Aims. The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant
The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of
Aims. Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. Methods. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. Results. The study confirms the low predictive value of ‘red flag’
Aims. Early cases of cauda equina syndrome (CES) often present with nonspecific
There is no universally agreed definition of
cauda equina syndrome (CES). Clinical signs of CES including direct
rectal examination (DRE) do not reliably correlate with cauda equina (CE)
compression on MRI. Clinical assessment only becomes reliable if
there are
Aims. To report our experience with trunnion corrosion following metal-on-polyethylene
total hip arthroplasty, in particular to report the spectrum of
presentation and determine the mean time to presentation. Patients and Methods. We report the presenting
Aims. The aim of the British Association for Surgery of the Knee (BASK) Meniscal Consensus Project was to develop an evidence-based treatment guideline for patients with meniscal lesions of the knee. Materials and Methods. A formal consensus process was undertaken applying nominal group, Delphi, and appropriateness methods. Consensus was first reached on the terminology relating to the definition, investigation, and classification of meniscal lesions. A series of simulated clinical scenarios was then created and the appropriateness of arthroscopic meniscal surgery or nonoperative treatment in each scenario was rated by the group. The process was informed throughout by the latest published, and previously unpublished, clinical and epidemiological evidence. Scenarios were then grouped together based upon the similarity of clinical features and ratings to form the guideline for treatment. Feedback on the draft guideline was sought from the entire membership of BASK before final revisions and approval by the consensus group. Results. A total of 45 simulated clinical scenarios were refined to five common clinical presentations and six corresponding treatment recommendations. The final guideline stratifies patients based upon a new, standardized classification of
Aims. Diabetes mellitus is the most common co-morbidity associated
with necrotising fasciitis. This study aims to compare the clinical
presentation, investigations, Laboratory Risk Indicator for Necrotising
Fasciitis (LRINEC) score, microbiology and outcome of management
of this condition in diabetic and non-diabetic patients. Patients and Methods. The medical records of all patients with surgically proven necrotising
fasciitis treated at our institution between 2005 and 2014 were
reviewed. Diagnosis of necrotising fasciitis was made on findings
of ‘dishwater’ fluid, presence of greyish necrotic deep fascia and
lack of bleeding on muscle dissection found intra-operatively. Information
on patients’ demographics, presenting
Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research. A literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had ‘suspected CES’; ‘early CES’; ‘incomplete CES’; or ‘CES with urinary retention’. Inter-rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss’s kappa.Aims
Methods
The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation.Aims
Methods
Intra-articular (IA) tumours around the knee are treated with extra-articular (EA) resection, which is associated with poor functional outcomes. We aim to evaluate the accuracy of MRI in predicting IA involvement around the knee. We identified 63 cases of high-grade sarcomas in or around the distal femur that underwent an EA resection from a prospectively maintained database (January 1996 to April 2020). Suspicion of IA disease was noted in 52 cases, six had IA pathological fracture, two had an effusion, two had prior surgical intervention (curettage/IA intervention), and one had an osseous metastasis in the proximal tibia. To ascertain validity, two musculoskeletal radiologists (R1, R2) reviewed the preoperative imaging (MRI) of 63 consecutive cases on two occasions six weeks apart. The radiological criteria for IA disease comprised evidence of tumour extension within the suprapatellar pouch, intercondylar notch, extension along medial/lateral retinaculum, and presence of IA fracture. The radiological predictions were then confirmed with the final histopathology of the resected specimens.Aims
Methods
The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis.Aims
Methods
The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition. Between July 2017 and July 2019, 40 patients with cervical OPLL were equally randomized to undergo surgery with an ACOE or a PTLF. The clinical and radiological results were compared between the two groups.Aims
Methods
We report five patients with nutritional osteomalacia who presented with the
1. Three patients are reported in whom a sudden acute internal derangement of the knee was caused by torsion of a pedunculated portion of the infrapatellar fat pad. 2. The
We present a patient with an arteriovenous fistula of the peroneal artery acquired after a left dome tibial osteotomy with midshaft fibular osteotomy. He had subsequently had a total knee replacement on that side. The arteriovenous malformation was only diagnosed when he represented with
Eighteen patients with acute compartment syndromes below the knee were treated with four-compartment fasciotomies using the double-incision technique. Pre-operative tissue pressure measurements ranged from 28 to 47 mmHg. If fasciotomy was performed within 24 hours of the onset of clinical
Six patients with severe haemophilic arthropathy of the elbow have been treated by limited excision arthroplasty using a sheet of silicone rubber as an interposition membrane. There were no complications. The
The familiar picture of spinal tuberculosis is one of destruction of adjacent vertebral bodies and of the intervening disc. There are, however, other patients without these radiographic changes and with no clinical deformity who present with
In this retrospective study, we analysed the clinical features of neurilemoma when it is located in muscle. Twelve patients had an intramuscular neurilemoma as shown on magnetic resonance (MR) scans and confirmed at operation. In six it was located in the upper limb, in five in the lower limb, and in one in the back. The mean age of the patients was 41 years (12 to 58). Nine complained only of a palpable mass and the other three of a mass with slight tenderness. None had neurological
1. Of 456 patients with features of herniated intervertebral disc eight were under twenty years of age. 2. Differences in the pattern of clinical presentation of the herniated disc syndrome in adults and in adolescents are discussed. 3. Whereas in the adult conservative treatment is usually successful, this is not so in the adolescent, in whom the
1. Thirteen instances of compression of the lower trunk of the brachial plexus at the thoracic inlet are described. 2. In each case the cause of compression was an aponeurotic band passing from the seventh cervical transverse process to the first rib. 3. The
Two patients, a Japanese man and woman both aged eighteen, developed
1. Nineteen patients with classical rheumatoid arthritis complicated by severe subluxation of the cervical spine are reported. 2. Thirteen patients had atlanto-axial subluxation. This was the only level ofinvolvement in ten. 3. The next most frequent level to be involved was C.4-5. This occurred in five patients. 4. Eleven patients required surgery for
1. Twenty-seven patients with a Brown-SeÌquard syndrome resulting from trauma have been studied, fourteen of the left side of the cord and thirteen of the right. There were sixteen gunshot wounds and eleven closed injuries. 2. The prognosis for recovery is much better than the initial catastrophic nature of the
1. The treatment is described of a consecutive series of fourteen patients suffering from rheumatoid arthritis causing a slip of the cervical vertebrae, mainly at the C.1-2 level, and a cord lesion. 2. The importance of a change of
We reviewed 52 cases of osteomyelitis of the calcaneum. The clinical
Six boys with fragmentation of the proximal pole of the patella are reported; the condition was bilateral in one. Four of the six presented with symptoms of Osgood-Schlatter's disease or Larsen-Johansson disease of the same or of the contralateral knee, but they had no
Between 1948 and 1975 147 patients were treated surgically for developmental stenosis of the lumbar vertebral canal, measurement of the mid-sagittal diameters in the whole area of stenosis being performed in 116 patients. Ninety-two of these patients were followed up for periods varying between one and twenty years. About two-thirds were completely relieved fo
Late degenerative changes are known to follow meniscectomy, but there is little agreement on their incidence or on which patients are most at risk. A total of 210 patients have been reviewed 10 to 22 years after meniscectomy, and long leg radiographs taken of both knees. Radiological degeneration was seen in 18%, while 7% had significant
1. Thirty-four patients with severe lumbo-sacral subluxation have been studied. Twenty-nine of these came for advice between the ages of nine and nineteen, and of these, twenty-five developed
We investigated the incidence of evidence of irritation of the brachial plexus in 119 patients with whiplash injuries sustained in road-traffic accidents. We compared the
Thirty-five patients who had been surgically treated for major symptomatic isolated chronic anterior cruciate ligament deficiency by lateral extra-articular reconstruction alone were reviewed at an average of five years after operation. Seventy-seven per cent of patients reviewed were improved subjectively, and 83% of patients who were examined had objective evidence of only minor instability or none at follow-up. However, only a few patients had "normal" knees and many continued to have minor symptoms of instability with some restriction of activity. Most of the unsatisfactory results were in patients with significant chondral pathology at the time of reconstruction. While an extra-articular pivot-shift repair did not correct all the
A series of 75 patients who had undergone anterior cervical fusion between 1965 and 1977 were reviewed. The patients were divided into two groups: those in Group A had had the level of fusion indicated by cine radiography, whereas in Group B the level had been determined by plain radiographs and clinical
1. Paralysis of the femoral nerve secondary to haemorrhage of the iliopsoas muscle is described. 2. Four cases are presented. None of the patients had haemophilia, but one was receiving anticoagulant treatment–the second reported case in the literature. Only one case in a non-haemophiliac not receiving anticoagulants has been described previously. We have added three more such cases. 3. This condition can usually be managed conservatively because recovery can be expected. We believe that operation is indicated only if the lesion progresses and the
1. Thirty-five children suffering from a mild illness with narrowing of an intervertebral disc have been studied. 2. Backache was the presenting symptom in only a small proportion of children, vague aching in the legs being almost as common at the onset. 3. Stiffness of the affected part of the spine is often present, but there may be no abnormal signs in the back. 4. Radiographs reveal a narrowed disc space with adjacent bony changes. There is usually progressive narrowing of the disc space which may go on to fusion of the affected vertebrae. Less commonly there is reconstitution of the affected disc. 5. The
Since January 1993 we have carried out MR arthrography on 23 patients with clinical
In a prospective, consecutive study we determined the frequency of common
Diurnal changes in the loads acting on the spine affect the water content and height of the intervertebral discs. We have reviewed the effects of these changes on spinal mechanics, and their possible clinical significance. Cadaveric lumbar spines subjected to periods of creep loading show a disc height change similar to the physiological change. As a result intervertebral discs bulge more, become stiffer in compression and more flexible in bending. Disc tissue becomes more elastic as its water content falls, and its affinity for water increases. Disc prolapse becomes more difficult. The neural arch and associated ligaments resist an increasing proportion of the compressive and bending stresses acting on the spine. Observations on living people show that these changes are not fully compensated for by modified muscle activity. We conclude that different spinal structures are more heavily loaded at different times of the day. Therefore, the time of onset of
1. The term "observation hip" refers to a form of hip disease affecting children and adolescents, the most significant features being the transient nature of the symptoms and the absence of a bony or cartilaginous lesion on radiographic examination. 2. With a view to determining the possible sequelae of the disorder, twenty-three patients aged between two and fifteen years at the onset of the condition were studied fifteen to thirty years later. 3. Varying degrees of coxa magna, osteoarthritis or simple broadening of the femoral neck in the "observed" hip joint were found in the radiographs of twelve of the twenty-three patients studied. 4. This analysis suggests that the " observation hip" syndrome is the result ofan inflammatory process ofthejoint due to varied etiology, whether from injury or infection. The developmental and degenerative changes which may occur are a consequence of hypervascularisation of the bone. Thus changes may develop without necessarily producing the epiphysial necrosis characteristic of the first stage of ischaemia in Legg-Calvé-Perthes' disease. 5. The persistence of this stage of hypervascularity, and therefore the possible outcome of the transient synovitis, may be conditioned by the age at onset of the pathological process, the severity of the condition, and the duration of the
We investigated the outcome of deep-vein thrombosis (DVT) in the calf after total knee arthroplasty (TKA) in 48 patients (45 women and three men) by clinical assessment and venographic study between three and four years after surgery. The mean age of the patients was 67.2 ± 7.7 years (52 to 85) and the mean follow-up was 42.6 ± 2.7 months (38 to 48). The diagnosis was osteoarthritis in 47 patients and rheumatoid arthritis in one patient. There were 44 calf thrombi, four popliteal thrombi but no thrombi in the femoral or iliac regions. Of the 48 patients, 24 were clinically symptomatic and 24 were asymptomatic. Clinical examination was carried out on 41 patients, of whom 37 underwent ascending venography. Seven were evaluated by telephone interview. No patient had the
Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients. Retrospective access to our prospectively maintained oncology database yielded a cohort of 48 patients across 23 years with a median follow-up of 12 months (0 to 78) and mean age at diagnosis of 92 years (90 to 99). Overall, 42 of 48 of 48 patients (87.5%) were managed surgically with either limb salvage or amputation.Aims
Methods
We have studied prospectively the outcome of wound discharge in patients after arthroplasty of the hip and knee. Over a period of 3.5 years 530 primary arthroplasties were carried out in one hospital. Postoperative wound infections developed in 82. At a mean follow-up of two years a comparison was made between these patients and 82 with healthy wounds, in terms of
1. The synovial membrane and capsule in osteoarthritis of the hip have been studied in twenty-five cases. Dissections have been made on fresh cadavers to establish the normal structure and function of these tissues at different ages. 2. Fragments of bone and cartilage were found beneath the synovial surface in twenty-three cases of the twenty-five cases of osteoarthritis. 3. The source of these fragments is the degenerate articular surfaces. 4. The fibrosis of the synovial membrane and capsule follows the synovial hyperplasia which accompanies the phagocytosis of these fragments. 5. A similar histological picture has been produced by injecting fragmented cartilage into the knee joints of rabbits. The injected fragments are found beneath the surface, and synovial hyperplasia is followed by subsynovial fibrosis. 6. The greatest amount of this joint debris is found in the lowest part of the joint cavity. 7. The joint capsule is particularly sensitive to traction. 8. All parts of the capsule are tight in extension, which is the weight-bearing position. 9. Fibrotic shortening of the capsule in the lowest part of the joint cavity explains many of the
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. The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination.Aims
Methods
Aims. The aim of this study was to report the outcome of the non-operative
treatment of high-grade posterior cruciate ligament (PCL) injuries,
particularly Hughston grade III injuries, which have not previously
been described. Patients and Methods. This was a prospective study involving 46 consecutive patients
who were athletes with MRI-confirmed isolated PCL injuries presenting
within four weeks of injury. All had Hughston grade II (25 athletes)
or III (21 athletes) injuries. Our non-operative treatment regimen
involved initial bracing, followed by an individualised rehabilitation
programme determined by the
1. The amount of orthopaedic surgery which is possible in patients with leprosy is immense. It is likely to decline with improved medical care as deformity rarely begins after the start of medical treatment. In spite of prolonged chemotherapy, skin smears often remain positive for more than five years and lifelong treatment may be necessary. 2. In Hong Kong the disease affects mainly those in the best working years of their lives and at an age when they should be best able to understand the benefits that treatment confers. Education of the public must be one of the main points of disease control. This education should extend to enable patients with anaesthetic extremities to learn the limitations that the disease places upon their activities. Thus they will be less liable to injure themselves and better able to prevent minor injuries from becoming serious. Ulceration only occurs in areas lacking protective sensation but, although bilateral anaesthesia is common, bilateral ulceration is not often seen. 3. In patients with diminished sensation or with paralysed muscle groups there is usually enlargement of the nerves but this may be difficult to detect. 4. Clawing of the fingers is best treated by standard surgical procedures but opposition transplant in the combined median and ulnar nerve paralysis of leprosy is less satisfactory. Any transplant must prevent hyperextension at the metacarpo-phalangeal joint and this is best done by providing a double insertion for the transplant. If the soft tissues between the first and second metacarpals are contracted it is better to perform osteotomy of the base of the first metacarpal bone rather than to perform the standard operation of soft-tissue release and skin grafting. 5. The value of tibialis posterior transplantation in drop-foot has been confirmed. 6. The problem of fitting an artificial limb to an anaesthetic stump has not been solved. It was often found that ulcers of the stump occurred even with well-fitting sockets and cooperative patients. If amputation above the foot is necessary it is usually wiser to try a through-knee amputation. 7. Return of power or sensation after the start of medical treatment is unusual but it is also unusual for these symptoms to be noted for the first time when the patient is taking sulphones. It would be worth while investigating the effects of decompression of the median nerve at the level of the wrist by dividing the carpal ligament in those patients developing
We report our experience of performing an elbow
hemiarthroplasty in the treatment of comminuted distal humeral fractures
in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72;
56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after
surgery. Functional outcome was measured with the Mayo Elbow Performance
Score (MEPS) and range of movement. The disabilities of the arm,
shoulder and hand questionnaire (DASH) was used as a patient rated
evaluation. Complications and ulnar nerve function were recorded.
Plain radiographs were obtained to assess prosthetic loosening,
olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion
was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°).
The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0
to 63). Four patients had additional surgery for limited range of
movement and one for partial instability. One elbow was revised
due to loosening, two patients had sensory ulnar nerve
Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue. Between October 2010 and July 2018, 102 patients with a mean age of 43 years (19 to 67), including 101 males, underwent distal biceps tendon repair less than six weeks after the injury, using cortical button fixation. The primary short-term outcome measure was the rate of complications. The primary long-term outcome measure was the abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Secondary outcomes included the Oxford Elbow Score (OES), EuroQol five-dimension three-level score (EQ-5D-3L), satisfaction, and return to function.Aims
Methods
The aim of this study was to determine the diagnostic accuracy of α defensin (AD) lateral flow assay (LFA) and enzyme-linked immunosorbent assay (ELISA) tests for periprosthetic joint infection (PJI) in comparison to conventional synovial white blood cell (WBC) count and polymorphonuclear neutrophil percentage (PMN%) analysis. Patients undergoing joint aspiration for evaluation of pain after total knee arthroplasty (TKA) or total hip arthroplasty (THA) were considered for inclusion. Synovial fluids from 99 patients (25 THA and 74 TKA) were analyzed by WBC count and PMN% analysis, AD LFA, and AD ELISA. WBC and PMN% cutoffs of ≥ 1,700 cells/mm3 and ≥ 65% for TKA and ≥ 3,000 cells/mm3 and ≥ 80% for THA were used, respectively. A panel of three physicians, all with expertise in orthopaedic infections and who were blinded to the results of AD tests, independently reviewed patient data to diagnose subjects as with or without PJI. Consensus PJI classification was used as the reference standard to evaluate test performances. Results were compared using McNemar’s test and area under the receiver operating characteristic curve (AUC) analysis.Aims
Methods
Metagenomic next-generation sequencing (mNGS) is useful in the diagnosis of infectious disease. However, while it is highly sensitive at identifying bacteria, it does not provide information on the sensitivity of the organisms to antibiotics. The purpose of this study was to determine whether the results of mNGS can be used to guide optimization of culture methods to improve the sensitivity of culture from intraoperative samples. Between July 2014 and October 2019, patients with suspected joint infection (JI) from whom synovial fluid (SF) was obtained preoperatively were enrolled. Preoperative aspirated SF was analyzed by conventional microbial culture and mNGS. In addition to samples taken for conventional microbial culture, some samples were taken for intraoperative culture to optimize the culture method according to the preoperative mNGS results. The demographic characteristics, medical history, laboratory examination, mNGS, and culture results of the patients were recorded, and the possibility of the optimized culture methods improving diagnostic efficiency was evaluated.Aims
Methods
Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included.Aims
Methods
The aim of this study was to use diffusion tensor imaging (DTI) to investigate changes in diffusion metrics in patients with cervical spondylotic myelopathy (CSM) up to five years after decompressive surgery. We correlated these changes with clinical outcomes as scored by the Modified Japanese Orthopedic Association (mJOA) method, Neck Disability Index (NDI), and Visual Analogue Scale (VAS). We used multi-shot, high-resolution, diffusion tensor imaging (ms-DTI) in patients with cervical spondylotic myelopathy (CSM) to investigate the change in diffusion metrics and clinical outcomes up to five years after anterior cervical interbody discectomy and fusion (ACDF). High signal intensity was identified on T2-weighted imaging, along with DTI metrics such as fractional anisotropy (FA). MJOA, NDI, and VAS scores were also collected and compared at each follow-up point. Spearman correlations identified correspondence between FA and clinical outcome scores.Aims
Methods
The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures. A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded.Aims
Methods
1. The
1. An account is given of fifty stress fractures of the fibula which occurred in athletes. 2. The characteristic
Injury of the neck may result when a motor vehicle is run into from behind; such injury is frequently the cause of prolonged disability and litigation. We report a series of 61 patients with these injuries. A classification, based upon the presenting
Four hundred and fifteen patients with cementless acetabular components of either a smooth threaded (130) or porous surfaced (285) variety were compared for clinical
We made a prospective longitudinal clinical and radiological study of 18 children diagnosed as having dysplasia epiphysealis capitis femoris. Half the cases were bilateral. Boys were affected five times more often than girls. There were no
1. Chondromalacia, sometimes a precursor of osteoarthritis, is present in the articular cartilage of the patella of most people by the age of thirty; it causes symptoms in only a few, and it gives rise to osteoarthritis in fewer still. It may progress slowly or quickly but there is no clinical method of assessing the prognosis at an early stage. 2. The earliest change is swelling of the cartilage associated with a decrease in the chondroitin sulphuric acid content of the matrix. Later the cartilage fissures and flakes off to expose the bone, and there are reactive changes in the cartilage, bone and synovial membrane. The process is described and the etiology discussed. 3. The
Carpal tunnel syndrome is a common condition and clinical diagnosis is often easily made. A system of direct referral for day-case carpal tunnel surgery was introduced. General practitioners, physicians and surgeons were advised of the service and the criteria for referral, which included female patients with bilateral
We describe 12 children with idiopathic scoliosis who had a persistent absent superficial abdominal reflex (SAR) on routine neurological examination. MRI showed syringomyelia to be present in ten. The average age at detection of the scoliosis was 4.3 years and at diagnosis of syringomyelia 6.6 years. In all ten children the SAR was consistently absent on the same side as the convexity of the curve. In two it was the only abnormal neurological sign. An absent SAR in patients with scoliosis is an indication for investigation for underlying syringomyelia. In the children with syringomyelia, six had thoracic and four thoracolumbar curves. The clinical features differed in the two groups. Patients with thoracic curves were generally asymptomatic. Their neurological signs were subtle and none had any motor signs. By contrast, patients with thoracolumbar curves had
Children with a mucopolysaccharidosis or mucolipidosis suffer progressive disability of the hands, particularly in relation to dysfunction of the median nerve. This is an increasing problem because bone-marrow transplantation has dramatically improved survival without apparently changing the musculoskeletal manifestations. We have reviewed 48 children with these syndromes who required carpal tunnel decompression, recording
To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer. A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls.Aims
Methods
The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter.Aims
Patients and Methods
Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection. A total of 119 patients undergoing revision total hip arthroplasty (THA) between June 2015 and December 2017 were included in the study. There were 56 men and 63 women with a mean age of 66.2 years (27 to 88). Synovial fluid was collected before arthrotomy for the assessment of LE using enzymatic colourimetric strips. Between five and six samples were stained with haematoxylin and eosin for FS histology, and considered suggestive of infection when at least five polymorphonuclear leucocytes were found in five high-power fields.Aims
Patients and Methods
Single-stage revision is not widely pursued due to restrictive inclusion criteria. In this study, we evaluated the results of single-stage revision of chronically infected total hip arthroplasty (THA) using broad inclusion criteria and cementless implants. Between 2010 and 2016, 126 patients underwent routine single-stage revision with cementless reconstruction with powdered vancomycin or imipenem poured into the medullary cavity and re-implantation of cementless components. For patients with a culture-negative hip, fungal infections, and multidrug-resistant organisms, a direct intra-articular infusion of pathogen-sensitive antibiotics was performed postoperatively. Recurrence of infection and clinical outcomes were evaluated. Three patients died and 12 patients (none with known recurrent infection) were lost to follow-up. There were 111 remaining patients (60 male, 51 female) with a mean age of 58.7 (Aims
Patients and Methods
Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation. Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted.Aims
Patients and Methods
The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation. A total of 134 haemodialyzed patients aged more than 50 years who underwent surgical treatment for pyogenic spondylodiscitis were included in the study. Their mean age was 66.4 years (50 to 83); 66 were male (49.3%) and 68 were female (50.7%). They were divided into two groups according to whether spinal instrumentation was used or not. Propensity score matching was used to attenuate the potential selection bias. The outcome of treatment was compared between these two groups.Aims
Patients and Methods
The surgical treatment of tuberculosis (TB) of the spine consists
of debridement and reconstruction of the anterior column. Loss of
correction is the most significant challenge. Our aim was to report
the outcome of single-stage posterior surgery using bone allografts
in the management of this condition. The study involved 24 patients with thoracolumbar TB who underwent
single-stage posterior spinal surgery with a cortical bone allograft
for anterior column reconstruction and posterior instrumentation
between 2008 and 2015. A unilateral approach was used for 21 patients
with active TB, and a bilateral approach with decompression and closing-opening
wedge osteotomy was used for three patients with healed TB.Aims
Patients and Methods
The aim of this study was to identify the most effective regimen
of multiple doses of oral tranexamic acid (TXA) in achieving maximum
reduction of blood loss in total knee arthroplasty (TKA). In this randomized controlled trial, 200 patients were randomized
to receive a single dose of 2.0 g of TXA orally two hours preoperatively
(group A), a single dose of TXA followed by 1.0 g orally three hours
postoperatively (group B), a single dose of TXA followed by 1.0 g
three and nine hours postoperatively (group C), or a single dose
of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively
(group D). All patients followed a routine enhanced-recovery protocol.
The primary outcome measure was the total blood loss. Secondary
outcome measures were hidden blood loss (HBL), reduction in the
level of haemoglobin, the rate of transfusion and adverse events.Aims
Patients and Methods
This multicentre, retrospective study aimed to improve our knowledge
of primary pyogenic spinal infections in children by analyzing a
large consecutive case series. The medical records of children with such an infection, treated
at four tertiary institutions between 2004 and 2014, were analyzed
retrospectively. Epidemiological, clinical, paraclinical, radiological,
and microbiological data were evaluated. There were 103 children,
of whom 79 (76.7%) were aged between six months and four years.Aims
Patients and Methods
Identifying predictors of compartment syndrome in the foot after
a fracture of the calcaneus may lead to earlier diagnosis and treatment.
The aim of our study was to identify any such predictors. We retrospectively reviewed 303 patients (313 fractures) with
a fracture of the calcaneus who presented to us between October
2008 and September 2016. The presence of compartment syndrome and
potential predictors were identified by reviewing their medical
records. Potential predictors included age, gender, concomitant
foot injury, mechanism of injury, fracture classification, time
from injury to admission, underlying illness, use of anticoagulant/antiplatelet
agents, smoking status and occupation. Associations with predictors
were analyzed using logistic regression analysis.Aims
Patients and Methods
Cervical spondylosis is often accompanied by dizziness. It has
recently been shown that the ingrowth of Ruffini corpuscles into
diseased cervical discs may be related to cervicogenic dizziness.
In order to evaluate whether cervicogenic dizziness stems from the
diseased cervical disc, we performed a prospective cohort study
to assess the effectiveness of anterior cervical discectomy and
fusion on the relief of dizziness. Of 145 patients with cervical spondylosis and dizziness, 116
underwent anterior cervical decompression and fusion and 29 underwent
conservative treatment. All were followed up for one year. The primary
outcomes were measures of the intensity and frequency of dizziness.
Secondary outcomes were changes in the modified Japanese Orthopaedic
Association (mJOA) score and a visual analogue scale score for neck
pain.Aims
Patients and Methods
The aim of this study was to determine whether patients with
metal-on-metal (MoM) arthroplasties of the hip have an increased
risk of cardiac failure compared with those with alternative types
of arthroplasties (non-MoM). A linkage study between the National Joint Registry, Hospital
Episodes Statistics and records of the Office for National Statistics
on deaths was undertaken. Patients who underwent elective total
hip arthroplasty between January 2003 and December 2014 with no
past history of cardiac failure were included and stratified as
having either a MoM (n = 53 529) or a non-MoM (n = 482 247) arthroplasty.
The primary outcome measure was the time to an admission to hospital
for cardiac failure or death. Analysis was carried out using data
from all patients and from those matched by propensity score.Aims
Patients and Methods
The aim of this study was to compare the efficacy of a corticosteroid injection for the
treatment of carpal tunnel syndrome (CTS) in patients with and without Raynaud’s
phenomenon. In a prospective study, 139 patients with CTS were treated with a corticosteroid
injection (10 mg triamcinolone acetonide); 34 had Raynaud’s phenomenon and 105
did not (control group). Grip strength, perception of touch with a Semmes-Weinstein
monofilament and the Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at
baseline and at six, 12 and 24 weeks after the injection. The Cold Intolerance Severity
Score (CISS) questionnaire was also assessed at baseline and 24 weeks after the
injection.Aims
Patients and Methods
The aim of this study was to compare the rate of mortality and
causes of death in Korean patients who undergo surgery for a fracture
of the hip, up to 11 years after the injury, with a control group
from the general population. National cohort data from Korean Health Insurance Review and
Assessment Service – National Sample Cohort were used. A ratio of
1:4 matched patients with a fracture who underwent surgery (3383,
fracture group) between 2003 and 2012, and controls (13 532) were
included. The matches were processed for age, gender, income, and
region of residence. We also undertook analyses of subgroups according
to age and gender. The mean follow-up was 4.45 years (1 to 11).Aims
Materials and Methods
Manipulation under anaesthetic (MUA) is a recognised form of
treatment for patients with a frozen shoulder. However, not all
patients benefit. Some have persistent or recurrent symptoms. There
are no clear recommendations in the literature on the optimal management
of recurrent frozen shoulder after a MUA. We aimed to address this
issue in this study. We analysed a prospectively collected, single-surgeon, consecutive
series of patients who underwent MUA for frozen shoulder between
January 1999 and December 2015. The Oxford Shoulder Scores (OSS)
and range of movement were the outcome measures. Aims
Patients and Methods
The aim of this study was first, to determine
whether CT scans undertaken to identify serious injury to the viscera were
of use in detecting clinically unrecognised fractures of the thoracolumbar
vertebrae, and second, to identify patients at risk of ‘missed injury’. We retrospectively analysed CT scans of the chest and abdomen
performed for blunt injury to the torso in 303 patients. These proved
to be positive for thoracic and intra-abdominal injuries in only
2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a
fracture of the thoracolumbar vertebrae and these constituted our subset
for study. There were eight women and 43 men with mean age of 45.2
years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable
fractures. Only 17 fractures (33.3%) had been anticipated after
clinical examination. Of the 22 unstable fractures, 11 (50%) were
anticipated. Thus, within the whole group of 303 patients, an unstable spinal
injury was missed in 11 patients (3.6%); no harm resulted as they
were all protected until the spine had been cleared. A subset analysis
revealed that patients with a high Injury Severity Score, a low
Glasgow Coma Scale and haemodynamic instability were most likely
to have a significant fracture in the absence of positive clinical
findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures
of the thoracolumbar spine. It should be combined with CT imaging
to reduce the risk of missed injury.
Instability in flexion after total knee replacement
(TKR) typically occurs as a result of mismatched flexion and extension
gaps. The goals of this study were to identify factors leading to
instability in flexion, the degree of correction, determined radiologically,
required at revision surgery, and the subsequent clinical outcomes.
Between 2000 and 2010, 60 TKRs in 60 patients underwent revision
for instability in flexion associated with well-fixed components.
There were 33 women (55%) and 27 men (45%); their mean age was 65
years (43 to 82). Radiological measurements and the Knee Society
score (KSS) were used to assess outcome after revision surgery.
The mean follow-up was 3.6 years (2 to 9.8). Decreased condylar
offset (p <
0.001), distalisation of the joint line (p <
0.001)
and increased posterior tibial slope (p <
0.001) contributed
to instability in flexion and required correction at revision to regain
stability. The combined mean correction of posterior condylar offset
and joint line resection was 9.5 mm, and a mean of 5° of posterior
tibial slope was removed. At the most recent follow-up, there was
a significant improvement in the mean KSS for the knee and function
(both p <
0.001), no patient reported instability and no patient
underwent further surgery for instability. The following step-wise approach is recommended: reduction of
tibial slope, correction of malalignment, and improvement of condylar
offset. Additional joint line elevation is needed if the above steps
do not equalise the flexion and extension gaps. Cite this article:
The aim of this study was to evaluate the feasibility
of using the intact S1 nerve root as a donor nerve to repair an avulsion
of the contralateral lumbosacral plexus. Two cohorts of patients
were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients
with a unilateral fracture of the sacrum and sacral nerve injury
were stimulated during surgery to establish the precise functional
distribution of the S1 nerve root and its proportional contribution
to individual muscles. In cohort 2, the contralateral uninjured
S1 nerve root of six patients with a unilateral lumbosacral plexus
avulsion was transected extradurally and used with a 25 cm segment
of the common peroneal nerve from the injured leg to reconstruct
the avulsed plexus. The results from cohort 1 showed that the innervation of S1 in
each muscle can be compensated for by L4, L5, S2 and S3. Numbness
in the toes and a reduction in strength were found after surgery
in cohort 2, but these symptoms gradually disappeared and strength
recovered. The results of electrophysiological studies of the donor
limb were generally normal. Severing the S1 nerve root does not appear to damage the healthy
limb as far as clinical assessment and electrophysiological testing
can determine. Consequently, the S1 nerve can be considered to be
a suitable donor nerve for reconstruction of an avulsed contralateral
lumbosacral plexus. Cite this article:
The cam-type deformity in femoroacetabular impingement
is a 3D deformity. Single measurements using radiographs, CT or
MRI may not provide a true estimate of the magnitude of the deformity.
We performed an analysis of the size and location of measurements
of the alpha angle (α°) using a CT technique which could be applied
to the 3D reconstructions of the hip. Analysis was undertaken in
42 patients (57 hips; 24 men and 18 women; mean age 38 years (16
to 58)) who had symptoms of femoroacetabular impingement related
to a cam-type abnormality. An α° of >
50° was considered a significant
indicator of cam-type impingement. Measurements of the α° were made
at different points around the femoral head/neck junction at intervals
of 30°: starting at the nine o’clock (posterior), ten, eleven and
twelve o’clock (superior), one, two and ending at three o’clock
(anterior) position. The mean maximum increased α° was 64.6° (50.8° to 86°). The two
o’clock position was the most common point to find an increased α°
(53 hips; 93%), followed by one o’clock (48 hips; 84%). The largest α°
for each hip was found most frequently at the two o’clock position
(46%), followed by the one o’clock position (39%). Generally, raised α angles
extend over three segments of the clock face. Single measurements of the α°, whether pre- or post-operative,
should be viewed with caution as they may not be representative
of the true size of the deformity and not define whether adequate
correction has been achieved following surgery. Cite this article:
As adverse events related to metal on metal hip
arthroplasty have been better understood, there has been increased
interest in toxicity related to the high circulating levels of cobalt ions.
However, distinguishing true toxicity from benign elevations in
cobalt levels can be challenging. The purpose of this review is
to examine the use of cobalt alloys in total hip arthroplasty, to
review the methods of measuring circulating cobalt levels, to define
a level of cobalt which is considered pathological and to review
the pathophysiology, risk factors and treatment of cobalt toxicity.
To the best of our knowledge, there are 18 published cases where
cobalt metal ion toxicity has been attributed to the use of cobalt-chromium
alloys in hip arthroplasty. Of these cases, the great majority reported
systemic toxic reactions at serum cobalt levels more than 100 μg/L.
This review highlights some of the clinical features of cobalt toxicity,
with the goal that early awareness may decrease the risk factors
for the development of cobalt toxicity and/or reduce its severity. Take home message: Severe adverse events can arise from the release
of cobalt from metal-on-metal arthroplasties, and as such, orthopaedic
surgeons should not only be aware of the presenting problems, but
also have the knowledge to treat appropriately. Cite this article:
The aim of this study was to examine the functional
outcome at ten years following lateral closing wedge high tibial osteotomy
for medial compartment osteoarthritis of the knee and to define
pre-operative predictors of survival and determinants of functional
outcome. 164 consecutive patients underwent high tibial osteotomy between
2000 and 2002. A total of 100 patients (100 knees) met the inclusion
criteria and 95 were available for review at ten years. Data were
collected prospectively and included patient demographics, surgical
details, long leg alignment radiographs, Western Ontario and McMaster Universities
osteoarthritis index (WOMAC) and Knee Society scores (KSS) pre-operatively
and at five and ten years follow-up. At ten years, 21 patients had been revised at a mean of five
years. Overall Kaplan–Meier survival was 87% (95% confidence interval
(CI) 81 to 94) and 79% (95% CI 71 to 87) at five and ten years,
respectively. When compared with unrevised patients, those who had
been revised had significantly lower mean pre-operative WOMAC Scores
(47 (21 to 85) This study has shown that improved survival is associated with
age <
55 years, pre-operative WOMAC scores >
45 and, a BMI <
30. In patients over 55 years of age with adequate pre-operative
functional scores, survival can be good and functional outcomes
can be significantly better than their younger counterparts. We
recommend the routine use of pre-operative functional outcome scores
to guide decision-making when considering suitability for high tibial osteotomy. Cite this article:
A prospective study was performed to develop
a clinical prediction rule that incorporated demographic and clinical factors
predictive of a fracture of the scaphoid. Of 260 consecutive patients
with a clinically suspected or radiologically confirmed scaphoid
fracture, 223 returned for evaluation two weeks after injury and
formed the basis of our analysis. Patients were evaluated within
72 hours of injury and at approximately two and six weeks after injury
using clinical assessment and standard radiographs. Demographic
data and the results of seven specific tests in the clinical examination
were recorded. There were 116 (52%) men and their mean age was 33 years (13
to 95; Our study has demonstrated that clinical prediction rules have
a considerable influence on the probability of a suspected scaphoid
fracture. This will help improve the use of supplementary investigations
where the diagnosis remains in doubt.
Back pain is a common symptom in children and
adolescents. Here we review the important causes, of which defects
and stress reactions of the pars interarticularis are the most common
identifiable problems. More serious pathology, including malignancy
and infection, needs to be excluded when there is associated systemic
illness. Clinical evaluation and management may be difficult and
always requires a thorough history and physical examination. Diagnostic
imaging is obtained when symptoms are persistent or severe. Imaging
is used to reassure the patient, relatives and carers, and to guide
management. Cite this article:
To confirm whether developmental dysplasia of
the hip has a risk of hip impingement, we analysed maximum ranges
of movement to the point of bony impingement, and impingement location
using three-dimensional (3D) surface models of the pelvis and femur
in combination with 3D morphology of the hip joint using computer-assisted methods.
Results of computed tomography were examined for 52 hip joints with
DDH and 73 normal healthy hip joints. DDH shows larger maximum extension
(p = 0.001) and internal rotation at 90° flexion (p <
0.001).
Similar maximum flexion (p = 0.835) and external rotation (p = 0.713)
were observed between groups, while high rates of extra-articular
impingement were noticed in these directions in DDH (p <
0.001).
Smaller cranial acetabular anteversion (p = 0.048), centre-edge
angles (p <
0.001), a circumferentially shallower acetabulum,
larger femoral neck anteversion (p <
0.001), and larger alpha
angle were identified in DDH. Risk of anterior impingement in retroverted
DDH hips is similar to that in retroverted normal hips in excessive
adduction but minimal in less adduction. These findings might be
borne in mind when considering the possibility of extra-articular
posterior impingement in DDH being a source of pain, particularly
for patients with a highly anteverted femoral neck. Cite this article:
In an initial randomised controlled trial (RCT)
we segregated 180 patients to one of two knee positions following total
knee replacement (TKR): six hours of knee flexion using either a
jig or knee extension. Outcome measures included post-operative
blood loss, fall in haemoglobin, blood transfusion requirements,
knee range of movement, limb swelling and functional scores. A second
RCT consisted of 420 TKR patients randomised to one of three post-operative
knee positions: flexion for three or six hours post-operatively,
or knee extension. Positioning of the knee in flexion for six hours immediately
after surgery significantly reduced blood loss (p = 0.002). There
were no significant differences in post-operative range of movement,
swelling, pain or outcome scores between the various knee positions
in either study. Post-operative knee flexion may offer a simple
and cost-effective way to reduce blood loss and transfusion requirements
following TKR. We also report a cautionary note regarding the potential risks
of prolonged knee flexion for more than six hours observed during
clinical practice in the intervening period between the two trials,
with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy
at their three-month review. Cite this article:
Accurate, reproducible outcome measures are essential
for the evaluation of any orthopaedic procedure, in both clinical
practice and research. Commonly used patient-reported outcome measures (PROMs) have
drawbacks such as ‘floor’ and ‘ceiling’ effects, limitations of
worldwide adaptability and an inability to distinguish pain from
function. They are also unable to measure the true outcome of an
intervention rather than a patient’s perception of that outcome. Performance-based functional outcome tools may address these
problems. It is important that both clinicians and researchers are
aware of these measures when dealing with high-demand patients,
using a new intervention or implant, or testing a new rehabilitation
protocol. This article provides an overview of some of the clinically-validated
performance-based functional outcome tools used in the assessment
of patients undergoing hip and knee surgery. Cite this article:
The spinal manifestations of neurofibromatosis include cervicothoracic kyphosis, in which scalloping of the vertebral body and erosion of the pedicles may render conventional techniques of fixation impossible. We describe a case of cervicothoracic kyphosis managed operatively with a vascularised fibular graft anteriorly across the apex of the kyphus, followed by a long posterior construct using translaminar screws, which allow segmental fixation in vertebral bodies where placement of the pedicle screws was impracticable.
An eight-week-old boy developed severe thoracic
spondylodiscitis following pneumonia and septicaemia. A delay in
diagnosis resulted in complete destruction of the T4 and T5 vertebral
bodies and adjacent discs, with a paraspinal abscess extending into
the mediastinum and epidural space. Antibiotic treatment controlled
the infection and the abscess was aspirated. At the age of six months,
he underwent posterior spinal fusion Spondylodiscitis should be included in the differential diagnosis
of infants who present with severe illness and atypical symptoms.
Delayed diagnosis can result in major spinal complications with
a potentially fatal outcome.
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.
We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix. Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control. The short form-36 questionnaire and Majeed’s scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs. Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed’s score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology. We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion.
We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children. Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.
We present the electromyographic (EMG) results
ten years after open decompression of the median nerve at the wrist
and compare them with the clinical and functional outcomes as judged
by Levine’s Questionnaire. This retrospective study evaluated 115
patients who had undergone carpal tunnel decompression at a mean
of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis
was found in 77 patients (67%), including those who were asymptomatic
at ten years. It is necessary to include both clinical and functional results
as well as electromyographic testing in the long-term evaluation
of patients who have undergone carpal tunnel decompression particularly
in those in whom revision surgery is being considered. In doubtful
cases or when there are differing outcomes, self-administered scales
such as Levine’s Questionnaire should prevail over EMG results when
deciding on the need for revision surgery.
We retrospectively reviewed 30 two-stage revision
procedures in 28 patients performed for fungal peri-prosthetic joint
infection (PJI) after a primary total knee replacement. Patients were
followed for at least two years or until the infection recurred.
The mean follow-up for patients who remained free of infection was
4.3 years (2.3 to 6.1). Overall, 17 patients were assessed as American
Society of Anesthesiologists grade 3 or 4. The surgical protocol included
removal of the infected implant, vigorous debridement and insertion
of an articulating cement spacer. This was followed by at least
six weeks of antimicrobial treatment and delayed reimplantation
in all patients. The mean interval between removal of the prosthesis
and reimplantation was 9.5 weeks (6 to 24). After reimplantation,
patients took antifungal agents orally for a maximum of six months. Fungal PJIs can be treated successfully by removal of all infected
material, appropriate antimicrobial treatment and delayed reimplantation.
Stable fractures of the ankle can be successfully treated non-operatively by a below-knee plaster cast. In some centres, patients with this injury are routinely administered low-molecular-weight heparin, to reduce the risk of deep-vein thrombosis (DVT). We have assessed the incidence of DVT in 100 patients in the absence of any thromboprophylaxis. A colour Doppler duplex ultrasound scan was done at the time of the removal of the cast. Five patients did develop DVT, though none had clinical signs suggestive of it. One case involved the femoral and another the popliteal vein. No patient developed pulmonary embolism. As the incidence of DVT after ankle fractures is low, we do not recommend routine thromboprophylaxis.
Total knee replacement (TKR) is one of the most
common operations in orthopaedic surgery worldwide. Despite its
scientific reputation as mainly successful, only 81% to 89% of patients
are satisfied with the final result. Our understanding of this discordance
between patient and surgeon satisfaction is limited. In our experience,
focus on five major factors can improve patient satisfaction rates:
correct patient selection, setting of appropriate expectations,
avoiding preventable complications, knowledge of the finer points
of the operation, and the use of both pre- and post-operative pathways.
Awareness of the existence, as well as the identification of predictors
of patient–surgeon discordance should potentially help with enhancing
patient outcomes. Cite this article:
We retrospectively examined the prevalence and
natural history of asymptomatic lumbar canal stenosis in patients treated
surgically for cervical compressive myelopathy in order to assess
the influence of latent lumbar canal stenosis on the recovery after
surgery. Of 214 patients who had undergone cervical laminoplasty
for cervical myelopathy, we identified 69 (32%) with myelographically
documented lumbar canal stenosis. Of these, 28 (13%) patients with
symptomatic lumbar canal stenosis underwent simultaneous cervical
and lumbar decompression. Of the remaining 41 (19%) patients with
asymptomatic lumbar canal stenosis who underwent only cervical surgery,
39 were followed up for ≥ 1 year (mean 4.9 years (1 to 12)) and
were included in the analysis (study group). Patients without myelographic
evidence of lumbar canal stenosis, who had been followed up for ≥ 1
year after the cervical surgery, served as controls (135 patients;
mean follow-up period 6.5 years (1 to 17)). Among the 39 patients
with asymptomatic lumbar canal stenosis, seven had lumbar-related
leg symptoms after the cervical surgery. Kaplan–Meier analysis showed that 89.6% (95% confidence interval
(CI) 75.3 to 96.0) and 76.7% (95% CI 53.7 to 90.3) of the patients
with asymptomatic lumbar canal stenosis were free from leg symptoms
for three and five years, respectively. There were no significant
differences between the study and control groups in the recovery
rate measured by the Japanese Orthopaedic Association score or improvement
in the Nurick score at one year after surgery or at the final follow-up. These results suggest that latent lumbar canal stenosis does
not influence recovery following surgery for cervical myelopathy;
moreover, prophylactic lumbar decompression does not appear to be
warranted as a routine procedure for coexistent asymptomatic lumbar
canal stenosis in patients with cervical myelopathy, when planning
cervical surgery.
The outcomes of 261 nerve injuries in 100 patients
were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in
18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)).
The initial grades for the 42 sutures and graft were 11 good, 14
fair and 17 poor. After subsequent revision repairs in seven, neurolyses
in 11 and free vascularised fasciocutaneous flaps in 11, the final
grades were 15 good, 18 fair and nine poor. Pain was relieved in
30 of 36 patients by nerve repair, revision of repair or neurolysis,
and flaps when indicated. The difference in outcome between penetrating
missile wounds and those caused by explosions was not statistically
significant; in the latter group the onset of recovery from focal
conduction block was delayed (mean 4.7 months (2.5 to 10.2)
