The aims of this study were to map the tibial PCL footplate using MRI in patients undergoing TKR and more importantly, to document the percentage disruption of this footplate as a result of the tibial cut.
From MRI analysis, the tibial PCL footplate had a mean surface area of 83 mm2 (range: 49 – 142), and there was a significant difference between male and female patients [Male: 104 mm2 Analysis of post-operative radiographs showed that the average tibial cut extended to 4 mm above the tip of the fibular head (range 2 mm below to 14 mm above). Over one third of patients had tibial cuts extending below the inferior most aspect of their PCL footplate (complete removal) and a further one third had cuts which extended into their PCL footplate (partial removal).
Proximal tibial cuts using conventional jigs resulted in the removal of a significant portion if not all of the PCL footplate in the majority of patients. Our findings suggest that when performing PCL retaining TKR’s, we commonly do not actually preserve the PCL.
Urinary retention following total hip and knee arthroplasty is a common problem frequently requiring catheterisation in the immediate post-operative period. The direct relationship between urinary tract instrumentation and deep sepsis in total hip replacements is well documented.
Nine (41%) patients underwent surgery and 11 (50%) required rehabilitation in the National Rehabilitation Centre, Dun Laoghaire, with an average length of inpatient stay of 9.22 months (range 5 – 14 months). Eight (36%) patients felt that their injury was preventable. Of those patients without neurology, 60% have returned to playing rugby.
Nine (41%) patients underwent surgery and 11 (50%) required rehabilitation in the National Rehabilitation Centre, Dun Laoghaire, with an average length of inpatient stay of 9.22 months (range 5 – 14 months). Eight (36%) patients felt that their injury was preventable. Of those patients without neurology, 60% have returned to playing rugby.
Nine patients had additional acetabular bone grafting with autologous femoral head, two patients had subtrochanteric osteotomy, and another patient had an adductor tenotomy performed at the time of their surgery. Follow-up ranged from 6 to 44 (mean 19.6) months.
Data recorded includes medical outcome scores (WOMAC and MOS SF-36), patient data, operative details (including type of prostheses used and operative technique employed), inpatient course, and any postoperative events. For revision procedures, additional data such as location of bony defects (Gruen zones) and acetabular bone loss (Paprosky classification) are also recorded. Follow up in a special Joint Register Clinic is at six months, two years and every five years thereafter for primary procedures. This is reduced to every two years in the case of revision procedures. To date, a pilot study involving four surgeons has prospectively captured data on 82 patients undergoing both primary and revision procedures in our unit. We aim to enrol all our patients in the register from July 2005, increasing the amount of data collected, which we hope will subsequently benefit patients undergoing hip and knee arthroplasty in the future.
To date the principal focus of the mechanism of cervical spine fracture has been directed towards head/neck circumference and vertebral geometric dimensions. However the role of other measurements, including chest circumference and neck length, in a standard cervical fracture population has not yet been studied in detail. Cervical fractures often involve flexion/extension type mechanisms of injury, with the head and cervical spine flexing/extending, using the thorax as an end point of contact. Thus, the thorax may play an important role in neck injuries.
Management of symptomatic residual acetabular dysplasia in adolescence and early adulthood remains a major therapeutic challenge. At our unit the two senior authors review all patients preoperatively and simultaneously perform each procedure. In the four years from 1998 forty-three Bernese osteotomies were performed in 40 patients with residual acetabular dysplasia. The mean average age at surgery was 21 years (range 12 – 43 years) and there were 34 female patients. The indication for surgery was symptomatic hip dysplasia (all idiopathic but for one male with a history of slipped capital femoral epiphysis) presenting with pain and restricted ambulation. 4 patients had previous surgery on the affected hip (2 Salter’s osteotomy, one Shelf procedure and one proximal femoral osteotomy). 27.5% of patients had symptomatic bilateral disease. 42% of patients had Severin class IV or V dysplasia at presentation. 100% of patients had preservation of the hip joint at last follow-up evaluation (mean 2.4 years), with excellent results in 82%, an average post-operative Harris hip score of 96, and an average d’Aubigne hip score of 16.1. The mean post-operative improvements in radiographic measures were as follows: Anterior centre edge angle +19.4°, Lateral centre angle +25.8°, Acetabular Index – 10.7°. Head to Ischial distance – 7.3mm. Surgical operative time decreased from 128 minutes to 43 minutes from the first to the most recent case. Average blood loss has reduced from 1850mls to 420mls over the four years experience. Predonation of 2 units of blood requested from all patients with baseline hemoglobin of >
12g/dl. When combined with intraopera-tive cell salvage the need for transfusion of homologous blood has been eliminated. All complications occurred in the first 9 patients: (one major – iliac vein injury requiring no further treatment; four moderate – lateral cutaneous nerve injuries; four minor – asymptomatic heterotopic ossification). Our experience confirms that the Ganz periacetabular osteotomy is an efficacious procedure for the treatment of the residually dysplastic hip, providing excellent clinical results, where early intervention is the key to improved outcome. It is a technically demanding procedure with a significant early learning curve and we believe that a two
No correlation was found between kyphotic deformity, extent of canal compromise and clinical outcome.
Percutaneous Radiofrequency Ablation (RFA) has become the method of choice in the treatment of a wide spectrum of disorders. It was introduced for the treatment of Trigeminal Neuralgia and has since been used both extensively and successfully in the treatment of this disorder. Over the past two decades it has been advocated in the treatment of hepatic metastases, lung tumours and cerebral tumours. In 1992 Rosenthal et al reported using this procedure for the treatment of Osteoid Osteomas with good outcome. Further case series have supported this modality of treatment. However, the biomechanical effects of RFA on cortical bone have not been reported to date. The study comprised of 16 large white land-raised male pigs. All were between 70–80kg in weight at the time of treatment. RFA was performed on the femur, tibia and humerus of each animal 24 hours, 1 week and 4 weeks before euthanisation. RFA was carried out via a percutaneous technique under fluoroscopic guidance. The fibula was not treated in each case and used as an intrinsic control to account for inter-group variability. The Modulus of Rigidity, Maximum Torsional Strength of all bones were determined and compared. There were three pathological fractures, all occurring in the hemerii and all occurring at 4 weeks post treatment. The Modulus of Rigidity and Maximum Torsional strength were significantly reduced at 24 hours and 1 week when compared with the control. However in the 4 weeks group the biomechanical strength of cortical bone was not significantly different and had almost returned to normal which is contradictory to the clinical setting. There was no significant difference at 24 hours and 1 week. RFA has become well established as the method of choice for the treatment of Osteoid Osteomas, however the biomechanical consequences of this procedure have not been reported to date. The torsional strength of RF ablated cortical bone is severely attenuated after 1 week, 40% reduction in torsional strength when compared with the control group. This study demonstrated that RFA of cortical bone is an effective treatment for cortical lesions however the biomechanical weakness promotes the need for weight-bearing restrictions when managing these patients postoperatively.
Between 1994 and 2002, 42 patients aged over 65 years were admitted to the spinal injuries unit with odontoid fractures. Data was retrospectively collected by analysis of the national spinal unit database, hospital inpatient enquiry (HIPE) system, chart and x-ray review. Mean age of patients was 79 years (66–88). Mean following-up with 4.4 years (1–9 yrs). Male to female ratio was 1:1.2 (M=19, F=23). Among the mechanism of injury, simple fall (low-energy) was the commonest underlying cause in 76% of the odontoid fracture, whereas 23% fractures were sustained as a result of motor vehicle accident. Fractures were classified according to Anderson and D’Alonzo method. There were 29 (69%) type 11 fractures, 13 (30%) were type 111 fractures and there was no type 1 fracture. Anterior and posterior displacements were recorded with almost equal frequency. Seven fractures displaced anteriorly and six fractures posteriorly. Primary union occurred in 59% of fractures. Forty (95.3%) fractures were treated non-operatively. Two fractures were stabilized primarily with C1/C2 posterior interspinous fusion. These fractures were odontoid type 11, anteriorly displaced. Three fractures (7.1%) failed to unite and another three fractures (7.1%) united with prolonged interval (9–11 months). Neurological compromise was mainly related to displacement of the fracture. The overall complication rate was significant (48%) with an associated in-hospital mortality of 11.1%. Loss of reduction, non-union after non operative treatment, pin site problems and complication due to associated injuries accounted primarily for this significant complication rate. Most fractures can be managed in orthosis but unstable fractures require rigid external immobilization or surgical fixation. Outcome was assessed using a cervical spine outcome questionnaire from Johns Hopkins School of Medicine. Questionnaires were sent by post to all patients identified. Non responders were subsequently contacted by phone, if possible, to complete the questionnaire. In the follow-up, additional 6(14.2%) patients were found deceased, 4 patients were unavailable for review and the remaining 69% had significant recovery. Functional outcome scores approached pre-morbid level in all patients. Outcome of these patients are related to increasing age, co-morbidity and the severity of neurological deficit.
Management of symptomatic residual acetabular dysplasia in adolescence and early adulthood remains a major therapeutic challenge. At our unit the two senior authors review all patients preoperatively and simultaneously perform each procedure. In the four years from 1998 forty-three Bernese osteotomies were performed in 40 patients with residual acetabular dysplasia. The mean average age at surgery was 21 years (range 12 – 43 years) and there were 34 female patients. The indication for surgery was symptomatic hip dysplasia (all idiopathic but for one male with a history of slipped capital femoral epiphysis) presenting with pain and restricted ambulation. 4 patients had previous surgery on the affected hip (2 Salter’s osteotomy, one Shelf procedure and one proximal femoral osteotomy). 27.5% of patients had symptomatic bilateral disease. 42% of patients had Severin class IV or V dysplasia at presentation. 100% of patients had preservation of the hip joint at last follow-up evaluation (mean 2.4 years), with excellent results in 82%, an average post-operative Harris hip score of 96, and an average d’Aubigne hip score of 16.1. The mean post-operative improvements in radiographic measures were as follows: Anterior centre edge angle +19.4°, Lateral centre angle +25.8°, Acetabular Index – 10.7°. Head to Ischial distance – 7.3mm. Surgical operative time decreased from 128 minutes to 43 minutes from the first to the most recent case. Average blood loss has reduced from 1850mls to 420mls over the four years experience. Predonation of 2 units of blood requested from all patients with baseline hemoglobin of >
12g/dl. When combined with intraoperative cell salvage the need for transfusion of homologous blood has been eliminated. All complications occurred in the first 9 patients: (one major – iliac vein injury requiring no further treatment; four moderate – lateral cutaneous nerve injuries; four minor – asymptomatic heterotopic ossification). Our experience confirms that the Ganz peri-acetabular osteotomy is an efficacious procedure for the treatment of the residually dysplastic hip, providing excellent clinical results, where early intervention is the key to improved outcome. It is a technically demanding procedure with a significant early learning curve and we believe that a two-surgeon approach is invaluable to the management of these difficult cases.
The thoracic spine has always been associated with a stability that is considerably augmented by the rib cage and associated ligaments. Fractures of the thoracic spine require great forces to be applied, causing high levels of other injuries. In addition, the narrow spinal canal dimensions result in high levels of neurological compromise when fractures occur. Between February 2nd 1995 and March 21st 2001, 1249 patients were admitted to our spinal tertiary referral unit. Of these, 77 had suffered fractures to some part of their upper thoracic spine (T1–T6), of which, 32 required surgical procedures. Using patient case notes, we retrospectively studied this series. Twenty-six of the 32 patients were male, with an average age of the group of 24.4 +/− 11.3 years and an average impatient stay of 17.5 +/− 10.5 days. 29 patients suffered fractures at more than one level and 23 patients suffered complete neurological compromise. Only 2 patients were neurologically intact. 90.7% sustained their injuries in road traffic accidents, with 53.9% of the male group being involved in motorcycle accidents. Multiple imaging (in addition to plain film radiography) was required in 30 cases with 20 patients suffering injuries apart from their spinal fracture. Of these, 15 had associated chest injuries. Cardiothoracic surgical consultants were required in 56.3% of cases, and from the general surgeons in 37.5% of patients. 59.4% of patients required intensive care unit therapy, with another 4 patients going to the high dependency unit. Fractures to the upper thoracic spine are injuries with devastating consequences, both due to high levels of neurological compromise and concomitant injuries. This series would suggest that patients suffering from these injuries are best treated in a multi-disciplinary approach within a general setting, rather that in a specialist orthopaedic unit, where other medical and surgical services may not be readily available.
The Mater Hospital is Ireland’s primary referral centre for spinal injuries receiving 80–90% of all spinal cases annually. In today’s society the number of people competing at more competitive and professional levels is also increasing. Over the years, a lot of work has gone into safety precautions in sport. However despite those improvements our impression was that the incidence of both minor and serious sporting injuries is increasing. The purpose of this study was to determine the incidence, pattern and mechanism of sports-related spinal injuries in Ireland over the last decade. Data was collected by performing an audit of the National Spinal Injuries Database from 1994–2001. This database is a prospective computerized database. Data entered relates to the initial presentation, mechanism, level of injury and their acute in-hospital management. On average 200–220 patients are admitted annually to the National Injuries Spinal Unit. 173 of these were related to sport, which represented 13% of total spinal injuries. 80% are male under 40 years. 29% sustained neurological deficit. The sports responsible for most spinal injuries in Ireland were equestrian (43.8%), followed by rugby (16.4%), diving (15%), GAA (13.6%) and skiing (3%). Rugby injuries were most likely to cause neurological damage. Equestrian accidents commonly caused thoracolumbar fractures while injuries sustained in diving, rugby and GAA were mostly to the cervical spine. Sport is an important cause of spinal injuries in Ire-land. Coaches and team doctors must be educated about safe practices and emergency management of these terrible injuries and for those unfortunately affected in the prime of their lives adequate rehabilitation resources need to be implemented so as to lessen their economic burden.
Data = mean ± standard deviation. Statistical analysis was by students t test. A significant result between control and stimulated groups is indicated by: * p=0.024m, † p=0.0007 or ‡ p=0.012. Methylprednisolone (2mg/ml) caused a significant (p=0.044) 30-fold reduction in IL-6 production and a significant (p=0.00004) 500-fold reduction in IL-8 levels as compared with nucleus pulposus cultured with 5 μg/ml LPS alone for 24 hours. Addition of 500 μM indomethacin significantly (p=0.04) decreased IL-6 production by a factor of 120 and IL-8 levels by a factor of 50 (p=0.00004). Necrotic cell death, as measured by lactate dehydrogenase (LDH) concentration, was not significant in any of the experiments.
In summary, this study suggests that patients with symptomatic knee arthritis are likely to have meniscal derangement and medial collateral oedema. A greater understanding of the origin of pain in the degenerate knee may assist in the choice of management options for these patients.
Standard protocol following total hip arthroplasty dictates that the hip is kept in a position of abduction until soft tissue healing is sufficient to provide stability. This is maintained by use of an abduction pillow while in bed, meaning that the patient must sleep on their back. Many patients find this position uncomfortable and have significant difficulty in sleeping.
The thoracic spine has always been associated with a stability that is considerably augmented by the rib cage and associated ligaments. Fractures of the thoracic spine require great forces to be applied, causing high levels of other injuries. In addition, the narrow spinal canal dimensions result in high levels of neurological compromise when fractures occur. Between 2 February 1995 and 21 March 2001, 1249 patients were admitted to our spinal tertiary referral unit. Of these, 77 had suffered fractures to some part of their upper thoracic spine (T1-T6), of which 32 required surgical procedures. Using patient case notes, we retrospectively studied this series. 26 of the 32 patients were male, with an average age of the group of 24.4 ± 11.3 years and an average inpatient stay of 17.5 ± 10.5 days. 29 patients suffered fractures at more than one level and 23 patients suffered complete neurological compromise. Only 2 patients were neurologically intact. 90.7% sustained their injuries in road traffic accidents, with 53.9% of the male group being involved in motorcycle accidents. Multiple imaging (in addition to plain film radiography) was required in 30 cases with 20 patients suffering injuries apart from their spinal fracture. Of these, 15 had associated chest injuries. Cardiothoracic surgical consultations were required in 56.3% of cases, and from the general surgeons in 37.5% of patients. 59.4% of patients required intensive care unit therapy, with another 4 patients going to the high dependency unit. Fractures to the upper thoracic spine are injuries with devastating consequences, both due to high levels of neurological compromise and concomitant injuries. This series would suggest that patients suffering from these injuries are best treated in a multi-disciplinary approach within a general setting, rather than in a specialist orthopaedic unit, where other medical and surgical services may not be readily available.