The true axial shoulder projection: Diagnostic aid for acromioclavicular joint dislocation?

INTRODUCTION: Acromioclavicular joint dislocations are common. Differentiating between horizontal and vertical instability is challenging, but possible to diagnose on axial radiographs. No clear consensus for axial radiograph parameters currently exists. We aim to establish a reproducible technique to assess whether an axial radiograph represents a true axial view of the shoulder. METHODS: One hundred CT scans of normal uninjured shoulders were examined using multiplanar reformatting to assess the distance between the anterior glenoid (reference line) and anterior-most aspect of the acromion in the axial plane. Measurements were repeated and performed by multiple observers to give of intra- and inter-observer reliability. RESULTS: The mean distance from the anterior acromion to the reference line was -2.6 mm (i.e. posteriorly placed) (SD = 5.8 mm, range -16.9-13.2 mm). Most (89%) of the measurements were between 9 and -9 mm to the reference line. Intra-observer reliability was high with Cronbach's α measurement as 0.997. Inter-observer reliability gave a Cronbach's α measurement of 0.959. CONCLUSION: When the anterior aspect of the acromion lies within 10 mm either side of a line parallel to the scapula blade at the anterior aspect of the glenoid on an axial radiograph, it represents a true axial projection of the glenohumeral joint (GHJ).Level of evidence: IV, Case series.

The incidence and outcome of chondral tumours as incidental findings on investigation of shoulder pathology.

PURPOSE: The aim of this study is to describe outcomes of incidental chondral tumours in the shoulder referred to our Bone Tumour Unit (BTU). METHODS: Our hospital radiology database was searched using the filtered terms "enchondroma", "low-grade chondral tumour", "chondrosarcoma" with "humerus", "arm", "shoulder", "scapula" and "clavicle". Case note review of results assessed primary reasons for referral, radiological diagnosis, recommended management with subsequent reviews and outcomes, either in clinic or surveillance scan reports. RESULTS: Ninety-nine patients had full case note review, mean age 54.5 years (range 18-84 years). Mean follow-up was 41.7 months (range 1-265 months). Over 50% of patients were referred for shoulder pain. Three patients had high-grade chondrosarcoma. Forty-three patients had interval scans, none showing any changes. Thirty-five patients had surgery for their lesions with one recurrence. Forty-four patients had alternative diagnoses made on clinical and radiological examination. At most recent follow-up, 70% of these patients were asymptomatic after physiotherapy/surgical attention to their alternative diagnoses. CONCLUSIONS: Chondral lesions in the shoulder have low risk of malignant transformation and are rarely responsible for shoulder symptoms. We recommend patients be referred to a dedicated BTU for surveillance if there are any concerning features, but to proceed with management for any alternative diagnosis.

Successful return to high-level sports following early surgical repair of combined adductor complex and rectus abdominis avulsion.

Hip and groin injuries are common in athletes who take part in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion of the tendons attached to the symphysis pubis has previously been described: these can be managed both operatively and non-operatively. We describe an uncommon variant of this injury, namely complete avulsion of the adductor sleeve complex: this includes adductor longus, pectineus and rectus abdominis. We go on to describe a surgical technique which promotes a full return to the pre-injury level of sporting activity. Over a period of ten years, 15 high-level athletes with an MRI-confirmed acute adductor complex avulsion injury (six to 34 days old) underwent surgical repair. The operative procedure consisted of anatomical re-attachment of the avulsed tissues in each case and mesh reinforcement of the posterior inguinal wall in seven patients. All underwent a standardised rehabilitation programme, which was then individualised to be sport-specific. One patient developed a superficial wound infection, which was successfully treated with antibiotics. Of the 15 patients, four complained of transient local numbness which resolved in all cases. All patients (including seven elite athletes) returned to their previous level of participation in sport.

Five-year comparison of wear using oxidised zirconium and cobalt-chrome femoral heads in total hip arthroplasty: a multicentre randomised controlled trial.

Oxidised zirconium (OxZi) has been developed as an alternative bearing surface for femoral heads in total hip arthroplasty (THA). This study has investigated polyethylene wear, functional outcomes and complications, comparing OxZi and cobalt-chrome (CoCr) as part of a three-arm, multicentre randomised controlled trial. Patients undergoing THA from four institutions were prospectively randomised into three groups. Group A received a CoCr femoral head and highly cross-linked polyethylene (XLPE) liner; Group B received an OxZi femoral head and XLPE liner; Group C received an OxZi femoral head and ultra-high molecular weight polyethylene (UHMWPE) liner. At five years, 368 patients had no statistically significant differences in short-form-36 (p = 0.176 mental, p = 0.756 physical), Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.847), pain scores (p = 0.458) or complications. The mean rate of linear wear was 0.028 mm/year (standard deviation (SD) 0.010) for Group A, 0.023 mm/year (SD 0.010) for Group B, and 0.09 mm/year (SD 0.045) for Group C. Penetration was significantly higher in the UHMWPE liner group compared with both XLPE liner groups (p < 0.001) but no significant difference was noted between CoCr and OxZi when articulating with XLPE (p = 0.153). In this, the largest randomised study of this bearing surface, it appears that using a XLPE acetabular liner is more important in reducing THA component wear than the choice of femoral head bearing, at mid-term follow-up. There is a non-significant trend towards lower wear, coupling OxZi rather than CoCr with XLPE but long-term analysis is required to see if this observation changes with time and becomes significant.

Automated characterisation of ultrasound images of ovarian tumours: the diagnostic accuracy of a support vector machine and image processing with a local binary pattern operator.

INTRODUCTION: Preoperative characterisation of ovarian masses into benign or malignant is of paramount importance to optimise patient management. OBJECTIVES: In this study, we developed and validated a computerised model to characterise ovarian masses as benign or malignant. MATERIALS AND METHODS: Transvaginal 2D B mode static ultrasound images of 187 ovarian masses with known histological diagnosis were included. Images were first pre-processed and enhanced, and Local Binary Pattern Histograms were then extracted from 2 × 2 blocks of each image. A Support Vector Machine (SVM) was trained using stratified cross validation with randomised sampling. The process was repeated 15 times and in each round 100 images were randomly selected. RESULTS: The SVM classified the original non-treated static images as benign or malignant masses with an average accuracy of 0.62 (95% CI: 0.59-0.65). This performance significantly improved to an average accuracy of 0.77 (95% CI: 0.75-0.79) when images were pre-processed, enhanced and treated with a Local Binary Pattern operator (mean difference 0.15: 95% 0.11-0.19, p < 0.0001, two-tailed t test). CONCLUSION: We have shown that an SVM can classify static 2D B mode ultrasound images of ovarian masses into benign and malignant categories. The accuracy improves if texture related LBP features extracted from the images are considered.

Athletic activity after lower limb arthroplasty: a systematic review of current evidence.

In this systematic review, our aim was to explore whether or not patients are able to return to athletic activity following lower limb joint replacement. We also investigated any evidence as to whether participation in athletic activity post-joint replacement increases complications and reduces implant survival. A PubMed, Embase and Sports Discus search was performed using the MeSH terms 'Sport', 'Athletic', 'Athlete', 'Physical', 'Activity', 'Arthroplasty', 'Total Hip Replacement', 'Hip Resurfacing', 'Total Knee Replacement', 'Unicompartmental Knee Replacement' and 'Unicondylar Knee Replacement'. From this search, duplications were excluded, the remaining abstracts were reviewed and any unrelated to the search terms were excluded. The remaining abstracts had their full papers reviewed. Following joint replacement, participation in sporting activity is common principally determined by pre-operative patient activity levels, BMI and patient age. The type of joint replaced is of less significance. Total time spent performing activity does not change but tends to be at a lower intensity. There is little evidence in the literature of an association between high activity levels and early implant failure.

Distal femoral replacement in periprosthetic fracture around total knee arthroplasty.

INTRODUCTION: Total knee arthroplasty is a common orthopaedic procedure in the UK; consequently, revision surgery and periprosthetic fractures are increasing in incidence. Strategies for management of these cases include non-operative strategies, internal plate fixation and revision of the distal femoral component. One under-reported practice is to perform distal femoral replacement in cases with poor distal femoral bone stock. MATERIALS AND METHODS: The department's electronic database was searched for all patients undergoing revision of total knee arthroplasty. From these, all patients having distal femoral replacement for periprosthetic fracture around the distal femoral component using the Stryker Global Modular Replacement System (GMRS) implant were filtered. A retrospective analysis of the patient notes was performed to examine the patient demographics, surgical factors and postoperative complications. Postoperative scores were performed for these patients. RESULTS: From 2005 onwards, 11 patients (mean age 81 years, range 61-90 years) had their implants revised with a distal femoral replacement for periprosthetic fracture with associated poor bone stock. Follow up was for a mean of 33 months (range 4-72 months). One of these patients died of causes unrelated to their operation. Of the rest, all implants survived without the need of re-operation. The mean postoperative Oxford Knee Score for these patients was 22.5 (range 5-34). CONCLUSIONS: Distal femoral replacement for patients with fracture around a total knee arthroplasty has been performed in our department with few complications and acceptable functional outcomes. It is a technically challenging operation and it should be a salvage procedure reserved for patients with poor bone stock and low demands where other methods of fixation are not suitable. LEVEL OF EVIDENCE: IV.

Novel phage-based bio-processing of pathogenic Escherichia coli and its biofilms.

To explore new approaches of phage-based bio-process of specifically pathogenic Escherichia coli bacteria in food products within a short period. One hundred and forty highly lytic designed coliphages were used. Escherichia coli naturally contaminated and Enterohemorrhagic Escherichia coli experimentally inoculated samples of lettuce, cabbage, meat, and egg were used. In addition, experimentally produced biofilms of E. coli were tested. A phage concentration of 10(3) PFU/ml was used for food products immersion, and for spraying of food products, 10(5) PFU/ml of a phage cocktail was used by applying a 20-s optimal dipping time in a phage cocktail. Food samples were cut into pieces and were either sprayed with or held in a bag immersed in lambda buffer containing a cocktail of 140 phages. Phage bio-processing was successful in eliminating completely E. coli in all processed samples after 48 h storage at 4°C. Partial elimination of E. coli was observed in earlier storage periods (7 and 18 h) at 24° and 37°C. Moreover, E. coli biofilms were reduced >3 log cycles upon using the current phage bio-processing. The use of a phage cocktail of 140 highly lytic designed phages proved highly effective in suppressing E. coli contaminating food products. Proper decontamination/prevention methods of pathogenic E. coli achieved in this study can replace the current chemically less effective decontamination methods.

Platelet-rich plasma in sports medicine: hot favourite or non-starter?

In the field of sports injury, musculoskeletal injuries require prompt treatment to allow a quick return to the pre-injury level of function. Ideally, any given treatment should, among other factors, be minimally invasive and highly effective, with minimal side effects. One emerging strategy to accelerate tissue healing is the use of platelet rich plasma. Platelet-rich plasma has been used in clinical practice since the 1980s, in dentistry, maxillofacial surgery and dermatology (Margolis et al, 2001). The treatment developed because platelet-rich plasma is seen as a preparation of growth factors which facilitate rapid healing of damaged tissue. There have been wide variations in agreeing a definition of platelet-rich plasma.

Evaluation of a rapid microbial detection method via phage lytic amplification assay coupled with Live/Dead fluorochromic stains.

AIMS: To develop a method for rapid detection of bacteria via bacteriophage amplification coupled with exogenous fluorochromic stains. METHODS AND RESULTS: A method for the rapid detection of bacteria was developed which consisted of exposing the sample suspected to contain target cells to host-specific phage. After at least one infection cycle, bacteria known to be infected by the phage (helper cells) were added and the number of nascent phage particles was estimated using the Live/Dead BacLight Bacterial Viability kit. Using Pseudomonas aeruginosa, it was shown that the dead helper cell population following phage infection was proportional to the initial number of target cells present in the original sample. Approximately 1 x 10(1) CFU per ml of P. aeruginosa could be detected within 4 h without the need for enrichment. CONCLUSIONS: The phage lytic amplification assay coupled with exogenous fluorochromic stains was able to detect approx. 1 x 10(1) CFU per ml of the target bacterium within 4 h. SIGNIFICANCE AND IMPACT OF THE STUDY: A method to detect low number of bacterial cells in a sample within 4 h without the need for enrichment was developed.

Novel antiviral agents: a medicinal plant perspective.

Several hundred plant and herb species that have potential as novel antiviral agents have been studied, with surprisingly little overlap. A wide variety of active phytochemicals, including the flavonoids, terpenoids, lignans, sulphides, polyphenolics, coumarins, saponins, furyl compounds, alkaloids, polyines, thiophenes, proteins and peptides have been identified. Some volatile essential oils of commonly used culinary herbs, spices and herbal teas have also exhibited a high level of antiviral activity. However, given the few classes of compounds investigated, most of the pharmacopoeia of compounds in medicinal plants with antiviral activity is still not known. Several of these phytochemicals have complementary and overlapping mechanisms of action, including antiviral effects by either inhibiting the formation of viral DNA or RNA or inhibiting the activity of viral reproduction. Assay methods to determine antiviral activity include multiple-arm trials, randomized crossover studies, and more compromised designs such as nonrandomized crossovers and pre- and post-treatment analyses. Methods are needed to link antiviral efficacy/potency- and laboratory-based research. Nevertheless, the relative success achieved recently using medicinal plant/herb extracts of various species that are capable of acting therapeutically in various viral infections has raised optimism about the future of phyto-antiviral agents. As this review illustrates, there are innumerable potentially useful medicinal plants and herbs waiting to be evaluated and exploited for therapeutic applications against genetically and functionally diverse viruses families such as Retroviridae, Hepadnaviridae and Herpesviridae

The Desert Ship heritage and science.

The camel's contribution to desert life dwindles as modern transport offers alternatives for crossing the desert. Yet recent insights into the camel's immune system have shown that this animal may still play an important role in the future of mankind. The camel has unique antibodies that could be very important in biotechnological applications and medicine.

Development and optimization of a novel immunomagnetic separation- bacteriophage assay for detection of Salmonella enterica serovar enteritidis in broth.

Salmonella is the second-leading cause of food-borne illness in most developed countries, causing diarrhea, cramps, vomiting, and often fever. Many rapid methods are available for detection of Salmonella in foods, but these methods are often insensitive or expensive or require a high degree of technical ability to perform. In this paper we describe development and characterization of a novel assay that utilizes the normal infection cycle of bacteriophage SJ2 for detection of Salmonella enterica serovar Enteritidis in broth. The assay consists of four main stages: (i) capture and concentration of target cells by using immunomagnetic separation (IMS); (ii) infection of the target bacterium with phage; (iii) amplification and recovery of progeny phage; and (iv) assay of progeny phage on the basis of their effect on a healthy population of host cells (signal-amplifying cells). The end point of the assay can be determined by using either fluorescence or optical density measurements. The detection limit of the assay in broth is less than 10(4) CFU/ml, and the assay can be performed in 4 to 5 h. The results of this study demonstrate that the IMS-bacteriophage assay is a rapid, simple, and sensitive technique for detection of Salmonella serovar Enteritidis in broth cultures which can be applied to preenriched food samples.

The specific and sensitive detection of bacterial pathogens within 4 h using bacteriophage amplification.

This paper describes a novel approach, termed the 'phage amplification assay', for the rapid detection and identification of specific bacteria. The technique is based on the phage lytic cycle with plaque formation as the assay end-point. It is highly sensitive, quantitative and gives results typically within 4 h. The assay comprises four main stages: (1) phage infection of target bacterium; (2) destruction of exogenous phage; (3) amplification of phage within infected host and (4) plaque formation from infected host with the aid of helper bacteria. A key component of this assay is a potent virucidal agent derived from natural plant extracts, pomegranate rind extract (PRE). In combination with ferrous sulphate PRE can bring about an 11 log-cycle reduction in phage titre within 3 min. This is achieved without any injury to the infected target bacteria. Subsequently, any resulting plaques are derived only from infected target organisms. Data are presented for a range of bacterial hosts including Pseudomonas aeruginosa, Salmonella typhimurium and Staphylococcus aureus. The detection limit for Ps. aeruginosa was 40 bacteria ml-1 in a time of 4 h and 600 bacteria m-1 for Salm. typhimurium. Application of the principles of this technology to other bacterial genera is discussed.

Infection and removal of L-forms of Listeria monocytogenes with bred bacteriophage.

Phage breeding was employed to produce a bacteriophage (Listeria monocytogenes phage ATCC 23074-B1) which was specific for L-forms of L. monocytogenes. The bred phage was compared to its unbred parent for lytic activity and specificity. It was also tested for its ability to prevent L-form biofilm formation on stainless steel and compared with an organic acid (lactic) at L-form biofilm inactivation on stainless steel. The bred phage lysed only L-forms of L. monocytogenes in broth culture and only plaqued on L-form lawns. Likewise, the unbred phage performed similarly with classical cell-walled culture and lawns. The bred phage successfully inhibited L-form biofilm formation on stainless steel and was as successful as lactic acid (130 ppm) at inactivating pre-formed L-form biofilms. Both reduced viable cell numbers by 3-long cycles over a 6 h period. It appears that phage breeding technology may be an attractive alternative to chemical sanitizers which lack specificity and can be toxic.

In vivo bioluminescence to detect the attachment of L-forms of Listeria monocytogenes to food and clinical contact surfaces.

A bioluminescent phenotype of Listeria monocytogenes was employed to study the adhesion and biofilm formation of both classical and L-forms to relevant food and clinical contact surfaces. Attachment of both parental (cell-walled) and L-forms to intravenous tubing and stainless steel was compared using viable counts and bioluminescence. Both cell types attached themselves to intravenous tubing and stainless steel. Parental cell numbers attached to intravenous tubing were 1 log higher than L-form numbers, and on stainless steel, attached L-form numbers were 1 log higher. Bioluminescence measurements yielded a pattern similar to viable count measurements. There was a clear relationship between light output of attached bacteria and their viability and, thus, a bioluminescent phenotype provides a rapid monitor of both microbial viability and biofilm formation by L-forms.

In vivo bioluminescence: a cellular reporter for research and industry.

The detection of specific bacterial pathogens, indicator microorganisms and antimicrobial substances, and the recovery of microorganisms from sub-lethal injury, are all aspects of importance to industry which are currently being targeted using in vivo bioluminescence. In all instances, a key requirement for the application of bioluminescence is the establishment of a strict correlation between in vivo bioluminescence and cell viability, as determined by colony counting on agar plates. Comparative studies for biocides (phenol, chlorhexidine diacetate, phenol thioether), for a virucide (hypochlorite) and for cellular recovery of S. typhimurium from sub-lethal injury, all indicate that such a correlation is valid. Furthermore, real-time measurements of in vivo bioluminescence reveal a major population of bacterial cells that retain functional intracellular biochemistry, but are defective in their ability to replicate post of freeze injury.

In vitro studies of haemolysis by some staphylococci grown in chemically defined media.

Staphylococcus aureus (five strains) and Staph. epidermidis (one strain) have been evaluated for comparative growth and haemolysin titre in both brain heart infusion (BHI) and in developed, nutritionally adequate, chemically defined media (CDMs) varying only in amino acid composition. The ability to show a particular haemolytic profile was strain-dependent and the haemolytic titre (HU50/ml) was both strain- and medium-dependent. Highest titres of both alpha and beta type haemolysins were obtained in BHI. Maximum titres were in general detected in the late exponential phase in both CDMs and BHI. Titres declined during the stationary phase in CDMs. Staphylococcus epidermidis produced a delta-type haemolysis profile on BHI-based blood agars, but only rabbit blood was sensitive in agars based on a developed, chemically defined medium (CDM/A; 13 amino acids) in which all six staphylococci grew. The addition of yeast extract to CDM/A increased alpha haemolysin titre, but suppressed beta haemolysin formation; beta haemolysin was, however, detected in yeast extract/phosphate-buffered saline. Strain Wood 46 degraded haemoglobin, but only in (initially) whole blood; red blood cell-free haemoglobin-rich plates (BHI) were unaffected during growth. A novel haemolytic profile is described for Staph. aureus NCTC 8532 growing on blood agars based on CDM/A and may relate to the production of methaemoglobin during haemolysis.