Total fibula dislocation: A rare variant of a Bosworth fracture-dislocation injury.

To our knowledge and from our review of the literature, this is a previously unreported variant of a Bosworth fracture - total fibula dislocation. A 45 year old male presented after a high energy external rotation injury to his lower leg and was diagnosed with a total fibula dislocation with the distal fibula dislocated and incarcerated posteriorly to the tibia. Definitive management was operative with fixation of the proximal tibiofibular joint and repair of the posterolateral corner structures as well as fixation distally of the syndesmosis injury. A graded rehabilitation programme was followed and 6 months postoperatively the patient was hill walking and jogging. Bosworth fracture-dislocations are rare injuries that can often be missed during the initial presentation, especially when there is no fracture associated with a dislocation. An underappreciation for the severity of this injury can have major sequelae and the clinician should have a high index of suspicion when diagnosing this injury. An appreciation for Bosworth fracture dislocations and their variations are important for the trauma surgeon.

(in vivo Gastrocnemius Muscle) Tendon Ratio in Patients with Cerebral Palsy.

BACKGROUND: The position of the gastrocnemius tendon in relation to the leg length may be different in children with cerebral palsy as compared to normal children. The palpation of muscle bellies or previous experience of the operating surgeon is employed to place the surgical incision for lengthening of the gastrocnemius aponeurosis. Inaccurate localisation may cause incorrect incisions and a risk of iatrogenic damage to the vital structures (i.e. sural nerve). OBJECTIVES: The aim of our study is to compare gastrocnemius length in-vivo between paretic and unaffected children and create a formula to localise the muscle-tendon junction accurately. METHODS: 10 children with di/hemiplegia (range 2-14y) were recruited. None of them had received any conventional medical treatment. An equal number of age/sex matched, typically developing children (range 4-14y) were recruited. Ultrasound scanning of the gastrocnemius muscle at rest was performed to measure the length of gastrocnemius bellies. We also measured the heights and leg lengths in all the children. RESULTS: The gastrocnemius medial muscles were shorter in Cerebral Palsy children when compared to similar aged normal children. In cerebral palsy children, the gastrocnemius muscle and leg ratio ranged between 35 to 50% (average ratio of 45%). CONCLUSION: Using these figures, we created an average percentage for gastrocnemius muscle length that may be used clinically to identify the tendon for open/endoscopic lengthening and also to make simple and accurate localisation of gastrocnemius muscle-tendon junction for surgical access. This decreases the length of the surgical incision and may reduce the risk of iatrogenic injuries.

The presentation of rickets to orthopaedic clinics: return of the English disease.

Rickets is a potentially treatable disease of the bone that is most commonly due to deficiency of vitamin D and is increasing in incidence in developed countries. Risk factors include dietary factors, the practice of covering up and darker skin pigmentation. This small retrospective case study set out to examine all cases of rickets presenting to the Paediatric Orthopaedic clinic over a 15-month period. Rickets presented in a bimodal fashion in the 6 cases identified: in males and females aged 3 or less and female adolescents aged 10 and above. This is in keeping with what is known regarding the rapid phases of growth during development. Five cases were from ethnic minority groups. Both female adolescents presented with genu valgum. Rickets can present primarily to Orthopaedic clinics with vague musculoskeletal symptoms. We recommend that biochemical screening be performed on patients from ethnic minorities who may be 'at risk'.

Introduction of laparoscopic bariatric surgery in England: observational population cohort study.

OBJECTIVES: To describe national trends in bariatric surgery and examine the factors influencing outcome in bariatric surgery in England. DESIGN: Observational population cohort study. SETTING: Hospital Episode Statistics database. PARTICIPANTS: All patients who had primary gastric bypass, gastric banding, or sleeve gastrectomy procedures between April 2000 and March 2008. MAIN OUTCOME MEASURES: 30 day mortality, mortality at one year after surgery, unplanned readmission to hospitalwithin 28 days, and duration of stay in hospital. RESULTS: 6953 primary bariatric procedures were carried out during the study period, of which 3649 were gastric band procedures, 3191 were gastric bypass procedures, and 113 were sleeve gastrectomy procedures. A marked increase occurred in the numbers of bariatric procedures done, from 238 in 2000 to 2543 in 2007, with an increase in the percentage of laparoscopic procedures over the study period (28% (66/238) laparoscopic procedures in 2000 compared with 74.5% (1894/2543) in 2007). Overall, 0.3% (19/6953) patients died within 30 days of surgery. The median length of stay in hospital was 3 (interquartile range 2-6) days. An unplanned readmission to hospital within 28 days of surgery occurred in 8% (556/6953) of procedures. No significant increase in mortality or unplanned readmission was seen over the study period, despite the exponential increase in minimal access surgery and consequently bariatric surgery. CONCLUSIONS: Bariatric surgery has increased exponentially in England. Although postoperative weight loss and reoperation rates were not evaluated in this observational population cohort study, patients selected for gastric banding had lower postoperative mortality and readmission rates and a shorter length of stay than did those selected for gastric bypass.

PADI4 genotype is not associated with rheumatoid arthritis in a large UK Caucasian population.

BACKGROUND: Polymorphisms of the peptidylarginine deiminase type 4 (PADI4) gene confer susceptibility to rheumatoid arthritis (RA) in East Asian people. However, studies in European populations have produced conflicting results. This study explored the association of the PADI4 genotype with RA in a large UK Caucasian population. METHODS: The PADI4_94 (rs2240340) single nucleotide polymorphism (SNP) was directly genotyped in a cohort of unrelated UK Caucasian patients with RA (n=3732) and population controls (n=3039). Imputed data from the Wellcome Trust Case Control Consortium (WTCCC) was used to investigate the association of PADI4_94 with RA in an independent group of RA cases (n=1859) and controls (n=10 599). A further 56 SNPs spanning the PADI4 gene were investigated for association with RA using data from the WTCCC study. RESULTS: The PADI4_94 genotype was not associated with RA in either the present cohort or the WTCCC cohort. Combined analysis of all the cases of RA (n=5591) and controls (n=13 638) gave an overall OR of 1.01 (95% CI 0.96 to 1.05, p=0.72). No association with anti-CCP antibodies and no interaction with either shared epitope or PTPN22 was detected. No evidence for association with RA was identified for any of the PADI4 SNPs investigated. Meta-analysis of previously published studies and our data confirmed no significant association between the PADI4_94 genotype and RA in people of European descent (OR 1.06, 95% CI 0.99 to 1.13, p=0.12). CONCLUSION: In the largest study performed to date, the PADI4 genotype was not a significant risk factor for RA in people of European ancestry, in contrast to Asian populations.

Association of the HLA-DRB1 gene with premature death, particularly from cardiovascular disease, in patients with rheumatoid arthritis and inflammatory polyarthritis.

OBJECTIVE: To examine the role of the variants of the PTPN22 and HLA-DRB1 genes as predictors of mortality in inflammatory polyarthritis (IP) and rheumatoid arthritis (RA). METHODS: Patients were recruited from a primary care-based inception cohort of patients with IP and were followed up prospectively. For patients who died, the cause and date of death was obtained. Cox proportional hazards regression models were used to assess the association of the HLA-DRB1 (including the shared epitope [SE]) and PTPN22 genes with the risk of death from all causes and from cardiovascular disease (CVD) and to assess the interactions between SE, smoking, and anti-cyclic citrullinated peptide (anti-CCP) status, adjusted by age at symptom onset and sex. RESULTS: DNA samples were available from 1,022 IP patients. During followup, 751 of them (74%) satisfied the American College of Rheumatology 1987 criteria for RA, and 242 of them (24%) died. Carriage of 2 copies of SE alleles predicted death from all causes (hazard ratio [HR] 1.57 [95% confidence interval (95% CI) 1.1-2.2]) and from CVD (HR 1.68 [95% CI 1.1-2.7]). This effect was most marked for individuals with the HLA-DRB1*01/*04 combination. An interaction of smoking, SE alleles, and anti-CCP antibodies was observed and was associated with the greatest risk of death from CVD (HR 7.81 [95% CI 2.6-23.2]). No association of the PTPN22 gene with mortality was detected. CONCLUSION: SE alleles, particularly compound heterozygotes, are associated with death from all causes and from CVD, independently of autoantibody status. However, the combination of SE, smoking, and anti-CCP antibodies is associated with a high risk of premature death in patients with IP and RA, which raises the possibility of a targeted strategy to prevent CVD in these patients.