Adam Stuart Dowrick

Does the disabilities of the arm, shoulder and hand (DASH) scoring system only measure disability due to injuries to the upper limb?

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was designed, and has been validated, as a measure of disability in patients with disorders of the upper limb, the influence of those of the lower limb on disability as measured by the DASH score has not been assessed. The aim of this study was to investigate whether it exclusively measures disability associated with injuries to the upper limb. The Short Musculoskeletal Functional Assessment, a general musculoskeletal assessment instrument, was also completed by participants. Disability was compared in 206 participants, 84 with an injury to the upper limb, 73 with injury to the lower limb and 49 controls. We found that the DASH score also measured disability in patients with injuries to the lower limb. Care must therefore be taken when attributing disability measured by the DASH score to injuries of the upper limb when problems are also present in the lower limb. Its inability to discriminate clearly between disability due to problems at these separate sites must be taken into account when using this instrument in clinical practice or research.

Nutritional status and short-term outcome of hip arthroplasty.

Purpose. To review nutritional status and outcome of 90 patients who underwent total hip arthroplasty (THA) or hemiarthroplasty. Methods. Records of 51 women and 39 men aged 26 to 96 (median, 71) years who underwent elective THA (n=48) for osteoarthritis, or trauma-related THA (n=10) or hemiarthroplasty (n=32) for subcapital femoral neck fractures using an uncemented femoral stem were retrospectively reviewed. Patient demographics and intra- and post-operative complications were recorded. Patient co-morbidities were assessed according to the Charlson grading system. Nutritional status was assessed using haematological markers of serum albumin (ALB) level and total lymphocyte count (TLC). Samples were taken on the day of the operation and within 24 hours of operation. Suboptimal nutrition was defined as a serum ALB level of <3.5 g/dl and a TLC of <1.50 cells/mm. Results. 86% of trauma patients and 30% of elective patients were malnourished preoperatively (p<0.001). Preoperatively, more males than females had suboptimal ALB levels (28% vs. 8%, p=0.033) and TLC (82% vs. 31%, p<0.001). Age was inversely proportional to preoperative ALB and TLC values; patients older than 75 years had significantly lower values. Of those staying >7 days in hospital, 67% were aged >75 years as opposed to 31% were aged ≤75 years (p=0.001). Male gender, old age, and presentation with trauma were risk factors for suboptimal nutritional parameters (p<0.001 for all). Patients with suboptimal ALB and TLC values had a significantly longer stay in hospital (p=0.032 and p=0.021, respectively). Conclusion. The rate of malnourishment was significantly higher in patients having trauma-related surgery than in those having elective surgery. Malnourished patients are at greater risk of prolonged hospital stay. Preoperative nutritional assessment may be useful in predicting patients at high surgical risk.

Iris colour, ethnic origin and progression of age-related macular degeneration

Aim: To investigate the relationship between iris colour, ethnic origin and the progression of age‐related macular degeneration (AMD).

Ethical Issues in the Design of Randomized Trials: To Sham or Not to Sham

The placebo effect is based on the expectations of the patient regarding the effectiveness of the treatment. The high levels of stress and rituals involved with surgery can lead to a strong placebo effect. However, the ethical principles of performing sham surgery to measure any placebo effect have been questioned, and sham-controlled surgical trials are rarely conducted. While there are a number of ethical principles that must be considered to justify the implementation of a sham-controlled surgical clinical trial, four areas deserve particular attention: equipoise, risk minimization, informed consent, and deception. Particularly in orthopaedics, where equipoise is common, sham-controlled trials may be important to ensure that inferior or ineffective treatments do not become standard practice.

Post-operative numbness and patient satisfaction following plate fixation of clavicular fractures.

INTRODUCTION AND AIM Numbness across the shoulder and upper chest wall is a frequent complication following plate fixation of clavicular shaft fractures. This is usually attributed to damage to branches of the supraclavicular nerve caused by the surgical approach. We investigate whether the use of an incision perpendicular to the long axis of the clavicle (vertical incision) rather than one parallel to it (horizontal incision) is associated with reduced post-operative numbness and improved patient satisfaction. METHODS We retrospectively assessed a group of patients who underwent plate fixation of a fractured clavicle at our institution. Using a patient-completed questionnaire, we compared differences in numbness, scar satisfaction, pain, and overall satisfaction with the operation, between those who received a horizontal incision (n=21) versus those treated using a vertical incision (n=14). RESULTS The likelihood of experiencing post-operative numbness was less in the vertical incision group. Those who had undergone vertical incisions also reported a significantly reduced degree of numbness and significantly less awareness of the numbness with clothing and shoulder straps. There was no statistically significant difference between the groups in terms of pain and scar satisfaction. Patients who reported being most bothered by their numbness also tended to report the highest dissatisfaction with the operation. CONCLUSION Vertical incisions for plate fixation of clavicular shaft fractures may be associated with reduced post-operative numbness and avoid some cases of patient dissatisfaction. Surgeons should consider using this approach in plate fixation of clavicle fractures.

Methodology of the Cardiovascular Health and Age-Related Maculopathy (CHARM) Study.

Age-related macular degeneration (AMD) is responsible for the majority of visual impairment in the Western world. Epidemiological studies examining risk factors for AMD are needed to develop strategies for the prevention of blindness from this condition. A number of potentially modifiable risk factors for AMD have been identified; however, only smoking has been a consistent risk factor across the numerous studies. A growing body of evidence suggests that AMD and cardiovascular disease may have common risk factors. The Cardiovascular Health and Age Related Maculopathy (CHARM) Study was established to examine the risk factors for AMD and its progression, in particular risk factors associated with cardiovascular disease. Examining risk factors for prevalent AMD, cases with AMD were compared with age and gender matched controls with no AMD features. For the assessment of AMD progression, the study examined in 2001 and 2002 those participants with early AMD, or age-related maculopathy (ARM), who had undergone baseline examination between 1992 and 1995 and compared the characteristics of those who had progression of AMD with those who did not. The CHARM study involved both ophthalmic and cardiovascular examinations. Standardised clinical eye examination and grading of the macular stereo photographs were used to determine the AMD status and progression. To examine cardiovascular status, carotid artery ultrasound imaging, analysis of systemic arterial compliance, augmentation index and pulse wave velocity were performed. The traditional and novel risk factors for CVD such as levels of glucose, cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, fibrinogen, C-reactive protein, immunoglobulins A and M, homocysteine, oxidized LDL and the exposure to the Chlamydia Pneumoniainfection were determined. DNA was collected for apolipoprotein E genotyping. The present paper outlines the primary aims of the CHARM study, the methodology involved and the recruitment results.

Alendronate-associated femoral insufficiency fractures and femoral stress reactions.

Purpose. To report characteristics and outcomes of 8 patients who underwent intramedullary nailing for alendronate-associated femoral insufficiency fractures. Methods. Records of 7 women and one man aged 54 to 91 (mean, 72) years who underwent intramedullary nailing for spontaneous or low-energy, alendronate-associated femoral insufficiency fractures were retrospectively reviewed. Contralateral femurs were assessed for stress reactions. Results. All patients had at least 4 (range, 4–10) years of alendronate use. Five patients had experienced prodromal pain lasting one day to 5 months. Five patients had received concurrent glucocorticoid therapy. At the 6-month follow-up, 6 patients had bony union, one had hypertrophic non-union and underwent dynamisation and nail exchange and eventually achieved union at month 16, and one had fixation loss and underwent nail exchange and bone grafting and eventually achieved union at month 9. In 3 patients, the contralateral femurs were painful, and cortical stress reactions were noted. They underwent prophylactic intramedullary nailing. Radiographs showed no evidence of new stress reactions or fractures. Conclusion. Contralateral involvement in patients with alendronate-associated femoral insufficiency fractures is not uncommon. Early prophylactic intramedullary nailing may provide effective pain relief and prevent progression to a fracture.

Risk factors for non-union in the non-operative management of type II dens fractures: Risk factors in type II dens fracture healing

Background:  Despite the publication of numerous studies, there remains controversy regarding the non‐operative treatment of type II dens fractures. The halo‐thoracic vest (HTV) and rigid cervical collar are the most commonly used. We sought to compare the outcomes of patients managed with these devices in terms of risk factors for non‐union and complication rates.

Risk factors for non-union in the non-operative management of type II dens fractures.

BACKGROUND Despite the publication of numerous studies, there remains controversy regarding the non-operative treatment of type II dens fractures. The halo-thoracic vest (HTV) and rigid cervical collar are the most commonly used. We sought to compare the outcomes of patients managed with these devices in terms of risk factors for non-union and complication rates. METHODS This study was a retrospective review of adult patients with type II dens fractures treated non-operatively at a Level 1 Trauma Centre between 2001 and 2007. Patient medical records and imaging studies were reviewed. Union was defined as stable fibrous union or bony union at 3 months. RESULTS Sixty-seven patients were included – 35 treated using a HTV and 32 with a collar. Non-union was associated with increased time in HTV or collar (P = 0.011), a mechanism of injury involving a low fall (P = 0.008), or low velocity injuries (P = 0.04). The proportion of patients with stable union at 3 months was 60% for the HTV group versus 35% for the cervical collar group (P = 0.10). There were trends to support increased risk of non-union with age ≥65 years (P = 0.13) or with fracture displacement ≥2 mm (P = 0.17) at the time of presentation. Clinically significant complications of the HTV were more common than those experienced with collar. Of HTV patients, 60% suffered one or more complications compared with 6% for collar. CONCLUSIONS We were unable to demonstrate any statistically significant advantage or disadvantage of either device. Further investigation of mortality and morbidity would be beneficial.

Novel measures of cardiovascular health and its association with prevalence and progression of age-related macular degeneration: the CHARM study

BackgroundTo determine if novel measures of cardiovascular health are associated with prevalence or progression of age-related macular degeneration (AMD).MethodsMeasures of the cardiovascular system: included intima media thickness (IMT), pulse wave velocity (PWV), systemic arterial compliance (SAC), carotid augmentation index (AI). For the prevalence study, hospital-based AMD cases and population-based age- and gender-matched controls with no signs of AMD in either eye were enrolled. For the progression component, participants with early AMD were recruited from two previous studies; cases were defined as progression in one or both eyes and controls were defined as no progression in either eye.Results160 cases and 160 controls were included in the prevalence component. The upper two quartiles of SAC, implying good cardiovascular health, were significantly associated with increased risk of AMD (OR = 2.54, 95% CL = 1.29, 4.99). High PWV was associated with increased prevalent AMD. Progression was observed in 82 (32.3%) of the 254 subjects recruited for the progression component. Higher AI (worse cardiovascular function) was protective for AMD progression (OR = 0.30, 95%CL = 0.13, 0.69). Higher aortic PWV was associated with increased risk of AMD progression; the highest risk was seen with the second lowest velocity (OR = 6.22, 95% CL = 2.35, 16.46).ConclusionThe results were unexpected in that better cardiovascular health was associated with increased risk of prevalent AMD and progression. Inconsistent findings between the prevalence and progression components could be due to truly different disease etiologies or to spurious findings, as can occur with inherent biases in case control studies of prevalence. Further investigation of these non-invasive methods of characterizing the cardiovascular system should be undertaken as they may help to further elucidate the role of the cardiovascular system in the etiology of prevalent AMD and progression.