Aims

The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld.

Aims

The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated.

Aim

To analyse the prevalence of culture negative periprosthetic joint infections (PJI) when adequate culture techniques are applied, and to evaluate the outcome of patients who were treated with antibiotics for a culture negative PJI versus those in whom treatment was withheld.

Aims

Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation.

The identification of the extent of neural damage in patients with acute or chronic spinal cord injury is imperative for the accurate prediction of neurological recovery. The changes in signal intensity shown on routine MRI sequences are of limited value for predicting functional outcome. Diffusion tensor imaging (DTI) is a novel radiological imaging technique which has the potential to identify intact nerve fibre tracts, and has been used to image the brain for a variety of conditions. DTI imaging of the spinal cord is currently only a research tool, but preliminary studies have shown that it holds considerable promise in predicting the severity of spinal cord injury.

This paper briefly reviews our current knowledge of this technique.

In 2006, approximately 1.3 million peer-reviewed scientific articles were published, aided by a large rise in the number of available scientific journals from 16 000 in 2001 to 23 750 by 2006. Is this evidence of an explosion in scientific knowledge or just the accumulation of wasteful publications and junk science? Data show that only 45% of the articles published in the 4500 top scientific journals are cited within the first five years of publication, a figure that is dropping steadily. Only 42% receive more than one citation. For better or for worse, “Publish or Perish” appears here to stay as the number of published papers becomes the basis for selection to academic positions, for tenure and promotions, a criterion for the awarding of grants and also the source of funding for salaries. The high pressure to publish has, however, ushered in an era where scientists are increasingly conducting and publishing data from research performed with ‘questionable research practices’ or even committing outright fraud. The few cases which are reported will in fact be the tip of an iceberg and the scientific community needs to be vigilant against this corruption of science.

Study design

Prospective clinical and radiological analysis of children with complex cervical deformities for the safety of cervical pedicle screw insertion.

Study Design

Prospective analysis of computerised tomogram images of 376 normal pediatric cervical pedicles

Introduction

The results of a prospective study of primary bone grafting in a selective group of patients with High energy open fractures (Grade III) of limbs with communition or bone loss are presented.

Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous methods.

We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. During the entire procedure, the tool navigator was used frequently to reconfirm the location and the depth of burring. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus.

The age of the patients varied from 10 years to 27 years. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it was attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years.

Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation.

Background: Intraarticular loose bodies following simple dislocations can lead to early degeneration. Non concentric reduction may indicate retained loose bodies and offer a method to identify patients requiring exploration to avoid this undesirable outcome.

Methods: 117 consecutive simple dislocations of the hip presenting to the hospital from January 2000 to June 2006 were assessed for congruency after reduction by fluoroscopy and good quality radiographs. Patients with non concentric reduction underwent open exploration to identify the etiology and removal of loose bodies. The post operative results were analyzed using Thomson and Epstein clinical and radiological criteria.

Results: 12 of the 117 (10%) dislocations had incongruent reduction which was identified by a break in Shenton’s line and an increase in medial joint space in seven patients, superior joint space in three patients or a concentric increase in two patients. CT scan performed identified the origin of the osteocartilagenous fragment to be from the acetabulum in six patients, femoral head in four, from both in one and one patient had inverted posterior labrum. In addition to this a patient had posterior capsular interposition. Following debridement, congruent reduction was achieved in all patients. At an average follow up of four years and nine months (4.9 years), the functional outcome evaluated by Thompson and Epstein criteria was excellent in 11 cases and good in one case.

Conclusions: Intra articular loose bodies were identified by non-concentric reduction in 12 out of 117 patients with simple hip dislocation. Careful evaluation by immediate post reduction fluoroscopy and good quality radiographs are a must following reduction of hip dislocations.

Introduction: Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous Methods:

Methods: We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus.

Results: The age of the patients varied from 10 to 27. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it is attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years.

Conclusions: Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation.

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded.

At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion.

Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.

Limb-injury severity scores are designed to assess orthopaedic and vascular injuries. In Gustilo type-IIIA and type-IIIB injuries they have poor sensitivity and specificity to predict salvage or outcome.

We have designed a trauma score to grade the severity of injury to the covering tissues, the bones and the functional tissues, grading the three components from one to five. Seven comorbid conditions known to influence the management and prognosis have been given a score of two each. The score was validated in 109 consecutive open injuries of the tibia, 42 type-IIIA and 67 type-IIIB. The total score was used to assess the possibilities of salvage and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group I scored less than 5, group II 6 to 10, group III 11 to 15 and group IV 16 or more.

A score of 14 to indicate amputation had the highest sensitivity and specificity. Our trauma score compared favourably with the Mangled Extremity Severity score in sensitivity (98% and 99%), specificity (100% and 17%), positive predictive value (100% and 97.5%) and negative predictive value (70% and 50%), respectively. A receiver-operating characteristic curve constructed for 67 type-IIIB injuries to assess the efficiency of the scores to predict salvage, showed that the area under the curve for this score was better (0.988 (± 0.013 sem)) than the Mangled Extremity Severity score (0.938 (± 0.039 sem)). All limbs in group IV and one in group III underwent amputation. Of the salvaged limbs, there was a significant difference in the three groups for the requirement of a flap for wound cover, the time to union, the number of surgical procedures required, the total days as an in-patient and the incidence of deep infection (p < 0.001 for all). The individual scores for covering and functional tissues were also found to offer specific guidelines in the management of these complex injuries.

The scoring system was found to be simple in application and reliable in prognosis for both limb-salvage and outcome measures in type-IIIA and type-IIIB open injuries of the tibia.

Study Design: An in-vivo serial magnetic resonance imaging study of diffusion characteristics in human lumbar discs over 24 hours in healthy volunteers and patients with low back pain. Objective: Nutrition to the disc is solely by diffusion but no firm data is available on diffusion pattern in humans. This study reports diffusion patterns in a human population studied and documents the 24-hour diffusion pattern.

Methods: T1-weighted images were obtained pre and post-contrast with Gadodiamide-0.3mmol/kg at 5, 10 minutes, 2, 4, 6, 12 and 24hours. Diffusion was calculated by measuring signal intensity values in seven regions of interest (anterior and posterior annulus, anterior, posterior, peripheral (PNP) and central (CNP) parts of nucleus pulposus (NP). Enhancement percentage (EP), Peak enhancement percentage (PEP) and time to achieve PEP (T_max) were calculated.

Subjects: Of the 215 discs in 43 persons (10 volunteers and 33 patients) 96 discs were normal and considered for study.

Results: Diffusion occurred mainly from the endplate (rather than annulus). The mean EP of PNP and CNP at 5 minutes was 6.7, 3.9; 10minutes was 7.5, 4.0; 2 hours was 36.6, 17.9; 4hrs was 42.8, 29.8; 6hrs was 51.7, 40.5; 12hrs was 35.9, 27.8 and 24 hours was 33.3, 27.9. Though PEP was achieved at 6 hours in NP, the CNP lagged behind throughout. Univariate ANOVA showed that there was significant difference (p< 0.0001) in PEP of NP between the age groups of less than ten (72.4) and higher (37.9). The mean PEP at the NP of lower two discs (26.8) was less compared to upper two discs 41.0(p=0.059). Stepwise linear regression analysis showed that diffusion to the CNP was significantly influenced by age (R² =0.324), followed by level of disc (R²=0.5).

Conclusion: This is the first study to document the normal 24-hour diffusion pattern across lumbar discs. The data can form the basis for comparison of diffusion changes in degeneration, Modic’s endplate changes and smoking.

Ochronosis, the musculoskeletal manifestation of alkaptonuria, is known to lead to degenerative changes of the spine and weight-bearing joints. Symptoms related to degeneration of tendons or ligaments with spontaneous ruptures have not previously been reported. Three patients are described with four spontaneous ruptures of either the patellar tendon or tendo Achillis as the first symptom of alkaptonuria.

The progression of post-tubercular kyphosis in 61 children who received ambulatory chemotherapy was studied prospectively. The angles of deformity and kyphosis were measured for each patient at diagnosis, 3, 6, 9, 12 and 18 months later and every year thereafter for 15 years. During the course of the disease signs of instability appeared on the radiographs of some of the children. These were dislocation of the facets, posterior retropulsion of the diseased fragments, lateral translation of the vertebrae in the anteroposterior view and toppling of the superior vertebra. Each sign was allocated one point to create a spinal instability score. The influence on the progression of the deformity of the level of the lesion, the vertebral body loss, the number of segments involved, the angle of deformity before treatment and the spinal instability score was analysed.

The mean angle of deformity at the start of treatment was 35°. This increased to 41° at 15 years. Progression occurred during the active phase of the disease and again after cure when variations in progression were observed. Type-I progression showed an increase in deformity until growth had ceased. This could occur either continuously (type Ia) or after a lag period of three to five years (type Ib). Type-II progression showed decrease in deformity with growth. This could occur immediately after the active phase (type IIa) or after a lag period of three to five years (type IIb). Type-III progression showed minimal change during either the active or healed phases and was seen only in those with limited disease.

Multiple regression analysis showed that a spinal instability score of more than 2 was a reliable predictor of patients with an increase of more than 30° in deformity and a final deformity of over 60°. Since signs of radiological instability appear early in the disease, they can be reliably used to identify children whose spine is at risk for late progressive collapse. Surgery is advised in these cases.