The effect of smoking on union rates following corrective osteotomies around the knee: A systematic review and meta-analysis.

BACKGROUND: Distal femur osteotomies (DFO) and high tibial osteotomies (HTO), are well-established treatment options for joint preservation in active patients with uni-compartmental osteoarthritis. Optimal outcomes are contingent on adequate preoperative evaluation of patient-specific factors. This systematic review and meta-analysis aims to explore the difference in union rates between smokers and non-smokers following corrective osteotomies around the knee. METHODS: A systematic search of the MEDLINE and EMBASE databases was performed in accordance with the PRISMA guidelines to identify studies reporting smoking status in adults who developed delayed and/or non-union following HTO or DFO. Studies were pooled using a random effect model [Review Manager (RevMan) software, V.5.4] and heterogeneity was estimated using I2. RESULTS: Data for meta-analysis was available for 1,406 osteotomies from 10 studies, performed in patients with mean age ranging from 38-54 years, and 65% were male. The union rate among non-smokers was 97.3% (1100/1131) compared with 89.5% (246/275) among smokers; OR 4.59 [95% CI 1.99 to 10.62], p-value < 0.001. Subgroup analysis revealed that the risk of non-union in smokers after opening wedge osteotomy was almost double (OR 4.8) that of closing wedge osteotomies (OR 2.9). CONCLUSION: Smoking increases the risk of non-union during elective knee osteotomy surgery. Our findings also suggest that smokers have a better chance of achieving union with closing wedge osteotomy compared to open wedge osteotomy.

Indications for a single-stage exchange arthroplasty for chronic prosthetic joint infection: a systematic review.

AIMS: Prosthetic joint infections (PJIs) of the hip and knee are associated with significant morbidity and socioeconomic burden. We undertook a systematic review of the current literature with the aim of proposing criteria for the selection of patients for a single-stage exchange arthroplasty in the management of a PJI. MATERIAL AND METHODS: A comprehensive review of the current literature was performed using the OVID-MEDLINE, EMBASE, and Cochrane Library databases and the search terms: infection and knee arthroplasty OR knee revision OR hip arthroplasty OR hip revision, and one stage OR single stage OR direct exchange. All studies involving fewer than ten patients and follow-up of less than two years in the study group were excluded as also were systematic reviews, surgical techniques, and expert opinions. RESULTS: The initial search revealed 875 potential articles of which 22 fulfilled the inclusion and exclusion criteria. There were 16 case series and six comparative studies; five were prospective and 14 were retrospective. The studies included 962 patients who underwent single stage revision arthroplasty of an infected hip or knee joint. The rate of recurrent infection ranged from 0% to 18%, at a minimum of two years' follow-up. The rate was lower in patients who were selected on the basis of factors relating to the patient and the local soft-tissue and bony conditions. CONCLUSION: We conclude that single-stage revision is an acceptable form of surgical treatment for the management of a PJI in selected patients. The indications for this approach include the absence of severe immunocompromise and significant soft-tissue or bony compromise and concurrent acute sepsis. We suggest that a two-stage approach should be used in patients with multidrug resistant or atypical organisms such as fungus.

Assuring the long-term total joint arthroplasty: a triad of variables.

OBJECTIVES: The primary objective of this study was to compare accuracy in restoring the native centre of hip rotation in patients undergoing conventional manual total hip arthroplasty (THA) versus robotic-arm assisted THA. Secondary objectives were to determine differences between these treatment techniques for THA in achieving the planned combined offset, component inclination, component version, and leg-length correction. MATERIALS AND METHODS: This prospective cohort study included 50 patients undergoing conventional manual THA and 25 patients receiving robotic-arm assisted THA. Patients undergoing conventional manual THA and robotic-arm assisted THA were well matched for age (mean age, 69.4 years (sd 5.2) vs 67.5 years (sd 5.8) (p = 0.25); body mass index (27.4 kg/m2 (sd 2.1) vs 26.9 kg/m2 (sd 2.2); p = 0.39); and laterality of surgery (right = 28, left = 22 vs right = 12, left = 13; p = 0.78). All operative procedures were undertaken by a single surgeon using the posterior approach. Two independent blinded observers recorded all radiological outcomes of interest using plain radiographs. RESULTS: The correlation coefficient was 0.92 (95% confidence interval (CI) 0.88 to 0.95) for intraobserver agreement and 0.88 (95% CI 0.82 to 0.94) for interobserver agreement in all study outcomes. Robotic THA was associated with improved accuracy in restoring the native horizontal (p < 0.001) and vertical (p < 0.001) centres of rotation, and improved preservation of the patient's native combined offset (p < 0.001) compared with conventional THA. Robotic THA improved accuracy in positioning of the acetabular component within the combined safe zones of inclination and anteversion described by Lewinnek et al (p = 0.02) and Callanan et al (p = 0.01) compared with conventional THA. There was no difference between the two treatment groups in achieving the planned leg-length correction (p = 0.10). CONCLUSION: Robotic-arm assisted THA was associated with improved accuracy in restoring the native centre of rotation, better preservation of the combined offset, and more precise acetabular component positioning within the safe zones of inclination and anteversion compared with conventional manual THA.

Are leg length and hip offset comparable after hip resurfacing and cementless total hip arthroplasty?

INTRODUCTION: The purpose of this study was to determine if hip resurfacing arthroplasty (HRA) and cementless total hip arthroplasty (THA) were comparable in correcting leg length and hip offset in patients with primary osteoarthritis. METHODS: A retrospective analysis was performed of 80 patients who underwent either HRA or cementless THA for primary osteoarthritis (40 in each group) between 2006 and 2008. Standardised anteroposterior radiographs taken pre-operatively and at one year following surgery were used to calculate the total offset and leg length in both hips. RESULTS: At one year following surgery, no leg length discrepancy was identified in either group. A difference of 0.39 cm (p=0.046) remained between the mean total offset of the operated hip and the contralateral non-operated hip in the HRA group. No difference in offset was observed between the two hips after surgery in the THA group (p=0.875). CONCLUSIONS: Leg length is restored by HRA and THA. A difference remains in offset after HRA although we attribute this to intentional medialisation of the acetabular cup.

Metal-on-metal bearings: the evidence so far.

Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.

Teamwork in the operating department.

The Gynaecology theatre team of the Leicester Royal Infirmary NHS Trust were runners-up in the 1997 3M/NATN joint award. This article is a report of their work on the concept of teamwork and its benefits to the organisation and delivery of patient care in the operating department.

Degeneracy in human multicopy RBM (YRRM), a candidate spermatogenesis gene.

In order to search for mutations in the multicopy RBM genes that might be associated with male infertility, we have used sequence data from the reported cDNA clone to determine the intron exon boundaries of the YRRM 1 gene. This gene has 12 exons, three of which encode the putative RNA binding domain of the protein. Different copies of the gene contain sequence variations and, additionally, give rise to transcripts with different numbers of copies of the repeated SRGY motif. Since mutations in the RNA binding domain would seem likely to have an effect on the activity of the protein, we have scanned these exons for mutations by SSCP on DNA from normal and infertile men. Sequence differences in the exon encoding the N-terminal part of the RNA binding domain account for at least four different classes of the gene and give rise to different SSCP conformers. Sequence analysis shows that one of these classes is a pseudogene and that the members of another class are nonfunctional. RT-PCR shows that all classes are transcribed and that the A class is most abundant. We have found a point mutation that alters the highly conserved RNP2 motif in one infertile patient. This mutation is also found in his father. We have used PCR followed by SSCP analysis to map RBM on a Y Chromosome (Chr) YAC contig and have demonstrated a distribution that spans a major part of this chromosome's euchromatin.

An RBM homologue maps to the mouse Y chromosome and is expressed in germ cells.

We have isolated a murine homologue of the human Y-linked RBM genes (previously termed YRRM), a gene family implicated in spermatogenesis and which encodes proteins containing an RNA recognition motif. A number of very similar copies of this gene (called Rbm) are present in the mouse. These mouse homologues are also Y-encoded, mapping on the short arm of the chromosome, proximal to Sry. Expression is confined to the testis, specifically the germ line on the basis of lack of expression in the germ-line negative testes of adult sex-reversed mice. The timing of Rbm transcription is regulated, with fetal message levels reaching a peak at 15 d.p.c. Transcripts are clearly detectable by 4 days after birth and reach their highest level at 14 d.p.p. which is the time at which the Y chromosome condenses during meiotic prophase. These results suggest that Rbm is functionally involved in germline RNA metabolism.

EagI and NotI linking clones from human chromosomes 11 and Xp.

EagI and NotI linking libraries were prepared in the lambda vector, EMBL5, from the mouse-human somatic cell hybrid 1W1LA4.9, which contains human chromosomes 11 and Xp as the only human component. Individual clones containing human DNA were isolated by their ability to hybridise with total human DNA and digested with SalI and EcoRI to identify the human insert size and single-copy fragments. The mean (+/- SD) insert sizes of the EagI and NotI clones were 18.3 +/- 3.2 kb and 16.6 +/- 3.6 kb, respectively. Regional localisation of 66 clones (52 EagI, 14 NotI) was achieved using a panel of 20 somatic cell hybrids that contained different overlapping deletions of chromosomes 11 or Xp. Thirty-nine clones (36 EagI, 3 NotI) were localised to chromosome 11; 17 of these were clustered in 11q13 and another nine were clustered in 11q14-q23.1. Twenty-seven clones (16 EagI, 11 NotI) were localised to Xp and 10 of these were clustered in Xp11. The 66 clones were assessed for seven different microsatellite repetitive sequences; restriction fragment length polymorphisms for five clones from 11q13 were also identified. These EagI and NotI clones, which supplement those previously mapped to chromosome 11 and Xp, should facilitate the generation of more detailed maps and the identification of genes that are associated with CpG-rich islands.

Construction of a YAC contig and an STS map spanning 3.6 megabase pairs in Xp22.1.

We have constructed a 3.6 Mb sequence tagged sites (STS)-based yeast artificial chromosome (YAC) contig, consisting of 58 individual YAC clones, spanning the region PDHA1 and DXS451 on Xp22.1. In addition to establishing the order of PDHA1, ISPK-1, DXS2504, DXS1528 and the 13 known polymorphic loci as Xpter-PDHA1-DXS443-DXS3424-ISPK-1-DXS12 29-DXS2504-DXS1528-DXS365-DXS7101- DXS1683-DXS1052-DXS274-DXS92-DXS1226-DX S41-DXS989-DXS451-Xcen, we have also developed 35 novel STSs from YAC end clones. These results provide a high density of STS markers (approximately 1 per 70 kb). Furthermore, a detailed long-range restriction map of the contig has been constructed with rare-cutter enzymes and this has refined and verified the physical distances between markers inferred from YAC sizes and their STS content. The integration of the physical mapping data with previous genetic mapping data and the use of STSs and non-chimeric YAC clones reported here should facilitate the construction of a transcript map of this region and the positional cloning of disease genes in this portion of Xp22.1.