Value of the 'clicky hip' in selective screening for developmental dysplasia of the hip.

AIMS: The aim of this study was to review the value of accepting referrals for children with 'clicky hips' in a selective screening programme for hip dysplasia. PATIENTS AND METHODS: A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant. RESULTS: There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to 'clicky hip' with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with 'clicky hip' and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a 'clicky hip' and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips. CONCLUSION: There is significant value in reviewing children with an isolated 'clicky hip'. Many children who require treatment are referred to the orthopaedic service as 'clicky hip' with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, 'clicky hip' is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635-638.

Manipulation and reduction of paediatric fractures of the distal radius and forearm using intranasal diamorphine and 50% oxygen and nitrous oxide in the emergency department: a 2.5-year study.

UNLABELLED: A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation. The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED. By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method. TAKE HOME MESSAGE: Simple easily reducible fractures of the distal radius and forearm in children can be successfully and safely treated in the ED using this approach, thus avoiding theatre admission and costly hospital stay.

End caps prevent nail migration in elastic stable intramedullary nailing in paediatric femoral fractures: a biomechanical study using synthetic and cadaveric bones.

End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure. Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°. In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007). These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push-out can be effectively reduced by the use of end caps.

The outcomes of displaced paediatric distal radius fractures treated with percutaneous Kirschner wire fixation: a review of 248 cases.

This study aimed to evaluate the effect of manipulation under anaesthesia (MUA) and Kirschner wire (K-wire) fixation of displaced, paediatric distal radius fractures on residual radiological angulation, displacement, and shortening, as well as functional outcomes, including complication rates. A retrospective review was conducted of all paediatric patients undergoing MUA and K-wire fixation for an extra-articular distal radius fracture over a period of 5 years. A total of 248 patients were included in the study with a mean age of 9.9 years (3-15). Mean follow-up was 6.6 weeks (4-156). There was a statistically significant increase in median dorsal angulation (p<0.0001) between initial post-operative and follow-up radiographs at the time of K-wire removal. The number of K-wires used did not have a significant effect on dorsal angulation (p=0.9015) at time of K-wire removal, nor did the use of an above or below elbow cast (p=0.3883). Seventeen patients required a further general anaesthetic (5 revision operations, 12 removal of migrated K-wires). Eighty-seven percentage of (215 patients) of patients had normal function at follow-up post-K-wire removal. Angulation at time of K-wire removal of more than 15° was significantly associated with reduced functional outcome (p=0.0377). A total of 41 patients (17%) had complications associated with K-wire use. We conclude that though K-wire fixation is an effective technique, it does not prevent re-angulation of the fracture and is associated with a significant complication rate. Given the remodelling potential and tolerance to deformity in children, surgeons should give careful thought before utilising this technique for all displaced or angulated paediatric distal radius fractures. If used, 1 K-wire with immobilisation in a below elbow cast is sufficient in most cases.

Current screening recommendations for developmental dysplasia of the hip may lead to an increase in open reduction.

Most centres in the United Kingdom adopt a selective screening programme for developmental dysplasia of the hip (DDH) based on repeated clinical examination and selective ultrasound examination. The Newborn Infant Physical Examination protocol implemented in 2008 recommends a first examination at birth and then a second and final examination at six to ten weeks of age. Due to concerns over an increase in late presentations we performed a retrospective review of our 15-year results to establish if late presentation increases treatment requirements. Of children presenting before six weeks of age, 84% were treated successfully with abduction bracing, whereas 86% of children presenting after ten months eventually required open reduction surgery. This equates to a 12-fold increase in relative risk of requiring open reduction following late presentation. Increasing age at presentation was associated with an increase in the number of surgical procedures, which are inevitably more extensive and complex, with a consequent increased in cost per patient. The implementation of an opportunistic examination at three to five months could help to reduce the unintended consequences of the Newborn Infant Physical Examination programme.

Clinical evaluation of end caps in elastic stable intramedullary nailing of femoral and tibial shaft fractures in children.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) may be complicated by the loss of reduction following push out of the nails at the entry site in unstable femoral and tibial fractures, especially in older and heavier children and following technical failures. An end cap system addressing this complication was evaluated clinically. METHODS: In a retrospective case series, 49 femoral and five tibial fractures in 54 pediatric patients treated by ESIN and end caps were documented in two European tertiary centers. End caps were used to interlock standard ESIN nails. The results were evaluated regarding difficulties in the placement and removal of the end cap system, fracture stability and healing, and return to normal activities by analyzing patient charts and X-rays. RESULTS: Fifty-three of 54 fractures were stabilized sufficiently with ESIN and end caps. Loss of reduction was observed in one patient, requiring additional surgery. Six complications were observed, five of which were not related to end caps. There were no significant leg length differences or varus/valgus deformities. A rotational difference of >10°-20° was found in one patient. Removal of the end caps and nails was rated as simple and uncomplicated in 35/37 cases. CONCLUSIONS: End caps avoided postoperative instability in the majority of pediatric patients with lower limb shaft fractures, even in heavier, older patients and those with instable fracture types. End caps, however, will not compensate for operative technical insufficiency concerning reduction or nail placement. To maximize the stability of ESIN-instrumented unstable fractures, end caps require properly placed nails.

Human papillomavirus prevalence at the USA-Mexico border among women 40 years of age and older.

The incidence of cervical cancer increases with age among USA Hispanics and women living in Latin America starting in the fourth decade of life. We conducted a study of women > or = 40 living at the USA-Mexico border to determine the prevalence and risk factors for human papillomavirus (HPV) infection detected by polymerase chain reaction. In all, 9.2% of participants tested HPV positive. Compared with women aged 50-59, odds ratios of 8.82 and 6.67 were observed for women > or = 60 and 40-49, respectively. Among women aged 40-49, both oncogenic and non-oncogenic HPV infections were detected; however, women > or = 60 were positive for predominantly oncogenic genotypes. HPV risk significantly increased with > or = 2 lifetime sexual partners in adjusted models. These data suggest that the prevalence of HPV infection may have a second peak among post-menopausal Hispanic women.

Bier's block using prilocaine: safe, cheap and well tolerated.

OBJECTIVES: To examine the safety of prilocaine Bier's block performed for Colles fracture manipulation, and assess patient satisfaction. METHOD: Fifteen-year retrospective review of all patients undergoing Colles fracture manipulation with a prilocaine Bier's block looking for the incidence of significant neurological or cardiovascular events. A confidential questionnaire was administered to 50 consecutive patients to assess patient satisfaction with the method of anaesthesia. RESULTS: 1504 males with mean age 48 years and 5906 females with mean age 66 years received a prilocaine Bier's block for distal radial fracture manipulation. There were no documented incidences of anaphylaxis, arrhythmia, convulsions or collapse. Of 50 consecutive patients, all but two were satisfied with this form of anaesthesia. The pressure cuff inflation was considered the worst part of the procedure. CONCLUSION: Bier's block performed with prilocaine is at least as safe as other commonly used methods of anaesthesia for distal radial fracture reduction with high patient satisfaction. The procedure can be safely carried out by a single medical practitioner with appropriate patient monitoring and assistance from trained nursing staff.

Arthroscopic washout of the shoulder for septic arthritis in infants. A new technique.

The operative treatment of septic arthritis of the shoulder in infants has been facilitated by the use of a 30 degrees wrist arthroscope. We have treated three children under the age of three years using this technique. After initial aspiration of the joint, an arthroscope was inserted using the posterior approach. Washout was performed under direct vision and complete clearance of pus allowed assessment of the inflammation and the damage to articular cartilage. The procedure was minimally invasive and gave excellent cosmesis without compromising care. Full recovery was achieved with a single intervention.

The effect of microgravity and space flight on the chemical senses.

The effect of space flight and microgravity on the chemical senses is reviewed. Skylab-4 and Soyuz 30-31 studies revealed changes in taste thresholds while no effect was found in a Canadian investigation (41-G) and conflicting results were obtained on another Soyuz mission. Two simulated microgravity studies found no effect on taste or smell sensitivity; while 5 other studies found an effect. Microgravity induces physiological changes including an upward shift of body fluids toward the head, which may lead to an attenuation of the olfactory component in the flavor of foods. Chemosensory changes may also relate to space sickness, Shuttle atmosphere, stress, radiation, and psychological factors.

Distal radial fractures in young goalkeepers: a case for an appropriately sized soccer ball.

OBJECTIVES: To assess the rate of wrist fractures in young goalkeepers sustained by the specific mechanism of "saving the ball" and the potential influence of ball size and environmental conditions. METHODS: A prospective, clinic based study in one institution over a 17 month period. Patients were identified by specific questioning. Information on play circumstances and subsequent clinical progress was documented. RESULTS: Twenty nine fractures of the distal radius were identified in young goalkeepers (age range 6-15 years) as a direct result of saving the ball. Most were managed simply in a plaster cast. Three patients required minor surgical interventions, and all fractures went on to unite without significant complications. Where ball size was known, 12 of the 15 fractures in children aged 11 years or less occurred as the result of impact with an adult sized ball compared with three when a junior ball was involved. This is statistically significant (p = 0.039). In the 10 children aged 12-15 years, only one fracture involved a junior ball; this is also statistically significant (p = 0.027). Six of the injuries (21%) occurred when the ball was kicked by an adult. Injuries occurred in both organised and informal games throughout the year. CONCLUSIONS: This specific mechanism of injury has not been widely acknowledged nor has the potential influence of ball size as a causative factor been examined. Recommendations for an appropriately sized soccer ball for young players exist but are not in universal use. Increased awareness of this particular injury mechanism is required.

The posterolateral approach to the distal humerus for open reduction and internal fixation of fractures of the lateral condyle in children.

Our study describes a posterolateral approach to the distal humerus for open reduction and internal fixation of displaced fractures of the lateral condyle. A total of 20 patients had open reduction and internal fixation over a four-year period using this approach, and at a mean follow-up of 12 months had full union, range of movement and no complications, either clinical or radiological. This approach is well suited to the exact visualisation and accurate reduction of this difficult fracture with minimal dissection of tissues.

Process options in hepatitis B surface antigen extraction from transgenic potato.

The process conditions for recombinant hepatitis B surface antigen (HBsAg) extraction from transgenic potato were examined. The effects of temperature, the reducing agent beta-mercaptoethanol (BME), and proteinase inhibitors on the level of antigenic activity of recovered HBsAg were determined. Sedimentation profiles were performed to characterize HBsAg assembly into virus-like particles. Increasing the temperature of the sample for about 1 min increased the measured HBsAg antigenic activity. The optimum temperature was around 50 degrees C. A 3-fold enhancement of the antigenic activity was obtained in extract from transgenic potato expressing HBsAg, when monoclonal antibodies were used to assay for HBsAg. When antigenic activity was determined by polyclonal antibodies, no enhancement in the antigenic activity was obtained. Temperature may affect the conformation of the a epitope to which the monoclonal antibodies bind or alter the fluidity of surface lipid regions. BME increased the antigenic activity of HBsAg up to 4-fold when monoclonal antibodies directed against the a determinant were used, but there was no increase with polyclonal antibodies. This observation suggests that BME affects the structure or presentation of the a epitope. In the presence of BME and leupeptin, a proteinase inhibitor, higher antigenic activity was obtained. Leupeptin might protect the antigen, which might become more susceptible to proteolytic degradation after reduction, as a result of stimulation of sulfhydryl proteases. Although both temperature and BME increased the antigenic activity of HBsAg individually, when combined their interaction was antagonistic, resulting in reduced antigenic activity. Different proteinase inhibitors, including leupeptin, aprotinin, E-64, pefabloc, and pepstatin, had no significant effect on HBsAg from potato extract in a 2 h period in the absence of BME. The sedimentation profile of potato-produced HBsAg was determined in 5-30% sucrose gradients. Yeast-derived recombinant HBsAg was used as a positive control. The HBsAg from transgenic potato showed sedimentation and density properties that are very similar to the yeast-produced antigen, indicating assembly into virus-like particles. BME treatment did not change the sedimentation profile.

Ozonation and alkaline-peroxide pretreatment of wheat straw for Cryptococcus curvatus fermentation.

Crop residues in an Advanced Life Support System (ALS) contain many valuable components that could be recovered and used. Wheat is 60% inedible, with approximately 90% of the total sugars in the residue cellulose and hemicellulose. To release these sugars requires pretreatment followed by enzymatic hydrolysis. Cryptococcus curvatus, an oleaginous yeast, uses the sugars in cellulose and hemicellulose for growth and production of storage triglycerides. In this investigation, alkaline-peroxide and ozonation pretreatment methods were compared for their efficiency to release glucose and xylose to be used in the cultivation of C. curvatus. Leaching the biomass with water at 65 degrees C for 4 h prior to pretreatment facilitated saccharification. Alkaline-peroxide and ozone pretreatment were almost 100% and 80% saccharification efficient, respectively. The sugars derived from the hydrolysis of alkaline-peroxide-treated wheat straw supported the growth of C. curvatus and the production of edible single-cell oil.

A structural explanation for the binding of multiple ligands by the alpha-adaptin appendage domain.

The alpha subunit of the endocytotic AP2 adaptor complex contains a 30 kDa "appendage" domain, which is joined to the rest of the protein via a flexible linker. The 1.9 A resolution crystal structure of this domain reveals a single binding site for its ligands, which include amphiphysin, Eps15, and epsin. This domain when overexpressed in COS7 fibroblasts is shown to inhibit transferrin uptake, whereas mutants in which interactions with its binding partners are abolished do not. DPF/W motifs present in appendage domain-binding partners are shown to play a crucial role in their interactions with the domain. A single site for binding multiple ligands would allow for temporal and spatial regulation in the recruitment of components of the endocytic machinery.

Engineering concepts for food processing in bioregenerative life support systems.

Long-duration manned missions, such as Mars exploration, will require development of new and cost-effective food production and delivery systems. Requirements for both carry-on preserved food and food processed from on-board crops exceed the capabilities of existing food processing and preservation technologies. For the transit phase, new food products, preservation methods, and processing technologies for ground-based food processing are required. The bioregenerative surface phase requires methods for processing of in situ-grown crops, treatment of food wastes, preparation of daily meals, and design of nutritious and appealing plant-based menus, all within severe cost and labor constraints. In design of the food supply for a long-term mission, the designers must select and apply both the packaged food and in situ processing technologies most appropriate for the specific mission requirements. This study aims to evaluate the strengths and weaknesses of different food system strategies in the context of different types of mission, and to point out the most important areas for future technology development.

Early femoral loosening in one design of cemented hip replacement.

We have studied aseptic loosening of the femoral component in 76 patients with primary total hip replacement using the Capital prosthesis. The mean follow-up was 26 months (10 to 37). Twelve femoral components (16%) were definitely and eight (10%) were possibly loose. They were characterised by a thin cement mantle (p < 0.001) and excessive residual cancellous bone in the proximomedial region (p < 0.01). We recommend that the cement mantle around the prosthesis should be 2 to 3 mm and that further long-term studies are needed to evaluate the wear properties of titanium-nitride-coated titanium femoral heads.

NAD-independent lactate and butyryl-CoA dehydrogenases of Clostridium acetobutylicum P262.

Clostridium acetobutylicum P262 cells that were growing on lactate and acetate had an NAD-independent lactate dehydrogenase(iLDH) activity of 200 nmol mg protein-1 min-1. Ammonium sulfate precipitation and DEAE cellulose caused a 35-fold purification. Gel filtration indicated that the iLDH had a molecular weight of approximately 55 kDa, but two bands were always observed. Phenyl sepharose could not separate the two proteins, and hydroxyapatite caused a complete loss of activity. The semi-purified iLDH had a Vmax of 13,000 nmol mg protein-1 min-1 and a Km value of 3.5 mM for D-lactate. The Vmax and Km values for L-lactate were 300 nmol mg protein-1 min-1 and 0.7 mM. The iLDH had a pH optimum of 7.5, was not activated by fructose-1,6-bisphosphate (FDP), and could be coupled to either 3-(4,5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) or dichlorophenol-indophenol (DCPIP), but not methyl viologen (MV) or benzyl viologen (BV). The iLDH did not have strong absorbance between 500 and 300 nm, and trichloroacetic acid or acid ammonium sulfate extracts had virtually no fluorescence at 450 nm. The crude extracts also had MTT-linked butyryl-CoA dehydrogenase activity (60 nmol mg protein-1 min-1). The NAD-independent butyryl-CoA dehydrogenase eluted from DEAE-cellulose as two fractions. The yellow fraction was extremely unstable, but the green fraction could be stored for short periods of time at 5 degrees C. The green-colored butyryl-CoA dehydrogenase had strong absorption at 450 nm, and gel filtration indicated that it had a molecular weight of 90 kDa. The NAD-independent butyryl-CoA dehydrogenase could be coupled to MTT, DCPIP, or MV, but not BV. Because the NAD-independent lactate and butyryl-CoA dehydrogenase could both be linked to low potential carriers, these two enzymes may function as oxidation-reduction system in vivo.