Several studies have reported the rate of post-operative
mortality after the surgical treatment of a fracture of the hip,
but few data are available regarding the delayed morbidity. In this
prospective study, we identified 568 patients who underwent surgery
for a fracture of the hip and who were followed for one year. Multivariate
analysis was carried out to identify possible predictors of mortality
and morbidity. The 30-day, four-month and one-year rates of mortality
were 4.3%, 11.4%, and 18.8%, respectively. General complications
and pre-operative comorbidities represented the basic predictors
of mortality at any time interval (p <
0.01). In-hospital, four-month
and one-year general complications occurred in 29.4%, 18.6% and
6.7% of patients, respectively. After adjusting for confounding variables,
comorbidities and poor cognitive status determined the likelihood
of early and delayed general complications, respectively (p <
0.001). Operative delay was the main predictor of the length of
hospital stay (p <
0.001) and was directly related to in-hospital
(p = 0.017) and four-month complications (p = 0.008). Cite this article:
We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36). The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8° of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score.
The August 2014 Trauma Roundup360 looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring.
The aim of this study was to determine whether chilled irrigation
saline decreases the incidence of clinical upper limb palsy (ULP;
a reduction of one grade or more on manual muscle testing; MMT),
based on the idea that ULP results from thermal damage to the nerve
roots by heat generated by friction during bone drilling. Irrigation saline for drilling was used at room temperature (RT,
25.6°C) in open-door laminoplasty in 400 patients (RT group) and
chilled to a mean temperature of 12.1°C during operations for 400
patients (low-temperature (LT) group). We assessed deltoid, biceps,
and triceps brachii muscle strength by MMT. ULP occurring within
two days post-operatively was categorised as early-onset palsy.Aims
Methods
Osteoid osteoma is treated primarily by radiofrequency
(RF) ablation. However, there is little information about the distribution
of heat in bone during the procedure and its safety. We constructed
a model of osteoid osteoma to assess the distribution of heat in
bone and to define the margins of safety for ablation. Cavities
were drilled in cadaver bovine bones and filled with a liver homogenate
to simulate the tumour matrix. Temperature-sensing probes were placed
in the bone in a radial fashion away from the cavities. RF ablation
was performed 107 times in tumours <
10 mm in diameter (72 of
which were in cortical bone, 35 in cancellous bone), and 41 times
in cortical bone with models >
10 mm in diameter. Significantly
higher temperatures were found in cancellous bone than in cortical
bone (p <
0.05). For lesions up to 10 mm in diameter, in both
bone types, the temperature varied directly with the size of the
tumour (p <
0.05), and inversely with the distance from it. Tumours
of >
10 mm in diameter showed a trend similar to those of smaller
lesions. No temperature rise was seen beyond 12 mm from the edge
of a cortical tumour of any size. Formulae were developed to predict
the expected temperature in the bone during ablation. Cite this article:
In our department we use an enhanced recovery
protocol for joint replacement of the lower limb. This incorporates the
use of intravenous tranexamic acid (IVTA; 15 mg/kg) at the induction
of anaesthesia. Recently there was a national shortage of IVTA for
18 weeks; during this period all patients received an oral preparation
of tranexamic acid (OTA; 25 mg/kg). This retrospective study compares
the safety (surgical and medical complications) and efficacy (reduction
of transfusion requirements) of OTA and IVTA. During the study period
a total of 2698 patients received IVTA and 302 received OTA. After
adjusting for a range of patient and surgical factors, the odds
ratio (OR) of receiving a blood transfusion was significantly higher
with IVTA than with OTA (OR 0.48 (95% confidence interval 0.26 to
0.89), p = 0.019), whereas the safety profile was similar, based
on length of stay, rate of readmission, return to theatre, deep
infection, stroke, gastrointestinal bleeding, myocardial infarction,
pneumonia, deep-vein thrombosis and pulmonary embolism. The financial
benefit of OTA is £2.04 for a 70 kg patient; this is amplified when
the cost saving associated with significantly fewer blood transfusions
is considered. Although the number of patients in the study is modest, this
work supports the use of OTA, and we recommend that a randomised
trial be undertaken to compare the different methods of administering
tranexamic acid. Cite this article:
This study demonstrates a significant correlation
between the American Knee Society (AKS) Clinical Rating System and
the Oxford Knee Score (OKS) and provides a validated prediction
tool to estimate score conversion. A total of 1022 patients were prospectively clinically assessed
five years after TKR and completed AKS assessments and an OKS questionnaire.
Multivariate regression analysis demonstrated significant correlations between
OKS and the AKS knee and function scores but a stronger correlation
(r = 0.68, p <
0.001) when using the sum of the AKS knee and
function scores. Addition of body mass index and age (other statistically
significant predictors of OKS) to the algorithm did not significantly
increase the predictive value. The simple regression model was used to predict the OKS in a
group of 236 patients who were clinically assessed nine to ten years
after TKR using the AKS system. The predicted OKS was compared with
actual OKS in the second group. Intra-class correlation demonstrated
excellent reliability (r = 0.81, 95% confidence intervals 0.75 to
0.85) for the combined knee and function score when used to predict
OKS. Our findings will facilitate comparison of outcome data from
studies and registries using either the OKS or the AKS scores and
may also be of value for those undertaking meta-analyses and systematic
reviews. Cite this article:
The April 2013 Wrist &
Hand Roundup360 looks at: whether botox is just for Hollywood; supercharging nerve repairs; YouTube research; options for Keinbock’s disease; volar plates; driving and plasters; symptomatic radial malunion; and MRI and acute scaphoid fractures.
Studies describing the effect of body mass index (BMI) on the outcome of total hip replacement have been inconclusive and contradictory. We examined the effect of BMI on medium-term outcome in a cohort of 1617 patients who underwent a primary total hip replacement for osteoarthritis. These patients were followed prospectively for five years with the outcomes of dislocation, revision, duration of surgery and deep and superficial infection studied, as well as collecting Harris hip scores (HHS) and Short-Form 36 (SF-36) questionnaires pre-operatively and at review. A multivariate analysis was performed to see whether BMI is an independent predictor of poor outcome. We found that patients with a BMI of ? 35 kg/m2 have a 4.42 times higher rate of dislocation than those with a BMI <
25 kg/m2. Increasing BMI is also associated with superficial infection and poorer HHS and SF-36 scores at five years. These trends remain significant even when multivariate analysis adjusts for age, gender, prosthesis, operating consultant, pre-operative HHS and SF-36, and comorbidities including diabetes mellitus, cardiac disease and osteoporosis. Despite the increased risks, the five-year outcome scores indicate that obese patients have much to gain from total hip replacement. Thus total hip replacement should not be withheld from patients solely on the grounds of an elevated BMI. However, longer-term follow-up of this cohort is required to establish whether adverse outcomes become more evident with time.
The February 2013 Spine Roundup360 looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses.
The October 2014 Children’s orthopaedics Roundup360 looks at: spondylolisthesis management strategies; not all cervical collars are even; quality of life with Legg-Calve-Perthe’s disease; femoral shaft fractures in children; percutaneous trigger thumb release – avoid at all costs in children; predicting repeat surgical intervention in acute osteomyelitis; and C-Arm position inconsequential in radiation exposure
In 1994 a cerebral palsy (CP) register and healthcare
programme was established in southern Sweden with the primary aim
of preventing dislocation of the hip in these children. The results from the first ten years were published in 2005 and
showed a decrease in the incidence of dislocation of the hip, from
8% in a historical control group of 103 children born between 1990
and 1991 to 0.5% in a group of 258 children born between 1992 and
1997. These two cohorts have now been re-evaluated and an additional
group of 431 children born between 1998 and 2007 has been added. By 1 January 2014, nine children in the control group, two in
the first study group and none in the second study group had developed
a dislocated hip (p <
0.001). The two children in the first study
group who developed a dislocated hip were too unwell to undergo
preventive surgery. Every child with a dislocated hip reported severe pain,
at least periodically, and four underwent salvage surgery. Of the
689 children in the study groups, 91 (13%) underwent preventive
surgery. A population-based hip surveillance programme enables the early
identification and preventive treatment, which can result in a significantly
lower incidence of dislocation of the hip in children with CP. Cite this article:
This study reports the clinical and sonographic
outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years
and aimed to determine factors associated with re-tear. A total
of 69 consecutive repairs were performed in 68 patients with a mean
age of 77 years (70 to 86). Constant-Murley scores were collected
pre-operatively and at one year post-operatively. The integrity
of the repair was assessed using ultrasound. Re-tear was detected
in 20 of 62 patients (32%) assessed with ultrasound. Age at operation We conclude that arthroscopic rotator cuff repair in patients
aged ≥ 70 years is a successful procedure. The gender and age of
the patient are important factors to consider when planning management. Cite this article:
Our aim in this retrospective study of 52 children with spastic hemiplegia was to determine the factors which affected the amount of residual pelvic rotation after single-event multilevel surgery. The patients were divided into two groups, those who had undergone femoral derotation osteotomy and those who had not. Pelvic rotation improved significantly after surgery in the femoral osteotomy group (p <
0.001) but not in the non-femoral osteotomy group. Multiple regressions identified the following three independent variables, which significantly affected residual pelvic rotation: the performance of femoral derotation osteotomy (p = 0.049), the pre-operative pelvic rotation (p = 0.003) and the post-operative internal rotation of the hip (p = 0.001). We concluded that there is a decrease in the amount of pelvic rotation after single-event multilevel surgery with femoral derotation osteotomy. However, some residual rotation may persist when patients have severe rotation before surgery.
Inflammatory markers such as the C-reactive protein (CRP), white blood cell count and body temperature are easy to measure and are used as indicators of infection. The way in which they change in the early post-operative period after instrumented spinal surgery has not been reported in any depth. We measured these markers pre-operatively and at one, four, seven and 14 days postoperatively in 143 patients who had undergone an instrumented posterior lumbar interbody fusion. The CRP proved to be the only sensitive marker and had returned to its normal level in 48% of patients after 14 days. The CRP on day 7 was never higher than that on day 4. Age, gender, body temperature, operating time and blood loss were not related to the CRP level. A high CRP does not in itself suggest infection, but any increase after four days may presage infection.
The aim of this study was to determine whether there is any significant
difference in temporal measurements of pain, function and rates
of re-tear for arthroscopic rotator cuff repair (RCR) patients compared
with those patients undergoing open RCR. This study compared questionnaire- and clinical examination-based
outcomes over two years or longer for two series of patients who
met the inclusion criteria: 200 open RCR and 200 arthroscopic RCR
patients. All surgery was performed by a single surgeon. Objectives
Methods
The most common injury in rugby resulting in
spinal cord injury (SCI) is cervical facet dislocation. We report
on the outcome of a series of 57 patients with acute SCI and facet
dislocation sustained when playing rugby and treated by reduction
between 1988 and 2000 in Conradie Hospital, Cape Town. A total of
32 patients were completely paralysed at the time of reduction.
Of these 32, eight were reduced within four hours of injury and
five of them made a full recovery. Of the remaining 24 who were
reduced after four hours of injury, none made a full recovery and only
one made a partial recovery that was useful. Our results suggest
that low-velocity trauma causing SCI, such as might occur in a rugby
accident, presents an opportunity for secondary prevention of permanent
SCI. In these cases the permanent damage appears to result from
secondary injury, rather than primary mechanical spinal cord damage.
In common with other central nervous system injuries where ischaemia
determines the outcome, the time from injury to reduction, and hence
reperfusion, is probably important. In order to prevent permanent neurological damage after rugby
injuries, cervical facet dislocations should probably be reduced
within four hours of injury.
We report an independent prospective review of the first 230 Birmingham hip resurfacings in 212 patients at a mean follow-up of five years (4 to 6). Two patients, one with a loose acetabular component and the other with suspected avascular necrosis of the femoral head, underwent revision. There were two deaths from unrelated causes and one patient was lost to follow-up. The survivorship with the worst-case scenario was 97.8% (95% confidence interval 95.8 to 99.5). The mean Harris hip score improved significantly (paired On radiological review at five years, one patient had a progressive lucent line around the acetabular component and six had progressive lucent lines around the femoral component. A total of 18 femoral components (8%) had migrated into varus and those with lucent lines present migrated a mean of 3.8° (1.02° to 6.54°) more than the rest. Superolateral notching of the femoral neck and reactive sclerosis at the tip of the peg of the femoral component were associated with the presence of lucent lines (chi-squared test, p <
0.05), but not with migration of the femoral component, and are of unknown significance. Our results with the Birmingham hip resurfacing continue to be satisfactory at a mean follow-up of five years.
Aseptic loosening of the acetabular component continues to be the most common indication for revision of total hip replacements in younger patients. Early in the evolution of the cemented hip, arthroplasty surgeons switched from removal to retention of the acetabular subchondral bone plate, theorising that unfavourable mechanical forces were the cause of loosening at the bone-cement interface. It is now known that the cause of aseptic loosening is probably biological rather than mechanical and removing the subchondral bone plate may enhance biological fixation of cement to bone. With this in mind, perhaps it is time to revive removal of the subchondral bone as a standard part of acetabular preparation.
Wear of metal-on-metal bearings causes elevated levels of cobalt and chromium in blood and body fluids. Metal-on-metal bearings have two distinct wear phases. In the early phase, the wear rate is high. Later, it decreases and the bearing enters a steady-state phase. It is expected that as the wear rates decline, the level of cobalt detected in plasma will also decrease. We studied the baseline and exercise-related cobalt rise in 21 patients (13 men and eight women) with a mean age of 54 years (38 to 80) who had undergone successful hip resurfacing at a mean of 44 months (10 to 96) earlier. Our results showed that circulating baseline cobalt levels were not significantly correlated with the time since implantation (r = 0.08, p = 0.650). By contrast, the exercise-related cobalt rise was directly correlated with the inclination angle of the acetabular component (r = 0.47, p = 0.032) and inversely correlated with the time since implantation (r = −0.5, p = 0.020). Inclination of the acetabular component should be kept less than 40° to decrease the production of wear debris.