Is it safe for patients to drive after intra-articular knee injection?

BACKGROUND: Intra-articular knee injection is a central component in the current management of knee pain. While this is a routinely performed outpatient procedure, institutional policies for driving post injection differ. This study examines brake response times (BRTs) before and after intra-articular knee injection. Our hypothesis is that BRTs would not significantly differ and thus patients driving ability/safety is unaffected. METHODS: Forty-five patients previously listed for right intra-articular knee injection were prospectively evaluated. Patients underwent baseline assessment of BRT prior to injection. All patients received 10 ml of fluid consisting of one milliliter of 10 mg/ml triamcinolone mixed with nine milliliters of 0.5% levobupivacaine. BRT was re-examined on the same day prior to discharge home. Pre- and post-injection BRTs were examined using the same machine and assessor. RESULTS: The mean age of the cohort was 64.0 ± 12.4 and compromised of 37.8% males. There was no significant difference in the mean pre- and post-injection braking time (0.83 ± 0.29 vs 0.78 ± 0.30 s, p = .42), or in the rate of failed braking time (11.1% vs 6.7%, p = .46). CONCLUSION: This study found that BRT did not significantly differ before and after the intra-articular injection, nor did it cause an increased number of patients failing their BRTs. These findings suggest patients should not be prevented from driving after intra-articular knee injection.

Outcomes following subcapital osteotomy for severe slipped upper femoral epiphysis.

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy. Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head-shaft slip angle from 53.8(°) (standard deviation (SD) 3.2) pre-operatively to 9.1(°) (SD 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, SD 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention. This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

The Irish National Joint Registry: where are we now?

BACKGROUND: Ireland is currently in the process of establishing a National Joint Registry. AIM: We aim to determine which implants and surgical techniques are currently being used by Irish orthopaedic surgeons and to examine the impact that a National Joint Registry may have on arthroplasty practice in Ireland. METHODS: The study consisted of a postal questionnaire sent to all public service consultant orthopaedic surgeons in The Republic of Ireland. RESULTS: We had a response rate of 76.6 %. Of this 76.6, 86.4 % regularly perform total hip arthroplasty (THA) and 84.7 % perform total knee arthroplasty. Of those who perform THA, 86.3 % use different implants in younger patients. Thirteen different femoral implants are used, and seven different knee implants. We conservatively estimate that at least 3,918 total hip arthroplasties and 2,604 total knee arthroplasties are performed in Ireland each year. At present we have no way to precisely monitor the number of arthroplasty procedures being performed, and we have no way of accurately monitoring the short- or long-term outcomes of the many implants used. CONCLUSIONS: The establishment of a National Joint Registry for Ireland would benefit the Irish orthopaedic community, and given the large number of procedures being performed, may also be of benefit to the international orthopaedic community.

Risk factors for surgical site infection following operative ankle fracture fixation.

BACKGROUND: Ankle fracture is a common injury and there is an increasingly greater emphasis on operative fixation. AIM: The purpose of the study was to determine the complication rate in this cohort of patients and, in doing so, determine risk factors which predispose to surgical site infection. METHODS: A prospective cohort study was performed at a tertiary referral trauma center examining risk factors for surgical site infection in operatively treated ankle fractures. RESULTS: Univariate and multivariate analysis was performed. Female gender and advancing age were determined to be the risk factors in univariate analysis. Drain usage and peri-operative pyrexia were found to be significant for infection in multivariate analysis. CONCLUSION: This study allows surgeons to identify those at increased risk of infection and counsel them appropriately. It also allows for a high level of vigilance with regard to soft tissue handling intra-operatively in this higher risk group.

Leucocyte esterase in the rapid diagnosis of paediatric septic arthritis.

Septic arthritis may affect any age group but is more common in the paediatric population. Infection is generally bacterial in nature. Prompt diagnosis is crucial, as delayed treatment is associated with lifelong joint dysfunction. A clinical history and application of Kocher's criteria may indicate that there is a septic arthritis. However, definitive diagnosis is made on culture of septic synovial fluid. The culture process can take over 24h for the initial culture to yield bacterial colonies. Leucocyte esterase is released by leucocytes at the site of an infection. We hypothesise that leucocyte esterase can be utilized in the rapid diagnosis of septic arthritis and shorten the time to decisive treatment whilst simultaneously decreasing unnecessary treatment of non-septic joints.

The effect of inclement weather on trauma orthopaedic workload.

BACKGROUND: Climate change models predict increasing frequency of extreme weather. One of the challenges hospitals face is how to make sure they have adequate staffing at various times of the year. AIMS: The aim of this study was to examine the effect of this severe inclement weather on hospital admissions, operative workload and cost in the Irish setting. We hypothesised that there is a direct relationship between cold weather and workload in a regional orthopaedic trauma unit. METHODS: Trauma orthopaedic workload in a regional trauma unit was examined over 2 months between December 2009 and January 2010. This corresponded with a period of severe inclement weather. RESULTS: We identified a direct correlation between the drop in temperature and increase in workload, with a corresponding increase in demand on resources. CONCLUSIONS: Significant cost savings could be made if these injuries were prevented. While the information contained in this study is important in the context of resource planning and staffing of hospital trauma units, it also highlights the vulnerability of the Irish population to wintery weather.

Immune gene therapy as a neoadjuvant to surgical excision to control metastatic cancers.

We investigated if the range of efficacy of a gene-based immunotherapy of solid tumours against systemic disease could be extended when used as a neoadjuvant to surgery. Hundred percent mice whose subcutaneous tumours were surgically removed 4 days post-electroporation with GM-CSF and B7-1 plasmid were systemically resistance to tumour rechallenge. In mice bearing both subcutaneous and hepatic tumours, neoadjuvant treatment of the primary tumour resulted in significant reduction in, or elimination of, hepatic tumour growth, with a significant increase in survival, indicating that control of the primary tumour by immunotherapy was not a prerequisite for containment of systemic disease.

Comminuted fracture of the thoracic spine.

BACKGROUND: Road deaths fell initially after the introduction of the penalty points but despite this, the rate of spinal injuries remained unchanged. AIMS: We report a patient with a dramatic spinal injury, though without neurological deficit. We discuss the classification, management and economic impact of these injuries. METHODS: We describe the management of a patient with a comminuted thoracic spinal fracture without neurological injury. We conducted a literature review with regard to the availability of literature of the management of these injuries. RESULTS: This 17-year-old female was managed surgically and had a good functional outcome. There is no clear consensus in the published literature on the management of these injuries. CONCLUSIONS: Comminuted thoracic spinal factures are potentially devastating. Such a patient presents challenges in determining the appropriate treatment.

The natural history of developmental dysplasia of the hip after early supervised treatment in the Pavlik harness. A prospective, longitudinal follow-up.

Between June 1988 and December 1997, we treated 332 babies with 546 dysplastic hips in a Pavlik harness for primary developmental dysplasia of the hip as detected by the selective screening programme in Southampton. Each was managed by a strict protocol including ultrasonic monitoring of treatment in the harness. The group was prospectively studied during a mean period of 6.5 +/- 2.7 years with follow-up of 89.9%. The acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured on annual radiographs to determine the development of the hip after treatment and were compared with published normal values. The harness failed to reduce 18 hips in 16 patients (15.2% of dislocations, 3.3% of DDH). These required surgical treatment. The development of those hips which were successfully treated in the harness showed no significant difference from the normal values of the AI for the left hips of girls after 18 months of age. Of those dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA <20 degrees) and 0.2% persistent severe late dysplasia (CEA <15 degrees). All could be identified by an abnormal CEA (<20 degrees) at five years of age, and many from the progression of the AI by 18 months. Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in the harness. We conclude that, using our protocol, successful initial treatment of DDH with the Pavlik harness appears to restore the natural development of the hip to normal. We suggest that regular radiological surveillance up to five years of age is a safe and effective practice.