Search

Summary Background Patients with Achilles tendon rupture who have non-operative treatment have traditionally been treated with immobilisation of the tendon in plaster casts for several weeks. Functional bracing is an alternative non-operative treatment that allows earlier mobilisation, but evidence on its effectiveness and safety is scarce. The aim of the UKSTAR trial was to compare functional and quality-of-life outcomes and resource use in patients treated non-operatively with plaster cast versus functional brace. Methods UKSTAR was a pragmatic, superiority, multicentre, randomised controlled trial done at 39 hospitals in the UK. Patients (aged ≥16 years) who were being treated non-operatively for a primary Achilles tendon rupture at the participating centres were potentially eligible. The exclusion criteria were presenting more than 14 days after injury, previous rupture of the same Achilles tendon, or being unable to complete the questionnaires. Eligible participants were randomly assigned (1:1) to receive a plaster cast or functional brace using a centralised web-based system. Because the interventions were clearly visible, neither patients nor clinicians could be masked. Participants wore the intervention for 8 weeks. The primary outcome was patient-reported Achilles tendon rupture score (ATRS) at 9 months, analysed in the modified intention-to-treat population (all patients in the groups to which they were allocated, excluding participants who withdrew or died before providing any outcome data). The main safety outcome was the incidence of tendon re-rupture. Resource use was recorded from a health and personal social care perspective. The trial is registered with ISRCTN, ISRCTN62639639. Findings Between Aug 15, 2016, and May 31, 2018, 1451 patients were screened, of whom 540 participants (mean age 48·7 years, 79% male) were randomly allocated to receive plaster cast (n=266) or functional brace (n=274). 527 (98%) of 540 were included in the modified intention-to-treat population, and 13 (2%) were excluded because they withdrew or died before providing any outcome data. There was no difference in ATRS at 9 months post injury (cast group n=244, mean ATRS 74∙4 [SD 19∙8]; functional brace group n=259, ATRS 72∙8 [20∙4]; adjusted mean difference –1∙38 [95% CI –4∙9 to 2∙1], p=0·44). There was no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group, p=0·40). The mean total health and personal social care cost was £1181 for the plaster cast group and £1078 for the functional bract group (mean between-group difference –£103 [95% CI –289 to 84]). Interpretation Traditional plaster casting was not found to be superior to early weight-bearing in a functional brace, as measured by ATRS, in the management of patients treated non-surgically for Achilles tendon rupture. Clinicians may consider the use of early weight-bearing in a functional brace as a safe and cost-effective alternative to plaster casting. Funding UK National Institute for Health Research Health Technology Assessment Programme.

With restructuring within the NHS, there is increased public and media interest in surgical outcomes. The Nottingham Hip Fracture Score (NHFS) is a well-validated tool in predicting 30-day mortality in hip fractures. VLAD provides a visual plot in real time of the difference between the cumulative expected mortality and the actual death occurring. Survivors are incorporated as a positive value equal to 1 minus the probability of survival and deaths as a negative value equal to the probability of survival. Downward deflections indicate mortality and potentially suboptimal care. We prospectively included every hip fracture admitted to UHW that underwent surgery from January–August 2014. NHFS was then calculated and predicted survival identified. A VLAD plot was then produced comparing the predicted with the actual 30-day mortality. Two hundred and seventy-seven patients have completed the 30-day follow-up, and initial results showed that the actual 30-day mortality (7.2 %) was much lower than that predicted by the NHFS (8.0 %). This was reflected by a positive trend on the VLAD plot. Variable life-adjusted display provides an easy-to-use graphical representation of risk-adjusted survival over time and can act as an “early warning” system to identify trends in mortality for hip fractures.

Stiffness following total knee arthroplasty is a disabling complication. One of the management options of stiffness includes manipulation under anaesthesia, but no real consensus exist on appropriate timing of intervention, and the timing and results of the manipulation under anaesthesia (MUA) are under debate in the literature. Our aim was to determine the efficacy of single and multiple manipulations under anaesthesia following total knee arthroplasty and to determine the most appropriate timing for manipulation. We retrospectively reviewed 86 patients who underwent manipulation for stiffness following primary total knee replacement with at least 1-year follow-up. Range of motion before surgery, at the time of the MUA, immediately after MUA and at 6 weeks and 1 year post-MUA were recorded. At the end of 1 year post-manipulation, manipulations performed at less than 20 weeks, following primary total knee arthroplasty, showed 31° of flexion gain as compared to only 1.5° of flexion gain when manipulation was undertaken after 20 weeks. Of the 86 patients, 21 had multiple manipulations with no significant difference in flexion gain after the second manipulation. Patients on warfarin (26%) had an increased incidence of stiffness and poor flexion gain. This study showed that better results were achieved when manipulation was performed at less than 20 weeks (particularly between 12 and 14 weeks) from primary surgery with no added benefit from re-manipulations.

IntroductionFailure of acetabular components frequently leads to bone loss with extensive elongated defects in the surrounding bone. In these cases the use of an oblong cup has been described as an option for acetabular reconstruction. We report the longest follow up results obtained with this implant to date.Materials and MethodsA prospective study was conducted to evaluate the results of the BOFOR oblong revision cup. Between 2001 and 2006, 15 acetabular revisions were performed for aseptic loosening of the acetabular cup. The acetabular defects were classified as type 2A to 3A, according to Paprosky's criteria. No allografts were used in any of the cases. The mean follow-up was 90 months (range 60–120 months).ResultsClinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 39 points preoperatively to 84 points postoperatively and a mean Oxford Hip Score from 55 points preoperatively to 22 points postoperatively. Only one case underwent re-revision due to aseptic loosening in a patient with severe ankylosing spondylitis. There were no cases of dislocation or infection. One patient had a sciatic nerve neurapraxia. After an average follow up of 7.5 years, 93% of the investigated implants remained in-situ without further revision.ConclusionThis study shows that the BOFOR cup provided good clinical results and showed satisfactory stability at early to midterm follow-up.

The aim of this study was to find out whether discharging pin sites following Kirschner-wire fixation of distal radial fractures warrant early wire removal. In a prospective study of 50 patients with a closed distal radial fracture treated by manipulation and either percutaneous or mini-incision Kirschner-wiring, we identified 14 patients (28%) with discharging pin sites. All of the cases were observed within the first two weeks following surgery. Of the 14 cases, only 2 patients had a positive swab culture and were treated with systemic antibiotics. In all cases the Kirschner wires were left in situ until serial radiographs demonstrated satisfactory union. Three patients (8.6%) in the percutaneous group had superficial radial nerve irritation, which settled following wire removal. Deep soft tissue infection, pyoarthrosis, osteomyelitis, and extensor tendon rupture were not encountered. We conclude that pin site discharge, whether sterile or infected, is in general not an indication for early wire removal.

The purpose of this study was to show the significance of a positive Propionibacterium acnes sample around a joint replacement. Records from the microbiology laboratory data over a 3-year period were reviewed to identify patients with prosthetic joints from whom Propionibacterium acnes was isolated at least once. The medical records of all those patients were retrieved and the demographic, clinical, microbiological and haematological data were collected and examined. The preoperative values of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded. Fifty patients underwent a routine revision of a joint arthroplasty; six patients had a joint aspiration. Only one patient had further revision surgery for infection. The preoperative values of ESR and CRP were very variable. The presence of a positive sample around a joint arthroplasty is of uncertain significance. Further studies are needed in order to establish uniform criteria for the diagnosis of infection caused by Propionibacterium acnes.

A prospective study was undertaken to assess the efficacy and financial cost of the use of an autologous blood transfusion device in the reduction of allogeneic blood requirements of patients undergoing primary unilateral total knee arthroplasty. Forty-nine consecutive patients received either the CellTrans blood salvage device (group A of 32 patients) or the Redivac high vacuum drainage system (group B of 17 patients). The preoperative and postoperative haemoglobin levels were recorded at 72 or 96 hours. Nine percent of group A patients received an allogeneic blood transfusion compared to 59% in group B. There was an average saving of 1.1 unit of allogeneic blood per patient in group A (p0.001). The total cost per patient was about Euro 111 less for the group A patients. Autologous re-infusion was found in this study to be an effective method of reducing allogeneic blood requirements and to afford significant cost savings in primary unilateral knee arthroplasty.

In this article, we provide an account of two rare cases of Stewart-Treves syndrome, that is, cutaneous angiosarcoma secondary to lymphedema, treated at our center. Unusually, both occurred in the lower extremity. The first case was treated initially with a wide local excision, followed by a further re-excision, and eventually an above-the-knee amputation because of recurrence. In the second case, a hindquarter amputation was undertaken after a positron emission tomographic scan, which revealed the extent and spread of the lesions. In cases of cutaneous angiosarcoma, a positron emission tomographic scan can be extremely helpful in demonstrating the extent of subcutaneous spread and planning surgical management.