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Management of partial extensor tendon lacerations of the hand and forearm: A national survey of practice in the United Kingdom.
BACKGROUND: Partial extensor tendon lacerations of the hand and forearm are common. There is a lack of evidence to guide their management and it is also unclear at what threshold surgeons would consider repair necessary. This study aimed to identify national surgical management of partial extensor tendon lacerations of the hand and forearm (zones 2-8) and assess surgeons' willingness to randomise in a future trial. METHODS: A 34-item online survey was developed by the steering group and, via a trainee-led collaborative model, was disseminated to plastic and orthopaedic surgeons in the UK. Summary data were calculated for each survey item, and the variations between zones and specialties were explored using linear regression. RESULTS: 142 complete responses were recorded (response rate 71%). On average, respondents said that 46% tendon division was the maximum they would manage in clinical practice without surgical repair. There was no significant difference in this percentage between zones or surgical specialties. Importantly, the majority (83%) of surgeons would be willing to randomise patients in a clinical trial to repair versus no-repair, within 29%-61% tendon division, demonstrating clinical equipoise. CONCLUSIONS: There is significant variation in UK practice regarding the surgical management of partial extensor tendon lacerations of the hand and forearm and clinical equipoise exists regarding the decision to repair or not. A definitive randomised trial is warranted to identify the optimum management of this common injury.
Hip Fracture Intervention Study for Prevention of Hypotension Trial: a Pilot Randomized Controlled Trial.
BACKGROUND: Hypotension during anesthesia for surgery for hip fracture is common and associated with myocardial injury, stroke, acute kidney injury, and delirium. We hypothesized that maintaining intraoperative blood pressure close to patients' preoperative values would reduce these complications compared to usual care. METHODS: A pilot feasibility patient- and assessor-blinded parallel group randomized controlled trial. People with unilateral hip fracture aged ≥70 years with capacity to give consent before surgery were eligible. Participants were allocated at random before surgery to either tight blood pressure control (systolic blood pressure ≥80% preoperative baseline and mean arterial blood pressure ≥75 mm Hg) or usual care. Feasibility outcomes were protocol adherence, primary outcome data completeness, and recruitment rate. The composite primary outcome was myocardial injury, stroke, acute kidney injury or delirium within 7 days of surgery. RESULTS: Seventy-six participants were enrolled, and 12 withdrew before randomization. Sixty-four participants were randomized, 30 were allocated to control, and 34 to intervention. There was no crossover, all 64 participants received their allocated treatment, primary outcome was known for all participants. The composite primary outcome occurred in 14 of 30 participants in the control group compared with 23 of 34 participants in the intervention group (P = .09), relative risk 1.45 (95% confidence interval [CI], 0.93-2.27). CONCLUSIONS: A randomized controlled trial of tight intraoperative blood pressure control compared to usual care to reduce major postoperative complications after fractured neck of femur surgery is possible. However, the data would suggest a large sample size would be required for a definitive trial.
Total joint replacement in sub-Saharan Africa: a systematic review
Outcomes of arthroplasty in sub-Saharan Africa are not widely reported. To our knowledge, this systematic review is the first to explore this topic. Scopus, EMBASE, Medline and PubMed databases were searched, utilising MeSH headings and Boolean search strategies. All papers from South Africa were excluded. Twelve papers reporting 606 total hip replacements (THRs) and 763 total knee replacements (TKRs) were included. Avascular necrosis was the most common indication for THR, whereas osteoarthritis was the main indication for TKR. HIV prevalence of up to 33% was seen. Improvements were seen in patient-reported outcome measures in both THR and TKR. The dislocation rate in THR was 1.6%. The deep infection rate was 1.6% for TKRs and 0.5% for THRs. Positive results were reported, with comparable complications to high-income countries. However, there is likely to be significant reporting bias and the introduction of mandatory registries would enable more accurate monitoring across the region.
Dementia and osteoporosis in a geriatric population: Is there a common link?
AIM To determine the existence of a common pathological link between dementia and osteoporosis through reviewing the current evidence base. METHODS This paper reviews the current literature on osteoporosis and dementia in order to ascertain evidence of a common predisposing aetiology. A literature search of Ovid MEDLINE (1950 to June 2016) was conducted. The keywords "osteoporosis", "osteoporotic fracture", "dementia" and "Alzheimer's disease" (AD) were used to determine the theoretical links with the most significant evidence base behind them. The key links were found to be vitamins D and K, calcium, thyroid disease, statins, alcohol and sex steroids. These subjects were then searched in combination with the previous terms and the resulting papers manually examined. Theoretical, in vitro and in vivo research were all used to inform this review which focuses on the most well developed theoretical common causes for dementia (predominantly Alzheimer's type) and osteoporosis. RESULTS Dementia and osteoporosis are multifaceted disease processes with similar epidemiology and a marked increase in prevalence in elderly populations. The existence of a common link between the two has been suggested despite a lack of clear pathological overlap in our current understanding. Research to date has tended to be fragmented and relatively weak in nature with multiple confounding factors reflecting the difficulties of in vivo experimentation in the population of interest. Despite exploration of various possible mechanisms in search for a link between the two pathologies, this paper found that it is possible that these associations are coincidental due to the nature of the evidence available. One finding in this review is that prior investigation into common aetiologies has found raised amyloid beta peptide levels in osteoporotic bone tissue, with a hypothesis that amyloid beta disorders are systemic disorders resulting in differing tissue manifestations. However, our findings were that the most compelling evidence of a common yet independent aetiology lies in the APOE4 allele, which is a well-established risk for AD but also carries an independent association with fracture risk. The mechanism behind this is thought to be the reduced plasma vitamin K levels in individuals exhibiting the APOE4 allele which may be amplified by the nutritional deficiencies associated with dementia, which are known to include vitamins K and D. The vitamin theory postulates that malnutrition and reduced exposure to sunlight in patients with AD leads to vitamin deficiencies. CONCLUSION Robust evidence remains to be produced regarding potential links and regarding the exact aetiology of these diseases and remains relevant given the burden of dementia and osteoporosis in our ageing population. Future research into amyloid beta, APOE4 and vitamins K and D as the most promising aetiological links should be welcomed.
The biomechanical effect of bone quality and fracture topography on locking plate fixation in periprosthetic femoral fractures
Optimal management of periprosthetic femoral fractures (PFF) around a well fixed prosthesis (Vancouver B1) remains controversial as adequate fixation needs to be achieved without compromising the stability of the prosthesis. The aim of this study was to highlight the effect of bone quality i.e. canal thickness ratio (CTR), and fracture topography i.e. fracture angle and its position in relation to the stem, on the biomechanics of a locking plate for a Vancouver B1 fracture. A previously corroborated simplified finite element model of a femur with a cemented total hip replacement stem was used in this study. Canal thickness ratio (CTR) and fracture topography were altered in several models and the effect of these variations on the von Mises stress on the locking plate as well as the fracture displacement was studied. Increasing the CTR led to reduction of the von Mises stress on the locking plate as well as the fracture movement. In respect to the fracture angle with the medial cortex, it was shown that acute angles resulted in lower von Mises stress on the plate as opposed to obtuse angles. Furthermore, acute fracture angles resulted in lower fracture displacement compared to the other fractures considered here. Fractures around the tip of the stem had the same biomechanical effect on the locking plate. However, fractures more distal to the stem led to subsequent increase of stress, strain, and fracture displacement. Results: highlight that in good bone quality and acute fracture angles, single locking plate fixation is perhaps an appropriate management method. On the contrary, for poor bone quality and obtuse fracture angles alternative management methods might be required as the fixation might be under higher risk of failure. Clinical studies for the management of PFF are required to further support our findings.
Back-carrying infants to prevent developmental hip dysplasia and its sequelae: Is a new public health initiative needed?
Background: Developmental dysplasia of the hip (DDH) is rarely encountered in the native sub-Saharan African population. We present a retrospective review of the incidence of symptomatic DDH in Malawi and a systematic review of the role of back-carrying as a potential influence of prevalence in this population group.
Technical tips and pearls: A simple technique to view radiographs intraoperatively
Since the introduction of computer-based X-ray imaging it has been a source of frustration for theatre staff when X-ray images become obscured by screen savers intra-operatively. We describe a simple technique that allow continuous, uninterrupted radiograph viewing on any windows based computer.
Open reduction internal fixation of lateral humeral condyle fractures in children. A series of 105 fractures from a single institution
Lateral humeral condyle fractures account for 17 % of the distal humeral condyle fractures. Displaced and/or rotated fractures require appropriate reduction and stabilisation. There are, however, a number of controversies in the surgical management of these patients. The aim of the present study was to review the results of patients with a displaced lateral humeral condyle fracture treated with open reduction and internal fixation (ORIF). We retrospectively reviewed children treated with ORIF of lateral humeral condyle fractures at a single institution over a period of 13 years. All cases were identified through the trauma register. Case notes and radiographs were retrieved. Fracture classification, mode of fixation, time to union, and final outcomes at the latest follow-up were reviewed. One hundred and five lateral condyle fractures were identified in 76 male and 29 female patients. Average age was 6.2 years. Ninety-two were Milch type II and 13 Milch type I. According to the Jacob’s classification, 38 were type II and 67 type III. All fractures were treated with open reduction and fixation with K-wires. Average time to radiological union was 33 days. Follow-up ranged between 2 and 8 years (average 3.2 years). Radiological hypertrophy of the lateral condyle was present in 45 cases (42 %). Three patients developed a pseudo-cubitus varus deformity. Further four patients developed a true cubitus varus. There was one case of superficial infection of the K-wires and one case of delayed union. At the latest follow-up, 96 % of the patients achieved an excellent final result and 4 % a good final result. Our results demonstrate that fracture union and excellent final outcomes can be expected in all patients using our protocol, whereby all patients with a displaced fracture are managed by ORIF with K-wire fixation, with the wires only being removed after there is evidence of radiological union. Compared to recent reports of closed reduction internal fixation, this series demonstrates good results with no complications directly relating to the open reduction technique. Level of evidence Case series, Level IV.
Establishing a children’s orthopaedic hospital for Malawi: A review after 10 years
Background: BEIT CURE International Hospital (BCIH) opened in 2002 providing orthopaedic surgical services to children in Malawi. This study reviews the hospital’s progress 10 years after establishment of operational services. In addition we assess the impact of the hospital’s Malawi national clubfoot programme (MNCP) and influence on orthopaedic training. Methods: All operative paediatric procedures performed by BCIH services in the 10th operative year were included. Data on clubfoot clinic locations and number of patients treated were obtained from the MNCP. BCIH records were reviewed to identify the number of healthcare professionals who have received training at the BCIH. Results: 609 new patients were operated on in the 10th year of hospital service. Patients were treated from all regions; however 60% came from Southern regions compared with the 48% in the 5th year. Clubfoot, burn contracture and angular lower limb deformities were the three most common pathologies treated surgically. In total BCIH managed 9,842 patients surgically over a 10-year period. BCIH helped to establish and co-ordinate the MNCP since 2007. At present the program has a total of 29 clinics, which have treated 5748 patients. Furthermore, BCIH has overseen the full or partial training of 5 orthopaedic surgeons and 82 orthopaedic clinical officers in Malawi. Conclusion: The BCIH has improved the care of paediatric patients in a country that prior to its establishment had no dedicated paediatric orthopaedic service, treating almost 10,000 patients surgically and 6,000 patients in the MNCP. This service has remained consistent over a 10-year period despite times of global austerity. Whilst the type of training placement offered at BCIH has changed in the last 10 years, the priority placed on training has remained paramount. The strategic impact of long-term training commitments are now being realised, in particular by the addition of Orthopaedic surgeons serving the nation.
Evaluation of fracture topography and bone quality in periprosthetic femoral fractures: A preliminary radiographic study of consecutive clinical data
The unique configuration of periprosthetic femoral fractures (PFFs) is a major determinant of the subsequent management. The aim of this preliminary study was to investigate potential relationships between fracture angle (FA), fracture level (FL) and bone quality of Vancouver type B PFF. The FA, FL and the canal thickness ratio (CTR) were quantified for 27 patient X-rays. The CTR is an indicator of the underlying bone quality. Relationships between these factors were studied for the whole X-ray set, for a subgroup involving fracture above the tip of the stem and for subgroups with stable and unstable implants. When considering all cases, no significant correlation was found between the FA and any other measurement. Considering only cases with unstable implants, a statistically significant correlation was found between the FA and the FL (R2 = 0.489, p = 0.002). No correlation was found between FA and any other measurement for stable implants suggesting that FA could be considered as an independent factor when classifying B1 fractures. Considering all cases, a weak correlation was found between CTR and FL (R2 = 0.152, p = 0.044) suggesting that fractures below the tip of the stem may indicate a lower bone quality. This preliminary study suggests that the effect of FA on the optimal management of Vancouver type B1 fractures could be considered, independent of the quality of the bone or fracture position. Furthermore, fractures around or below the tip of the stem may suggest a poor bone quality. Larger number of patients is required to confirm these initial findings. © 2013 Elsevier Ltd.
Disease-modifying osteoarthritis drugs: In vitro and in vivo data on the development of DMOADs under investigation
Introduction: Osteoarthritis is a disabling affliction, and disease-modifying osteoarthritis drugs (DMOADs) would be highly desirable adjuncts to symptomatic relief as they may delay the disease process. Areas covered: This study is a comprehensive review of the recent literature on the efficacy of DMOADs in the treatment of OA. In vitro and in vivo evidence was collected using MEDLINE® (1950 to November 2012) and EMBASE (1980 to November 2012) databases. Several drugs have demonstrated DMOAD effects in OA. They can be divided into three groups based on their predominant mode of action: those targeting cartilage, inflammatory pathways and subchondral bone. OARSI guidelines recommend glucosamine and chondroitin sulphates and diacerein as DMOADS, and NICE will recommend glucosamine sulphate in the next update of guidelines. Exploration of improved outcome measures and identification of subgroups of patients most likely to benefit from different DMOADs are likely to be the most important areas of development over the coming years. Expert opinion: It is expected that a wider range of prospective clinical studies will be embarked upon in the coming years. Trials including MRI as well as joint space narrowing (JSN) should be designed in a systematic manner, powered with sufficient numbers to demonstrate clinical benefit at different stages of disease. © 2013 Informa UK, Ltd.
Locking plate fixation for Vancouver B1 periprosthetic femoral fractures: A critical analysis of 135 cases
Purpose: The overall incidence of periprosthetic femoral fractures (PPF) is between 0.1 and 6 % of all total hip arthroplasties. Locking compression plates (LCP) have been used for the treatment of Vancouver B1 PPFs with variable results. The aim of this study is to examine the literature on locking plate failure rates, mode and reasons for failure. Methodology: A literature search was conducted for studies reporting the management of PPF of the femur with LCP fixation. The primary medical search engines used for the study were Ovid MEDLINE and EMBASE databases up to August 2012. Results: Twelve studies were identified, reporting overall union rates of 91 % in 135 fractures. Only 7 (5 %) fractures required revision surgery due to plate fracture (5) or pull out (2). Important trends in plate complications included: stress riser at the end of the plate, stress concentration in the fracture area due to rigid fixation, early loading and absence of cortical strut grafting for biological support when needed. Conclusion: LCP has been used successfully in the management of Vancouver B1 PPF. However, potential areas of improvement include, leaving the fracture site free of locking screws, therefore, not disturbing the soft tissue envelope around the fracture and also reducing plate stiffness. Adding cortical strut allografts to improve stability and bone quality, if needed, may also improve outcome. Limitations in the use of strut grafts or transverse fractures below the tip of the stem that cannot be controlled with single or double plating may require long stem revision to achieve axial stability. © 2013 The Japanese Orthopaedic Association.
Nailed cementoplasty: A salvage technique for rorabeck type II periprosthetic fractures in octogenarians
Periprosthetic femoral fractures around a total knee arthroplasty present a surgical challenge in octogenarians with advanced osteoporosis. We describe a salvage technique combining retrograde intramedullary nailing augmented with polymethylmethacrylate cement in 5 patients followed up for a median time of 12 months. The nail/cement construct bridges the femoral canal tightly and simulates a stemmed cemented revision component. All patients had an uncomplicated recovery and returned to their preinjury functional status within 4 months. This procedure does not disrupt the soft tissue envelope around the fracture site, is easy to perform and permits immediate full range of movement. When standard retrograde nailing or plating alone is inadequate in maintaining severely osteoporotic fracture reduction, nailed cementoplasty is proposed as a salvage procedure in octogenarians unfit for lengthy interventions. © 2010 Elsevier Inc.
Biological therapy of bone defects: The immunology of bone allo-transplantation
Importance of the field: Bone is one of the most transplanted tissues worldwide. Autograft is the ideal bone graft but is not widely used because of donor site morbidity and restricted availability. Allograft is easily accessible but can transmit infections and elicit an immune response. Areas covered in this review: This review identifies all in vitro and in vivo evidence of immune responses following bone transplantation and highlights methods of improving host tolerance to bone allotransplantation. What the reader will gain: In humans, the presence of anti-HLA specific antibodies against freeze-dried and fresh-frozen bone allografts has been demonstrated. Fresh-frozen bone allograft can still generate immune reactions whilst freeze-dried bone allografts present with less immunogenicity but have less structural integrity. This immune response can have an adverse effect on the graft's incorporation and increase the incidence of rejection. Decreasing the immune reaction against the allograft by lowering the immunogenic load of the graft or lowering the host immune response, would result in improved bone incorporation. Take home message: It is essential that the complex biological processes related to bone immunogenicity are understood, since this may allow the development of safer and more successful ways of controlling the outcome of bone allografting. © 2010 Informa UK Ltd.
Investigating the role of PDGF as a potential drug therapy in bone formation and fracture healing
Background: Platelet-derived growth factor (PDGF) has been shown in vivo to increase bone formation and supplement fracture healing, and may have a role as a therapeutic agent in the treatment of bone loss and fracture healing in humans. Objective: A comprehensive review of the recent literature on the effect of PDGF on bone mineral density and fracture healing. Methods: In vitro and in vivo evidence was systematically collected using medical search engines MEDLINE/OVID (1950 to March 2008) and EMBASE (1980 to March 2008) databases. Results/conclusion: Evidence to date suggests that PDGF-BB, and to a lesser extent PDGF-AA, may have potential therapeutic use in the treatment of osteoporosis and bone healing in humans. Additionally, by targeting α-receptors on osteoblasts, a potential anabolic effect on bone metabolism in humans can be anticipated; however, more research needs to be done to assess the role of β-receptors in human bone. © 2009 Informa UK Ltd.
Vertebral osteomyelitis and discitis due to Gardnerella vaginalis
Gardnerella vaginalis is a facultative anaerobic Gram-variable pleomorphic rod that forms part of the normal vaginal flora. It is most commonly associated with infection of the genital tract in women, but recognition of extravaginal G. vaginalis infection is becoming more frequent. We describe an unusual case of G. vaginalis vertebral osteomyelitis and discitis in a 38-year-old woman with no apparent predisposing factors. © 2009 SGM.
Prostaglandin EP2 and EP4 receptor agonists in bone formation and bone healing: In vivo and in vitro evidence
Background: Using agonists that selectively stimulate PGE2 receptors, the adverse effects that have limited the clinical utility of PGE2 can be avoided and there may be potential for their use as therapeutic agents in the treatment of bone loss in humans. Objective: A comprehensive review of the recent literature on the effect of prostaglandins and their agonists on bone mineral density and fracture healing. Methods: In vitro and in vivo evidence was collected using medical search engines MEDLINE® (1950 to March 2008) and EMBASE (1980 to March 2008) databases. Results/conclusion: EP4 receptors have been identified in human osteoblast cell lines and have also been shown to activate osteoblast directly and osteoclast indirectly via osteoblastic activation. Although there are strong in vitro and in vivo collective data indicating that EP2 receptors may have a role in mediating the anabolic effects of PGE2 on bone, to date no functional EP2 receptors have been identified on human osteoblasts or osteoclasts. This suggests that PGE2 effect on bone formation and resorption in humans may be governed by activation of the EP4 receptor on osteoblasts. Selective EP4 receptor agonists may therefore provide therapeutic potential for systemic use in the treatment of osteoporosis and fracture healing. Further studies need to be carried out in order fully elicit the role of EP2 receptor agonists in fracture healing and bone formation in humans. © 2009 Informa UK Ltd. All rights reserved.
An unusual periarticular fracture following ipsilateral anterior cruciate ligament reconstruction
We report an unusual pattern of a peri and intra-articular knee fracture following ACL reconstruction. The pattern of injury was opposite to the graft tunnels which contradicts the well established iatrogenic stress riser theory which has been extensively described in the literature. The fractures were reduced anatomically by open means, the graft was found intact and preserved and the fractures were fixed internally protecting the graft and the tunnels. The patient made an uneventful recovery and the post operative MRI scan 12 months later demonstrated bone healing and an intact ACL. When the ACL graft is found intact in this type of injury, the fracture should be fixed around it taking care not to jeopardize its integrity or the tunnels. © 2008 Springer-Verlag.
Statins: Under investigation for increasing bone mineral density and augmenting fracture healing
Background: Statins are 3-hydroxy-3-methylglutaryl (HMG)-CoA reductase inhibitors and have been shown to possess anti-lipidaemic properties effective in lowering cholesterol. Recent evidence has suggested beneficial pleiotropic effects, including that of fracture healing, alongside its widely accepted ability to reduce the incidence of cardiovascular disease. Objectives: A comprehensive review of the recent literature on the effect of statins on bone mineral density and fracture healing. Methods: Medline/Ovid and EMBASE search and manual search of bibliography of key papers, on the effects of statins on bone metabolism including in vitro and in vivo studies, as well as clinical trials on the effects of statins on bone mineral density and fracture risk. Results/conclusions: There is robust in vitro and in vivo evidence to suggest the anabolic effects of statins on bone metabolism. Although evidence in patients with osteoporosis is conflicting, several studies have shown that the use of statins is associated with increases in bone mass density and reduction in fracture risk. Conflicting studies identified may be due to different routes of administration, types of statins employed and low doses used. Taken together, there is strong evidence to suggest that statins have beneficial effects on fracture healing that would support further clinical trials investigating such properties. © 2008 Informa UK Ltd.
The effect of β-blockers on bone metabolism as potential drugs under investigation for osteoporosis and fracture healing
Background: β-Adrenergic receptor antagonists (β-blockers) have a well-recognised antihypertensive action that is mediated through a reduction in cardiac output and in the release of renin from the kidneys and inhibition of the action of endogenous catecholamines on β-adrenergic receptors. This class of drugs has been shown to reduce the incidence of cardiovascular disease. Recent evidence suggests that β-blockers may also have an effect on bone structure, metabolism and fracture healing. Objective: This paper reviews in vitro and in vivo data that suggest β-blockers have primarily an anabolic effect on bone metabolism. Results: The sympathetic nervous system has a catabolic effect on bone, and in vitro studies have shown that adrenergic agonists stimulate bone resorption. The β-blocker propranolol has been shown to increase bone formation in ovariectomised female rats. Also, recent observational clinical studies provide evidence to show that β-blockers are associated with reduction in fracture risk in both men and women. Conclusion: Although there are some controversial studies, most research concludes that β-blockers show promise in the treatment of osteoporosis and fracture healing. © 2008 Informa UK Ltd.