Early outcomes and radiographic alignment of the Infinity total ankle replacement with a minimum of two year follow-up data.

BACKGROUND: The Infinity total ankle replacement (Wright Medical Technology, Memphis, TN) is a low profile, fluoroscopically navigated, fixed-bearing device. We hypothesised that the fluoroscopic navigation would allow more accurate alignment of the prosthesis than conventional techniques. We present our minimum two year follow up data of Infinity ankle replacements. METHODS: All total ankle replacements (TARs) performed at our institution were prospectively followed-up with EQ5-D and MOx-FQ scores as well as intra-operative radiation exposure and radiographic alignment data. Post-operative radiographs were used to measure the alignment of the prostheses. We identified 20 implants with minimum of two year follow up which were compared to a control group of 20 Zenith TAR's (Corin, Cirencester, UK). RESULTS: Intra-operative fluoroscopic navigation has allowed excellent alignment of all prostheses. Median deviations from 90° alignment to the anatomical axis of the tibia were 1.5° and 1.2° in the anterior-posterior (AP) and lateral planes respectively, compared to 2.8° and 3.1° in the Zenith group. This difference reached significance (p=<0.05) using the Mann-Whitney U test. At 2 years, MOx-FQ scores had fallen from pre-operative mean of 63.9∓17.1 to 15∓12.7. EQ-5D VAS scores had improved from 71.3∓17.3 to 81.4∓9.7 points. Radiation exposure had a mean screening time of 82∓29.4s and a decrease in exposure per patient was observed over time. No patients have undergone, or are awaiting, revision surgery. Complications include one intraoperative medial malleolar tip avulsion fracture, one medial malleolar stress fracture, and one patient who developed CRPS. CONCLUSIONS: We present evidence that this system achieves better anatomical alignment of the components when compared to techniques without fluoroscopic navigation. The implant survival and complication profile at a minimum of two years is satisfactory.

Impact of dietary macronutrient profile on feline body weight is not consistent with the protein leverage hypothesis.

The protein leverage hypothesis proposes that the need to prioritise protein intake drives excess energy intake (EI) when the dietary ratio of protein to fat and carbohydrate is reduced. We hypothesised that cats may become prone to overconsuming energy content when moderate protein diets were offered, and considered the potential influence of fat and carbohydrate on intake. To determine the effect of dietary protein and macronutrient profile (MNP) on EI, weight and body composition, cats (1-4 years) were offered food in excess of energy requirements (ER). A total of six diets were formulated, containing moderate (approximately 7 % w/w; approximately 22 % metabolisable energy (ME)) or high (approximately 10 % w/w; approximately 46 % ME) protein and varying levels of carbohydrate and fat. For 4 weeks, 120 cats were offered 100 % of their individual ER of a diet at the MNP selected by adult cats (50:40:10 protein energy ratio:fat energy ratio:carbohydrate energy ratio). EI, body weight (BW), body composition, activity and palatability were measured. Subsequently, cats were offered one of the six diets at 200 % of their individual ER for 4 weeks when measurements were repeated. Cats offered excess high protein diets had higher EI (kJ/kg) throughout, but at 4 weeks BW was not significantly different to baseline. Cats offered excess moderate protein diets reduced EI and gradually lost weight (average loss of 0·358 (99 % CI 0·388, 0·328) kg), irrespective of fat:carbohydrate and initial palatability. The data do not support the protein leverage hypothesis. Furthermore, cats were able to adapt intake of a wet diet with high protein in an overfeeding environment within 28 d.

Randomised comparison of two skin preparation methods in foot and ankle surgery.

BACKGROUND: Foot and ankle surgery has an increased incidence of post-operative surgical site infections. The aim of this study was to examine the efficacy and efficiency of an alternative method of surgical site preparation for foot and ankle surgery. METHOD: Fifty-one volunteers were recruited for this study which compared standard gauze painting using 2% chlorhexidine with 70% alcohol to immersion of the foot and ankle in a non-sterile bag filled with 60mL of the same solution and rubbing all skin surfaces (bag immersion method). Each method was applied to different feet of each volunteer in a randomised order. Commercially available impression agar slides were used to measure bacteria colony-forming-unit (CFU) counts from four areas of each foot after allowing the preparation to dry. Outcomes included CFU count and preparation time. RESULT: There was no difference between the methods in terms of CFU count (0 total CFU vs. 1). Preparation time was significantly shorter for the bag immersion method (63.98s vs. 67.98s). Two-side 90% confidence intervals (2.03-6.00) for the difference in means of preparation time demonstrated equivalence using a margin of ±20%. CONCLUSIONS: The bag immersion method is a valid alternative, equivalent in preparation timing and the elimination of transient skin flora when using 2% Chlorhexidine with 70% alcohol.

Balancing macronutrient intake in a mammalian carnivore: disentangling the influences of flavour and nutrition.

There is a large body of research demonstrating that macronutrient balancing is a primary driver of foraging in herbivores and omnivores, and more recently, it has been shown to occur in carnivores. However, the extent to which macronutrient selection in carnivores may be influenced by organoleptic properties (e.g. flavour/aroma) remains unknown. Here, we explore the roles of nutritional and hedonic factors in food choice and macronutrient balancing in a mammalian carnivore, the domestic cat. Using the geometric framework, we determined the amounts and ratio of protein and fat intake in cats allowed to select from combinations of three foods that varied in protein : fat (P : F) composition (approx. 10 : 90, 40 : 60 and 70 : 30 on a per cent energy basis) to which flavours of different 'attractiveness' (fish, rabbit and orange) were added. In two studies, in which animal and plant protein sources were used, respectively, the ratio and amounts of protein and fat intake were very consistent across all groups regardless of flavour combination, indicating regulation of both protein and fat intake. Our results suggest that macronutrient balancing rather than hedonistic rewards based on organoleptic properties of food is a primary driver of longer-term food selection and intake in domestic cats.

Ionizing Radiation Doses Detected at the Eye Level of the Primary Surgeon During Orthopaedic Procedures.

OBJECTIVES: To evaluate the ionizing radiation dose received by the eyes of orthopaedic surgeons during various orthopaedic procedures. Secondary objective was to compare the ionizing radiation dose received between differing experience level. DESIGN: Prospective comparative study between January 2013 and May 2014. SETTING: Westmead Hospital, a Level 1 Trauma Centre for Greater Western Sydney. PARTICIPANTS: A total of 26 surgeons volunteered to participate within the study. INTERVENTION: Experience level, procedure performed, fluoroscopy time, dose area product, total air kerma, and eye dose received was recorded. Participants were evaluated on procedure and experience level. MAIN OUTCOME MEASUREMENTS: Radiation dose received at eye level by the primary surgeon during an orthopaedic procedure. RESULTS: Data from a total of 131 cases was recorded and included for analysis. The mean radiation dose detected at the eye level of the primary surgeon was 0.02 mSv (SD = 0.05 mSv) per procedure. Radiation at eye level was only detected in 31 of the 131 cases. The highest registered dose for a single procedure was 0.31 mSv. Femoral nails and pelvic fixation procedures had a significantly higher mean dose received than other procedure groups (0.04 mSv (SD = 0.07 mSv) and 0.04 mSv (SD = 0.06 mSv), respectively). Comparing the eye doses received by orthopaedic consultants and trainees, there was no significant difference between the 2 groups. CONCLUSIONS: The risk of harmful levels of radiation exposure at eye level to orthopaedic surgeons is low. This risk is greatest during insertion of femoral intramedullary nails and pelvic fixation, and it is recommended that in these situations, surgeons take all reasonable precautions to minimize radiation dose. The orthopaedic trainees in this study were not subjected to higher doses of radiation than their consultant trainers. On the basis of these results, most of the orthopaedic surgeons remain well below the yearly radiation dose of 20 mSv as recommended by the International Commission on Radiological Protection.

Impact of alternative metrics on estimates of extent of occurrence for extinction risk assessment.

In International Union for Conservation of Nature (IUCN) Red List assessments, extent of occurrence (EOO) is a key measure of extinction risk. However, the way assessors estimate EOO from maps of species' distributions is inconsistent among assessments of different species and among major taxonomic groups. Assessors often estimate EOO from the area of mapped distribution, but these maps often exclude areas that are not habitat in idiosyncratic ways and are not created at the same spatial resolutions. We assessed the impact on extinction risk categories of applying different methods (minimum convex polygon, alpha hull) for estimating EOO for 21,763 species of mammals, birds, and amphibians. Overall, the percentage of threatened species requiring down listing to a lower category of threat (taking into account other Red List criteria under which they qualified) spanned 11-13% for all species combined (14-15% for mammals, 7-8% for birds, and 12-15% for amphibians). These down listings resulted from larger estimates of EOO and depended on the EOO calculation method. Using birds as an example, we found that 14% of threatened and near threatened species could require down listing based on the minimum convex polygon (MCP) approach, an approach that is now recommended by IUCN. Other metrics (such as alpha hull) had marginally smaller impacts. Our results suggest that uniformly applying the MCP approach may lead to a one-time down listing of hundreds of species but ultimately ensure consistency across assessments and realign the calculation of EOO with the theoretical basis on which the metric was founded.

A radiographic comparison of femoral offset after cemented and cementless total hip arthroplasty.

Restoring femoral offset during total hip arthroplasty is important. Femoral offset and leg lengths are inextricably linked by the caput-collum-diaphysis (CCD) angle of the implant being used. We investigate the restoration of offset and leg lengths using the radiographs of a consecutive series of patients following implantation with either a high CCD angled cementless, or an anatomical CCD angled cemented femoral component. Although our data suggests that we are able to restore femoral offset and leg lengths using either device, we recommend additional caution when using non-anatomical high CCD angled implants.

Arthroscopic triple fusion joint preparation using two lateral portals: a cadaveric study to evaluate efficacy and safety.

BACKGROUND: Arthroscopic triple fusion has several advantages over open techniques, but its use has yet to become widespread. Preliminary published techniques use five portals with neurovascular risk. Our aim was to assess the safety and efficacy of an alternative lateral two portal technique. METHODS: Four cadaveric hindfeet were arthroscopically prepared for a triple fusion using two lateral portals. The distance to relevant subcutaneous nerves was measured as well as the prepared joint surface percentage. RESULTS: Mean distance from mid-lateral portal to the nearest sural nerve branch was 22.3mm (range 20-24mm) and from the dorsolateral portal to the intermediate branch of the superficial peroneal nerve was 7.8mm (range 4-11mm). Mean percentages of joint preparation were 63% (talar head), 62% (navicular), 75% (calcaneum) and 74% (cuboid). CONCLUSIONS: Two lateral arthroscopic portals allow adequate joint preparation for triple fusion procedures. The proximity of subcutaneous nerves is important to appreciate when using these portals.

Identifying the world's most climate change vulnerable species: a systematic trait-based assessment of all birds, amphibians and corals.

Climate change will have far-reaching impacts on biodiversity, including increasing extinction rates. Current approaches to quantifying such impacts focus on measuring exposure to climatic change and largely ignore the biological differences between species that may significantly increase or reduce their vulnerability. To address this, we present a framework for assessing three dimensions of climate change vulnerability, namely sensitivity, exposure and adaptive capacity; this draws on species' biological traits and their modeled exposure to projected climatic changes. In the largest such assessment to date, we applied this approach to each of the world's birds, amphibians and corals (16,857 species). The resulting assessments identify the species with greatest relative vulnerability to climate change and the geographic areas in which they are concentrated, including the Amazon basin for amphibians and birds, and the central Indo-west Pacific (Coral Triangle) for corals. We found that high concentration areas for species with traits conferring highest sensitivity and lowest adaptive capacity differ from those of highly exposed species, and we identify areas where exposure-based assessments alone may over or under-estimate climate change impacts. We found that 608-851 bird (6-9%), 670-933 amphibian (11-15%), and 47-73 coral species (6-9%) are both highly climate change vulnerable and already threatened with extinction on the IUCN Red List. The remaining highly climate change vulnerable species represent new priorities for conservation. Fewer species are highly climate change vulnerable under lower IPCC SRES emissions scenarios, indicating that reducing greenhouse emissions will reduce climate change driven extinctions. Our study answers the growing call for a more biologically and ecologically inclusive approach to assessing climate change vulnerability. By facilitating independent assessment of the three dimensions of climate change vulnerability, our approach can be used to devise species and area-specific conservation interventions and indices. The priorities we identify will strengthen global strategies to mitigate climate change impacts.

Arthroscopic resection of talocalcaneal coalitions--a bicentre case series of a new technique.

BACKGROUND: Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. We describe an arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). METHODS: Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years. RESULTS: Pain and SAFAS improved in 7 patients. Subtalar movements were improved in all feet. All patients achieved early good function but one relapsed requiring subsequent fusions. One posterior tibial nerve was damaged. CONCLUSIONS: Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. Patient selection and preoperative planning are crucial to avoid relapse and complication. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

A review of techniques for gene therapy in bone healing.

Gene therapy has been successfully used in several areas of medicine as a technique to either alter defective genes or as method to enable delivery of therapeutic proteins. Despite advances in surgical and pharmaceutical interventions for diseases of bone regeneration and healing, results in certain patient groups remain sub-optimal. With this consideration, gene therapy is currently being investigated as a means of facilitating healing and improving outcomes. Two broad techniques which are currently utilised by research teams are discussed in this review; ex vivo and in vivo. The underlying principle is similar in each case; the use of gene therapy to alter target cells to deliver proteins which facilitate bone regeneration. However, whereas ex vivo techniques involve performing genetic manipulations outside the body and then introducing the altered cells to the desired site, in vivo techniques execute genetic manipulations inside the body by the introduction of vectors directly to the desired location. Results from small animal models for both techniques are promising, however, further research is required to demonstrate both safety and efficacy prior to any future clinical application.

Consistent proportional macronutrient intake selected by adult domestic cats (Felis catus) despite variations in macronutrient and moisture content of foods offered.

We investigated the ability of domestic cats to regulate the macronutrient composition of their diet when provided with foods that differed not only in macronutrient content but also in texture and moisture content, as typically found in the main forms of commercially manufactured cat foods. Cats were provided with foods in different combinations (1 wet + 3 dry; 1 dry + 3 wet; 3 wet + 3 dry) in three separate experiments. Within each experiment cats were offered the wet and dry food combinations in two (naïve and experienced) diet selection phases where all the foods were offered simultaneously, separated by a phase in which the foods were offered sequentially in 3-day cycles in pairs (1 wet with 1 dry). Using nutritional geometry we demonstrate convergence upon the same dietary macronutrient composition in the naïve and experienced self-selection phases of each experiment as well as over the course of the 3-day cycles in the pair-wise choice phase of each experiment. Furthermore, even though the dietary options were very different in each of these experiments the macronutrient composition of the diets achieved across all experiments were remarkably similar. These results indicate that a mammalian obligate carnivore, the domestic cat, is able to regulate food selection and intake to balance macronutrient intake despite differences in moisture content and textural properties of the foods provided.

Geometric analysis of macronutrient selection in breeds of the domestic dog, Canis lupus familiaris.

Although many herbivores and omnivores have been shown to balance their intake of macronutrients when faced with nutritionally variable foods, study of this ability has been relatively neglected in carnivores, largely on the assumption that prey are less variable in nutrient composition than the foods of herbivores and omnivores and such mechanisms therefore unnecessary. We performed diet selection studies in 5 breeds of adult dog (Canis lupus familiaris) to determine whether these domesticated carnivores regulate macronutrient intake. Using nutritional geometry, we show that the macronutrient content of the diet was regulated to a protein:fat:carbohydrate ratio of approximately 30%:63%:7% by energy, a value that was remarkably similar across breeds. These values, which the analysis suggests are dietary target values, are based on intakes of dogs with prior experience of the respective experimental food combinations. On initial exposure to the diets (i.e., when naive), the same dogs self-selected a diet that was marginally but significantly lower in fat, suggesting that learning played a role in macronutrient regulation. In contrast with the tight regulation of macronutrient ratios, the total amount of food and energy eaten was far higher than expected based on calculated maintenance energy requirements. We interpret these results in relation to the evolutionary history of domestic dogs and compare them to equivalent studies on domestic cats.

Pattern and time phase of shoulder function and power recovery after arthroscopic rotator cuff repair.

BACKGROUND: It has been our observation that early during rehabilitation after rotator cuff repair, patients may take a step back before improving. The purpose of this study is to investigate the pattern and time phase of changes in Constant score and strength recovery after arthroscopic rotator cuff repair. MATERIALS AND METHODS: Forty-five patients undergoing arthroscopic rotator cuff repair were prospectively enrolled in this study. Patients underwent scoring preoperatively with the Constant score. All were followed up at 3 months and 6 months after surgery. The Constant score and strength at 3 months were compared with those at the 6-month mark. RESULTS: The mean Constant score improved from 46.4 points (SD, 17.3) preoperatively to 51.8 points (SD, 13.5) 3 months postoperatively (P = .0777). At 6 months postoperatively, the mean Constant score was 69.0 points (SD, 11.1), a significant increase from both the preoperative (P < .0001) and 3-month (P < .0001) results. The mean preoperative strength result of 4.5 kg (SD, 3.2) decreased significantly to 3.3 kg (SD, 1.8) at 3 months postoperatively (P = .0154) before improving to 5.8 kg (SD, 2.6) at 6 months postoperatively. The improvement in strength at 6 months was significant compared with both the preoperative (P = .0070) and 3-month (P < .0001) results. CONCLUSIONS: Although there is highly significant improvement in overall function (Constant score) and strength 6 months postoperatively, patients appear to take a step back before improving, in fact with a drop in strength at 3 months. This may cause concern in patients and may require assurance that time and effort with physiotherapy will improve function and symptoms.

Postprandial glucose and insulin profiles following a glucose-loaded meal in cats and dogs.

Data from intravenous (i.v.) glucose tolerance tests suggest that glucose clearance from the blood is slower in cats than in dogs. Since different physiological pathways are activated following oral administration compared with i.v. administration, we investigated the profiles of plasma glucose and insulin in cats and dogs following ingestion of a test meal with or without glucose. Adult male and female cats and dogs were fed either a high-protein (HP) test meal (15 g/kg body weight; ten cats and eleven dogs) or a HP + glucose test meal (13 g/kg body-weight HP diet + 2 g/kg body-weight D-glucose; seven cats and thirteen dogs) following a 24 h fast. Marked differences in plasma glucose and insulin profiles were observed in cats and dogs following ingestion of the glucose-loaded meal. In cats, mean plasma glucose concentration reached a peak at 120 min (10.2, 95 % CI 9.7, 10.8 mmol/l) and returned to baseline by 240 min, but no statistically significant change in plasma insulin concentration was observed. In dogs, mean plasma glucose concentration reached a peak at 60 min (6.3, 95 % CI 5.9, 6.7 mmol/l) and returned to baseline by 90 min, while plasma insulin concentration was significantly higher than pre-meal values from 30 to 120 min following the glucose-loaded meal. These results indicate that cats are not as efficient as dogs at rapidly decreasing high blood glucose levels and are consistent with a known metabolic adaptation of cats, namely a lack of glucokinase, which is important for both insulin secretion and glucose uptake from the blood.

The effect of dietary starch level on postprandial glucose and insulin concentrations in cats and dogs.

A charge made against feeding dry foods to cats is that the high carbohydrate (i.e. starch) content results in high blood glucose levels which over time may have detrimental health effects. The present study determined the post-meal concentrations of plasma glucose and insulin in adult cats (seven males and four females) and dogs (Labrador retrievers; four males and five females) fed dry diets with low-starch (LS), moderate-starch (MS) or high-starch (HS) levels. In a cross-over design with at least 7 d between the test meals, plasma glucose and insulin concentrations were measured following a single meal of a LS, MS and HS diet (209 kJ/kg bodyweight). Only the HS diet resulted in significant post-meal increases in plasma glucose concentration in cats and dogs although the time-course profiles were different between the species. In cats, plasma glucose concentration was significantly increased above the pre-meal concentration from 11 h until 19 h after the meal, while in dogs, a significant increase above baseline was seen only at the 7 h time point. Plasma insulin was significantly elevated in dogs 4-8 h following the MS diet and 2-8 h after the HS diet. In cats, plasma insulin was significantly greater than baseline from 3-7 and 11-17 h after the HS diet. The time lag (approximately 11 h) between eating the HS diet and the subsequent prolonged elevation of plasma glucose concentration seen in cats may reflect metabolic adaptations that result in a slower digestive and absorptive capacity for complex carbohydrate.

Geometric analysis of macronutrient selection in the adult domestic cat, Felis catus.

We report feeding studies on adult domestic cats designed to disentangle the complex interactions among dietary protein, fat and carbohydrate in the control of intake. Using geometric techniques that combine mixture triangles and intake plots from the geometric framework, we: (1) demonstrate that cats balance their macronutrient intake, (2) estimate the composition of the target balance and (3) reveal the priorities given to different macronutrients under dietary conditions where the target is unachievable. Our analysis indicates that cats have a ceiling for carbohydrate intake, which limits ingestion and constrains them to deficits in protein and fat intake (relative to their target) on high-carbohydrate foods. Finally, we reanalyse data from a previous experiment that claimed that kittens failed to regulate protein intake, and show that, in fact, they did. These results not only add to the growing appreciation that carnivores, like herbivores and omnivores, regulate macronutrient intake, they also have important implications for designing feeding regimens for companion animals.

Talar body fracture associated with unrecognised talocalcaneal coalition.

We report the case of a talar body fracture occurring in association with a previously undiagnosed talocalcaneal coalition. A rotational injury during a football tackle produced a grossly deformed ankle that was reduced in the emergency department. The unusual appearance of the medial sub-talar region on plain radiographs prompted further imaging by computerised tomography, which confirmed an osseous talocalcaneal coalition. Operative findings included a talar body fracture that could only be reduced after excision of the osseous coalition. The fracture was reduced and fixed. The patient made a good postoperative recovery with favourable AOFAS scores in the medium term at 1 year.