Recent Submissions

  • Is it safe for extended-role radiographers to measure migration percentage in children with cerebral palsy?.

    Oakley, BJ; Srinivasan, Sreebala C. M.; Srivatsan, S (Radiography, 2020-11)
    Introduction In the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration.The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals. Results The inter-rater reliability between radiographers was 0.938 (95% CI 0.914–0.991). The intra-rater reliability was 0.941 (95% CI 0.931–0.949).The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889–0.957). Conclusion The reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy. Implications for practice We recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.
  • Adding evidence of the effects of treatments into relevant wikipedia pages: a randomised trial

    Chatterjee-Woolman, Suravi (BMJ Evidence-Based Medicine, 2022-07)
    Background Wikipedia is among the most popular sites on the internet, and around a fifth of all healthcare searches online directs to a Wikipedia page. In recent years steps have been taken to enhance the quality of their healthcare pages, such as the creation of the WikiProject Medicine initiative. In 2014 a partnership was formalised between Wikipedia and Cochrane Collaboration with similar aims. Three years ago, a group of medical students helped to formulate a protocol for the first ever randomised trial, whose aim was to test the value of Wikipedia in informing users about healthcare. Objectives To investigate the effects of adding high-grade quantitative evidence of outcomes of treatments into relevant Wikipedia pages on further information-seeking behaviour by the end-user. Methods: We randomised 70 Wikipedia pages, identified as highly relevant to up-to-date Cochrane Schizophrenia systematic reviews that contained a Summary of Findings table. Eligible Wikipedia pages in the intervention group (35) were seeded with tables listing best evidence of the effects of treatment, and hyperlinks to the source Cochrane review. Eligible pages in the control group (35) remained unchanged. Results The main outcome measures were routinely collected data on access to the full text and summary web page of the relevant Cochrane reviews (after 12 months). There was 100% follow-up of the 70 randomised pages. Six of the 35 in the intervention group had the tabular format deleted by other Wikipedia users during the course of the study, but all pages continued to report the same data within the text. The study found no evidence of significant effect on either of the co-primary outcomes: full text access adjusted ratio of geometric means 1.30, 95% CI: 0.71 to 2.38; page views 1.14, 95% CI: 0.6 to 2.13. Results were similar for all other outcomes, with the exception of Altmetric score for which there was evidence of clear effect (1.36, 95% CI: 1.05 to 1.78). Conclusions The pursuit of fair balance within Wikipedia healthcare pages is impressive and its reach unsurpassed. Enriching Wikipedia content is, potentially, a powerful way to improve health literacy among the public, and it is possible to test the effects of seeding pages with evidence. Though increased traffic to Cochrane reviews in the intervention group lacked statistical significance, there was nonetheless consistently an increase in all outcome measures. For every person that sought and clicked the reference on the 'intervention' Wikipedia page to seek more information (the primary outcome), many more are likely to have been informed by the page alone; the inclusion of high-quality data may have lessened the desire to click out to the original source. If demonstrated that the end-user becomes more informed as a result of such intervention, the potential as a tool for dissemination could be invaluable. Future studies should take such factors into consideration, and aim to replicate, expand and further develop our trial. Trial registration number IRCT2017070330407N2
  • A prospective study of two methods of analgesia in shoulder arthroscopic procedures as day case surgery

    Goel, Vivek (2020-05)
    Background & purpose: The recent advances in anaesthesia and analgesia have significantly improved the early recovery and effective post-operative pain control in day care surgery e.g. shoulder arthroscopic procedures. Adequate analgesia improves the early rehabilitation for a better outcome. We prospectively evaluated the post-operative pain relief following the two methods of analgesia i.e. regional Inter-scalene block (ISB) vs Intra-articular (IA) injection using 0.5% Chirocaine in various therapeutic arthroscopic shoulder procedures. Methods: A prospective comparative study was performed on a group of 105 patients (ASA grade I or II) who underwent the following procedures at two different hospitals: diagnostic arthroscopy, subacromial decompression (SAD) alone, SAD in combination with mini open cuff repairs or distal clavicle excision, anterior stabilization (Bankart's repair) and inferior capsular shift. A successful Inter-scalene block (0.5% Chirocaine-30mls) preceded the general anaesthesia (Group 1-52 patients). Local intra-articular infiltration (0.5% Chirocaine - 20 mls) was given postoperatively (Group 2-53 patients). Post operatively visual analogue scores (VAS) from 0 (no pain) to 10 (severe pain) were assessed in post-anaesthesia care unit (PACU), at 4hrs, at 24hrs and at 48 h. The amount of morphine consumption for the first 2 days after surgery was recorded. Results: Patient characteristics were similar in both groups at both the hospitals. The median postoperative pain score of VAS <3 was observed in both groups. Significant difference (p < 0.0001) was observed in the VAS scores between the two groups at all the time intervals. The mean length of adequate sensory block in group 1 was significantly higher than in group 2 [20.5 h: 4.2 h] (p < 0.001). The mean analgesic (morphine) consumption was lower in Group 1 as compared to Group 2 [4.6 mg/24 h: 18.8mg/24 h](p < 0.0001). Bone shaving procedures e.g. SAD, SAD + Rotator Cuff repair, SAD + Lateral clavicular excision required significantly higher analgesia in both groups compared to the soft tissue procedures. Conclusion: Single dose ISB provided longer and effective postoperative analgesia. The bone shaving procedures required more analgesia in IA Group as compared to ISB Group.
  • Radiofrequency denervation of the lumbar facet joints: guidelines for the RADICAL randomised controlled trial

    Veemarajan, Bala (2021-08)
    Background and aim: The RADICAL trial has been funded by the National Institute for Health Research (NIHR) to evaluate the clinical and cost-effectiveness of radiofrequency denervation (RFD) for low back pain. Recommendations have been published which aim to standardise selection of patients and RFD technique. However, it is important to ensure these recommendations are acceptable to clinicians within the context of the trial. The aim of this work was to develop standardised criteria for the trial entry and RFD technique for implementation within the RADICAL trial. Methods: Fourteen pain clinicians completed a survey, which involved reviewing the current recommendations and indicating whether they disagreed with any of the recommendations and if so why. Responses were collated and presented at a half-day workshop with 14 attendees. During the workshop, the National Low Back and Radicular Pain Pathway (NLBRPP) guidelines for patient selection and an article by Eldabe and colleagues presenting recommendations on the RFD technique were reviewed. Attendees discussed whether each component of the recommendations should be mandatory, mandatory with alteration or clarification or optional within the RADICAL trial. Results: Attendees agreed during the workshop that 5 of the 10 criteria for patient selection described in the NLBRPP should be mandatory within the RADICAL trial. Three were agreed as mandatory criteria but required further clarification, one of which involved defining a positive response to a diagnostic medial branch block as ⩾60% pain relief. Two criteria had optional components. After reviewing the recommendations on the RFD technique from Eldabe and colleagues, seven components were agreed as mandatory, three were mandatory with alterations and three were optional. Conclusion: When evaluating complex interventions, such as RFD, it is important to ensure agreement and clarity on the clinical protocol, so that the intervention can be reproduced, if found to be effective.
  • Low trauma posterior native hip dislocation with acute longitudinal transverse myelitis due to SARS-CoV-2 - A case-report

    Pandya, Chiraag; Sangoi, Dhrumin; Badhe, Sachin (2021-08)
    Background: Native hip dislocations are most commonly seen after high energy trauma. While there are documented cases of hip dislocation with associated stroke, we present a case of posterior hip dislocation in the context of acute longitudinal transverse myelitis due to a rare presentation of SARS-CoV-2. Case report: A 60-year-old male presented with bilateral lower limb weakness with a shortened internally rotated left leg. Plain radiographs revealed a posteriorly dislocated native left hip and MRI of the spine showed acute longitudinal transverse myelitis of the cervical and thoracic regions. His nasopharyngeal swab was positive for SARS-CoV-2. His hip was reduced, and he was treated with intravenous steroids. His neurological symptoms improved with follow-up MRI showing resolution of the transverse myelitis. Conclusion: This case illustrates a classic orthopaedic emergency in the context of a rare presentation of SARS-CoV-2, and the vigilance that orthopaedic doctors must have when examining patients with lower limb neurological deficit.
  • Does Patellar Resurfacing Matter? Midterm Follow-Up of MRK Total Knee Replacement

    Sangoi, Dhrumin; Gokhale, Nikhil; Kothari, Paresh; Kulkarni, Sushrut (2020-09)
    Background: Many designs of TKR have been developed to optimize the kinematics and improve satisfaction, including the 'medial rotating' philosophy. The purpose of this study is to report the mid-term clinical outcome of MRK knees and evaluate whether resurfacing the patella makes any difference in outcome. Methods: A retrospective analysis was done of 104 MRK total knee replacement done between 2008 and 2017. Patients were called for a review for evaluation of OKS, Baldini and Feller scores. Demographics of the patients, clinical outcome, complications were assessed. Results: 62 had patellar resurfacing. Mean follow-up was 74.45 months in non- resurfaced and 54.93 months in resurfaced group. Mean flexion range in both groups at final follow-up was 101.45. Median OKS at follow-up was 36 (12-47) in non-resurfaced and 37 (9-48) in resurfaced group. Patella scores were better in resurfaced group-Baldini score median (range) was 90 (25-100) in non-resurfaced v/s 100 (30-100) in resurfaced, Feller score median (range) was 25 (12-30) in non-resurfaced v/s 28 (10-30) (p 0.042) in resurfaced. The patellofemoral component of the OKS (Q5 + Q7 + Q12) median showed an improvement from 3 (1-11) to 6.5 (3-11) in non-resurfaced and from 3 (0-12) to 8 (2-12) (p 0.039) in resurfaced group. There were five complications overall (4.8%). Conclusion: These results show a satisfactory outcome at mid-term follow-up. We found a statistically significant difference in Feller score and in the patellofemoral component of OKS between the groups of MRK knee suggesting specific benefits of patellar resurfacing with this implant.
  • Bilateral traumatic distal femoral transphyseal fracture in a 9-year-old male

    Davis, Timothy P (Journal of Surgical Case Reports, 2021-01)
    A case of bilateral traumatic distal femoral Salter-Harris Type I fracture presented to our emergency department. History was of a 9-year-old male playing at a building site when a concrete block fell from height on to his knees, which were extended in a sitting position. Management was with analgesia and transfer to theatre followed by closed reduction and internal fixation-position was assessed under mobile X-ray. The patient made a full clinical recovery within 18 weeks and was followed-up over 5 years. There was no clinical effect on final adult length of femur and no deficit in range of movement. The foot-drop observed at presentation resolved over a period of 12 weeks. This case highlights the importance of performing a thorough neurovascular examination of the patient at presentation, followed by a careful closed reduction and internal fixation under anaesthesia, being careful not to damage the distal femoral growth plates.
  • Rehabilitation following proximal humeral fracture in the UK National Health Service: A survey of publicly facing information

    Rohun, Jason (2021)
    Introduction Proximal humeral fractures (PHF) are a common injury in the older population but there is limited research evaluating rehabilitation following PHF. The aim of this study was to understand current National Health Service (NHS) practice for rehabilitation following PHF as a platform for conducting future research. Methods Two reviewers independently undertook electronic searches for publicly available information sheets (PIS) from websites of NHS Trusts that included detail about rehabilitation following PHF, for example, duration of immobilisation. One reviewer extracted data and a second reviewer verified this. Results Seventeen PIS from 17 different NHS trusts were identified. All provided some information on the method of immobilisation but only six provided guidance on duration of immobilisation with the median time being 2 weeks (range 0–6). The median time to commencement of passive exercise was 2 weeks (range 0–4) and 9 weeks (range 6–12) for active exercise. Only one PIS reported on the time for commencement of resisted exercises and this was reported as 6 weeks. The median time recommended return to work was 7.5 weeks (range 6–12). Conclusion This study found limited publicly available information for rehabilitation following PHF in the NHS but offers some insight into current approaches. Our results will facilitate development of relevant information for patients and evaluation of rehabilitation strategies in future research.
  • Adding evidence of the effects of treatments into relevant Wikipedia pages: a randomised trial.

    Chatterjee-Woolman, Suravi (, 2020-02)
    Objectives: To investigate the effects of adding high-grade quantitative evidence of outcomes of treatments into relevant Wikipedia pages on further information-seeking behaviour by the use of routinely collected data. Setting: Wikipedia, Cochrane summary pages and the Cochrane Library. Design: Randomised trial. Participants: Wikipedia pages which were highly relevant to up-to-date Cochrane Schizophrenia systematic reviews that contained a Summary of Findings table. Interventions: Eligible Wikipedia pages in the intervention group were seeded with tables of best evidence of the effects of care and hyperlinks to the source Cochrane review. Eligible Wikipedia pages in the control group were left unchanged. Main Outcome Measures: Routinely collected data on access to the full text and summary web page (after 12 months). Results: We randomised 70 Wikipedia pages (100% follow-up). Six of the 35 Wikipedia pages in the intervention group had the tabular format deleted during the study but all pages continued to report the same data within the text. There was no evidence of effect on either of the coprimary outcomes: full-text access adjusted ratio of geometric means 1.30, 95% CI: 0.71 to 2.38; page views 1.14, 95% CI: 0.6 to 2.13. Results were similar for all other outcomes, with exception of Altmetric score for which there was some evidence of clear effect (1.36, 95% CI: 1.05 to 1.78). Conclusions: The pursuit of fair balance within Wikipedia healthcare pages is impressive and its reach unsurpassed. For every person who sought and clicked the reference on the 'intervention' Wikipedia page to seek more information (the primary outcome), many more are likely to have been informed by the page alone. Enriching Wikipedia content is, potentially, a powerful way to improve health literacy and it is possible to test the effects of seeding pages with evidence. This trial should be replicated, expanded and developed.
  • An infective cause for the limping child.

    Uzoho, Chukwudi; Desai, Vikram (2019-09)
    A 7-year-old girl presented with left hip pain and a limp, in the absence of any other systemic features, having recently been treated for a urinary tract infection. Examination revealed limited active hip movements on the left, with a tendency to weight bear on the contralateral side. Biochemical investigations were significant for raised inflammatory markers, and subsequent MRI imaging revealed osteomyelitis of the left pubis and ischium with an associated large soft tissue collection. Treatment was bimodal with surgical drainage and long-term antibiotics. The patient consequently recovered, without significant effect on either growth or mobility. (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)
  • The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial.

    Desai, Vikram (2019-07-17)
    BACKGROUND: Late-stage isolated medial knee osteoarthritis can be treated with total knee replacement (TKR) or partial knee replacement (PKR). There is high variation in treatment choice and little robust evidence to guide selection. The Total or Partial Knee Arthroplasty Trial (TOPKAT) therefore aims to assess the clinical effectiveness and cost-effectiveness of TKR versus PKR in patients with medial compartment osteoarthritis of the knee, and this represents an analysis of the main endpoints at 5 years. METHODS: Our multicentre, pragmatic randomised controlled trial was done at 27 UK sites. We used a combined expertise-based and equipoise-based approach, in which patients with isolated osteoarthritis of the medial compartment of the knee and who satisfied general requirements for a medial PKR were randomly assigned (1:1) to receive PKR or TKR by surgeons who were either expert in and willing to perform both surgeries or by a surgeon with particular expertise in the allocated procedure. The primary endpoint was the Oxford Knee Score (OKS) 5 years after randomisation in all patients assigned to groups. Health-care costs (in UK 2017 prices) and cost-effectiveness were also assessed. This trial is registered with ISRCTN (ISRCTN03013488) and (NCT01352247). FINDINGS: Between Jan 18, 2010, and Sept 30, 2013, we assessed 962 patients for their eligibility, of whom 431 (45%) patients were excluded (121 [13%] patients did not meet the inclusion criteria and 310 [32%] patients declined to participate) and 528 (55%) patients were randomly assigned to groups. 94% of participants responded to the follow-up survey 5 years after their operation. At the 5-year follow-up, we found no difference in OKS between groups (mean difference 1.04, 95% CI -0.42 to 2.50; p=0.159). In our within-trial cost-effectiveness analysis, we found that PKR was more effective (0.240 additional quality-adjusted life-years, 95% CI 0.046 to 0.434) and less expensive (- pound910, 95% CI -1503 to -317) than TKR during the 5 years of follow-up. This finding was a result of slightly better outcomes, lower costs of surgery, and lower follow-up health-care costs with PKR than TKR. INTERPRETATION: Both TKR and PKR are effective, offer similar clinical outcomes, and result in a similar incidence of re-operations and complications. Based on our clinical findings, and results regarding the lower costs and better cost-effectiveness with PKR during the 5-year study period, we suggest that PKR should be considered the first choice for patients with late-stage isolated medial compartment osteoarthritis.
  • Limited capsular release and controlled manipulation under anaesthesia for the treatment of frozen shoulder.

    Bidwai, Amit S. (2016-01)
    Background In light of recent interest in the cost-effectiveness of the treatment options available for frozen shoulder, we aimed to determine the results of limited anterior capsular release and controlled manipulation under anaesthesia (MUA) in the treatment of primary frozen shoulder in terms of patient-related outcomes measure, range of motion and re-intervention rates. Methods This single-surgeon series included prospectively collected data on all patients undergoing capsular release with MUA from March 2011 until June 2013, with a minimum follow-up of 6 months from the index procedure. Outcome measures included pre- and postoperative Oxford Shoulder Score (OSS), range of motion and need for re-intervention. Results Fifty-four procedures were performed in 52 patients. Mean age 50 years (range 42 years to 59 years); male: female ratio = 11: 41. There was a highly statistically significant improvement in both pain and function modules of the OSS (p < 0.005) and range of motion (p < 0.005) at 6 months. The median postoperative score was 41 from a maximum of 48 points, with an average mean improvement of 24 points. Seventeen patients were diabetics. There was no significant difference in pre-operative and postoperative OSS or range of motion between the diabetic group and the non-diabetic groups. No patients required surgical re-intervention. Conclusions A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion.
  • Clinical Outcomes of the Modified Broström Technique in the Management of Chronic Ankle Instability After Early, Intermediate, and Delayed Presentation.

    Hassan, Sami; Sian, Tanvir; Shah, Rohi; Aziz, Abdul; Kothari, Paresh (2018-07)
    The modified Broström technique (MBT) is considered the reference standard for surgical management of ankle instability, with good short-term outcomes. However, limited evidence is available regarding outcomes for delayed presentations of instability. We report our outcomes for patients who underwent ligament repair using the MBT, from a single-surgeon retrospective study of consecutive patients. The minimum postoperative follow-up period was 6 months during a 5-year study period. The patients were retrospectively divided into 3 groups according to the delay in presentation: group 1, 6 months to 2 years; group 2, 2 to 4 years; and group 3, >4 years. We collected data on patient demographics, injury pattern, and intraoperative surgeon findings. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (AHS) was used to evaluate patient outcomes and satisfaction with surgery. Twenty-six patients were treated with MBT. The mean follow-up period was 36.9 (range 6-42) months. Twenty-five (96.2%) patients had unilateral injuries, and 1 (3.85%) had bilateral repairs. Of the 26 patients, 21 (80.8%) completed the AOFAS-AHS, with a mean score of 87.4 (range 12 to 100). The mean interval from injury to surgery was 47.9 months. The results were excellent in 15 (71.4%), good in 3 (14.3%), fair in 1 (4.8%), and poor in 2 (9.5%) using the AOFAS-AHS. We found no significant difference in the overall AOFAS-AHS score or postoperative satisfaction among the groups (p > .05). All patients had a stable ankle joint at their final follow-up visit. In conclusion, patients with persistent or chronic ankle instability have good clinical outcomes and satisfaction after the MBT, irrespective of the time from injury to presentation.
  • Midterm results with Birmingham Hip Resurfacing/Synergy stem modular metal-on-metal total hip arthroplasty.

    Srinivasan, Sreebala C. M. (2013-08)
    Large head modular metal-on-metal total hip replacement (MoMTHR) has been shown to have increased revision rates in the National joint registry and in literature. We reviewed 41 consecutive patients with 44 hips who had large head MoM THR using a Birmingham Hip Resurfacing (BHR) cup/Synergy stem combination between June 2005 and Nov 2009 with a mean followup of 59.5 months. In this series we had a revision rate of 6.8% (3/44) for adverse reaction to metal debris (ARMD), persistent groin pain and instability. Kaplan-Meier analysis showed a mean cumulative survival rate of 79.2% (95% CI: 75.5%-82.9%) In addition there is a subset of 5/44 patients (113%) with mild grade groin pain who may need revision in the future. Based on these findings, we do not recommend performance of large head MoMTHR in the future.
  • Combined Hip Arthroscopy and Limited Open Osteochondroplasty for Anterior Femoroacetabular Impingement: Early Patient Reported Outcomes.

    Srinivasan, Sreebala C. M. (2013-03)
    Many surgical techniques have been described for femoroacetabular impingement (FAI) surgery to help with improvement of pain and function in symptomatic patients. The aim of this study was to evaluate early patient reported outcomes and complications using combined hip arthroscopy and limited open osteochondroplasty technique. We retrospectively analysed 27 hips in 26 patients. Outcomes were assessed using the nonarthritic hip score (NAHS), UCLA score and Visual analogue scale (VAS) pain score. The average age of patients was 31.3 years and they were followed up for an average of 22.3 months. Average improvement of NAHS score was 39.55 points (p<.0001), 18 patients (72%) had at least 30 points increase in NAHS. There was 3 points average improvement in UCLA score (p<.0001). 17 patients (68%) had UCLA activity level of 6 and above. The average improvement of VAS pain score was 27.5 points (p<.0001). Minor complications included neuropraxia of the lateral femoral cutaneous nerve in three patients who recovered at three months with no sequelae, while one patient developed asymptomatic heterotopic ossification Brooker grade I. One patient had neuropraxia of the sciatic nerve which recovered completely within six months. One patient had a conversion to THR at 12 months. This is an effective technique to treat FAI for reducing pain and improving function at short term follow-up and has a low complication rate without appearing to have a significant learning curve. The failure rate can be reduced if proper case selection is done.
  • Tritanium Acetabular Cup in Revision Hip Replacement: A Six to Ten Years of Follow-Up Study.

    Srinivasan, Sreebala C. M. (2018-08)
    Background: The use of highly porous acetabular components has shown to produce good results in revision acetabular surgery. Their surface characteristics enhance initial fixation and bone ingrowth which are prerequisites for adequate osseointegration. The purpose of this study is to analyze the mid-term to long-term survival, clinical and radiological outcomes using the Tritanium cup (Stryker, Mahwah, NJ) in revision hip surgery.Methods: This is a retrospective review of all patients who underwent acetabular revision surgery using "Tritanium revision cup" between April 2007 and November 2010 at our institution. Sixty-two patients were included with a mean age of 67.5 years (32-86). According to Paprosky classification, 10 patients had type I defect, 8 had type IIA, 27 had type IIB, 7 had type IIC, and 10 suffered from type IIIA defect. A Kaplan-Meier analysis was used to determine the survival of the cup. Functional outcomes were assessed using Oxford Hip Score. Plain radiographs were performed to assess implant fixation and osseointegration.Results: The acetabular cup aseptic survivorship was 98.4% at a mean follow-up of 87.6 months. The mean Oxford Hip Score improved from 14.5 (3-31) preoperatively to 38.5 (12-48) at the final follow-up. Two cups were revised (3.2%): 1 for aseptic loosening and 1 for infection.Conclusion: Tritanium revision acetabular cup has shown excellent mid-term to long-term clinical and radiographic results with low failure rate and minimal complications. Longer term follow-up would be of value to assess the ongoing survival of this implant construct.
  • The incidence and causative organisms of infection in elective shoulder surgery.

    Bidwai, Amit S. (2018-07)
    Background Deep infection remains a serious complication of orthopaedic surgery. Knowledge of infection rates and causative organisms is important to guide infection control measures. The aim of the present study was to determine infection rates and causative organisms in elective shoulder surgery. Methods Cases complicated by infection were identified and prospectively recorded over a 2-year period. All patients undergoing elective shoulder surgery in the concurrent period at a single Specialist Upper Limb Unit in the UK were identified from the hospital electronic database. Results In total, 1574 elective shoulder cases were performed: 1359 arthroscopic (540 with implant insertion) and 215 open (197 with implant insertion). The overall infection rate in open surgery of 2.5% was significantly higher than arthroscopic implant cases at 0.7% (p < 0.005). The overall infection rate in implant arthroscopic surgery was significantly higher at 0.7% compared to 0% in non-implant related surgery. (p < 0.05) Conclusions Patients undergoing open shoulder surgery have a significantly higher risk of infection compared to arthroscopic shoulder surgery. Arthroscopic surgery with implant insertion has a statistically significantly higher risk of developing deep infection compared to procedures with no implant insertion. We recommend prophylactic antibiotics in open shoulder surgery and arthroscopic shoulder surgery with implant insertion.
  • Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression.

    Dekker, Andrew; Salar, Omer; Karuppiah, S; Bayley, Edward; Kurian, Jomy (2016-06)
    Background: Subacromial impingement is common and frequently treated with arthroscopic subacromial decompression (ASD); however, its efficacy has recently been questioned. Poor surgical outcomes have been associated with anxiety and depression within other orthopedic subspecialties but not within this group of patients. We hypothesized that anxiety and depression are associated with worse outcomes after ASD. Methods: A retrospective review of prospectively collected data was carried out of patients undergoing ASD. Inclusion criteria were short-term relief with injection therapy and presence of Hawkins sign. Rotator cuff tears were excluded. Patients completed the Oxford Shoulder Score (OSS), Hospital Anxiety and Depression Scale (HADS), and visual analog scale for pain before and after surgery in outpatient clinic followup at 6 weeks and by postal questionnaire at 6 months. Results: The 86 patients who participated in the study were analyzed in 2 groups defined by HADS scores, group A being depressed and group B nondepressed. Both groups had less pain and improved OSS at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation (P < .01) between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation (P < .01) between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction (P < .05). Conclusion: Patients with HADS score > 11 before ASD have worse outcomes. This should be taken into account when counseling patients for surgery. (C) 2016 Journal of Shoulder and Elbow Surgery Board of Trustees.
  • Adolescent idiopathic scoliosis (AIS): a multifactorial cascade concept for pathogenesis and embryonic origin

    Moulton, Alan (2016-01)
    This paper formulates a novel multifactorial Cascade Concept for the pathogenesis of adolescent idiopathic scoliosis (AIS). This Concept stems from the longitudinal findings of Clark et al. (J Bone Miner Res 29(8): 1729-36, 2014) who identified leptin body composition factors at 10 years of age associated with a scoliosis deformity found at 15 years. We interpret these findings in the light of some concepts for AIS pathogenesis. In particular, we speculate that the leptin body composition effect is linked to central nervous system development and the initiation of the asynchronous neuro-osseous growth mechanism that involves the creation of a neuraxis tether of relative anterior vertebral overgrowth. The latter mechanism in combination with age and gender-related anatomical variants of vertebral backward tilt (dorsal shear concept), human upright posture, adolescent growth factors, Hueter-Volkmann effect in vertebrae and vertebral bone mass abnormalities, lead to AIS, possibly both initiation and progression of scoliosis curvatures. Being multifactorial, while the Cascade Concept cannot be tested for all its components, some components should be testable by the method of numerical simulation. Clark et al. (J Bone Miner Res 29(8): 1729-36, 2014) also suggested the origin of scoliosis was in the embryonic stages of life from cell types, including adipocytes and osteoblasts, derived from the same progenitor cells, and myoblasts from mesodermal somites. The involvement of cell types from different developmental origins suggests a process acting in embryonic life at a similar time, probably environmental, as previously proposed from anthropometric studies. As a Complex disease, AIS will involve genetic, environmental and life style factors operating in development and growth; this possibility needs evaluating in epidemiological studies.
  • Antibiotic prophylaxis in orthopaedic surgery: difficult decisions in an era of evolving antibiotic resistance

    Morris, D.L.J. (2016-08)
    Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics.

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