Novel clinical and radiological measures of lower limb obesity.

Osteoarthritis of the knee is strongly associated with central obesity, and the prevalence of obesity in patients undergoing knee arthroplasty procedures is expected to increase. Central obesity is associated with multiple adverse outcomes after knee arthroplasty, but the impact of obesity specifically around the operated knee is poorly understood. One reason for this is the absence of a standardized measure, analogous to BMI for central obesity, to facilitate research. The aim of this study was to develop a radiological limb obesity scoring system which reliably corresponds with anthropometric measurements. Detailed anthropometric and radiological measurements were taken from patients undergoing total and unicompartmental knee replacement. Anthropometric measurements were combined into a composite score using principal components analysis. Different radiological scoring methods were evaluated against the anthropometric measure using correlation and regression analyses. Intraclass correlation coefficients were used to evaluate intra- and inter-observer reliability of the radiographic measurements. Measurements were obtained from fifty patients. There was a significant correlation between the composite anthropometric score and unadjusted radiological soft tissue width at the level of the femoral condyles (p < 0.001). There was also a significant correlation with the ratio of tissue to bone widths at the same level (p < 0.001), and fit was improved by including variables coding for soft tissues overlapping the medial or lateral boundaries of the radiograph. We have demonstrated a methodology for producing standardized radiological limb obesity scores which are strongly correlated with anthropometric measurements, and which can be easily applied in diverse clinical and research settings.

Preoperative sizing of hip hemiarthroplasties to accurately estimate head size from non- standardised pelvic radiographs: Can it be done?

BACKGROUND: Preoperative sizing of implants for hip fracture patients requiring a hemiarthroplasty is difficult due to non-standardised radiographs, absence of sizing marker, variable patient position and body habitus. We investigated whether a simple tool could help predict femoral head size, allowing surgeons to safely proceed with surgery when implant stocks are limited, and to potentially improve theatre efficiency. METHODS: Three independent reviewers measured the maximum width of the contralateral (intact) femoral head using PACS software in 50 cases of intracapsular hip fracture. This was linearly regressed on actual implant size to calculate the average magnification coefficient. Inter- and intra-rater reliability were evaluated using intraclass correlation coefficients (ICC). RESULTS: The best fitting magnification constant was 118% (95% confidence interval 16.0-19.7%), which achieved a mean error of 1.7 mm. Prediction accuracy was significantly improved by allowing a constant (intercept) as a second parameter in the regression model (p = 0.01), which achieved a mean error of just 1.4 mm from the implant used. The inclusion of the constant reduces errors at the upper and lower extremes of head sizes. ICCs for inter- and intra-rather agreement were 0.94 and 0.98 respectively. CONCLUSION(S): We have shown that hip hemiarthroplasty head sizes can be reliably and accurately predicted from non-standardised pre-operative radiographs. We have devised a method which can easily be adopted by other centres and tailored to the characteristics of their radiology department.

Excised Femoral Heads in Hip Fracture Patients: Is Osteoporosis Worse Than Cancer?

Introduction Annually 80,000 hip fractures are treated at an estimated cost of two billion pounds. The 2011 guidance from the Royal College of Pathologists recommended all specimens where there is fracture through or below the articular surface should be examined to exclude/ identify an underlying cause (pathological fracture). The questions posed in this study are three-fold. Firstly, how does our practice for hip fracture patients comply with the above audit standards? Secondly, what is the prognostic significance of a past medical history of malignancy on survival? Thirdly, is there any other prognostic survival difference attributable to the diagnosis concluded from the histological analysis of the excised femoral head specimens? Methods A retrospective analysis of all hip fractures receiving joint arthroplasty was undertaken between January 2011 and March 2014. Mortality was recorded for a minimum follow-up of 30 months post-operatively. Each excised femoral head was histologically examined by a single consultant histopathologist, and all pre-operative X-rays were reviewed by a consultant radiologist. Histological diagnoses were recorded, and statistical analysis including Kaplan-Meier survival was performed. Results A total of 327 consecutive fractures were identified. Out of 187 specimens sent for analysis, only two revealed metastatic deposits in patients with known disseminated malignancy. A previous medical history of malignancy did not confer a significant increase in mortality over a five-year postoperative period (p = 0.42). A histological diagnosis of osteoporosis significantly increased mortality over a five-year postoperative period (p = 0.004). A comparative analysis found that patients with a histological diagnosis of osteoporosis had the poorest survival. Conclusion A histological femoral head analysis may diagnose previously undiagnosed osteoporosis, allowing the clinician to intervene in a disease process, which if left untreated, can lead to a significant increase in mortality.

Congenital talipes equinovarus and congenital vertical talus secondary to sacral agenesis.

Sacral agenesis is a rare congenital defect which is associated with foot deformities such as congenital talipes equinovarus (CTEV) and less commonly congenital vertical talus (CVT). We report a 3-year-old Caucasian girl who was born with right CTEV and left CVT secondary to sacral agenesis. Her right foot was managed with a Ponseti casting method at 2 weeks, followed by an Achilles tenotomy at 4 months. The left foot was initially managed with a nocturnal dorsi-flexion splint. Both feet remained resistant and received open foot surgery at 10 months producing plantigrade feet with neutral hindfeet. At 19 months, she failed to achieve developmental milestones and examinations revealed abnormal lower limb reflexes. A full body MRI was performed which identified the sacral agenesis. We advocate early MRI of the spine to screen for spinal defects when presented with resistant foot deformities, especially when bilateral.

Unusual fracture combination in a paediatric acute ankle (combined medial talar compression fracture with medial malleolus fracture in an immature skeleton): a case report.

Talar compression fractures are uncommon orthopaedic injuries, especially in the immature skeleton. Fractures of the talar body constitute >5% of all foot and ankle fractures. The combination of a medial compression fracture and corresponding medial malleolar fracture is rare and not previously reported injury in the literature. We present a case report of a skeletally immature 15-year-old Caucasian male who sustained a medial malleolar and corresponding medial talus fracture after being ejected from his pushbike. This report outlines the potential difficulties in diagnosing an unusual fracture combination and the importance of initial management including necessary diagnostic imaging to identify such injuries. Through this case, we aim to highlight the need for having high suspicions of underlying fractures in paediatric trauma cases. The long-term complications and risks of osteonecrosis of the talus can have detrimental effect on a patient's outcome; therefore, we also emphasize the need for regular monitoring and long-term follow-up.

Minimising negative ankle and foot X-rays in the Emergency Department -- are the Ottawa ankle rules good enough?

OBJECTIVES: To review fracture rates in patients who had X-rays of either the ankle or foot or both in the Emergency Department of a district hospital. METHOD: A retrospective review of 2589 Emergency Department patients who had X-rays of the ankle or foot or both over a 12-month period. RESULTS: There were 1199 ankle X-rays taken of which 193 (16%) showed a significant fracture. There were 1081 patients who had a foot X-rayed of which 165 (15%) showed a significant fracture. Younger patients had more X-rays but older patients were more likely to have a fracture. There were 309 patients who had an ipsilateral ankle and foot X-rayed at the same time, and of these 42 (14%) showed one fracture and just two (0.6%) showed a significant fracture of both ankle and foot. CONCLUSIONS: The approach to X-raying ankle and feet in this study is probably widespread, and Ottawa Ankle Rules still seem to be of limited use in diagnosing fractures. This low yield of positive X-ray could be accepted or a more sophisticated ankle rule introduced.