John O’Byrne

Effects of home-based resistance training and neuromuscular electrical stimulation in knee osteoarthritis: a randomized controlled trial.

BackgroundQuadriceps femoris muscle (QFM) weakness is a feature of knee osteoarthritis (OA) and exercise programs that strengthen this muscle group can improve function, disability and pain. Traditional supervised resistance exercise is however resource intensive and dependent on good adherence which can be challenging to achieve in patients with significant knee OA. Because of the limitations of traditional exercise programs, interest has been shown in the use of neuromuscular electrical stimulation (NMES) to strengthen the QFM. We conducted a single-blind, prospective randomized controlled study to compare the effects of home-based resistance training (RT) and NMES on patients with moderate to severe knee OA.Methods41 patients aged 55 to 75 years were randomised to 6 week programs of RT, NMES or a control group receiving standard care. The primary outcome was functional capacity measured using a walk test, stair climb test and chair rise test. Additional outcomes were self-reported disability, quadriceps strength and cross-sectional area. Outcomes were assessed pre- and post-intervention and at 6 weeks post-intervention (weeks 1, 8 and 14 respectively).ResultsThere were similar, significant improvements in functional capacity for the RT and NMES groups at week 8 compared to week 1 (p≤0.001) and compared to the control group (p < 0.005), and the improvements were maintained at week 14 (p≤0.001). Cross sectional area of the QFM increased in both training groups (NMES: +5.4%; RT: +4.3%; p = 0.404). Adherence was 91% and 83% in the NMES and RT groups respectively (p = 0.324).ConclusionsHome-based NMES is an acceptable alternative to exercise therapy in the management of knee OA, producing similar improvements in functional capacity. Trial registration: Current Controlled Trials ISRCTN85231954

Outcome following deep wound contamination in cemented arthroplasty

Infection remains a devastating complication of joint replacement surgery causing a significant burden to both patient and surgeon. However, despite exhaustive prophylactic measures, intraoperative contamination still occurs during cemented arthroplasty with current infection rates of 1–2%. A study was undertaken to determine the incidence of perioperative contamination in cemented arthroplasty patients, to identify contaminating organisms, to identify contaminated regions within the operative wound, to identify factors associated with increased contamination, and finally to assess the medium-term clinical outcome in patients with confirmed intraoperative wound contamination. Eighty consecutive patients undergoing hip and knee cemented arthroplasty were prospectively enrolled over a 6-month period. All scrubbed personnel wore total body exhaust isolation suits and procedures were carried out in ultra-clean air theatres. Of 441 samples, contamination was identified at 21 sites (4.8%) representing a cohort of 18 patients (22.5%). Longer duration of surgery predisposed to higher contamination rates while lower contamination rates were significantly related to fewer gowned personnel within the ultra-clean system, and fewer total personnel in theatre during the procedure. None of the patients developed clinical evidence of deep prosthetic infection at follow-up. We noted a high incidence of intraoperative contamination despite standard prophylaxis. However, this was not reflected by a similar rate of postoperative infection. This may be due to a small bacterial inoculum in each case or may be due to the therapeutic effect of perioperative intravenous antibiotic prophylaxis.RésuméL’infection reste une complication grave de la chirurgie de remplacement articulaire et, en dépit des mesures prophylactiques, la contamination opératoire existe encore durant les arthroplasties cimentées avec un taux d’infection de 1 à 2%. Le but de ce travail était de déterminer l’incidence de cette contamination, d’identifier les micro-organismes en cause et les régions contaminées au sein du champ opératoire, de préciser les facteurs associés favorisant et enfin d’étudier le devenir à moyen terme des patients avec une contamination opératoire confirmée. Quatre-vingt patients consécutifs, opérés pour une arthroplastie cimentée de hanche ou de genou, étaient enrôlés prospectivement pendant une période de 6 mois. Tout le personnel habillé chirurgicalement portait un scaphandre isolant et l’opération se déroulait dans une enceinte à air ultra filtré. A partir de 441 échantillons une contamination était identifiée sur 21 sites (4,8%), représentant un groupe de 18 patients (22,5%). Une plus longue durée opératoire prédisposait à un plus grand taux de contamination. Un faible taux de contamination était significativement en relation avec un moindre nombre de personnes à l’intérieur de l’enceinte ultra-filtrée et avec un moindre nombre de personnes dans la salle d’opération pendant la réalisation de l’arthroplastie. Aucun patient n’avait développé d’infection profonde au dernier recul. Le taux élevé de contaminations opératoires malgré les précautions prophylactiques ne se retrouve pas dans un taux similaire d’infections post-opératoires. Ceci est peut-être due à la petitesse de l’inoculum bactérien dans chaque cas ou encore à l’effet thérapeutique de l’antibiothérapie prophylactique intra-veineuse.

Overuse ankle injuries in professional Irish dancers

BACKGROUND Overuse ankle injuries have been described in elite athletes and professional ballet dancers however the spectrum of injuries experienced by professional Irish dancers has not been defined. METHODS A troupe of actively performing dancers from an Irish-dance show were recruited (eight male, ten female; mean age, 26 years). The prevalence of overuse injuries in the right ankle was determined from magnetic resonance imaging. Foot and ankle self-report questionnaires were also completed (AOFAS and FAOS). RESULTS Only three ankles were considered radiologically normal. Achilles tendinopathy, usually insertional, was the most frequent observation (n=14) followed by plantar fasciitis (n=7), bone oedema (n=2) and calcaneocuboid joint degeneration (n=2). There were limited correlations between MRI patterns and clinical scores indicating that many conditions are sub-clinical. Dancers with ankle pain had poor low (p=0.004) and high (p=0.013) level function. CONCLUSIONS Overuse ankle injuries are common in Irish dancers. Incorporating eccentric exercises and plantar fascia stretching into a regular training program may benefit this population.

Locking compression plate breakage and fracture non-union: a finite element study of three patient-specific cases

Background & purposeThe locking compression plate (LCP) system offers a number of advantages in fracture fixation combining angular stability through the use of locking screws with traditional fixation techniques. However, the system is complex, requiring careful attention to biomechanical principles and good surgical technique.MethodsFrom a series of clinical cases, where locking plate fixation was used in fractures of long bones, three were selected. Patient-specific geometric information was obtained from AP and lateral plain radiographs, and the Finite Element (FE) models were generated manually.ResultsThe first case study highlighted the importance of the working length on the construct stability. By increasing the working length, the construct became more flexible. The resulting increase in interfragmentary motion promoted indirect healing with the formation of callus. In the second case study, plate breakage occurred as a result of an inappropriate fixation technique. The fixation involved the use of locked screws at the level of the fracture passing the fracture line. This reduced the flexibility of the implant which hindered the micro-motion needed for callus formation. Fatigue failure eventually occurred due to cyclic loading past the yield stress of the LCP. In the third case study, the long working length of the construct made it relatively flexible. The larger area of stress distribution on the plate reduced the local strain, resulting in a protective effect against fatigue failure of the implant.InterpretationIn Conclusion, successful application of the LCP demands a good understanding of the biomechanics and careful preoperative planning.

Irish National Joint Registry: a concept

Despite the well-documented benefits, some countries have yet to agree on the establishment of a national joint register. A questionnaire study was undertaken to ascertain the opinions of the consultant orthopaedic surgeons and specialist registrars, regarding establishment of an Irish National Joint Register. The aim was to find out the possible reasons why a national joint register has not been established in Ireland. A 69% first response rate was recorded. Ninety-seven percent believe it is time to set up a registry and 81% say it should be made compulsory for unwilling surgeons and hospitals to participate. Despite the overwhelming support, privacy and liability issues were major concerns. Fifty-eight percent agree that access to registry report by general public can expose surgeons and hospitals to medico-legal implications. Legislation may be required to protect the integrity of a national joint replacement registry to ensure that the data are used as intended.

CT guided radiofrequency ablation of intra-articular osteoid osteoma of the hip

BackgroundOsteoid osteoma is a painful benign bone tumour. Previously the standard therapy was surgical excision. Image guided radiofrequency ablation can be clinically applied to ablate the tumour in a minimally invasive manner.AimsWe present a case of an 18-year-old boy who presented with features of chronic left hip arthropathy secondary to intra-articular osteoid osteoma, subsequently successfully treated by percutaneous CT guided radiofrequency ablation.ResultsThe CT guided radiofrequency ablation was technically successful as a day case procedure without complication.The patient returned to normal function within one week. No recurrence occurred in the three-year follow-up period.ConclusionRadiofrequency ablation is a safe, minimally invasive and effective tech nique for treatment of osteoid osteoma.

The 90/90 pillow reduces blood loss after knee arthroplasty

Our goal was to evaluate the 90/90 pillow as an effective means of preventing blood loss after knee arthroplasty. We performed a prospective randomized case-control study on 40 patients undergoing knee arthroplasty. All patients were treated in a standard fashion, except for the use of the 90/90 pillow in one group. The 90/90 pillow flexes the knee to 90 degrees and is in situ for 24 hours after surgery. We measured blood loss at time points from 1 to 48 hours. Range of motion was assessed, as were analgesic requirements. Statistical analysis was performed on our results. We found a statistically significant reduction in blood loss without compromising range of motion. We advocate the 90/90 pillow after all knee arthroplasties.

Use of a cementless modular implant for arthroplasty in developmental dysplasia of the hip: Early results

Total hip arthroplasty for osteoarthritis secondary to developmental dysplasia of the hip (DDH) is technically difficult due to the abnormal anatomy involved. Surgery may be facilitated by using a modular femoral prosthesis, which allows intra-operative variations in neck length and version to accommodate final acetabular position. The aim of this study was to assess our early results with the S-ROM hip (DePuy), a cementless modular femoral implant, for arthroplasty in patients with DDH. We performed 22 total hip replacements on 20 patients over a three and a half year period. Ten patients had had previous osteotomies performed, including two of whom had Ganz peri-acetabular osteotomies performed in our centre. Follow-up ranged from 6 to 44 (mean 19.6) months. Harris hip scores improved from an average of 42 points pre-operatively to 90 points post-operatively. No radiographic evidence of osteolysis was seen around the femoral implant. Two patients required revision of their acetabular components. Both had satisfactory outcomes. Our early results with the S-ROM femoral prosthesis correlate well with those from other studies involving arthroplasty for DDH. This implant is extremely versatile and easy to use in this complex patient population.RésuméL’arthroplastie totale de hanche pour coxarthrose secondaire à une dysplasie constitue une difficulté technique en raison des modifications anatomiques. La chirurgie peut être facilitée en utilisant une prothèse fémorale modulaire, qui autorise des variations per-opératoires de longueur, d’excentration et d’antéversion du col afin de s’adapter à la position acétabulaire finale. Le but de cette étude était d’évaluer nos premiers résultats avec la hanche S-ROM (DePuy, Johnson et Johnson Company), un implant fémoral modulaire non cimenté dédié aux patients porteurs de dysplasie. Nous avons réalisé vingt deux remplacements totaux de hanche chez 20 patients, étalés sur une période de trois ans et demi. Dix patients avaient été opérés auparavant par ostéotomies, y compris deux par ostéotomies peri-acétabulaires de Ganz exécutées dans notre Centre. Le follow-up s’est étendu de six à 44 mois (moyenne 19.6 mois). Le score de hanche de Harris a été amélioré en passant, en moyenne, de 42 points en pré-opératoire à 90 points en post-opératoire. Aucun signe radiographique d’ostéolyse n’a été constaté autour de l’implant fémoral. Deux patients ont nécessité une révision de leurs composants acétabulaires. Tous les deux ont eu des résultats satisfaisants. Nos premiers résultats avec la prothèse S-ROM fémorale se corrèlent bien avec ceux d’autres études d’arthroplasties pour hanches dysplasiques. L’auteur aîné trouve cet implant extrêmement souple, et facile à employer dans cette population patiente complexe.

An assessment of the quality of clinical records in elective orthopaedics using the STAR score

BackgroundLitigation claims related to surgery have increased significantly in recent years. Despite the medico-legal importance of clinical records, there have been few published studies describing the quality of medical records in orthopaedic surgery. This study aimed to evaluate the quality of clinical note taking in an elective orthopaedic setting over a 10-year period by comparing medical records from 2003 and 2013.MethodsWe used the previously validated Surgical Tool for Auditing Records (STAR) on a sample of 20 medical records from each year. We performed statistical analysis to determine if significant differences existed between 2003 and 2013.ResultsThere was an overall improvement in the quality of medical records from 76.7% (range 68–82%) in 2003, to 81% (range 72–88%) in 2013 (P value < 0.05). There were significant improvements in the subsequent entry score, from 5.15 to 6.3 (P value < 0.05) and discharge summary score, 6.65 to 7.95 (P value < 0.05). The score for the operative record section decreased from 8.45 to 8.0 (P value < 0.05).ConclusionThe overall standard of medical records in both 2003 and 2013 was high and comparable to other surgical specialties. There was no possible correlation observed between standards of medical records and increasing litigation claims in surgery. Widespread implementation of Electronic Medical Records (EMRs) is likely to have a significant impact on the quality of medical records. Further research is required to determine how the design of EMRs influences how healthcare professionals record data.

SYMPTOMATIC KNEE OSTEOARTHRITIS, A SEARCH FOR THE SOURCE OF THE PAIN

ConclusionThese results suggest that there is a direct correlation between clinical symptoms and meniscal derangement in severe osteoarthritis. Isolated articular defects and bone marrow oedema did not correlate well with location of pain. A greater understanding of the origin of pain in the degenerate knee may assist in the choice of management options for these patients.