Aims

COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.

The best method of stabilisation of the ankle syndesmosis remains a topic of debate; a relatively recent development is the ankle tightrope – a tensionable fibrewire suture device. Despite over 30,000 successful surgeries reported, evidence supporting its use when compared with screw fixation remains extremely limited. We retrospectively compared two consecutive groups of patients whose syndesmotic injuries were stabilised either with a tightrope or screws. The aim of our study was to compare complications arising after insertion of these devices.

All patients undergoing tightrope stabilisation of the syndesmosis between January 2006 and February 2009 were included as the treatment group. The control group was made up of a similar number of consecutive patients who underwent screw stabilisation between November 2010 and January 2011. Data was obtained through theatre records, case notes and from the local PACS X-ray system. Eighteen eligible cases were identified in the tightrope group compared with sixteen eligible cases treated with screws. Both groups had similar baseline demographics with respect to distribution of age and gender.

Twenty two percent (n = 4) of tightropes were removed secondary to wound breakdown or knot prominence. Other complications included persistent syndesmotic widening (n = 2, 11%), knot prominence without removal (n = 1, 5.5%) and synostosis (n = 1, 5.5%). In comparison, only 1 patient (6.3%) experienced a complication (pain and decreased RoM) in the control group. A total of 14 screws were removed. Thirteen screws were removed uneventfully. One patient was discharged to another hospital for a planned removal of screw, but was lost to follow-up. The remaining two patients elected not to have their screws removed.

Adverse weather conditions during the winter months put increased pressure on orthopaedic trauma departments across the country. The increased incidence of injuries has resulted in a strain on resources at a local level and a situation can arise whereby cases need to be prioritised according to clinical need and fitness of the patient. Ankle fractures, frequently caused by slipping in adverse weather conditions, tend to be an injury where a high proportion of patients are young and active and can therefore cope better physiologically waiting several days for their operation. It is well documented that there is a window of opportunity when operating on ankle fractures, during which the swelling will permit fixation. We aimed to establish whether a link exists between delay to surgery for ankle fractures, the length of post-op hospital stay and the rate of complications.

We included all patients who underwent surgical fixation of an ankle fracture over a three month period between 1.1.10 and 31.01.11. Data was obtained through theatre records, discharge and clinic letters and from the local PACS X-ray system. Basic patient data, admission, theatre and discharge dates were collected along with details regarding mechanism of injury, type of fracture, fixation and documented complications. Patients were subdivided into two groups: those who underwent surgery within 48 hours of injury and those who waited longer than 48 hours. Many of the patients in the delayed surgery group remained inpatient until after their surgery whilst those more capable of mobilising with crutches were allowed home to elevate.

64 patients underwent fixation of an acute ankle fracture during the three month study period. 28 patients (44%) had a documented fall on ice or snow. 29 patients were operated upon within 48 hours. 35 patients surgery was delayed by a mean of 9 days (3-28). The mean length of post op hospital stay for the early surgery group was 3.00 days. In the delayed surgery group the mean length of stay was 4.28 days (p=0147). There were 4 complications in the early group (14%) compared with 7 in the delayed group (20%).

Delaying surgery for ankle fractures more than 48 hours suggests a trend towards an increased length of post-operative hospital stay and a slightly increased rate of complications but not to significant levels. A larger sample size may have provided a significant difference. Given this trend, we recommend early fixation of ankle fractures wherever possible providing soft tissue swelling allows tension free wound closure.

Stabilisation of the ankle syndesmosis remains a topic of debate regarding the best method of fixation; the most recent development is the ankle tightrope - a tensionable fibrewire suture. Despite over thirty thousand successful surgeries(1) reported, evidence supporting its use remains extremely limited. The aim of our study was to identify complications arising after insertion of this device for syndesmotic instability.

All patients undergoing tightrope stabilisation of the ankle syndesmosis in Aberdeen Royal Infirmary between January 2006 and February 2009 inclusive were incorporated in our study. Patient identifier data was collated at the time of operation by a research nurse with case records collected and analysed by the authors at the end of the study period. Nineteen cases were identified with one subsequently excluded due to death. Of the remaining patients thirteen were male and five female. Age ranged from sixteen to fifty-eight years. Five patients required tightrope fixation alone, the remainder necessitating bony fixation according to AO recommendations. Time in cast immobilisation ranged from five to eight weeks, time to full weight bearing six to ten weeks and time to discharge eight weeks to fifteen months.

In this series, 22% of tightropes were removed secondary to wound breakdown or knot prominence. Other complications included syndesmotic widening(11%), knot prominence without removal(5.5%) and synostosis(5.5%).

Incontrast to previously published literature (2,3,4,5,6) this, the second largest series to date, demonstrates a high complication rate(44%) - perhaps the tightrope is not as advantageous as initially thought.

Purpose of the Study: To ascertain the role of Dynesys system (Zimmer Spine, Minneapolis) in the surgical management of chronic low back pain

Methods: 55 patients with persistent low back pain despite conservative measures were treated with Dynesys over a period of two and a half years. Participants either underwent Dynesys procedure alone or in combination with fusion or decompression surgery. Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and SF-36 questionnaires were completed pre-operatively and at one and two years post-operatively. Pre-operative testing using the Distress and Risk Assessment Method (DRAM) identified psychological distress prior to surgery. Patient Oriented Outcome questionnaires were circulated retrospectively following surgery to obtain data regarding patient’s perceptions and expectations of their outcome.

Results: Overall, the mean ODI reduced by 10.23% after one year and 16.15% after two years following surgery. VAS improved by 12mm one year and by 17mm two years after operation. Patients with psychological distress pre-operatively showed less improvement in their ODI and VAS at two-year follow up. The results of fusion were similar to Dynesys alone, and patients who also had decompression had best results. 72.2% patients reported an improvement following their surgery and the same percentage would have the operation again in retrospect.

Conclusion: This is the first study exploring clinical outcomes following surgery using Dynesys dynamic stabilization system in patients with disabling low back pain. Previous studies have reported good outcome in the treatment of spinal stenosis. Over 70% patients in our study reported improvement following the procedure but more evidence is needed to determine if it is a viable alternative to spinal fusion.

Aim: To assess the kinematic changes that occur within the lumbar spine 2 years following insertion of the Dynesys Spinal stabilisation implant.

Materials and Methods: Twenty patients who were treated with Dynesys surgical stabilisation for dominant lower back pain underwent positional MRI scanning before and two years following surgery.

The patients were divided into two groups, A and B. The first, Group A, in which only Dynesys was used and the second, Group B, in which Dynesys was used adjacent to one or more fused segments.

Results: The results of the pMRI measurements showed that the range of movement (ROM) of the L1/S1 angle in Group A reduced by 11.8o{pre-op=37.9o, postop=26.1o(p=0.085)} while in Group-B reduced by 12.3o {pre-op=37.8o, postop=25.5o(p=0.017)}.

The ROM of the end plate angle at the instrumented segments in Group A reduced from 5.72^o to 1.44^o{difference 4.28^o(p=0.005)} and in Group B reduced from 6.00^o to 2.17^o,{difference 3.83^o(p=0.001)}.

The ROM of the end plate angle at the level above instrumentation in Group A reduced from 8.2^o to 5.1^o {reduction 3.1^o(p=0.085)}, while in group-B increased from 7.3^o to 7.5^o, a difference of 0.2^o (p=0.877).

The mean anterior disc height in Group A reduced by 2.1mm (p< 0.001) from 9.59mm to 7.44mm. The posterior disc height also reduced from 6.56mm to 6.26mm, a difference of 0.3mm, (p=0.434). In Group B, the anterior disc height reduced by 1.98mm (pre-op=9.04mm, post-op= 7.06mm, p=0.001) and the posterior height by 0.35mm (pre-op 6.14mm to post op 5.79mm, p=0.443)

Discussion: This study shows that the Dynesys stabilisation system allows some movement at the operated segment two years following surgery. The study also confirms that the adjacent segment hypermobility often seen following spinal fusion surgery is eliminated.

Background: It has been demonstrated that a relationship exists between pro-inflammatory cytokine levels and psychological distress. Psychological distress commonly co-exists with back pain and may be detrimental to rehabilitation in such patients undergoing surgery. We aim to establish whether a link exists between psychological distress and increased levels of Interleukin- 6 (IL-6) and it’s soluble receptor (sIL-6r) in patients undergoing surgery for low back pain.

Methods: All individuals selected for spinal fusion or stabilisation surgery, in whom low back pain was the predominant feature, were eligible for inclusion. Participants completed both the Distress and Risk Assessment Method (DRAM) and Hospital Anxiety and Depression Score (HADS) questionnaires pre-operatively. Blood samples for serum IL-6, sIL-6r and high sensitivity C-Reactive Protein (CRP) levels were extracted at recruitment and results were compared with questionnaire findings.

Results: 63 patients were recruited of whom 90.5% had some degree of measurable psychological distress. Patients were divided into two groups based upon the degree of their distress.

Mean IL-6 levels were higher in groups of patients with more distress measured by the DRAM and HADS depression component but were lower in patients with more anxiety. IL-6 receptor levels were higher in patients with raised DRAM and HADS anxiety scores.

No significant correlation between questionnaire responses and cytokine levels was found. A correlation exists between IL-6 and CRP levels even at normal levels of CRP.

Conclusion: There does not appear to be a significant relationship between IL-6 and sIL-6r levels and psychological distress in back pain patients.

Aim: To assess the kinematic changes that occur within the lumbar spine 2 years following insertion of the Dynesys Spinal stabilisation implant.

Materials and Methods: Twenty patients who were treated with Dynesys surgical stabilisation for dominant lower back pain underwent positional MRI scanning before and two years following surgery.

The patients were divided into two groups, A and B. The first, Group A, in which only Dynesys was used and the second, Group B, in which Dynesys was used adjacent to one or more fused segments.

Results: The results of the pMRI measurements showed that the range of movement (ROM) of the L1/S1 angle in Group A reduced by 11.8o{pre-op=37.9o, postop=26.1o(p=0.085)} while in Group-B reduced by 12.3o {pre-op=37.8o, postop=25.5o(p=0.017)}.

The ROM of the end plate angle at the instrumented segments in Group A reduced from 5.72^o to 1.44^o{difference 4.28^o(p=0.005)} and in Group B reduced from 6.00^o to 2.17^o,{difference 3.83^o(p=0.001)}.

The ROM of the end plate angle at the level above instrumentation in Group A reduced from 8.2^o to 5.1^o {reduction 3.1^o(p=0.085)}, while in group-B increased from 7.3^o to 7.5^o, a difference of 0.2^o (p=0.877).

The mean anterior disc height in Group A reduced by 2.1mm (p< 0.001) from 9.59mm to 7.44mm. The posterior disc height also reduced from 6.56mm to 6.26mm, a difference of 0.3mm, (p=0.434). In Group B, the anterior disc height reduced by 1.98mm (pre-op=9.04mm, post-op= 7.06mm, p=0.001) and the posterior height by 0.35mm (pre-op 6.14mm to post op 5.79mm, p=0.443)

Discussion: This study shows that the Dynesys stabilisation system allows some movement at the operated segment two years following surgery. The study also confirms that the adjacent segment hypermobility often seen following spinal fusion surgery is eliminated.