Injury patterns of e-scooter-related orthopaedic trauma in central London: a multicentre study.

PURPOSE: Electric scooters (e-Scooters) are being increasingly used in urban areas as a new means of transport. E-scooter sharing schemes have recently been piloted in the United Kingdom; however, there are no published data on orthopaedic injuries and user behaviour patterns in the UK. We aim to identify the patterns and severity of orthopaedic injuries related to e-scooter use. METHODS: We performed a retrospective review of all orthopaedic referrals relating to e-scooter use from 1 March to 30 November 2020 at three hospitals, including one major trauma centre in central London. Data including patient demographics, mechanism of injury, diagnosis and treatment were collected. RESULTS: One hundred and five orthopaedic injuries were identified in 83 patients. The median age was 32 years and 83% were male. Seventy-nine (95.2%) patients were riders, four were pedestrians. All e-scooters were privately owned. There were 93 fractures (88.6% of total injuries noted) including 12 (12.9%) open. Fifty-two (56.0%) were upper limb fractures, 39 (41.9%) lower limb and 2 (2.1%) spinal and rib fractures. Twenty-five patients (30.1%) required an operation and 29 (34.9%) required hospital admission. Helmet use was present in 34.1%. The most common place of injury was the road (65.1%) followed by pavement (32.9%). CONCLUSION: E-scooters can cause serious injury, most commonly in males. There was an equal distribution of upper and lower limb injuries, with many associated with high-energy trauma requiring operative intervention. Helmet use was seen in one third of riders. As e-scooter use continues to increase across the UK, additional steps should be taken to ensure the safety of the riders and public.

An international patient-centred study of retroperitoneal fibrosis.

BACKGROUND: The impact that rare chronic disorders, such as retroperitoneal fibrosis (RPF), can have on the physical and psychological aspects of a patient's health is poorly understood. Patient-related outcome measures and experiences provide a unique opportunity to understand the impact rare chronic disorders have on a patient's life as well as allowing healthcare providers to compare and improve performance. AIM: To understand the physical and psychosocial impact that RPF has upon peoples' lives. DESIGN: An international online questionnaire was therefore created to gain insights into how patients with RPF, a rare fibro-inflammatory condition, viewed their health and experiences. METHODS: An international online questionnaire comprising 62 questions/free text options, was designed in collaboration with two patient advocates and the multi-disciplinary Renal Association Rare Disease Registry (RaDaR) RPF Group the questionnaire was anonymous and freely accessible on a GOOGLE Form online platform for 6 months. RESULTS: A total of 229 patients from 30 countries across 5 continents responded. Four key issues were identified; (i) pain; (ii) therapy-related side effects; (iii) lack of informed doctors/information about their condition and its management; and (iv) psychological burden. Variations in diagnosis and management are highlighted with 55% undergoing a biopsy to reach a diagnosis of RPF; 75% of patients underwent a further interventional procedure with 60% concurrently treated medically. CONCLUSION: This study will guide further development of clinical and academic multi-disciplinary activity and shows the importance of trying to understand the impact of rare chronic disorders on the physical and psychological aspects of a patient's health.

Ensilicated tetanus antigen retains immunogenicity: in vivo study and time-resolved SAXS characterization.

Our recently developed ensilication approach can physically stabilize proteins in silica without use of a pre-formed particle matrix. Stabilisation is done by tailor fitting individual proteins with a silica coat using a modified sol-gel process. Biopharmaceuticals, e.g. liquid-formulated vaccines with adjuvants, frequently have poor thermal stability; heating and/or freezing impairs their potency. As a result, there is an increase in the prevalence of vaccine-preventable diseases in low-income countries even when there are means to combat them. One of the root causes lies in the problematic vaccine 'cold chain' distribution. We believe that ensilication can improve vaccine availability by enabling transportation without refrigeration. Here, we show that ensilication stabilizes tetanus toxin C fragment (TTCF), a component of the tetanus toxoid present in the diphtheria, tetanus and pertussis (DTP) vaccine. Experimental in vivo immunization data show that the ensilicated material can be stored, transported at ambient temperatures, and even heat-treated without compromising the immunogenic properties of TTCF. To further our understanding of the ensilication process and its protective effect on proteins, we have also studied the formation of TTCF-silica nanoparticles via time-resolved Small Angle X-ray Scattering (SAXS). Our results reveal ensilication to be a staged diffusion-limited cluster aggregation (DLCA) type reaction. An early stage (tens of seconds) in which individual proteins are coated with silica is followed by a subsequent stage (several minutes) in which the protein-containing silica nanoparticles aggregate into larger clusters. Our results suggest that we could utilize this technology for vaccines, therapeutics or other biopharmaceuticals that are not compatible with lyophilization.

Thiopurine withdrawal during sustained clinical remission in inflammatory bowel disease: relapse and recapture rates, with predictive factors in 237 patients.

BACKGROUND: Thiopurines (azathioprine and mercaptopurine) remain integral to most medical strategies for maintaining remission in Crohn's disease (CD) and ulcerative colitis (UC). Indefinite use of these drugs is tempered by long-term risks. While clinical relapse is noted frequently following drug withdrawal, there are few published data on predictive factors. AIM: To investigate the success of planned thiopurine withdrawal in patients in sustained clinical remission to identify rates and predictors of relapse. METHODS: This was a multicentre retrospective cohort study from 11 centres across the UK. Patients included had a definitive diagnosis of IBD, continuous thiopurine use ≥3 years and withdrawal when in sustained clinical remission. All patients had a minimum of 12 months follow-up post drug withdrawal. Primary and secondary end points were relapse at 12 and 24 months respectively. RESULTS: 237 patients were included in the study (129 CD; 108 UC). Median duration of thiopurine use prior to withdrawal was 6.0 years (interquartile range 4.4-8.4). At follow-up, moderate/severe relapse was observed in 23% CD and 12% UC patients at 12 months, 39% CD and 26% UC at 24 months. Relapse rate at 12 months was significantly higher in CD than UC (P = 0.035). Elevated CRP at withdrawal was associated with higher relapse rates at 12 months for CD (P = 0.005), while an elevated white cell count was predictive at 12 months for UC (P = 0.007). CONCLUSION: Thiopurine withdrawal in the context of sustained remission is associated with a 1-year moderate-to-severe relapse rate of 23% in Crohn's disease and 12% in ulcerative colitis.

Improvement in quality of life after arthroscopic capsular release for contracture of the shoulder.

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively. ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms.

The venous thromboembolic complications of shoulder and elbow surgery: a systematic review.

We investigated the incidence of and risk factors for venous thromboembolism (VTE) following surgery of the shoulder and elbow and assessed the role of thromboprophylaxis in upper limb surgery. All papers describing VTE after shoulder and elbow surgery published in the English language literature before 31 March 2012 were reviewed. A total of 14 papers were available for analysis, most of which were retrospective studies and case series. The incidence of VTE was 0.038% from 92 440 shoulder arthroscopic procedures, 0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures for fractures of the proximal humerus (open reduction and internal fixation or hemiarthroplasty). The incidence following replacement of the elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid arthritis and ischaemic heart disease were identified as the major risk factors.The evidence that exists on thromboprophylaxis is based on level III and IV studies, and we therefore cannot make any recommendations on prophylaxis based on the current evidence. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE.

Psychometric analysis of measuring functional outcomes in tibial plateau fractures using the Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires.

Patients participating in a modern prospective orthopaedic trauma database may be asked to complete many functional outcome measures, adding to the burden of study participation. This prospective study assessed the utility and responsiveness of the generic Short Form 36 (SF-36) and the disease specific Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires in 55 patients treated operatively for tibial plateau fractures with the goal of determining if there was clear benefit of using multiple measures in a lower extremity peri-articular fracture population. There was very good correlation between all three scores at 6 and 12 months, indicating they are measuring similar factors. Responsiveness was assessed using the standard response mean (SRM), proportion of patients attaining the minimal clinically important difference (MCID) between 6 and 12 months, and floor and ceiling effects. The SRM for the SF-36 was statistically higher than the SRM for the SMFA or the WOMAC. Significantly more patients were found to have a MCID between 6 and 12 months post-surgery based on the SF-36 than the other two functional scores. There was no floor effect found on any of the 3 functional scores evaluated; however, a significant ceiling effect was noted with the WOMAC but not with the SF-36 or the SMFA. These results, along with the usefulness of the SF-36 for comparing disease burden across populations, favour the SF-36 as the instrument of choice in assessing functional outcome in patients with tibial plateau fractures.

Injuries to the tibiofibular syndesmosis.

The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.

Impaction grafting with a bone-graft substitute in a sheep model of revision hip replacement.

An experimental sheep model was used for impaction allografting of 12 hemiarthroplasty femoral components placed into two equal-sized groups. In group 1, a 50:50 mixture of ApaPore hydroxyapatite bone-graft substitute and allograft was used. In group 2, ApaPore and allograft were mixed in a 90:10 ratio. Both groups were killed at six months. Ground reaction force results demonstrated no significant differences (p > 0.05) between the two groups at 8, 16 and 24 weeks post-operatively, and all animals remained active. The mean bone turnover rates were significantly greater in group 1, at 0.00206 mm/day, compared to group 2 at 0.0013 mm/day (p < 0.05). The results for the area of new bone formation demonstrated no significant differences (p > 0.05) between the two groups. No significant differences were found between the two groups in thickness of the cement mantle (p > 0.05) and percentage ApaPore-bone contact (p > 0.05). The results of this animal study demonstrated that a mixture of ApaPore allograft in a 90:10 ratio was comparable to using a 50:50 mixture.

Femoral osteolysis following total hip replacement.

Total hip replacement represents the most significant advance in orthopaedic surgery in the 20th century. Periprosthetic osteolysis remains the most significant long-term complication with total hip replacement. It has been reported with all materials and prosthetic devices in use or that have been used to date. This paper reviews the current thinking on the aetiology, pathogenesis, management and future treatment options for osteolysis.

Trauma calls: role of the general surgeon and CT scanning.

BACKGROUND AND OBJECTIVE: General surgeons are required in only a minority of trauma call cases to assess for abdominal injuries. Computed tomography (CT) accurately detects blunt abdominal injuries and may have replaced the need for general surgeons at trauma calls. This study evaluated the role of general surgeons at trauma calls and assessed use of CT in cases of suspected abdominal trauma. METHODS: (a) Eighteen month analysis of trauma calls at a district general hospital and (b) three month prospective study of all trauma cases presenting to A&E. RESULTS: (a) There were 73 trauma calls and the mechanism of injury in most cases was a road traffic accident (RTA). Most patients had orthopaedic and/or neurosurgical injuries. The general surgeons assessed 22 trauma call patients. Abdominal injury was excluded in 13 (four by clinical examination and nine following CT). (b) Forty three patients fulfilled the criteria for a trauma call and 14 trauma calls were made. The mechanism of injury in most was RTA and most had orthopaedic and/or neurosurgical injuries. The general surgeons assessed 10/43 potential trauma call patients, and abdominal injury was excluded in five (one by clinical examination and four following CT). CONCLUSION: A&E staff managed most trauma calls. Most patients did not require general surgical intervention. For penetrating injuries, presence of a general surgeon remained crucial. For blunt injuries CT was an important adjunct. These data suggest that general surgeons do not routinely have to attend all trauma calls but can be called if abdominal and/or vascular injuries are specifically suspected.

The effects of acute ethanol intake on isoniazid pharmacokinetics.

AIM: To assess effects of acute ethanol intake on the pharmacokinetics of isoniazid in healthy male volunteers. METHODS: Sixteen healthy male, drug-free subjects were studied. Each received in the fasting state, on two occasions separated by at least 1 week, isoniazid (200 mg orally). On one occasion (assigned randomly), subjects received ethanol 0.73 g/kg, 1 h before isoniazid, followed by 0.11 g/kg ethanol orally every hour thereafter for 7 h. Plasma isoniazid and acetylisoniazid concentrations were measured by means of high-performance liquid chromatography. Blood ethanol concentrations were measured hourly by breath analysis. Plasma concentrations of isoniazid and acetylisoniazid were analysed using TOPFIT software. RESULTS: Peak concentrations of isoniazid were reached within 90 min, in both the ethanol-treated and control groups. The ethanol dosage regimen used resulted in peak blood ethanol concentrations between 78 mg/l and 103 mg/l. There was no significant difference in area under the curve, half-life of elimination or the ratio of acetylisoniazid to isoniazid (AcINH/INH) in the sample withdrawn 3 h after isoniazid dose. Acetylator phenotype for patients was the same in both phases, whether assessed by half-life of isoniazid or the AcINH/INH ratio at 3 h. CONCLUSIONS: Acute ethanol intake at this dose is unlikely to affect results of acetylation studies in which isoniazid is used as a substrate, whether the half-life of isoniazid or the AcINH /INH ratio at 3 h is used to phenotype patients.

Expansion rates of asymptomatic popliteal artery aneurysms.

OBJECTIVES: In the absence of symptoms the decision to operate on popliteal artery aneurysms (PA) is often made on PA diameter. Little information exists on growth rate and therefore optimum scanning intervals. The aim of this paper is to define growth rate of PA managed conservatively. METHODS: A prospective study of patients with asymptomatic PA was carried out. Patients were invited for ultrasound scanning at 6-12 months intervals. Diameter changes between consecutive pairs of scans were measured. A decision to operate was made in fit patients if PA became symptomatic and/or had a diameter above 3 cm. RESULTS: Twenty-one men (24 aneurysms) with a median age of 69 years (46-86) underwent 78 scans. Sixteen PA were on the right and eight on the left. Eighteen patients had bilateral aneurysms, 15 of which were complicated on one side at presentation and were dealt with surgically on that side. The median size at first scan was 19 mm (14-36). The median time interval to the first follow-up scan was 9 months and subsequent scans were 12 months. The mean rate of expansion at aneurysm sizes below 20 mm diameter was 1.5 mm/year. PA grew by 3.0 mm/year at sizes 20-30 mm and by 3.7 mm/year at sizes >30 mm. Among the risk factors analysed, hypertension appeared to increase the risk of aneurysm growth. CONCLUSION: The expansion rate of PA increases with increasing size of the PA. This rate of growth in relation to size at previous scan and threshold diameter for intervention should be borne in mind when planning surveillance intervals.