Search

Muhamed M Farhan-Alanie,1 Jayne Ward,1 Michael B Kelly,2 Khalid Al-Hourani3 1Department of Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK; 2Department of Trauma & Orthopaedics, Southmead Hospital, Bristol, UK; 3Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, UKCorrespondence: Muhamed M Farhan-Alanie, Email muhamed.farhan-alanie@nhs.netAbstract: Open tibial fractures may be associated with bone loss at the time of the injury or following surgical debridement of the fracture. This article discusses the various treatment options available and the latest developments surrounding the management of free bone fragments in open tibial fractures.Keywords: tibia, open, fracture, bone, fragments, trauma, devitalized, devitalised

Introduction: The SICOT Conference Committee continually tries to improve the quality of presentations at their annual international meetings. However to the author’s best knowledge, no previous study has been undertaken to determine abstract quality. This study aimed to determine the five-year publication rate of presentations made at the 2009 SICOT Annual International Conference (AIC), recognise predictors of full-text publication, identify inconsistencies between presentations and publications, and determine presentation-publication delay. Methods: We retrieved all 329 oral presentation abstracts from the 2009 SICOT Conference, recorded fundamental study details and conducted a comprehensive, electronic search of Medline and PubMed to determine publication status. For subsequent publications, we examined for inconsistencies between presentation abstracts and full-text publications, whether there were retrospectively identifiable publication predictors and calculated presentation-publication delay. Results: The five-year publication rate for all presentations was 31.3%, for oral presentations. The average presentation-publication delay was 23.4 months. Observational studies were the most commonly published studies. Publications most commonly resulted from studies related to hip and knee subspecialties. Conclusion: Our study shows that almost one third of all abstracts presented at SICOT led to a full-text publication. This is a positive outcome particularly when made in comparison to similar studies of other reputable international conferences such as European Federation of Orthopaedics and Traumatology (EFORT) and American Academy of Orthopaedic Surgeons (AAOS). This study re-enforces SICOT’s reputation as a world leading international conference with a strict peer-review process yielding high-quality presentations.

Objectives: To delineate whether a "safe" window exists for timing from definitive fixation to definitive soft tissue coverage in the treatment of open tibial diaphyseal fractures requiring flap coverage., Design: International multicenter, retrospective comparative cohort study., Patients/participants: Three hundred and seventy-three (n = 373) patients who sustained an open tibial shaft fracture requiring flap coverage., Methods: We evaluated the deep infection rates based on the timing between the definitive fixation and flap coverage. We determined several intervals of time from the day of definitive fixation (regardless of time from injury) and flap coverage. If performed on the same operative setting these were considered day 0. We evaluated coverage after 2 and 5 days from definitive fixation based on time versus infection rate curve inflection points. We adjusted for time to debridement and antibiotics within an hour., Main Outcome Measurement: Deep infection after definitive fixation and flap coverage., Results: The mean age of the cohort was 42.4 years (SD = 18.2) and 270 were male (72.4%). The deep infection rate after flap coverage was 20.6% (77/373). Definitive fixation to flap coverage time of up to 2 days was not associated with an increased risk of infection [relative risk (RR) = 1.12; 95% confidence interval, 0.92-1.37; P = 0.26]. There was an increased risk of deep infection for more than 2 days (RR = 1.59) and >5 days (RR = 1.64)., Conclusion: This study observed a "safe" window of up to 2 days between definitive fixation and flap coverage in open tibial shaft fractures requiring coverage before a statistical increase in risk of deep infection rate occurred., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine health-related quality of life (HRQoL) in patients who sustained type IIIB open tibial diaphyseal (OTA/AO-42) fractures and underwent orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction., Design: Consecutive cohort study., Patients/participants: The study included 74 patients who sustained a type IIIB open tibial diaphyseal fracture requiring orthoplastic reconstruction over a 4-year period in a major trauma center. All patients underwent a two-stage orthoplastic reconstruction protocol, with the second stage consisting of definitive fixation and flap coverage (free fascial anterolateral thigh flap) in a single sitting. Patients were contacted at a minimum of 30 months to measure HRQoL., Intervention: Patients requiring ORDB versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction., Main Outcome Measurements: The primary outcome measure was HRQoL ascertained using Euro-Qol (EQ)-5D and Short-Form (SF)-36 scores., Results: Thirty (n = 30) patients underwent ORDB with the remaining 44 not requiring devitalized bone as part of their reconstruction. The median age was 46.5 years [interquartile range (IQR) 29.0], with a median follow-up of 3.8 years (IQR 1.5). The median cohort EQ-5D was 0.743 (IQR 0.222), ORDB 0.743 (IQR 0.195) versus non-ORDB 0.748 (IQR 0.285), P = 0.71. The median physical component SF-36 score was 80 (IQR 50), ORDB 80 (IQR 34.5) versus non-ORDB 77.5 (IQR 58.75), P = 0.72. The median mental component SF-36 score was 80 (IQR 28), ORDB 80 (IQR 21) versus non-ORDB 80 (IQR 36), P = 0.29., Conclusions: In patients who sustained a type IIIB open tibial shaft fracture and who underwent a 2-stage orthoplastic reconstruction, ORDB does not seem to be associated with inferior health-related quality of life based on EQ-5D or SF-36 scores. The results of this approach should be considered within the strict combined orthoplastic approach in the study unit., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific 2-stage orthoplastic protocol., Design: Consecutive cohort study., Patients/participants: Ninety-three (n = 93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated using a 2-stage orthoplastic approach, between August 2015 and January 2018. After exclusions, 83 (n = 83) were eligible for analysis., Intervention: Colloid resuscitation and 2-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage 1 consists of "3-vessel view" early debridement and temporary internal fixation, with stage 2 consisting of a single-stage fix and flap., Main Outcome Measurements: Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion, and flap failure., Results: Eighty-three (n = 83) patients were included for analysis. The median age was 45.4 years [interquartile range (IQR) 35] with a median follow-up of 1.6 years (IQR 0.8). The median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of 0 (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, 18 patients (18/83, 21.7%) experienced nonischemic arterial injury, 5 patients (5/83, 6.0%) experienced nonunion, with 4 patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (P = 0.025) and nonunion (P < 0.001)., Conclusions: Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a 2-stage orthoplastic protocol, which includes early "3-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow-up., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures., Data Sources: MEDLINE, EMBASE, CENTRAL, and OpenGrey., Study Selection: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type., Data Extraction: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis., Data Synthesis: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)]., Results: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43-1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37-1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58-1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage., Conclusions: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Total shoulder arthroplasty is an established treatment with the commonest cause of failure loosening of the glenoid component. Hydroxyapatite metal-backed glenoid components could offer better survivorship due to improved fixation. The aim of this study was to investigate periprosthetic radiolucency rates associated with an uncemented, metal-backed polyethylene glenoid component with medium-term results., Methods: A single centre retrospective study examining radiological outcomes of the Epoca metal-backed glenoid component. Radiographs were analysed for post-operative adequacy of glenoid seating and radiographs at follow-up assessed for periprosthetic lucencies and any revision procedures were recorded., Results: Forty-one patients were followed up with a mean follow-up time of 5.5 years (3-8 years). Primary indication for total shoulder arthroplasty was osteoarthritis (80%). Mean age was 69 years (53-86 years). Ninety-five per cent of glenoid components were completely seated. At follow-up six patients had undergone revision (14.6%). Thirty of the remaining patients (86%) did not demonstrate any radiolucency on follow-up radiographs. Complete glenoid seating post-operatively was associated with lower rate of subsequent radiolucency and revision (P < 0.01)., Conclusion: Low rates of radiolucency at medium-term follow-up with an uncemented metal-backed glenoid, however significant rates of revision. Complete seating of the glenoid component was associated with lower rates of radiolucency and revision., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2020 The British Elbow & Shoulder Society.)

Background: Open complete articular injuries of this distal humerus are rare injuries which are challenging to manage. The study unit aims to present a small case series of Gustilo-Anderson type III open complete articular fractures which have undergone a single-stage definitive fixation and soft-tissue coverage, presenting their functional outcomes., Methods: Retrospective case series identifying all type IIIB AO 13-C3 distal humeral fractures from the unit trauma database. The primary outcome was the Oxford Elbow Score. Secondary outcomes included deep infection, nonunion, and reoperation., Results: A total of six patients were identified, (four open type IIIA, 2 type IIIB). All patients underwent single-sitting definitive fixation and soft-tissue coverage. Mean range of motion arc was 90 degrees. The median Oxford Elbow Score was 35 (range 21-43), representative of mild to moderate arthritis. One patient (n = 1) developed deep infection at 24 months and required reoperation. All patients (n = 6) proceeded to union at the latest follow-up. We present a case report of a 59-years-old patient who sustained a type IIIB, AO 13-C3 distal humeral fracture who underwent single-sitting definitive fixation and flap coverage., Conclusion: This case series reports that positive functional outcomes representative of mild/moderate arthritis at short to midterm follow-up can be achieved after definitive fixation and soft-tissue coverage in a single sitting, including when the soft tissue is deficient. This is a rare injury which is under-reported in the literature., (© 2021 The Authors.)

Background: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear., Methods: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection., Results: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214)., Conclusions: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement., Level of Evidence: Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence., Competing Interests: Disclosure: On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G176)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The ability of total knee and hip arthroplasty (TKA/THA) to facilitate return to work (RTW) when it is the patient's preoperative intent to do so remains unclear. We aimed at determining whether TKA/THA facilitated RTW in patients of working age who intended to return., Methods: This is a prospective cohort study of 173 consecutive patients <65 years of age, undergoing unilateral TKA (n = 82: median age 58; range, 39-65; 36 [43.9%] male) or THA (n = 91: median age 59; range, 34-65; 42 [46.2%] male) during 2018. Oxford knee/hip scores, Oxford-Activity and Participation Questionnaire, and EuroQol-5 dimension (EQ-5D) scores were measured preoperatively and at 1 year when an employment questionnaire was also completed., Results: Of patients who intended to RTW, 44 of 52 (84.6%) RTW by 1 year following TKA (at mean 14.8 ± 8.4 weeks) and 53 of 60 (88.3%) following THA (at mean 13.6 ± 7.5 weeks). Failure to RTW despite intent was associated with job physicality for TKA (P = .004) and negative preoperative EQ-5D for THA (P = .01). In patients unable to work before surgery due to joint disease, fewer RTW: 4 of 21 (19.0%) after TKA; and 6 of 17 (35.3%) after THA. Preoperative Oxford knee score >18.5 predicted RTW with 74% sensitivity (P < .001); preoperative Oxford hip score >19.5 predicted RTW with 75% sensitivity (P < .001). Preoperative EQ-5D indices were similarly predictive (P < .001)., Conclusion: In this United Kingdom study, preoperative intent to RTW was the most powerful predictor of actual RTW following TKA/THA. Where patients intend to RTW following TKA/THA, 85% RTW following TKA and 88% following THA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Total shoulder arthroplasty has shown good clinical efficacy in treating primary and secondary degenerative conditions of the glenohumeral joint. Glenoid loosening, however, remains the commonest cause of failure. The purpose of this study was to investigate the rate of radiographic periprosthetic lucency associated with the use of an uncemented, pegged, metal-backed polyethylene glenoid component., Materials and Methods: A retrospective, single-centre study using the Epoca (Synthes, Paoli, Pennsylvania) metal-backed glenoid component. Operations were performed by two experienced consultant upper limb surgeons. Radiographs were analysed for immediate post-operative component seating and periprosthetic radiolucent lines at predefined regular post-operative intervals. Intra- and inter-observer reliability was assessed to improve validity of results., Results: Mean age and follow-up was 72 (48-91) years and 2.5 years (2-5), respectively. Main indications for total shoulder arthroplasty were primary osteoarthritis, rheumatoid arthritis, revision for failed hemi-arthroplasty and acute fracture. Ninety-six per cent of components were completely seated post-operatively. Fifty-four (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up. Complete post-operative glenoid seating was significantly associated with the absence of later periprosthetic radiolucency (p < 0.01)., Conclusion: This study reports low early radiolucency rates with the pegged, uncemented, metal-backed polyethylene glenoid prosthesis used. Excellent post-operative glenoid seating is associated with a significantly lower rate of radiolucency. Longer follow-up data are required to confirm these early promising results. Level of evidence: Therapeutic, level IV., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2018 The British Elbow & Shoulder Society.)

Aim Due to the frequency and high mortality and morbidity associated with neck of femur fractures, pathways of care have been established in the United Kingdom. These include the Enhanced Recovery Program (ERP), which aims to maximise the quality of care whilst reducing their length of stay, and the Best Practice Tariff (BPT) which if adhered to warrants £1335 per neck of femur fracture. We conducted a prospective audit to assess adherence to these pathways in a trauma unit. Methods An audit was carried out between November 2015 and May 2016. The information was obtained from neck of femur fracture proformas, anaesthetic charts and drug charts by two investigators. Results Nine out of the 10 ERP components were adhered to in all 31 patients. This highlighted a deficiency in requesting day one post-operative osteoporosis bloods, which was only carried out in 61.3% of patients. As an intervention, a reminder sticker was placed on the operation note as an intervention. Re-audit following the introduction of the stickers showed a marked improvement of 90%. During the initial admission 38.7% of patients adhered to the BPT. The main area for improvement was fracture prevention assessment, specifically Fracture Risk Assessment Tool (FRAX) scores and Nottingham Hip Fracture Scores. To improve this these sections were highlighted in the proformas to promote their importance. Additionally, a smartphone application was made available to doctors to aid with ease of calculation. Following these interventions, 93% of patients had this data entered, with an improvement in overall tariff attainment to 63.3%. Conclusions The introduction of simple measures is beneficial both for patient safety and economically for hospitals., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Wilson et al.)

Introduction: Several classifications for proximal humeral fractures exist, with excellent reliability and reproducibility of such classifications being a desirable feature. Despite their widespread use, these systems are variable in both reliability and accuracy. We aimed to, a) assess and compare the reliability of the Neer (complete and abbreviated versions) and Arbeitsgemeinschaft für Osteosynthesefragenbeing (AO) classifications, and b) identify if computed tomography (CT) made any difference to the reliability of Neer and AO classifications when compared to plain radiographs alone.  Materials and methods: This is a single-centre retrospective study identifying all proximal humeral fractures presenting between February 2016 and February 2017 as a result of trauma that subsequently proceeded to CT. Two specialty orthopaedic trainees analysed the plain radiographs as well as CT images over two rounds, spaced two weeks apart. The Neer 16-grade, abbreviated Neer 6-grade and AO classifications were used. Intra- and inter-observer reliability of each classification system was assessed using the Kappa coefficient.  Results: Twenty-two patients were included. The mean age was 62 years (SD 14.5). Management changed in 9/22 patients based on CT. Computed tomography changed Neer-16 type in 16% observations, Neer-6 in 10%, and AO in 23%. This was significant when comparing Neer-6 and AO classifications (p = 0.04). Neer-6 had the best inter-observer reliability (0.737) with the management of one patient changing after CT. On X-ray and CT, intra-observer agreement was substantial, >0.7, using Neer-16 and Neer-6 (p<0.005). Inter-observer agreement for Neer-16 and Neer-6 was substantial, >0.7 (p<0.005). In comparison, intra- and inter-observer agreements for AO were lower on X-ray and CT, 0.4-0.6, (p<0.005)., Conclusion: Our study shows that simplicity is key with a high degree of reliability in the abbreviated Neer classification. Computed tomography allowed greater reliability than radiographs in classifying fractures, affecting management decisions in 41% of patients. The comprehensive Neer classification showed similar intra- and inter-observer reliabilities to AO., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Stoddart et al.)

Objective: To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures., Design: Retrospective comparative cohort study over a 2-year period., Setting: Level 1 trauma center., Patients/participants: A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis., Intervention: Time to initial debridement and definitive management., Main Outcome Measurement: Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant., Results: Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion., Conclusions: Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Understanding the control of viral infections is of broad importance. Chronic hepatitis C virus (HCV) infection causes decreased expression of the iron hormone hepcidin, which is regulated by hepatic bone morphogenetic protein (BMP)/SMAD signalling. We found that HCV infection and the BMP/SMAD pathway are mutually antagonistic. HCV blunted induction of hepcidin expression by BMP6, probably via tumour necrosis factor (TNF)-mediated downregulation of the BMP co-receptor haemojuvelin. In HCV-infected patients, disruption of the BMP6/hepcidin axis and genetic variation associated with the BMP/SMAD pathway predicted the outcome of infection, suggesting that BMP/SMAD activity influences antiviral immunity. Correspondingly, BMP6 regulated a gene repertoire reminiscent of type I interferon (IFN) signalling, including upregulating interferon regulatory factors (IRFs) and downregulating an inhibitor of IFN signalling, USP18. Moreover, in BMP-stimulated cells, SMAD1 occupied loci across the genome, similar to those bound by IRF1 in IFN-stimulated cells. Functionally, BMP6 enhanced the transcriptional and antiviral response to IFN, but BMP6 and related activin proteins also potently blocked HCV replication independently of IFN. Furthermore, BMP6 and activin A suppressed growth of HBV in cell culture, and activin A inhibited Zika virus replication alone and in combination with IFN. The data establish an unappreciated important role for BMPs and activins in cellular antiviral immunity, which acts independently of, and modulates, IFN.

Background: Fast and accurate diagnosis of conditions of the hand and wrist is essential in guiding management. We aimed to analyse the predictive value of ultrasound in identifying different pathologies in the hand and wrist by correlating pre-operative ultrasound findings with per-operative surgical findings., Methods: We retrospectively reviewed the case notes of all patients under the care of the senior author on whom a hand/wrist ultrasound had been performed between January 2007-May 2013. Of these only patients who proceeded to surgery were included as this was the correlating endpoint. Positive and negative predictive values (PPV/NPV) and sensitivity and specificity were calculated for ultrasound in identifying (i) post-repair complete tendon ruptures (versus intact repairs with scar adherence), (ii) ganglionic cysts, (iii) soft tissue masses and (iv) nerve injuries., Results: Of 70 patients who underwent ultrasound, 36 proceeded to surgery. Fifteen patients were post traumatic and the remaining 21 were elective presentations. The median age was 38 (range 14-87) with a 1.25:1 male to female ratio. All results had a 95% confidence interval. Ultrasound had a 100% PPV for identifying post-repair complete tendon ruptures and for ganglionic cysts (sensitivities 75% and 87% respectively). Of our 6 soft tissue masses ultrasound also showed a 100% PPV. For the two nerve injury patients, PPV was 100%., Conclusions: Our study shows that ultrasound is diagnostic for post-repair tendon ruptures and ganglionic cysts, and shows promising results for benign soft tissue masses and nerve injuries. We propose the use of ultrasound as an extension to physical examination in a dynamic clinic setting.

Hepcidin regulates systemic iron homeostasis. Suppression of hepcidin expression occurs physiologically in iron deficiency and increased erythropoiesis but is pathologic in thalassemia and hemochromatosis. Here we show that epigenetic events govern hepcidin expression. Erythropoiesis and iron deficiency suppress hepcidin via erythroferrone-dependent and -independent mechanisms, respectively, in vivo, but both involve reversible loss of H3K9ac and H3K4me3 at the hepcidin locus. In vitro, pan-histone deacetylase inhibition elevates hepcidin expression, and in vivo maintains H3K9ac at hepcidin-associated chromatin and abrogates hepcidin suppression by erythropoietin, iron deficiency, thalassemia, and hemochromatosis. Histone deacetylase 3 and its cofactor NCOR1 regulate hepcidin; histone deacetylase 3 binds chromatin at the hepcidin locus, and histone deacetylase 3 knockdown counteracts hepcidin suppression induced either by erythroferrone or by inhibiting bone morphogenetic protein signaling. In iron deficient mice, the histone deacetylase 3 inhibitor RGFP966 increases hepcidin, and RNA sequencing confirms hepcidin is one of the genes most differentially regulated by this drug in vivo. We conclude that suppression of hepcidin expression involves epigenetic regulation by histone deacetylase 3.Hepcidin controls systemic iron levels by inhibiting intestinal iron absorption and iron recycling. Here, Pasricha et al. demonstrate that the hepcidin-chromatin locus displays HDAC3-mediated reversible epigenetic modifications during both erythropoiesis and iron deficiency.

Lemierre's syndrome is a rare condition characterised by pharyngitis leading to septic thrombophlebitis of the internal jugular vein. Complications include pulmonary septic emboli, septic arthritis and disseminated intravascular coagulation. The authors present a case of a healthy woman aged 25 years with septic arthritis of the shoulder due to this unusual cause. This diagnosis was made via a combination of clinical, radiological and microbiological findings. It was successfully treated via surgical and antimicrobial interventions. The patient made a good recovery with minimal associated morbidity or loss of function. This case highlights the importance for awareness and high index of suspicion for rarer causes of septic arthritis in young healthy adults as early appropriate intervention maximises prognosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Context: Paracetamol (acetaminophen) overdose is a common reason for emergency hospital admission in the UK and the leading cause of acute liver failure in the Western world. Currently, the antidote acetylcysteine (NAC) is administered at a dose determined only by body weight without regard for the body burden of paracetamol., Objective: To determine whether higher plasma paracetamol concentrations are associated with increased risk of liver injury despite prompt treatment with intravenous NAC., Methods: Patients admitted to hospital for treatment with intravenous NAC following a single acute paracetamol overdose entered the study if NAC was commenced within 24 h of drug ingestion (N = 727 hospital presentations). Based on the plasma paracetamol concentration at first presentation to hospital, a series of nomograms were created: 0-100, 101-150, 151-200, 201-300, 301-500 and over 501 mg/L. The primary endpoints were acute liver injury (ALI - peak serum ALT activity >150 U/L and double the admission value) and hepatotoxicity (peak ALT >1000 U/L)., Results: ALI and hepatotoxicity were more common in patients with higher admission plasma paracetamol concentrations despite NAC treatment (ALI: nomogram 0-100: 6%, 101-150: 3%, 151-200: 3%, 201-300: 9%, 301-500: 13%, over 501 mg/dL: 27%. p < 0.0001). This dose-response relationship between paracetamol concentration and ALI persisted even in patients treated with NAC within 8 h of overdose (nomogram 0-100: 0%, 101-150: 0.8%, 151-200: 2%, 201-300: 3.6%, 301-500: 12.5%, over 501mg/L: 33%. p < 0.0001) and in patients with normal ALT activity at first presentation (nomogram: 0-100: 0%, 101-150: 1.2%, 151-200: 1.5%, 201-300: 5.3%, 301-500: 10.8% p < 0.0001)., Discussion: Patients with increased concentrations of plasma paracetamol at hospital presentation are at higher risk of liver injury even when intravenous NAC is promptly administered before there is biochemical evidence of toxicity., Conclusion: This study supports theoretical concerns that the current intravenous dose of NAC may be too low in the setting of higher paracetamol exposure.

Study Design Narrative review. Objective Upper cervical epidural abscess (UCEA) is a rare surgical emergency. Despite increasing incidence, uncertainty remains as to how it should initially be managed. Risk factors for UCEA include immunocompromised hosts, diabetes mellitus, and intravenous drug use. Our objective is to provide a comprehensive overview of the literature including the history, clinical manifestations, diagnosis, and management of UCEA. Methods Using PubMed, studies published prior to 2015 were analyzed. We used the keywords "Upper cervical epidural abscess," "C1 osteomyelitis," "C2 osteomyelitis," "C1 epidural abscess," "C2 epidural abscess." We excluded cases with tuberculosis. Results The review addresses epidemiology, etiology, imaging, microbiology, and diagnosis of this condition. We also address the nonoperative and operative management options and the relative indications for each as reviewed in the literature. Conclusion A high index of suspicion is required to diagnose this rare condition with magnetic resonance imaging being the imaging modality of choice. There has been a shift toward surgical management of this condition in recent times, with favorable outcomes.

To our knowledge, there are no reports in the literature of patients with Parkinson disease (PD) developing upper cervical spine infections. Our objective is to present a case of upper cervical epidural abscess in a patient with PD and to review upper cervical spine infection. We present the patient's presentation, physical examination, imaging findings, and management as well a review of the literature. A 66-year-old male with PD presented to the emergency department (ED) following referral by a neurologist for a presumed C2 fracture. The preceding history was 1 week of severe neck pain requiring a magnetic resonance imaging (MRI), which was initially interpreted as a C2 fracture. On admission from the ED, further review of the MRI appeared to show anterior prevertebral abscess and an epidural abscess. The patient's neurological examination was at baseline. In the span of 2 days, the patient developed significant motor weakness. A repeat MRI demonstrated expansion of the epidural collection and spinal cord compression. Surgical management consisting of C1 and C2 laminectomy, irrigation, and debridement from anterior and posterior approaches was performed. Postoperatively, the patient did not recover any motor strength and elected to withdraw care and died. Spinal epidural abscess requires a high index of suspicion and needs prompt recognition to prevent neurological impairment. Upper cervical spine infections are rare but can lead to lethal consequences.

We present the transient long thoracic nerve (LTN) injury during instrumented posterior spinal arthrodesis for idiopathic scoliosis. The suspected mechanism of injury, postoperative course and final outcome is discussed. The LTN is susceptible to injury due to its long and relatively superficial course across the thoracic wall through direct trauma or tension. Radical mastectomies with resection of axillary lymph nodes, first rib resection to treat thoracic outlet syndrome and cardiac surgery can be complicated with LTN injury. LTN injury producing scapular winging has not been reported in association with spinal deformity surgery. We reviewed the medical notes and spinal radiographs of two adolescent patients with idiopathic scoliosis who underwent posterior spinal arthrodesis and developed LTN neuropraxia. Scoliosis surgery was uneventful and intraoperative spinal cord monitoring was stable throughout the procedure. Postoperative neurological examination was otherwise normal, but both patients developed winging of the scapula at 4 and 6 days after spinal arthrodesis, which did not affect shoulder function. Both patients made a good recovery and the scapular winging resolved spontaneously 8 and 11 months following surgery with no residual morbidity. We believe that this LTN was due to positioning of our patients with their head flexed, tilted and rotated toward the contralateral side while the arm was abducted and extended. The use of heavy retractors may have also applied compression or tension to the nerve in one of our patients contributing to the development of neuropraxia. This is an important consideration during spinal deformity surgery to prevent potentially permanent injury to the nerve, which can produce severe shoulder dysfunction and persistent pain.

Background: Paracetamol is a major cause of poisoning. Treatment decisions are predominately based on the dose ingested and a timed blood paracetamol concentration because most patients present to hospital soon after overdose, before hepatotoxicity can be confirmed/excluded using serum alanine transaminase (ALT). Nonetheless, ALT is measured at hospital presentation; we investigated its value in predicting hepatotoxicity., Methods: From March 2011 to May 2012, patients admitted to the Royal Infirmary of Edinburgh for paracetamol overdose treatment were identified. We determined the value of admission ALT (below or above our upper limit of normal-50 IU/l) at predicting three endpoints: 1-doubling of ALT; 2-peak ALT >1000 IU/l; 3-peak international normalized ratio (INR) >2., Results: From 500 patients, 410 met the entry criteria; 264 presented within 8 h of overdose, 54 between 8 and 24 h, 53 after 24 h and 39 were staggered ingestions. Admission ALT was increased in 71. For endpoint 1 (ALT doubling), the positive predictive value (PPV) of admission ALT was 19% [95% confidence interval (CI) 12-30] with a negative predictive value (NPV) of 98% (95% CI 96-99); endpoint 2 (ALT >1000 IU/l: PPV 23% (95% CI 14-34) and NPV 100% (95% CI 99-100) and for endpoint 3 (INR >2): PPV 14% (95% CI 7-25) and NPV of 100% (95% CI 99-100). The NPV remained high when only late presenters were included., Conclusion: Admission ALT within the normal range has a high NPV and could be used, alone or in combination with newer biomarkers, to identify lower risk patients at hospital presentation.

Background: An association between coracoid fracture and glenohumeral instability with both a seizure disorder and the subsequent development of coracoid nonunion has not previously been recognized. This is clinically important as patients with a seizure disorder and glenohumeral instability frequently require a primary osseous reconstructive procedure, such as coracoid osteotomy and transfer to the anterior glenoid rim (the Bristow-Latarjet procedure), to address glenoid osseous deficiency. We report on coracoid fracture nonunion in five patients with a seizure disorder and anterior glenohumeral instability and discuss the implications for surgical treatment., Methods: Coracoid fracture was specifically sought on three-dimensional reconstructions of computed tomography scans in a consecutive series of 234 patients presenting to our unit with recurrent anterior instability. In addition to demographic data, we specifically sought information on any history of shoulder injury, the mechanism of injury, or previous seizure activity in these patients. In patients with a coracoid fracture or nonunion viewed to be at high risk of failure with a soft-tissue procedure, an open osseous reconstructive procedure was performed. The type of operative procedure was determined by the location of the nonunion., Results: We identified six coracoid fracture nonunions in association with anterior glenohumeral instability in five patients (mean age, 26.8 years; range, twenty-four to thirty years). All patients had instability occurring in association with seizures. In the four shoulders with the anatomic location of the coracoid nonunion at its so-called elbow, a standard Bristow-Latarjet procedure was performed. In the two shoulders in which the nonunion was more distal, an Eden-Hybbinette procedure was performed., Conclusions: We recommend having a high index of suspicion of coracoid fracture when treating patients with a seizure disorder who have anterior glenohumeral instability. In these patients, preoperative computed tomographic images allow the diagnosis of a coracoid nonunion to be made prior to surgery and help to determine whether there is sufficient intact coracoid bone to allow a Bristow-Latarjet procedure to be performed.