Hallux valgus interphalangeus: reliability of radiological assessment.

BACKGROUND: Reliable radiographic measurement of hallux valgus interphalangeus (HVI) deformity has a role in guiding surgical management. HVI can be assessed using: The aim of the study is to investigate the reliability of these radiological parameters. METHODS: Seventy foot radiographs in patients pre and post hallux valgus corrective surgery were assessed by 3 observers. HVI was assessed using the radiological measurements described above. Two-way random, single measure intra-class correlation coefficients were calculated to assess agreement. RESULTS: Inter-observer reliability showed good agreement for DASA [ICC=0.77(0.61-0.88)], and excellent for HIA [ICC=0.92(0.85-0.96)] and PDPA [ICC=0.91(0.84-0.96)]. Intra-observer reliability was excellent for all angles; DASA [ICC=0.88 (0.76-0.95)], HIA [ICC=0.94(0.86-0.97)] and PDPA [ICC=0.83(0.65-0.92)]. CONCLUSIONS: Reliability is good to excellent among these three radiological techniques for assessing HVI. The HIA and PDPA are slightly more reliable.

Unicompartmental Knee Arthroplasty: The Past, Current Controversies, and Future Perspectives.

Unicompartmental knee arthroplasty (UKA) is a bone conserving and ligament-sparing procedure that reliably restores normal knee kinematics and function for arthritis limited either to the medial or the lateral compartment of the knee. Although there is enough evidence to demonstrate that the UKA offers good medium to long-term success given the correct patient selection, prosthesis design, and implantation technique, there are several reports to suggest inferior survival rates in comparison with the total knee arthroplasty (TKA). Furthermore, it is a specialized procedure which works well in the hands of the experienced operator and therefore different authors' tend to draw different conclusions based on the same evidence, and as a result, there is great variability in the usage of the UKA. The aim of this current concept's review is to present to the readers the history of the UKA especially with reference to implant design, discuss current controversies, and outline the future perspectives of this novel procedure.

Management of anticoagulation in hip fractures: A pragmatic approach.

Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures.The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents.We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration.Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy.The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal.The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties.Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients. Cite this article: EFORT Open Rev 2017;2:394-402. DOI: 10.1302/2058-5241.2.160083.

The fate of acutely inflamed joints with a negative synovial fluid culture.

PURPOSE: The purpose of this study was to evaluate the management and fate of acutely inflamed joints with a negative synovial fluid culture. METHODS: Between January and December 2009, all the patients who presented to our institution with an acutely inflamed joint and were subjected to microbiological assessment of their synovial fluid, were included in the study. Patients with a positive synovial fluid culture, a prosthetic joint replacement in situ and where an aspirate was obtained for a rheumatological diagnosis were excluded. This cohort was then divided into two groups depending on whether a diagnosis could be established through the course of their treatment. Group I included patients in whom a diagnosis could be established and group II included patients in whom a diagnosis could not be established. A thorough review of the patients' medical records and the hospital database was performed. Following this, a database consisting of the patient demographics, clinical features, investigations, treatment and outcome was created. RESULTS: A total of 144 patients met the inclusion criteria (group I: 95, group II: 49). The most commonly affected joint in both the groups was the knee. The average time to presentation was shorter in group II. Clinical findings at presentation were comparable in both groups. However, inflammatory markers were more likely to be raised in group II in comparison with group I. Eighty-two percent of group II required antibiotic treatment compared with 15% of group I. The mean duration of antibiotic treatment in group I was ten days and in group II was 26 days. Mean hospital stay differed significantly between the two groups, with group II being more than twice as long as compared with group I (p=0.001). The rate of mortality was also higher in group II (8.2%, p=0.03). CONCLUSION: Our study shows that patients presenting with an acutely inflamed joint and a negative synovial fluid culture in whom a diagnosis cannot be established during their hospital stay have a longer hospital stay and an increased rate of mortality as compared with patients in whom a diagnosis can be established.

Role of Newman's classification in predicting outcomes in patients with crystal arthritis.

PURPOSE: The aim of the study was to evaluate the utility of Newman's classification in predicting outcomes in patients presenting with crystal arthritis. METHODS: Between January and December 2009, all patients who presented to our institution with acute crystal arthritis and were investigated with microbiological assessment of their synovial fluid were included in the study. Patients were divided into two groups depending on the fulfilment of Newman's criteria for culture-negative septic arthritis. Group 1 included patients that fulfilled Newman's B criteria. Group 2 included patients that fulfilled Newman's C criteria. A database looking at the demographics, mode of presentation, investigations, treatment and outcomes was then established and the results compared between the two groups. RESULTS: A total of 58 patients were identified (group 1: n = 13; group 2: n = 45). The average age was 71 years (range 33-96). The joint most commonly involved was the knee followed by the wrist. Clinical findings at presentation were comparable in both groups; however, WBC and C-reactive protein (CRP) were more likely to be raised in group 1. Although most patients in group 1 were treated with antibiotics (62%) there was still a higher rate of morbidity, greater use of supportive therapy and a longer hospital stay (22.3 days, SD 17.4) in comparison with group 2, where most patients were treated by observation only (76%, mean hospital stay 3.5 days, SD ± 4.4). The difference in length of hospital stay was statistically significant (p < 0.0001). CONCLUSIONS: Newman's criteria are a good indicator for prognosis in patients with crystal arthritis. However, the presence of crystals in an acutely inflamed joint does not exclude the need for supportive therapy and long hospital stay even in the absence of positive synovial fluid culture.