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The Bone & Joint Journal
Vol. 104-B, Issue 6 | Pages 715 - 720
1 Jun 2022
Dunsmuir RA Nisar S Cruickshank JA Loughenbury PR

Aims

The aim of the study was to determine if there was a direct correlation between the pain and disability experienced by patients and size of their disc prolapse, measured by the disc’s cross-sectional area on T2 axial MRI scans.

Methods

Patients were asked to prospectively complete visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores on the day of their MRI scan. All patients with primary disc herniation were included. Exclusion criteria included recurrent disc herniation, cauda equina syndrome, or any other associated spinal pathology. T2 weighted MRI scans were reviewed on picture archiving and communications software. The T2 axial image showing the disc protrusion with the largest cross sectional area was used for measurements. The area of the disc and canal were measured at this level. The size of the disc was measured as a percentage of the cross-sectional area of the spinal canal on the chosen image. The VAS leg pain and ODI scores were each correlated with the size of the disc using the Pearson correlation coefficient (PCC). Intraobserver reliability for MRI measurement was assessed using the interclass correlation coefficient (ICC). We assessed if the position of the disc prolapse (central, lateral recess, or foraminal) altered the symptoms described by the patient. The VAS and ODI scores from central and lateral recess disc prolapses were compared.


Bone & Joint Open
Vol. 3, Issue 1 | Pages 85 - 92
27 Jan 2022
Loughenbury PR Tsirikos AI

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.


The Bone & Joint Journal
Vol. 103-B, Issue 8 | Pages 1400 - 1404
1 Aug 2021
Sim FCJ Birley E Khan AL Loughenbury PR Millner P

Aims

The aim of this study was to determine whether there is an increased prevalence of scoliosis in patients who have suffered from a haematopoietic malignancy in childhood.

Methods

Patients with a history of lymphoma or leukaemia with a current age between 12 and 25 years were identified from the regional paediatric oncology database. The medical records and radiological findings were reviewed, and any spinal deformity identified. The treatment of the malignancy and the spinal deformity, if any, was noted.


The Bone & Joint Journal
Vol. 100-B, Issue 8 | Pages 1054 - 1059
1 Aug 2018
Kelly C Harwood PJ Loughenbury PR Clancy JA Britten S

Aims

Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum.

Materials and Methods

A total of 20 embalmed cadaveric lower limbs were divided into two groups. Wires were inserted using two possible insertion points and at varying angles. In Group A, wires were inserted one-third along a line between the point of the heel and the tip of the lateral malleolus while in Group B, wires were inserted halfway along this line. Standard dissection techniques identified the structures at risk and the distance of wires from neurovascular structures was measured. The results from 19 limbs were subject to analysis.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 419 - 419
1 Jul 2010
Loughenbury PR MacDonald DA
Full Access

Introduction: Tibial augments are required to replace bone loss in the proximal tibia during revision total knee replacement and can be either a rectangular ‘block’ shape or an angled ‘wedge’ shape.

Purpose of study: We have identified a high failure rate with the ‘wedge’ shape currently used in the Co-ordinate (DePuy) revision knee system.

Methods: We report a series of revision total knee replacement procedures performed using the Co-ordinate system. All revision ‘angled’ tibial wedge implants were selected from our prospective database containing follow up records for knee replacements. Patients underwent clinical and radiological review at three months following the procedure, on the anniversary of surgery and then on a yearly basis. Those with fewer than 12 months follow-up were excluded.

Results: Between December 1993 and February 2006, a total of 34 patients (19 female, 15 male) required revision knee arthroplasty with an ‘angled’ wedged tibial augment. Mean age at surgery was 59.3 years (range 46–93). Five cases were excluded due to absence of follow-up (four requiring further surgery for infection and one due to unrelated medical complications). Of the remaining 29 cases, 16 (55.2%) had no problems with the tibial implant, while 13 (44.8%) exhibited radiological changes on review. Tibial implant migration was seen in 5 cases (17.2%), all within three years of surgery. One of these has needed further revision surgery and the other four are expected to need revision in the future. Seven (24.1%) were found to have a tibial radiolucent zone, which was progressive in four cases. There was one case of stem dissociation.

Conclusion: ‘Angled’ tibial wedge implants are associated with a high rate of implant migration and loosening, presumably due to the effect of shear forces. Use of these implants should be reserved for low demand patients.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 7 | Pages 1041 - 1044
1 Jul 2010
Loughenbury PR Harwood PJ Tunstall R Britten S

Anatomical atlases document safe corridors for placement of wires when using fine-wire circular external fixation. The furthest posterolateral corridor described in the distal tibia is through the fibula. This limits the crossing angle and stability of the frame. In this paper we describe a new, safe Retro-Fibular Wire corridor, which provides greater crossing angles and increased stability. In a cadaver study, 20 formalin-treated legs were divided into two groups. Wires were inserted into the distal quarter of the tibia using two possible corridors and standard techniques of dissection identified the distance of the wires from neurovascular structures.

In both groups the posterior tibial neurovascular bundle was avoided. In group A the peroneal artery was at risk. In group B this injury was avoided. Comparison of the groups showed a significant difference (p < 0.001).

We recommend the Retro-Fibular wire technique whereby wires are inserted into the tibia mid-way between the posteromedial border of the fibula and the tendo Achillis, at 30° to 45° to the sagittal plane, and introduced from a posterolateral to an anteromedial position. Subsequently, when using this technique in 30 patients, we have had no neurovascular complications or problems relating to tethering of the peroneal tendons.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 571 - 571
1 Aug 2008
Loughenbury PR Tunstall R Britten S
Full Access

Introduction: An important factor affecting the stability of circular fine wire frames is the wire crossing angle, where an angle of 90 degrees confers optimal stability. Safe anatomical ‘corridors’ have been described to avoid neurovascular structures, but often limit the crossing angle. In the distal tibia the posterior tibial artery and tibial nerve wind medially facilitating safe placement of a posterior to anterior ‘retrofibular’ wire. The present study aims to identify structures at risk during ‘retrofibular’ wire placement and determine the level at which this can be used safely.

Methods: A dissection based study of 10 embalmed lower limbs. Wires of 1.8mm diameter were inserted at increments along the tibia. These were placed against the posterior surface of the fibula and ‘stepped’ medially past the posteromedial border onto the tibia. Wires were introduced from posterior to anterior, between 30 degrees and 45 degrees to the sagittal plane. This angle is estimated, reproducing clinical practice. Standard dissection techniques were used to identify the path of wires and distance from neurovascular structures.

Results: In the distal quarter of the tibia wires avoided the posterior tibial neurovascular bundle (mean distance 21.7mm) although passed close to the peroneal artery (mean distance 1.2 mm). Of the 30 wires placed in the distal tibia, 29 (97%) passed through the leg without damage to any neurovascular structures. Anterior tendons were tethered by 13% of wires placed in the distal quarter of the tibia.

Discussion: Retrofibular wire placement facilitates an optimal crossing angle, although is not described in standard atlases. Use in the lower quarter of the tibia does not threaten the posterior tibial neurovascular bundle. However, peroneal artery injury is a possibility. The clinical significance of peroneal artery injury at this level is unclear but should be considered when using this technique.