Aims

We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant.

Vertebroplasty is a minimal invasive surgical procedure for treatment of vertebral compressive fractures, whereby cement is injected percutaneously into a vertebral body. Cement viscosity is believed to influence injectability, cement wash-out and leakage. Altering the liquid to powder ratio can affect the viscosity, level of cohesion and extent cement fill within the vertebral body and the ultimately strength and stiffness of the cement-vertebra composite. The association of these combined factors remains unclear. The aim of this study was to determine the relationship between cement viscosity and the potential augmentation of strength and stiffness in a model simulating in-vitro prophylactic vertebroplasty of osteoporotic vertebral bodies.

Samples of synthetic bone (Sawbone) representing osteoporotic bone were manually injected with 1mL of calcium phosphate cement using a 11G cannulated needle. Calcium phosphate cement was produced by mixing alpha-tricalcium phosphate, calcium carbonate and hydroxyapatite with an aqueous solution of 5 wt% disodium hydrogen phosphate. Three liquid to powder ratio (LPR) representing different viscosity levels were used; i.e. 0.5mL/g (low viscosity), 0.45mL/g (medium viscosity) and 0.35mL/g (high viscosity). Cement filled samples were then placed in an oven (37oC) for 20 min and then immersed in Ringer's solution (37oC) for 3 days. Samples of synthetic bone without cement injection were used as controls.

Potential for leakage and wash-out was determined using gravimetric analysis. Extent of cement fill was determined using computer tomography (CT).

Samples were tested under axial compression at a rate of 1 mm/min and the strength and stiffness determined. Statistical significance against controls was determined using a one-way analysis of variance (p<0.05).

Low viscosity cement showed more cement leakage (p=0.512) and increased cement wash-out after 3 days in Ringer's solution (p=0.476). Qualitative assessment of cement fill within the vertebral body using CT imaging supported the wash-out results. The strength (p<0.05-0.01) and stiffness (p<0.01) of samples significantly increased by cement injection in comparison to control, the extent of this increase was greater with increasing cement viscosity.

Linear correlation analysis showed a definite association between the mechanical properties and viscosity of injected cement and was dependent on the amount of cement retained within the synthetic bone post-setting.

Introduction: Open tibial fractures presenting to the 3 Northern Ireland trauma hospitals with over 36 months (2003–2006) were considered regarding the BAO/BAPS guidelines, which recommended joint orthopaedic/plastic management with definitive tissue coverage within 5 days.

Methods: Details of Gustillo-Anderson classification, method and timing of surgery, and complications were identified retrospectively from a regional database and patient notes.

Results: Of 111 patients with 115 fractures, 28 were Gustillo-Anderson grade 1, 21 were grade 2, 28 were grade 3a, 35 were grade 3b, and 3 were grade 3c. Grade 1 fractures were chiefly treated by IM nailing or cast. Most grade 2 and 3 injuries received IM nailing or external frames and primary closure within 5 days. Most grade 3b fractures were treated with external frames and tissue coverage after day 5, 46% having documented plastics referrals, and 20% receiving flaps All grade 3c fractures required amputation. Complications occurred in 42% of patients, mainly soft tissue infections (19%) and delayed union (10%) or non-union (12%). Only 42% of grade 3 injuries had documented referrals to plastics. Only 26% of patients were treated initially at the regional plastics unit (with orthpaedics on-site) but only 11% of patients required transfer for plastics input (chiefly for flaps).

Conclusions: Complications were common despite most patients meeting the guidelines regarding time to definitive surgery. With increasing Gustillo-Anderson grade the number of procedures increased and method of management changed for orthopaedic and plastics procedures. Many patients with Gustillo 3 injuries had no recorded referral to plastics.

Purpose: Frozen shoulder or adhesive capsulitis is a painful and progressive loss of both active and passive range of motion without any known intrinsic cause. The natural history and histological stages have been described to help explain the pathogenesis. There have been conflicting reports evaluating the effects of intra-articular corticosteroid injections in the treatment to improve the natural history. We report our non-operative experience with the use of glenohumeral corticosteroid injections in patients diagnosed with adhesive capsulitis of the shoulder.

Method: 129 consecutive patients with a diagnosis of frozen shoulder were followed from 1997–2002. A detailed physical examination in both the erect and supine position documented range of motion. A VAS was used to document pain. All patients underwent a glenohumeral injection with 40 mg DepoMedrol and 9 ml 1% plain lidocaine at the time of initial presentation and at monthly follow-up with the following criteria: 1. No improvement in pain of 2 VAS levels 2. No improvement in erect abduction or forward flexion of 20° or 3. No improvement in erect or supine IR or ER of 10°. A maximum of 3 injections was used. Patients were followed until complete resolution of symptoms or if surgical intervention was needed. Successful treatment was considered if there was complete resolution of pain, full function, and patient satisfaction. Initial and follow-up ASES and HSS L’Insalata scores were recorded.

Results: Thirty-one patients were lost to follow-up leaving 98 patients to be evaluated. There were 69 females with average age of 40.7 years and 29 males with average age of 53.2 years. Overall success was 71.4% (71% females, 72.4% males). Successful treatment occurred at 4.15 months in females and 4.5 months in males. 85.7% of both female and male patients recovered with 1 or 2 injections. Poor prognostic indicators were Diabetes Mellitus, absent physiotherapy, workman’s compensation, post-operative stiffness cases, dominant arm, and stage 3 cases. Average ASES scores were 41.8 at presentation and 92.7 at resolution and HSS L’Insalata scores were 52.5 at presentation and 91.0 at resolution. There were no complications with our technique.

Conclusion: Glenohumeral corticosteroid injections for the patient with adhesive capsulitis are considered to be safe and an effective method of treatment for resolution of pain and improvement in functional range of motion. We recommend glenohumeral corticosteroid injections at the time of presentation and with close follow-up for frozen shoulder as part of the initial treatment regime. We have suggested an algorithm for the timing of intra-articular injections based on pain and objective range of motion.

This study was performed to evaluate the clinical and radiographic outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF) with rhBMP-2 and polyetheretherketone (PEEK) cages with our standard treatment of allograft spacers and demineralised bone matrix.

Forty-six patients who underwent primary ACDF were included in the study. Twenty two patients with PEEK spacers and rhBMP-2 were compared to twenty four patients with allograft spacers and demineralised bone matrix all supplemented with an anterior locking plate. All patients were examined preoperatively and at two, six, twelve and twenty-four weeks and one and two years following surgery. Their cervical Oswestry scores,VAS for neck and arm pain and a pain diagram were recorded at every visit. A radiographic examination was also performed and patients were questioned for dysphagia, hoarseness of voice and any other difficulties. Radiographs were evaluated for prevertebral swelling, bone formation, subsidence and likelihood of fusion. CT scans were performed in any individual at twelve months if there was a concern of non union.

There was no significant difference in pain scores between rhBMP-2 and allograft spacer patients. There was improvement in both groups from their preoperative scores. Incidence of hoarseness of voice was also similar in both groups. There were statistically significant more patients with dysphagia in the rhBMP-2 group at two and six weeks following surgery. All patients in the rhBMP-2 group achieved a radiological diagnosis of probable fusion at their latest follow up (thirty-eight levels). In the allograft group 23/24 patients achieved a diagnosis of probable fusion (39/40 levels). End plate resorption was observed radiologically in 100% of the levels where rhBMP-2 was used. Prevertebral swelling on lateral radiographs was significantly greater in patients with rhBMP-2 causing dysphagia. The cost of implants was three times higher in patients with PEEK cage and rhBMP-2.

The use of rhBMP-2 leads to consistent fusion in the cervical spine. Significantly higher rates of prevertebral swelling, dysphagia and s higher cost are major drawbacks. End plate resorption was an unusual radiographic finding with the use of rhBMP-2.

A 20-year-old man, known to have systemic lupus erythematosus, presented with a year-long history of thoracolumbar backache. He made intermittent use of simple analgesics, and had received steroid therapy over five years from the age of 13. Clinical examination revealed a mild right thoracic rib hump. Plain radiographs and CT scan showed a thoracic aortic aneurysm with an estimated 50% loss of the left anterolateral part of vertebral bodies T7, T8 and T9.

The patient required resection of the aneurysm and replacement graft. An orthopaedic opinion was requested about the possible need for simultaneous spinal stabilisation surgery. The vertebral bone loss was considered similar to the bone loss seen in bullet injuries of the spine, and therefore unlikely to result in spinal instability. This proved to be the case in follow-up radiological examination at 16 months.

A 22-year-old man was admitted to hospital after being assaulted. He complained of a painful neck and upper limbs, with weakness and numbness of his upper limbs.

Initial treatment was skull traction for six weeks, during which the motor power in the upper limbs recovered. CT scan of the cervical spine showed a lytic expanding bone lesion in the atlas. At 10 weeks he was transferred to a Spinal Centre, walking normally, with good bladder and bowel control. He was complaining of intermittent occipital headaches and pain at the cervicothoracic junction. He was wearing a cervical orthosis. His neck movements were guarded and markedly restricted. No neurological deficit was detected. A right-sided brachiocephalic artery angiogram showed no abnormality. MR scan showed definite narrowing of the spinal canal at the C2 vertebral level and stress studies some vertebral instability at the atlanto-axial level. Under general anaesthetic a transoral biopsy, curettage, and bone grafting of the atlas was carried out. The biopsy material comprised white membranous-type material, which had the histological features of hydatid cysts. A posterior spinal fusion with instrumentation was performed over posterior vertebral arches Cl to C3. Postoperatively ultrasound of the abdomen and radiograph of the chest did not reveal any further evidence of hydatid disease. Treatment with albendazole was commenced. The diagnosis was not anticipated preoperatively.

Eight patients with neurofibromatosis presented with symptoms of cervical spine involvement over a period of 17 years, five of them within the second decade of life. The symptoms included neurological deficit in five, a neck mass in four, and deformity in three; only two complained of pain. Osteolysis of vertebral bodies with kyphosis of more than 90 degrees was the most common radiological feature. Posterior fusion failed in the one patient in whom it was performed. Good results were achieved by anterior fusion, alone, or combined with posterior fusion. Surgical complications included one death in a patient with a malignant neurofibroma, and one case of transient neurological deterioration.

Spasm or contracture of the gastrocnemius muscle is predominantly responsible for the equinus deformity of the foot in cerebral palsy. Its release is therefore logical in the treatment of all cases which do not respond to conservative measures. The authors have demonstrated, by the use of metal markers and radiographic control at operation, that adequate release cannot be achieved by severance of the calcaneal tendon alone, and that in order to ensure relaxation of the gastrocnemius muscle, the operation of choice is gastrocnemius recession by the method of Strayer, coupled with lengthening of the calcaneal tendon to deal with such degree of the deformity as may be attributable to shortening of the soleus. A survey of 100 limbs treated by this method revealed a recurrence rate of equinus of 9% and a degree of calcaneus deformity resulting in inadequate push-off in 3% of cases after an average follow-up period of six years.

1. The case is described of an eight-year-old girl with the Morquio syndrome (mucopolysaccharidosis type IV) who died from acute tetraplegia, due to atlanto-axial subluxation which occurred during general anaesthesia.

2. Hypoplasia of the dens of the axis vertebra entails a high risk of vertebral dislocation and spinal cord damage especially in circumstances such as general anaesthesia when excessive movements of the head may occur.