Aims

The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture.

Introduction

The use of antibiotic-loaded polymethylmethacrylate bone-cement spacers during two-stage exchange procedures is the standard in the treatment of patients with delayed prosthetic joint infection. The real antimicrobial activity of these spacers is unclear because the adherence of bacteria to cement might result in clinical recurrence of infection. The purpose of the study is to evaluate the in vitro formation of Pseudomonas Aeruginosa (PA) and Staphylococcus spp. biofilm on antibiotic-loaded bone cement.

Several studies have reported the rate of post-operative mortality after the surgical treatment of a fracture of the hip, but few data are available regarding the delayed morbidity. In this prospective study, we identified 568 patients who underwent surgery for a fracture of the hip and who were followed for one year. Multivariate analysis was carried out to identify possible predictors of mortality and morbidity. The 30-day, four-month and one-year rates of mortality were 4.3%, 11.4%, and 18.8%, respectively. General complications and pre-operative comorbidities represented the basic predictors of mortality at any time interval (p < 0.01). In-hospital, four-month and one-year general complications occurred in 29.4%, 18.6% and 6.7% of patients, respectively. After adjusting for confounding variables, comorbidities and poor cognitive status determined the likelihood of early and delayed general complications, respectively (p < 0.001). Operative delay was the main predictor of the length of hospital stay (p < 0.001) and was directly related to in-hospital (p = 0.017) and four-month complications (p = 0.008).

Cite this article: Bone Joint J 2015;97-B:383–90

BACKGROUND:

Modern total hip arthroplasty (THA) has shown a great improvement in pain, function and range of motion of patients but data on patients' quality of life after this surgery as assessed by validated tools are lacking.

Coloured bone cements have been introduced to make the removal of cement debris easier at the time of primary and revision joint replacement. We evaluated the physical, mechanical and pharmacological effects of adding methylene blue to bone cement with or without antibiotics (gentamicin, vancomycin or both). The addition of methylene blue to plain cement significantly decreased its mean setting time (570 seconds (sd 4) vs 775 seconds (sd 11), p = 0.01), mean compression strength (95.4 MPa (sd 3) vs 100.1 MPa (sd 6), p = 0.03), and mean bending strength (65.2 MPa (sd 5) vs 76.6 MPa (sd 4), p < 0.001) as well as its mean elastic modulus (2744 MPa (sd 97) vs 3281 MPa (sd 110), p < 0.001). The supplementation of the coloured cement with vancomycin and gentamicin decreased its mean bending resistance (55.7 MPa (sd 4) vs 65.2 MPa (sd 5), p < 0.001).The methylene blue significantly decreased the mean release of gentamicin alone (228.2 µg (sd 24) vs 385.5 µg (sd 26), p < 0.001) or in combination with vancomycin (498.5 µg (sd 70) vs 613 µg (sd 25), p = 0.018) from the bone cement. This study demonstrates several theoretical disadvantages of the antibiotic-loaded bone cement coloured with methylene blue.

The purposes of the present study were to assess the outcome of surgery for carpal tunnel syndrome (CTS), to evaluate histological findings of subsynovial connective tissue (SSCT) of patients with CTS in comparison with a control group, and to assess whether the histologic appearance of the flexor tenosynovium is correlated with clinical history, preoperative or postoperative physical examination, general health, symptoms and function as assessed by validated tools, or nerve conduction studies.

Materials and Methods: We studied 30 consecutive patients who had idiopathic CTS and were referred to our institution for surgery. All patients had had diagnostic neurophysiological testing. A study specific questionnaire, a historical-objective scale (Hi-Ob), the Boston Carpal Tunnel Questionnaire (BCTQ), the SF-36 questionnaire were administered to the patients preoperatively and six months after surgery. A standard open carpal tunnel release was performed and 1 cm 3 of tickened synovium was removed from the flexor digitorum superficialis tendons. Specimens of SSCT from flexor tendon at wrist were also obtained from ten fresh-frozen cadavers witrh no history of CTS. Seriated hematoxylin and eosin stained sections were obtained and conventional light microscopy at a magnification of 20X was performed. The number of cells, the number of vessels, the surface of the lumen of the vessels, the total vascular surface, the thickness of the wall of vessels in each selected image were measured with an Autocad software. The results per specimen were averaged for statistical analysis.

Results: Six months after surgery the SF-36 mental and physical summary scores (P< 0.001 and P=0.001, respectively), the Symptom severity score (P< 0.001) and the HI-Ob (P< 0.001) improved. In comparison with cadavers, the typical pathologic findings of SSCT of patients with CTS were vascular hypertrophy and vessel’s wall thickening. At multivariate linear regression analyses greater histopathological changes were important predictor of lower SF-36 scores following surgery. As for the electromyographic parameters, higher preoperative values of 3M SCV and MCV were positively associated with SF-36 BP and SF scores. The greater neurophysiological impairment of the median nerve was predictive of lower SF-36 VT at follow up. Older patients, females and patients who had had the higher number or severity of comorbidities preoperatively achieved the lower SF-36 scores following surgery.

Conclusions: We demonstrated many variables to be associated with the CTS and its surgical treatments thus confirming data from previous reports and suggesting new important associations that have not been described previously. Physicians should consider these results when discussing with patients on the likely outcomes of carpal tunnel surgery.

No studies have focused on the relationships between pathological changes in the subsynovial connective tissue and clinical or neurophysiological findings in patients suffering from carpal tunnel syndrome (CTS). Twenty-five consecutive patients (mean age 58.8±10 years; range 39–79) operated on for idiopathic CTS were evaluated before surgery and six month later. The indication for surgery was the presence of symptoms despite a three-month trial of conservative management. Mean duration of symptoms was 5.3±4.6 years (range 0.5–15). On admission, demographic and medical history data were recorded from all the patients. Subsequently, patients underwent preoperative physical examination and an outcome set including a mixed historic and objective scale (Hi-Ob), the Italian version of the Boston Carpal Tunnel Questionnaire (BCTQ) and the official Italian version of the SF-36 questionnaire was administered. The baseline diagnostic work-up included standard radiographs of the hand and wrist, blood examination and neurophysiological testing. Patients underwent open carpal tunnel release and thickened synovium from the flexor digitorum superficialis tendons was harvested. The number of cells, the number, diameter and density of the vessels, and the total surface of angiogenetic foci were measured. On the SF-36 questionnaire, the preoperative physical component summary (PCS) and mental component summary (MCS) scores averaged 36.5±4.2 and 40.8±5.7, respectively; at follow they averaged 47±10.2 and 46.8±7.3, respectively, with significant improvement for PCS. Preoperative and postoperative Hi-Ob scores measured 3.4±0.5 and 1.3±0.5, respectively. The BCTQ symptoms scale averaged 3.9±0.3 before surgery and 1.5±0.2 at follow up, whereas the BCQT functional status scale measured 3.4±0.5 at baseline and 1.4±0.3 six months after the operation. Univariate and multiple linear regression analysis were used to evaluate relationships between explanatory variables and outcomes. A high grade of preoperative neurophysiologic impairment was in direct relationship with the improvement in SF-36’s PCS score obtained with surgery (p=0.017). Conversely, no association was detected between neurophysiological grade and the postoperative improvement in Hi-Ob or BCQT scales. The univariate analysis showed a trend toward a direct association between number of vessels in the synovium and the improvement of BCTQ symptoms at follow-up (p=0.06). This trend was confirmed to a lesser extent at the multivariate analysis. With the numbers available, no other histological parameters were associated with the baseline neurophysiological findings or clinical outcomes. Although our results should be interpreted cautiously due to the small sample size, we conclude that the severity of pathological changes in the flexor synovium during CTS do not influence the baseline severity or outcome of this syndrome.

We have studied 180 patients (128 men and 52 women) who had undergone lumbar discectomy at a mean of 25.4 years (20 to 32) after operation. Pre-operatively, most patients (70 patients; 38.9%) had abnormal reflexes and/or muscle weakness in the leg (96 patients; 53.3%). At follow-up 42 patients (60%) with abnormal reflexes pre-operatively had fully recovered and 72 (75%) with pre-operative muscle impairment had normal muscle strength. When we looked at patient-reported outcomes, we found that the Short form-36 summary scores were similar to the aged-matched normative values. No disability or minimum disability on the Oswestry disability index was reported by 136 patients (75.6%), and 162 (90%) were satisfied with their operation. The most important predictors of patients’ self-reported positive outcome were male gender and higher educational level. No association was detected between muscle recovery and outcome.

Most patients who had undergone lumbar discectomy had long-lasting neurological recovery. If the motor deficit persists after operation, patients can still expect a long-term satisfactory outcome, provided that they have relief from pain immediately after surgery.

Aim of the present study was to investigate clinical outcomes and quality of life after standard discectomy for lumbar disc herniation on a minimum 25-year follow-up throughout validated tools. Between 1973 and 1979, a total of 343 patients underwent single or double level standard lumbar discectomy at the Orthopaedic Department of Naples Federico II University Hospital, Italy. Fifty patients died from causes unrelated to disc surgery. Out of the remnants, one hundred fifty-eight patients could be traced and contacted by mail (46.1% survey rate). All of them (100% response rate) completed and sent back three questionnaires: the official Italian version of the Short Form-36 Health Survey (SF-36), the Oswestry Disability Questionnaire, and a questionnaire ideated by the authors to evaluate the degree of satisfaction with surgery. Forty-two patients even accepted to undergo clinic examination. The study population consisted of 97 males and 61 females. The mean age at the time of surgery was 37.8 +/− 8.7 years (18–62), whereas on follow up it was 65.8 +/− 8.9 (44–89). The average follow up in the study group was 27 years (25–31). The eight SF-36 scales averaged 72.53 +/− 31.3 for physical functioning, 63.1 +/− 30.1 for bodily pain, 61.30 +/− 44.4 for role-physical, 54.57 +/− 22.2 for general health, 56.62 +/− 19.2 for vitality, 72.08 +/− 30 for social functioning, 67.56 +/− 41.4 for role-emotional, and 62.28 +/− 19 for mental health. The mean SF-36 physical composite score (PCS) and mental composite score (MCS) were 44.2 +/− 11.6 (17.3–64.5) and 45.7 +/− 9,9 (13.2–62.4), respectively. The mean Oswestry Disability Score was 16.67 +/− 22.82 (0–96). One hundred forty-two patients (89.9%) were satisfied with the results of surgery, whereas sixteen (10.1%) were dissatisfied. One hundred and one (89.2%) would have had the same operation again. Nineteen patients underwent recurrent back surgery, giving a reoperation rate of 12%. As for the objective findings, we noted slight improvement of motor disturbances, hyporeflexia, and radicular tension signs with respect to preoperative period. Lumbar alignment abnormalities and trunk mobility did not show significant changes. On multivariate analysis worst SF-36 PCS scores were associated with increasing age (P = 0.039), low educational level (P = 0.002), and reoperation (P = 0.008). Similar correlations were appreciated for the Oswestry Disability Score. Negative role of female gender (P = 0.012) in determining the score of SF-36 MCS was also detected. To the best of our knowledge, no patient-oriented evaluation of lumbar discectomy outcomes has been reported with a similar ultra-long-term follow-up. The minimum 25-year results obtained in the present study were satisfying for both general health and disability indicators. The general health scores were similar to age-adjusted normative values.

Aims: The purpose of this study is to evaluate the possible utility of a low-cost radiation-free technique for predicting degenerative changes in the lumbar spine. Methods: In 117 patients with low back pain or pain in the lower limb, ultrasonographic parameters (speed of sound, broadband ultrasound attenuation, stiffness) of the calcaneus were correlated with (1) evidence for degenerative changes and stenosis on magnetic resonance scans of the lumbar spine and (2) Oswestry Low Back Pain Disability Questionnaire Score. Linear and logistic regression as well as ROC curves analyses were used to evaluate the correlation. Results: Lumbar spine stenosis was associated with elevated calcaneal ultraso-nographic parameters. For the identiþcation of a narrowing of the lumbar spinal canal below 100mm2 of dural sac crosssectional area, speed of sound showed an 89% sensitivity in males older than 60. In these patients, we also found a signiþcant positive correlation between ultrasonographic parameters and scores on a MRI-based degenerative scale. No signiþcant correlation was found between disability score and lumbar spine degeneration or ultrasonographic parameters. Conclusions: Calcaneal ultrasonography is frequently used as a diagnostic test for osteoporosis. Its values are highly correlated with lumbar spine stenosis in elderly symptomatic males, and this low-cost radiation-free diagnostic method can be used to identify those patients needing more extensive diagnostic testing.