Incisional metastatic breast carcinoma deposit in a total knee replacement presenting as peri-prosthetic joint infection-a case report.

Cutaneous metastasis from the primary breast carcinoma occurs when the disease is wide spread and can present as skin infection especially in a previous well-healed scar. If the secondary deposit is over a total knee incisional site it can mimic peri-prosthetic joint infection. We report a rare and unusual case of a woman who presented with clinical signs and symptoms of a peri-prosthetic total knee replacement which on biopsy turned out to be cutaneous metastasis from a previously treated breast cancer. Chronic granulation tissue in a total joint incisional scar may present as peri-prosthetic joint infection. A good history taking and clinical examination with specimens from the skin lesions send for both microbiology and histopathology is recommended to arrive at an early and accurate diagnosis.

A comparative study of hip fracture care and outcomes in major trauma centres versus trauma units.

INTRODUCTION: There is good evidence to support that major trauma networks significantly reduce morbidity and mortality in severely injured patients. However, following the introduction of major trauma centres (MTCs) in England in 2012, early concerns were raised regarding the effect on hip fracture patients. The aim of our study was to review data from the National Hip Fracture Database for fractured neck of femur (FNOF) patients, comparing patient outcomes between MTCs and trauma units (TUs), and the national regions of the UK. METHODS: NHFD data from 2018 for all hospitals in England, Wales and NI was collected using the charts and dashboards available online. We recorded data for the following outcomes: time to surgery, acute hospital length of stay, overall hospital length of stay, discharge to original residence within 120 days, crude 30-day mortality and adjusted 30-day mortality. We conducted a one-way ANOVA test to calculate statistical differences for each outcome measure by MTC vs TU and then separately for the regions of the UK divided into England, Wales and Northern Ireland (NI). RESULTS: Data for 175 hospitals are included in this study; 22 of which were MTCs. The total number of operative cases were 65,848. 9668 of these occurred in MTC compared to 56,180 in TUs. This equates to an annual average of 439 per MTC and 367 per TU. Despite this, there was no statistically significant difference observed in all outcomes for MTC vs TU. Patients in NI waited longer for their surgery (60.3 h, p < 0.001), whilst patients in Wales had the longest overall hospital length of stay (31.6 days, p < 0.001). However, there was no difference in patients' crude 30-day mortality (p = 0.480) or adjusted 30-day mortality (p = 0.191). CONCLUSION: These findings are reassuring for MTCs in England. We found no evidence to suggest that FNOF patients are treated inferiorly, or have worse outcomes, at MTCs vs TUs. FNOF patients in NI waited longer for their surgery but this did not have any significant difference on 30-day mortality rates. The care of FNOF patients in NI may warrant further study.

Peroneal artery safe zone in the posterolateral approach to the distal tibia: A CT angiogram based anatomical study.

OBJECTIVES: The posterolateral approach to the distal tibia is commonly used for stabilisation of ankle fractures as it allows good visualisation and direct reduction of the posterior distal tibia and malleolar fragments. This approach can also be used for internal fixation of an associated lateral malleolus fracture. The aim of our study is to describe the surgical anatomy of the peroneal artery (PA) in relation to the tibial plafond and the distal fibula; thereby suggesting a safe zone during proximal dissection of posterolateral approach. METHODS: Using Computed Tomography Angiographic (CTA) study, the course of the PA in relation to the tibial plafond and distal fibula was analysed in 142 lower limbs (bilateral limbs of 71 adult patients; 43 males and 28 females). Axial, coronal, and sagittal CT sections were cross-linked to specify the position of the PA. The PA course was identified and the level of its distal bifurcation over the tibia was marked. Perpendicular measurements were made from this point to the tibial plafond and tip of distal fibula. RESULTS: The PA bifurcated distally at mean 58.3±24.2mm (SD) (range: 37.0-115.0mm) proximal to the right tibial plafond and mean 81.9±24.4mm (range: 54.0-137.0mm) from the right distal fibular tip. In the contralateral side, the PA bifurcated at mean 57.9±23.3mm (range: 36.0-125.0mm) proximal to the left tibial plafond and 81.8±23.9mm (range: 54.0-147.0mm) from the left distal fibular tip. The difference between the right and the left side of distal bifurcation point diameter of the same patient was assessed, range (0.0-58.0mm) with median 2.0mm and IQR 10.0mm. Three different PA vasculature patterns were identified. CONCLUSIONS: It is important for surgeons to be aware of the surgical anatomy of PA to avoid inadvertent injury during posterolateral approach to distal tibia. The PA may bifurcate as close as 36mm from the tibial plafond with possible variation bilaterally. Therefore, special attention needs to be considered by the operating surgeon while dissecting in this region due to the wide anatomical variation in vasculature. However, once the PA is mobilised, any fixation modality including posterior buttress plate could be safely performed.

Effect of Covid-19 on best practice care of hip fracture patients: An analysis from the National Hip Fracture Database (NHFD).

BACKGROUND: Best practice tariff (BPT) has brought significant improvements in hip fracture care; the 2019 report showing a 30-day mortality of 6.1%. Data relating to more than 65,000 patients who sustain a fractured neck of femur (FNOF) are recorded each year in the National Hip Fracture Database (NHFD). The aim of our study was to review the impact of COVID-19 on BPT. METHODS: Data was extracted from the NHFD for England, Wales and Northern Ireland. The months of March to June 2020 (lockdown period related to COVID-19) were compared to the same period in 2019. Data used in this study was collated and analysed between 14th and 17th October 2020. RESULTS: Data for more than 40,000 patients was reviewed. BPT dropped -4.3% in March, -12.6% in April, -12.9% in May 2020, and -7.2% in June. Prompt surgery remained stable (four-month average + 0.1%). The most significant changes were noted for timely orthogeriatric review (-7.6%, p < 0.001), bone health assessment (-7.3%, p < 0.001) and post-operative delirium assessment (-6.6%, p < 0.001). 30-day mortality increased to 13.7% in March 2020 and remained high in April 2020 (11.3%) and May (7.3%). Acute hospital length of stay was lowest in May 2020 (11.7 days). CONCLUSION: Patients sustaining FNOF in March 2020 had an associated 30-day mortality of 13.7%. During the COVID-19 pandemic, there was a significant reduction in BPT. The most significant changes were observed in timely orthogeriatric review. Maintaining a high standard of multidisciplinary care for this vulnerable group of patients is crucial during future spikes of COVID-19.

The use of ultrasound in the diagnosis of adverse reaction to metallic debris following metal on metal hip replacement.

BACKGROUND AND PURPOSE: The role of imaging in the diagnosis of adverse reaction to metallic debris (ARMD) with metal on metal (MoM) hip replacements is still unclear. A comparative study was undertaken to evaluate the efficacy of ultrasound in diagnosis of ARMD. PATIENTS AND METHODS: The study group included 35 patients with a clinical and histological diagnosis of ARMD. The control group included 16 asymptomatic patients of MoM hip replacements with low blood metal ions levels. Various sonographic features around hip in patients diagnosed with ARMD were recorded. RESULTS AND INTERPRETATION: Fluid collection around iliopsoas and gluteal tendons following a MoM hip replacement is highly suggestive of ARMD and should not be thought of as an uncomplicated tendonitis. This study shows ultrasound as a reliable investigation in the diagnosis of ARMD following MoM hip replacements.

Effect of Sodium Hyaluronate on Recovery after Arthroscopic Knee Surgery.

The aim of this study was to evaluate the effect of a single immediate postoperative instillation of 10 mL of sodium hyaluronate (Viscoseal) into the knee following arthroscopy. A single-center, prospective, randomized, controlled study was undertaken. Consenting knee arthroscopy patients were randomized into two groups following surgery: the study group received 10 mL of sodium hyaluronate intra-articularly, while the control group received an intra-articular instillation of 10 mL of Bupivacaine. Pre- and postoperative visual analogue scale scores for pain and Western Ontario and McMaster Universities (WOMAC) scores for knee function were obtained. Overall, 48 patients under the care of a single surgeon were randomized into two groups of 24. There were no statistically significant demographic differences at baseline. Three patients were lost to follow-up. There was a statistically significant difference in pain scores favoring the study group compared with the control group at 3 and 6 weeks postoperatively (p < 0.05), and a statistically significant difference in WOMAC scores favoring the study group compared with the control group at 3 and 6 weeks postoperatively (p = 0.01). Synovial fluid replacement with sodium hyaluronate following arthroscopic knee surgery conferred statistically significant improvements in pain and function scores compared with Bupivacaine in the short term (3-6 weeks).

Navigation-assisted versus conventional total knee replacement: no difference in patient-reported outcome measures (PROMs) at 1 and 2 years.

INTRODUCTION: Navigation technique for total knee replacement has been shown to improve accuracy of prosthesis alignment in several studies. The purpose was to compare the patient-reported outcome measures in primary total knee replacement (TKR) using navigation versus conventional surgical technique at 1- and 2-year follow-up. MATERIALS AND METHODS: A retrospective review of prospectively collected patient-reported outcome data for 351 consecutively performed primary TKR was included in the study. The study group (N = 113) included patients who had Triathlon TKR using articular surface mounted (ASM Stryker) navigation technique and control group (N = 238) included patients who had Triathlon TKR using conventional jig. In addition to the WOMAC (Western Ontario and McMaster University Osteoarthritis Index) and SF-36 (Medical Outcomes Trust Short Form-36), a short self-report questionnaire evaluating the level of satisfaction, quality of life and whether patients would undergo knee replacement again. RESULTS: WOMAC: no significant difference between the groups was noted in mean WOMAC pain, function and stiffness scores at 1- and 2-year follow-up. SF-36: no significant difference between the groups was seen except in the physical function component of score at 1 year (p = 0.019). Navigation group mean 56.78 (CI 51.06-62.5) versus conventional group mean 48.34 (44.68-52.01) but this difference was not observed at 2-year follow-up. CONCLUSIONS: The overall patient-reported outcome scores improved after total knee replacement but appear to be comparable in both groups at 1- and 2-year follow-up.

Volar radiocarpal dislocation: case report and review of literature.

We describe here an unusual case of volar dislocation of the radiocarpal joint due to a complete tear of the dorsal radiocarpal ligament. Plain radiographs taken at initial presentation did not reveal any obvious abnormality. There was no associated bony lesion or intrinsic wrist ligament injury. Radiocarpal dislocations should be considered in the diagnosis of high-energy wrist injuries, even when initial radiographs look normal. The importance of a high index of suspicion in high velocity wrist injuries and need for further evaluation and imaging is highlighted.

Shoulder ultrasonography versus arthroscopy for the detection of rotator cuff tears: analysis of errors.

PURPOSE: To compare shoulder ultrasonography with arthroscopy for detecting specific rotator cuff tears. METHODS: 96 shoulders in 56 men and 34 women aged 28 to 65 (mean, 42) years with rotator cuff problems underwent a shoulder ultrasonography by a single radiologist, and then a shoulder arthroscopy by a single surgeon. The ultrasonographic and arthroscopic findings were compared with regard to tendon-specific tears and disparities in diagnosis. RESULTS: For detection of supraspinatus tendon tears, ultrasonography attained a sensitivity of 89%, specificity of 43%, positive predictive value of 76%, and negative predictive value of 100%. For detection of subscapularis tendon tears, ultrasonography attained a sensitivity of 30%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 78%. Sensitivity, specificity, and predictive values were good in larger full-thickness tears, but were significantly reduced in sub-centimetre and partial-thickness tears, particularly of the subscapularis tendon. CONCLUSIONS: Surgeons should be aware of the potential disparities between ultrasonographic and arthroscopic findings and be prepared to adjust the surgical procedure during arthroscopy.

Nailing versus plating in humerus shaft fractures: a prospective comparative study.

There is a debate about the choice of operative intervention in humerus shaft fractures requiring surgical intervention. A prospective, comparative study of management of acute humeral shaft fractures treated by antegrade interlocking nail fixation and dynamic compression plating was undertaken over a period of three years. Twenty patients of interlocking nailing and sixteen patients of plating were included after considering the inclusion and exclusion criteria. Functional scoring criteria were used for postoperative assessment and the average follow-up period was one year. A higher rate of excellent and good results and a tendency for earlier union was seen with the plating group in our series.

Good medical records: a guide for the foundation year doctor.

Maintaining good medical records is essential for providing safe and effective patient care. The General Medical Council (2006), in Good Medical Practice, suggests that doctors should 'keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed'. While good medical practice is necessary throughout one's medical career it is important to develop good qualities early in the training.

Postoperative acute compartment syndrome in the nonoperated "well leg": implications to orthopaedic nursing.

Acute compartment syndrome after fractures and injuries and in operated limbs is a dreadful complication and is well known to orthopaedic nursing community. Acute compartment syndrome in a nonoperated leg after an orthopaedic procedure has been infrequently reported and discussed. It has been more commonly discussed in colorectal, gynecologic, and urologic practice. It is vital to realize the possibility of this iatrogenic injury on the nonoperated limb. The article reviews the literature to identify and discuss the risk factors for this limb-threatening condition and thus the implications to orthopaedic nursing.

Penetrating injury of the hand with a door handle: a case report.

INTRODUCTION: Penetrating injuries of the hand with various sharp objects have previously been reported. In this report we describe an unusual penetrating injury of the hand caused by a door handle. CASE PRESENTATION: A 32-year-old woman presented with a door handle stuck into her hand. After a preliminary assessment she was immediately taken to theatre. Broad spectrum antibiotics were administered along with tetanus toxoid. Soft tissue, including neurovascular integrity, was assessed and confirmed during the operation. She had a good functional recovery at follow-up. CONCLUSION: A door handle can occasionally cause a penetrating injury of the hand which should be treated with early intervention, including a careful assessment of soft tissue and neurovascular integrity.

Novel use of Steinman pin in removal of broken interlocking screws.

Broken screws after interlocking nailing of long bones are commonly seen in Orthopaedic practice. Removal of such screws can be difficult particularly the distal part which is often held within the bone. We describe a simple technique of using Steinman pin to aid removal of broken screws in a case of non-union fracture tibia with broken interlocking nail and screws. Steinman pin being easily available and the reproducible technique make it a useful aid for removal of broken interlocking screws.