Acetic Acid as Part of a Debridement Protocol During Revision Total Knee Arthroplasty

Background

Thorough debridement is mandatory in revision for infected total knee arthroplasties (TKA). We investigated a novel adjuvant chemical debridement strategy using acetic acid (AA) that seeks to create a hostile environment for microorganisms. We report the first orthopedic in vivo series using an AA soak in infected TKAs. We also investigated the in vitro efficacy of AA against bacteria isolated from these knees.

Revision Total Knee Arthroplasty Using an Uncemented Metaphyseal Sleeve,Rotating Hinge Prosthesis: A Case Series of 99 Patients

BackgroundHinge knee replacement is a salvage procedure with historically high failure and complication rates. We aim to analyze the use of an uncemented metaphyseal sleeve revision knee replacement in our unit—a third-generation rotating hinge knee prosthesis. This is the largest reported series of this implant with longest follow up.MethodsWe retrospectively identified 99 revision cases performed (2002-2018). In total, 67 of 99 (68%) cases were performed for aseptic etiology, whereas 32 of 99 (32%) cases were performed for infection. Clinical outcomes were assessed using the Oxford Knee Score, survivorship analysis, and incidence of revision/reoperations. Mean follow-up was 7 years (range 1.5-18).ResultsAt follow-up, the mean Oxford Knee Score had improved from 10 points to 25 points. At mean 7 years of follow up, 18 of 99 cases had undergone revision giving a survivorship of 81% (90% aseptic). In total, 10 of 18 cases were performed for infection (10%) and 9 of 18 cases were performed for aseptic reasons (9%), of which 5 were for patella resurfacing (2 revision), 2 for failure of bony ingrowth, and 1 for fracture. Twenty-six patients (26%) had complications postoperatively, with patella disorders and reduced range of movement the most common. Patients who did not undergo patella resurfacing were significantly more likely to need revision of any cause (P = .01).ConclusionThis is the largest study of this prosthesis with longest follow-up. It demonstrates good survivorship and improvement in knee pain. Those with infection are at greatest risk of revision. Significant numbers have patella dysfunction/anterior knee symptoms therefore patella resurfacing should be considered when using this implant.Level of EvidenceIV.     

Septic complications of knee replacements and their treatment

The introduction of the modern total knee replacement has been revolutionary in treatment of degenerative joint disease. Over recent years there has been a significant increase in the number of primary replacements and revision procedures. Prosthetic joint infection is an important and devastating complication which has not been eliminated by modern day practice. Patient selection, operating environment, surgical technique and soft tissue management can reduce but not eliminate the incidence of infection. When infection occurs, it should be managed as part of a multidisciplinary team to ensure an optimal outcome. Revision for infection can be performed as a single-stage or two-stage procedure. When revision surgery fails, salvage options should be considered including: salvage arthroplasty, arthrodesis, resection arthroplasty and amputation. The challenges for the surgeon to overcome include: a poor soft tissue envelope, ligamentous or extensor mechanism disruption and bone loss. Complications are not uncommon with salvage options and therefore meticulous preoperative planning and a thorough consent process are mandatory. The management of patients with an infected implant should performed by consultants who have specialized expertise and who work in networks. This is necessary to achieve the best results. This article will also discuss the salvage options.     

A pilot study of fascia Bowen therapy for 8-11 year-old boys with developmental coordination disorder

BackgroundDevelopmental coordination disorder (DCD), also known as dyspraxia, is a disorder emerging in childhood characterised by motor skill impairments. The motor difficulties often produce negative effects in other areas of life, such as poor self-esteem and reduced social interactions. One treatment used for DCD is fascia Bowen therapy, which involves stimulating the fascia tissues of the body using finger and thumb rolling movements over the skin to improve overall muscle movement. However, no studies to date have been reported testing the effectiveness of fascia Bowen in DCD.MethodsThe present pilot study tested the effectiveness of 6 weeks of fascia Bowen in 10 boys aged 8–11 years with DCD. None of the boys had ever received treatment in any form before this study. Motor skills were assessed using the Movement Assessment Battery for Children-2 (MABC-2) and the DCD questionnaire, and psycho-social functioning was measured using the Self-Perception Profile, Spence Social Skills Questionnaire, and Strengths and Difficulties Questionnaire. All measures of interest were assessed before and after the therapy.ResultsResults showed significant improvement in motor function post-intervention, with 60% of the children no longer clinically being classified as having a movement difficulty on the MABC-2. However, no significant improvements were seen in psycho-social measures, at least within the short time-frame of the therapy in the current study.ConclusionsThe current pilot study revealed improvements in motor functioning after fascia Bowen therapy, across both performance and questionnaire measures, but that these improvements did not extend to wider areas of life. Further research in DCD is needed to test the effectiveness of fascia Bowen in larger studies with expanded ages and both genders over longer periods, including the generalisation of results of these longer interventions to different areas of life beyond motor ability.     

Treating the boxer's fracture in Wales: a postal survey

INTRODUCTION

There is no standardised treatment for fifth metacarpal neck fractures. Treatment of this common fracture can vary from immediate mobilisation to immobilisation in a plaster cast for 3 weeks. There is no literature identifying current practice amongst surgeons.

SUBJECTS AND METHODS

This survey''s aim was to reveal current practice in Wales by means of a postal questionnaire sent to all Welsh orthopaedic consultants.

RESULTS

The questionnaire had a 60% response rate. Results demonstrated varied opinion regarding the degree of displacement warranting reduction. Overall, 10% of surgeons reduce the fracture at 30° of displacement, 29% at 40°, 18% at 50° and 20% at 60° of displacement. The treatment was also very varied. Most surgeons preferred to treat these fractures with neighbour strapping (43%,) while others preferred plaster immobilisation (39%) or immediate mobilisation (10%.) Only 22% of surgeons discharge these patients back to the community after their first visit to out-patients while 13% offer two follow-up appointments.

CONCLUSIONS

The treatment being offered for this common fracture in Wales is inconsistent. There is a need to develop evidence- based best practice guidelines which should standardise the treatment of this common injury. Perhaps, a large multicentre outcome study may enable this to be drawn up in the future.     

A unified emergency care system from first aid to definitive care

The Unified Emergency Care System (UECS) provides an integrated system of medical support from point of injury to the time a casualty is handed over to specialist care within hospital. It enables personnel at all skill levels to deliver life-saving support to casualties with a broad range of acute injuries and illness. The UECS facilitates standardised training with each level building upon the previous, yet it retains an inherent flexibility to adapt to specific operational and service requirements.     

"When you're using gear you put HIV to the back of your mind and forget about it": constructs of risk

This article presents findings from a qualitative study concerning drug injectors' constructs of human immunodeficiency virus (HIV) risk behavior. Analysis of data obtained from in-depth interviews (some with a vignette) of drug injectors found that when individuals needed an injection of drugs and were experiencing drug withdrawal they were more likely to take drug injecting risks. This was often discussed within an overall preoccupation with drug use. The substantive focus of the analysis goes on to explore drug injectors' desire to think about the consequences of HIV risk behavior at a later point in time. These exploratory findings highlight how further research needs to be undertaken in order to improve understanding of the temporal issues concerning drug injecting HIV risk behavior.     

Towards a culturally acceptable end-of-life survey questionnaire: a Bengali translation of VOICES

AIM: To assess the cultural acceptability and appropriateness of an English end-of-life survey questionnaire translated into Bengali for use in east London. STUDY DESIGN: Group discussions with informal carers (n=3 groups) and professionals (n = l1 group). SAMPLE AND SETTING: Informal carers within a Bengali-speaking community (n = 26) in east London participated in three groups discussions led by three community workers trained in interviewing procedures. These data were followed up with one group discussion with bilingual health and social care professionals (n = 6). ANALYSIS: Data subject to content analysis. RESULTS: Participants were supportive of the development of the translated questionnaire. However, attention should be paid to vocabulary, shared meanings, cultural equivalence and the ways people conceptualize health and illness, and death and dying. CONCLUSIONS: These findings, together with participants' views on the administration of the questionnaire, will prompt revisions to the research approach when targeting ethnic and cultural groups in the future.     

Intramedullary femoral nailing: removing the nail improves subjective outcome

Intramedullary nailing has become an established treatment for femoral fractures. We reviewed the subjective and objective outcome of locked intramedullary nailing since its introduction to our unit in 1988. The outcome was assessed subjectively using the Short Form 36 (SF 36) health questionnaire and objectively by clinical, radiological and case note review.From 1988 to 1995, 220 intramedullary femoral nails were inserted at the North Staffordshire Royal Infirmary. Of these we were able to match the SF 36 questionnaire and case review of 91 patients. Fifty-six patients were male and 35 female with an average age of 40. Acute trauma accounted for 86 cases (six with an injury severity score >15 and seven open injuries). There was a 24% incidence of minor complications; there were no deep infections and no major complications. All cases recorded subjective scores within the normal range but 34 symptomatic patients who had their femoral nails removed (mainly for persistent pain or prominent metalwork) recorded noticeably higher scores in all eight assessment areas.Intramedullary nailing for femoral fractures is a technically demanding procedure and results in both a good objective and subjective outcome. It is associated with a low rate of major complications but a relatively high rate of minor complications. We conclude that the removal of intramedullary femoral nails is justified in symptomatic patients. It results in an improved subjective outcome and has a low complication rate.