisation. This justifies its use as part of routine practice aiding early mobilisation of patients requiring restricted weight bearing or single legged weight bearing, especially in those with reduced cardio-pulmonary reserve as it is less physiologically demanding and does not rely on upper body strength.

Tonsillectomy discharge information - An improvement in both patient safety and satisfaction.

Approximately 20,000 adult and 25,000 paediatric tonsillectomies are performed each year in England. 0.9% of these patients return to theatre for post-tonsillectomy bleeding. The Royal College of Surgeons of England (RCSEng) have produced guidelines regarding emergency surgery, with standards for tonsillectomy discharge information. We audited our compliance with these guidelines and patient satisfaction regarding the information currently provided. Theatre records identified all tonsillectomies carried out between December 2012 and February 2013. 71 patients and their electronic discharge information were reviewed for post-operative bleeding information. Each patient was contacted, with a second call made to those who did not answer. 35 patients took part in our telephone questionnaire. Only 35% of patients had post-operative bleeding information on their discharge summary. 51% received no written information either in clinic or on the day of surgery, 66% recalled a verbal explanation. Only 54% knew to go to A&E if they experienced bleeding. 40% were not satisfied with their discharge information, stating that they wanted to know about bleeding, recovery expectations, and information regarding oral intake. A focus group was formed to discuss potential solutions to the audit outcomes and a tonsillectomy leaflet was produced inline with the trust patient information template. It contained specific instructions regarding bleeding and the nearest A&E contact details. It was reviewed by three tonsillectomy patients and their feedback regarding further information on post-operative diet, throat appearance and pain expectations was incorporated. A second cycle of the audit took place between August and September 2013. Results showed improvement, with 83% receiving an information leaflet and 100% a verbal explanation. 100% of patients were satisfied with their discharge information and 100% knew what to do if they bled. As a result we now meet the standards set out by the RCSEng and have increased our patient safety and satisfaction rates.

Cerebral infarction following a carotid Doppler ultrasound: a chance association?

The authors present a case report of a 64-year-old lady with multiple risk factors for atherosclerosis, who suffered an ischaemic stroke immediately following carotid Doppler ultrasound despite therapeutic warfarin and antiplatelet therapy. This event was only 16 days after the patient suffered a first ischaemic stroke during diagnostic coronary angiography following a syncopal episode accompanied with a raised troponin-T. The temporal relationship between the carotid Doppler ultrasound and second ischaemic stroke raised the question whether it was possible that the investigation had caused the stroke, a complication not previously recognised.

Ecrg4 expression and its product augurin in the choroid plexus: impact on fetal brain development, cerebrospinal fluid homeostasis and neuroprogenitor cell response to CNS injury.

BACKGROUND: The content and composition of cerebrospinal fluid (CSF) is determined in large part by the choroid plexus (CP) and specifically, a specialized epithelial cell (CPe) layer that responds to, synthesizes, and transports peptide hormones into and out of CSF. Together with ventricular ependymal cells, these CPe relay homeostatic signals throughout the central nervous system (CNS) and regulate CSF hydrodynamics. One new candidate signal is augurin, a newly recognized 14 kDa protein that is encoded by esophageal cancer related gene-4 (Ecrg4), a putative tumor suppressor gene whose presence and function in normal tissues remains unexplored and enigmatic. The aim of this study was to explore whether Ecrg4 and its product augurin, can be implicated in CNS development and the response to CNS injury. METHODS: Ecrg4 gene expression in CNS and peripheral tissues was studied by in situ hybridization and quantitative RT-PCR. Augurin, the protein encoded by Ecrg4, was detected by immunoblotting, immunohistochemistry and ELISA. The biological consequence of augurin over-expression was studied in a cortical stab model of rat CNS injury by intra-cerebro-ventricular injection of an adenovirus vector containing the Ecrg4 cDNA. The biological consequences of reduced augurin expression were evaluated by characterizing the CNS phenotype caused by Ecrg4 gene knockdown in developing zebrafish embryos. RESULTS: Gene expression and immunohistochemical analyses revealed that, the CP is a major source of Ecrg4 in the CNS and that Ecrg4 mRNA is predominantly localized to choroid plexus epithelial (CPe), ventricular and central canal cells of the spinal cord. After a stab injury into the brain however, both augurin staining and Ecrg4 gene expression decreased precipitously. If the loss of augurin was circumvented by over-expressing Ecrg4 in vivo, BrdU incorporation by cells in the subependymal zone decreased. Inversely, gene knockdown of Ecrg4 in developing zebrafish embryos caused increased proliferation of GFAP-positive cells and induced a dose-dependent hydrocephalus-like phenotype that could be rescued by co-injection of antisense morpholinos with Ecrg4 mRNA. CONCLUSION: An unusually elevated expression of the Ecrg4 gene in the CP implies that its product, augurin, plays a role in CP-CSF-CNS function. The results are all consistent with a model whereby an injury-induced decrease in augurin dysinhibits target cells at the ependymal-subependymal interface. We speculate that the ability of CP and ependymal epithelium to alter the progenitor cell response to CNS injury may be mediated, in part by Ecrg4. If so, the canonic control of its promoter by DNA methylation may implicate epigenetic mechanisms in neuroprogenitor fate and function in the CNS.

Sentinel node biopsy in head and neck cancer: preliminary results of a multicenter trial.

BACKGROUND: The aim was to determine the reliability and reproducibility of sentinel node biopsy (SNB) as a staging tool in head and neck squamous cell carcinoma (HNSCC) for T1/2 clinically N0 patients by means of a standardized technique. METHODS: Between June 1998 and June 2002, 227 SNB procedures have been performed in HNSCC cases at six centers. One hundred thirty-four T1/2 tumors of the oral cavity/oropharynx in clinically N0 patients were investigated with preoperative lymphoscintigraphy (LSG), intraoperative use of blue dye/gamma probe, and pathological evaluation with step serial sectioning and immunohistochemistry, with a follow-up of at least 12 months. In 79 cases SNB alone was used to stage the neck carcinoma, and in 55 cases SNB was used in combination with an elective neck dissection (END). RESULTS: In 125/134 cases (93%) a sentinel node was identified. Of 59 positive nodes, 57 were identified with the intraoperative gamma probe and 44 with blue dye. Upstaging of disease occurred in 42/125 cases (34%): with hematoxylin-eosin in 32/125 (26%) and with additional pathological staging in 10/93 (11%). The sensitivity of the technique with a mean follow-up of 24 months was 42/45 (93%). The identification of SNB for floor of mouth (FOM) tumors was 37/43 (86%), compared with 88/91 (97%) for other tumors. The sensitivity for FOM tumors was 12/15 (80%), compared with 30/30 (100%) for other tumor groups. CONCLUSION: SNB can be successfully applied to early T1/2 tumors of the oral cavity/oropharynx in a standardized fashion by centers worldwide. For the majority of these tumors the SNB technique can be used alone as a staging tool.