This study examined spinal fractures in patients
admitted to a Major Trauma Centre via two independent pathways,
a major trauma (MT) pathway and a standard unscheduled non-major
trauma (NMT) pathway. A total of 134 patients were admitted with
a spinal fracture over a period of two years; 50% of patients were
MT and the remainder NMT. MT patients were predominantly male, had
a mean age of 48.8 years (13 to 95), commonly underwent surgery
(62.7%), characteristically had fractures in the cervico-thoracic
and thoracic regions and 50% had fractures of more than one vertebrae,
which were radiologically unstable in 70%. By contrast, NMT patients
showed an equal gender distribution, were older (mean 58.1 years;
12 to 94), required fewer operations (56.7%), characteristically
had fractures in the lumbar region and had fewer multiple and unstable
fractures. This level of complexity was reflected in the length
of stay in hospital; MT patients receiving surgery were in hospital
for a mean of three to four days longer than NMT patients. These
results show that MT patients differ from their NMT counterparts
and have an increasing complexity of spinal injury. Cite this article:
In severe destructive spinal infections, with neurological deficit, progressive deformity or uncontrolled sepsis, the mainstay of treatment is surgical debridement with anterior and posterior stabilisation. We retrospectively reviewed 14 patients (11 Male 3 female) with a mean age of 63 (range 38 to 85) who underwent anterior only surgery consisting of an expandable vertebral body cage and a ventrolateral locking plate (Synthes). Organisms included Tuberculosis (7), Staphylococcus (5), E-Coli (1) and Pseudomonas (1). Radiological and functional outcomes were assessed upto 18 months post surgery. Cobb angles were used to measure angular deformity. Good early results in terms of safety, resolution of pain, control of deformity and improvement of neurological deficits was observed. Average blood loss was 633mls (range 300mls to 1500mls) with a mean deformity correction of 23 degrees. Post operative radiological assessment showed the cages to be relatively stable in the under 80 yrs groups (mean loss of correction 15 %). In elderly patients (>
80 yrs) there was significant subsidence leading to a loss of correction (mean 52%) which required stabilisation using vertebral body cement augmentation. In one case, there was implant displacement requiring revision and additional posterior stabilisation. 11 patients showed significant improvement in neurology and 3 patients remained neurologically normal ie Frankel E. We propose assessing severe spinal infections using the spinal trilogy of neurological deficit, deformity and sepsis. Anterior stabilisation using an expandable cage and locking plate alone or with additional vertebral body cement augmentation in elderly patients provides a satisfactory solution for severe destructive spinal infections. It preserves the posterior column and reduces the need for further posterior surgery.
Injuries to the spinal cord are rarely isolated problems. Multiple trauma patients with spinal injuries can face significant long-term disability. In this retrospective, descriptive study we investigated the relationship between the level of spinal trauma and the injuries associated with this. We aimed to define the populations at risk and highlight trends identified.
CaSO4 and CaCO3 3% alginate hydrogels were injected into the NP cavity of a bovine tail. After 90 minutes the tail was dissected to reveal the gel. NP cells released from pooled bovine NP tissue were dispersed into the CaSO4 and CaCO3 alginate gels (10x106 cells.mL-1) with and without hylan (Synvisc®) and cultured for 21 days.
Injectable alginate suspensions formed solid viscoelastic gels, filling the exact shape of the NP cavity. NP DNA and ECM synthesis was significantly greater in the CaCO3 alginate gel than in the CaSO4 alginate gel (p<
0.05). Synvisc® significantly increased sulphated GAG (p<
0.01) and collagen (p<
0.05) production. These effects were supported histologically and immunohistologically where cells in the CaCO3 and Synvisc® gels stained more intensely for proteoglycan and collagen type II.
Scoliosis and hip subluxation/dislocation are common and often coexistent problems encountered in patients with cerebral palsy (CP). The underlying mechanism may be related to muscle imbalance. Surgical correction may become necessary in severe symptomatic cases. The effect of surgical correction of one deformity on the other is not well understood. We retrospectively reviewed a series of 17 patients with total body cerebral palsy with diagnoses of both scoliosis and hip subluxation who had undergone either surgical correction of their scoliosis (9 patients) or a hip reconstruction to correct hip deformity (8 patients). In all patients, the degree of progression of both deformities was measured, radiographically, using the Cobb angle for the spine and the percentage migration index for hip centre of rotation at intervals before and at least 18 months post surgery. All patients who underwent scoliosis correction had a progressive increase in the percentage of hip migration at a rate greater than that prior to scoliosis surgery. Similarly, patients who underwent a hip reconstruction procedure demonstrated a more rapid increase in their spine Cobb angles post surgery. There may be a relationship between hip subluxation/dislocation and scoliosis in CP patients. Surgery for either scoliosis or hip dysplasia may in the presence of both conditions lead to a significant and rapid worsening of the other. The possible negative implications on the overall functional outcome of the surgical procedure warrants careful consideration to both hip and the spine before and after surgical correction of either deformity. In selected cases there may be an indication for one procedure to follow soon after the other.
Bovine and human articular chondrocytes were seeded in 2% alginate constructs and cultured for up to 19 days in a rotating-wall-vessel (RWV) and under static conditions. Culture within the RWV enhanced DNA levels for bovine chondrocyte-seeded constructs when compared with static conditions but did not produce enhancement for human cells. There was a significant enhancement of glycosaminoglycans and hydroxyproline synthesis for both bovine and human chondrocytes. In all cases, histological analysis revealed enhanced Safranin-O staining in the peripheral regions of the constructs compared with the central region. There was an overall increase in staining intensity after culture within the RWV compared with static conditions. Type-II collagen was produced by both bovine and human chondrocytes in the peripheral and central regions of the constructs and the staining intensity was enhanced by culture within the RWV. A capsule of flattened cells containing type-I collagen developed around the constructs maintained under static conditions when seeded with either bovine or human chondrocytes, but not when cultured within the RWV bioreactor.
The purpose of this study was to examine the effects of hyaluronic acid supplementation on chondrocyte metabolism Bovine articular chondrocytes were isolated and seeded into alginate constructs. These were cultured in medium containing hyaluronic acid at varying concentrations. Samples were assayed for biochemical and histological changes. There was a dose-dependent response to the exposure of hyaluronic acid to bovine articular chondrocytes
Autologous chondrocyte implantation (ACI) and mosaicplasty are both claimed to be successful for the repair of defects of the articular cartilage of the knee but there has been no comparative study of the two methods. A total of 100 patients with a mean age of 31.3 years (16 to 49) and with a symptomatic lesion of the articular cartilage in the knee which was suitable for cartilage repair was randomised to undergo either ACI or mosaicplasty; 58 patients had ACI and 42 mosaicplasty. Most lesions were post-traumatic and the mean size of the defect was 4.66 cm2. The mean duration of symptoms was 7.2 years and the mean number of previous operations, excluding arthroscopy, was 1.5. The mean follow-up was 19 months (12 to 26). Functional assessment using the modified Cincinatti and Stanmore scores and objective clinical assessment showed that 88% had excellent or good results after ACI compared with 69% after mosaicplasty. Arthroscopy at one year demonstrated excellent or good repairs in 82% after ACI and in 34% after mosaicplasty. All five patellar mosaicplasties failed. Our prospective, randomised, clinical trial has shown significant superiority of ACI over mosaicplasty for the repair of articular defects in the knee. The results for ACI are comparable with those in other studies, but those for mosaicplasty suggest that its continued use is of dubious value.
Mosaicplasty 100 consecutive patients aged 15–45 with a symptomatic articular cartilage lesion in the knee suitable for cartilage repair were randomised at arthroscopic assessment to undergo either mosaicplasty or ACI. 42 patients underwent mosaicplasty, 58 had ACI. Mean age at time of surgery was 31 years and the average defect size 4. 66 cm2. 46% of the defects were post-traumatic, 19% had osteochondritis dissecans, 14% had chondromalacia patella and 16% had lesions of unknown aetiology. 53% had a medial femoral condyle lesion, 25% patella, 18% lateral femoral condyle, 3% trochlea and there was one defect of the lateral tibial plateau. The mean duration of symptoms was 7. 2 years and the average number of previous operations (excluding arthroscopies) was 1. 5. Only 6 patients had no prior surgical interventions to the affected knee. The mean follow-up was 1. 7 years. Patients were evaluated using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical assessment. Arthroscopy and biopsy was performed at one year and repair assessed with the International Cartilage Repair Society grading system. Clinical results at one year showed 70% of mosaic-plasty patients and 87% of ACI patients had a good or excellent result. Arthroscopy at one year demonstrated more complete healing in ACI patients. Eleven (26%) of the mosaicplasty group subsequently failed clinically and arthroscopically, with peak failure at 2 years. At one year follow-up, both techniques of articular cartilage repair can be useful in selected patients. ACI is preferred for lesions of the patella. Long-term follow-up is needed to assess the durability of articular cartilage repair using these methods, in particular mosaicplasty which showed signs of progressive failure over 2 years.
Autologous Chondrocyte Implantation’ (ACI) is a cartilage repair technique that involves implantation of cultured chondrocytes beneath a membrane of autologous periosteum. In this study a porcine biodegradable membrane was also used to assess its effectiveness. The aim is to restore articular cartilage to symptomatic defects, rather than initiating a fibrocartilagenous repair. We undertook a prospective study of 125 consecutive patients who underwent ACI. Average age at the time of surgery was 30. 9 years (range 14 – 49), 55% of patients were male. The average size of the defect was 4. 35 cm². 44% of defects were attributable to known traumatic incidents, 2 1 % had osteochondritis dessicans, 18% chondromalacia patella, 12% had defects of unknown aetiology and 5% other. The average duration of symptoms prior to this surgery was 7. 16 years. The mean number of previous operations (excluding arthroscopies) was 1. 6. Only 9 patients had no previous major surgery to the affected knee. 44% had defects of the medial femoral condyle, 31% patella, 20% lateral femoral condyle and 5% had a trochlea lesion. 26% of the defects were covered with periosteum and 74% with a porcine collagen membrane (chondrogide) Minimum follow-up was six months, 70 patients had minimum follow-up of one year. Mean follow-up 18 months. Patients were assessed using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical evaluation. Arthroscopy and biopsy was performed at one year and the repair assessed using the International Cartilage Research Society grading system. At one year follow-up overall 41 % patients had an excellent result, 48% good, 8% fair and 3% poor. For defects of the medial femoral condyle, 88% had a good or excellent result, 85% for the lateral femoral condyle and 80% for the patella. 61 patients were arthroscopically assessed at one year. 50/61 (82%) demonstrated ICRS grade 1 or 2 repair. Healing of the defect occurred with either a periosteum or chondrogide defect cover. Results at one year suggest that ACI is a successful articular cartilage repair technique in selected patients. Long-term follow-up is required to assess the durability of the repair.
The use of intra-articular hyaluronic acid injections for the treatment of early osteoarthritis is in widespread clinical use. Hyaluronate (HA) is a major component of connective tissue Bovine articular chondrocytes were isolated by sequential digestion with pronase and collagenase and seeded in 2% alginate at 1x107 cells/ml. The constructs were cultured for up to 14 days in standard culture medium (DMEM + 20% Fetal calf serum) containing varying concentrations of HA (Sigma), including doses equivalent to those found in vivo. The medium was replaced every 3 days and representative constructs were removed from culture, digested and assayed for DNA, glycosaminoglycans and Collagen. Further constructs were fixed in 4% paraformaldehyde for standard histology and immunolocalisation of collagen types I, II and chondroitin-6-sulphate. Chondrocytes cultured in the HA system proliferated (increase in DNA) at a faster rate than the controls. There was a 2.2 fold increase in cell concentration at 14 days compared to a 1.2 fold increase in the controls. Total GAG levels at each time point were significantly greater for cells cultured in HA than in controls. Histologically, constructs were characterised by extensive cell cluster formation and intense Safranin-O staining. The newly synthesised matrix also stained positive for type II collagen. By contrast, control constructs exhibited minimal cluster formation, Safranin-O and type II collagen staining. Cells maintained with HA exhibited a significantly greater rate of proliferation and matrix production. The presence of matrix rich in type II collagen indicates maintenance of chondrocytic phenotype. By contrast, cells cultured without HA did not show these features. These results support the use of intra-articular injections for the treatment of osteoarthritis. The benefits of HA injections may be due to cellular mechanisms as well as mechanical.
The use of intra-articular corticosteroid injections for their anti-inflammatory effects is widespread amongst clinicians. Despite their use in both rheumatoid arthritis and osteoarthritis, the effect of these agents on articular chondrocytes is not fully established. Previous reports suggest a detrimental effect on cartilage explants resulting from inhibition of matrix synthesis Bovine articular chondrocytes were isolated by sequential digestion with pronase and collagenase and seeded in 2% alginate at 1x107 cells/ml. The constructs were cultured for up to 15 days in standard culture medium (DMEM + 20% Fetal calf serum) containing varying concentrations of MP, including doses equivalent to those found in vivo. The medium was replaced every 3 days and representative constructs were removed from culture, digested and assayed for DNA and glycosaminoglycans. Further constructs were fixed in 4% paraformaldehyde for standard histology and immunolocalisation of collagen types I, II and chondroitin-6-sulphate. Chondrocytes cultured in MP containing medium showed a significant abnormality in cell morphology compared to controls at the day 15 time point. Histologically there was evidence of cell necrosis, reduced amounts of extracellular matrix and loss of collagen type II staining. The effects were dose dependant, with significant damage occurring even at clinical doses. Biochemical analysis revealed a reduction in DNA content and an inhibition of glycosaminoglycan and collagen type II synthesis. In contrast, in the controls, there was cell proliferation with a cell doubling time of 14 days, collagen type II containing extracellular matrix synthesis occurred and the chondrocytes maintained their phenotype throughout the culture period. Methylprednisolone has a significant detrimental effect on cultured articular chondrocytes in vitro. There was significant cell necrosis associated with inhibition of extracellular matrix synthesis. Based on these results, intra-articular corticosteroid injections should be used with extreme caution.
Nicotine is a constituent of tobacco smoke and is present in the body fluids of smokers Bovine nucleus pulposus (NP) intervertebral disc cells were isolated by sequential digestion of caudal spinal disc nuclei with pronase and collagenase and seeded in 2% alginate at 5x106 cells/ml. The constructs were cultured for 21 days in standard culture medium (DMEM + 20% Fetal calf serum) containing free base nicotine (Sigma) at concentrations ranging from 25nM and 300nM, which reflected the normal physiological concentrations found in the serum of smokers. The medium was replaced every 3 days and representative constructs were removed from culture, digested and assayed for DNA, glycosaminoglycan (GAG) and hydroxyproline content at time points 3, 7, 14 and 21 days. Further constructs were processed for standard histology and immunolocalisation of collagen types I, II and chondroitin-6-sulphate. The results were analysed statistically using an ANOVA test followed by a non-parametric Dunnit’s test. NP cells demonstrated a dose dependent response. At 25nM dose of nicotine there was a significant increase (p<
0.05) in DNA content, GAG and collagen synthesis in the constructs. At 100nM, 200nM and 300nM doses, there was a significant dose dependent decrease (p<
0.05) in all of these parameters compared to controls cultured under nicotine free conditions. In addition, adverse morphological changes were observed on histology, which included reduced cell proliferation, disrupted cell architecture, disintegration of cells and extracellular matrix. Immunohistochemistry showed the production of type I collagen rather than type II collagen as in the controls. Nicotine has an overall detrimental effect on cultured nucleus pulposus disc cells in vitro. There was significant inhibition of cell proliferation and extracellular matrix synthesis. Nicotine in tobacco smoke may therefore play a role in the aetiology of disc degeneration that leads to back pain in smokers.
Deep infection is a devastating complication of total joint arthroplasty. In a significant proportion of cases it remains a diagnostic challenge. Haematological tests are not specific, particularly in chronic cases, and radiological investigations such as bone scan and radiographs are of only limited value. The most common infective organisms are staphylococcus and some streptococcus species. Acidity is a well established occurrence in infective processes and is caused by the direct production of acid by the organism or by enzymatic degradation of tissues Nineteen consecutive patients undergoing either revision total knee replacement (TKR) or arthroscopic synovial biopsy were included in the study. All had had their primary joint replacement within the previous 3 years. All had a painful total knee replacement and some had evidence of loosening of the prosthesis on radiological investigations. The following investigations were performed on each patient, White cell count (WCC), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), interface synovial biopsy for histology and microbiology and a synovial fluid aspiration from the affected joint prior to application of a tourniquet. A blood gas analyser was used to measure pH, pCO2, pO2, Lactate and Glucose in all synovial fluid specimens. Seven patients were diagnosed as having an infected TKR on clinical and laboratory investigations. The mean synovial fluid biochemistry results were pH = 7.09, pO2= 5.08kPa, pCO2=10.40kPa, Lactate = 5.33 mmol/l, Glucose = 2.30 mmol/l. In the non-infected group the results were pH = 7.23, pO2 = 7.72kPa, pCO2 = 8.41kPa, Lactate = 4.03 mmol/l, Glucose = 3.42 mmol/l. The differences in pH, pCO2/pO2 ratio, and glucose levels were statistically significant (t-Test p <
0.05) between the two groups. Lactate levels were not significantly different. There was no correlation between high WCC’s and synovial fluid biochemistry or laboratory results for infected cases. Using laboratory results as a gold standard and a synovial fluid pH of less than 7.20, the sensitivity was 85% and specificity 77% for diagnosing an infection. Using a combination of the synovial fluid biochemistry results these values were greater. Synovial fluid biochemistry is significantly altered in infected total knee replacements. pH levels below 7.2, pCO2/pO2 ratio above 2.5 and Glucose levels below 2.5 mmol/l are strong indicators of an infected TKR. Synovial pH assessment may prove to be a quick, cheap and effective method of diagnosing an infected TKR and may also apply to other joints. Further studies using non-problematic TKR’s as controls are required.