The pelvic girdle and spine vertebral column work as a long chain influenced by pelvic tilt. Spinal deformities or other musculoskeletal conditions may cause patients to compensate with excessive pelvic tilt, producing alterations in the degree of lumbar lordosis and subsequently causing pain. The objective of this study is to assess the effect of open and closed chain anterior or posterior pelvic tilt on lumbar spine kinematics using an in vitro cadaveric spine model.

Three human cadaveric spines with intact pelvis were suspended with the skull fixed in a metal frame. Optotrak 3D motion system tracked real-time coordinates of pin markers on the lumbar spine. A force-torque digital gage applied consistent force to standardize the acetabular or sacral axis’ anterior and posterior pelvic tilt during simulated open and closed chain movements, respectively.

In closed chain PPT, significant differences in relative intervertebral compression existed between L1/L2 [-2.54 mm] and L5/S1 [-11.84 mm], and between L3/L4 [-2.78 mm] and L5/S1 [-11.84 mm] [p <.05]. In closed chain APT, significant differences in relative intervertebral decompression existed between spinal levels L1/L2 [2.87mm] and L5/S1[24.48 mm] and between L3/L4 [2.94 mm] and L5/S1 [24.48 mm] [p <.05]. In open chain APT, significant differences in relative intervertebral decompression existed between spinal levels L4/L5 [1.53mm] and L5/S1 [25.14 mm] and between L2/L3 [1.68 mm] and L5/S1 [25.14 mm] [p<.05 for both]. Displacement during closed chain PPT was significantly greater than during open chain PPT, whereas APT showed no significant differences.

In PPT, open chain pelvic tilts did not produce as much lumbar intervertebral displacement compared to closed chain. In contrast, APT saw no significant differences between open and closed chain. Additionally, results illustrate the increase in lumbar lordosis during APT and the loss of lordosis during PPT.

Aims

Falls are a common occurrence among hospital inpatients and can lead to injury, prolonged hospitalisation and delayed rehabilitation. There is major economic burden associated with this. Post operative orthopaedic patients have certain risk factors that predispose them to falls including decreased mobility, use of opioids and, in some cases, history of previous falls.

Classical AO teaching recommends that a syndesmosis screw should be inserted at 25 to 30 degree angle to the coronal plane of the ankle. In practice accurately judging the 25/30 degree angle can be difficult, and there are several reports based on post operative CT scans demonstrating that a significant minority of patients have poorly operatively reduced syndesmotic injuries.

The CT scans of 200 normal ankles in one hundred individuals which had been performed as part a CT angiogram were retrospectively examined. The centroid of the fibula and tibia in the axial plane 15mm proximal to the talar dome was calculated. Since a force vector between the centroid of the fibula and the tibia in the axial plane should not displace the fibula relative to the tibia, a line connecting the two centroids was therefore postulated to be the ideal syndesmosis line, and also the optimum position in which to place a compression clamp after reducing the syndesmosis. Where this ideal line passed through the lateral border of the fibula, and through the medial malleolus was then noted.

The ideal syndesmosis line was shown to pass through the fibula with in 2mm of the lateral cortical apex of the fibula, and the anterior half of the medial malleolus in 100% of the ankles studied. The results support the concept that in the operatively reduced syndesmosis, the anterior half of the medial malleolus can be used as a reliable guide for aiming the syndesmosis drill hole, provided that the fibular entry point is at or adjacent the lateral fibular apex.

The corollary of these findings is that a screw inserted through a plate on the standard antero-lateral border of the fibula, or a plate in the anti-glide position posteriorly, cannot lie in the centroidal axis of the ankle.

Background

Post operative analgesia is an important part of Total Knee Arthroplasty (TKA) to facilitate early mobilisation and patient satisfaction. We investigated the effect of periarticular infiltration of the joint with chirocaine local anaesthetic (LA) on the requirement of analgesic in the first 24 hrs period post op.

Introduction: Failed surgical treatment of hip fractures typically leads to profound functional disability and pain for the individual, technical challenges for the surgical team, and an increase in the financial burden on society. This study had three purposes:

to determine the reason/s for failure of internal fixation

Methods: Between 1999 and 2005 41 patients (30 women and 11 men) with a mean age of 70 were treated at our institution with a total hip arthroplasty for failed dynamic hip screw fixation of a fracture of the proximal femur. The radiographs and medical charts of all patients were obtained following institutional approval. The quality of the reduction of the fracture achieved was assessed on the basis of displacement and alignment. Screw position was also assessed. Each patient who had undergone salvage arthroplasty (Group 1) was matched with a patient who had undergone total hip arthroplasty for degenerative disease in our unit (Group 2). Patients were matched for age, sex, implant and time since insertion of the implant. All surviving patients form both groups were followed up for a minimum of two years (mean 5 years). Three main outcome measures were compared between the two groups; surgical complications, the Oxford hip score, and radiographic analysis of the femoral component for signs of loosening

Results: Failure to achieve a good reduction and optimal screw placement was evident in 80% of cases of failed fixation. A high incidence of complications was recorded in the perioperative period during conversion to a salvage arthroplasty. Functional outcome was statistically inferior in Group1, this group also had a much higher incidence of complications. Radiographs at 2 years post operatively showed evidence of femoral stem loosening in 16% of the salvage group compared with 3% in the primary hip arthroplasty group.

Conclusion: When undertaking surgical stabilisation of proximal femoral fractures one should make every effort to achieve the best reduction and most accurate fixation possible. Factors such as osteoporosis, compliance with post-operative mobilisation and delay in fracture fixation are to some extent ‘out of the surgeon’s hands’. Conversion to arthroplasty is technically challenging, and is associated with higher complication rate and poorer outcome than primary hip arthroplasty. We recorded a high incidence of femoral stem loosening in patients who had undergone conversion to hip arthroplasty for failed fixation and would recommend more frequent clinical and radiographic follow up of these patients

Aims: Treatment options for proximal humeral fractures are not very clear, specially in osteoporotic bones. Non operative treatment if on one hand leads to unpredicted and poor outcomes, the operative treatment on the other hand leads to devascularization of fractured fragments and implant failure leading to unacceptable results. Newer interlocking plates, which are applied with minimum soft tissue stripping of fractured fragments and better fixation abilities seems a promising alternative. We present our experience with such plates.

Patients and Methods: Over a period of two years 2002 and 2003, we used 50 plates to treat Neer’s two and three parts and surgical neck of humerus fractures. We reviewed our clinical results with PHILOS plates, which is in interlocking plate. Average age was 34 (24–82). 21 Male and 29 Females. We followed them clinically and radiologically for healing. The shoulder function was assesses with DASH scoring system. The DASH system questionnaire was filled by patients before the fracture and after healing of the fractures. We used a regimen of progressive rehabilitation of shoulder from immediate post operative period. All the complications including union issues, shoulder function, wound problems, nerve injuries, infection and implant failure were noted. Two different techniques were used to fix the fracture with the plate.

Statistical analysis was performed on the data collected through DASH questionnaires along with multivariate and univariate analysis and t-tests.

Results: We were able to follow all the patients who filled the pre fracture and post healing DASH system questioner. X-rays and clinical findings were available for all the patients in the study. All the patients united with average length of 6 weeks (5–12 weeks). All the fractures united. There were no deep infections; however, two patients had to have a week of oral antibiotics for superficial wound infection. There were no permanent nerve injuries. Eight patients had transient axillary nerve paresis, which resolved after 10–15 days. Patient satisfaction with the procedure was high.

48 % of patients showed a rise in DASH scores after the fracture healing, indicating decrease shoulder function. This was statistically analysed and failed to reach any significance p=0.867. There was no difference between the two techniques in terms of complications and union rates.

Conclusions: PHILOS interlocking plates in our study showed 100% union rate with no or minimal complications and preservation of shoulder function. They are technically not difficult to apply and allow immediate post operative mobilization. Hence we recommend their use in primary fixation of proximal humerus fractures.

Accurate and relevant patient chart notes are a key component in successful patient care. Hospital charts also constitute an important medicolegal record. The key to defensibility of at least 40% of medical claims rests with the quality of the medical records. With this in mind, we decided to assess the quality of chart note keeping in our unit. A retrospective review of fifty randomly chosen charts was performed. A scoring system was devised to audit ten key criteria comprising patient details, admission note, daily progress notes, signature clarity, consent form, operation note, post-operative plan, post-operative x-ray review, specification of right or left side and discharge letter. Members of the orthopaedic surgical staff were then informed of the chart review and the nature and purpose of the study was explained in detail. They were also told that there would be another chart audit at some random time over the following three months. Subsequently, a further fifty charts were assessed using the same criteria and scoring system. Overall, charts scored poorly in the areas of patient details, clarity of signatures, post-operative x-ray review and left-right specification. Criteria that scored satisfactorily included admission note, consent form, operation note, post-operative plan an discharge letter. Meticulous hospital notes are vitally important in the day-to-day management of patients for successful continuity of care and also for protection of the medical staff should any adverse outcomes arise. In this litigious society consultants and junior medical staff need to be reminded of the importance of optimal note keeping.

Introduction: The purpose of this study was to evaluate the design of a titanium/polyolefin artificial disc, assess its safety and measure outcome to determine if a RCT is justified.

Methods: All subjects entered this pilot study with one or two-level disc disruption at l4/l5 and/or l5/s1 and had disabling low back pain for at least 12 months. The diagnosis was confirmed by discography. Independent assessment included physical examination, VAS for pain, Low-Back Outcome Score (LBOS), Oswestry Disability Index (ODI), SF-36, lateral flexion/extension radiographs and MRI. This was carried out preoperatively, at 6 and 12 weeks, 6 months and at 1 and 2 years. Surgery was performed by an anterior retroperitoneal approach.

Results: Twenty-eight cases (14 males; average 41 years) were operated on during 1998–2000. Surgery was performed at L5/S1 in 19, L4/L5 in 5 and both levels in 4. Operating time averaged 130 minutes with 180mls average blood loss. There were no operative complications and average length of stay was 6 days. At 2 years there was 39% average improvement in vas, 15-point average improvement in ODI, 14 point average improvement in LBOS and improvement in 5 of the 8 SF-36 sub-scales. Complications included detection by plain radiographs of early partial displacement of implant in one case and late heterotopic calcification in another. Thin section helical CT, first carried out in early 2001, revealed polyolefin tears in 10 patients, four undergoing revision surgery since 2-year follow-up. CT revealed instances of osteolysis associated with polyolefin failure and hetero-topic bone formation not seen on plain radiographs.

Discussion: Although improvements in clinical outcome comparable to that reported with fusion were obtained at two years, detection of elastomer tears by thin section CT in 36% of patients indicated the prosthesis was not suitable for clinical use. This finding was unexpected given the results of prior extensive mechanical testing¹.

Aim: We evaluated the Vancouver system of classiþcation and treatment of Periprosthetic fractures. Methods: There were 24 consecutive patients, 17 males and 7 females with a mean age of 78.9 yrs (range 67–88). Two type A fractures were both of the AG type and unstable, were revised with a cemented Exeter stem reinforced with strut grafts. Of the nineteen patients type B fractures, one a B1 that was þxed with the cable grip system and strut graft. The B2 fractures were revised with a long stem cemented Exeter component reinforced with strut grafts. All the B3 fractures were revised with a long stem uncemented component with strut grafts. Of the three type C fractures two were þxed with the plate and cable grip system and the third with a supracondylar nail. Results: The follow up was regular, mean duration being 18.5 months (range 6–26). The review was both clinical using the Harris Hip Score (HHS) and radio-graphic.22 patients had a good result with a mean HHS of 82.7 (range 80–86.4). Two patients had a poor result with a mean HHS of 70 (range69–71). These attributed to progressive Parkinsonñs disease and a loose contra-lateral Hip Replacement. Conclusions: The Vancouver classiþcation system is the only one of its type to be subjected to psychometric testing and show substantial agreement. Based on it appropriate treatment of each fracture can be instituted. It allows a more rational approach to treatment for fracture þxation but also addresses associated problems. Our experiences and results point to this way of treatment.

Introduction: There is still controversy regarding the treatment of acute Lumbar Radicular pain. Most authorities recommend bed rest, anti-inflammatory medication and physical therapy (Riew et al JBJS 1982 and Tulder ET AL Spine 22–1997) Comparing the outcome of operative and conservative treatment in selected patients many authors (Weber et al, Hakelius et al) did not find any significant difference after first year and no difference after 4 years. However many patients treated conservatively complains of persistent pain and seek further intervention.

Aim: We did a prospective study to determine the effectiveness of selective nerve root injection in relieving pain in patients with Lumbar radicular pain.

Material and Methods: We included 27 consecutive patients in our study, who had selective nerve root block. Inclusion criteria were Degenerative Lumbar Radicular pain or spinal stenosis, MRI correlating with Lumbar radiculopathy and no benefit from 6 weeks Anti-inflammatory medication, Rest, Physical treatment and activity modification. Informed consent taken from all patients for this study. Each patient was given Low Back Pain outcome score questionnaire of Greenough and Fraser and Oswestry Disability index of Fairbank, to be filled pre and post injection in day ward and at regular intervals up to 3 months post-injection. Adcortyl 20mg with 1 ml of 1% Lignocaine were injected under image in theatre after confirming the site with radioculogram and pain replication.

Results: From the total of 27 patients, 25 (92%) showed improvement in their symptoms in first week. Out of these 25 patients, 18(66%) had long-term improvement and 7(26%) showed short-term relief. Statistically significant improvement at every stage of assessment was observed.

Conclusion: The selective nerve root block combined with careful history, physical examination and quality radiolographic studies, is an important tool in the diagnosis and treatment of patients with predominant Lumbar radicular symptoms. It gives acceptable results in form of pain relief in 3 months. It has a role in lumbar Radicular pain largely in patients where surgery is not appropriate for whatever reasons.

A prospective study to evaluate the design, outcome and complications of the AcroFlex titanium/polyolefin artificial lumbar disc replacement.

11 subjects with single-level discographically proven discogenic pain of at least six months duration and refractory to conservative treatment underwent Total Disc Replacement (TDR) using the AcroFlex TDR. Surgery was performed by an anterior retroperitoneal approach. The following outcome measures were recorded pre-operatively, at 6 weeks and 3, 6, 12 and 24 months: Visual Analogue Score (VAS), Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), and SF-36. Physical examination and radiological assessment (plain radiographs, flexion/extension views, cine-radiography) were performed at the same time intervals. Complications and reoperations were recorded.

11 patients were enrolled since April 1998 (7 male / 4 female). The mean age was 41. 3 years. All patients have been followed for a minimum of two years.

Surgery averaged 136 minutes with 143 mls blood loss. There were no operative complications. The average length of stay was 6. 1 days. The mean VAS reduced from 8. 8 to 4. 4 at two years. ODI improved from 51. 3 (mean) to 20. 9 (mean) at 24 months. The mean LBOS of 18. 4 improved to 47. 3 at two years.

Patients showed improvement in all subsets of the SF-36. Radiological examination confirmed a mean flexion/extension arc of 6. 6 degrees with restoration of native disc height. Adverse events included one disc expulsion (under radiological observation), one autofusion (F/E views still confirm movement) and one catastrophic rubber failure requiring revision to combined anterior/posterior interbody fusion. As a result of this case all patients underwent ultra fine cut CT scans. An additional 4 cases showed small anterior tears in the rubber and are currently asymptomatic.

The two-year outcome of the AcroFlex TDR is reported in 11 patients. Improvements in VAS, ODI, LBOS and all domains of the SF-36 were reported by 10 of 11 patients. Radiological outcome confirmed preservation of movement and restoration of disc height. Adverse events including disc expulsion, autofusion and rubber failure demand continued vigilance.

In Ireland and the United Kingdom, there were 22 deaths as a direct result of blood transfusion during the period October 1996 to September 1998. Added to this mortality, there were 366 cases of complications directly related to blood transfusion.

With the introduction of a Haemovigilance Nurse, changing surgical personnel and an increased public awareness of the potential hazards of transfusion, we were anxious to review whether transfusion rates have changed in our Regional Orthopaedic Centre for the period January 1999 to July 2000

All patients undergoing primary or revision arthroplasty in our Regional Orthopaedic Unit during the study period were retrospectively reviewed.

459 primary or revision arthroplasties were performed in the study period. Prior to the introduction of a haemovigilance Nurse, from the period January 1999 to October 1999, transfusion rates for primary arthroplasties averaged 1.41 units/patient with 74% of patients being transfused. After the introduction of a haemovigilance Nurse, from November 1999 to July 2000, transfusion rates for primary arthroplasties averaged 0.51 units/patient, with 31% of patients being transfused.

Prior to the introduction of a haemovigilance Nurse revision arthroplasties averaged 2.5 units/patient, with 100% of patients being transfused. After the introduction of the haemovigilance Nurse transfusion averaged 1.2 units/patient, with 62% of patients being transfused.

There was a statistically significant difference between transfusion rates prior to the introduction of a Haemovigilance Nurse and new surgical personnel and the period after their introduction (p< 0.005).

In the current climate post the Finlay Tribunal and the resultant increased public awareness, transfusing a patient without justifiable cause is no longer acceptable.

Patients in this unit are now transfused according to clinical needs and accurate measurement of intra-operative and post-operative blood loss, compared to their calculated maximum allowed blood loss (MABL). The changing transfusion rates seen in our Unit correspond to the introduction of a Haemovigilance Nurse and a change in surgical personnel. Our new transfusion protocol is working well without compromising patient care.

We reviewed all patients with a clinically infected foot ulcer attending a specialised neuropathic foot clinic. Neuropathy was confirmed by the inability to feel a 5.07 Semmes-Weinstein hair, areflexia and impaired vibration sense, as measured by a biothesiometer.

Of 40 patients who attended the clinic over a two-year period, six with ischaemic ulcers were excluded. The remaining 34 had plain radiographs of the foot followed by a ^99mTc-MDP bone scan. If the latter was positive, an ¹¹¹In-labelled WBC scan was performed with planar and/or tomographic dual-isotope studies where appropriate. Bone and WBC scans were performed in 31 patients. In ten, isotope imaging showed infection localised to the soft tissues only and conservative treatment was successful in them all. Eighteen patients were treated surgically with excision of the involved bone, which was sent for culture and histological examination.

Dual-isotope scans had a sensitivity of 93% and a specificity of 83%. ^99mTc-MDP bone scans with the appropriate ¹¹¹In-labelled WBC scans can reliably determine the site and extent of osteomyelitis in the neuropathic diabetic foot.