The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison.Objectives
Methods
The aim of this study was to assess the role
of synovial C-reactive protein (CRP) in the diagnosis of chronic periprosthetic
hip infection. We prospectively collected synovial fluid from 89
patients undergoing revision hip arthroplasty and measured synovial
CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white
blood cell (WBC) count and synovial percentages of polymorphonuclear
neutrophils (PMN). Patients were classified as septic or aseptic
by means of clinical, microbiological, serum and synovial fluid
findings. The high viscosity of the synovial fluid precluded the
analyses in nine patients permitting the results in 80 patients
to be studied. There was a significant difference in synovial CRP
levels between the septic (n = 21) and the aseptic (n = 59) cohort.
According to the receiver operating characteristic curve, a synovial
CRP threshold of 2.5 mg/l had a sensitivity of 95.5% and specificity
of 93.3%. The area under the curve was 0.96. Compared with serum
CRP and ESR, synovial CRP showed a high diagnostic value. According
to these preliminary results, synovial CRP may be a useful parameter
in diagnosing chronic periprosthetic hip infection. Cite this article:
Instability is a common indication for early
revision after both primary and revision total knee arthroplasty
(TKA), accounting for up to 20% in the literature. The number of
TKAs performed annually continues to climb exponentially, thus having
an effective algorithm for treatment is essential. This relies on
a thorough pre- and intra-operative assessment of the patient. The
underlying cause of the instability must be identified initially
and subsequently, the surgeon must be able to balance the flexion
and extension gaps and be comfortable using a variety of constrained
implants. This review describes the assessment of the unstable TKA, and
the authors’ preferred form of treatment for these difficult cases
where the source of instability is often multifactorial. Cite this article:
Venous thromboembolism (VTE) is a major potential complication following orthopaedic surgery. Subcutaneously administered enoxaparin has been used as the benchmark to reduce the incidence of VTE. However, concerns have been raised regarding the long-term administration of enoxaparin and its possible negative effects on bone healing and bone density with an increase of the risk of osteoporotic fractures. New oral anticoagulants such as rivaroxaban have recently been introduced, however, there is a lack of information regarding how these drugs affect bone metabolism and post-operative bone healing. We measured the migration and proliferation capacity of mesenchymal stem cells (MSCs) under enoxaparin or rivaroxaban treatment for three consecutive weeks, and evaluated effects on MSC mRNA expression of markers for stress and osteogenic differentiation.Objectives
Methods
Previous standards for assessing the reliability
of a measurement tool have lacked consistency. We reviewed the most
current American Society for Testing and Materials and International
Organisation for Standardisation (ISO) recommendations, and propose
an algorithm for orthopaedic surgeons. When assessing a measurement
tool, conditions of the experimental set-up and clear formulae used
to compile the results should be strictly reported. According to
these recent guidelines, accuracy is a confusing word with an overly
broad meaning and should therefore be abandoned. Depending on the
experimental conditions, one should be referring to bias (when the study
protocol involves accepted reference values), and repeatability
(sr, r) or reproducibility (SR, R). In the absence of accepted reference
values, only repeatability (sr, r) or reproducibility (SR, R) should
be provided. Take home message: Assessing the reliability of a measurement
tool involves reporting bias, repeatability and/or reproducibility
depending on the defined conditions, instead of precision or accuracy. Cite this article:
The Nottingham Hip Fracture Score (NHFS) was
developed to assess the risk of death following a fracture of the
hip, based on pre-operative patient characteristics. We performed
an independent validation of the NHFS, assessed the degree of geographical
variation that exists between different units within the United
Kingdom and attempted to define a NHFS level that is associated
with high risk of mortality. The NHFS was calculated retrospectively for consecutive patients
presenting with a fracture of the hip to two hospitals in England.
The observed 30-day mortality for each NHFS cohort was compared
with that predicted by the NHFS using the Hosmer–Lemeshow test.
The distribution of NHFS in the observed group was compared with
data from other hospitals in the United Kingdom. The proportion
of patients identified as high risk and the mortality within the
high risk group were assessed for groups defined using different
thresholds for the NHFS. In all 1079 hip fractures were included in the analysis, with
a mean age of 83 years (60 to 105), 284 (26%) male. Overall 30-day
mortality was 7.3%. The NHFS was a significant predictor of 30-day
mortality. Statistically significant differences in the distribution
of the NHFS were present between different units in England (p <
0.001). A NHFS ≥ 6 appears to be an appropriate cut-point to identify
patients at high risk of mortality following a fracture of the hip. Cite this article:
The term mid-flexion instability has entered
the orthopaedic literature as a concept, but has not been confirmed
as a distinct clinical entity. The term is used freely, sometimes
as a synonym for flexion instability. However, the terms need to
be clearly separated. A cadaver study published in 1990 associated
joint line elevation with decreased stability at many angles of
flexion, but that model was not typical of clinical scenarios. The
literature is considered and it is proposed that the more common
entity of an uncorrected flexion contracture after a measured resection arthroplasty
technique is more likely to produce clinical findings that suggest
instability mid-flexion. It is proposed that the clinical scenario encountered is generalised
instability, with the appearance of stability in full extension
from tight posterior structures. This paper seeks to clarify whether mid-flexion instability exists
as an entity distinct from other commonly recognised forms of instability. Cite this article:
The December 2015 Research Roundup360 looks at: Biomarkers in periprosthetic joint infection; HbA1c and complications in arthroplasty; Getting to the bottom of biofilms; Effective antibiosis for biofilms; Stem cells and avascular necrosis; Predicting LOS in total joint arthroplasty; Long-term antibiotics reduce recurrence in periprosthetic infection
The purpose of this study was to refine an accepted contaminated
rat femur defect model to result in an infection rate of approximately
50%. This threshold will allow examination of treatments aimed at
reducing infection in open fractures with less risk of type II error. Defects were created in the stablised femurs of anaethetised
rats, contaminated with Objectives
Methods
This study identifies early risk factors for symptomatic nonunion
of displaced midshaft fractures of the clavicle that aid identification
of an at risk group who may benefit from surgery. We performed a retrospective study of 88 patients aged between
16 and 60 years that were managed non-operatively. Aims
Methods
Assessment of skeletal age is important in children’s
orthopaedics. We compared two simplified methods used in the assessment
of skeletal age. Both methods have been described previously with
one based on the appearance of the epiphysis at the olecranon and
the other on the digital epiphyses. We also investigated the influence
of assessor experience on applying these two methods. Our investigation was based on the anteroposterior left hand
and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1
) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal
growth spurt. A total of nine observers examined the radiographs
with the observers assigned to three groups based on their experience (experienced,
intermediate and novice). These raters were required to determined
skeletal ages twice at six-week intervals. The correlation between
the two methods was determined per assessment and per observer groups. Interclass
correlation coefficients (ICC) evaluated the reproducibility of
the two methods. The overall correlation between the two methods was r = 0.83
for boys and r = 0.84 for girls. The correlation was equal between
first and second assessment, and between the observer groups (r ≥ 0.82).
There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%)
and observer effect (ICC ≤ 3%) for each method. There was no significant
(p <
0.05) difference between the levels of experience. The two methods are equally reliable in assessing skeletal maturity.
The olecranon method offers detailed information during the pubertal
growth spurt, while the digital method is as accurate but less detailed,
making it more useful after the pubertal growth spurt once the olecranon
has ossified. Cite this article:
We explore the limitations of complete reliance
on evidence-based medicine which can be diminished by confounding
issues and sampling bias. Other strategies which may be reasonably
invoked are discussed. Cite this article:
We report the five-year outcome of a randomised
controlled trial which used radiostereometric analysis (RSA) to assess
the influence of surface oxidised zirconium (OxZr, Oxinium) on polyethylene
wear A total of 120 patients, 85 women and 35 men with a mean age
of 70 years (59 to 80) who were scheduled for primary cemented total
hip arthroplasty were randomly allocated to four study groups. Patients
were blinded to their group assignment and received either a conventional
polyethylene (CPE) or a highly cross-linked (HXL) acetabular component
of identical design. On the femoral side patients received a 28
mm head made of either cobalt-chromium (CoCr) or OxZr. The proximal head penetration (wear) was measured with repeated
RSA examinations over five years. Clinical outcome was measured
using the Harris hip score. There was no difference in polyethylene wear between the two
head materials when used with either of the two types of acetabular
component (p = 0.3 to 0.6). When comparing the two types of polyethylene
there was a significant difference in favour of HXLPE, regardless
of the head material used (p <
0.001). In conclusion, we found no advantage of OxZr over CoCr in terms
of polyethylene wear after five years of follow-up. Our findings
do not support laboratory results which have shown a reduced rate
of wear with OxZr. They do however add to the evidence on the better
resistance to wear of HXLPE over CPE. Cite this article:
Percutaneous placement of pedicle screws is a
well-established technique, however, no studies have compared percutaneous
and open placement of screws in the thoracic spine. The aim of this
cadaveric study was to compare the accuracy and safety of these
techniques at the thoracic spinal level. A total of 288 screws were
inserted in 16 (eight cadavers, 144 screws in percutaneous and eight
cadavers, 144 screws in open). Pedicle perforations and fractures
were documented subsequent to wide laminectomy followed by skeletalisation
of the vertebrae. The perforations were classified as grade 0: no
perforation, grade 1: <
2 mm perforation, grade 2: 2 mm to 4
mm perforation and grade 3: >
4 mm perforation. In the percutaneous
group, the perforation rate was 11.1% with 15 (10.4%) grade 1 and
one (0.7%) grade 2 perforations. In the open group, the perforation
rate was 8.3% (12 screws) and all were grade 1. This difference
was not significant (p = 0.45). There were 19 (13.2%) pedicle fractures
in the percutaneous group and 21 (14.6%) in the open group (p =
0.73). In summary, the safety of percutaneous fluoroscopy-guided
pedicle screw placement in the thoracic spine between T4 and T12
is similar to that of the conventional open technique. Cite this article:
Hip displacement, defined in this study as a
migration percentage (MP) of more than 40%, is a common, debilitating complication
of cerebral palsy (CP). In this prospective study we analysed the
risk of developing hip displacement within five years of the first
pelvic radiograph. All children with CP in southern and western Sweden are invited
to register in the hip surveillance programme CPUP. Inclusion criteria
for the two groups in this study were children from the CPUP database
born between 1994 and 2009 with Gross Motor Function Classification
System (GMFCS) III to V. Group 1 included children who developed
hip displacement, group 2 included children who did not develop
hip displacement over a minimum follow-up of five years. A total
of 145 children were included with a mean age at their initial pelvic
radiograph of 3.5 years (0.6 to 9.7). The odds ratio for hip displacement was calculated for GMFCS-level,
age and initial MP and head-shaft angle. A risk score was constructed
with these variables using multiple logistic regression analysis.
The predictive ability of the risk score was evaluated using the
area under the receiver operating characteristics curve (AUC). All variables had a significant effect on the risk of a MP >
40%. The discriminatory accuracy of the CPUP hip score is high (AUC
= 0.87), indicating a high ability to differentiate between high-
and low-risk individuals for hip displacement. The CPUP hip score
may be useful in deciding on further follow-up and treatment in
children with CP. Cite this article:
The accurate assessment of skeletal maturity
is essential in the management of orthopaedic conditions in the growing
child. In order to identify the time of peak height velocity (PHV)
in adolescents, two systems for assessing skeletal maturity have
been described recently; the calcaneal apophyseal ossification method
and the Sanders hand scores. The purpose of this study was to compare these methods in assessing
skeletal maturity relative to PHV. We studied the radiographs of
a historical group of 94 healthy children (49 females and 45 males),
who had been followed longitudinally between the ages of three and
18 years with serial radiographs and physical examination. Radiographs
of the foot and hand were undertaken in these children at least
annually between the ages of ten and 15 years. We reviewed 738 radiographs
of the foot and 694 radiographs of the hand. PHV was calculated
from measurements of height taken at the time of the radiographs. Prior to PHV we observed four of six stages of calcaneal apophyseal
ossification and two of eight Sanders stages. Calcaneal stage 3
and Sanders stage 2 was seen to occur about 0.9 years before PHV,
while calcaneal stage 4 and Sanders stage 3 occurred approximately
0.5 years after PHV. The stages of the calcaneal and Sanders systems can be used in
combination, offering better assessment of skeletal maturity with
respect to PHV than either system alone. Cite this article:
We investigated whether the indentation of bone
cement spacers used in revision of infected joint arthroplasty with a
MacDonald dissector increased the elution of antibiotic The fluid sampled at 72 hours from the indented discs containing
0.17 g gentamicin (0.88% w/w) contained a mean of 113 mcg/ml (90.12
to 143.5) compared with 44.5 mcg/ml (44.02 to 44.90) in the fluid
sampled from the plain discs (p = 0.012). In discs containing 0.33
g gentamicin (1.75% w/w), the concentration eluted from the indented discs
at 72 hours was a mean of 316 mcg/ml (223 to 421) compared with
a mean of 118 mcg/ml (100 to 140) from the plain discs (p <
0.001). At two weeks, these significant differences persisted. At nine
weeks the indented discs eluted a greater concentration for all
gentamicin doses, but the difference was only significant for the
discs containing 0.17 g (0.88% w/w, p = 0.006). However if the area
under the curve is taken as a measure of the total antibiotic eluted,
the indented discs eluted more gentamicin than the plain discs for
the 0.17 g (0.88% w/w, p = 0.031), the 0.25 g (1.41% w/w, p <
0.001) and the 0.33 g (1.75% w/w, p <
0.001) discs. When preparing antibiotic spacers for use in staged revision
arthroplasty surgery we recommend indenting the spacer with a MacDonald
dissector to increase the elution of antibiotic. Cite this article:
