This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery.

Cite this article: Bone Joint J 2023;105-B(5):471–473.

The April 2024 Knee Roundup³⁶⁰ looks at: Challenging the status quo: re-evaluating the impact of obesity on unicompartmental knee arthroplasty outcomes; Timing matters: the link between ACL reconstruction delays and cartilage damage; Custom fit or off the shelf: evaluating patient outcomes in tailored versus standard knee replacements; Revolutionizing knee replacement: a comparative study on robotic-assisted and computer-navigated techniques; Pre-existing knee osteoarthritis and severe joint depression are associated with the need for total knee arthroplasty after tibial plateau fracture in patients aged over 60 years; Modern digital therapies?; A matched study on fracture rates following knee replacement surgeries;

Aims

To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour.

Spinal cord injury (SCI) is a devastating disorder for which the identification of exacerbating factors is urgently needed. Although age, blood pressure and infection are each considered to be prognostic factors in patients with SCI, exacerbating factors that are amenable to treatment remain to be elucidated. Microglial cells, the resident immune cell in the CNS, form the first line of defense after being stimulated by exposure to invading pathogens or tissue injury. Immediately after SCI, activated microglia enhance and propagate the subsequent inflammatory response by expressing cytokines, such as TNF-α, IL-6 and IL-1β. Recently, we demonstrated that the activation of microglia is associated with the neuropathological outcomes of SCI. Although the precise mechanisms of microglial activation remain elusive, several basic research studies have reported that hyperglycemia is involved in the activation of resident monocytic cells, including microglia. Because microglial activation is associated with secondary injury after SCI, we hypothesized that hyperglycemia may also influence the pathophysiology of SCI by altering microglial responses. The mice were anesthetized with pentobarbital (75 mg/kg i.p.) and were subjected to a contusion injury (70 kdyn) at the 10th thoracic level using an Infinite Horizons Impactor (Precision Systems Instrumentation). For flow cytometry, the samples were stained with the antibodiesand analyzed using a FACS Aria II flow cytometer and the FACSDiva software program (BD Biosciences). We retrospectively identified 528 SCI patients admitted to the Department of Orthopaedic Surgery at the Spinal Injuries Center (Fukuoka, Japan) between June 2005 and May 2011. The patients' data were obtained from their charts. We demonstrate that transient hyperglycemia during acute SCI is a detrimental factor that impairs functional improvement in mice and human patients after acute SCI. Under hyperglycemic conditions, both in vivo and in vitro, inflammation was enhanced through promotion of the nuclear translocation of the nuclear factor kB (NF-kB) transcription factor in microglial cells. During acute SCI, hyperglycemic mice exhibited progressive neural damage, with more severe motor deficits than those observed in normoglycemic mice. Consistent with the animal study findings, a Pearson χ2 analysis of data for 528 patients with SCI indicated that hyperglycemia on admission (glucose concentration ≥126 mg/dl) was a significant risk predictor of poor functional outcome. Moreover, a multiple linear regression analysis showed hyperglycemia at admission to be a powerful independent risk factor for a poor motor outcome, even after excluding patients with diabetes mellitus with chronic hyperglycemia (regression coefficient, −1.37; 95% confidence interval, −2.65 to −0.10; P < 0.05). Manipulating blood glucose during acute SCI in hyperglycemic mice rescued the exacerbation of pathophysiology and improved motor functional outcomes. Our findings suggest that hyperglycemia during acute SCI may be a useful prognostic factor with a negative impact on motor function, highlighting the importance of achieving tight glycemic control after central nervous system injury

Patients with spinal injuries are very vulnerable to early complications or secondary spinal cord injuries before and during transfer, which may delay their rehabilitation. We designed transfer guidelines following concerns raised in a pilot study of the transfer of 16 patients. We then examined the effectiveness of the guidelines in 100 consecutive patients and completed the cycle by re-auditing a further 254 consecutive admissions after incorporating changes from the initial audit. The transfer guidelines addressed ten areas of clinical concern. We recorded a 50% improvement in airway monitoring and management. There was also improvement in anti-ulcer therapy and thromboprophylaxis (from 50% to 96%). We saw a 50% improvement in the use of appropriate support staff during the transfer. The re-audit showed that initial improvements were maintained and further improvements were noted in the transfer of relevant documentation and investigations. Improvement was also noted in the use of a vacuum mattress for the transfer of spinal injury patients and subsequently reduced incidence of pressure sores by a statistically significant level, which helped in the early rehabilitation of these patients. The majority of transfers were safe. The transfer guidelines were easy to use and improved patient care by ensuring that common problems had been addressed before and during transfer. This system reduced the risk of preventable complications during inter-hospital transfer. There may be wider application of similar guidelines to other trauma patients who require inter-hospital transfer, where there is a possibility of preventable secondary injury

Purpose: We report a series of 16 GUEPAR total elbow prostheses implanted in a single centre. Material and methods: Between 1988 and 1996, sixteen GUEPAR prostheses were implanted in 13 patients (three bilateral implantations). There were 11 women and two men, mean age 61 years (51–81). Twelve patients (14 elbows) had rheumatoid polyarthritis and one patient (two elbows) had post-traumatic degenerative disease. The V transtricepital approach was used in 15 cases and the Bryan-Morrey approach in one. Postoperatively, the elbows were immobilised at 45° flexion for the normal period (18 days) followed by active mobilisation. Results were analysed with the Mayo Clinic score. The radiographs were examined in search for lucent lines and signs of loosening and prosthetic instability. Results: At a mean follow-up of four years (2–12), the mean Mayo Clinic score had improved from 33 to 75 points (45–100). Eleven elbows were pain free at last follow-up. Extension and flexion progressed 22° giving a postoperative amplitude of 34° to 129°. Pronation supination progressed by 15° giving a 154° rotation amplitude. The function score improved from 6 to 18 points. Seven of the sixteen elbows achieved normal function. Outcome was excellent for seven elbows, good for one, fair for three and poor for five. In two elbows, instability required changing the ulnar implant. There were four implant loosenings that required revision at 24, 36 ,36 and 48 months after the initial implantation. The radiographic analysis demonstrated a complete lucent line around the humeral and ulnar implant in one case, around the ulnar implant in one case. There were two peroperative fractures of the humerus and on postoperative fracture due to a fall. Ulnar paresthesia was observed in two cases requiring secondary neurolysis in one. There were no infections or secondary injury to the triceps. Discussion: The GUEPAR prosthesis is a non-constrained prosthesis essentially indicated for rheumatoid polyarthritis. If the intrinsic stability is lost, the implant is contraindicated if there is loss of bone stock or if the instability is major. In selected cases, a generally painless elbow with recovery of the functional amplitude can be achieved with this prosthesis. Nevertheless, the presence of four early loosenings in our series as well as two instabilities suggest this implant should be abandoned in favour of a semi-constrained implant

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.

Achilles tendinopathy is characterised by chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. Extracorporeal shockwave treatment (ESWT) is of potential benefit in refractory cases where conservative management with analgesia, physiotherapy and corticosteroid injection have been unsuccessful. Patients with refractory Achilles tendinopathy enrolled between October 2010 and October 2011 received three sessions of ESWT over three weeks. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale were reassessed at six and 16 weeks post treatment. 51 patients completed follow up. Mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. Significant improvement (p<0.05) in VAS scores (rest and activity) and VISA-A scores was observed between baseline and 16 weeks. Mean Likert score was 3 (somewhat improved) at 16 weeks. Patients suffering Achilles tendinopathy for longer than 25 months had significantly less improvement than those affected for a shorter period. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy

Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering. NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research. Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment. 51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE

Aims

Anterior cruciate ligament (ACL) surgery in children and the adolescent population has increased steadily over recent years. We used a national database to look at trends in ACL reconstruction and rates of serious complications, growth disturbance, and revision surgery, over 20 years.

Introduction: Apoptosis has been observed following experimental contusive and transective spinal cord injury, but it is not known whether this is related to secondary excitotoxic injury or other factors. This study examines apoptosis after a purely excitotoxic injury and the relationship between apoptosis and syrinx formation. Methods: Twenty-four male Sprague-Dawley rats were divided into six groups. Twenty rats received four 0.5 μL injections of 24 mg/mL quisqualic acid and 1% Evans blue between the rostral C8 and caudal T1 level. Ten microliters of 250 mg/mL kaolin were then injected into the subarachnoid space. Animals were sacrificed at 1, 5, 10, 20 and 50 days following the injections. There were 4 control animals. Spinal cord tissue was frozen and sectioned, and damaged DNA was detected immunohistochemically by using anti-single-stranded DNA monoclonal antibody. The area and density of single strand DNA were semi-quantitated. Results: No significantly damaged DNA was found in the 1 day group. Light staining of single-stranded DNA was observed at C6, C7, T1 and T2 levels in 30% of the section area in the 5 and10 day groups. Moderate staining of damaged DNA occurred at C7 and T1 levels in 25–30% of the section area at 20 day group. Syrinxes formed in this group. Heavy staining and larger syrinxes were noted in the 50 day group. Discussion: Apoptosis increased with time after excito-toxic injury. These findings suggest that apoptosis may play a pivotal role in syrinx pathogenesis