Aims

It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients.

Aims

The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm.

The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient.

A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.

The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 (sd 13.59) in the intact screw group, 92.40 (sd 12.69) in the broken screw group, and 85.80 (sd 11.33) in the removed screw group (p = 0.0466).

There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. Paradoxically, patients with a broken syndesmosis screw had the best clinical outcome. Our data do not support the removal of intact or broken syndesmosis screws, and we caution against attributing post-operative ankle pain to breakage of the syndesmosis screw.

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit.

The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49).

The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism.

The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient.

The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone.

In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.

Fractures of the neck of the phalanx of the finger are uncommon, but problematic, injuries in children. Displaced fractures may heal with malunion leading to loss of movement or angular deformity. Remodelling of the phalangeal neck is reported to be minimal because of the distance of the fracture from the physis. We report three displaced fractures in two children who presented late. The fractures were treated conservatively and remodelled completely. Both patients regained full movement of the fingers.

Colchicine is often used in the treatment of diseases such as familial Mediterranean fever (FMF) and gout. We have previously reported that patients with FMF who had colchicine on a daily basis and who had a total hip arthroplasty showed no heterotopic ossification after surgery. The mechanism by which colchicine causes this clinical phenomenon has never been elucidated. We therefore evaluated the effect of various concentrations of colchicine on cell proliferation and mineralisation in tissue culture, using rat and human cells with and without osteogenic potential. Cell proliferation was assessed by direct cell counts and uptake of (³H)thymidine, and mineralisation by measuring the amount of staining by Alizarin Red.

Our findings indicate that concentrations of colchicine of up to 3 ng/ml did not affect cell proliferation but inhibition was observed at 10 to 30 ng/ml. Mineralisation decreased to almost 50%, which was the maximum inhibition observed, at concentrations of colchicine of 2.5 ng/ml. These results indicate that colchicine at low concentrations, of up to 3 ng/ml, has the capacity to inhibit selectively bone-like cell mineralisation in culture, without affecting cell proliferation. Further clinical and laboratory studies are necessary to evaluate the effects of colchicine on biological processes involving the proliferation of osteoblasts and tissue mineralisation in vivo, such as the healing of fractures, the formation of heterotopic bone and neoplastic bone growth.

The risk of articular penetration during tibial nailing is well known, but the incidence of unrecognised damage to joint cartilage has not been described. We have identified this complication in the treatment of tibial fractures, described the anatomical structures at risk and examined the most appropriate site of entry for tibial nailing in relation to the shape of the bone, the design of the nail and the surgical approach.

We studied the relationship between the intra-articular structures of the knee and the entry point used for nailing in 54 tibiae from cadavers. The results showed that the safe zone in some bones is smaller than the size of standard reamers and the proximal part of some nails. The structures at risk are the anterior horns of the medial and lateral menisci, the anterior part of the medial and lateral plateaux and the ligamentum transversum. This was confirmed by observations made after nailing 12 pairs of cadaver knees. A retrospective radiological analysis of 30 patients who had undergone tibial nailing identified eight at risk according to the entry point and the size of the nail. Unrecognised articular penetration and damage during surgery were confirmed in four.

Although intramedullary nailing has been shown to be a successful method for treating fractures of the tibia, one of the most common problems after bony union is pain in the knee. Unrecognised intra-articular injury of the knee may be one cause of this.

We performed a lateral approach for the release of post-traumatic stiffness of the elbow in 22 patients using a modified technique designed to spare the lateral ligaments. They were reviewed after a mean interval of 26 months. The total humeroulnar joint movement had increased from a mean of 74° to 129° and forearm rotation from a mean of 135° to 159°. Both pain and function in the elbow had improved significantly. This modified lateral approach allows release of post-traumatic contracture without disruption of the lateral collateral ligament or the origins of the extensor tendon at the lateral epicondyle of the humerus. The advantages include a simplified surgical procedure, less operative morbidity, and unrestricted rehabilitation.

We measured bone mineral density (BMD) in the proximal femur by dual-energy X-ray absorptiometry (DEXA) in 20 patients after cemented total hip arthroplasty over a period of one year. We found a statistically significant reduction in periprosthetic BMD after six months on the medial side and on the lateral side adjacent to the mid and distal thirds of the prosthesis. At one year after operation there was a mean 6.7% reduction in BMD in the region of the calcar and a mean 5.3% increase in BMD in the femoral shaft distal to the tip of the implant. These changes reflect a pattern of reduced stress in the proximal femur and increased stress around the tip of the prosthesis. They support current concepts of bone remodelling in the proximal femur in response to prosthetic implantation.

We reviewed 12 patients six years after they had undergone total hip replacement with a cementless prosthesis, the Ribbed Hip System (Waldemar Link GmbH & Co, Hamburg, Germany). Aseptic loosening of one or both components had necessitated revision surgery in seven patients, in five within two years of operation. In view of our experience we question the wisdom of allowing the uncontrolled use of new prosthesis without postoperative surveillance.

Dual-energy X-ray absorptiometry (DEXA) is increasingly used to measure changes in bone mineral density (BMD) around femoral prostheses after total hip arthroplasty. We have studied the factors which affect the accuracy of these measurements. The coefficient of variation was < 2% using a hydroxyapatite phantom, 2.7% in an anthropomorphic phantom specimen, and < 1% in repeated measurements on implanted cadaver femora. The precision did not vary with different implant materials or designs. In patients we found a mean precision error of 2.7% to 3.4%. The most significant factor affecting reproducibility was rotation of the femur. We conclude that DEXA is a precise method of measurement for small changes in BMD around femoral implants, but that correct and careful positioning of patients is essential to obtain reliable results.

The prevalence of HIV infection in East Africa has increased rapidly in recent years. We made a prospective study of the incidence of HIV-seropositivity in patients undergoing orthopaedic procedures in a large district hospital in Bulawayo, Zimbabwe. One of our aims was to determine whether a clinically-based screening programme, derived from the Centre for Disease Control classification of HIV infection, could identify high-risk individuals before surgery. During a 3-month period, 76 patients were tested, and 12 were HIV-positive (16%). Only two of these patients (17%) had clinical features associated with HIV infection; ten (83%) were entirely asymptomatic. Our results indicate that preoperative clinical screening is unlikely to be successful in identifying seropositive patients before routine surgery.

We studied the pedigrees of 17 index patients with osteosarcoma, recording malignant disease and cause of death for first- and second-degree relatives. There were seven cancers and five cancer deaths per 2151.5 person-years in first-degree relatives of osteosarcoma patients under the age of 50 years, a significantly greater incidence than in an age- and sex-matched population group (p < 0.001). This excess of malignancy was largely due to two families which fulfilled the criteria for the Li-Fraumeni cancer family syndrome. Both of these families were shown to have the genetic alterations in the p53 gene which have been implicated in this syndrome. Our study suggests that orthopaedic surgeons seeing new cases of osteosarcoma should arrange screening for familial malignancy.

The nerve roots of the cauda equina may be visualised by contrast-enhanced CT scans and by surface-coil MRI. We have identified the pattern of anatomy from L2-L3 to L5-S1 in 10 human cadaver specimens and correlated this with anatomical dissections. Individual roots are slightly more distinct on contrast-enhanced CT than on surface-coil MRI. There is a crescentic oblique pattern of nerve roots at the lower lumbar levels which is still apparent in the more crowded proximal sections. In all cases, the axial images correlated precisely with the dissections. Current imaging modalities can help the clinical understanding and management of abnormalities in this region of the spine.

Prompt surgical decompression is the only means of preventing the late sequelae of ischaemic contracture in post-traumatic compartment syndromes. However, controversy exists regarding the length of dermotomy required for adequate decompression in the lower extremity. This study investigated the skin envelope as a potential contributing factor. Wide fascial releases were performed through limited 8 cm incisions in eight cases of post-traumatic lower extremity compartment syndrome. In nine of 29 compartments the pressure remained greater than 30 mmHg. Lengthening the skin incisions to an average of 16 cm decreased intracompartmental pressures significantly. This study documents the skin envelope as a contributing factor in acute compartment syndromes of the leg. The use of generous skin incisions is supported and the need for intra-operative compartment pressure measurements in the treatment of this condition is emphasised.

Hip rotation in extension and flexion was studied in 23 patients with idiopathic intoeing gait. In extension all the hips had markedly increased medial rotation and limited lateral rotation, fulfilling the criteria of excessive femoral anteversion. In flexion, however, rotation varied widely; in one group of patients medial rotation remained greater than lateral, but in the second group lateral rotation was equal to or greater than medial. CT scans showed that the hips in the first group were significantly more anteverted than those in the second. Clearly measurement of hip rotation in extension alone does not provide a dependable indication of femoral anteversion in children with intoeing gait; rotation in flexion also needs to be measured.

In controlled clinical studies of adult diabetics a 42% incidence of signs of Dupuytren's disease was found. The incidence was highest in the older patients with a longer history of diabetes, but was not related to the severity of the diabetes. The features of Dupuytren's disease in the diabetics has a distinctive pattern, being more severe in men than women and, compared with controls, having a radial shift towards the middle finger. The disease was mild and of benign prognosis, rarely needing operation. In a further study, 13% of patients with Dupuytren's disease were found to have a raised blood glucose level. The question is posed as to whether the biochemical disturbance causes the Dupuytren's disease or whether the pattern of inheritance predisposes to both Dupuytren's disease and diabetes.

Scoliosis Clinic and the Department of Human Genetics, Hadassah University Hospital, Jerusalem Scoliosis appeared in fifteen members of a family in three generations. The eight members examined showed an idiopathic type of scoliosis. Father-to-son transmission occurred more than once. Although at first appearance transmission of the scoliosis is as an autosomal dominant trait, the concept of polygenic inheritance, as has been shown in previous population studies, could also explain the inheritance in this family

1. Four cases of abnormal arrangement of the lower lumbar and sacral nerves within the spinal canal are reported.

2. In all four cases the presentation was like that associated with acute lumbar disc protrusion, though in only two cases was a protrusion found at operation.

3. The significance of the findings is discussed and the findings are compared with those in the eighteen other recorded cases.

1. Epidural abscess should be suspected in patients with lumbar and sciatic pain who have a history of staphylococcal skin infections or of diabetes.

2. The diagnosis of epidural abscess should be considered before that of herniation of a disc if the patient presents an otherwise unexplained pyrexia. The absence of radiographic changes is no bar to this diagnosis.

3. The hazards of lumbar puncture in cases of epidural abscess are obvious.

4. Early diagnosis and operation are essential to control the infective lesion and to ensure recovery of the neural lesion.

Twenty-one post-irradiation fractures of the femoral neck are reported in seventeen patients who had been treated by radiotherapy for carcinoma of the uterus.

The clinical and radiological appearances are described and the diagnosis, prognosis and treatment of this type of fracture are discussed.

Histological material has been studied in three cases.

It is concluded:

1. That there is a characteristic clinical picture in which premonitory pain is of paramount significance.

2. That when the diagnosis is considered, the likelihood of irradiation damage should take precedence over the remote possibility of metastatic invasion.

3. That the disability varies, but in general the prognosis is favourable.

4. That there is no specific line of treatment applicable to these fractures.

5. That avascularity is not the underlying cause of this lesion.

1. In patients who develop de Quervain's disease variations from the standard pattern of tendons at the wrist are the rule rather than the exception.

2. Conservative treatment is of no value.

3. Adequate exposure, allowing full recognition of all anatomical structures in the region, is advisable, but branches of the radial nerve must be treated with respect.

4. The extensor pollicis brevis tendon is normally small and may pass through a separate osteofibrous canal.

5. Though incision only of the stenosing tendon sheaths may be sufficient, thorough excision is more certain and does no harm.