Abstract

Aims

Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type.

Allogeneic blood transfusion is associated with many complications and significant cost. The RD&E has looked at the use of autologous drains after our study of 100 cases showed an improved post-operative haemoglobin and reduced length of stay. There is a need to identify those patients of increased need for an autologous drain, in order to decrease the frequency of allogeneic transfusion. In 2007 a protocol was drawn up using information from our study of 191 cases which showed an average haemoglobin drop post-operatively of 3.05g/dl and average intra-operative blood loss of 285 ml. This protocol gives the surgeon triggers for autologous drain use; preoperative haemoglobin of <13g/dl, intra-operative blood loss of >400ml, tourniquet use, patient weight <50kg and patients refusing donated blood.

In 2007-08, 65% of a further 275 cases analysed met the triggers for use of an autologous system. The remaining patients received low vacuum drains. Of the 275 patients, only 2 (<1%) of those who did not fulfil the criteria for an autologous drain required allogeneic blood, compared with 43 patients (24%) of those deemed high risk of transfusion, and assigned autologous drains. The protocol was therefore deemed to be successful in identifying those patients who required additional support and expenditure to minimise allogeneic blood transfusion.

Analysis of this data led to recommended changes to the protocol in order to maximise the efficiency of the autologous drain use. In 2010 a further patient cohort studied showed a reduction in allogeneic blood transfusion to <10% of those receiving autologous drains, and an increase to 5% of those with low vacuum drains.

Due to the increased cost of autologous drains (£68) compared with the low vacuum systems (£32), and the cost of allogeneic units at £141, the expenditure per patient was calculated and shown to fall from £92 in 2007 to £78 in the 2010.

In conclusion, this protocol allows the clinician to appropriately target the use of the more expensive autologous drains to those of increased risk of transfusion. This protocol helps to minimise unnecessary allogeneic blood transfusion risks, and this has been shown to be more cost effective.

Allogeneic blood transfusion is associated with complications and significant cost. The RD&E has looked at the use of autologous drains to decrease the frequency of allogeneic transfusion after our study of 100 cases showed an improved post-operative haemoglobin and reduced length of stay. In 2007 a protocol to identify those patients of increased need for an autologous drain was made using a study of 191 cases showed an average haemoglobin drop post-operatively of 3.05g/dl and average intra-operative blood loss of 285 ml. This protocol gave triggers for autologous drain use; preoperative haemoglobin of <13g/dl, intra-operative blood loss >400ml, tourniquet use, patient weight <50kg and patients refusing donated blood.

In 2007-08, 65% of a further 275 cases analysed met the triggers for use of an autologous system. The remaining patients received low vacuum drains. Of the 275 patients, only 2 (<1%) of those who did not fulfil the criteria for an autologous drain required allogeneic blood, compared with 43 patients (24%) of those deemed high risk of transfusion, and assigned autologous drains. The protocol was successful in identifying those patients who required additional support and expenditure to minimise allogeneic blood transfusion.

Analysis of this data led to recommended changes to the protocol in order to maximise the efficiency of the autologous drain use.

Due to the increased cost of autologous drains (£68) compared with the low vacuum systems (£32), and the cost of allogeneic units at £141, the expenditure per patient was calculated and shown to fall from £92 in 2007 to £78 in a further patient cohort in 2010.

In conclusion, this protocol allows the clinician to appropriately target the use of the more expensive autologous drains to those of increased risk of transfusion. This helps to minimise unnecessary allogeneic transfusion, and this has been shown to be cost effective.

Introduction The goals of this study were to investigate the association between paediatric flexion-distraction fractures of the lumbar spine and abdominal injuries and to analyse the variety of the abdominal injuries seen with this type of fracture.

Methods A retrospective chart review was performed at three hospitals (British Columbia Children’s Hospital, Vancouver, Canada, Mater Children’s Hospital and Royal Children’s Hospital, Brisbane). All patients under the age of fifteen who had suffered a flexion-distraction fracture were included. Data collected from the chart related to seating position, the use of seat belts and the spinal and abdominal injuries. The time elapsed from presentation to the time of diagnosis of abdominal injury was also recorded.

Results Forty one patients were included. There were 16 male and 25 female patients. All injuries were due to motor vehicle accidents. The average age at the time of accident was 9 years and 8 months. Twenty-two of the forty-one patients (53%) suffered an intra-abdominal injury. Twenty-one of these patients required operative intervention for their abdominal trauma. The spectrum of injuries included small bowel, large bowel, mesenteric and solid organ injuries. Eighteen of the twenty-two patients sustained a small bowel injury.

Discussion Abdominal trauma after flexion-distraction fractures of the lumbar spine is common. Often the abdominal trauma is significant and may require a laparotomy. A high index of suspicion should be maintained for all patients who present to the orthopaedic department with this type of injury.

Introduction: Peridural fibrosis is a reaction that occurs outside the dura and occurs in the healing process following lumber surgery¹.The fibrosis is recognised as one of the possible causes of the failed back syndrome following lumbar spinal surgery. ADCON-L Anti-Adhesion Barrier Gel has been shown to be of Benefit in patients undergoing discectomy in reducing symptomatic fibrosis. The aim of this prospective study is to elicit the advantages and potential risks of using ADCON-L in more extensive decompression procedures and in instrumented spinal fusions.

Method: ADCON-L anti-adhesion barrier gel, has been used in 288 patients undergoing the following surgeries: posterior lumbar interbody fusion (PLIF) (49), decompression and instrumented fusion posterior interbody supplementary fixation (PISF) (96), decompression and Graf ligament stabilisation (31), decompression of stenosis (54), discectomy (41), and revision discectomy or decompression (17). Any adverse clinical events, including pseudarthrosis, new, recurrent or deteriorating leg pain, paraesthesia or neurological deficit, were documented. Patients with neurological symptoms suggestive of fibrosis including deteriorating leg pain were evaluated with an MRI scan with gadolinium enhancement. Fusion rates were evaluated where appropriate.

Results: Two patients developed significant early (< 4 weeks) recurrent sciatica. MRI demonstrated a recurrent disc prolapse at the same level in one patient, who required re-operation, but no fibrosis was noted at the surgery. Late developing leg pain occurred in 16 patients. All these patients were evaluated with MRI with gadolinium enhancement. Independent radiological assessment indicated the principal cause of the leg pain to be peridural fibrosis in 9 patients (3.1%). Other causes included recurrent disc prolapse or lateral recess stenosis. Early post-operative wound seepage or superficial wound infections occurred in 5 (1.7%). There were no late infections. Two patients developed a postoperative pseudomeningocoele. One required re-exploration and repair, the other settled with conservative treatment. At review 1 to 4 years (mean 2.7 years) after undergoing PISF and PLIF fusion had achieved in 93.1% of cases.

Discussion: Previous prospective randomised multi-centre studies have shown the effectiveness of ADCON-L gel in reducing peridural fibrosis in patients following discectomy. Our study shows that there is low incidence of peridural fibrosis and associated leg pain when ADCON-L is used in all forms of degenerative lumbar spine surgery. There is a low complication rate and good fusion rate.

Introduction: Endoscopic techniques are an established method for anterior correction and instrumentation of thoracic scoliosis. Deterioration in respiratory function for up to two years following a thoracotomy ¹ has been cited as a disadvantage of anterior approaches and has led certain authors to recommend posterior approaches. ² This prospective study establishes the pattern of change in respiratory function in patients during the first 12 months following endoscopic scoliosis surgery.

Methods: 67 patients have undergone endoscopic scoliosis correction performed by the senior author (GNA). The patients were intubated with a double lumen tube. The lung was deflated on the ipsilateral side to the spinal correction and instrumentation throughout the procedure. A chest drain was inserted per operatively and removed on day two post-operation. All the patients underwent respiratory function tests (RFTs) as part of the preoperative workup. These included absolute and predicted FVC, as well as absolute and predicted FEV1.Thirty patients underwent postoperative RFTs for the purpose of this study. 10 patients had RFTs at 12 months following surgery. A further 20 patients had repeat RFTs scheduled at 3 months, 6 months and 12 months post operatively.

Results: The RFTs of all 10 patients within the initial group had returned to their preoperative level at twelve months The RFTs of the further 20 patients showed a reduction in all parameters at the 3 month period post-operation but these had shown improvement at the 6 month period. The results are indicated for pre-op, 3months, 6 months and 12 months respectively. FVC 2.82, 2.51, 2.84 and 3.10 FVC% predicted 82.2%, 70.6%, 79.0% and 89.4%. FEV1 2.48, 2.23, 2.49 and 2.67 FEV% predicted 75.3%, 67.3%, 75.1% and 79.6

Discussion: The provisional results have shown that there is a reduction in the respiratory function in the immediate post-operative period following endoscopic scoliosis correction, but this does not lead to serious respiratory compromise. The respiratory function returns to the preoperative level at 12 months, showing there is no long-term deterioration of respiratory function following endoscopic correction and instrumentation.

Introduction: Spontaneous spinal epidural haematoma is an uncommon clinical problem which may lead to severe and permanent neurological deficit. The treatment options for spinal cord compression by extradural haematoma in the anticoagulated patient are limited. The majority of cases reported have been treated surgically.¹ Operative intervention carries a potential risk of extending the haematoma with further deterioration of the neurological deficit.

Methods: A case of paraplegia following spontaneous epidural haemorrhage is reported with a review of the prognostic factors that determine likely improvement in neurological function post-surgery.

Case report: A 59-year old man was referred to the regional Spinal Trauma Centre with a 34-hour history of severe lower back pain of sudden onset and 14 hour history of neurological deficit in both legs and urinary overflow incontinence. He had undergone aortic valve replacement two years previously, with subsequent anticoagulation with Warfarin. Examination showed complete paraplegia below L3 with grade 1 power on hip flexion only. On catheterisation, the residual volume of urine was 1200mls. The INR was 3.5. An MRI of the spine showed epidural haematoma that extended from the level of T11 to L5.

The patient was treated non-operatively. On discharge at 10 weeks he had normal sensation to L3 and grade 5-power on left knee extension and grade 4-power on the right. There was no motor recovery distal to this. He had a hypotonic neurological bladder with sufficient resting tone in the sphincter to prevent incontinence.

Discussion: Although associated with a definite mortality, surgical decompression of the spinal cord and evacuation of the haematoma improves neurological outcome and is the treatment of choice.¹ The decision to treat non-operatively should be based on the duration and severity of the neurological deficit. A literature review identifies neurological deficit greater than 12 hours and severe neurological deficit on presentation are poor prognostic indicators.² The prognosis for neurological recovery in this case was poor. In a patient with severe coexisting medical problems these factors can assist when making the decision to operate on an individual patient with spinal epidural haematoma.

Introduction: Chance fractures in children are rare the mechanism of injury is a flexion-distraction inertial force created during a motor vehicle accident when wearing a two-point seat belt or lap belt. High velocity paediatric Chance fractures are frequently associated with intra-abdominal injuries, although this may not be appreciated at the time of initial presentation.

Methods: The cases of two brothers who sustained Chance fractures with complete neurological deficits and intra-abdominal injuries from a motor vehicle accident are presented.

Results: The two brothers were rear seat passengers in car involved in a head-on collision with a tree. They were both wearing three point seat belts but had removed the chest straps, thus effectively converting them to a two-point harness.

Case 1. Boy age 3 years 10 months sustained a bony Chance fracture through the L3 vertebrae with a complete neurological deficit at the L1 level. There was an associated closed head injury and severe abdominal bruising. He underwent a CT scan of his abdomen on day of admission and posterior stabilisation of the spinal fracture on day 4. Seven days post-admission he was diagnosed with pancreatitis. He continued to have abdominal pain and vomiting. Further repeat abdominal CT scans, ultrasound examinations and abdominal contrast studies were performed. Ten weeks following admission he underwent laparotomy and a section of ischaemic small bowel was removed.

Case 2. Boy age 2 years 8 months presented with a ligamentous Chance fracture of L2 / L3 with a complete neurological deficit at T12. He had a closed head injury and severe abdominal bruising. He underwent CT scan on the day of admission and a diagnostic peritoneal tap on day two with aspiration of straw coloured fluid. The spinal fracture was stabilised 10 days post-admission with posterior instrumentation. On day 14 he underwent a laparoscopy and subsequent laparotomy with drainage of an abscess secondary to a perforated caecum.

Discussion: Chance fractures or flexion-distraction fractures of the spine are rare occurrences in children with few cases reported. They represent severe trauma and are often related to the wearing of two-point seat belt fixation. There is a high associated incidence of abdominal injuries which may be difficult to diagnose. The authors support the view of Beaunoyer¹ that a diagnostic laparoscopy or laparotomy should be considered strongly in patients with lumbar Chance fractures. Abdominal bruising and neurological defi cit are cardinal signs, reflecting severe trauma.

Introduction: The foot is an unusual site for presentation of Ewings tumour. Haemangioma of the vertebra is a common finding in adults, but is rarely reported in children.¹ Although rarely symptomatic, the lesion may cause diagnostic confusion particularly in the presence of comorbidity. A previous case report details an adult patient with a ‘pseudohaemangioma’ that was subsequently found to be an Ewings tumour.²

Methods: A review of the literature and a case report is presented of a boy with a Ewing’s sarcoma of the foot presenting with an asymptomatic lytic lesion in the spine.

Results: The 12-year-old male initially presented with pain and swelling in the right foot. Subsequent investigation and biopsy confirmed a diagnosis of Ewing’s sarcoma in the second metatarsal. The child received 5 cycles of combined chemotherapy, and the primary tumour was excised from the metatarsal with fibular graft reconstruction.

Part of the clinical work up had included an isotope bone scan, which revealed a focal area of increased uptake in the L1 vertebra. On MRI, the vertebral lesion had a ‘halo’ of high intensity signal with infraction of the upper vertebral endplate. There were no clinical symptoms arising from the vertebral lesion. The differential diagnosis of the L1 lesion suggested was either a meta-static Ewing’s tumour or an aggressive haemangioma. Given the possibility of a multifocal or metastatic lesion, a vertebrectomy and reconstruction with femoral allograft was performed. A second stage posterior stabilisation from T12 to L2 was performed. Histological examination of the resected vertebra revealed a benign capillary haemangioma. On recent review one year after treatment, the patient remains in remission from his tumour and has successful graft incorporation with minimal symptoms from his spine.

Discussion: Haemangioma is a benign tumour commonly found in the vertebral body. Asymptomatic spinal haemangiomas do not require surgical excision. Clinico-pathological distinction between vertebral haemangioma and metastatic disease can be difficult, particularly in children where the haemangiomata may be in a ‘blastic’ phase. The combination of an extremely unusual age of presentation and the presence of a separate malignant primary bone tumour in this patient introduced a significant clinical dilemma in treatment.

Introduction: Sports injuries to the cervical spine account for about one in ten of all cervical spine injuries. They occur at all levels of participation. Fortunately, the number of patients suffering spinal cord injury is relatively small. Neurological injuries may range from transient quadriparesis through to complete quadriplegia. The decision to allow sportsmen to return to sport following a cervical spine injury is complex. It is based on such factors as history, clinical examination, the nature of the injury, as well as age and other psychosocial factors. The evidence that exists to aid this decision process is at times conflicting. The aim of this presentation is to review some of the contentious issues that exist in the decision making by reference to case presentations of high level sportsmen who were treated following a variety of cervical spine injuries.

Methods: Four high-level rugby players (22–31 years old) presented with different cervical spine injuries sustained during sporting activities. Two subjects sustained a “stinger” and two a transient quadriparesis which rapidly resolved. Radiological evaluation included assessment of spinal canal diameter.¹

Results: Two had a C5-6 disc bulge with developmental spinal stenosis. A third had a congenital fusion C2-3 with a disc bulge and developmental stenosis at C3-4. Case 4 had degenerative disc disease at C5-6. All were treated non-operatively and returned to sport. All suffered a recurrence of the neurological symptoms and subsequently underwent an anterior interbody fusion (Case 4 for subluxation of C6-7). Three successfully resumed rugby six months after surgery while one elected not to continue.

Discussion: The decision to allow a patient to return to contact sports following a cervical spine injury may be difficult. The four cases presented highlight some of these contentious issues such as transient neurological deficit and the effect that surgery may have on a patient’s ability to return safely to sport. A review of the literature may assist in the decision making.^1,2 This may be conflicting and difficult to interpret. Neurological signs, instability, displacement, fusion of more than one level and occipito-atlanto-axial pathologies are considered absolute contraindications.³

Background: The necessity for radiographic follow up of infants with hip clicks and normal ultrasound is not clear.

Materials and methods: Infants referred to a paediatric hip clinic whose sole risk factor for DDH was a soft tissue hip click who had a normal ultrasound scan on initial assessment were identified. A follow up six month AP pelvis radiograph was assessed and acetabular index(A.I), position of femoral ossific nucleus and Shen-ton’s line measured. Infants with rotated pelvis Xrays were excluded. Inter-observer variability for acetabular index was measured and dysplasia defined according to Tonnis.

Results: 171 infants (193 clicking hips) met the criteria for inclusion. 48 male and 109 female with unilateral clicks (57 right, 64 left) and 36 bilateral clicks. 10 were excluded due to rotation of the AP pelvis Xray. Inter-observer error for A.I. was 4°. All A.I. were within normal ranges. Shenton’s line was unbroken and all hips were located.

Conclusion: In this study infants with soft tissue hip clicks and a normal ultrasound scan on initial assessment had a normal Xray at six months.

Aim: To evaluate the outcome of uncemented femoral revision after total hip arthroplasty using the CLS system at Southland Hospital, Invercargill, between 1995 and 2001.

Methods: A retrospective study of 28 hips, representing the total experience of Southland Hospital with the CLS femoral prosthesis for revision surgery. For evaluation we used the Harris Hip Score and reviewed the radiographs.

Results: Twenty-eight hips(23 male and five female),with an average age of 66 years(33 years to 82 years). The mean interval from the primary surgery to the revision was 7.6 years (range one day to 24 years). The majority (60%) of the revisions was for aseptic loosening, 10% for infection, 10% for periprosthetic fracture and the remainder for recurrent dislocation. There was one case of a mismatch of the femoral and acetabular components requiring revision on the same day. The majority of patients reported a favourable outcome, two experienced serious complications, neither requiring revision.

Conclusions: Our results suggested that the CLS stem was a very useful method of correction following failure of total hip arthroplasty, with a high level of patient satisfaction.