Abstract

Introduction

Given the rising incidence of obesity in the adult population, it is more than likely that orthopaedic surgeons will be treating more obese patients with lumbar disc pathologies. The relationship between obesity and recurrent herniated nucleus pulposus (HNP) following microdiscectomy remains unclear.

Background

Spondylolysis (SL) of the lower lumbar spine is frequently associated with spina bifida occulta (SBO). There has not been any study that has demonstrated biomechanical or genetic predispositions to explain the coexistence of these two pathologies.

Introduction

Lumbar spondylolysis is a fatigue fracture of the pars interarticularis and correlates with Spina Bifida Oculta (SBO) in 67%.

We described a technique of measuring the flexibility of the rib prominence clinically before surgery, and aimed to analyse the results in patients with adolescent idiopathic scoliosis who underwent posterior correction with pedicle screw instrumentation.

This prospective study investigated the magnitude of rib humps before and after the operation when the patient was in Adam's forward bending posture. Also preoperatively, a flexion and derotation manoeuvre was performed and the corrected rib prominence was measured. This is compared to the magnitude of the rib hump present postoperatively at three months' follow up.

Seven consecutive patients with adolescent idiopathic scoliosis that underwent posterior surgical correction.

Clinical measurement of rib prominence using scoliometer.

The magnitude of the curve improved from a mean preoperative Cobb angle of 53.6+/−11.2° (range 45.3–72.5°) to a mean postoperative Cobb angle of 7.8+/−9.3° (range 0.4–17.6°). The mean preoperative magnitude of the rib hump was 12.3+/−6.9° (range 5-20°) which was then corrected to a mean magnitude of 1.3+/−2.2° (range 0-5°) by performing the above described flexion derotation manoeuvre. The mean postoperative magnitude of the rib hump was 3.0+/−3.1° (range 0-8°) with the patient in Adam's forward bend position. There was positive correlation between the postoperative residual rib hump and the reduced rib hump measured preoperatively using our described technique (r=0.8,p=0.05).

This flexion derotation test is a useful in assessing the amount of postoperative persistent rib hump after posterior correction of adolescent idiopathic scoliosis using pedicle screw instrumentation with derotation technique.

This is the first study to use the English Indices of Multiple Deprivation 2007, the Government’s official measure of multiple deprivation, to analyse the effect of socioeconomic status on the incidence of fractures of the hip and their outcome and mortality. Our sample consisted of all patients admitted to hospital with a fracture of the hip (n = 7511) in Nottingham between 1999 and 2009.

The incidence was 1.3 times higher (p = 0.038) in the most deprived populations than in the least deprived; the most deprived suffered a fracture, on average, 1.1 years earlier (82.0 years versus 83.1 years, p < 0.001). The mortality rate proved to be significantly higher in the most deprived population (log-rank test, p = 0.033), who also had a higher number of comorbidities (p = 0.001).

This study has shown an increase in the incidence of fracture of the hip in the most deprived population, but no association between socioeconomic status and mortality at 30 days. Preventative programmes aimed at reducing the risk of hip fracture should be targeted towards the more deprived if they are to make a substantial impact.

Introduction: Stiffness following total knee arthroplasty is a disabling problem resulting in pain and reduced function. Prevalence is not well defined and although various treatment modalities including manipulation, arthrolysis and revision surgery has been proposed with varying degrees of success for reduced flexion, these Methods: are deemed to be of limited value in fixed flexion deformity (FFD). There is limited literature on the natural history of FFD which is important to the decision process. The aim of our study was to evaluate the natural course of FFD following primary total knee arthroplasty.

Methods: Prospective review of a consecutive series of 1768 patients who underwent primary total knee arthroplasty over a 7 year (2001 to 2008) period. Demographic data included post-operative range of motion; type of prosthesis used, treatment modalities for stiffness and the final range of motion were recorded. FFD was defined as class 1(hyperextension to 0), Class 2 (1–10 degrees), Class 3(11–20 degrees) and Class 4(> 20 degrees).

All patients were reviewed by an independent reviewer (senior physiotherapist). All patients were followed from 6 weeks post surgery until FFD completely resolved or improved to patient satisfaction. Patients with infection, stiffness treated with manipulation or revision surgery were excluded from the study. Patients lost to follow-up were noted.

Results: Of the 1768 patients evaluated, 180 (10.2%) presented with a FFD. A total number of 18 patients were excluded from the study and 16 were lost to follow up. None (0%) were class 1, 134 (91.8%) were class 2, 10 (6.9%) were class 3 and 2 (1.4%) were class 4. The FFD group had a mean age of 60.5. Follow up period ranged from 1.3 to 63.3 months and the FFD improved from a mean of 8.16 degrees to 0.15 degrees (p< 0.001). In 94.5% patients the FFD completely resolved (i.e. < 5 deg) at a mean of 9.76 months. In the remaining 5.5% of patients, FFD improved from a mean of 16.4 to 6.9 degrees at a mean follow up of 15.5 months and was found to cause no functional deficit.

Conclusion: The overall prevalence of fixed flexion deformity is 10.2 % with only 0.7% in Class 3 and Class 4, which is comparable with the literature. The majority of patients will see a resolution of their fixed flexion deformity in less than 10 months with routine post operative physiotherapy. The small number of patients left with a residual FFD did not appear to suffer a functional deficit. Patients found to have a post operative FFD should be reassured and encouraged to participate in a standardised post operative physiotherapy regime.

Purpose of Study: To prospectively evaluate the outcome of single surgeon endoscopic anterior cruciate ligament (ACL) reconstruction with quadrupled hamstring tendons drilling femoral tunnel independent of the tibial tunnel.

Methods and Results: 28 patients underwent endoscopic ACL reconstruction by a single surgeon in a DGH setting. All patients had symptomatic ACL deficiency proven by either MRI or previous arthroscopy. All patients were prospectively scored using the International Knee Documentation Committee (IKDC) score, the Lysholm score, Tegner activity score and the SF36 score. In each patient, an ipsilateral four-strand semi-tendinosus/gracilis tendon graft was used. The femoral tunnel was drilled through the anteromedial portal independent of the tibial tunnel as per the technique described by Leo Pinczewski, Sydney, Australia. This technique was used to place the femoral end of the graft in a more lateral position than obtained by the traditional transtibial technique. The ACL graft was fixed using RCI interference screws. All patients underwent standard accelerated rehabilitation program. All patients were reviewed clinically and radiologically at a mean follow-up 9 months. A significant improvement was noted in all the scores at the time of follow-up. Radiologically all femoral and tibial tunnels were satisfactorily placed with the femoral tunnels being in the 10 o’clock or 2 o’clock position with no evidence of tunnel widening. None of the grafts had failed. We feel that this technique may allow better rotational stability following ACL reconstruction.

Introduction: Elective joint replacement patients routinely require transfusion following surgery. Haemoglobin must remain within red blood cells in order to be functional. The process of surgery and collection in the reinfusion drain may disrupt cell membranes resulting in non functional haemoglobin. The filtration and collection process does not eliminate free haemoglobin. This results in intracellular and free haemoglobin being transfused into patients giving false functional haemoglobin levels.

Aim: To determine the proportion of intracellular haemoglobin in autologous blood transfusion drain following joint replacement.

Research Methodology: Research ethical approval was obtained prior to conducting this study. 20 consecutive patients undergoing elective total hip replacement (THR) and 20 consecutive patients undergoing elective knee replacement (TKR) from April 08–July 08 were consented to participate in this study. A standard full blood count sample of 3 mls was taken from the rein-fused blood. Each sample had the total haemoglobin (THb) concentration determined (i.e. free and intra-cellular) from the blood in the specimen tube. The sample was then centrifuged, and the THb of the supernatant was determined. This determined the concentation of ‘free’ haemoglobin. From these two respective values, the proportion of haemolysed haemoglobin was determined from each sample.

Results: There were a total of 35 participants of which 20 were TKR and 15 were THR. The average THb concentration for the THR and TKR were 7.7g/dl and 10.3g/dl respectively. The proportion of haemolysed Hb was 1.46% and 0% respectively. The THb and proportion of haemolysed Hb for all 35 patients were 8.76g/dl and 0.63%.

Conclusion: Autologous blood transfusion is not only safe and economical but remains an effective procedure with a negligible proportion of haemolysis