Mid inter-epicondyle trochlea intersection (MIELTI): Proposal of a new index for identifying the deepest part of the trochlea.

BACKGROUND: Tibial tuberosity trochlear groove distance (TT-TG) is an important radiological measurement in patellofemoral instability (PFI). Where instability is recurrent, a value ≥20 mm is considered an indication for tubercle medialisation. Trochlear dysplasia commonly accompanies PFI. It can make identification of the deepest part of the trochlea difficult, which makes the TT-TG difficult or impossible to assess. To address this, we propose a new method of identifying the deepest part of trochlea based on the femoral epicondyles. It is named the tibial tuberosity mid inter-epicondyle trochlea intersection distance (TT-MIELTI). METHODS: The TT-TG and TT-MIELTI of 30 consecutive non-dysplastic knee MRIs were compared, excluding 96 knees with dysplasia, sulcus angles ≥135°, a tibial tuberosity anterior cortex which was not fully demonstrated, artefact, fracture, or Osgood Schlatter's disease. To assess inter-observer reliability three blinded researchers measured the TT-TG and the TT-MIELTI of all 30 knees. To assess intra-observer repeatability one researcher repeated the measurements after six weeks. RESULTS: The intraclass correlation coefficient (ICC) test demonstrated good to excellent values for all measurements (TT-TG and TT-MIELTI correlation ICC 0.94-0.97; TT-TG inter-observer reliability ICC = 0.85, intra-observer repeatability ICC = 0.90; TT-MIELTI inter-observer reliability ICC = 0.86, intra-observer repeatability ICC = 0.89. All p values < .001.) CONCLUSIONS: In non-dysplastic knees the mid inter-epicondyle trochlea intersection (MIELTI) accurately identifies the deepest part of the trochlea, and TT-MIELTI is a reliable alternative to the TT-TG. Re-assessment in dysplastic knees would be of benefit to establish its usefulness in the clinical setting.

Enhanced recovery for fractured neck of femur: a report of 3 cases.

Enhanced recovery is now a standard model of care in most UK elective surgical units. For hip and knee arthroplasty this approach typically includes opioid-sparing anesthesia (OSA), local infiltration analgesia (LIA), and day of surgery mobilization. There is evidence that these interventions shorten hospital stay and improve outcomes, without increasing complications or readmissions. These interventions may also benefit patients undergoing surgery for femoral neck (hip) fractures. This group of patients are frail and elderly, and are at high risk from surgery, anesthesia, and opioid and bed rest-related complications. Hip fractures are also a major public health concern. They are common, expensive to treat, and associated with poor outcomes. Despite this there are no published descriptions of the use of OSA and LIA to enable day of surgery mobilization in patients with hip fractures. We present 3 patients who underwent hip fracture surgery according to an enhanced recovery protocol that incorporated all 3 interventions. In each case day of surgery mobilization was achieved safely and comfortably, without requirement for strong opioids postoperatively. The cases demonstrate that these interventions can be well tolerated by patients with hip fracture, including those with impaired mobility or cognitive function. The protocol is compatible with all common operations for hip fracture, and with spinal or general anesthesia. It is inexpensive and requires minimal expertise. It may have the potential to improve care and shorten hospital stay, while reducing cost. Further investigation is required.

Secretions from placenta, after hypoxia/reoxygenation, can damage developing neurones of brain under experimental conditions.

Some psychiatric diseases in children and young adults are thought to originate from adverse exposures during foetal life, including hypoxia and hypoxia/reoxygenation. The mechanism is not understood. Several authors have emphasised that the placenta is likely to play an important role as the key interface between mother and foetus. Here we have explored whether a first trimester human placenta or model barrier of primary human cytotrophoblasts might secrete factors, in response to hypoxia or hypoxia/reoxygenation, that could damage neurones. We find that the secretions in conditioned media caused an increase of [Ca(2+)]i and mitochondrial free radicals and a decrease of dendritic lengths, branching complexity, spine density and synaptic activity in dissociated neurones from embryonic rat cerebral cortex. There was altered staining of glutamate and GABA receptors. We identify glutamate as an active factor within the conditioned media and demonstrate a specific release of glutamate from the placenta/cytotrophoblast barriers invitro after hypoxia or hypoxia/reoxygenation. Injection of conditioned media into developing brains of P4 rats reduced the numerical density of parvalbumin-containing neurones in cortex, hippocampus and reticular nucleus, reduced immunostaining of glutamate receptors and altered cellular turnover. These results show that the placenta is able to release factors, in response to altered oxygen, that can damage developing neurones under experimental conditions.

Impact of intermittent pneumatic foot pumps on delay to surgery following ankle fracture.

BACKGROUND: Ankle fractures requiring open reduction and internal fixation (ORIF) are common and place considerable burden on inpatient beds. ORIF cannot be performed once the associated swelling is too excessive to permit tension-free wound closure. Where ORIF cannot be performed before the onset of swelling in the first 24-48h, patients typically require up to 7 days of inpatient bed-rest and elevation to reduce swelling to an acceptable level for ORIF. The primary aim of this study was to determine whether delay to ORIF could be reduced with the pre-operative application of an intermittent pneumatic foot pump (IPF). These devices were designed as anti-embolic adjuncts, but have also been shown to be effective in the reduction of swelling. We compared 12 patients managed with an IPF to 12 matched historical controls who were not. No previous studies have addressed this question in unselected patients requiring ankle ORIF. METHODS: We performed a retrospective, controlled, before and after study of 24 patients who underwent ankle ORIF at our orthopaedic unit. Foot pumps were applied in the Accident and Emergency Department to ankle fracture patients requiring admission, and kept in place until ORIF. Data was collected from patient case notes for all patients. Patients were matched for age, gender, American Society of Anaesthesiologists (ASA) Grade, and pre-injury mobility. The primary outcome measure was time to surgery. We also recorded total hospital stay, and calculated cost savings. RESULTS: Patients managed with IPFs had a statistically significant 50% reduction in time from presentation to surgery compared to those managed without (p=0.024), and had a reduced hospital stay (p=0.116). This resulted in a net saving of £10,480 (£953 per patient). CONCLUSIONS: We conclude that foot pumps reduce the time to surgery and total hospital stay of patients requiring ankle ORIF, and are cost effective.