Hip fractures are a major cause of morbidity and mortality in the elderly and are thought to represent an increasing cohort of our patients. It is estimated that the cost of caring for each patient for their hospital admission is €10,000. There is significant regional and international variation in the incidence rates of such injuries, depending on age, sex and ethnic variations in populations. Recent Irish literature would suggest that the rates in Ireland are exponentially increasing while in the US the rate may be decreasing. The length of stay of such patients is also an important issue especially in the current economic environment. The aim of this study was to define the incidence of hip fractures in the South East. The aim was also to examine any changes to their length of stay that have occurred in a 11 years period.

Independent searches of the operating theatre register and the HIPE (hospital in-patient enquiry scheme) database were undertaken for the time period. Population data was obtained from central census office and the HSE South East offices.

The combined incidence of hip fractures in 2008 and 1998 was 96.06 and 100.90 per 100,000 respectively. The male to female ratio in 2008 was 1:2.67, while in 1998 it was 1:3.04. 13% of the patients in 2008 where under 65 years of age, while in 1998 this figure was 8%. In 1998 the mean length of stay was 17.15. By 2008 this had increased to 23.95 days. The dramatic increase in acute hospital length of stay over the period was estimated to have a burden of more than 14 million euros on health board fund.

This study provides data on a large patient group which is of paramount importance. Health service resources can be allocated appropriately in the future in terms of acute and step-down care based on this data set and results.

Introduction

Increasing numbers of elderly patients are being prescribed Clopidogrel, an anti-platelet agent for medical reasons. There are no international guidelines as to the management of patients with hip fractures on Clopidogrel in peri-operative period especially in relation to timing of the surgery. In Waterford Regional Hospital in Ireland, hip fracture surgery is deferred for 4 days and platelets are reserved for the operative/post-operative period, in case they have significant bleeding or an associated complication. We conducted a retrospective study on patients admitted over a period of 1 year.

Background

Since its first description, the pathology, natural history and treatment of lateral epicondylitis have remained controversial. For those who fail conservative management, surgery remains an option. The optimal method of surgery remains debatable and is further confounded by a relative lack of long-term follow up studies.

Primary arthroplasty of the hip and knee are amongst the most common elective surgical procedures carried out. Results are uniformly good with low complication rates. However, there is a subset of patients in whom a general malaise has been noted. Many of these patients have been seen to have elevated liver function tests.

This study set out to examine the effects of primary arthroplasty on liver function and to establish differences between subsets of patients in a consecutive single surgeon series between June 2003 and September 2007 inclusive.

In total, 374 procedures were carried out on 350 patients. There were 186 male and 164 female patients. The mean age of the patients was 64.97+/−10.02 years with no significant difference between sexes. Hip replacement accounted for 196 cases (69 cemented, 68 hybrid and 59 cementless) and there was 178 knee replacements. All 4 measurements (AST, ALT, Alk phos, Gamma GT) were significantly elevated at 1 week post-op compared to pre-op and 1 day post-op. All except Alk phos returned to normal at 6 weeks post-op. There were no differences recorded between males and females, hips and knees and the subsets of hips.

It is clear from these results that liver function is affected by primary arthroplasty with no single subset providing a reason. Additional research is required to further evaluate these changes.

Hypothesis

Athletes significantly alter their lumbar spinal motion when performing squat lifting at heavy weights. This altered motion effects a change in pressure in the posterior annulus of lumbar discs.

Revision of the femoral component during revision hip arthroplasty may pose significant technical challenges, most notably femoral fracture and bone perforation. The in-cementing technique allows use of the original bone-cement interface which has been proven to be biomechanically stronger than recementing after complete removal of the original cement mantle.

This study reviews a series of 54 consecutive revision hip arthroplasty procedures carried out by the senior author using the in-cementing technique from November 1999 to March 2003. Patients were followed up clinically and radiologically with serial outpatient reviews and their functional outcome was assessed using the Harris hip scoring system, the Oxford hip scoring system and the University of California at Los Angeles (UCLA) activity profile. Their physical and mental well-being was also assessed using the SF-36 self-questionnaire.

Fifty-four procedures were performed on 51 patients. There were 31 males and 20 females. The average age was 70.3+/-8.1 years (range: 45-83 years). The average time to revision from the original procedure was 132.8+/-59.0 months (range: 26-286 months). The average length of follow-up was 29.2+/-13.4 months (range: 6-51 months) post revision arthroplasty. Two patients suffered dislocations, one of which was recurrent and was revised with a Girdlestone's procedure. No patient displayed any evidence of radiographical loosening. The average Harris hip score of the study group was 85.2+/-11.6 (range: 51.9-98.5). The average Oxford hip score recorded was 19.6+/-7.7 (range: 12-41) and the average UCLA activity profile score was 5.9+/-1.6 (range: 3-8). The SF-36 questionnaire had an average value of 78.0+/-18.3 (range: 31.6-100).

In conclusion, the results of this study show excellent clinical and radiological results of the in-cementing technique with high patient satisfaction in terms of functional outcome. This technique merits consideration where possible in revision hip arthroplasty.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=15), and compares them with a control group with isolated long bone fractures (n=12). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days (12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-β using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-β levels of 142.79+/-29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p=0.009 vs. all other time points, ANOVA). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51+/-36.81 ng/ml) and long bone (102.28=/-47.58 ng/ml) groups at 84 days post-injury (p=0.009 and p=0.04 respectively, ANOVA).

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-β in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Compartment syndrome is a devastating complication of limb trauma requiring prompt decompression by means of fasciotomy; however to date little is known about the long term morbidity directly related to the fasciotomy procedure.

This is a retrospective study from June 2001 to July 2008 of all patients undergoing fasciotomy in a tertiary referral centre following trauma to a limb. In total this comprised of 66 patients and of these one had since died and five were uncontactable. Therefore 60 patients were surveyed, 48 of whom underwent lower limb fasciotomy and 12 underwent upper limb fasciotomy. Patients were subjected to a phone survey with end points including weakness, parasthaesia and dysasthaesia which had persisted for more than one year post-op. The results were then correlated with time to fasciotomy, site of fasciotomy, initial post-op complications and Methods: of closure.

42 out of 60 patients (70%) reported persistent symptoms. Of these 20 (33%) reported that their symptoms limited them severely either occupationally or socially. Lower morbidity was seen in the upper versus the lower limb fasciotomy group, with decreased incidence of persistent severe symptoms (16.7% versus 35%).

Twelve patients had early post-op complications (seven wound infections, 1 cardiac arrest, 2 amputations, 2 haematomas requiring evacuation). Amongst those with post-op complications, 10 out of 12 had persistent symptoms with severe symptoms seen in 80%.

In terms of Methods: of closure, 39 patients had delayed primary closure, six were allowed to heal by secondary intention and 15 patients underwent skin grafting. All patients who underwent skin graft were symptomatic at the time of survey with 80% being severely symptomatic. Meanwhile of the patients allowed to heal by seconday intention 83% were asymptomatic.

Mean time to closure of fasciotomy was four days. In those patients who were closed in three days or less, 47% were asymptomatic with 23% mildly symptomatic. In the group closed between 8–14 days 37% were symptomatic while all patients closed after 14 days were severely symptomatic.

These results demonstrate significant morbidity associated with the fasciotomy procedure. Incidence was highest amongst those undergoing leg or thigh fasciotomy, those who had early post-op complications, those who were closed late and those who were closed with split/ full thickness skin graft. This was most dramatic in those who underwent skin grafting, a vast majority of whom were severely symptomatic. Long term sequelae were lowest in those with upper limb fasciotomies, those undergoing early primary closure and those that were allowed to heal by secondary intention.

Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a major element of this but no consensus exists as to the detection or management of this condition. Reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

The aim of this study was to evaluate the nutritional status of 415 patients with operatively managed hip fractures and determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC) assays. Protein-energy malnutrition (PEM) was defined as serum albumin < 3.5g/dl and a TLC < 1,500 cells/mm3. Delay to operation, duration of in-patient stay, re-admission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

Survival data was available for 377 patients at 12 months. Of 377 patients, 53% (n=200) had both a serum albumin and TLC levels taken at admission, while 47% (n=177) had not. The incidence of PEM was 51%. Inhospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Older patients were more likely to have lower albumin (p=0.017) and TLC (p=0.023). Nursing home patients were also more likely to have lower albumin (p=0.033). Multivariate analysis revealed a significant difference in 12-month mortality, with patients who had both a low albumin and a low TLC 4.6 times (95% CI: 1.0–21.3) more likely to die within 12 months postoperatively than patients who had normal values of both laboratory parameters. This was significant after adjusting for age, gender and domicile (p=0.049).

Serum albumin and TLC in combination are accurate predictors of 12-month mortality in hip fracture patients. These results highlight the relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the relationship between nutrition and outcome.

Background: Protein energy malnutrition (PEM) is an accepted predictor of poor outcome in hip fracture patients. There is no universally accepted definition of PEM. Admission screening for PEM is not routinely performed for hip fracture patients. The reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

Aims: To determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC), as clinical markers of PEM and predictors of outcome for hip fracture patients.

Methods: Retrospective review of 415 patients with operatively managed hip fracture. Protein-energy malnutrition was defined as albumin < 3.5g/dl and TLC < 1,500 cells/ mm3. Delay to operation, duration of in-patient stay, readmission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

Results: Survival data was available for 377 patients at 12 months. Of 377 patients, 53% (n=200) had both a serum albumin and TLC levels taken at admission (study), while 47% (n=177) had not (control). Incidence of PEM was 51%. Older patients were more likely to have lower albumin (p=0.03) and TLC (p=0.012). Nursing home patients were also more likely to have lower albumin (p=0.049). In-hospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Patients with PEM had a higher 12-month mortality compared to patients who had normal values of both laboratory parameters (Odds Ratio=4.52; p=0.049).

Conclusion: Serum albumin and TLC in combination are accurate predictors of 12-month mortality in hip fracture patients. These results underscore the clinical relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the relationship between nutrition and outcome in these patients.

Hypothesis: Athletes significantly alter their lumbar spinal motion when performing squat lifting at heavy weights. This altered motion effects a change in pressure in the posterior annulus of lumbar discs.

Study Design:

3-D motion analysis of lumbar spinal motion in athletes, during squat weight lifting.

Methods: 48 athletes performed 6 lifts at 40% maximum, 4 lifts at 60% max and 2 lifts at 80% max. 3-D motion analysis system, measured lumbar spine motion. Exercise performed as a ‘free’ squat and repeated with a weight lifting support belt.

4 cadaveric sheep spinal motion segments mounted in purpose built jig, replicating angulation seen in the in vivo motion study. These samples were then fixed to a tension/compression loading frame, replicating the forces seen in the in vivo study. Pressure measurement was achieved using a Flexiforce single element force sensor strip, positioned at the posterior annulus.

Posterior annulus pressure was measured during axial compression and on compression with the specimen fixed at 3° of extension.

Results:

Significant decrease (p< 0.05) in flexion in all groups when lifting at 40% max was compared with lifting at 60% and 80% of max. Flexion from calibrated zero point ranged from 24.7° (40% group), to 6.8° (80% group). A progressively significant increase (p< 0.05) seen in extension in groups studied when lifting at 40% max was compared with lifting at 60% and 80% max lift. Extension from a calibrated zero point ranged from − 1.5° (40% group), to − 20.3° (80% group). No statistically significant difference found between motion seen when performing the exercise as a ‘free’ squat or when lifting using a support belt in any group studied.

Comparing axially loaded specimens with specimens loaded in extension, there was an average increase in pressure of 36.4% in the posterior annulus, when the spine was loaded in 3° of extension at a pressure equivalent to the 80% lift in the in vivo motion study, in comparison to axial loading.

Conclusions: Squat weight lifting at heavier weights, causes athletes to lift at a progressively greater degree of extension. The use of a weight lifting support belt does not significantly alter spinal motion during lifting. The increased extension at heavier weights results in a stress concentration in the posterior annulus of lumbar discs.

Lateral patellar dislocation is a common cause of acute traumatic haemarthrosis in young active patients, usually occurring during sporting activites. Patients can often be unaware it has occurred. Often magnetic resonance imaging offers the first diagnosis. Most patellar dislocations are treated conservatively with an emphasis on early return to movement.

We report on a series of 80 consecutive patients who were diagnosed as having had a transient patellar dislocation by MRI from November 2001 to April 2008 as evidenced by the characteristic countercoup pattern of bone bruising seen on the lateral femoral condyle. In addition to the patellar findings, the images were reviewed with specific reference to the medial collateral ligament, a heretofore undescribed concomitant injury.

During the study period, 80 patients (66 males, 14 females) were diagnosed on MRI as having had transient patellar dislocation. The mean age (mean +/− standard deviation) of the cohort was 23.9+/−7.5 years (range:11–60 years). In all but two cases, normal anatomical alignment had been restored. In addition to multiple patellar chondral findings, the condition of the MCL was commented upon in 77 cases (96.3%). Of these, 40 (51.9%) had documented damage to the MCL. These injuries were classified as grade 1 (n=20), grade 1/2 (n=2), grade 2 (n=13), grade 2/3 (n=2) and grade 3 (n=3). Male patients were more likely to have had MCL damage 54.5% vs. 28.6% (p=0.07, Chi-Square).

These results serve to highlight the co-existence of MCL injuries with patellar dislocation to a relatively high incidence. This injury should be suspected and examined for in the case of prolonged symptoms after dislocation especially in male patients.

In the past autogenous bone grafting has been the mainstay of treatment in patients with fracture non-unions. The harvesting of bone graft is, however associated with significant donor site morbidity. Recently there has been much interest in the use of synthetic osteo-inductive agents.

We performed a review series of thirteen patients with sixteen non-unions in whom op-1, a bone morphogenetic protein (available commercially as Osigraft) was used to promote union.

This was a retrospective chart review and union was judged on the basis of radiological union as reported by the radiology department and documented by the surgeon responsible and clinical union based on the ability to weight bear with minimal or no pain as documented in the patients’ records.

At nine months twelve of sixteen non-unions (75%) had achieved clinical and radiographic union. Three patients had repeat grafting, all of whom went on to union. Mean time to grafting after initial treatment for all patients was 8.9 +/−6.1 months. Mean time to union was 5.1 +/− 1.6 months.

We conclude that the use of osteo-inductive agents, in particular BMP-7 (op-1) results in good clinical and radiological outcomes. What remains unclear is whether they are superior to the traditional approach of autogenous grafting.

Metastatic bone disease is increasing in association with ever improving medical management of osteophylic malignant conditions. The precise timing of surgical intervention for secondary lesions in long bones can be difficult to determine. This paper aims to validate a classic scoring system.

All radiographs were examined twice by 3 orthopaedic oncologists and scored according to the Mirels’ scoring system. The Kappa statistic was used for the purpose of statistical analysis.

The results show agreement between observers (κ=0.35–0.61) for overall scores at the 2 time intervals. Inter-observer agreement was also seen with subset analysis of size (κ=0.27–0.60), site (κ=0.77–1.0) and nature of the lesion (κ=0.55–0.81). Similarly, low levels of intra-observer variability were noted for each of the 3 surgeons (κ=0.34, 0.39, 0.78 respectively).

These results validate the Mirels’ scoring system across a wide spectrum of malignant pathology. We continue to advocate its use in the management of patients with long bone metastases.

The cervical spine exhibits the greatest range of motion amongst the spinal segments due to its tri-planar components of movement. As a result, measurement of movements has proved difficult. A variety of methods have been used in an attempt to measure these movements but none have provided satisfactory triplanar data.

This paper uses the Zebris ultrasonic 3-D motion analysis system to measure flexion, extension, range of lateral bending and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested unrestrained and in soft and hard collars, as well as in Philadelphia, Miami J and Minerva orthoses.

Results show that the Minerva is the most stable construct for restriction of movement in all planes in both groups (p< 0.001 vs. all groups (p=0.01 vs. Philadelphia in female extension), ANOVA). In the male group, the standard hard collar provides the second best resistance to flexion, lateral bending and axial rotation. The female group showed no one orthosis in second place overall. Looking at these results allows ranking of the measured orthoses in order of their three-dimensional stability. Furthermore, they validate the Zebris as a reliable and safe method of measurement of the complex movements of the cervical spine with low intersubject variability.

In conclusion, this paper, for the first time presents reproducible data incorporating the composite triplanar movements of the cervical spine thus allowing comparative analysis of the three-dimensional construct stability of the studied orthoses. In addition, these results validate the use of the Zebris system for measurement of cervical spine motion.

The trampoline is a popular source of recreational and competitive sport. However, little is documented about the dangers associated with its use particularly in the paediatric population.

We reviewed paediatric patients referred to our service from April to September 2005 inclusively, having been injured on a trampoline. This unit services a catchment area of approximately 400,000 patients.

Eighty-eight patients were assessed (mean age: 8 years 6 months). There were 33 males and 55 females. Most injuries (53/88) occurred while bouncing on the trampoline, while 34 were secondary to falls off the trampoline. The injured child was supervised in only 40% cases. In 31 cases, the injury was attributable to the presence of others on the trampoline. Thirty-six children required surgery. Fracturesof the upper extremities occurred in 70% of cases.

Injuries related to the recreational use of trampolines are an important and significant cause of paediatric injury. These results strongly suggest that there is a clear need for guidelines.

Lateral patellar dislocation is a common cause of acute traumatic haemarthrosis in young active patients, usually occurring during sporting activites. However, patellar dislocation is usually transient with patients often unaware it has occurred. Often magnetic resonance imaging (MRI) offers the first diagnosis. Most patellar dislocations are treated conservatively with an emphasis on early return to movement.

We report on a series of 30 patients who were diagnosed as having had a transient patellar dislocation by MRI from December 2001 to October 2007 as evidenced by the characteristic countercoup pattern of bone bruising seen on the lateral femoral condyle. In addition to the patellar findings, the images were reviewed with specific reference to the medial collateral ligament, a heretofore undescribed concomitant injury.

During the study period, 30 patients (26 males, 4 females) were diagnosed on MRI as having had transient patellar dislocation. The mean age (mean +/− standard deviation) of the cohort was 23.1+/−6.1 years (range:14 – 36 years). In all but one case, normal anatomical alignment had been restored. In addition to multiple patellar chondral findings, the condition of the MCL was commented upon in 29 cases (97%). Of these, 12 (41%) had documented damage to the MCL. These injuries were classified as grade 1 (n=7), grade 2 (n=3) and grade 2/3 as defined by incomplete detachment of the MCL from the medial femoral condyle (n=2).

These results serve to highlight the co-existence of MCL injuries with patellar dislocation to a relatively high incidence. This injury should be suspected and examined for in the case of prolonged symptoms after dislocation. In addition, the current vogue for early rehabilitation needs to be regarded with some circumspection.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. While the benefits are obvious, this excessive bone growth also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=15), and compares them with a control group with isolated long bone fractures (n=12). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days(12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-.) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-.; levels of 142.79±29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (.0.009 vs. all other time points, ANOVA). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51±36.81 ng/ml) and long bone (102.28±47.58 ng/ml) groups at 84 days post injury (p=0.009 and p=0.04 respectively, ANOVA).

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-.; in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Fractures of the proximal humerus account for 4–5% of all fractures with 80% requiring no surgical treatment. However, the management of the other 20% remains controversial. Multiple surgical modalities have been examined with no consensus as to which if any is the most effective.

This study followed a series of 27 patients who had PHILOS plate fixation of their proximal humeral fractures. All patients were followed up clinically and radiologically for at least one year to a mean of 27.6+/−7.8 months.

We reviewed 27 patients with a mean age of 62.2 years (16 patients were aged at least 60 years). The patients were classified as per the AO system into type A (n=11), type B (n=12) and type C (n=3) fractures. The mean DASH score was 51.8. The mean SF-36 scores for physical and social functions were 68.7 and 88.0 respectively. The mean Constant score was 50.5%.

These results how that the PHILOS plate offers good functional outcomes across a spectrum of fracture severities and in an older population group. Its use should be considered where appropriate in the management of displaced proximal humeral fractures.

Patients with DDH are known to be at risk of early degenerative changes to their hips. To date, no consensus exists as to the most appropriate management of this group, with many surgical options being associated with specific complications such as dislocation and early wear. In addition, modern resurfacing methods are considered by many to be contra-indicated in patients with DDH due to the technical difficulty of the procedure.

This prospective study analyses a single surgeon series of known DDH hips that underwent metal on metal resurfacing from November 1999 to July 2004 inclusive.

There were 31 resurfacings carried out on 28 patients (11 males, 17 females). The mean age of the study group at the time of surgery was 43.9+/−9.1 years. No patient was lost to follow up. Pre-operatively, 23 hips were classified as Crowe I (n=9), II (n=5), III (n=5) and IV (n=4). Patients were followed up to a mean of 46.4+/−18.1 months. The mean Harris Hip scores were 54.9+/−9.3 pre-operatively and 98.1+/−4.9 post-operatively (p< 0.001, Student’s t-test). Using the UCLA activity profile, the mean scores were 3.2+/−1.0 pre-operatively and 6.4+/−1.8 post-operatively (p< 0.001, Student’s t-test).

Although the management of young patients with early degenerative changes secondary to DDH remains controversial, the results of this study suggest that not only is resurfacing technically possible even in advanced cases, it also offers excellent functional outcomes and should be considered in appropriate cases.

Introduction: The position of the L4/5 disc inter-space is commonly believed to be represented by a line drawn between the two highest points of the iliac crests. This line is used frequently as a pre-operative guide for incision placement, in patients undergoing spinal surgery.

Aim: To investigate whether a line drawn between the two highest points on the iliac crests corresponds to the L4/5 disc inter-space, in varying patient age groups.

Patients and Methods: We reviewed 450 AP and lateral lumbar spine radiographs in patients ranging in age from 20 – 90 years. Patients with an obvious deformity or previous spinal surgery were excluded from the study. In the AP films, a line was drawn between the two highest points on the iliac crests. From this line, the distance to the midpoint of the L4/5 disc was measured.

Results: In all age groups measured, the true L4/5 disc inter-space lay below the line between the iliac crests, at an average of 4.33mm below the supracristal plane. The plane intersected the spine at the L4/5 interspace in only 31.9% of cases and was found to lie at the lower half of the L4 body or above in 49.3% of cases.

Conclusions: These results show that, using a line drawn between the two highest points on the iliac crests as a guide to the position of the L4/5 disc interspace may lead to unintentionally cranial positioning of an incision or cannulation in this area. Therefore, it is advisable to perform a pre-operative AP and lateral radiograph of the lumbar spine, to enable accurate incision placement when performing spinal surgery in this area.

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.

Method: This prospective study analysed 164 male patients who underwent primary arthroplasty between September 2004 and March 2005 inclusive. Patients who had previous urological intervention for obstructive symptoms were excluded from the study. Upon admission and prior to surgery, all patients answered an 8-point urinary symptom questionnaire and were tested on their ability to micturate while supine.

Result: 34 patients required urinary catheterisation – 130 did not. The average age of the catheterised group was 69.5+/−10.7 years (range 45–90) and the non catheterised group was 65.2+/−10.5 years (range 33–85). There was no difference between these groups (p=0.134, ANOVA). Similarly, there was not difference (p=0.919, ANOVA) between the blood loss in the 2 groups, 880.6+/−455.5 mls and 895+/−533.7 mls respectively. With regards to the symptom questionnaire, the average score in the catheter group was 3.1+/−2.4 and the non-catheter group was 2.0+/−1.8 (p=0.034, ANOVA). The ability to micturate in a supine position was of no predictive value with 22 patients in the catheter group able to do so.

Conclusion: These results show the value of a urinary symptom questionnaire used pre-operatively in predicting those who may require post-operative urinary catheterisation. By appropriate use of this tool, patients with potential for post-operative retention may be identified before surgery. Consequently, this group should be catheterised pre-operatively thus reducing their risk of infection.

Introduction: The position of the L4/5 disc inter-space is commonly believed to be represented by a line drawn between the two highest points of the iliac crests. This line is used frequently as a pre-operative guide for incision placement, in patients undergoing spinal surgery.

Aim: To investigate whether a line drawn between the two highest points on the iliac crests corresponds to the L4/5 disc inter-space, in varying patient age groups.

Patients and Methods: We reviewed 450 AP and lateral lumbar spine radiographs in patients ranging in age from 20 – 90 years. Patients with an obvious deformity or previous spinal surgery were excluded from the study. In the AP films, a line was drawn between the two highest points on the iliac crests. From this line, the distance to the midpoint of the L4/5 disc was measured. This was achieved in the lateral films, by finding the midpoint between the two iliac crests and again measuring the distance from this point to the midpoint of the L4-5 disc.

Results: In all age groups measured, the true L4-5 disc inter-space lay below the line between the iliac crests. In the patient group a 20–30 yrs, the inter-iliac crest line lay on average 1.86 mm above the true l4–5 disc space. In the patients aged 30–40 yrs the line was on average 2.49 mm above the disc space. Patients aged 40–50 yrs the line was 6.05 mm above the disc space. In patients aged 50–60 yrs and 60–70 yrs, the line was 3.17 mm above the disc space. In the 70–80 yrs age group, the line was 4.5 mm above the true disc space. In the oldest group of patients studied (80–90 yrs), the line was positioned 9.06 mm above the true disc space. The results were analysed using the ANOVA system to assess their statistical significance. Comparison of the patients aged 20–30 yrs versus patients aged 80–90 yrs yielded a p value of p=0.0045. Patients aged 60–70 yrs versus patients aged 80–90 yrs, p=0.0049. Patients aged 50–60 yrs versus patients aged 80–90 yrs, p=0.0023. Patients aged 30–40 yrs versus patients aged 80–90 yrs, p=0.0004. Patients aged 70–80 yrs versus patients aged 80–90 yrs, p=0.03. Comparison of other patient groups, were of low statistical significance

Conclusions These results show that, while the L4/5 disc inter-space does broadly correspond to a line drawn between the iliac crests, there is a significant variation between different age groups and within individual age groupings. Therefore, it is advisable to perform a pre-operative AP and lateral radiograph of the lumbar spine, to enable accurate incision placement when performing spinal surgery in this area.

Bertolotti’s syndrome, first described in 1917, is characterised by the presence of an anomaly of unilateral or bilateral enlargement of the transverse process of the most caudal vertebra that may articulate or fuse with the sacrum or ilium. This gives rise to low back pain. Although described, relevant literature is sparse and in particular, no evidence exists as to its incidence specifically in young people.

This study analysed all MRI scans of the lumbosacral spine performed on patients between July 2003 and November 2004 inclusive. MRI scans for all indications were included in the study.

Out of a total of 818 MRI scans of the lumbosacral spine, 627 showed disc disease. Of these, 35 had radiological signs of Bertolotti’s syndrome (7 bilateral, 28 unilateral). There were 22 males and 17 females in this group. The average age of the Bertolotti group was 31.8+/−12.0 years (range: 15–60). This was less than those with multiple disc disease whose average age was 44.0+/−15.6 years (p< 0.0002, ANOVA), those with isolated disc disease (41.1+/−16.0 years, p=0.013, ANOVA) and those with isolated disc disease at the L4/5 level (46.0+/−11.3 years, p=0.003, ANOVA). The overall incidence of Bertolotti’s syndrome in this study was 5.6%. However, 18 of the patients in the Bertolotti group were under 30 years of age giving an overall incidence in this age group of 8.9%.

Bertolotti’s syndrome is a frequently occurring pathology in the lumbosacral spine. It occurs in significantly younger patients than either multi-level disc disease or isolated disc disease including at the L4/5 level. In the under 30 group its incidence of 8.9% mandates that it must form part of a differential list in the investigation of low back pain in young people.

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.

Study design: We prospectively studied all patients with cervical spine fractures who were admitted to the National Spinal Injuries Unit from 1 July 2000 to 1 March 2001. Anthropometrical measurement of head circumference, neck circumference, chest circumference, and neck length were analysed. Ages ranged from 18 to 55 years, and all patients with concomitant cervical pathology were excluded from the study. Mechanism of injury involved flexion/extension type injuries in all cases; those with direct axial loading were excluded. A control group of 40 patients (age 18–50 years) involved in high velocity trauma with associated long bone fractures, in whom cervical injury was suspected, but who were without any cervical fracture, or associated pathology, were similarly measured.

Results: Our analysis revealed a statistically significant increase in chest size in the male control group versus the male fracture group (97.89 cm versus 94.19 cm, P < 0.05, Student’s t-test). There was a correspondingly significant increase in chest circumference between the female controls versus the female fracture group (92.33 cm versus 88.88 cm, P < 0.05, Student’s t-test). Our results revealed no statistical difference in head circumference, neck circumference, or neck length between each of the groupings. These results indicate a proportionately larger chest may be a protective factor in cervical spine fractures.

Revision of the femoral component during revision hip arthroplasty may pose significant technical challenges, most notably femoral fracture and bone perforation. The in-cementing technique allows use of the original bone-cement interface that has been proven to be biomechanically stronger than recementing after complete removal of the original cement mantle.

This historical prospective study reviews a series of 54 consecutive revision hip arthroplasty procedures carried out by the senior author using the in-cementing technique from November 1999 to March 2003. Patients were followed up clinically and radiologically with serial outpatient reviews and their functional outcome was assessed using the Harris hip scoring system, the Oxford hip scoring system and the University of California at Los Angeles (UCLA) activity profile. Their physical and mental well being was also assessed using the SF-36 self-questionnaire.

Fifty-four procedures were performed on 51 patients. There were 31 males and 20 females. The average age was 70.3+/−8.1 years (range: 45 – 83 years). The average time to revision from the original procedure was 132.8+/−59.0 months (range: 26 – 286 months). The average length of follow up was 29.2+/−13.4 months (range: 6 – 51 months) post revision arthroplasty. Two patients suffered dislocations, one of which was recurrent and was revised with a Girdlestone’s procedure. No patient displayed any evidence of radiographical loosening. The average Harris hip score of the study group was 85.2+/−11.6 (range: 51.9 – 98.5). The average Oxford hip score recorded was 19.6+/−7.7 (range: 12 – 41) and the average UCLA activity profile score was 5.9+/−1.6 (range: 3 – 8). The SF-36 questionnaire had an average value of 78.0+/−18.3 (range: 31.6 – 100) with an average physical score of 73.3+/−22.2 (range: 20.5 – 100).

In conclusion, we feel the results of this study show excellent clinical and radiological results of the in-cementing technique with high patient satisfaction in terms of functional outcome. This technique merits consideration where possible in revision hip arthroplasty.

Increased bone turnover and fracture healing is associated with acute spinal cord injuries. Experimental work to date has been confined to animal models. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi.

This paper evaluates two groups of patients with spinal column fractures – those with neurological compromise and those without, and compares them with a control group with isolated long bone fractures. Serum was taken from these patients at 10 days post injury and was analysed for the known osteogenic cytokines Insulin-like Growth Factor-1 (IGF-1) and Transforming Growth Factor-b1 (TGF-b1) as well as being added to an osteoblast cell culture line to analyse cell proliferation.

The results for the IGF-1 show a higher level in the neurology group compared to the no neurology group (p=0.038). In the TGF-B1 assay, the neurology group has a lower level than the other two groups (p< 0.0001 and p=0.002 respectively). However, when this group is subdivided into patients with complete and incomplete neurology, it can be seen that the levels of the complete group are elevated, although not significantly so (p=0.228).

All three groups stimulated markedly increased osteoblast cell proliferation versus a control group (p=0.086, p=0.005 and p=0.002 respectively). However, the neurology group is significantly lower than the other two groups (p=0.007 and p=0.001 respectively). Furthermore the complete group causes a lower proliferation rate than the incomplete group (p=0.539).

In conclusion, at 10 days post injury when the acute inflammatory reaction is subsiding and new bone is being laid down, patients with acute spinal cord injuries have increased bone turnover. This increase is being indirectly mediated by IGF-1, and more elevated levels with more severe neurological compromise suggest a contributory role of TGF-b1. Direct stimulation of osteoblasts does not appear to have any role to play in this accelerated bone healing.

Background: CT scanning is an essential part of the preoperative planning process prior to surgical fixation of acetabular fractures. Considerable disparity exists between the clinical and radiological outcome following open reduction and internal fixation of these fractures. It is suggested that this disparity is due to poor assessment of the quality of reduction using plain radiographs alone.

Aim: To investigate the role of post-operative CT scanning following ORIF of acetabular fractures.

Methods. Prospective study commenced in January 2000 of all patients in our institution undergoing internal fixation of acetabular fractures. Post operative axial CT scans were compared with plain radiographs (AP pelvis and 45 degree oblique Judet views) with regard to the sensitivity to detect articular fracture reduction in terms of gap displacement and step deformity or offset. A simplified binary measurement of radiological outcome was used stratifying radiological result into anatomical and non anatomical. Three observers independently reviewed the plain radiographs and CT scans at two separate time points and categorised the radiographic outcome as described. The interobserver reproducibility and intraobserver reliability of these measurements was expressed as a kappa statistic. In addition in those patients greater than 18 months following surgery we attempted to correlate the radiographic with the clinical outcome using the Harris hip score and the SF-36 score.

Results: 20 patients were recruited. Plain films were equieffective in detecting post-operative articular fragment displacement (p=0.24). The interobserver and intraobserver agreement between the radiological outcome measurements were good with respective kappa values of 0.61 and 0.65. There was a weak association between clinical and radiographic outcome as ascribed by post operative CT scans.

Conclusion: While there may be an argument for the use of post operative CT scanning of acetabular fractures in selective cases, we did not find any significant benefit of CT scans over plain radiographs in the assessment of reduction or radiological outcome following these injuries. Hence we do not routinely advocate their use in the post operative setting.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days(12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-b) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-b levels of 142.79+/−29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p< 0.001 vs. day 1, day 5 and day 10 and p=0.005 vs. 42 days, ANOVA univariate analysis). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51+/−36.81 ng/ml) and long bone (102.28=/−47.58 ng/ml) groups at 84 days post injury (p=0.011 and p=0.021 respectively, ANOVA univariate analysis). There was statistically significant difference in TGF-b levels seen between the clinically more severely injured patients i.e. complete neurological deficit and the less severely injured patients i.e. incomplete neurological deficit.

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-b in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Introduction: Fractures of the sternum result from a direct blow or from an indirect mechanism with hyperflexion of the spine. The association between spinal injury and sternal fractures has been reported but is commonly overlooked and underestimated.

Aims: Our aim was to study the clinical and radiological effects of an attendant sternal fracture on vertebral fractures. Berg first described the extra stability afforded to the thoracic spine by the sternal-rib complex and the adverse effects of damage to this “4th column” apropos of 2 cases.

Materials and Methods: None patients were admitted to our unit from October 1996 to August 2001 suffering from vertebral fractures and concomitant sternal fractures. The clinical notes and plain film radiographs of these patients were studied.

Results: The average age of the 9 patients (5 males and 4 females) was 33 years (range 21–73). Seven had been involved in road traffic accidents and 2 had fallen from a height. Four patients had injuries to their cervical spine, 4 to their thoracic spine and one had a lumbar spine fracture. In terms of neurological compromise, only one of the cervical groups had a neurological deficit compared to all 4 in the thoracic group (2 complete and 2 incomplete). The patient with the lumbar spine fracture suffered incomplete neurological compromise. All 6 of the patients with neurological compromise underwent surgical management. The other 3 patients were treated conservatively.

Conclusion: It has been traditionally accepted that the sternum is injured only in association with upper thoracic spine. Our findings suggest that spinal injury at lower thoracic, upper lumbar or cervical level may also be associated with sternal injuries. However, the relative severity of the vertebral injury and neurological compromise in the thoracic spine subgroup offers clear support of Berg’s “4th column” theory of thoracic spine fractures when compared to fractures of the cervical or lumbar spine with sternal injuries.

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 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.