Total Knee Arthroplasty in Patients Who Have Skeletal Dysplasia: A Center's Experience With a Mean 9-Year Follow-Up.

BACKGROUND: Total knee arthroplasty (TKA) in patients who have skeletal dysplasia (SD) is a technically challenging surgery due to deformity, joint contracture, and associated comorbidities. Patients presenting with this condition have traditionally been treated with conservative measures, leading to poor outcomes. The aim of this study was to follow-up on patients who had SD following TKA, specifically with regards to clinical outcomes. METHODS: A total of 31 knees (22 patients) with SD that had undergone TKA in our institution were included in our study. The mean follow-up from index surgery was 110.3 months (range: 20 to 291). The type of dysplasia, implant used, and clinical outcomes with patient-reported outcome measures are presented. RESULTS: There were 8 patients (36.3%) who had a diagnosis of achondroplasia, followed by multiple epiphyseal dysplasia (31.8%) and spondyloepiphyseal dysplasia (22.7%). There were 14 men and 8 women who had a mean age of 51 years (range: 28 to 73). Custom implants were required in 12 cases (38.7%), custom jigs were used in 6 cases (19.4%), and robotic-assisted surgery was used in 2 (6.5%) TKAs. Hinged prostheses were used in 17 cases (54.8%), posterior-stabilized in 9 (29.0%), and cruciate-retaining implants in 5 (16.1%). There was 1 patient who sustained an intraoperative medial tibial plateau fracture treated with concomitant open reduction and internal fixation. There was 1 revision that occurred during the follow-up period with a patella resurfacing for continued anterior knee pain. Postoperatively, Oxford Knee Scores improved on average by 12.2 points. The 10-year and 20-year all-cause revision-free survival was 96.8, respectively. CONCLUSIONS: Despite the technical challenges and complexity associated with this unique patient cohort, we demonstrated excellent implant survivorship and clinical outcomes post-TKA with mid-term to long-term follow-up of more than 20 years. We recommend preoperative cross-sectional imaging for precise planning and implant templating with multidisciplinary team decision-making. Despite our results, functional outcomes remain inferior to primary arthroplasty within the general population, although we still recommend this treatment modality to appropriately counseled patients. LEVEL OF EVIDENCE: III.

An innovative training and recruitment programme in surgery.

INTRODUCTION: Staff shortages and rising locum costs prompted Barking, Havering and Redbridge University Hospitals NHS Trust to design an innovative training pathway for doctors in surgery. The 'Academy of Surgery' is a 2-year structured educational programme with rotations through surgical and emergency care specialties and includes a funded MSc. METHODS: We recruited 27 doctors over a 2-year period. The first cohort started in October 2018, the second in October 2019. These doctors are heavily supervised in a 2-year programme that aims to prepare them for higher specialty training. They undergo regular assessment and annual review of competencies and progression. They receive regular formal classroom teaching and there are regular sessions to discuss welfare. RESULTS: Surgical rotas are now fully staffed and not reliant on locum doctors. This has led to significant cost savings. Locum spending in 2017 was £3,856,000 vs £1,284,000 in 2020 - a net saving of £1,187,000 over 2 years. CONCLUSION: This innovative training programme has contributed to full staffing of a number of surgical rotas within our Trust and delivered a large financial saving for the NHS. We hope to expand this work into neighbouring trusts.

Can findings on peripheral blood smear differentiate leptospirosis from other infections? A preliminary comparative study.

Background: Blood smear changes have never been investigated as a potential tool to aid in the diagnosis of leptospirosis. Methods: Blood smears prepared from patients with leptospirosis, dengue and sepsis within the first 5 days of illness were reported by haematologists blinded to the diagnosis. Results: A total of 20, 28 and 22 patients with leptospirosis, dengue and sepsis, respectively, were analysed. Neutrophil leucocytosis, toxic changes in neutrophils, left shift, reactive lymphocytes, target cells and thrombocytopaenia were seen in 60%, 70%, 40%, 70%, 50% and 65% of the leptospirosis patients, respectively. The combination of reactive lymphocytes with toxic neutrophils or neutrophil leucocytosis was highly suggestive of leptospirosis. Conclusions: Peripheral blood smear findings may be helpful in differentiating leptospirosis from other common acute febrile illnesses.

Clinical manifestations of scrub typhus.

The mite-borne rickettsial zoonosis scrub typhus is widely prevalent in parts of Southeast and Far East Asia, and northern Australia. The disease is an acute febrile illness, associated with rash and often an eschar, which responds dramatically to treatment with antibiotics. In some cases it results in a serious illness leading to multiple organ involvement and death. The disease manifestations are thought to result from a systemic vasculitis, caused by both direct effects of the organisms as well as an exaggerated immune response, although little is understood about its pathogenesis. A wide spectrum of clinical manifestations, affecting nearly every organ system, have been described with scrub typhus. Some of these manifestations are serious and life threatening. In this systematic review, we summarise the typical and atypical manifestations of scrub typhus reported in the literature. Awareness of these unusual manifestations will hopefully guide clinicians towards diagnosing the condition early, and initiating early appropriate antibiotics and other supportive measures.