Image-guided synovial biopsy with a focus on infection.

Image-guided biopsy of the synovium is a relatively uncommon but safe procedure with a high-diagnostic yield in the correct clinical scenario. Whilst surgical and arthroscopic techniques are still commonly performed and remain the gold standard, they are more invasive, expensive and not widely available. Ultrasound and X-ray-guided synovial biopsy are being increasingly performed by radiologists to diagnose both native and periprosthetic joint infection (PJI) to guide surgical and microbiological management. The purpose of this review article is to present the historical background to synovial biopsy particularly related to potential joint infection, including common and uncommon pathogens encountered, sampling techniques and pitfalls, focusing mainly on its role in PJI and its role in patient pathways and decision-making within a joint infection multi-disciplinary framework.

A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change?

OBJECTIVES: The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. METHODS: A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. RESULTS: A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001). CONCLUSIONS: Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively.Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178-184. DOI: 10.1302/2046-3758.55.2000596.

Early rehabilitation following less invasive surgical stabilisation plate fixation for distal femoral fractures.

OBJECTIVE: The less invasive surgical stabilisation (LISS) plate fixation method is an orthopaedic procedure for the fixation of distal femoral fractures. Early physiotherapy treatments of motion and mobilisation have been advocated following this procedure. This article critically appraises the evidence base assessing the early rehabilitation of patients following LISS fixation for distal femoral fractures. DATA SOURCES: A review of EMBASE, Medline, CINAHL and AMED, and a hand search were undertaken. REVIEW METHODS: Two independent reviewers identified all eligible articles. Two reviewers extracted the data, which were verified by a third reviewer. All included articles were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool. RESULTS: Seventeen case series assessing 508 patients with 535 fractures were reviewed. No clinical trials comparing physiotherapy programmes were identified. The review identified that following LISS fixation for distal femoral fractures, patients begin range-of-motion exercises immediately and are initially required to restrict weight-bearing following surgery. It remains unclear whether casts, braces or immobilisation aids are applied during the initial postoperative period. CONCLUSION: The efficacy of different physiotherapy protocols following LISS fixation for distal femoral fractures remains unclear. Further well-designed randomised controlled trials are required to compare different postoperative physiotherapy rehabilitation programmes for patients following LISS fixation of distal femoral fractures in order to determine the optimal postoperative management for this complex patient group.

The clinical and radiological outcomes of the LISS plate for distal femoral fractures: a systematic review.

PURPOSE: The purpose of this systematic review was to assess the literature evaluating the clinical and radiological outcomes following less invasive surgical stabilisation system (LISS) fixation of distal femoral fractures (AO 32/33). METHODS: A review of EMBASE, Medline, CINAHL and AMED from their inception to November 2008, sources of grey literature and a pertinent hand search of specialist orthopaedic journals was undertaken. RESULTS: Twenty-one studies assessing 663 patients with 694 fractures were reviewed. The findings suggest that the LISS system may be an appropriate fixation method for the management of distal femoral fractures. However, there remains a high incidence of loss of reduction (n=134; 19%), delayed or non-union (n=40; 6%) and implant failure (n=38; 5%). On analysis, such complications were largely confined to articles published before 2005, therefore during the infancy of the widespread clinical application of this trauma system. On critical appraisal, the evidence-base remains limited by recruiting small, under-powered sample sizes and poorly accounting for confounding variables such as osteoporosis, diabetes, multi-trauma and fracture classification. CONCLUSION: Further study is required to assess the outcomes of LISS fixation in specific patient populations, and to compare the outcome of this fixation method to condylar plates and intrameduallary devices, to determine the optimal management strategy for this complex patient group.

Biomaterials and cardiovascular devices.

In the field of cardiovascular surgery there is presently a lack of biomaterials possessing essential characteristics of the native tissue or organ which is to be replaced. This paper describes various biomaterials that have been introduced into the circulatory system and the complex reactions that subsequently occur. The risk of infection is also discussed as well as prevention and treatment regimes that can be used. Examples of future biomaterial development are outlined in an attempt to achieve biocompatibility.

The response of primary rat and human osteoblasts and an immortalized rat osteoblast cell line to orthopaedic materials: comparative sensitivity of several toxicity indices.

When studying the biocompatibility of orthopaedic biomaterials it is often necessary to discriminate between responses which show mild cytotoxicity. It is therefore essential to use a very sensitive index of toxicity. We have compared the sensitivity of four well-established indices of toxicity: total cell protein content, leakage of lactate dehydrogenase (LDH), reduced glutathione content and the MTT assay, with that of a novel index, alkaline phosphatase (ALP) activity. Comparisons were made by detecting nickel chloride toxicity in osteoblasts. ALP activity, the novel method, proved the most sensitive index of toxicity and it provides a convenient automated assay for assessing the interactions of materials with osteoblasts. The responses to nickel chloride and to aqueous extracts prepared from carbon fibre reinforced epoxy and polyetheretherketone (peek), two candidate materials for orthopaedic implants, were compared in primary and immortalized rat osteoblasts, and in primary human osteoblasts. Although the immortalized rat osteoblast cell line, FFC, was consistently the most sensitive cell type, the responses of the human cells and the FFC cell line were similar in terms of ALP activity throughout the range of nickel concentrations studied. Neither peek nor epoxy material extracts showed a significant decrease in the MTT or ALP responses in any of the three cell types. Our data suggest that immortalized rat osteoblasts may provide an in vitro model system for screening the biocompatibility of orthopaedic polymers.

Interactions of orthopaedic metals with an immortalized rat osteoblast cell line.

The toxicity of nickel, chromium (III) and (VI), vanadium and aluminium was compared in an immortalized neonatal rat osteoblast cell line using the MTT assay and a novel index of cytotoxicity, alkaline phosphatase (ALP) activity. Where toxicity was observed, ALP was a consistently more sensitive detection method than the MTT assay. The toxicity of the metals increased in the order aluminium < chromium (III) < vanadium < nickel < chromium (VI). alpha-Tocopherol partially prevented nickel-induced toxicity (as assessed by ALP activity), whereas ascorbic acid had no protective effect. Chromium (VI) was more toxic than (III), with significant toxicity observed at 0.5 microM. It is thought that Cr (III) cannot readily penetrate the cell membrane and this may account for the lower toxicity. Aluminium had a stimulatory effect on cell growth at low concentrations (0.5 microM). The combination of immortalized rat osteoblasts and the ALP activity test provides a powerful tool for in vitro testing of orthopaedic materials.

In vitro biocompatibility testing of polymers for orthopaedic implants using cultured fibroblasts and osteoblasts.

The biocompatibility of two polymers for potential use as orthopaedic implant materials in an isoelastic hip prosthesis was investigated. The interactions of polyetheretherketone (PEEK) and epoxy resin polymers (with and without carbon fibre reinforcement) with both fibroblasts and osteoblasts were tested using cell protein, intracellular reduced glutathione (GSH), leakage of lactate dehydrogenase and the MTT assay as indices of cellular cytotoxicity. The epoxy resin polymer was slightly cytotoxic to and inhibited the growth rate of fibroblasts (as assessed by total cell protein), and depleted GSH in both cell types. In contrast, the PEEK material did not display overt signs of cytotoxicity and, in fact, increased osteoblast cell protein content. This suggests that, of these two materials, PEEK would be the one of choice for development of an isoelastic implant and, in view of its stimulatory effect on osteoblast protein content, it may encourage ingrowth of bone around the prosthesis and thus minimize joint loosening.

Deaths from abuse of volatile substances: a national epidemiological study.

A survey of the United Kingdom detected 282 deaths from abuse of volatile substances during 1971-83. Deaths appeared to have increased in the most recent years, reaching 80 in 1983. Age at death ranged from 11 to 76 years but most deaths (72%) occurred under 20 years. Ninety five per cent of the subjects were male, and in 1983 deaths from volatile substance abuse accounted for 2% of all deaths in males aged 10-19. All areas of the United Kingdom were affected, the rates being highest in Scotland and urban areas. All social classes were affected, though rates were highest in social class V and the armed forces. The volatile substances abused were gas fuels (24%), mainly butane; aerosol sprays (17%); solvents in glues (27%); and other volatile substances, such as cleaning agents (31%). In 51% of cases death was attributed to the direct toxic effects of the substance abused, in 21% to plastic bag asphyxia, in 18% to inhalation of stomach contents, and in 11% to trauma. Deaths associated with the abuse of glues were more likely to be traumatic, but all substances appeared capable of killing directly by their toxic effects, probably by a cardiac mechanism. Only a small proportion of deaths (6%) were due to the abuse of glues among children under 16; hence current attempts to limit access of children to glues will probably have little impact on overall mortality.

An investigation of 140 deaths associated with volatile substance abuse in the United Kingdom (1971-1981).

1 In the UK, from 1971 to 81, 140 deaths associated with volatile substance abuse (VSA) were identified from press reports and a variety of other sources. Data about each death were obtained from inquest proceedings, post-mortem and toxicological reports, and death certificates. 2 Based on the year 1981, in which 39 deaths occurred, VSA deaths accounted for over 1% of deaths from all causes, and nearly 2% of deaths from injury and poisoning in males aged 10-19 years. 3 The median age was 16.8 years (range 11-63), and 79% were under age 20. The male to female ratio was 13:1. 4 Death rates were highest in conurbations, and in Scotland, Northern Ireland and Northern England. Deaths tended to be more frequent among manual social classes but this association was not marked. 5 The chief substances were butane (28%), solvents in adhesives (23%), other solvents (26%), aerosols (15%) and fire extinguishing agent (5%). Solvents in adhesives were more important with increasing age. 6 Most deaths occurred alone, at home. In about 41% of cases, death appeared to be only indirectly associated with VSA (trauma 8%, plastic bag over head 19%, and inhalation of stomach contents 14%). In 49% death was attributed to the direct toxic effects of the substance; this proportion was highest with aerosols and lowest with solvents in adhesives. 7 The implications of these findings for prevention, monitoring and research are discussed.

Kidney microvillus peptidases--are they transmembrane proteins?

The membrane of kidney microvilli is richly endowed with peptidases. Present information is that there are at least eight examples located in this membrane. Three of the group are known to be among the major proteins that can be identified by dodecyl sulphate electrophoresis of the purified microvillus fraction. These three peptidases, aminopeptidase M, serine peptidase (dipeptidyl peptidase IV) and neutral endopeptidase can be labelled by lactoperoxidase iodination from either the luminal or the inner surfaces of the membrane, a result consistent with the view that the polypeptide chains span the microvillus membrane. The serine peptidase has been purified by two methods, permitting a comparison of the detergent-released and proteinase-released forms. The two forms differ in the presence and absence of the hydrophobic anchor that secures the enzyme to the membrane. Preliminary studies support the view that this hydrophobic domain is relatively small and that it includes the N-terminal region of the polypeptide chain.

Peptidases of the kidney microvillus membrane.

The microvillus membrane of the kidney is highly differentiated in its complement of enzymes and other proteins. In addition to the five well documented peptidases that are present in the membrane, recent work suggests that aminopeptidase P, carboxypeptidase P and an enzyme tentatively referred to as "leucine hydrazidase" are also microvillus enzymes. Microvillus serine peptidase (dipeptidyl peptidase IV) has been purified after detergent solubilization. The catalytic and molecular properties of this form and the form released by autolysis have been compared in an attempt to gain understanding of the intramembranous domain of this protein. Current views on the molecular organization of the microvillus are discussed.