Successful reverse total shoulder replacement in a patient with Apert syndrome.

Apert syndrome, first described in the literature by a French pediatrician Eugene Apert, is a rare congenital form of acrocephalodactyly with autosomal dominant inheritance. Classically, this syndrome is characterized by craniosynostosis, midface hypoplasia, and symmetrical syndactyly of hands and feet resulting from embryonic anomalies during the third week of gestation. It is also associated with a variety of abnormalities of the viscera, involving the neurological, genitourinary, and cardiorespiratory systems. Glenohumeral manifestations of Apert syndrome include glenoid dysplasia, an oblong humeral head with a prominence of the greater tuberosity, acromial prominence, and inferior subluxation of the glenohumeral joint. This pathological anatomy results in progressive degenerative changes, synchondrosis, and restriction in shoulder joint mobility, particularly in flexion and abduction. While surgical options for the accompanying deformities of the feet and spine are described, interventions for shoulder pathology are not well-defined. Joint replacement surgery could offer such patients pain relief and improved function. Reverse total shoulder arthroplasty is yet to be described in Apert syndrome and this case report presents the outcome in a 48-year-old male. Level of evidence: IV case report.

Intervention rates are low after direct discharge from the Edinburgh trauma triage clinic: Outcomes of 6,688 patients.

AIM: The Edinburgh Trauma Triage clinic (TTC) is an established form of Virtual Fracture clinic (VFC) that permits the direct discharge of simple, isolated fractures from the Emergency Department (ED). Small, short-term cohort studies of similar systems have been published, but to detect low rates of complications requires a large study sample and longer-term follow-up. This study details the outcomes of all patients with injuries suitable for a direct discharge protocol over a four-year period, reviewed at a minimum of three years after attendance. PATIENTS: All TTC records between February 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and mallet finger injuries were included. TTC outcome, including any deviations from a well-established direct discharge protocol, were noted. All records were re-assessed at a minimum of 36 months after TTC triage (mean 54 months) to ascertain which injuries attended the trauma clinic after initial discharge. Reasons for attendance, the source of referral and any subsequent surgical procedures were identified. RESULTS: There were 6688 patients with fractures of the radial head (1861), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and mallet finger injuries (370). 298 (6%) patients were re-referred after direct discharge and attended trauma clinic at a mean time after injury of 11.9 weeks, of whom 11 (0.2%) underwent a surgical intervention. Serious adverse events, defined as those in which a patient may not have come to harm if early clinical review had been undertaken, occurred in 1 patient (0.01%). CONCLUSION: Intervention after direct discharge of simple pre-defined injuries of the elbow, hand and foot is low. Within a TTC system, patients with these injuries can be safely discharged without routine follow-up.

Sinus pericranii: long-term outcome in a 10-year-old boy with a review of literature.

Sinus pericranii is a rare cranial venous anomaly in which there is an abnormal communication between intracranial dural sinuses and extracranial venous structures, usually via an emissary transosseous vein. We report the case of a 10-year-old boy who was successfully managed conservatively. The clinical findings, investigations and management are discussed. We focus on the long-term management of these patients, with a review of the relevant literature.

Rare progression of cholangiocarcinoma: distal femoral metastasis.

Cholangiocarcinoma (CCA) is a rare cancer of the bile duct epithelial cells, with metastases to long bones rarely reported. We present the case of a woman aged 61 years, diagnosed with CCA 6 years previously. She presented with right thigh discomfort, rapidly progressing to immobility with severe pain. Radiological investigations revealed a lytic lesion in her right distal femur, most likely a metastatic deposit, at high risk of pathological fracture. This was managed with an en bloc resection and implantation of a distal femoral replacement. Pathology specimens from theatre confirmed metastatic CCA. Despite sustaining a subsequent fractured neck of femur on the operative side, she recovered well from surgery, with minimal pain and improved mobility on discharge. She restarted palliative chemotherapy. This case illustrates the option of definitive major surgery for the management of metastatic bone disease. As in this case, this can lead to improved symptom control and quality of remaining life.

Cognitive outcome after on- and off-pump coronary artery bypass grafting surgery: a systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to compare cognition following coronary artery bypass grafting (CABG) surgery with or without cardiopulmonary bypass (CPB) (on- or off-pump). DESIGN: Systematic review and meta-analysis of randomized control trials comparing cognitive outcome in patients undergoing CABG surgery on- or off-pump as assessed by continuous measures from a battery of 7 psychometric tests. SETTING: Multi-institutional centers performing CABG surgery. PARTICIPANTS: Patients with coronary artery disease requiring CABG surgery. INTERVENTIONS: CABG surgery with or without CPB. MEASUREMENTS AND MAIN RESULTS: A structured literature search identified 13 randomized control trials that included a total of 2,405 patients. Results from 7 psychometric tests were grouped into early (≤3 months) and late (6-12 months) postoperative periods. No significant differences were found between on- and off-pump groups in any of the 7 psychometric tests in either the early (p range 0.21-0.78) or late (p range 0.09-0.93) postoperative period. CONCLUSION: The results suggested that CPB may not be associated with cognitive decline that is associated with CABG surgery.

Medium-term results of Oxford phase-3 medial unicompartmental knee arthroplasty.

PURPOSE: To review medium-term results of 49 consecutive patients who underwent Oxford phase-3 medial unicompartmental knee arthroplasty by a single surgeon. METHODS: Records of 28 women (mean age, 71 years) and 21 men (mean age, 68 years) who underwent minimally invasive Oxford phase-3 medial unicompartmental knee arthroplasty by a single surgeon were retrospectively reviewed. The Oxford knee score and visual analogue scale (VAS) scores for pain and satisfaction were assessed at the latest follow-up by an independent observer, as were postoperative radiographs for implant position, osteoarthritic changes in the non-replaced compartments, and radiolucent lines of >2 mm or implant subsidence. The survival rate was calculated using Kaplan-Meier survival analysis. Patient demographics, postoperative alignment (varus/ valgus), Oxford knee scores, and the progression of osteoarthritis in the other compartments were included in a multiple logistic regression (MLR) analysis to identify significant factors affecting the probability of being satisfied (VAS scores for satisfaction of ≤2). RESULTS: The mean follow-up duration was 7.2 years. No patient was lost to follow-up. Two patients with no knee symptoms died (unrelated to surgery) before the 5-year follow-up. The cumulative survival rate at the 9-year follow-up was 91.2% (95% confidence interval, 87.6-94.5%). There were 4 early failures (before 4 years). One patient early in the series developed avascular necrosis of the lateral femoral condyle with an over-corrected tibiofemoral valgus of 12º at 8 months; the other 3 complained of anterior knee pain, without signs of osteoarthritis. All 4 patients underwent revision with total knee arthroplasty. There were 43 patients with more than 5 years of follow-up and without revision of the prosthesis. Patients who were not satisfied (n=6) were more likely to be <65 years old (n=4, adjusted odds ratio [OR], 3.1; MLR p=0.002) and male (n=4; adjusted OR, 2.3; MLR p=0.02). Six of the 43 patients had lucent lines on radiographs, all of which were partial and under the tibial component. Progression of the arthritis in the patellofemoral and/or lateral compartments was worse in 5 patients. CONCLUSION: Careful patient selection and good surgical technique contributed to good outcome. Younger male patients should be counselled regarding the higher chance of limited satisfaction.

Multi-limb coordination and rhythmic variability under varying sensory availability conditions in children with DCD.

Children with Developmental Coordination Disorder (DCD) have sensory processing deficits; how do these influence the interface between sensory input and motor performance? Previously, we found that children with DCD were less able to organize and maintain a gross motor coordination task in time to an auditory cue, particularly at higher frequencies [Whitall, J., Getchell, N., McMenamin, S., Horn, C., Wilms-Floet, A., & Clark, J. (2006). Perception-action coupling in children with and without DCD: Frequency locking between task relevant auditory signals and motor responses in a dual motor task. Child: Care, Health, and Development, 32, 679-692]. In the present study, we examine the same task (clapping in-phase to marching on a platform) under conditions involving the removal of vision and hearing. Eleven children with DCD (mean=7.21, SD=0.52 years), 7 typically developing (TD) children (mean=6.95+/-0.72 years), and 10 adults performed continuous clapping while marching under four conditions: with vision and hearing, without vision, without hearing, and without both. Results showed no significant condition effects for any measure taken. The DCD group was more variable in phasing their claps and footfalls than both the adult group and the TD group. There were also significant group effects for inter-clap interval coefficient of variation and inter-footfall interval coefficient of variation, with the DCD group being the most variable for both measures. Coherence analysis between limb combinations (e.g., left arm-right arm, right arm-left leg) revealed that the adults exhibited significantly greater coherence for each combination than both of the children's groups. The TD group showed significantly greater coherence than the DCD group for every limb combination except foot-foot and left hand-right foot. Measures of approximate entropy indicated that adults differed from children both with and without DCD in the structure of the variability across a trial with adults showing more complexity. Children with DCD are able to accomplish a self-initiated gross-motor coordination task but with increased variability for most but not all measures compared to typically developing children. The availability of visual and/or auditory information does not play a significant role in stabilizing temporal coordination of this task, suggesting that these are not salient sources of information for this particular task.

Inter- and intra-batch variability in the handling characteristics and viscosity of commonly used antibiotic-loaded bone cements.

BACKGROUND: Several factors can affect the viscosity of a cement and therefore its handling characteristics. We performed an in vitro study to ascertain whether anecdotal observations of differences in handling between batches of the same brand of cement actually existed. METHODS: 3 batches of Simplex P Tobramycin (SPT), Refobacin Bone Cement (RBC), SmartSet GHV (SSG) and Palacos R+G (PRG) were tested. 6 replicates of each batch were vacuum-mixed and their viscosity in relation to time was measured under laboratory conditions using a rheometer. We examined the handling characteristics of 6 replicates of each batch after they were hand-mixed under theater conditions. RESULTS: Inter- and intra-batch variability was seen in the viscosity of all brands of cement tested. Interbatch calculations were influenced by high intra-batch variability in viscosity. The viscosity of RBC cement was similar to that of SSG, but different to that of PRG (p = 0.01 at 5 N and p = 0.009 at 40 N). INTERPRETATION: Our results suggest that in clinical practice, extrinsic factors such as preparation conditions and methods probably play a more important role than the intrinsic variability of cements. However, variability in handling and viscosity will exist in all brands of cement prepared under theater conditions and the surgeon must be aware of why they may act differently.