Use of epidural analgesia post-operatively in spinal surgery is becoming increasingly common. We have conducted a prospective study examining the side-effects associated with epidurals and the need for additional analgesia in 36 adult patients undergoing either lumbar spine decompression, lumbar spine fusion, or a combination of decompression and fusion. A mixture of bupivacaine and fentanyl was used for up to 72 hours post-operatively via an epidural catheter placed under direct vision at the time of surgery. All patients had urinary catheters inserted peri-operatively. 15 patients experienced one or more side-effects; 6 patients had a subjectively unpleasant sensory block, 3 patients developed a motor block, 4 patients had pruritus, 3 developed hypotension, and 2 had episodes of nausea or vomiting. All these features resolved upon reduction of the epidural rate or cessation of the epidural. All patients required additional oral analgesia at some point during their observation. There were no serious complications, such as infection, permanent neurological deficit, or cord compression. We conclude epidural analgesia following lumbar spine surgery is a safe practice, although the high rate of side-effects necessitates close observation by fully trained staff. It appears additional oral analgesia is required to obtain satisfactory levels of analgesia.
It has been suggested that recent reduction in hours worked by orthopaedic trainees in the UK may result in less exposure to operative procedures. To examine this possible change, operative data showing the participation of specialist registrars in orthopaedic trauma cases were examined over 6-month periods in 2002 and 2007. Operations specifically examined included dynamic hip screw, hip hemiarthroplasty, manipulation under anaesthetic, ankle fracture fixation, and tension band wiring. A traditional on-call system was used throughout but the number of working hours was reduced. Analysing individual operations, the results demonstrated a general trend for trainees to perform fewer procedures in the 2007 group, but this difference was not statistically significant. Level of consultant supervision was not significantly different except for hip hemiarthroplasty, which was higher in 2007. When considering all operations together, there was a significant decrease in the number of procedures performed by trainees in 2007, and although there was a trend for more supervision, this was not significant. Trainees were present for a significantly lower proportion of procedures in 2007 than 2002. We conclude that it appears operative experience in orthopaedic trainees may be less than 5 years ago and this may be associated decreased attendance in theatre.
Immobilisation is known to be a risk factor for thromboembolic events and the management of ankle fractures often involves immobilisation of the fracture in a below knee cast. Recent literature has found a 5% rate of subclinical deep vein thrombosis (DVT) and suggested thromboembolic prophylaxis is not required. This study involved all adult patients with isolated ankle fractures presenting to a district general hospital orthopaedic department over a 6 month period. This included patients undergoing internal fixation as well as non-operative management. A 3 to 7 month follow-up was performed to assess the incidence of clinical DVT or pulmonary embolism (PE) proven using Doppler imaging, venogram, and computed tomography pulmonary angiography. 119 patients met the entry criteria and, of these, 3 patients developed DVT and 2 patients presented with pulmonary embolus. 15 patients in the study were taking aspirin (75–300 mg daily) during their cast immobilisation and 1 patient was taking warfarin. None of these patients developed a thromboembolic complication. 4.8% of patients not taking aspirin or warfarin experienced a thromboembolic complication. This study demonstrates a relatively high incidence of symptomatic thromboembolism following ankle fractures in the absence of prophylaxis. Previous studies have found aspirin to be an effective method of prophylaxis following hip fractures and total hip arthroplasty. We recommend that thromboembolism prophylaxis is necessary following ankle fractures and suggest that aspirin may be an economical option. Larger studies are needed to evaluate the role of aspirin in this setting.
Manoli and Schaeffer in 1987, showed that fixation by antiglide plate demonstrated superior static biomechanical properties compared to lateral plating. However there are some shortcomings in their study and hence we decided to perform our biomechanical study. The shortcomings of the Manoli study are. They did not use an interfragmentary lag screw for lateral plate fixation. It was a cadaveric study where the bone does not accurately represent the live bone. The quality of the bone ranging from normal to osteoporotic bone varies from cadaver to cadaver and hence there is no uniformity between the samples.
These bones were custom made for the experiment. We used two sets of bones, one representative of normal bone (Set A n=10) and the other of osteoporotic bone quality (Set B n=10). Each of the sets A &
B will have two types of fixations for artificially created Weber B Fractures.
Lateral plate with interfragmentary lag screw. Antiglide plate with interfragmentary lag screw. The strength of the fixation was measured by restressing the bone until the fixation failed using an Instron machine which simultaneously applied torque and compressive forces to the fibular construct. The resulting data was analysed on a computer and statistical analysis was performed.
Coronal alignment is an important factor in long-term survival of TKA. Many implant systems are available and most aim to produce a posterior slope on the tibial component to reproduce the 70 seen in the normal tibia. We hypothesized that resecting the tibial plateau with a posterior slope can introduce error in coronal plane alignment in TKA. We used a standard saw-bones model in conjunction with a computer navigation system that is available for use in TKA (Stryker Orthopaedics). The normal protocol for preliminary referencing was followed; care was taken to identify tibial landmarks (tibial plateau reference point, true sagittal plane and transmalleolar axis). We then used a standard extramedullary alignment jig (Scorpio TKR System, Stryker Orthopaedics) with cutting blocks designed to give 0, 3, 5 and 7 degrees of posterior slope and varied the position of the alignment jig. Variations included:
Medial rotation of the cutting block, Medialisation of the plateau reference point, Mediolateral translation of the distal jig, and External rotation of the distal jig. In all experiments, there was a greater deviation from ideal coronal alignment as the slope on the tibial cut was increased. The greatest influence was with external rotation of the distal part of the jig, which produced 30 of varus at only 150 of external rotation with a 70 slope. Medialisation of the proximal reference point worsened this to 4.50 of varus. We have quantified the degree of coronal malalignment that can occur for different posterior slopes during tibial resection for TKA. We recommend either using a minimal slope or navigation to ensure correct implant positioning. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.
There is little published data concerning long-term outcome in pyogenic spinal infection. Previous studies have used either neurological outcome in isolation, or non-validated quality of life measure instruments yielding data that is difficult to interpret. To assess long-term outcome following pyogenic spinal infection through standardised outcome measures, Oswestry Disability Index (ODI) and Short Form-36 (SF-36) were utilised. All cases of pyogenic spinal infection presenting to a single institution over the period 1993–2003 were retrospectively identified. Inclusion in each case was based on consistent clinical, imaging and microbiology criteria. The follow-up was by clinical review, American Spinal Injury Association (ASIA) classification, ODI and SF-36. The outcome was compared to normative data for the Irish population. Twenty-nine cases of pyogenic spinal infection were identified. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) who had persistent neurological deficit according to ASIA classification. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and those who recovered (p=0.003). SF-36 scores failed to reach those of a normative population, even after apparent full recovery. A strong correlation was observed between ODI and SF-36 Physical Function scores (rho=0.61, p<
0.05). Seventeen percent (n= 5) of admissions resulted in acute sepsis-related death. Delay in diagnosis of spinal infection (p= 0.025) and neurological impairment at diagnosis (p<
0.001) were associated with neurological deficit at follow-up examination. Previous spinal surgery was a significant predictor of adverse outcome in patients requiring readmission <
1 year (p= 0.018). The finding of high rates of adverse outcome and using SF-36 and ODI suggests under-reporting of poor outcome in other series. We advocate use of validated standardised spinal outcome questionnaires to accurately assess long-term outcome and facilitate comparison between case series.
Medial rotation of the cutting block Medialisation of the plateau reference point Medio-lateral translation of the distal jig 4. External rotation of the distal jig
The use of arthroplasty registers was initiated by Sweden in 1979. The practice has been adopted globally as best practice for recording the outcome of joint replacement surgery and for identifying early problems. The Trent and Wales Arthroplasty Audit Group began in 1990 and have recently produced outcome results. We have analysed the short-term outcomes of arthroplasty procedures at a DGH in order to assess comparability to this “gold-standard”. In 2004, 231 primary arthroplasties were performed, by the two senior authors, at Musgrove Park Hospital (149 THR, 82 TKR). There was an overall complication rate of 8.7%. There was 1 periprosthetic infection in a THR that required revision (0.043%). 9 patients developed wound complications, principally superficial infections and haematoma formation. 2 patients, both THR developed, thromboembolic complications, one DVT and one pulmonary embolus. There was one periprosthetic fracture around a THR. The dislocation rate for THR was 3.35% (5/149). 3 of these were performed through a posterior approach and 2 through an anterolateral. 3 have required revision surgery. We have demonstrated comparable results following joint arthroplasty to published teaching hospital series. We have shown that adequate infrastructure can exist in smaller units to accurately record outcome data following arthroplasty surgery.
Shoulder Arthroscopy techniques may pose surgical risk to vascular structures that may cause active bleeding during surgery. The vascularity of the subacromial structures showed constant patterns of distribution and specific sources of bleeding were analyzed. Knowledge of the vascular anatomy may decrease the bleeding during subacromial arthroscopy surgery. Shoulder Arthroscopy techniques may pose surgical risk to vascular structures that may cause active bleeding during surgery. A detailed anatomy map of frequent sources of bleeding is more than desired in order to properly identify these bleeding points, and avoid the unnecessary overuse of thermal tools and pressure pumps to control the hemorrhage. Our purpose is to study the vascular anatomy of the subacromial space, and to map the major sources of expected bleeding during subacromial arthroscopy surgery. Ten shoulders of five adult cadavers underwent whole body arterial perfusion with a mixture of lead oxide, gelatin and water. The shoulders were dissected, photographed, tissue specimens were radio graphed, scanned and analyzed with a digital software analyzer. Careful dissection of the different arteries of the subacromial bursa, and anatomic landmarks of the walls were documented. Correlations of bleeding areas during subacromial arthroscopic surgery and cadaver dissection were carried out. A vascular map of the bursa was created. The vascularity of the subacromial structures showed constant patterns of distribution and specific sources of bleeding were analyzed. We divided this space into walls with their major arteries as follows: Anterior wall: Acromial branch of the thoracoacromial artery. Posterior wall: Acromial branch of the suprascapular artery. Medial wall: Anterior and posterior Arteries of the AC joint. Lateral wall: No major arteries identified. Vascularity of the roof and floor is also described. The subacromial space is highly vascular. Knowledge of the vascular anatomy may decrease the bleeding during subacromial arthroscopy surgery.
non-English speakers non-resident in Ireland previous diagnosis of osteoporosis or commenced on treatment for osteoporosis not fit to attend for DEXA scan not willing to participate in the study 100 consecutive patients presenting to the fracture service with distal radial fragility fractures were prospectively identified. Data was collected, including body mass index (BMI), risk factors for osteoporosis, and the OST risk index calculated. A DEXA scan was then performed on the patient’s hips and lumbar spine.
All patients in Group 1 and 2 went on to satisfactory radiological and clinical union. A higher complication rate was noted in the Polarus nail group, with 3 patients requiring removal of metal due to soft tissue or subacromial impingement. In addition one patient developed a non-union and required Philos plate fixation. All groups demonstrated a significant decrease in shoulder range of motion following injury, however this was less marked in Group 1 (Philos plate). In addition, patients in group 1 (Philos plate) demonstrated a more rapid recovery in terms of severity of pain, functional impairment and range of motion in the early postoperative phase. However, no significant long-term difference was noted in terms of post-operative pain or functional deficit between group 1 and 2. The poor outcome in group 3 was associated with a high incidence of shoulder pain and secondary procedures.
Minor trauma e.g. minor fall No neurological deficit Exclusion criteria Patients over 65years who were involved in major trauma. Non-Irish residents.
On examination two patients had a clinically evident kyphosis. The mean range of anterior flexion was 78.9° + 15°. The mean VAS pain score was 2.2 + 2.0. No significant correlation existed between the magnitude of the initial vertebral collapse and the Oswestry or SF36 scores. No significant further vertebral collapse was noted on radiographic follow up. A small cohort of patients did develop chronic back pain. These patients’ outcome could not be predicted on the basis of initial radiographs.
In contrast, the coronal femoral osteotomies had a worse healing response. The alignment of the fracture line perpendicular to the plane of motion of the joint exposes the repair tissue within it to increased shear and tensile stresses. This may play a negative role in the repair of these coronal defects when compared to sagittal osteotomies, which are relatively protected from the high transarticular pressures and showed a greater tendency to remodel their articular surface.
A marked reduction in osteomyelitis was noted over the twenty-four year incidence of the study. In addition, a shift in the causative organism was noted from an incidence of H Influenzae in the 70’s of up to 30%, to less than 5% in the 90’s. The treatment regime changed markedly over the course of the study period, with a significantly reduced duration of hospital stay reflecting the move away from protracted periods of hospitalisation.