The 15 year ankle arthroplasty experience in a university hospital.

INTRODUCTION: The study aim was to review the experience of ankle replacement surgery in a university teaching hospital. METHODS: A retrospective review of primary ankle replacements performed between 2005 and 2019 was undertaken. Implant survival and reasons for revision surgery were assessed, along with patient reported outcomes and complications. RESULTS: There were 157 ankle replacements implanted in 140 patients with a mean follow up 7.5 years (range 1.0-14.5). There were 108 Mobility™, 19 Zenith™ and 30 Infinity™ ankle replacements with an overall revision rate of 9.6% at a mean 4.0 years (range 0.1-11.0). Overall survivorship analysis for 5, 10 and 15 years was respectively 92.4%, 89.3% and 86.6%. DISCUSSION: The revision rate was comparable to international registers and aseptic loosening was the commonest reason for revision. This study, in a teaching university hospital with an average of 10 primary ankle replacements each year, highlighted ankle arthroplasty provides good functional outcomes and medium term implant survivorship. This supports the use of ankle arthroplasty within foot and ankle specialist centres achieving appropriate outcomes.

Concussion management application for amateur sports.

Concussion management has become one of the most popular topics in sports medicine. Significant resources are being invested in developing protocols for professional sport associations such as the NFL and FIFA. These protocols are often expensive and require substantial resources to implement. The problem, however, runs much deeper than just professional sports. Currently there exists little infrastructure to effectively manage concussion in amateur settings such as high school, club and university sport. A more holistic approach is required to ensure that the same standard of concussion management is being implemented across the board, regardless of the available medical and financial resources. An application was developed that will allow for easily accessible baseline testing and access to a player's concussion history from anywhere in the world. The application will be used to monitor players from the day they start playing sport until they potentially become professional sport players.

Notch-induced mammary tumorigenesis does not involve the lobule-limited epithelial progenitor.

The mouse mammary epithelial cell hierarchy contains both multipotent stem cell as well as lineage-limited duct and lobular progenitor cell functions. The latter-also termed parity-identified mammary epithelial cells (PI-MECs)-are marked by beta-galactosidase (ß Gal) expression following pregnancy and involution in whey acidic protein promoter (WAP)-Cre/Rosa26-flox-stop-flox-lacZ (WC/R26) mice, and are the targets of tumorigenic transformation in mouse mammary tumor virus-erbB2 transgenic mice. In this study, we demonstrate that an epithelial population distinct from PI-MECs is transformed during WAP-Int3 tumorigenesis. As expected, WAP-Int3/WC/R26 triple-transgenic mice failed to undergo secretory alveolar development, failed to lactate and developed mammary tumors. Following pregnancy and involution, ß Gal+ mammary epithelial cells were found in the normal mammary tissue, but the resulting mammary tumors were all ß Gal-. WAP-Int3/WC/R26 mammary glands contained ample estrogen receptor alpha (ERα)+ MECs, but only rare (<1%) progesterone receptor (PR)+ and RANKL+ cells. In addition, dissociated MECs from WAP-Int3/WC/R26 glands failed to regenerate a mammary tree upon transplantation into a cleared fat-pad of a nu/nu recipient mouse. However, when mixed with normal MECs, PI-MECs from WAP-Int3/WC/R26 mice contributed progeny to the resulting functional outgrowth. The WAP-Int3/WC/R26-derived PI-MECs displayed all of the properties of fully functional lobular progenitors including giving rise to ERα+, PR+, smooth muscle actin+ and RANKL+ epithelial progeny. These results demonstrate that WAP-Int3 has no oncogenic effect upon PI-MECs and that the expansion of functional lobular progenitors is required for secretory alveolar development and lactation. Furthermore, lobular progenitor function is ultimately controlled by signals within its microenvironment.

Prune belly syndrome.

The majority of paediatric surgeons will encounter a patient with prune belly syndrome (PBS) only a few times in their clinical practice. There have been many opposing views in the literature regarding the pathogenesis and management of this complex condition. A detailed review was conducted using PubMed to identify key publications involving PBS. This article discusses the evolution of our understanding of the pathogenesis and diagnosis of PBS, including its typical characteristics. We describe the management options available for bilateral intra-abdominal testes, the deficient abdominal wall, the dilated urinary system and examine the evidence base used to support the current approaches employed.

Tensioning of Prolene reduces creep under cyclical load: relevance to a simple pre-operative manoeuvre.

A longitudinal stretch or 'pre-tensioning' is a method employed by some surgeons to improve the handling characteristics of a suture. We used a tensile tester to assess the effect of pre-tensioning on the mechanical properties of two suture materials (3-0 Prolene and 3-0 Ethibond) commonly used for flexor tendon repair. A cyclical loading programme was used to simulate an early rehabilitation regime. All sutures were subsequently tested to failure (for ultimate tensile strength). The pre-tensioned Prolene sutures showed significantly less creep after cyclical loading in comparison to controls. Conversely pre-tensioning had no measurable effect on the deformation of Ethibond by creep. There was no effect on ultimate tensile strength for either material. The propensity of Prolene to creep (and thereby form a 'gap' in tendon repairs) can be reduced by pre-tensioning.

Setting the speed limit: a pilot study of the rate of serum creatinine decrease after endoscopic valve ablation in neonates.

PURPOSE: In neonates with a posterior urethral valve serum creatinine is increased. It decreases after successful relief of obstruction. Clinicians consider urinary diversion if serum creatinine remains increased. However, the optimal rate of decrease of serum creatinine is not defined. We generated useful data on the rate of serum creatinine decrease in neonates with a posterior urethral valve by introducing the idea of a prediction curve. MATERIALS AND METHODS: We reviewed the medical charts of 15 consecutive children treated for a posterior urethral valve in the neonatal period at our institute between 2002 and 2007. The 11 children with a delayed diagnosis of a posterior urethral valve were excluded from analysis. Serial serum creatinine levels in the cohort of 15 patients were analyzed to estimate 1) the rate of decrease after valve ablation and 2) the time needed to achieve a nadir. RESULTS: One child died of renal insufficiency on day 10 of life and was excluded from study. Serum creatinine attained a nadir at about age 6 months but 73% of the total decrease occurred within the first 2 months of life, which was also equal to a 45% decrease from the peak values recorded soon after birth. The rate of decrease did not appear to be influenced by the peak values. Children with normal peak creatinine or intercurrent problems did not follow the trend. CONCLUSIONS: The rate of decrease in serum creatinine in the first few months of life may provide useful information on the adequacy of valve ablation.

Ureteral triplication: a rare anomaly with a variety of presentations.

Ureteral triplication remains a very rare congenital malformation of the urinary tract with a wide spectrum of presentation. The sporadic nature of this condition and its association with other anomalies makes evidence-based management difficult. We report two cases of triplication in association with the VACTERL syndrome, one developing pelvi-ureteric junction obstruction and the other vesico-ureteric reflux.

The normal mammary microenvironment suppresses the tumorigenic phenotype of mouse mammary tumor virus-neu-transformed mammary tumor cells.

The microenvironment of the mammary gland has been shown to exert a deterministic control over cells from different normal organs during murine mammary gland regeneration in transplantation studies. When mouse mammary tumor virus (MMTV)-neu-induced tumor cells were mixed with normal mammary epithelial cells (MECs) in a dilution series and inoculated into epithelium-free mammary fat pads, they were redirected to non-carcinogenic cell fates by interaction with untransformed MECs during regenerative growth. In the presence of non-transformed MECs (50:1), tumor cells interacted with MECs to generate functional chimeric outgrowths. When injected alone, tumor cells invariably produced tumors. Here, the normal microenvironment redirects MMTV-neu-transformed tumorigenic cells to participate in the regeneration of a normal, functional mammary gland. In addition, the redirected tumor cells show the capacity to differentiate into normal mammary cell types, including luminal, myoepithelial and secretory. The results indicate that signals emanating from a normal mammary microenvironment, comprised of stromal, epithelial and host-mediated signals, combine to suppress the cancer phenotype during glandular regeneration. Clarification of these signals offers improved therapeutic possibilities for the control of mammary cancer growth.

The hidden blood loss after hip fracture.

INTRODUCTION: Despite advances in surgical and anaesthetic techniques the mortality after hip fracture has not significantly changed in the last 40 years. Pre-operative anaemia is a risk factor for peri-operative death. We speculate that a significant proportion of the blood loss related to hip fractures has occurred prior to surgery. Identifying patients at risk of pre-operative anaemia can facilitate appropriate medical optimisation. This study is unique in its attempt to quantify the blood loss associated with the initial hip injury. METHODS: In a retrospective study all patients with both a diagnosis of hip fracture and an operative delay of >48 h were assessed. The information collected included: fracture classification, serial haemoglobins and patient co-morbidities. The exclusion criteria included a pre-injury diagnosis of anaemia, anti-coagulation and gastrointestinal bleeds. RESULTS: Between 2007/2008 sixty-eight intracapsular and fifty extracapsular hip fracture patients had serial haemoglobins and operative delays of >48 h (mean 75 h, range 48-270 h). The mean lowest recorded haemoglobin prior to surgery for both extracapsular and intracapsular fractures were 95.0 g/L (+/-SEM 2.2) and 108.5 g/L (+/-SEM 2.2) respectively. This difference was statistically significant (Student's t-test p<0.05). The mean haemoglobin drop in the extracapsular and intracapsular fracture groups was 20.2 g/L (range 0-49 g/L) and 14.9 g/L (range 0-59 g/L) respectively. CONCLUSIONS: Hip fracture patients have a large drop in haemoglobin that is associated with the initial trauma rather than the operation. This highlights the need for anaesthetic and orthopaedic staff to be vigilant to the risk of pre-operative anaemia in this cohort of frail patients even when the initial haemoglobin is apparently normal.

Management of urethrocutaneous fistula following hypospadias repair.

Urethrocutaneous fistulas complicating hypospadias repair appear a common problem. There appears less data in the literature regarding the risk and management of recurrent fistulas. A retrospective review of urethrocutaneous fistulas complicating hypospadias repair was performed to evaluate their aetiology, management and outcome. Between 1993 and 2003, 1,753 patients had a hypospadias repair at our institution. Overall 123 (7%) boys developed a fistula, although detailed information was available on 117 patients only. Median age was 3.5 years at the time of fistula repair; 13% had anterior, 57% had middle and 30% had posterior hypospadias. The most common primary surgical procedure was a Durham Smith two-stage repair in 29% (n = 34), followed by a Tubularised Incised Plate urethroplasty in 19% (n = 22) and an Onlay in 14% (n = 16). Thirty-one (27%) patients developed a recurrent fistula, 9 (29%) of which recurred following a second repair. None recurred after a third repair. The risk of a recurrent fistula after an initial distal fistula repair was 12.5% and after a posterior fistula was 62% (chi(2) = 15.4, P = 0.001). Use of a stent, suture type, numbers of fistula and closure attempts did not influence the recurrence rate. Undiagnosed distal obstruction was thought to be related to 27 of 117 first fistula repairs (23%) and 4 of 31 second fistula repairs (13%). The risk of recurrent urethrocutaneous fistula was increased in those boys with a posterior fistula, following a simple repair or when there was evidence of distal urethral obstruction.

Spontaneous compartment syndrome in association with simvastatin-induced myositis.

Compartment syndrome as a result of simvastatin-induced myositis is extremely rare. This case discusses a patient with spontaneous onset compartment syndrome that necessitated four-compartment fasciotomy. A thorough investigation into its cause highlighted statin-induced myositis as the most likely aetiological agent. When investigating a patient with unexplained spontaneous compartment syndrome it is important to consider drug-induced myositis. This case reinforces the difficulty faced in diagnosing spontaneous compartment syndrome.

Paraileostomy recontouring by collagen sealant injection: a novel approach to one aspect of ileostomy morbidity. Report of a case.

INTRODUCTION: Poorly fitting stoma appliances, resulting in stomal leakage and subsequent skin excoriation, remain a significant cause of ileostomy-related morbidity. One cause of ill-fitting stoma bags is the presence of parastomal dermal contour defects/irregularities. These may occur after surgical complications or change in patient weight and body habitus. METHODS: We report the case of a 29-year-old man who, after panproctocolectomy and formation of ileostomy for ulcerative colitis, experienced significant problems with stoma bag application because of dermal contour defects. As a result, he suffered from significant stomal leakage and skin excoriation. After a single treatment of cutaneous parastomal infiltration of porcine collagen (Permacol Injection), applied stoma bags achieved a watertight seal, and the patient experienced complete and sustained resolution of his symptoms. CONCLUSIONS: Porcine collagen is a safe, versatile, and relatively easy method of restoring irregular skin defects surrounding abdominal stomas, thus resolving the significant patient morbidity associated with ill-fitting stomal appliances. Such a technique avoids the need for surgical stoma refashioning, which may be associated with significant morbidity and unsatisfactory outcomes.

Interventions for primary vesicoureteric reflux.

BACKGROUND: Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered the main cause of permanent renal parenchymal damage in children with reflux. Management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. Controversy remains as to the optimum strategies. OBJECTIVES: To evaluate the benefits and harms of different treatment options for primary VUR. SEARCH STRATEGY: Randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. Date of last search: June 2006 SELECTION CRITERIA: Any treatment of VUR including surgery, antibiotic prophylaxis of any duration, non-invasive techniques and any combination of therapies. DATA COLLECTION AND ANALYSIS: Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model. MAIN RESULTS: Eleven studies (1148 children) were identified. Seven compared correction of VUR (by surgery or endoscope) plus antibiotics for 1-24 months with antibiotics alone, two compared antibiotics with no treatment and two compared different materials for endoscopic correction of VUR. Risk of UTI by 2, 5 and 10 years was not significantly different between surgical and medical groups (2 years RR 1.07, 95% CI 0.32 to 2.09; 5 years RR 0.99, 95% CI 0.79 to 1.26; 10 years RR 1.06, 95% CI 0.78 to 1.44). Combined treatment resulted in a 50% reduction in febrile UTI by 10 years (RR 0.54, 95% CI 0.55 to 0.92) but no concomitant reduction in risk of new or progressive renal damage by 10 years (RR 1.03, 95% CI 0.53 to 2.00). In two small studies no significant differences in risk for UTI (RR 0.75, 95% CI 0.15 to 3.84) or renal damage (RR 1.70, 95% CI 0.36 to 8.07) were found between antibiotic prophylaxis and no treatment. AUTHORS' CONCLUSIONS: It is uncertain whether the treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.

Secondary perineal hernia following open abdominoperineal excision of the rectum: report of a case and review of the literature.

This is a case report of a 46-year-old man who presented with a painful perineal lump four months after abdominoperineal excision of the rectum (APER) with pre-operative radiotherapy and adjuvant chemotherapy. Perineal hernia (suspected clinically) was confirmed by magnetic resonance imaging, and the patient underwent open Permacol mesh repair via a perineal approach. Symptomatic perineal herniation after surgical resection is a rare phenomenon, and the approach to management remains challenging. Several different surgical approaches and techniques of repair have been described. In this report, we review the literature surrounding the presentation, aetiology and repair of this unusual post-operative complication. Furthermore, our case confirms that closure of the hernial orifice with mesh via a perineal approach is a satisfactory technique.

Necrotising myositis: a surgical emergency that may have minimal changes in the skin.

Necrotising myositis is a surgical emergency. It is underappreciated that it may present without changes in the skin. Diagnosis is therefore often delayed. We describe a case of necrotising myositis necessitating glenohumeral disarticulation. Remarkable features were the absence of skin signs and the rapidity with which the patient became extremely septic. A review of the literature has shown the importance of early diagnosis and quick decision making to minimise mortality.

A method to assess posterior urethral valve ablation.

PURPOSE: There are few published reports addressing the assessment of posterior urethral valve ablation. This study was performed to provide a ratio to measure successful treatment of posterior urethral valves. MATERIALS AND METHODS: A total of 35 patients with posterior urethral valves were treated by a single surgeon between 1995 and 2004. Of these patients 23 were younger than 1 year at diagnosis and were selected for this study. A urethral ratio was calculated by dividing the posterior urethral diameter by the anterior urethral diameter. A total of 31 males undergoing cystography for urinary tract infections were evaluated as normative controls. The urethral ratio was also measured and calculated for these patients. RESULTS: Median patient age was 1.5 months. In 13 patients preoperative cystograms were available and in 20 patients postoperative cystograms were available for review. Measurements were made of the posterior urethral and anterior urethral diameters. Median preoperative ratio in 13 patients was 8.6. This ratio decreased postoperatively to 3.1 in 15 patients who only required 1 ablation and 8.0 in 5 patients who required a second ablation. After a second ablation the ratio decreased to 3.1. The 5 cases requiring a second ablation were initially managed by cystoscopy and a flexible electrode. None of the patients treated initially with a resectoscope required a second ablation. Urethral ratio was 2.6 in 31 normal males undergoing cystogram for investigation of a urinary tract infection. CONCLUSIONS: Calculating urethral ratio in patients with posterior urethral valves allows objective measurement of the technical success of valve ablation.

Red herring: a rare cause of small bowel obstruction.

This is a case report of a 73-year-old man with a small bowel obstruction secondary to an incarcerated paracaecal hernia. His large right inguinal hernia, initially suspected as a potential source of obstruction, turned out to be a red herring. Congenital internal hernias are a very rare cause of bowel obstruction. In this report we review the literature and embryology behind these uncommon occurrences.

Influence of RANTES, SDF-1 and TGF-beta levels on the value of interleukin-7 as a predictor of virological response in HIV-1-infected patients receiving double boosted protease inhibitor-based therapy.

OBJECTIVES: Interleukin-7 (IL-7), RANTES (regulated on activation, normal T cell expressed and secreted), stromal cell-derived factor-1 (SDF-1) and transforming growth factor-beta (TGF-beta) appear to share certain biological properties in vitro and all are involved in HIV-1 disease progression. Our earlier observations indicated that IL-7 levels decrease upon CD4 T-cell recovery and represent a new, independent predictor of virological response. Here, we examine associations among circulating levels of IL-7, RANTES, SDF-1 and TGF-beta in hopes of gaining insight into their contribution to the predictive value of IL-7. METHODS: Levels of IL-7, RANTES, SDF-1 and TGF-beta, and immune and viral parameters were assessed in HIV-1-infected patients. RESULTS: Cross-sectional (n=148) and longitudinal (n=36) analyses showed that levels of IL-7, but not RANTES, SDF-1 or TGF-beta, were increased in HIV-1-infected adults compared with those of healthy controls. In the cross-sectional study, levels of IL-7 were correlated with RANTES (r=0.31, P=0.002) and TGF-beta (r=0.53, P<0.001) but not with SDF-1 (r=0.12, P=0.22), and these associations were more pronounced in patients with CD4 T-cell counts >200 cells/microL. In contrast to IL-7, levels of RANTES, SDF-1 and TGF-beta were not correlated with CD4 T-cell counts. Longitudinal analysis revealed a marked decline in IL-7 levels accompanied by an increase in CD4 T-cell count following antiretroviral therapy (ART), but no changes in RANTES, SDF-1 or TGF-beta levels. Multivariate regression analysis showed no influence of baseline RANTES, SDF-1 or TGF-beta levels on the value of IL-7 as a predictor of virological response at 48 weeks. CONCLUSIONS: Collectively, these results indicate that changes in IL-7 levels did not induce changes in RANTES, SDF-1 or TGF-beta. Furthermore, they indicate that RANTES, SDF-1 or TGF-beta levels do not explain the predictor value of IL-7 in patients receiving ART.