To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs).Aims
Methods
Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to
Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform. In all, 188 patients with suspected CES underwent a LS lumbosacral MRI between the beginning of September 2017 and the end of July 2018. These images were read by a consultant musculoskeletal radiologist. All images took place on a 3T or 1.5T MRI scanner at Stoke Mandeville Hospital, Aylesbury, UK, and Royal Berkshire Hospital, Reading, UK.Aims
Methods
The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury. The outcome of radial head resection was compared with prosthetic arthroplasty in 29 and 15 patients with terrible triad injuries, respectively. There were ten female patients (34.5%) in the resection group and six female patients (40%) in the prosthesis group. The mean age was 40.7 years (Aims
Patients and Methods
The aim of this study was to compare the pain caused by the application
of a tourniquet after exsanguination of the upper limb with that
occurring after simple elevation. We used 26 healthy volunteers (52 arms), each of whom acted as
their own matched control. The primary outcome measure was the total pain experienced by
each volunteer while the tourniquet was inflated for 20 minutes.
This was calculated as the area under the pain curve for each individual
subject. Secondary outcomes were pain at each time point; the total
pain experienced during the recovery phase; the ability to tolerate the
tourniquet and the time for full recovery after deflation of the
tourniquet. Aims
Patients and Methods
Aims. The aim of this study was to evaluate the time course of changes
in parameters of diffusion tensor imaging (DTI) such as fractional
anisotropy (FA) and apparent diffusion coefficient (ADC) in patients
with symptomatic lumbar disc herniation. We also investigated the
correlation between the severity of neurological symptoms and these parameters. . Patients and Methods. A total of 13 patients with unilateral radiculopathy due to herniation
of a lumbar disc were investigated with DTI on a 1.5T MR scanner
and underwent micro discectomy. There were nine men and four women,
with a median age of 55.5 years (19 to 79). The changes in the mean
FA and ADC values and the correlation between these changes and the
severity of the neurological symptoms were investigated before and
at six months after surgery. . Results. The mean FA values were significantly lower (p = 0.0005) and
mean ADC values were significantly higher (p = 0.0115) in compressed
nerves than in intact nerves. Although the FA values increased significantly
at six months after surgical treatment (p = 0.020), the ADC values
decreased but not significantly (p = 0.498). There were strong correlations
between the DTI parameters such as the FA value and the severity
of the neurological symptoms as assessed using the Japanese Orthopaedic
Association (JOA) score and the Roland-Morris Disability Questionnaire (RDQ). . Conclusion. This preliminary study suggests that it may be possible to use
DTI to diagnose, quantitatively evaluate and follow-up patients
with lumbar
The widespread use of MRI has revolutionised
the diagnostic process for spinal disorders. A typical protocol
for spinal MRI includes T1 and T2 weighted sequences in both axial
and sagittal planes. While such an imaging protocol is appropriate
to detect pathological processes in the vast majority of patients,
a number of additional sequences and advanced techniques are emerging.
The purpose of the article is to discuss both established techniques
that are gaining popularity in the field of spinal imaging and to
introduce some of the more novel ‘advanced’ MRI sequences with examples
to highlight their potential uses. Cite this article:
We present the results of 62 consecutive acetabular
revisions using impaction bone grafting and a cemented polyethylene
acetabular component in 58 patients (13 men and 45 women) after
a mean follow-up of 27 years (25 to 30). All patients were prospectively
followed. The mean age at revision was 59.2 years (23 to 82). We performed Kaplan–Meier (KM) analysis and also a Competing
Risk (CR) analysis because with long-term follow-up, the presence
of a competing event (i.e. death) prevents the occurrence of the
endpoint of re-revision. A total of 48 patients (52 hips) had died or had been re-revised
at final review in March 2011. None of the deaths were related to
the surgery. The mean Harris hip score of the ten surviving hips
in ten patients was 76 points (45 to 99). The KM survivorship at 25 years for the endpoint ‘re-revision
for any reason’ was 58.0% (95% confidence interval (CI) 38 to 73)
and for ‘re-revision for aseptic loosening’ 72.1% (95% CI 51 to
85). With the CR analysis we calculated the KM analysis overestimates
the failure rate with respectively 74% and 93% for these endpoints.
The current study shows that acetabular impaction bone grafting
revisions provide good clinical results at over 25 years. Cite this article:
We report a new surgical technique of open carpal
tunnel release with subneural reconstruction of the transverse carpal
ligament and compare this with isolated open and endoscopic carpal
tunnel release. Between December 2007 and October 2011, 213 patients with carpal
tunnel syndrome (70 male, 143 female; mean age 45.6 years; 29 to
67) were recruited from three different centres and were randomly
allocated to three groups: group A, open carpal tunnel release with
subneural reconstruction of the transverse carpal ligament (n =
68); group B, isolated open carpal tunnel release (n = 92); and
group C, endoscopic carpal tunnel release (n = 53). At a mean final follow-up of 24 months (22 to 26), we found no
significant difference between the groups in terms of severity of
symptoms or lateral grip strength. Compared with groups B and C,
group A had significantly better functional status, cylindrical
grip strength and pinch grip strength. There were significant differences
in Michigan Hand Outcome scores between groups A and B, A and C,
and B and C. Group A had the best functional status, cylindrical
grip strength, pinch grip strength and Michigan Hand Outcome score. Subneural reconstruction of the transverse carpal ligament during
carpal tunnel decompression maximises hand strength by stabilising
the transverse carpal arch. Cite this article:
The treatment of infected nonunions is difficult.
Antibiotic cement-coated (ACC) rods provide stability as well as delivering
antibiotics. We conducted a review of 110 infected nonunions treated
with ACC rods. Patients were divided into two groups: group A (67
patients) with an infected arthrodesis, and group B (43 patients)
with an infected nonunion in a long bone. In group A, infected arthrodesis,
the success rate after the first procedure was 38/67 (57%), 29/67
(43%) required further surgery for either control of infection or
non-union. At last follow-up, five patients required amputation,
representing a limb salvage rate of 62/67 (93%) overall. In all,
29/67 (43%) presented with a bone defect with a mean size of 6.78
cm (2 to 25). Of those with a bone defect, 13/29 (45%) required
further surgery and had a mean size of defect of 7.2 cm (3.5 to
25). The cultures were negative in 17/67 (26%) and the most common
organism cultured was methicillin-resistant Cite this article:
The outcome of high tibial osteotomy (HTO) deteriorates
with time, and additional procedures may be required. The aim of
this study was to compare the clinical and radiological outcomes
between unicompartmental knee replacement (UKR) and total knee replacement
(TKR) after HTO as well as after primary UKR. A total of 63 patients (63
knees) were studied retrospectively and divided into three groups:
UKR after HTO (group A; n = 22), TKR after HTO (group B; n = 18)
and primary UKR (group C; n = 22). The Oxford knee score (OKS),
Knee Society score (KSS), hip–knee–ankle angles, mechanical axis
and patellar height were evaluated pre- and post-operatively. At
a mean of 64 months (19 to 180) post-operatively the mean OKS was
43.8 (33 to 49), 43.3 (30 to 48) and 42.5 (29 to 48) for groups
A, B and C, respectively (p = 0.73). The mean KSS knee score was
88.8 (54 to 100), 88.11 (51 to 100) and 85.3 (45 to 100) for groups
A, B and C, respectively (p = 0.65), and the mean KSS function score
was 85.0 (50 to 100) in group A, 85.8 (20 to 100) in group B and
79.3 (50 to 100) in group C (p = 0.48). Radiologically the results
were comparable for all groups except for patellar height, with
a higher incidence of patella infra following a previous HTO (p
= 0.02). Cite this article:
Like athletes, musicians are vulnerable to musculoskeletal
injuries that can be career ending or have a severe negative financial
impact. All ages are affected, with a peak incidence in the third
and fourth decades. Women are slightly more likely to be affected
than men. It is incumbent upon orthopaedic surgeons to be able to
complete a thorough physical assessment, be aware of the risk factors
associated with musculoskeletal symptoms in musicians, and have
a detailed knowledge of the specific syndromes they suffer and their
appropriate treatment. In this paper we review the common hand injuries that afflict
musicians and discuss their treatment. Cite this article:
Diabetes mellitus is recognised as a risk factor
for carpal tunnel syndrome. The response to treatment is unclear,
and may be poorer than in non-diabetic patients. Previous randomised
studies of interventions for carpal tunnel syndrome have specifically
excluded diabetic patients. The aim of this study was to investigate
the epidemiology of carpal tunnel syndrome in diabetic patients,
and compare the outcome of carpal tunnel decompression with non-diabetic
patients. The primary endpoint was improvement in the QuickDASH
score. The prevalence of diabetes mellitus was 11.3% (176 of 1564).
Diabetic patients were more likely to have severe neurophysiological
findings at presentation. Patients with diabetes had poorer QuickDASH
scores at one year post-operatively (p = 0.028), although the mean
difference was lower than the minimal clinically important difference
for this score. After controlling for underlying differences in
age and gender, there was no difference between groups in the magnitude of
improvement after decompression (p = 0.481). Patients with diabetes
mellitus can therefore be expected to enjoy a similar improvement
in function.
The use of passive stretching of the elbow after
arthrolysis is controversial. We report the results of open arthrolysis in
81 patients. Prospectively collected outcome data with a minimum
follow-up of one year were analysed. All patients had sustained
an intra-articular fracture initially and all procedures were performed
by the same surgeon under continuous brachial plexus block anaesthesia
and with continuous passive movement (CPM) used post-operatively
for two to three days. CPM was used to maintain the movement achieved
during surgery and passive stretching was not used at any time.
A senior physiotherapist assessed all the patients at regular intervals.
The mean range of movement (ROM) improved from 69° to 109° and the
function and pain of the upper limb improved from 32 to 16 and from
20 to 10, as assessed by the Disabilities of the Arm Shoulder and
Hand score and a visual analogue scale, respectively. The greatest
improvement was obtained in the stiffest elbows: nine patients with
a pre-operative ROM <
30° achieved a mean post-operative ROM
of 92° (55° to 125°). This study demonstrates that in patients with
a stiff elbow after injury, good results may be obtained after open
elbow arthrolysis without using passive stretching during rehabilitation.
Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient’s local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.
We have reviewed 38 surgically treated cases of spontaneous posterior interosseous nerve palsy in 38 patients with a mean age of 43 years (13 to 68) in order to identify clinical factors associated with its prognosis. Interfascicular neurolysis was performed at a mean of 13 months (1 to 187) after the onset of symptoms. The mean follow-up was 21 months (5.5 to 221). Medical Research Council muscle power of more than grade 4 was considered to be a good result. A further 12 cases in ten patients were treated conservatively and assessed similarly. Of the 30 cases treated surgically with available outcome data, the result of interfascicular neurolysis was significantly better in patients <
50 years old (younger group (18 nerves); good: 13 nerves (72%), poor: five nerves (28%)) than in cases >
50 years old (older group (12 nerves); good: one nerve (8%), poor: 11 nerves (92%)) (p <
0.001). A pre-operative period of less than seven months was also associated with a good result in the younger group (p = 0.01). The older group had a poor result regardless of the pre-operative delay. Our recommended therapeutic approach therefore is to perform interfascicular neurolysis if the patient is <
50 years of age, and the pre-operative delay is <
seven months. If the patient is >
50 years of age with no sign of recovery for seven months, or in the younger group with a pre-operative delay of more than a year, we advise interfascicular neurolysis together with tendon transfer as the primary surgical procedure.
We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery.
Idiopathic calcium pyrophosphate deposition disease (pseudogout) has a variable presentation. Many joints are usually affected; single joint disease is uncommon. We present a case report of primary monoarticular pseudogout affecting the hip. The diagnosis was made on the appearance and analysis of specimens obtained at arthroscopy. Monoarticular pseudogout is rare, but should be considered in the differential diagnosis of any presentation of joint pain.
Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement.
Complex regional pain syndrome is characterised by an exaggerated response to injury in a limb with intense prolonged pain, vasomotor disturbance, delayed functional recovery and trophic changes. This review describes the current knowledge of the condition and outlines the methods of treatment available with particular emphasis on the knee.
