The surgeon and his tools-the case for a focused orthopaedic theatre induction programme

<p>Abstract</p> <p>Background</p> <p>Induction programme for trainee doctors in the UK generally do not focus on the surgical aspects of their jobs. In this context we decided to conduct a telephonic survey among the hospitals belonging to three orthopaedic training regions in the UK from the point of view of the diversity of instrumentations and implants used for index procedures.</p> <p>Results</p> <p>We chose four index trauma & orthopaedic procedures (Total hip replacement, total knee replacement, intramedullary nailing and external fixator systems for long bone fractures). A telephonic survey was done in six NHS trust hospitals which were part of an orthopaedic training rotation (2 from England, 2 from Wales and 2 from Scotland). In total there were 39 different instrumentation systems for these 4 index procedures in the 6 trusts (see table <tblr tid="T1">1</tblr>). These comprise 12 Total hip replacement (THR) systems, 14 total knee replacement (TKR) systems, 9 intra-medullary nailing systems, and 4 external fixator systems. The number of different systems for each trust ranged from 7 to 19. There is a vast array of implants and instrumentation systems in each trust, as highlighted by our survey. The surgical tools are not the same in each hospitals. This situation is more complicated when trainees move to new hospitals as part of training rotations.</p> <tbl id="T1"> <title> <p>Table 1</p> </title> <caption> <p>Number of implants/instrumentations used in each of the 6 UK trusts (3 training regions).</p> </caption> <tblbdy cols="7"> <r> <c ca="left"> <p>IMPLANT</p> </c> <c ca="center"> <p>E1</p> </c> <c ca="center"> <p>E2</p> </c> <c ca="center"> <p>W1</p> </c> <c ca="center"> <p>W2</p> </c> <c ca="center"> <p>S1</p> </c> <c ca="center"> <p>S2</p> </c> </r> <r> <c cspan="7"> <hr/> </c> </r> <r> <c ca="left"> <p><it>Total Knee Replacement</it></p> </c> <c ca="center"> <p>4</p> </c> <c ca="center"> <p>5</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>4</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>2</p> </c> </r> <r> <c ca="left"> <p><it>Total Hip Replacement</it></p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>4</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>6</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>3</p> </c> </r> <r> <c ca="left"> <p><it>Intramnedullary nailing</it></p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>1</p> </c> <c ca="center"> <p>1</p> </c> <c ca="center"> <p>6</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>3</p> </c> </r> <r> <c ca="left"> <p><it>External fixators</it></p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>1</p> </c> <c ca="center"> <p>1</p> </c> </r> <r> <c cspan="7"> <hr/> </c> </r> <r> <c ca="left"> <p><it>TOTAL</it></p> </c> <c ca="center"> <p>11</p> </c> <c ca="center"> <p>13</p> </c> <c ca="center"> <p>8</p> </c> <c ca="center"> <p>18</p> </c> <c ca="center"> <p>9</p> </c> <c ca="center"> <p>9</p> </c> </r> </tblbdy> <tblfn> <p>E = England, W = Wales, S = Scotland</p> </tblfn> </tbl> <p>Conclusion</p> <p>In view of this we feel that more focused theatre based induction programmes for higher surgical trainees is advocated in each hospital trust so trainees can familiarise themselves with the tools available to them. This could include discussion with the consultants and senior theatre staff along with representatives from the companies supplying the implants and instrumentation systems.</p

Rare case of autonomic instability of the lower limb presenting as painless Complex Regional Pain Syndrome type I following hip surgery: two case reports

<p>Abstract</p> <p>Introduction</p> <p>According to the International Association for the Study of Pain criteria of 1994, pain is a diagnostic requirement for Complex Regional Pain Syndrome type I. However, other authors have suggested that patients can rarely present with the sensory and vascular symptoms of Complex Regional Pain Syndrome without pain. This entity has not been reported following hip surgery in the English medical literature.</p> <p>Case presentation</p> <p>We present two cases of Complex Regional Pain Syndrome-like symptoms following hip surgery and with the total absence of pain. The first case was a 29-year-old Caucasian woman who had a reattachment of the greater trochanter following non-union of an intertrochanteric osteotomy of the hip. Five weeks later, the patient presented with features of Complex Regional Pain Syndrome but with the absence of pain. The second patient was a 20-year-old Caucasian woman who had undergone an open debridement and repair of a torn acetabular labrum. Ten days later, the patient presented with features suggestive of Complex Regional Pain Syndrome which was again painless. Both patients were non-weight bearing at presentation and the symptoms resolved following recommencement of weight bearing.</p> <p>Conclusions</p> <p>The authors believe these symptoms are manifestations of vascular changes to the lower limb as a result of non-weight bearing status. Painless Complex Regional Pain Syndrome-like symptoms may occur in patients who are kept non-weight bearing following hip surgery. However, vascular insufficiency and deep venous thrombosis must be excluded before this diagnosis is made. If the clinical situation permits, early weight bearing may relieve symptoms. Orthopaedic and vascular surgeons should be aware of this entity when a postoperative patient presents to them with the above clinical picture. This is also relevant to general practitioners who are likely to see the patients in the postoperative period.</p

Prevalence, Distribution and Functional Significance of the −237C to T Polymorphism in the IL-12Rβ2 Promoter in Indian Tuberculosis Patients

Cytokine/cytokine receptor gene polymorphisms related to structure/expression could impact immune response. Hence, the −237 polymorphic site in the 5′ promoter region of the IL-12Rβ2 (SNP ID: rs11810249) gene associated with the AP-4 transcription motif GAGCTG, was examined. Amplicons encompassing the polymorphism were generated from 46 pulmonary tuberculosis patients, 35 family contacts and 28 miscellaneous volunteers and sequenced. The C allele predominated among patients, (93.4%, 43/46), and in all volunteers and contacts screened, but the T allele was exclusively limited to patients, (6.5%, 3/46). The functional impact of this polymorphism on transcriptional activity was assessed by Luciferase-reporter and electrophoretic mobility shift assays (EMSA). Luciferase-reporter assays showed a significant reduction in transcriptional efficiency with T compared to C allele. The reduction in transcriptional efficiency with the T allele construct (pGIL-12Rb2-T), in U-87MG, THP-1 and Jurkat cell lines, were 53, 37.6, and 49.8% respectively, compared to the C allele construct (pGIL-12Rb2-C). Similarly, densitometric analysis of the EMSA assay showed reduced binding of the AP-4 transcription factor, to T compared to the C nucleotide probe. Reduced mRNA expression in all patients (3/3) harboring the T allele was seen, whereas individuals with the C allele exhibited high mRNA expression (17/25; 68%, p = 0.05). These observations were in agreement with the in vitro assessment of the promoter activity by Luciferase-reporter and EMSA assays. The reduced expression of IL-12Rβ2 transcripts in 8 patients despite having the C allele was attributed to the predominant over expression of the suppressors (IL-4 and GATA-3) and reduced expression of enhancers (IFN-α) of IL-12Rβ2 transcripts. The 17 high IL-12Rβ2 mRNA expressers had significantly elevated IFN-α mRNA levels compared to low expressers and volunteers. Notwithstanding the presence of high levels of IL-12Rβ2 mRNA in these patients elevated IFN-α expression could modulate their immune responses to Mycobacterium tuberculosis