Are vegans being overlooked in our prescribing practices: An orthopaedic perspective from Bristol, United Kingdom.

Aim: Bristol is considered the vegan capital of the UK. The UK vegan index reveals that Bristol has 360,000 Google searches each month for Vegan content. However, the possible animal source of the medications we prescribe is not commonly contemplated. Medications in the UK must pass through animal trials prior to licensing and therefore cannot be vegan. There are, alternatives available for some medications, that do not contain animal products. The aim of this study is to review the presence of content of animal origin (CAO) in common medicines in Trauma and Orthopaedics (T&O) and explore alternatives. Methods: We evaluated the presence and source of CAO in commonly used medications in T&O practice. The British National Formulary (BNF), our local pharmacy guidelines and the online Summary of Product Characteristics (SPCs) for the medications were reviewed. We also assessed the suitability of current COVID-19 vaccines for patients who have reservations against CAO. Results: All unfractionated or standard heparin is porcine in origin; Fondaparinux is a simple alternative. Cholecalciferol (vitamin D3) manufacture involves the use of lanolin from sheep's wool. Vitamin D2 (ergocalciferol) is an alternative with no CAO. All widely available Covid-19 vaccines in the UK are suitable for administration to vegans and all religious faiths. Propofol, widely used as an anaesthetic agent, contains egg proteins. Conclusion: Disclosure of animal content would help patients make informed choices. With an increasingly informed population and ethnic diversity, we should be aware of the drugs that may contain animal products so that we can offer alternatives. Sometimes, pharmaceutical companies cannot guarantee or differentiate the specific sources of animal-derived ingredients, as various suppliers are used in the manufacturing process and the sources can change on a regular basis. Patients are more likely to adhere to prescribed medicines if they have been involved in prescribing decisions.

The fate of acetabular fracture fixation at 10 years: rates of conversion to arthroplasty.

BACKGROUND: Post-traumatic arthritis, implant failure, non-union or avascular necrosis may result in a total hip arthroplasty (THA) after acetabular fracture fixation (AFF). The aim of this study was to report the occurrence of THA after AFF and analyse factors that predict its occurrence. PATIENTS AND METHODS: All patients with AFF between 2010 and 2014, in a major trauma centre, were included. Patients treated conservatively or with acute THA were excluded. Data regarding classification of fracture, details of surgery and follow-up using EQ-5D and Oxford Hip Score (OHS) were recorded prospectively. Postoperative radiographs and CT scans were analysed for accuracy of reduction. The number of patients who underwent secondary THA and indications were recorded. RESULTS: 122 patients with a mean age of 42 years were included. At a mean follow-up of 10 years, the mean OHS was 39 (range 22-48) and EQ-5D was 22 (range 10-25). THA was performed in 10 patients (8%), 50% of which were performed between 2-5 years after AFF. Age >40 years, posterior dislocation and presence of posterior wall fracture, were the only factors associated with progression to THA. The survivorship of fixation at 5 years was 95% (95% CI, 91-98%) and at 10 years was 91% (95% CI, 86-96%). CONCLUSIONS: Conversion to THA after AFF was 8%, with even anatomically reduced posterior wall fractures having a poor prognosis. A period of follow-up of at least 5 years is suggested in patients with risk factors.

Psychological, physical and social factors influence decision to return to sport after revision ACL reconstruction with BPTB graft.

PURPOSE: There is limited evidence in literature regarding the patient-reported factors that influence their return to sport (RTS) in revision anterior cruciate ligament reconstruction (ACLR). The medium-term results of a prospective consecutive cohort of patients undergoing single- and two-stage revision ACLR with bone patellar tendon bone graft (BPTB) and patient-reported factors that influence their decision to return to sport are presented in this study. METHODS: Seventy-two patients were included in this prospective study. Single- or two-stage revision with BPTB graft was performed based on pre-operative planning. Iliac crest bone graft was used. Pre-operative and follow-up Lysholm and Tegner activity scores and RTS, level of sport and patient-reported factors affecting RTS were recorded. The mean follow-up was 9 years (SD 2.7 years). RESULTS: Single-stage revision ACLR was performed in 61 patients. In 11 patients (15%), revision ACLR was performed in two stages. There was a significant improvement in Lysholm score from mean 51.1 to 86.7 (p < 0.001). The incidence of re-rupture in this cohort was 0%. The median Tegner score was 6 (range 2-9). Twenty-five patients (34.7%) did not return to any sport at final follow-up. Twenty-nine (40.2%) patients returned to their pre-injury level of sport. Fear of reinjury (79%, p < 0.001) and persistent knee symptoms (35.8%, p = 0.03) were the most common factors limiting RTS in non-returners. CONCLUSION: Psychological and social factors may have an influence on RTS in addition to physical factors. LEVEL OF EVIDENCE: Level III.

Chronic Wear-Induced Bearing Dislocation in a Fixed-Bearing Unicompartmental Knee Arthroplasty: A Case Report.

Case: We present a case of late onset, bearing wear-induced failure of locking mechanism, resulting in bearing dislocation and rapidly progressive severe metallosis in a medial fixed-bearing (FB) unicompartmental knee arthroplasty (UKA). Conclusion: Bearing dislocation is a rare complication of chronic wear in FB UKA, and early recognition is essential to prevent metallic component articulation-induced metallosis and catastrophic failure.

Kinematic 3-D motion analysis of shoulder resurfacing hemiarthroplasty - An objective assessment method.

Shoulder replacement is indicated in the treatment of pain due to osteoarthritis. Few studies have objectively assessed range of motion (RoM) gains at different post-operative time points. This is a prospective 3D motion analysis study to objectively quantify RoM changes at multiple time points following shoulder resurfacing arthroplasty (SRA) for primary gleno-humeral osteoarthritis, comparing it with clinically measured RoM. Clinical assessment, Visual Analog Scale (VAS) pain score, Constant-Morley (CS) and Oxford Shoulder Score (OSS) were recorded. Motion analysis was performed for RoM and three activities of daily living tasks (ADL), pre-operatively and post-operatively at 4 and 12 months. Nineteen shoulders in fifteen patients were included. The mean age was 72 years (range 52-84). There were significant improvements in external and internal rotation, ability to place the hand behind the head and reach the fifth lumbar vertebra, at 4 months on clinical examination and kinematic analysis with no further improvements at 12 months. There was significant improvement in abduction at 4 months with further improvement at 12 months, which was significantly more than noted on clinical assessment. In contrast, kinematic analysis showed a reduction in flexion between 4 and 12 months, while clinically there appeared to be an improvement between these time periods. This is the first study to prospectively utilise objective kinematic 3-D motion analysis in addition to clinical measurements and outcome scores, to investigate the outcome of resurfacing arthroplasty at multiple time points after surgery, providing an understanding into the trends of change in these parameters.

Retention of Monoblock Femoral Components Using a Dual Mobility Bearing: A Report of 3 Cases.

CASE: We present the results of 3 cases followed up for a minimum period of 4.5 years of revision total hip arthroplasty using a metal acetabular shell with retention of a well-fixed monoblock femoral component by inserting a dual mobility polyethylene bearing onto the femoral head in situ. CONCLUSION: This is the first case series to use this technique to address acetabular osteolysis and avoid removing a well-fixed monoblock femoral component at the time of revision surgery.

Cup-cage construct for massive acetabular defect in revision hip arthroplasty- A case series with medium to long-term follow-up.

OBJECTIVE: Cup-cage reconstruction has emerged as a possible solution for managing massive acetabular defects with a few existing studies reporting encouraging results at mid-term follow-up. We present our experience with this unitised construct. METHOD: Six patients (7 hips) with a mean age of 76 years (73-81) were revised due to catastrophic aseptic failure of a primary cup implanted 10-19 years previously, having a Paprosky type 3B acetabular defect. RESULTS: At a mean follow-up of 72 months (63-140) no cases have required re-revision. Oxford Hip Scores improved from an average of 8 (1-17) preoperatively to an average of 36 (18-45) at the last follow-up. WOMAC scores preoperatively averaged 76 (49-96) and postoperatively averaged 26.5 points (0-69) at the last follow-up. SF-12 scores improved in both components. One patient showed non-progressive osteolysis around the ischial flange and one had less than 5 mm migration of the construct. One patient died of unrelated causes. CONCLUSION: Our study presents one of the longest follow-up of cup-cage construct and supports the previously reported good results; it encourages the use of this construct in reconstruction of massive acetabular defect, with or without pelvic discontinuity.

Comparative analysis of different total hip replacement implants used in a single health region of the United Kingdom - minimum 15 years follow-up.

We describe the functional and radiological results at minimum 15 years follow up of four groups of total hip replacement(THR) implants used in our health region. 876 THRs in 837 patients who were included in the study that used prospectively collected data in the Tayside Arthroplasty Audit Group(TAAG) database. There were 387 Charnley/Ogee cemented THRs, 188 hips in the cemented CPT/ZCA group, 106 hips in the uncemented Bicontact/Plasmacup group and 195 hips in the hybrid Exeter/Trident group. The most common complications were dislocation (3.88%) and superficial infection (3.76%). With revision surgery for any reason as the end point, the survivorship of at 15 years in our series was 98.45% in the cemented Charnley/Ogee THR group, 96.8% in the cemented CPT/ZCA group, 96.22% in the uncemented Bicontact/Plasmacup group and 97.94% in the Exeter/Trident hybrid THR group. There was no statistically significant difference in the number of hips at risk of revision, Harris Hip Scores and complication rates at 15 years. We feel that the choice of implant is best based on individual templating and training of the surgeon. Prospective randomised controlled trials and joint registry data may make implant selection easier in the future.

10-year results of ReCap hip resurfacing arthroplasty: a non-designer case series.

INTRODUCTION: We present the 10-year results of the ReCap Magnum HRA system in a consecutive single surgeon's series from a non-designer centre. PATIENTS AND METHODS: Hip resurfacing arthroplasty (HRA) was performed in active males under 65 years and in pre-menopausal females with adequate bone density proven by a DEXA scan. Clinical follow-up; annual Oxford hip scoring, UCLA scoring and whole blood metal ion level measurement. Kaplan-Meier method was used to determine survivorship with revision as the end point. Radiographs were analysed for; acetabular inclination, notching, neck thinning and change in implant position. 72 HRAs were performed in 66 patients with a mean age of 45.7 years. The mean follow-up was 10.63 ± 0.54 years (range 10-11.75 years). RESULTS: The survivorship of the cohort at minimum 10 years was 97.22% (95% confidence interval 94.14-99.01). There was a significant improvement in the Oxford Hip Score from 15.77 ± 4.33 to 45.67 ± 4.43 (p < 0.001) and the UCLA score from 3.14 ± 0.74 to 7.07 ± 1.16 (p < 0.001). Mean whole blood cobalt and chromium levels were 28.83 ± 8.42 nmol/l and 39.93 ± 9.64 nmol/l respectively. There were 2 revisions, due to avascular necrosis and implant failure. In our series the implant has performed well with <1% failure per year. We did not note any difference between the genders, since all the females in our series had been screened for osteopenia using a DEXA scan. All our patients returned to an active lifestyle which was maintained at final follow-up. CONCLUSION: Strict selection criteria and a well-designed implant result in good long-term functional and radiological results with hip resurfacing.

Withdrawn: A Randomized Controlled Trial Comparing Modular and Nonmodular Neck Versions of a Titanium Stem.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Intramedullary devices in the management of Judet III and IV paediatric radial neck fractures.

PURPOSE: The aim of this study is to discuss the results of different intramedullary devices used in the management of paediatric radial neck fractures and to suggest methods to avoid the pitfalls of the technique. METHODS: Thirty patients with isolated Judet III and IV fractures were included in this prospective study. Judet I and II fractures and radial neck fractures associated with other injuries were excluded. The final results were graded using the Metaizeau functional scoring system and Oxford Elbow Score. RESULTS: The functional result was good to excellent in 24 of 30 cases (80%). The mean Oxford Elbow Score was 44.32. The mean follow-up was 40.11 months. The complications seen were radiocapitellar joint penetration - 6 cases at mean 4.87 weeks, redisplacement - 6, radial epiphyseal sclerosis - 5, and heterotopic ossification - 1 case. CONCLUSION: Intramedullary K wires may result in radiocapitellar joint penetration. Titanium Elastic Nail System should not be used as purely fixation devices as they may not prevent redisplacement. Regular follow-up until at least 6 weeks is essential. Patients who have a Judet IV fracture and need open reduction should be given a guarded prognosis. The paper highlights the pitfalls of the technique and makes recommendations regarding the type of implant, follow-up and patient counselling in Judet IV fractures.

Pelvic pyomyositis in children: changing trends in occurrence and management.

AIMS: We present the largest series of paediatric pelvic pyomyositis from a temperate country, analyse the factors influencing long term prognosis and suggest a diagnostic protocol. MATERIALS AND METHOD: We included 41 patients diagnosed with primary paediatric pelvic pyomyositis between 1998 and 2016, in this study with a mean age of 7.5 years. Demographic, clinical, radiological and follow-up data were reviewed. Statistical analysis was performed to analyse the influence of early diagnosis and treatment on the final outcome. RESULTS: There was an increased occurrence of primary pelvic pyomyositis in the last two years. Of cases identified, 85% fulfilled Kocher's criteria for hip septic arthritis. The mean time to diagnosis was 2.8 ± 0.8 days. The most common muscle affected was obturator internus (65.85%) and multifocal involvement was common (46.34%). Early diagnosis and antibiotic treatment within seven days from the time of onset of symptoms was the only factor that influenced final outcome (p < 0.001). DISCUSSION AND CONCLUSION: Pyomyositis is no longer restricted to tropical countries. The time from onset of symptoms to start of antibiotic treatment influences the final outcome. Clinical examination and inflammatory markers have low specificity in distinguishing between pyomyositis, septic arthritis, osteomyelitis or other infections. MRI is more sensitive and can diagnose pyomyositis in its early stages. Every suspected case of septic arthritis of the hip should undergo an ultrasound. MRI scan may be performed if the ultrasound shows inconclusive evidence of an effusion. Early identification will facilitate early antibiotic treatment which will improve the final outcome. CLINICAL RELEVANCE: There is an increasing occurrence of this tropical disease in temperate countries. Early diagnosis with an MRI scan and early antibiotic use results in good outcomes.

Cemented total hip replacement in patients under 55 years.

Background and purpose - About 86,000 total hip replacements (THR) have been registered in patients under 55 years in the National Joint Registry of England and Wales (NJR). The use of uncemented implants has increased, despite their outcomes not having been proven to be significantly better than cemented implants in this registry. We determined the implant survivorship and functional outcomes of cemented THR in patients under 55 years at a minimum follow-up of 22 years. Patients and methods - 104 hips in 100 patients were included in this prospective study. Functional outcome was assessed using the Harris Hip Score and radiographs were assessed for implant failure and "at risk" of failure. Kaplan-Meier survivorship analysis was performed. Results - 89% of hips showed good to excellent results at final follow-up with a mean Harris Hip Score of 88 at a mean follow-up of 25 years. Revision was performed in 3/104 hips. 14 acetabular components and 4 femoral components were "at risk" of failure. The survivorship at minimum 22 years with revision for any reason as the end-point was 97% (95% CI 95-98). Interpretation - Cemented hip replacements perform well in young patients with good long-term functional and radiographic outcomes.

Blood Metal Ion Levels Have Limited Utility in the Surveillance of Asymptomatic Large-Head Metal-on-Metal Total Hip Arthroplasties.

BACKGROUND: Blood cobalt (Co) and chromium (Cr) ion levels have been used as surveillance tools for adverse reaction to metal debris (ARMD) in metal-on-metal (MoM) articulations with varying thresholds in different countries. The aim of our study is to present the serial 12-year blood Co and Cr levels in a cohort of MoM total hip arthroplasties (THAs) with femoral head size ≥36 mm and analyze their utility in asymptomatic patients at current thresholds. METHODS: A total of 256 patients with unilateral MoM THA with femoral head size ≥36 mm were included in this study with data collected prospectively. The implants used were Birmingham hip resurfacing cup-Freeman stem (BHR-F) or an Articular Surface Resurfacing cup-Corail/S-ROM stem. Annual follow-up with blood Co and Cr measurements was done as per Medicines and Healthcare Products Regulatory Agency (MHRA) of the United Kingdom guidelines. Receiver operating characteristic curve was plotted based on the sensitivity and specificity of blood metal ion values to detect ARMD. The metal ion levels in asymptomatic patients were analyzed separately. RESULTS: Receiver operating characteristic curves showed poor discriminatory ability for both Co and Cr values in predicting ARMD at 7 µg/L. The sensitivity of Co and Cr was 82.1% and 53.5%, respectively, and their positive predictive values were 43.8% and 67.6%, respectively. After 7 years, there was no significant change in Co values, and there was a decline in Cr value after 9 years in asymptomatic patients. CONCLUSION: To the best of our knowledge, this is the first study to describe the behavior of serial blood metal ion levels in asymptomatic large-diameter MoM THA. We suggest that annual blood Co and Cr have limited discriminant capacity in diagnosing the occurrence of metallosis and their measurement beyond 7 years is of limited utility in asymptomatic patients.

Factors Influencing Outcome in the Management of Scaphoid Non-union and Comparison of Matti Russe and Interpositional Grafting Techniques.

BACKGROUND: Scaphoid non-union is often caused due to missed fractures, inadequate or inappropriate management. Matti-Russe and interpositional grafting techniques are used in the treatment of non-union. There are very few studies in literature that compare the outcomes of these techniques. The aim of our study was to analyse the factors influencing outcome in the management of scaphoid non-union and to compare the results of the Matti Russe procedure with interpositional grafting techniques. METHODS: Fifty scaphoid non-unions with a mean follow-up of 39.9 ± 5.5 months were included in this retrospective study. Demographic parameters, treatment, functional and radiological outcomes were recorded. The influence of demographic and treatment factors on union in this cohort was statistically analysed. RESULTS: Union was achieved in 76% of cases. Good to excellent results were achieved in 84% of patients. There was no significant difference in union rates, deformity correction achieved and period of immobilisation between the MR and IG techniques. The occurrence of arthritic changes correlated with the time interval between injury and surgery (p = 0.002). CONCLUSIONS: The most important factor that influences the outcome is the time period between the occurrence of the fracture and surgery for non-union. The Matti-Russe procedure can achieve comparable results to interpositional grafting techniques with a shorter period of immobilisation than previously thought to be required. We believe that the presence of a deformity is not a contraindication for the procedure.

Numbness Around the Total Knee Arthroplasty Surgical Scar: Prevalence and Effect on Functional Outcome.

BACKGROUND: Numbness around the surgical scar can be a source of discomfort or dissatisfaction in a proportion of patients undergoing total knee arthroplasty (TKA). Literature reports wide variation in its prevalence and the consequence of numbness on the outcome of TKA is not clear. We investigated the prevalence of numbness, along with contributing factors, and assessed its effect on the functional outcome of TKA. METHODS: In total, 258 knees were included in this prospective patient-reported outcome measure case-control study. Demographic details, type and length of incision, pre-operative and 1-year post-operative Knee Society Scores were recorded and compared. RESULTS: The prevalence of numbness at 1 year was 53%, with a female preponderance. Patients older than 70 years were less affected. Discomfort due to numbness was recorded in 8.7% of the patients, 75% of which were female. The length of the incision correlated positively with the presence of numbness. The Knee Society Scores did not correlate with the presence or area of numbness. CONCLUSION: Our findings indicate a high prevalence of numbness after TKA. Nevertheless, numbness does not affect the functional outcome.

Medium term outcomes of primary and revision Coonrad-Morrey total elbow replacement.

BACKGROUND: Total elbow replacement (TER) is indicated in inflammatory arthritis, osteoarthritis and fractures that are not amenable to reconstruction. There is no series in literature, to the best of our knowledge, regarding the results of revision of the Souter-Strathclyde prosthesis (SSP) to the Coonrad-Morrey prosthesis (CMP). The aim of this study is to present the medium term results of primary CMP total elbow replacement and revision of the SSP to CMP. MATERIALS AND METHODS: 50 primary CMPs (Group I) and 11 revision CMPs (Group II) were included in the study. Demographic, operative, followup and radiological data were analysed. The indication for revision of the primary implant was peri-prosthetic fracture in six cases, aseptic loosening in four cases and instability in one case. RESULTS: The mean age in Group I was 67.28 ± 12.45 years and in Group II was 57.09 ± 11.25 years. The mean period of followup was 8.08 ± 2.95 years and 7.46 ± 2.39. There was a significant improvement in range of motion and pain in both groups. The complications seen were nerve palsy, infection, fractures and heterotopic ossification. The 5-year survival rate in Group I was 94%. The results were good in 36 elbows, fair in 8 elbows and poor in 5 elbows. In Group II, the results were good in 8 elbows, fair in 2 elbows and poor in 1 elbow. The complications seen were nerve palsy, fractures and heterotopic ossification. DISCUSSION: Primary CMP TER provides a functionally useful range of movement of 100° which is enough to perform most activities of daily living. It also produces a pain free and stable joint. Similar results are achieved after revision of the SSP to CMP. The unique toggle-hinge mechanism of articulation provides inherent stability and good survivorship. CONCLUSION: Semiconstrained prostheses like CMP provide good functional results and survivorship and are the implant of choice in both primary and revision total elbow replacements.

Femoral Head-Trunnion Dissociation Secondary to Corrosion of a Modular Total Hip Replacement: A Case Report.

CASE: We report a rare case of modular femoral head-trunnion dissociation. The patient presented with a sudden onset of groin pain and an inability to bear weight. Intermittent clunking was reported to have started around five years after implantation of the hip replacement. The duration of symptoms, radiographic findings, and analysis of the retrieved components support the theory of chronic trunnion failure due to corrosion. CONCLUSION: This is, to our knowledge, the first case of dissociation of the femoral head from the trunnion in which substantial macroscopic wear of the trunnion was observed and likely contributed to the dissociation. A new onset of clicking or clunking should be investigated as it may be a harbinger of head-neck dissociation.

Adverse reactions to metal debris in metal-on-polyethylene total hip arthroplasty using a titanium-molybdenum-zirconium-iron alloy stem.

We report a series of three patients who underwent uncemented total hip arthroplasty with a modular titanium-molybdenum-zirconium-iron stem and a cobalt-chrome-molybdenum head on an ultra-high molecular weight highly cross-linked polyethylene liner bearing. All three cases subsequently developed pain and adverse reaction to metal debris, leading to revision of the implants within thirty-six months. They were subsequently found to have hypersensitivity to cobalt or chromium. However where tested, blood metal ion levels were within MHRA guideline limits. Corrosion was noted at the taper-trunnion junction. It is possible, that the multi alloy head-neck combination may lead to corrosion. Hypersensitivity to metal ions may result to ARMD at lower metal ion levels. The use of ceramic heads may help avoid this risk.

Ilizarov's method for treatment of nonunion of diaphyseal fractures of the humerus.

BACKGROUND: Nonunion in diaphyseal fractures of the humerus can be treated by various modalities like plating and bone grafting, exchange nailing, fibular strut grafting and Ilizarov's method of ring fixation. To achieve union in infected nonunion in which multiple surgeries have already been done is further challenging. We conducted a prospective study wherein the outcome of the treatment of nonunion of diaphyseal fractures of the humerus by Ilizarov's method was analyzed. MATERIALS AND METHODS: Nineteen patients with diaphyseal nonunion of the humerus were treated by Ilizarov's external fixator. These included nonunion after plating (n=11), intramedullary nailing (n=1) or conservative methods (n=7). In post-surgical infected nonunion (n=6), the implants were removed, debridement done, bone fragments were docked followed by application of ring fixator and compression. In aseptic nonunion (n=13), distraction for three weeks followed by compression was the protocol. Early shoulder and elbow physiotherapy was instituted. The apparatus was removed after clinical and radiological union and the results were assessed for bone healing and functional status. RESULTS: Fracture union was achieved in all the 19 cases. Pin site infection was seen in 2 cases (10.52%). The bone healing results were excellent in eighteen cases (94.73%) and good in one case (5.26%).The functional results were found to be excellent in fourteen cases (73.68%), good in four (21.05%) and fair in one case (5.26%). CONCLUSION: Ilizarov's method is an excellent option for treatment of septic and aseptic non union of diaphyseal fractures of the humerus as it addresses all the problems associated with non union of the humerus like infection, deformity and joint stiffness.