The credibility and creativity of an author may be gauged by the number of scientific papers he or she has published, as well as the frequency of citations of a particular paper reflecting the impact of the data on the area of practice. The object of this study was to identify and analyse the qualities of the top 100 cited papers in orthopaedic surgery. The database of the Science Citation Index of the Institute for Scientific Information (1945 to 2008) was used. A total of 1490 papers were cited more than 100 times, with the top 100 being subjected to further analysis. The majority originated in the United States, followed by the United Kingdom. The top 100 papers were published in seven specific orthopaedic journals.

Analysis of the most-cited orthopaedic papers allows us a unique insight into the qualitites, characteristics and clinical innovations required for a paper to attain ‘classic’ status.

We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus. The incidence of this infection was 1% over a period of five years. We studied SSI in 15 patients (16 infections) with a mean age of 72.7 years (53 to 81). In all, 12 of the infections occurred early and half of the infections involved the prosthesis, resulting in an increase of 11-fold in the cumulative hospital stay.

Methicillin-resistant Staph. aureus was successfully eradicated in all the patients after a mean follow-up of 53.6 months (25 to 88). Superficial incisional infections resolved after antibiotic therapy alone while deep infections required multiple operative debridements. Attempted retention of the implant in early organ space infections was successful in only one of five patients. Only three patients with implant-level infections obtained a pain-free, functional prosthesis while a further three required excision arthroplasty. We have formulated a protocol of treatment which may serve as a guide in the management of these infections.

This prospective five-year study analyses the impact of methicillin-resistant Staphylococcus aureus (MRSA) on an Irish orthopaedic unit. We identified 318 cases of MRSA, representing 0.76% of all admissions (41 971). A total of 240 (76%) cases were colonised with MRSA, while 120 (37.7%) were infected. Patients were admitted from home (218; 68.6%), nursing homes (72; 22.6%) and other hospitals (28; 8.8%). A total of 115 cases (36.6%) were colonised or infected on admission. Many patients were both colonised and infected at some stage. The length of hospital stay was almost trebled because of the presence of MRSA infection.

Encouragingly, overall infection rates have not risen significantly over the five years of the study despite increased prevalence of MRSA. However, the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively.

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function.

We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR.

Introduction: Clavicular non-union, although rare, is a debilitating and often painful condition. The aim of our study was to assess the long-term functional and radiological outcome of clavicular non-unions treated with open reduction and bone grafting in a regional trauma unit. A total of 24 non-unions treated between 1994 and 2001 were retrospectively analysed using chart and radiological review and subsequently assessed with the American Academy of Orthopaedic Surgeons DASH questionnaire.

Results: There were 13 males and 10 females with a median age of 38 years (range 21–65). One patient had bilateral injuries. The average time from injury to operation was 10.3 months (range 3–29) and the average follow-up post-operatively was 42.1 months (range 6–75). All patients were treated using a DCP or reconstruction plate with autogenous bone grafting. Twenty-two of the 24 non-unions eventually healed. The plate was eventually removed in 3 cases all due to pain. Analysis of the DASH upper limb scoring assessment indicated a slightly higher level of disability in the treated group than found in the normal population, but this was not significant and the procedure proved successful and well tolerated by most patients.

Conclusion: We conclude that the long-term outcome results of this procedure indicate it to be a well-tolerated and successful operation in treating the disability and pain associated with clavicular non-union. Most patients return to a daily level of function close to the general population.

Aim: To evaluate the effect of traction on the compartment pressures during intramedullary nailing of closed tibial shaft fractures.

Materials and Methods: The study design was a randomised prospective trial. The period of the study was September 1999 to December 2000. 30 consecutive patients with Tscherne C1 fractures were randomised into two groups. 16 patients underwent intramedullary nailing of the tibia with traction and 14 patients with traction. Compartment pressures were measured before the application of traction or commencement of the procedure and at the end of the procedure. The method described by Guilli and Templeman was used to measure all the four compartments of the injured limb. The pressures were measured with a Stryker® pressure monitor. The absolute and differential compartment pressures were recorded. All patients were followed up for the duration of at least 8 months and until fracture union.

Results: The data collected was analysed using paired student t-test. There was no statistically significant difference (p> 0.05) in the preoperative mean compartment pressures for both groups when all the four compartments were measured individually. The mean postoperative measurements were higher (range 9–10 mmHg) in all four compartments in the traction group. This was statistically significant (p< 0.05). None of the pressures reached the critical level as they were more than 30 mmHg below the diastolic pressure (differential pressure).

Conclusions: These results show that traction increases compartment pressures during intramedullary nailing of tibial shaft fractures. The group considered did not have compartment syndrome possibly due to less soft tissue injury. With greater soft tissue injury and greater preoperative compartment pressures, compartment pressures can reach a critical level necessitating decompression. We conclude that intramedullary nailing without traction reduces the chances of significant increase in compartment pressures and advocate the procedure be done without traction.

Abstract: The importance of nerve root inflammation accompanying disc herniation and its contribution to symptomatology was first proposed in the 1950’s. This encouraged the widespread administration of (percutaneous) epidural steroid injections in the non-surgical treatment of acute and chronic lumbar Radicular pain. It also prompted the local application of steroid preparations directly onto the nerve root at the time of disc compression.

The literature supporting this latter practice however, is scant and equivocal. A randomised double blind prospective study was therefore carried out to evaluate the benefits of epidural steroid application at the time of lumbar disc decompression. 50 consecutive patients undergoing elective lumbar discectomy were enrolled. Patients in the study group (n=25) received 20mg of tri-amcinolone acetonide, applied directly to the decompressed nerve root. The control group (n=25) received an equal volume of saline. Intraoperative analgesia was standardised and postoperative pain was measured by a 10cm visual analog pain scale at 2, 6, 12, 25 and 72 hours. Standardised post-operative analgesic protocols were established and the amounts of consumed analgesics were determined.

Statistical analysis was performed using the Mann-Whitney test. No statistically significant difference was noted in either pain score, analgesic consumption at 24, 38 or 72 hours or length of hospital stay, between the steroid treatment or control groups. This suggests that local epidural steroid administration after lumbar disc decompression offers no therapeutic advantage over mechanical decompression alone.