Paediatric supracondylar fractures are the most common elbow fracture in children, and is associated with an 11% incidence of neurologic injury. The goal of this study is to investigate the natural history and outcome of motor nerve recovery following closed reduction and percutaneous pinning of this injury. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics (age, weight), Gartland fracture classification, and associated traumatic neurologic injury were collected and analyzed with descriptive statistics. Patients with neurologic palsies were separated based on nerve injury distribution, and followed long term to monitor for neurologic recovery at set time points for follow up. Of the 246 patient cohort, 46 patients (18.6%) sustained a motor nerve palsy (Group 1) and 200 patients (82.4%) did not (Group 2) following elbow injury. Forty three cases involved one nerve palsy, and three cases involved two nerve palsies. No differences were found between patient age (Group 1 – 6.6 years old, Group 2 – 6.2 years old, p = 0.11) or weight (Group 1 – 24.3kg, Group 2 – 24.5kg, p = 0.44). A significantly higher proportion of Gartland type III and IV injuries were found in those with nerve palsies (Group 1 – 93.5%, Group 2 – 59%, p < 0 .001). Thirty four Anterior Interosseous Nerve (AIN) palsies were observed, of which 22 (64.7%) made a full recovery by three month. Refractory AIN injuries requiring longer than three month recovered on average 6.8 months post injury. Ten Posterior Interosseous Nerve (PIN) palsies occurred, of which four (40%) made full recovery at three month. Refractory PIN injuries requiring longer than three month recovered on average 8.4 months post injury. Six ulnar nerve motor palsies occurred, of which zero (0%) made full recovery at three month. Ulnar nerve injuries recovered on average 5.8 months post injury. Neurologic injury occurs significantly higher in Gartland type III and IV paediatric supracondylar fractures. AIN palsies remain the most common, with an expected 65% chance of full recovery by three month. 40% of all PIN palsies are expected to fully recover by three month. Ulnar motor nerve palsies were slowest to recover at 0% by the three month mark, and had an average recovery time of approximately 5.8 months. Our study findings provide further evidence for setting clinical and parental expectations following neurologic injury in paediatric supracondylar elbow fractures

A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury. We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded. The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement >5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41. Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this

Introduction. The rate of total hip arthroplasty (THA) surgery continues to dramatically rise in the United States, with over 300,000 procedures performed in 2010. Although a relatively safe procedure, THA is not without complications. These complications include acetabular fracture, heterotopic ossification, implant failure, and nerve palsy to name a few. The rates of neurologic injury for a primary THA are reported as 0.7–3.5%. These rates increase to 7.6% for revision THA. The direct anterior total hip arthroplasty (DATHA) is gaining popularity amongst orthopedic surgeons. Many of these surgeons elect to use the Hana® table during this procedure for optimal positioning capability. Although intraoperative mobility and positioning of the hip joint during DATHA improves operative access, select positions of the limb put certain neurologic structures at risk. The most commonly reported neurologic injuries in this regard are to the sciatic and femoral nerves. To our knowledge, the use of neuromonitoring during DATHA, especially those using the Hana® table, has not been described in the literature. Methods. The patient was a 60-year-old male with long standing osteoarthritis of the right hip and prior left THA. Somatosensory evoked potential (SSEP) leads were placed bilaterally into the hand (ulnar nerve) as well as the popliteal fossae (posterior tibial nerve). Unilateral electromyography leads were placed into the vastus medialis obliquus, biceps femoris, gastrocnemius, tibialis anterior, and abductor hallucis of the operative limb (Fig. 1). Once the patient was sterilely draped, a direct anterior Smith-Peterson approach to the hip was used. Results. After the patient completed standard pre-operative protocol, neuromonitoring leads were placed as described above. There were no complications, neuromonitoring remained stable from baseline, and the patient tolerated the procedure well. Moreover, the senior author routinely uses a prophylactic cable around the calcar, particularly in patients with osteoporotic bone, as was the case with this patient. The patient's post-operative course has been without complications as well. Conclusion. There are a few studies that have examined the pressure changes around the femoral nerve during a DATHA and found that the nerve was at most danger with misplacement of a retractor near the anterior lip of the acetabulum. Furthermore, the popularity of DATHA and the Hana® table make neuromonitoring more amenable for use since the whole limb does not need to be sterilely prepped as with other approaches to the hip. The reported rates of neurologic injury during any THA along with those developed from passage of prophylactic cerclage cables and the goals of reducing surgical complications make this novel technique intriguing. It allows the surgeon yet another safe and effective tool to decrease the likelihood of neurologic injury during DATHA. For any figures or tables, please contact the authors directly

Purpose:. Non-contiguous spinal injury can add significant complexity to the diagnosis, management and outcome in children. There is very little in the paediatric literature examining the nature, associated risk factors, management and outcomes of non-contiguous spinal injuries. The objective is to determine the incidence and clinical characteristics of non-contiguous spinal injuries in a paediatric population. The secondary objective is to identify high risk patients requiring further imaging to rule out non-contiguous spinal injuries. Methods:. All children up to 18 years of age with a spinal injury, as defined by ICD-09 codes at one paediatric trauma hospital were included (n=211). Data for patient demographics, mechanism of injury, spinal levels involved, extent of neurologic injury and recovery, associated injuries, medical complications, treatment and outcome were recorded. Results:. Twenty five (11.8%) out of 211 patients had non-contiguous spinal injuries. The mean age was 10.7 years. The most common pattern of injury was a double thoracic non-contiguous injury. 16% of cases of NCSI were initially missed, but with no clinical deterioration due to the missed diagnosis. Associated injuries occurred in 52% of patients with NCSI. Twenty-four percent of patients with multiple non-contiguous spinal injuries had a neurologic injury compared to 9.7% in patients with single level or contiguous injuries (p=0.046). Conclusions:. There is a high incidence of children with multiple non-contiguous spinal injuries who are more likely to suffer neurological injuries compared to patients with single level or contiguous spinal injuries. Patients with a single level spinal injury on existing imaging and a neurological injury should have entire spine lateral radiographs to exclude non-contiguous injuries. In patients without neurologic injury and a single spinal fracture, radiographs showing at least 7 levels above and below the fracture should be performed. All children with spinal injury should have associated injuries carefully excluded

Reverse shoulder arthroplasty is becoming a frequent treatment of choice for patients with shoulder disorders. Complication rates after reverse shoulder arthroplasty may be three-fold that of conventional total shoulder arthroplasty especially in high risk patient populations and diagnoses like revision arthroplasty, fracture sequelae, and severe glenoid bone loss. Complications include component malposition, stiffness, neurological injury, infection, dislocation or instability, acromial or scapular spine fractures, scapular notching, and loosening of implants. Recognition of preoperative risk factors and appropriate 3D planning are essential in optimizing patient outcome and intraoperative success. Failure of reverse shoulder arthroplasty is a significant challenge requiring appropriate diagnosis of the failure mode. The most common neurological injuries involve the brachial plexus and the axillary nerve due to traction, manipulation of the arm, aberrant retractor placement, or relative lengthening of the arm. Intraoperative fractures are relatively uncommon but include the greater tuberosity, acromion, and glenoid. Tuberosity fracture can be repaired intraoperatively with suture techniques, glenoid fractures may be insignificant rim fractures or jeopardise baseplate fixation and require abandoning RSA until glenoid fracture ORIF heals and then a second stage RSA. Periprosthetic infection after RSA ranges from 1 to 10% and may be higher in revision cases and frequently is Propionibacterium acnes and Staphylococcus epidermidis. Dislocation was one of the most common complications after RSA approximately 5% but with increased surgeon experience and prosthetic design, dislocation rates are approaching 1–2%. An anterosuperior deltoid splitting approach has been associated with increased stability as well as subscapularis repair after RSA. Scapular notching is the most common complication after RSA. Notching may be caused by direct mechanical impingement of the humerosocket polyethylene on the scapular neck and from osteolysis from polyethylene wear. Sirveaux classified scapular notching based on the defect size as it erodes behind the baseplate towards the central post. Acromial fractures are infrequent but more common is severely eroded acromions from CTA, with osteoporosis, with excessive lengthening, and with superior baseplate screws that penetrate the scapular spine and create a stress riser. Nonoperative care is the mainstay of acromial and scapular spine fractures. Recognizing preoperative risk factors and understanding component positioning and design is essential to maximizing successful outcomes

Evidence suggests that there 17% rise in cycling related injuries in the last year. The objective of the study is to analyze the pattern of injuries in cyclists who were treated as a MTC. This is a retrospective study performed at a Tertiary Trauma Centre in central London. All cyclists who were admitted as MTC to hospital between January 2011 and August 2013 were included. Overall there were 518 patients who were treated as vehicle- related Major Trauma Cases, out of which 118 (23%) were cyclists. Of the 118 cyclists, 98 (83%) were male and 20 (17%) female. The mean Injury Severity Score was 19.2 ±11.1 (mean/SD). There were 58 (49%) patients who required ITU support. Major proportion of patients (68 patients – 61%) sustained neurological injuries. There were 2 (1.7%) deaths, both due to neurological injuries. In comparison to other group of vehicles there is less number of bicycles on the roads. Our results show that the proportion of cyclists involved in road traffic incidents is higher (23%) than other vehicles. Our results show that large proportions (61%) of cyclists sustain neurological injuries, reinforcing the previous evidence that safe protective head gear is vital for cyclists

Simultaneous bilateral total hip arthroplasties (THAs) present unique and unwarranted dangers to the patient and surgeon alike. These include a significantly increased risk of blood transfusion (up to 50% in contemporary series even with the use of tranexamic acid), longer operative times, longer length of stays, and higher mortality rates in patients with minimal risk factors (age > 75 years, rheumatoid arthritis, higher ASA class, and/or male sex). This is even in light of the fact that the vast majority of literature has a substantial selection bias in which only the healthiest, youngest, non-obese, and most motivated patients are included. Traditionally, simultaneous bilateral THAs were completed in the lateral decubitus position. This required the surgeon and surgical team to reposition the patient onto a fresh wound, as well as additional prepping and draping. To mitigate these additional limitations of simultaneous bilateral THAs, there has been a recent trend towards utilizing the direct anterior approach. However, this particular approach presents its own unique set of complications such as an increased risk of periprosthetic femoral fracture and early femoral failure, an increased risk of impaired wound healing (particularly in obese patients), potential injury to the lateral femoral cutaneous nerve with subsequent neurogenic pain, and traction-related neurologic injuries. When compounded with the risks of simultaneous bilateral THAs, the complication profile becomes prohibitive for an elective procedure with an otherwise very low morbidity

Introduction. Catastrophic neck injury is rare in rugby, however the consequences are invariably devastating. Schoolboys have previously been identified as a group at risk. This study came about as a result of a recent increase in admissions of schoolboy rugby players to the National spinal injuries unit in Glasgow. Aim. To audit schoolboy rugby admissions to spinal injury units throughout the United Kingdom and Ireland, in doing so to appraise the current state of data collection. To obtain estimates of playing numbers from the Home unions. Method. Retrospective review of all 12 spinal injury units for records of cases subsequent to 1996. Representatives of each of the four home unions were contacted to confirm cases and establish playing numbers. Results. Records were available from 1996 in Scotland and Ireland and from 2000 in England and Wales. Two units collect prospective data, two had easily retrievable data. In the absence of any register data retrieval was challenging elsewhere. Of the 36 cases 24 would be classified as catastrophic 12 as near misses. The median age for injury was 17. 51% of injuries occurred in the tackle, 35% in the scrum. 92% of scrum injuries involved neurological damage, 61% with complete neurological loss at presentation, 8% with no neurological injury. Tackle injuries were associated with neurological damage in 42%, 26% with complete lesions and no neurological injury in 57%. Estimates for playing numbers (U18 inclusive) approximate to Scotland 19,000, Wales 30,000, Ireland 40,000 and England 1,200,00. Conclusion. •. A persistent number of schoolboys were injured through the study period. •. Recording of serious neck injuries is inconsistent through the United Kingdom and Ireland. •. The numbers injured in Scotland were disproportionate in view of the relative playing populations. •. Whilst less frequent, scrum injuries were more often associated with spinal cord injury

Introduction. Evidence suggests that intra-operative spinal cord monitoring is sensitive and specific for detecting potential neurological injury. However, little is known about surgeons' responses to trace changes and the resultant neurological outcome. Objective. To examine the role of intra-operative somatosensory evoked potential (SSEP) monitoring in the prevention of neurological injury, specifically sensitivity and specificity, and whether the abnormalities were reversible. Methods. 2953 consecutive complex spine operations (male 36% female 64%, median age 25yrs) prospectively performed using spinal cord monitoring at a single institution (2005–2009). All traces and neurophysiological events were prospectively recorded by the neurophysiology technician. All patients with a significant neurophysiology event were examined clinically by a neurologist, separate from the spinal surgery team. Significant trace abnormality was defined as a decrease in signal amplitude of 50% or a 10% increase in latency. Timing of trace abnormality, surgeon's response and prospective neurological outcome were recorded. Sensitivity, specificity, positive/negative predictive value were calculated. A Chi-squared test was performed to assess the impact of intervention on neurological outcome (p < 0.05). Results. 2953 operations involving SSEP monitoring were performed and 106 recorded a significant trace abnormality. This most often occurred during instrumentation and the most common reaction was adjustment of metalwork. SSEP monitoring had a sensitivity of 100%, specificity 97.3%, PPV 24%, NPV 100%. There were 79 false positives and no false negatives in this series. Chi-squared test was not significant (p=0.18) suggesting that intervention might not affect neurological outcome in this cohort. Conclusions. Triggering events are uncommon and the development of a persistent neurological deficit is rare with an incidence of 0.85% in this series of 2953 operations. In the majority of cases detection of a monitoring abnormality prompts a corrective reaction by the surgeon. Of those with an abnormal trace 76% were neurologically normal at follow up

Purpose. The purpose of this study was to determine the functional outcome, imaging and complications of conversion of hip fusion to uncemented total hip replacement. Method. The study group comprised eighteen patients who had undergone conversion of unilateral hip fusion to total hip replacement between 1996 and 2007. There were five men and 13 women. The diagnosis prior to fusion was traumatic injury in eight patients, developmental dysplasia in three patients, and septic arthritis in seven patients. Four of the patient who had septic arthritis in childhood had spontaneous hips fusion while the other underwent surgical arthrodesis. The mean age at the time of conversion was 53 years (range, 21–77) and the mean time between fusion and conversion to hip replacement was 33 years (range, 11–60). Mean follow up was five years (range 2–15 years). Data was collected by retrospective review of a prospective database. Uncemented acetabular components were used in all cases and uncemented femoral components were used in all but two patients. In three patients with abductor and soft tissue deficiency an intraoperative decision was made to use a constrained acetabular liner. Results. The Harris hip score increased from a mean of 49 pre operatively to 75 at a mean of five years p<0.001. There was poor correlation between patient age, duration of hip fusion and hip scores at six months, 12 months and at final follow-up at a mean of five years. Heterotopic ossification developed in seven of the 18 (39%) patients. It was grade one in four patients, grade two in one patient, grade three in one patient and grade four in one patient. Four complications occurred in four of the 18 (22%) patients. Two patients (11%) had neurological injury in the common peroneal nerve distribution. In one patient heterotopic ossification resulted in joint ankylosis. This patient underwent reoperation to excise the heterotopic ossification 16 months after the initial hip replacement procedure. One patient developed a deep venous thrombosis. There were no hip dislocations. One acetabular component was loose and had migrated at 15 years follow up. Conclusion. Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotopic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries. Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome. At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years

Patients with longstanding hip fusion are predisposed to symptomatic degenerative changes of the lumbar spine, ipsilateral knee and contralateral hip. In such patients, conversion of hip arthrodesis to hip replacement can provide relief of such symptoms. However, this is a technically demanding procedure associated with higher complication and failure rates than routine total hip replacement. The aim of this study was to determine the early functional results and complications in patients undergoing hip fusion conversion to total hip replacement, performed or supervised by a single surgeon, using a standardised approach and uncemented implants. We hypothesised that a satisfactory functional improvement can be achieved in following conversion of hip fusion to hip replacement. Eighteen hip fusions were converted to total hip replacements. A constrained acetabular liner was used in 3 hips. Mean follow up was 5 years (2 to 15 years). Two (11%) hips failed, requiring revision surgery and two patients (11%) had injury to the peroneal nerve. Heterotopic ossification developed in 7 (39%) hips, in one case resulting in joint ankylosis. No hips dislocated. Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotopic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function

To examine the effect of lateral spine curvature on somatosensory evoked potentials (SSEP) in patients with adolescent idiopathic scoliosis (AIS) compared to normal controls. We hypothesise that patients with AIS will show increased latency in their SSEPs when bending into their curve suggesting that their spinal cord is more sensitive to this increased lateral curvature. Patients were recruited from the paediatric scoliosis clinic in a single centre. Inclusion criteria were: diagnosis of AIS, age 10–18 years, major thoracic curve measuring greater than 10 degrees on Cobb measurement, and undergoing nonoperative management. Exclusion criteria were: any detectable neurologic deficit, and previous surgery on the brain or spine. SSEP recordings were obtained via stimulation of the posterior tibial nerve with surface electrode and measurement of the cortical response over the scalp. All recordings were performed three times: with the patient in neutral standing and maximum right and left side bending. SSEP recordings show that when AIS subjects bend into their curve, latency slows by an average of 0.5ms. However there was a bimodal distribution with most subjects showing minimal change (3ms). This subset was statistically different from both a control group, and the larger AIS group. There appears to be a subset of patients with AIS who have subclinical spinal cord dysfunction demonstrated by abnormal SSEPs. This may place these patients at slightly higher risk of neurologic injury at the time of surgery

Background. Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip is a technically demanding procedure. Restoration of the anatomical hip center frequently requires limb lengthening in excess of 4 cm and increases the risk of neurologic traction injury. However, it can be difficult to predict potential leg length change, especially in total hip arthroplasty for Crowe type IV developmental hip dysplasia. The purpose of the present study was to better define features that might aid in the preoperative prediction of leg length change in THAs with subtrochanteric femoral shortening osteotomy for Crowe type IV developmental dysplasia of the hip. Patients and Methods. Primary total hip arthroplasties with subtrochanteric femoral shortening osteotomy were performed in 70 hips for the treatment of Crowe type IV developmental hip dysplasia. The patients were subdivided into two groups with or without iliofemoral osteoarthritis. Leg length change after surgery was measured radiographically by subtracting the amount of resection of the femur from the amount of distraction of the greater trochanter. Preoperative passive hip motion was retrospectively reviewed from medical records and defined as either higher or lower motion groups. Results. The preoperative flexion of patients without iliofemoral osteoarthritis was significantly higher than for patients with iliofemoral osteoarthritis. All hips without iliofemoral OA had higher motion. The preoperative flexion in the higher motion group both with and without iliofemoral OA was significantly greater than in the lower group with iliofemoral OA (Figure 1). Leg length change in patients without iliofemoral osteoarthritis was significantly greater than with iliofemoral osteoarthritis (Figure 2), and the higher hip motion group had greater leg length change in THA than the lower motion group. No clinical evidence of postoperative neurologic injury was observed in patients with iliofemoral OA. Postoperative transient calf numbness in the distribution of the sciatic nerve was observed in 2 of 25 hips without iliofemoral OA (8.0%), however, no sensory and motor nerve deficit was observed. Discussion. The authors hypothesized that preoperative hip motion could affect soft tissue contractures, and our findings suggest that the soft tissues surrounding the hip joint with iliofemoral OA should be more contracted than the hip without OA. We also found leg length change in the higher motion group was greater than in the lower motion group. Previous studies reported limb lengthening in excess of 4 cm could increase the risk of nerve palsy. Transient calf numbness in the distribution of the sciatic nerve was observed in 2 hips without iliofemoral OA and their leg length change was not greater than 4 cm. Our findings suggest that hips without iliofemoral OA should be paid attention to protect the nerves from excessive elongation. The current study identifies several features that might help predict leg length change during the preoperative planning of total hip arthroplasty for Crowe type IV developmental hip dysplasia

The use of a tourniquet when performing total knee arthroplasty (TKA) is subject to different methodologies. Some surgeons see no need to use a tourniquet, others use the tourniquet only during cementation, some utilise the tourniquet from prior to incision to after cementation, while others maintain throughout and release after closure. At our center, use of the tourniquet is part of the TKA routine: position the patient, administer antibiotics, inflate the tourniquet, note pressure and time, complete preparation and draping, set time-out, and cut. We release the tourniquet after cementation of components, prior to assessment of patellofemoral tracking and closure. Advantages of using a tourniquet are enhanced TKA durability, less blood during cementation, and reduced intra-operative blood loss and need for transfusion. Adequately preparing the bone surfaces and cleaning away blood and fat are essential to good cement technique, providing better interdigitation and penetration and resulting in fewer radiolucencies and longer survivorship. Lateral retinacular release, performed to alleviate patellar maltracking, is not a benign procedure and is associated with increased patellar complications including loosening, fracture, and avascular necrosis. Several articles, including one from our center, have studied the effect of tourniquet deflation and patellar tracking, observing 31% to 86% reduction in maltracking and indication for lateral release when assessing after deflation. A prospective study of 28 patients undergoing same day bilateral TKA using a tourniquet inflated prior to incision and released after cementation on one side and either no tourniquet or tourniquet only during cementation of the contralateral side found slightly lowered quadriceps strength in the tourniquet group that persisted for up to 3 months. However, another recent prospective study of 120 patients assessing wound closure in 90 degrees flexion versus full extension, with the combination of an inflated versus deflated tourniquet, found that closure of the knee in flexion after tourniquet deflation significantly decreased post-operative pain and promoted early recovery of ROM. Safe use of the tourniquet is essential to avoid neurologic injury, and includes pneumatic, wider, contoured cuffs, moderate maximum applied pressure, and monitoring during release for emboli and metabolite return. Operative efficiency minimises overall operative and tourniquet time, thereby reducing risk of complications. Several meta-analysis reviews have compared TKA performed with versus without use of a tourniquet. All found using a tourniquet resulted in a significant decrease in operative time and intra-operative blood loss, but a trend for increase in deep vein thrombosis and wound complications. Other meta-analysis articles have studied time of tourniquet release comparing early versus late. These studies unanimously found late release to be associated with substantial increase in post-operative complications. Some studies found early release before wound closure to be associated with increased total blood loss and greater drop in hemoglobin while the other studies reported no differences in these measures. Our practice is to deflate the tourniquet prior to wound closure and to achieve hemostatis. The use of a tourniquet to perform TKA facilitates efficient operative technique, improves visualization of anatomical structures, facilitates the surgeon's focus on proper component positioning, and facilitates good cement technique

Background. Reverse Geometry shoulder replacement requires fixation of a base plate (called a metaglene) to the glenoid to which a convex glenosphere is attached. Most systems use screws to achieve this fixation. The suprascapular nerve passes close to the glenoid and is known to be at risk of injury when devices and sutures are inserted into the glenoid. We investigate the risk posed to the suprascapular nerve by placement of metaglene fixation screws. Materials and Methods. Ten cadaveric shoulder specimens were used. A metaglene was inserted and fixed using 4 screws. The suprascapular nerve was dissected and its branches identified. The screw tips and their proximity to the nerve and branches were identified and recorded. Results. The superior and posterior screws posed most risk to the suprascapular nerve. The nerve was engaged by the posterior screw on 4 occasions and was within 5 mm of the nerve or a branch of it in 5 others. The superior screw was extra osseous on 4 occasions, making contact with the nerve on 3 of those 4 specimens and being within 2 mm of it on the 4. th. . Conclusion. Metaglene fixation using screws poses a significant risk to the suprascapular nerve. Caution should be used when inserting the posterior and superior screws in particular. Short locking screws may allow adequate fixation while minimizing the risk of neurological injury

Background:. A shoulder dislocation is defined as chronic when it has been unreduced for more than one week. Chronic anterior shoulder dislocations are commonly encountered in Kwazulu-Natal for various reasons. Different surgical options exist to treat chronic anterior shoulder dislocations. However the outcome of surgically treated chronic shoulder dislocations has not been favourable in all studies. Methods:. We report on a combined case series of chronic anterior shoulder dislocations previously treated at Edendale Hospital (EDH), Pietermaritzburg and Inkosi Albert Luthuli Central Hospital (IALCH), Durban. Patients were identified retrospectively using departmental databases and their case files were retrieved. Patient demographics, duration of dislocation, mechanism of injury and reason for delayed treatment were recorded. When available, X-rays, CT scans and MRI scans were retrieved to identify associated bony and soft tissue pathology. Surgical outcome was assessed using range of movement (ROM), change in pain severity, patient satisfaction, as well as Oxford Shoulder Instability Score (OIS) and Rowe and Zarins score. Post-operative complications including redislocations were also identified. Results:. Twenty-six patients with chronic anterior shoulder dislocations were surgically treated. The average duration of dislocation was 9 months (range 2 weeks to 7 years). The most common reason for chronicity was delayed presentation to clinic or hospital (9 patients). A Hill Sachs lesion was present in 20 patients, and a pseudo-glenoid was often encountered in dislocations present for more than 4 weeks (14 of 23 patients). Three supraspinatus ruptures and 4 biceps tears were encountered while neurological injury was uncommon (2 patients). Surgical treatment included open reduction (1 patient), open reduction and Latarjet (15 patients), hemi-arthroplasty (2 patients), hemi-arthroplasty and Latarjet (3 patients) and reverse total shoulder arthroplasty (5 patients). Eighteen patients were available for follow-up. Most patients (16 out of 18 patients) were satisfied with their outcome. This was due to improvement in pain. Regardless of the type of surgery done, post-operative range of motion and surgical outcome scores were generally poor. Two patients were unsatisfied, due to redislocations. Conclusion:. Surgical treatment of chronic anterior shoulder dislocations resulted in satisfactory pain relief but marginal improvement in range of motion and overall shoulder function

The incidence of cervical spine injuries associated with facial fractures varies from study to study. The presence or absence of a cervical spine injury has important implications in trauma patients, influencing airway management techniques, choice of diagnostic imaging studies, surgical approach and timing for repair of concomitant facial fractures. There is general agreement that immediate management of cervical spine injuries is mandatory to prevent further neurological injury. Nevertheless, disagreement exists as to the actual incidence of cervical spinal trauma in conjunction with various facial fracture patterns. The purpose of this study was to review the incidence of cervical spine injury associated with various upper, middle and lower one-third facial fractures presenting to St. Michael's Hospital Regional Trauma Centre. A retrospective chart review was performed of patients presenting to the Trauma Service at St. Michael's Hospital from 1 January 1993 to 31 December 2003 inclusive. The data from this 10 year time span revealed a total of 124 patients with cervical spine injuries drawn from a cohort of 3,356 patients with craniomaxillofacial fractures. The overall incidence of cervical spine injury was 3.7%. Isolated upper 1/3 facial and skull fractures accounted for 1,711 of the patients and were associated with cervical spine injury in .53% of cases, while isolated middle 1/3 facial fractures were seen in 1,154 patients and were associated with a 1.13% rate of cervical injuries. The largest rate of association for cervical spine injury and isolated fractures was seen with lower 1/3 facial fractures at 1.51%. In contrast, combined facial fracture patterns involving two or more facial thirds accounted for the great majority of cervical spine injuries occurring at an incidence of 7.1%. The implications for trauma assessment, diagnosis and treatment of these injuries are reviewed

Aim. To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury. Method. We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made. All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit. Results. A total of 106 cases were identified, from which 36 cases were excluded, leaving 70 cases in the study. The mean age was 5 (range 1–11). 68 were extension-type injuries, of which 29 (41%) were type 2 and 39 (56%) type 3 according to the classification of Gartland. 2 were flexion-type. A mini-incision for placement of the medial K-wire was required in only 3 cases (4.3%), with percutaneous placement in all other cases. There was clinical evidence of partial ulnar nerve injury in 1 case (1.4%) which recovered spontaneously within 11 months. Conclusion. The results of this study demonstrate our protocol to be effective. Careful percutaneous placement of the medial wire can be performed in the majority of cases with little risk of significant or permanent injury to the ulnar nerve. Open placement of the medial wire is indicated in only a small proportion of cases. We suggest that the routine use of a medial mini-incision should be re-considered

Cahill et. al. published a large review of the use of BMP in spinal fusions. They reviewed the nationwide inpatient database, which represents approximately 25% of use U.S. Community Hospitals from the years 2002 to 2006. This included over 300,000 fusion type procedures. They noted increased complications with the use of anterior cervical procedures specifically increased complications with increased dysphasia and wound complications. Due to these concerns, the Food and Drug Administration released last year a public health notification about the potential life threatening complications related to the use of BMP in anterior cervical spine fusions. Joseph & Rampersaud noticed a 20% incidence of heterotopic ossification in patients undergoing this procedure versus only 8% for patients who had undergone fusions without BMP. Wong et. al. published a report on five cases of neurologic injury that relate to the use of BMP and the formation of heterotopic bone. Again, the suggestion of a barrier or closure defect was brought up and this may help minimise the risks; however, further work is noted. Multiple authors have noted a phenomenon of osteolysis occurring around graft fusion sites for the use of BMP. McCullen et. al. evaluated that 32 levels in 26 patients who had undergone a TLIF procedure. It is unclear the carcinogenic and tetraogenic effects of the use of BMP in the spine and also, the effects of repeat exposures on BMP has yet to be addressed. Finally, the long term cost and benefits of the use of BMP on the health care system has yet to be fully addressed. So in conclusion, BMP2 is effective in producing fusions especially in challenging environments, deformity, smoking and infection. However, the complications continue to be a concern especially with regards to interbody fusions as well as in the cervical spine