Informed consent: where are we in 2015?

A recent Supreme Court ruling in the United Kingdom has significantly altered the emphasis of informed consent, moving from a historically 'doctor-focused' to a more 'patient-focused' approach, in line with the situation in other international jurisdictions. The reasons for the change are discussed with some recommendations about how our attitudes need to change in the future. Cite this article: Bone Joint J 2015;97-B:1159-61.

Excision of a bony spike without fixation of the fractured clavicle in a jockey.

Various modalities are available for treatment of a clavicle fracture. Conservative treatment is successful in most cases. Open reduction, when indicated, usually is accompanied by fixation of the fracture. In the case of a jockey with a fractured clavicle, the fracture was complicated by tenting of the skin. The fracture was opened and a bony spike was excised extraperiosteally without doing internal fixation of the fracture to avoid skin necrosis and allow early return to work. The patient returned to his profession 2 weeks after surgery. Radiologic and clinical examinations revealed a satisfactory outcome at the 6-month followup.

Direct explanations for the development and use of a multi-layer perceptron network that classifies low-back-pain patients.

Using a new method published by the first author, this article shows how direct explanations can be provided to interpret the classification of any input case by a standard multilayer perceptron (MLP) network. The method is demonstrated for a real-world MLP that classifies low-back-pain patients into three diagnostic classes. The application of the method leads to the discovery of a number of mis-diagnosed training and test cases and to the development of a more optimal low-back-pain MLP network.

Oral extrusion of a screw after anterior cervical spine plating.

STUDY DESIGN: A case report of a 76-year-old woman who retched up a screw from a cervical spine locking plate 5 years after anterior cervical spine fusion. The literature relevant to this topic is reviewed. OBJECTIVES: To report the rare but potentially life-threatening complication of oral screw extrusion after anterior cervical spine plating, to review the relevant literature on the topic, and to discuss the clinical management of instrumentation failure in anterior cervical spine plating. SUMMARY OF BACKGROUND DATA: Anterior cervical spine fusion and stabilization is a well-established procedure. Complications include instrumentation failure, which can progress to extrusion through the gastrointestinal tract. Management is dependent on the severity and progression of clinical and radiologic signs and symptoms. Reoperation should be considered in certain cases. METHODS: A rare complication of anterior cervical spine plating in a 76-year-old woman 5 years after the initial operation is reported. The patient was assessed with serial physical examination and radiograph and one further follow-up 3 months after the first presentation. RESULTS: The patient was asymptomatic shortly after she retched up the screw, and at the 3-month follow-up was without evidence of progression of plate dislodgement. CONCLUSION: As reported, oral extrusion of cervical spine grafts or instrumentation is rare but potentially serious. Each case of instrumentation failure should be assessed individually to decide if conservative management is appropriate or if reoperation should be considered.

Graf ligament stabilisation: mid- to long-term follow-up.

Previous studies have looked at early follow-up of the Graf ligament stabilisation system. We present mid- to long-term results of this procedure. A retrospective review of Graf ligaments inserted since 1993 was undertaken. A total of 51 patients were reviewed. Pre-operative Oswestry Disability Index scores were compared to post-operative scores recorded via a postal questionnaire. There were 28 men and 23 women. The average age was 41 years (range, 2267 years). The mean pre-operative score was 46 (range, 22-78), the mean follow-up time was 51 months (range, 23-84 months) and the mean post-operative score was 40 (range, 0-82). There were 12 complications (4 requiring further surgery), and seven patients went on to require bony fusion procedures. Forty one per cent of the group would choose not to have the operation again. Longer-term results of this technique are not as encouraging as earlier studies. The continued use of this procedure should be viewed with caution.

Responsiveness of common outcome measures for patients with low back pain.

STUDY DESIGN: A prospective cohort study assessing the responsiveness of two disease-specific questionnaires and a generic health questionnaire for patients with low back pain and sciatica. OBJECTIVES: To compare the responsiveness of the eight scales and two summery scales of the SF-36 questionnaire with that of the Oswestry Disability Index and Low Back Outcome Score questionnaires. SUMMARY OF BACKGROUND DATA: Evaluation of treatment outcome is being determined more frequently from a patient's perspective, particularly the impact treatment has on current health status. METHODS: Patients were recruited from two orthopedic back pain clinics in a tertiary hospital. Patients completed the pretreatment questionnaire 1 month before treatment and follow-up questionnaires a minimum of 2-6 months after treatment. Patients undergoing surgery were also observed for a minimum of 2 years. RESULTS: Overall, the Oswestry Disability Index was most responsive; however, individual scales from the SF-36 questionnaire showed equal or greater sensitivity to change than the Oswestry Disability Index in each of the patient subgroups. The SF-36 Role Physical scale was prone to floor effects (a high percentage of respondents score zero), and the change scores from the SF-36 Role Emotional scale varied by 100 points in either direction in each of the patient subgroups. CONCLUSION: Responsiveness varied according to which method was used in its calculation. The responsiveness of the SF-36 questionnaire shows that it can be a useful adjunct in the assessment of patients with low back pain when combined with disease-specific questionnaires.

Partial excision of the clavicle for nonunion in National Hunt Jockeys.

National Hunt jockeys suffer a disproportionate number of clavicular fractures and their return to riding may be considerably delayed by refracture and symptomatic nonunion, with obvious implications. We report six such cases in which excision of the clavicular fragment distal to the fracture was associated with an early return to work and no recurrent injury to the shoulder.

'Buttonholed' femoral shaft fracture in adolescents: an indication for internal fixation?

Four patients aged 11 to 14 years sustained femoral shaft fractures. The fractures proved to be irreducible by conventional closed methods. At operation; either the proximal or distal end of the fracture was found to have 'buttonholed' through the lateral intermuscular septum, preventing reduction. The case histories and clinical results are presented. To our knowledge this complication has not been described previously, and we believe that it is an indication for open reduction and internal fixation, for reasons that will be discussed. In the patients described here there was no important leg length inequality as a result of the internal fixation.

A role for Na+/Ca2+ exchange in the generation of superoxide radicals by human neutrophils.

A Na+/Ca2+ exchange mechanism has been recently described in human neutrophils that constitutes the principal pathway for Ca2+ influx into resting cells. The potential role of this system in regulating the respiratory burst in response to activation by the chemotactic tripeptide N-formyl-methionyl-leucyl-phenylalanine was explored. In the presence of 1 mM Ca2+, a variety of di- and trivalent cations suppressed the generation of O(-2) radicals in a series of decreasing efficacy: La3+ approximately Zn2+ much greater than Sr2+ approximately Cd2+ greater than Ba2+ greater than Co2+ greater than Ni2+ approximately Mg2+. This sequence is similar to their rank order of activity in inhibiting 45Ca2+ influx via Na+/Ca2+ counter-transport. Benzamil, phenamil, and 2',4'-dichlorobenzamil, analogues of amiloride which selectively block Na+/Ca2+ exchange in neutrophils, likewise suppressed the release of O(-2) with apparent Ki values of approximately 30 microM. The effect of the cations was competitive with Ca2+, while the interaction between the benzamil derivatives and Ca2+ appeared to be noncompetitive in nature. Both the divalent cations and benzamil also inhibited the rise in cytoplasmic Ca2+ as monitored by fura-2 fluorescence: these agents reduced peak cytosolic Ca2+ levels after N-formyl-methionyl-leucyl-phenylalanine stimulation to values seen in the absence of extracellular Ca2+. These results are compatible with the hypothesis that the influx of Ca2+ via Na+/Ca2+ exchange contributes to the transient elevation in intracellular free Ca2+. The polyvalent cations block the entry of critical Ca2+ ions by competing with Ca2+ for binding to the translocation site on the exchange carrier, while benzamil acts by lowering the maximal transport rate. These studies emphasize that Na+/Ca2+ exchange through its effects on cytoplasmic Ca2+ plays a major regulatory role in activation of the respiratory burst in chemotactic factor-stimulated neutrophils.

Primary subacute osteomyelitis of the ilium.

Primary subacute osteomyelitis is an increasingly recognized clinical condition. PAO seems not to have been previously reported in the ilium. A 26-year-old man with iliac PAO illustrates the problem of differential diagnosis and treatment.

Morbidity following isolated fractures of the sacrum.

There is little information in the orthopaedic literature on the long-term results following isolated fractures of the sacrum. The present study traced patients with these fractures, and attempted to identify the incidence of long-term symptoms. The study revealed that isolated fractures of the sacrum are not always benign, and may result in chronic discomfort (sacrodynia) or persistent neurological symptoms.

Bone infarction as a cause of painful fingers in a child.

An unusual case of painful fingers in a two-year-old child is described. The possible aetiolgy is discussed. The condition normally runs a self-limiting course.