Reconstruction of the glenoid using autologous bone-graft and the SMR Axioma TT metal-backed prosthesis: the first 45 sequential cases at a minimum of two years' follow-up.

AIMS: We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency. PATIENTS AND METHODS: A prospective cohort study of the first 45 shoulder arthroplasties using the SMR Axioma Trabecular Titanium (TT) metal-backed glenoid with autologous bone graft. Between May 2013 and December 2014, 45 shoulder arthroplasties were carried out in 44 patients with a mean age of 64 years (35 to 89). The indications were 23 complex primary arthroplasties, 12 to revise a hemiarthroplasty or resurfacing, five for aseptic loosening of the glenoid, and five for infection. RESULTS: Of the 45 patients, 16 had anatomical shoulder arthroplasties (ASA) and 29 had reverse shoulder arthroplasties (RSA). Postoperatively, 43/45 patients had a CT scan. In 41 of 43 patients (95%), the glenoid peg achieved > 50% integration. In 40 of 43 cases (93%), the graft was fully or partially integrated. There were seven revisions (16%) but only four (9%) required a change of baseplate. Four (25%) of the 16 ASAs were revised for instability or cuff failure. At two-year radiological follow-up, five of the 41 cases (11%) showed some evidence of lucent lines. CONCLUSION: The use of a metal baseplate with a trabecular titanium surface in conjunction with autologous bone graft is a reliable method of addressing glenoid bone defects in primary and revision RSA setting in the short term. ASAs have a higher rate of complications with this technique.

Physical activity and exercise in adults with type 1 diabetes: understanding their needs using a person-centered approach.

Physical activity is a key component in the management of diabetes, but most people do not engage in recommended levels of physical activity. A recent consensus statement on exercise management in type 1 diabetes (T1D) fails to mention behavioral change and the specific determinants impacting on exercise management. The aim of this study is to investigate the needs of adults with T1D around physical activity and the challenges they face. Using a person-centered approach, focus groups and individual semi-structured interviews recorded the perspectives of 67 adults aged ≥18 with diabetes. Four global themes were identified: (i) it's a balancing act, (ii) winging it, (iii) engagement and (iv) encouraging uptake. These findings suggest that adults with T1D find it difficult to manage their diabetes and physical activity and decision-making is based on trial and error with minimal input from healthcare professionals. Participants want more information to enable them to manage their diabetes and physical activity effectively. Adults with T1D face unique challenges in relation to physical activity. Participants reported key determinants for being active. Research is needed to understand how physical activity promotion is best developed for those with T1D and the preparedness of healthcare professionals for delivering guidance to adults with T1D.

Heterotopic ossification following total elbow arthroplasty: a comparison of the incidence following elective and trauma surgery.

Aims: The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification. Patients and Methods: A total of 55 total elbow arthroplasties (TEAs) (52 patients) performed between June 2007 and December 2015 were eligible for inclusion in the study (29 TEAs for primary elective arthroplasty and 26 TEAs for trauma). At review, 15 patients (17 total elbow arthroplasties) had died from unrelated causes. There were 14 men and 38 women with a mean age of 70 years (42 to 90). The median clinical follow-up was 3.6 years (1.2 to 6) and the median radiological follow-up was 3.1 years (0.5 to 7.5). Results: The overall incidence of HO was 84% (46/55). This was higher in the trauma group (96%, 25/26) compared with the elective arthroplasty group (72%, 21/29) (p = 0.027, Fisher's exact test). Patients in the trauma group had HO of higher Brooker class. The presence of HO did not significantly affect elbow range of movement within the trauma or elective groups (elective arthroplasty, Mann-Whitney U test, p = 0.070; trauma arthroplasty, p = 0.370, Mann-Whitney U test). Conclusion: HO after total elbow arthroplasty is seen more commonly than previously reported. We have reported a significantly higher rate of HO in TEAs performed for trauma than those performed electively. Cite this article: Bone Joint J 2018;100-B:767-71.

Rotator cuff repair in patients over 70 years of age: early outcomes and risk factors associated with re-tear.

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019). We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

The use of bone morphogenic protein-7 (OP-1) in the management of resistant non-unions in the upper and lower limb.

The aim of the present study was to investigate the safety and efficacy of local implantation of BMP-7 for the treatment of resistant non-unions in the upper and lower limb. Fifty-two patients (30 males, mean age 52.8 years; range 20-81) were treated with local BMP-7 implantation in a bovine bone-derived collagen paste with or without revision of fixation. Thirty-six patients had closed injuries, ten had open injuries and six had infected non-unions. Patients had undergone a mean of 2 (1-5) operations prior to implantation of BMP-7. Clinical and radiological union was achieved in 94% at a mean time of 5.6 months (3-19). Two patients with subtrochanteric femoral fractures failed to achieve union secondary to inadequate fracture stabilisation, persistent unfavourable biological environment and systemic co-morbidities. One patient developed synostosis attributed to the BMP-7 application. This study demonstrates BMP-7 implanted in a bovine-derived collagen paste is an effective adjunctive treatment for resistant non-unions in the upper and lower limb.

Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients.

INTRODUCTION: There has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures. PATIENTS AND METHODS: Hip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture. RESULTS: 81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture. Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture. DISCUSSION AND CONCLUSION: Simultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.

High tibial osteotomy in medial compartment osteoarthritis and varus deformity using the Taylor spatial frame: early results.

We report the early results of high tibial osteotomy (HTO) in medial compartment osteoarthritis (OA) and varus deformity using the Taylor spatial frame (TSF). Between October 2005 and April 2007, 9 patients with medial compartment OA and varus deformity underwent TSF application and medial opening wedge HTO. Pre- and post-operative Oxford knee scores, SF-12 and visual analogue pain scores were recorded along with radiographic outcomes. Median follow-up was 19 months (range 15-35). Mean age at operation was 49 years (range 37-59). The median time spent in the frame was 18 weeks (range 12-37). The mean preoperative Oxford knee score was 28.7. This improved to a mean of 35.4 post-operatively (P = 0.0142). 6 (67%) patients had a documented pin-site infection. With TKR as an end point, the survival rate of HTOs was 88.9% at a median of 19 months follow-up. This study demonstrates that in selected patients the TSF provides a viable treatment option for performing HTO in medial compartment OA with varus deformity.

Treating the torn rotator cuff: current practice in the UK.

INTRODUCTION: The aim of this study was to characterise current rotator cuff repair activity in the UK with emphasis on the management of rotator cuff tears in the elderly population (over 70s). METHODS: A one-page web-based survey was created. All British Elbow and Shoulder Society (BESS) members and surgeons who listed the shoulder as an area of specialist interest on the website http://www.specialistInfo.com/ were invited to complete this. RESULTS: A total of 103 surgeons completed the survey; most (n =89, 86%) were BESS members. They had spent a median of 10 years (range: 9 months - 30 years) in consultant practice and performed an annual median of 200 (range: 0-1,000) arthroscopic shoulder procedures. For rotator cuff repair the favoured method was arthroscopic for 47 consultants (46.5%), open or mini-open for 41 (40.6%) and both for 13 (12.9%). The annual median number of arthroscopic and open cuff repairs was 20 (range: 0-250) and 12 (range: 0-100) respectively. The longer the time in practice, the fewer the reported number of arthroscopic cuff repairs (r(s)=-0.22, p=0.027) and the greater the number of open and mini-open cuff repairs (r(s)=0.33, p=0.001). In the management of a full-thickness rotator cuff tear in a patient over 70 years of age, 27 (26.7%) would perform an open or mini-open repair, 43 (42.6%) an arthroscopic repair and 22 (21.8%) would not attempt a repair. CONCLUSIONS: Surgeons performing a higher volume of arthroscopic cuff repairs annually were more likely to repair cuff tears and they predicted significantly better outcomes of cuff repair for both pain and shoulder movement. Our results reflect the existing conflicting evidence regarding the indications for and methods of treatment of rotator cuff disease.

Wrong-site surgery in orthopaedics.

Procedures performed at the incorrect anatomical site are commonly perceived as being relatively rare. However, they can be a devastating event for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong-site, wrong-procedure and wrong-patient events occur more commonly than we think. Furthermore, their incidence may be increasing as NHS Trusts increase the volume and complexity of procedures undertaken in order to cope with increasing demands on the system. In previous studies from North America orthopaedic surgery has been found to be the worst-offending specialty. In this paper we review the existing literature on wrong-site surgery and analyse data from the National Patient Safety Agency and NHS Litigation Authority on 292 cases of wrong-site surgery in England and Wales. Orthopaedic surgery accounted for 87 (29.8%) of these cases. In the year 2006 to 2007, the rate of wrong-site surgery in England and Wales was highest in orthopaedic surgery, in which the estimated rate was 1:105,712 cases.

The Thomas splint: its origins and use in trauma.

The Thomas splint is a common piece of equipment in emergency departments and orthopaedic units in hospitals worldwide. Its basic design has changed little since its first description by Hugh Owen Thomas was published in 1875. We have reviewed the origins of the Thomas splint as a means of correction of deformities of the lower limb and its evolution through both World Wars into an essential item for the management of trauma of the lower limb.

Description and reporting of surgical data--scope for improvement?

BACKGROUND: Surgical research articles utilise a variety of descriptive and inferential methods to present and analyse data. The aim of this study was to determine the appropriateness of descriptive methods (e.g. mean, median, SD, range) and survey the use of inferential methods (statistical tests) in key general surgical journals. METHODS: Articles were retrieved from the first three issues of four general surgical journals (Annals of Surgery, British Journal of Surgery, The Surgeon and the Annals of the Royal College of Surgeons of England) in the year 2005. Only original articles were included. Study characteristics, use and appropriateness of descriptive statistics and the number and types of statistical methods employed were evaluated. RESULTS: Of the 144 articles analysed, 119 made use of continuous data. Of these, the use of descriptive methods was inadequate or inappropriate in 50%. The use of '+/-' to describe data dispersion without further explanation occurred in 6.7% and standard error of mean (SEM) was inappropriately used in a further 9.2% of the articles. No statistical methods were described in 23% of the articles. The six most common tests used (Pearson's chi-square, Fisher's exact test, unpaired t test, Mann-Whitney test, log rank and the Cox proportional hazards) accounted for the majority (69%) of the statistical methods employed. CONCLUSION: These results highlight the need for training surgical researchers in 'data description and reporting' and for improved screening by journal reviewers/editors. Critical appraisal of surgical research can be undertaken with a comprehensive understanding of only a limited number of statistical methods.

Increase in meningococcal disease associated with the emergence of a novel ST-11 variant of serogroup C Neisseria meningitidis in Victoria, Australia, 1999-2000.

In the years 1999-2000, there was an increase in the incidence of meningococcal disease in Victoria, largely caused by Neisseria meningitidis serogroup C. This change was associated with a shift in age distribution of cases, with relatively more disease appearing in the 15-29 year age group, and with 40/58 serogroup C isolates in 2000 exhibiting a new macrorestriction pattern (pattern A). Thirty-four of 52 pattern A isolates tested displayed the novel phenotype C:2a:P1.4, and were consistently porA VR type P1.7-2,4 by DNA sequencing. Nine of 10 representative pattern A isolates analysed displayed a housekeeping gene allele profile (ST-11) that is characteristic of the electrophoretic type (ET)-15 variant that has caused outbreaks in Canada, the Czech Republic and Greece. Meningococci belonging to the ST-11 complex that were isolated in Victoria prior to 1999 did not display either restriction pattern A or PorA VR type P1.7-2,4.

X-ray and neutron structure of 1,8-(3,6,9-trioxaundecane-1,11-diyldioxy)-9,10-dihydro-10,10-dimethylanthracene-9-ol (P326); some pitfalls of automatic data collection.

The structure of the crown ether 1,8-(3,6,9-trioxaundecane-1,11-diyldioxy)-9,10-dihydro-10,10-dimethylanthracene-9-ol, C(24)H(30)O(6).H(2)O (1), code name P326, the parent compound for a series of derivatives, has been determined by both X-ray diffraction at room temperature and neutron diffraction at very low temperature. The unit cells are very similar at both temperatures and in both cases the crystals exhibit P2(1) symmetry with Z = 4 (two molecules, A and B, respectively, per asymmetric unit) and pseudosymmetry P2(1)/c. The higher symmetry is broken mainly by the two independent water molecules in the unit cell, some reflections which would be absent in P2(1)/c having strong intensities in both the X-ray and neutron data. In both molecules A and B hydrogen bonds involving the water molecule stabilize the macrocyclic ring structure, one involving the macrocyclic O(9) as a donor. Close contacts between the water and macrocyclic O atoms in each molecule also suggest the presence of two bifurcated hydrogen bonds, involving water HW2 to both O(16) and O(18), and water HW1 to both O(18) and O(20), respectively, with considerable variation in the geometry being present. Both molecules A and B exhibit very close pseudosymmetry across a plane perpendicular to the molecular plane and through atoms C(9) and O(18), and in addition are predominantly planar structures. The X-ray analysis failed to reveal one H atom per water molecule, each being subsequently included after location and refinement in the neutron analysis.

Switching osmolyte strategies: response of Methanococcus thermolithotrophicus to changes in external NaCl.

Methanococcus thermolithotrophicus, a thermophilic methanogenic archaeon, produces and accumulates beta-glutamate and L-alpha-glutamate as osmolytes when grown in media with <1 M NaCl. When the organism is adapted to grow in >1 M NaCl, a new zwitterionic solute, N(epsilon)-acetyl-beta-lysine, is synthesized and becomes the dominant osmolyte. Several techniques, including in vivo and in vitro NMR spectroscopy, HPLC analyses of ethanol extracts, and potassium atomic absorption, have been used to monitor the immediate response of M. thermolithotrophicus to osmotic stress. There is a temporal hierarchy in the response of intracellular osmolytes. Changes in intracellular K(+) occur within the first few minutes of altering the external NaCl. Upon hypoosmotic shock, K(+) is released from the cell; relatively small changes occur in the organic osmolyte pool on a longer time scale. Upon hyperosmotic shock, M. thermolithotrophicus immediately internalizes K(+), far more than would be needed stoichiometrically to balance the new salt concentration. This is followed by a decrease to a new K(+) concentration (over 10-15 min), at which point synthesis and accumulation of primarily L-alpha-glutamate occur. Once growth of the M. thermolithotrophicus culture begins, typically 30-100 min after the hyperosmotic shock, the intracellular levels of organic anions decrease and the zwitterion (N(epsilon)-acetyl-beta-lysine) begins to represent a larger fraction of the intracellular pool. The observation that N(epsilon)-acetyl-beta-lysine accumulation occurs in osmoadapted cells but not immediately after osmotic shock is consistent with the hypothesis that lysine 2,3-aminomutase, an enzyme involved in N(epsilon)-acetyl-beta-lysine synthesis, is either not present at high levels or has low activity in cells grown and adapted to lower NaCl. That lysine aminomutase specific activity is 8-fold lower in protein extracts from cells adapted to low NaCl compared to those adapted to 1.4 M NaCl supports this hypothesis.

Effects of Osmolyte Precursors on the Distribution of Compatible Solutes in Methanohalophilus portucalensis.

The halophilic methanogen Methanohalophilus portucalensis synthesizes three distinct zwitterions, (beta)-glutamine, N(sup(epsilon))-acetyl-(beta)-lysine (NA(beta)Lys), and glycine betaine, as osmolytes when it is grown at high concentrations of external NaCl. The selective distribution of these three species was determined by growing cells in the presence of osmolyte biosynthetic precursors. Glycine betaine is formed by the stepwise methylation of glycine. Exogenous glycine (10 mM) and sarcosine (10 mM), although internalized, do not bias the cells to accumulate any more betaine. However, exogenous N,N-dimethylglycine (10 mM) is available to the appropriate methyltransferase and the betaine generated from it suppresses the synthesis of other osmolytes. Precursors of the two zwitterionic (beta)-amino acids ((beta)-glutamate for (beta)-glutamine and (alpha)-lysine and diaminopimelate for NA(beta)Lys) have only small effects on (beta)-amino acid accumulation. The largest effect is provided by L-(alpha)-glutamine, suggesting that nitrogen assimilation is a key factor in osmolyte distribution.

Antibiotic prescribing during an outbreak of meningococcal disease.

During a prolonged outbreak of meningococcal disease caused by serogroup B serotype 15 sulphonamide-resistant strains in one British health district, there was considerable variation in attack rates by town. General practitioner (GP) antibiotic prescribing rates were compared in high and low incidence towns. The only significant difference found was that erythromycin prescribing was more frequent in the high incidence towns (rate ratio 4.0, 95% CI 3.2-4.8, in March 1987 and 3.0, 95% CI 2.4-3.7, in November 1987). This was probably due to increased GP consultation rates for upper respiratory tract infection (URTI), but higher erythromycin usage may have increased meningococcal acquisition rates or susceptibility to meningococcal disease. Antibiotic prescribing rates should be further investigated in defined areas of high and low incidence of meningococcal disease.

Flocculation of Esch. coli with cationic polymers: a model for the dose curve based on charge.

Continuously grown cells from a glucose limited chemostat were flocculated with four different cationic polymers. The polymer was added to the cells either dropwise or as a slug at the start of the flocculation period. Dose curves for each polymer type and using each method of polymer addition were constructed. It was evident that classical overdose was possible with all four polymers if slug addition was used. Continuous addition produced dose curves overdose was possible with all four polymers if slug addition was used. Continuous addition produced dose curves with no overdosing except when low molecular weight, low charge density polymer was used. The dose curves could be combined if they were based on amount of charge added. The dose curve was not linear, but fitted a logarithmic model well. Charge density was much more important than MW of the polymer.

Non-toxigenic Corynebacterium diphtheriae biovar gravis: evidence for an invasive clone in a south-eastern Australian community.

OBJECTIVE: To determine the prevalence and clonality of non-toxigenic Corynebacterium diphtheriae biovar gravis in a community with two cases of endocarditis caused by this organism. SETTING: A Koorie (Aboriginal) community in Gippsland, eastern Victoria, in 1994. METHODS: Nose and throat swabs were collected from 359 community contacts of the cases and cultured for C. diphtheriae. Strains isolated from the contacts were compared by pulsed-field gel electrophoresis (after digestion with Sma1, Not1 and Sfi1) with those from the invasive cases in the same community, another invasive case in Victoria, a cluster of invasive cases in New South Wales (NSW) (1990-1991), and other stored strains isolated from skin ulcers and sore throats. RESULTS: Non-toxigenic strains of C. diphtheriae biovar gravis were isolated from throat swabs of five of the case contacts. Uniform DNA patterns were found for the two community cases, the other Victorian case, nine of ten isolates from NSW, and the five throat isolates from case contacts. CONCLUSION: An invasive clone of C. diphtheriae biovar gravis appears to have been responsible for the three Victorian cases of endocarditis. It was also present among case contacts and responsible for previous invasive cases in NSW. Prophylactic treatment should be considered for clearly defined contacts in all instances where C. diphtheriae is isolated from a normally sterile site, regardless of the toxigenic nature of the strain.