9 research outputs found
The TROJAN project: creating a customized international orthopedic training program for junior doctors
No full textMusculoskeletal problems account for a vast proportion of presentations encountered by doctors globally, with figures ranging from 15-36%. However, the time medical schools allocate to learning orthopedics is by no means proportional to this. This study aims to bridge this gap by developing an international orthopedic teaching program tailored to the specific knowledge and skills required by junior doctors in different countries. This prospective study asked fifty junior doctors, who had recently completed an orthopedics job, what three orthopedic teaching topics taught retrospectively would have benefitted their clinical practice. The most requested topics were used to design educational workshops for junior doctors and these consequently comprised the TROJAN (Teaching Requested by Orthopaedic Juniors And Novices) training program. Data was collected from twenty-five junior doctors in KwaZulu-Natale State, South Africa, and twenty-five in London, UK. It is therefore in these two countries that the TROJAN program was subsequently made available. Participants who selected topics were within two years of graduating medical school and had worked an orthopedic or Accident and Emergency job within the last year. 49% of topics chosen by SA doctors were practical skills such as wrist and ankle fracture reduction techniques, and management of open fractures. The most requested topic by UK doctors (11 out of 25) was management of neck of femur fractures. This is rationalized by the fact South African doctors require more handson responsibility in their daily practice whereas in the UK greater emphasis is placed on optimizing patients for theatre and making sound management plans. TROJAN currently develops orthopedic skills and knowledge in junior doctors in South Africa and United Kingdom with teaching customized based upon location. Feedback has been exceptionally positive with every candidate thus far rating the usefulness of TROJAN as the highest option, very useful.</em
Guided Growth of the Proximal Femur for the Management of the ‘Hip at Risk’ in Children with Cerebral Palsy—A Systematic Review
No full textBackground: Guided growth is frequently used to modify lower-limb alignment in children, and recently temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF) has been used for the management of hips at risk of subluxation in cerebral palsy (CP) patients. The aim of our study was to evaluate the efficacy of TMH-PF in the management of neuromuscular hip dysplasia in children with cerebral palsy. Methods: A systematic search of the literature was performed by using PubMed, EMBASE, CINAHL, MEDLINE, Scopus and Cochrane databases. Pre- and postoperative radiographic changes of the migration percentage (MP), head-shaft angle (HSA) and acetabular index (AI) were included in a meta-analysis. Secondary outcomes were treatment complication rates, technical considerations and the limitations of this novel technique. Results: Four studies (93 patients; 178 hips) met the eligibility criteria for inclusion in the meta-analysis. All three radiographic measurements showed significant changes at a minimum of 2 years of follow-up. Mean changes for MP were 8.48% (95% CI 3.81–13.14), HSA 12.28° (95% CI 11.17–13.39) and AI 3.41° (95% CI 0.72–6.10), with I(2) of 75.74%, 0% and 87.68%, respectively. The serious complication rate was overall low; however, physeal ‘growing off’ of the screw was reported in up to 43% of hips treated. Conclusion: TMH-PF is an effective and predictable method to treat CP patients with ‘hips at risk’, and the overall complication rate is low; however, further work is required to identify the best candidates and surgical timing, as well as choice of technique and implant
Good to Excellent Functional Short-Term Outcome and Low Revision Rates Following Primary Anterior Cruciate Ligament Repair Using Suture Augmentation
No full textThe aim of this study was to evaluate the functional outcome of primary anterior cruciate ligament (ACL) repair using suture augmentation (SA) in 93 consecutive patients (67 female) with a minimum follow-up of 12 months. Patients’ outcomes were determined using International Knee Documentation Committee (IKDC) score, Lysholm score (LS) and Tegner score (TS). Knee-laxity was assessed using the KT-1000 arthrometer. Eighty-eight patients (67 female, mean age 42 years ± standard deviation (SD) 13) were available for follow-up after a mean time of 21 months (range 12–39). Three patients (3%) underwent revision surgery and were excluded from functional analysis. The mean IKDC score was 87.4 ± 11, mean LS was 92.6 ± 11, mean pre-traumatic TS was 6 ± 2 and mean postoperative TS was 6 ± 2, with a mean difference (TSDiff) of 1 ± 1. The interval from injury to surgery had no significant impact on the postoperative IKDC (p = 0.228), LS (p = 0.377) and TSDiff (p = 0.572). Patients’ age (>40 years), BMI (>30) and coexisting ligament or meniscal injuries did not seem to influence postoperative functional results. Primary ACL repair using SA provides good to excellent functional outcomes with a low probability of revision surgery at a minimum of 12 months
Do Adductor Tenotomies Prevent Progressive Migration in Children with Cerebral Palsy?:A Systematic Review
No full textBackground:Up to one-third of children with cerebral palsy (CP) develop migration of the hip, and the risk increases with a higher Gross Motor Function Classification System (GMFCS). In progressive hip migration in young children, adductor tenotomy is an accepted treatment option to delay or prevent progressive hip migration. However, there is quite a large variability in reported results. This systematic review aims to determine the effectiveness of a soft-tissue release in the prevention of progressive hip migration in children with CP.Methods:This systematic review was performed in accordance with the guidelines of the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statements. Our inclusion criteria were studies describing pediatric, skeletally immature patients with CP and a "hip at risk"of progressive hip migration. Exclusion criteria were simultaneous bony reconstructions, case reports, technical notes, published abstracts, or studies with a follow-up under 1 year postoperatively. The primary outcomes were defined as failure rate (progressive hip migration and/or need for bony surgery, as defined by each paper) and change in migration percentage (MP) at final follow-up. As secondary analyses, we evaluated the outcome after specific subtypes of surgeries and assessed whether performing lengthening of iliopsoas, neurectomy of the anterior branch of the obturator nerve, age at the time of surgery, GMFCS level, and postoperative management impact the outcome.Results:Our literature search identified 380 titles. Eighty-four articles underwent full-text review, of which 27 met our inclusion/exclusion criteria and were subsequently selected for quantitative analysis. A prevalence meta-analysis was performed including 17 studies (2,213 hips). Mean follow-up ranged from 12 to 148.8 months. The mean preoperative MP was 33.4% (2,740 hips) and 29.9% at follow-up. The overall reported failure rate was 39% (95% confidence interval, 26%-52%). Performing a release of only adductor longus had a failure rate of 87%, whereas more extensive soft-tissue releases showed significantly better results with failure rates ranging from 0 to 44% (p < 0.001). Lengthening of the iliopsoas had no significant impact on failure rate (p = 0.48), nor did performing an obturator neurectomy (p = 0.92).Conclusion:The failure rate of adductor tenotomies to prevent progressive hip migration appears to be as high as 39% in studies with a varying follow-up. The failure rates are significantly higher when isolated release of the adductor longus is performed. This systematic review supports clinical decision making in children with CP and early hip migration.Level of Evidence:Level IIA. See Instructions for Authors for a complete description of levels of evidence.</p
Good to Excellent Functional Short-Term Outcome and Low Revision Rates Following Primary Anterior Cruciate Ligament Repair Using Suture Augmentation
No full textThe aim of this study was to evaluate the functional outcome of primary anterior cruciate ligament (ACL) repair using suture augmentation (SA) in 93 consecutive patients (67 female) with a minimum follow-up of 12 months. Patients’ outcomes were determined using International Knee Documentation Committee (IKDC) score, Lysholm score (LS) and Tegner score (TS). Knee-laxity was assessed using the KT-1000 arthrometer. Eighty-eight patients (67 female, mean age 42 years ± standard deviation (SD) 13) were available for follow-up after a mean time of 21 months (range 12–39). Three patients (3%) underwent revision surgery and were excluded from functional analysis. The mean IKDC score was 87.4 ± 11, mean LS was 92.6 ± 11, mean pre-traumatic TS was 6 ± 2 and mean postoperative TS was 6 ± 2, with a mean difference (TSDiff) of 1 ± 1. The interval from injury to surgery had no significant impact on the postoperative IKDC (p = 0.228), LS (p = 0.377) and TSDiff (p = 0.572). Patients’ age (>40 years), BMI (>30) and coexisting ligament or meniscal injuries did not seem to influence postoperative functional results. Primary ACL repair using SA provides good to excellent functional outcomes with a low probability of revision surgery at a minimum of 12 months
Accelerated wear protocols for understanding clinical wear in modern hip prostheses
No full textThe copyright of this thesis rests with the author and no quotation from it or information derived from it may be published without the prior written consent of the authorSuccess of total hip replacements is well reported however, failures as a result of wear processes and the biological response to these products continue to challenge the orthopaedic community. Lately, corrosion of metal surfaces as well as wear particles have seen particular interest with elevated blood cobalt levels widely reported in patients receiving metal-on-metal (MoM) hip replacements. Some instances have also reported this in patients with metal-on-polyethylene (MoP) components and these corrosion products are believed to contribute to hypersensitivity reactions reported. This thesis considers wear and cobalt release in MoP and MoM hip bearings tested under standard and challenging hip simulator conditions and includes an exploration of novel bearing coatings to reduce cobalt release. The incorporation of silver into these coatings may be sufficient to produce an antibacterial response, reducing the risk of mid-term infections, another reported cause of failure.
Polyethylene wear was low under standard and clinically relevant adverse conditions in 28mm and 52 mm diameter MoP bearings (less than 35 mm3/mc). Cobalt release was measurable in 28 mm diameter MoP bearings (51 ppb/mc) with higher levels produced in large 52 mm diameters (123 ppb/mc), the first time this has been reported, although cobalt release was substantially less than that observed in MoM bearings (6909 ppb/mc). Alumina abrasives introduced in the lubricant substantially damaged MoP bearings, increasing the cobalt release to 70,690 ppb after 1 mc, greater than found after edge loaded MoM bearings (19,240 ppb). The removal of these particles still produced elevated cobalt levels compared to standard conditions and increased polyethylene wear to 435 mm3/mc.
A chromium nitride (CrN) coating in MoP bearings was resistant to this abrasive damage showing no delamination in the coating, with negligible cobalt released after 7.04 mc (153 ppb) and maintained a polyethylene wear rate below 20 mm3/mc. Silver CrN coatings on both bearing surfaces of MoM components prevented cobalt release under standard conditions, with silver release after 0.17 mc up to 3,720 ppb in high silver surface coatings, although the wear was relatively high (5.24 mm3/mc). A silver CrN coating with a low concentration of silver at the surface reduced wear and was resistant to 5 mc of edge loading. It generated 241 ppb of cobalt and maintained comparable steady state wear rates (0.65 mm3/mc) to the uncoated metal while releasing 18,786 ppb silver which may be sufficient to be an effective anti-microbial agent. These coatings may provide potential clinical benefits in MoP and MoM bearings by reducing both wear and cobalt release in ideal and adverse conditions. There may also be beneficial wear products in the form of silver, although further testing of optimised coatings is required
