Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.
We report patient-reported outcomes and complications
associated with contemporary periacetabular osteotomy (PAO) surgery
in treating symptomatic acetabular dysplasia and compare these outcomes
with total hip arthroplasty (THA) in patients with similar demographic
details. Two consecutive cohorts included patients between aged
18 to 40 years who had undergone either PAO (100 hips; 24 male,
76 female) or THA (55 hips; 18 male, 37 female). At a mean follow-up
of 5.9 years (2 to 13), there was significant improvement in the
modified Harris hip pain (p <
0.001, PAO and p <
0.001, THA),
function (p <
0.001, PAO and p = 0.001, THA), and total scores
(p <
0.001, PAO and p <
0.001, THA) within each cohort. There
were no significant differences in the clinical outcome scores between
the groups. Complication rates were low and similar in each cohort
(p = 0.68). Similar to THA, contemporary PAO surgery is a clinically
effective procedure that improves function and activity levels,
provides pain relief and is associated with an acceptable complication
rate. Cite this article:
We report our experience using a biodegradable
calcium sulphate antibiotic carrier containing tobramycin in the surgical
management of patients with chronic osteomyelitis. The patients
were reviewed to determine the rate of recurrent infection, the
filling of bony defects, and any problems with wound healing. A
total of 193 patients (195 cases) with a mean age of 46.1 years
(16.1 to 82.0) underwent surgery. According to the Cierny–Mader
classification of osteomyelitis there were 12 type I, 1 type II,
144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3
to 7.1) with recurrent infection occurring in 18 cases (9.2%) at
a mean of 10.3 months post-operatively (1 to 25.0). After further
treatment the infection resolved in 191 cases (97.9%). Prolonged
wound ooze (longer than two weeks post-operatively) occurred in
30 cases (15.4%) in which there were no recurrent infection. Radiographic
assessment at final follow-up showed no filling of the defect with
bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling
in eight (4.4%). A fracture occurred in nine (4.6%) of the treated
osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after
operation. We conclude that Osteoset T is helpful in the management of patients
with chronic osteomyelitis, but the filling of the defect in bone
is variable. Prolonged wound ooze is usually self-limiting and not
associated with recurrent infection. Cite this article:
A total of 22 patients with a tibial avulsion
fracture involving the insertion of the posterior cruciate ligament
(PCL) with grade II or III posterior laxity were reduced and fixed
arthroscopically using routine anterior and double posteromedial
portals. A double-strand Ethibond suture was inserted into the joint
and wrapped around the PCL from anterior to posterior to secure
the ligament above the avulsed bony fragment. Two tibial bone tunnels
were created using the PCL reconstruction guide, aiming at the medial
and lateral borders of the tibial bed. The ends of the suture were
pulled out through the bone tunnels and tied over the tibial cortex
between the openings of the tunnels to reduce and secure the bony
fragment. Satisfactory reduction of the fracture was checked arthroscopically and
radiographically. The patients were followed-up for a mean of 24.5 months (19 to
28). Bone union occurred six weeks post-operatively. At final follow-up,
all patients had a negative posterior drawer test and a full range
of movement. KT-1000 arthrometer examination showed that the mean
post-operative side-to-side difference improved from 10.9 mm (standard
deviation ( We conclude that this technique is convenient, reliable and minimally
invasive and successfully restores the stability and function of
the knee. Cite this article:
Pelvic obliquity is a common finding in adolescents
with cerebral palsy, however, there is little agreement on its measurement
or relationship with hip development at different gross motor function
classification system (GMFCS) levels. The purpose of this investigation was to study these issues in
a large, population-based cohort of adolescents with cerebral palsy
at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98,
65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their
last radiological review) with the common features of a migration
percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity
were investigated in 40 patients and the angle between the acetabular
tear drops (ITDL) and the horizontal reference frame of the radiograph
was found to be reliable, with good face validity. This was selected
for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to
8°). There was a strong correlation between hip morphology and the
presence of pelvic obliquity (effect of ITDL on Sharpe’s angle in
the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p
<
0.001). This was particularly true in non-ambulant adolescents
(GMFCS IV and V) with severe pelvic obliquity, but was also easily
detectable and clinically relevant in ambulant adolescents with mild
pelvic obliquity. The identification of pelvic obliquity and its management deserves
closer scrutiny in children and adolescents with cerebral palsy. Cite this article:
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 symptoms,
and radiographic signs of mild olecranon wear was noted in five
patients. Elbow hemiarthroplasty for comminuted intra-articular distal
humeral fractures produces reliable medium-term results with functional
outcome and complication rates, comparable with open reduction and
internal fixation and total elbow arthroplasty. Cite this article:
The April 2014 Knee Roundup360 looks at: mobile compression as good as chemical thromboprophylaxis; patellar injury with MIS knee surgery; tibial plateau fracture results not as good as we thought; back and knee pain; metaphyseal sleeves may be the answer in revision knee replacement; oral tranexamic acid; gentamycin alone in antibiotic spacers; and whether the jury is still out on unloader braces.
In this retrospective observational cohort study,
we describe 17 patients out of 1775 treated for various fractures who
developed mycobacterium tuberculosis (MTB) infection after surgery.
The cohort comprised 15 men and two women with a mean age of 40
years (24 to 70). A total of ten fractures were open and seven were
closed. Of these, seven patients underwent intramedullary nailing
of a fracture of the long bone, seven had fractures fixed with plates,
two with Kirschner-wires and screws, and one had a hemiarthroplasty
of the hip with an Austin Moore prosthesis. All patients were followed-up
for two years. In all patients, the infection resolved, and in 14
the fractures united. Nonunion was seen in two patients one of whom
underwent two-stage total hip arthroplasty (THA) and the other patient
was treated using excision arthoplasty. Another patient was treated
using two-stage THA. With only sporadic case reports in the literature,
MTB infection is rarely clinically suspected, even in underdeveloped
and developing countries, where pulmonary and other forms of TB
are endemic. In developed countries there is also an increased incidence
among immunocompromised patients. In this paper we discuss the pathogenesis
and incidence of MTB infection after surgical management of fractures
and suggest protocols for early diagnosis and management. Cite this article:
External fixation is widely used in orthopaedic
and trauma surgery. Infections around pin or wire sites, which are usually
localised, non-invasive, and are easily managed, are common. Occasionally,
more serious invasive complications such as necrotising fasciitis
(NF) and toxic shock syndrome (TSS) may occur. We retrospectively reviewed all patients who underwent external
fixation between 1997 and 2012 in our limb lengthening and reconstruction
programme. A total of eight patients (seven female and one male)
with a mean age of 20 years (5 to 45) in which pin/wire track infections
became limb- or life-threatening were identified. Of these, four
were due to TSS and four to NF. Their management is described. A
satisfactory outcome was obtained with early diagnosis and aggressive
medical and surgical treatment. Clinicians caring for patients who have external fixation and
in whom infection has developed should be aware of the possibility
of these more serious complications. Early diagnosis and aggressive
treatment are required in order to obtain a satisfactory outcome. Cite this article:
Metal-on-metal resurfacing of the hip (MoMHR)
has enjoyed a resurgence in the last decade, but is now again in question
as a routine option for osteoarthritis of the hip. Proponents of
hip resurfacing suggest that its survival is superior to that of
conventional hip replacement (THR), and that hip resurfacing is
less invasive, is easier to revise than THR, and provides superior
functional outcomes. Our argument serves to illustrate that none
of these proposed advantages have been realised and new and unanticipated
serious complications, such as pseudotumors, have been associated
with the procedure. As such, we feel that the routine use of MoMHR
is not justified. Cite this article:
We evaluated results at one year after surgical
correction of internal rotation deformities in the shoulders of
270 patients with obstetric brachial plexus palsy. The mean age
at surgery was 6.2 years (0.6 to 35). Two techniques were used:
open subscapularis elongation and latissimus dorsi to infraspinatus
transfer. In addition, open relocation was performed or attempted
in all patients with subluxed or dislocated joints. A mixed effects
model approach was used to evaluate the effects of surgery on internal
and external rotation, abduction, flexion and Mallet score. Independent
factors included operative status (pre- or post-operative), gender,
age, the condition of the joint, and whether or not transfer was
performed. The overall mean improvement in external rotation following
surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and
the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was
a mean decrease in internal rotation of between 27.6° and 34.4°
in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the
normal joint group. Abduction and flexion were unchanged following
surgery. Adding a latissimus dorsi transfer did not result in greater
improvement in the mean external rotation compared with elongation
of the subscapularis alone. Cite this article:
This study compared the clinical outcomes following
mini-open rotator cuff repair (MORCR) between early mobilisation
and usual care, involving initial immobilisation. In total, 189
patients with radiologically-confirmed full-thickness rotator cuff
tears underwent MORCR and were randomised to either early mobilisation
(n = 97) or standard rehabilitation (n = 92) groups. Patients were
assessed at six weeks and three, six, 12 and 24 months post-operatively.
Six-week range of movement comparisons demonstrated significantly
increased abduction (p = 0.002) and scapular plane elevation (p
= 0.006) in the early mobilisation group, an effect which was not
detectable at three months (p >
0.51) or afterwards. At 24 months
post-operatively, patients who performed pain-free, early active mobilisation
for activities of daily living showed no difference in clinical
outcomes from patients immobilised for six weeks following MORCR.
We suggest that the choice of rehabilitation regime following MORCR
may be left to the discretion of the patient and the treating surgeon. Cite this article:
We evaluated the outcome of treatment of nonunion
of an intracapsular fracture of the femoral neck in young patients
using two cannulated screws and a vascularised bone graft. A total
of 32 patients (15 women and 17 men, with a mean age of 36.5 years;
20 to 50) with failed internal fixation of an intracapsular fracture
were included in the study. Following removal of the primary fixation,
two cannulated compression screws were inserted with a vascularised
iliac crest bone graft based on the ascending branch of the lateral
femoral circumflex artery. At a mean follow-up of 6.8 years (4 to 10), union was achieved
in 27 hips (84%). A total of five patients with a mean age of 40.5
years (35 to 50) had a persistent nonunion and underwent total hip
arthroplasty as also did two patients whose fracture united but
who developed osteonecrosis of the femoral head two years post-operatively. Statistical
analysis showed that younger patients achieved earlier and more
reliable union (p <
0.001). The functional outcome, as assessed
by the Harris Hip score, was better in patients aged <
45 years
compared with those aged >
45 years (p <
0.001). These findings suggest that further fixation using two cannulated
compression screws and a vascularised iliac crest bone graft is
an effective salvage treatment in patients aged <
45 years, in
whom osteosynthesis of a displaced intracapsular fractures of the
femoral neck has failed. Cite this article:
The aim of this cadaver study was to identify
the change in position of the sciatic nerve during arthroplasty
using the posterior surgical approach to the hip. We investigated
the position of the nerve during this procedure by dissecting 11
formalin-treated cadavers (22 hips: 12 male, ten female). The distance
between the sciatic nerve and the femoral neck was measured before
and after dislocation of the hip, and in positions used during the
preparation of the femur. The nerve moves closer to the femoral
neck when the hip is flexed to >
30° and internally rotated to 90° (90°
IR). The mean distance between the nerve and femoral neck was 43.1
mm (standard deviation ( This study demonstrates that the sciatic nerve becomes closer
to the operative field during hip arthroplasty using the posterior
approach with progressive flexion of the hip. Cite this article:
Acute angulation at the thoracolumbar junction
with segmental subluxation of the spine occurring at the level above
an anteriorly hypoplastic vertebra in otherwise normal children
is a rare condition described as infantile developmental thoracolumbar
kyphosis. Three patient series with total of 18 children have been
reported in the literature. We report five children who presented
with thoracolumbar kyphosis and discuss the treatment algorithm. We
reviewed the medical records and spinal imaging at initial clinical
presentation and at minimum two-year follow-up. The mean age at
presentation was eight months (two to 12). All five children had
L2 anterior vertebral body hypoplasia. The kyphosis improved spontaneously
in three children kept under monitoring. In contrast, the deformity
was progressive in two patients who were treated with bracing. The
kyphosis and segmental subluxation corrected at latest follow-up
(mean age 52 months; 48 to 60) in all patients with near complete
reconstitution of the anomalous vertebra. The deformity and radiological
imaging on a young child can cause anxiety to both parents and treating
physicians. Diagnostic workup and treatment algorithm in the management
of infantile developmental thoracolumbar kyphosis is proposed. Observation
is indicated for non-progressive kyphosis and bracing if there is evidence
of kyphosis and segmental subluxation deterioration beyond walking
age. Surgical stabilisation of the spine can be reserved for severe
progressive deformities unresponsive to conservative treatment. Cite this article:
We undertook a retrospective study investigating
the accuracy and safety of percutaneous pedicle screws placed under
fluoroscopic guidance in the lumbosacral junction and lumbar spine.
The CT scans of patients were chosen from two centres: European
patients from University Medical Center Hamburg-Eppendorf, Germany,
and Asian patients from the University of Malaya, Malaysia. Screw
perforations were classified into grades 0, 1, 2 and 3. A total
of 880 percutaneous pedicle screws from 203 patients were analysed:
614 screws from 144 European patients and 266 screws from 59 Asian
patients. The mean age of the patients was 58.8 years (16 to 91)
and there were 103 men and 100 women. The total rate of perforation
was 9.9% (87 screws) with 7.4% grade 1, 2.0% grade 2 and 0.5% grade
3 perforations. The rate of perforation in Europeans was 10.4% and
in Asians was 8.6%, with no significant difference between the two
(p = 0.42). The rate of perforation was the highest in S1 (19.4%)
followed by L5 (14.9%). The accuracy and safety of percutaneous
pedicle screw placement are comparable to those cited in the literature
for the open method of pedicle screw placement. Greater caution
must be taken during the insertion of L5 and S1 percutaneous pedicle
screws owing to their more angulated pedicles, the anatomical variations
in their vertebral bodies and the morphology of the spinal canal
at this location. Cite this article:
Inherent disadvantages of reverse shoulder arthroplasty
designs based on the Grammont concept have raised a renewed interest
in less-medialised designs and techniques. The aim of this study
was to evaluate the outcome of reverse shoulder arthroplasty (RSA)
with the fully-constrained, less-medialised, Bayley–Walker prosthesis performed
for the treatment of rotator-cuff-deficient shoulders with glenohumeral
arthritis. A total of 97 arthroplasties in 92 patients (53 women
and 44 men, mean age 67 years (standard deviation ( The Bayley–Walker prosthesis provides reliable pain relief and
reasonable functional improvement for patients with symptomatic
cuff-deficient shoulders. Compared with other designs of RSA, it
offers a modest improvement in forward elevation, but restores external
rotation to some extent and prevents scapular notching. A longer
follow-up is required to assess the survival of the prosthesis and
the clinical performance over time. Cite this article:
MicroRNAs (miRNAs ) are small non-coding RNAs
that regulate gene expression. We hypothesised that the functions
of certain miRNAs and changes to their patterns of expression may
be crucial in the pathogenesis of nonunion. Healing fractures and
atrophic nonunions produced by periosteal cauterisation were created
in the femora of 94 rats, with 1:1 group allocation. At post-fracture
days three, seven, ten, 14, 21 and 28, miRNAs were extracted from
the newly generated tissue at the fracture site. Microarray and
real-time polymerase chain reaction (PCR) analyses of day 14 samples
revealed that five miRNAs, miR-31a-3p, miR-31a-5p, miR-146a-5p,
miR-146b-5p and miR-223-3p, were highly upregulated in nonunion.
Real-time PCR analysis further revealed that, in nonunion, the expression
levels of all five of these miRNAs peaked on day 14 and declined
thereafter. Our results suggest that miR-31a-3p, miR-31a-5p, miR-146a-5p,
miR-146b-5p and miR-223-3p may play an important role in the development
of nonunion. These findings add to the understanding of the molecular mechanism
for nonunion formation and may lead to the development of novel
therapeutic strategies for its treatment. Cite this article:
Despite the expansion of arthroscopic surgery
of the shoulder, the open deltopectoral approach to the shoulder
is still frequently used, for example in fracture fixation and shoulder
replacement. However, it is sometimes accompanied by unexpected
bleeding. The cephalic vein is the landmark for the deltopectoral
interval, yet its intimate relationship with the deltoid artery,
and the anatomical variations in that structure, have not previously been
documented. In this study the vascular anatomy encountered during 100 consecutive
elective deltopectoral approaches was recorded and the common variants
described. Two common variants of the deltoid artery were encountered.
In type I (71%) it crosses the interval and tunnels into the deltoid
muscle without encountering the cephalic vein. However, in type
II (21%) it crosses the interval, reaches the cephalic vein and
then runs down, medial to and behind it, giving off several small
arterial branches that return back across the interval to the pectoralis
major. Several minor variations were also seen (8%). These variations in the deltoid artery have not previously been
described and may lead to confusion and unexpected bleeding during
this standard anterior surgical approach to the shoulder. Cite this article: