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.

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.

Pre-operative urinary tract infection: is it a risk factor for early surgical site infection with hip fracture surgery? A retrospective analysis.

OBJECTIVE: The aims of the current study were to determine whether pre-operative urinary tract infections in patients presenting acutely with neck of femur fractures resulted in a delay to surgery and whether such patients were at increased risk of developing post-operative surgical site infections. DESIGN: A retrospective review of all patients presenting with a neck of femur fracture, at a single centre over a one-year period. The hospital hip fracture database was used as the main source of data. SETTING: UK University Teaching Hospital. PARTICIPANTS: All patients (n = 460) presenting across a single year study period with a confirmed hip fracture. OUTCOME MEASURES: The presence of pre-operative urinary tract infection, the timing of surgical intervention, the occurrence of post-operative surgical site infection and the pathogens identified. RESULTS: A total of 367 patients were operated upon within 24 hours of admission. Urinary infections were the least common cause of delay. A total of 99 patients (21.5%) had pre-operative urinary tract infection. Post-operatively, a total of 57 (12.4%) patients developed a surgical site infection. Among the latter, 31 (54.4%) did not have a pre-operative urinary infection, 23 (40.4%) patients had a pre-operative urinary tract infection, 2 had chronic leg ulcers and one patient had a pre-operative chest infection. Statistically, there was a strong relationship between pre-operative urinary tract infection and the development of post-operative surgical site infection (p-value: 0.0005). CONCLUSION: The results of our study indicate that pre-operative urinary tract infection has a high prevalence amongst those presenting with neck of femur fractures, and this is a risk factor for the later development of post-operative surgical site infection.

Optimal Timing for Hemoglobin Concentration Determination after Total Knee Arthroplasty: Day 1 versus Day 2.

PURPOSE: Postoperative hemoglobin (Hb) determination remains an essential parameter for quantifying blood loss following total knee replacement (TKR) surgery and guiding transfusion practice. In this study we aimed to ascertain the optimal timing for Hb determination postoperatively and assess its relationship to serum hematocrit (Hct). MATERIALS AND METHODS: This was a retrospective cohort analysis of 61 consecutive patients undergoing preoperative, day 1 and day 2 Hb and Hct concentration determination following TKR surgery. This was a single centre study in the United Kingdom. RESULTS: The mean fall in Hb concentration at day 1 was 2.9 g/dL in comparison to 3.3 g/dL at day 2. This indicated a significant difference of 0.39 g/dL (p=0.023). A total of 5 patients required blood transfusions following day 2 Hb determination. Postoperative Hct values varied in close relation with the Hb concentration with no significant differences demonstrated. Our study reveals a significant change between day 1 and day 2 Hb concentrations following TKR surgery, with no significant differing information provided through Hct determination. CONCLUSIONS: Our results support the use of delayed routine testing at day 2 following surgery as it is likely to more accurately reflect ongoing hidden blood loss into the joint cavity and within soft tissue planes.

Atraumatic Extra-articular Patellar Dislocation with Vertical Axis Rotation: A Case Study.

INTRODUCTION: Acute patellar dislocation is a common injury usually associated with a significant traumatic mechanism resulting in lateral displacement. Vertical axis rotation following dislocation is a rare variant of this type of injury and can prevent closed reduction in the acute setting. CASE PRESENTATION: A 32-year old gentleman presented with an irreducible patella dislocation following an unusual atraumatic mechanism. Following attempts at closed reduction under sedation and regional nerve block, eventual open reduction and soft tissue reconstruction was required under general anesthetic. During the open reduction procedure, it was noted that the patella had dislocated into a lateral extra-articular position and rotated around its vertical axis. Following patella reduction, the medial patellar retinaculum was repaired. Examination under anesthetic revealed satisfactory tracking of patella following repair. CONCLUSION: A review of the literature suggests dislocations such as the current presentation, are extremely rare and although have been described to occur with minor trauma, have never been described to occur following a largely atraumatic event. In such cases, closed reduction may be impossible even with adequate analgesia due to patella position and soft tissue obstruction. Open reduction is essential in these situations.

Are "Patellofemoral Symptoms" Truly Related to the Patellofemoral Joint?

PURPOSE: The pattern of symptoms of knee osteoarthritis has been thought to be indicative of specific compartment involvement. This study investigated whether there was a true correlation between patellofemoral joint (PFJ) symptoms and unicompartmental patellofemoral arthritis. MATERIALS AND METHODS: A prospective analysis of 34 patients rendered to be suffering from PFJ osteoarthritis and subsequently undergoing unicompartmental patellofemoral arthroplasty (PFA) was performed. A control cohort of 32 patients suffering from medial tibiofemoral joint (MTFJ) osteoarthritis was included in the analysis. Four questions derived from the Oxford knee score questionnaire, traditionally deemed to be indicative of PFJ osteoarthritis, were combined to create a PFJ subscore and statistically analyzed for their potential relationship with PFJ osteoarthritis and outcomes following PFA. RESULTS: The PFJ subscore indicated slightly worse pathology in patients undergoing PFA compared to MTFJ replacement, but the difference was not significant (9.7 and 9.6, respectively; p=0.851). The improvement in PFJ symptoms was higher in those undergoing PFA compared to MTFJ surgery; however, the difference was not statistically significant (3.7 and 2.2 respectively, p=0.074). CONCLUSIONS: We were unable to prove that these symptoms were predictive of PFJ pathology in the preoperative setting, nor were they useful in interpreting which symptoms would likely improve following PFA.