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A combination of a nonlocking plate with an allograft strut (construct D) resulted in the highest stiffness of the constructs examined for treating a periprosthetic fracture around a stable femoral component of a total hip replacement.

Summary Rivers and streams that do not flow permanently (herein intermittent rivers; IRs) make up a large proportion of the world's inland waters and are gaining widespread attention. We review the research on IRs from its early focus on natural history through to current application in management and policy. The few early studies of the ecology of IRs were largely descriptive. Nevertheless, in the 1970s, synthesis of this sparse research complemented work on temporary standing waters to found a powerful framework for much of the subsequent research on IRs. Research on the ecology and biogeochemistry of IRs continues to fuel our understanding of resistance and resilience to drying and flooding as disturbances. Syntheses of the growing literature, including cross‐continental and cross‐climate comparisons, are revealing the generality and individuality of ecological and ecosystem responses to flow cessation and surface water loss. Meanwhile, increasing numbers of experiments test the causality of these responses. Much of the increased consideration of IRs in research, management and policy is driven by the observed and projected shifts in flow regimes from perennial to intermittent associated with changes in land and water use and climate, superimposed on the high incidence of natural intermittency. The need to protect and better manage IRs is prompting researchers to develop new or modified methods to monitor flow status and assess the ecological condition of these systems. Intermittent river research and management will benefit from greater exploration of aquatic–terrestrial linkages, wet–dry cycling and temporal dynamics, more‐detailed mapping and predictive modelling of flow intermittency and the application of metapopulation and metacommunity concepts alongside multiple‐stressors and novel‐ecosystems research. By building on existing knowledge, continuing to develop quantitative models and distribution maps and using experiments to test hypotheses and concepts, we can further ecological understanding and wise management of these ubiquitous ecosystems.

The incidence of hip ''squeak'' associated with ceramic-on-ceramic bearings has been variably reported, ranging from 0.7% to 20.9%. We determined the patients' perception of squeaking in 306 patients (336 hips) in whom ceramic-on-ceramic total hip arthroplasties (THAs) were performed between 1997 and 2005. A questionnaire regarding hip noise was obtained by telephone. With a minimum followup of 2 years (mean, 3.9 years; range, 2-10 years), 290 patients (320 or 95% of the THAs) completed the questionnaire. Patients reported hip noise in 55 of the 320 THAs (17%); noise was perceived as squeak in 32 of the 320 (10%). Most squeaking hips (29 of 32) were pain-free and symptom-free. One patient was unhappy with his squeaking hip without pain. Our data suggest a much higher incidence of squeak as perceived by patients than previously reported.

BackgroundThe clinimetric properties of knee goniometry are essential to appreciate in light of its extensive use in the orthopaedic and rehabilitative communities. Intra-observer reliability is thought to be satisfactory, but the validity and inter-rater reliability of knee goniometry often demonstrate unacceptable levels of variation. This study tests the validity and reliability of measuring knee range of motion using goniometry and photographic records.MethodsDesign: Methodology study assessing the validity and reliability of one method ('Marker Method') which uses a skin marker over the greater trochanter and another method ('Line of Femur Method') which requires estimation of the line of femur. Setting: Radiology and orthopaedic departments of two teaching hospitals. Participants: 31 volunteers (13 arthritic and 18 healthy subjects). Knee range of motion was measured radiographically and photographically using a goniometer. Three assessors were assessed for reliability and validity. Main outcomes: Agreement between methods and within raters was assessed using concordance correlation coefficient (CCCs). Agreement between raters was assessed using intra-class correlation coefficients (ICCs). 95% limits of agreement for the mean difference for all paired comparisons were computed.ResultsValidity (referenced to radiographs): Each method for all 3 raters yielded very high CCCs for flexion (0.975 to 0.988), and moderate to substantial CCCs for extension angles (0.478 to 0.678). The mean differences and 95% limits of agreement were narrower for flexion than they were for extension. Intra-rater reliability: For flexion and extension, very high CCCs were attained for all 3 raters for both methods with slightly greater CCCs seen for flexion (CCCs varied from 0.981 to 0.998). Inter-rater reliability: For both methods, very high ICCs (min to max: 0.891 to 0.995) were obtained for flexion and extension. Slightly higher coefficients were obtained for flexion compared to extension, and with the Marker compared to the Line of Femur Method. For intra- and inter-rater reliability, the mean differences (within 2 degrees) and 95% limits of agreement (within 5 degrees) were generally clinically acceptable for both methods.ConclusionPhotography potentially offers a superior method of measurement over standard goniometry as visualising the centre of the knee is simplified in a two-dimensional plane and the permanent record provides greater assessor transparency as well as opportunity to confer. The Marker and Line of Femur Methods have moderate to substantial validity, but the inter- and intra-rater repeatability for trained observers are excellent with both methods yielding small mean differences with narrow limits of agreement. The Line of Femur Method offers the added advantage that it does not rely on inter-clinician consistency in identifying the greater trochanter.

The benefits of blood transfusion must be considered and evaluated in terms of risk factors relating to the adverse effects of transfusion. Transfusions may result in either serious or troublesome complications. Although the risk of transfusion-associated acquired immune deficiency syndrome (AIDS) is of paramount concern in the patient population, it has been virtually eliminated because of testing of donor units for antibody to human immunodeficiency virus. Serious and troublesome adverse effects of blood transfusion are listed and ranked in order of approximate frequency. About 20% of all transfusions result in some type of adverse effect. The major serious risk of blood transfusion today continues to be transfusion-associated viral hepatitis. This entity is usually subclinical but frequently results in serious chronic liver disease. Transfusions should be avoided unless patient care would be compromised if withheld.

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