• Posterior interosseous nerve palsy caused by parosteal lipoma: a case report.

      Salama, Hatem (210)
      An 83-year-old woman presented with weakness in her right-hand and wrist extensors and swelling in the proximal part of the right forearm. Electromyography (EMG) confirmed involvement of posterior interosseous nerve at the level of proximal forearm. MR imaging demonstrated the characteristics of lipoma which extended on the anterolateral aspect of the right forearm and at the level of the radius neck. The lesion was parosteal lipoma causing compression and paralysis of the posterior interosseous nerve without sensory deficit. In this paper, posterior interosseous nerve palsy due to compression of a parosteal lipoma recovered after excision of the lipoma followed by intensive rehabilitation for six month. Surgical excision should be performed to ensure optimal recovery from the nerve paralysis.
    • The national clinical audit of falls and bone health: the clinical management of hip fracture patients.

      Youde, Jane; Husk, Janet; Lowe, Derek; Grant, Robert; Potter, Jonathan; Martin, Finbarr (2009-11)
      BACKGROUND: The standards of care for older people who present with a fractured neck of femur (#NOF) have been defined by previously published national guidelines. To assess compliance with these standards the Healthcare Commission commissioned the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians to deliver 'The National Clinical Audit of Falls and Bone Health for Older People'. METHODS: The audit was developed by a multi-disciplinary team using available best evidence to set audit standards. All acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England were recruited. Patients >65 years old presenting with a proven #NOF were included in the audit with a target of 20 cases per participating site. RESULTS: Data was entered for 3184 #NOF patients. 80% (2555/3184) were female with a median age of 83 years admitted from their own home (68% 2152/3184). Over 97% (3172/3184) presented to the A&E department on the same day as the fall (88% 2813/3184). The time in the A&E department was less than 2h in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240min. 35% (1080/3088) of #NOF patients were operated on within 24h of admission. Causes of delay to theatre included awaiting medical review (59% 566/956) or organisational reasons (29% 278/956). 48% (1480/2998) of patients were sat out of bed within 24h. Only 35% (1115/3184) of patients were cared for in an orthogeriatric setting. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10-27 days. CONCLUSIONS: There are currently unacceptable wide variations in the delivery of clinical care to older people presenting with a #NOF. Of concern were the long lengths of time in A&E for many patients and the low level of routine access to pre-operative medical assessment. It is hoped that the launch of joint initiatives between the British Orthopaedic Association and the British Geriatric Society aimed at delivering service improvements in this area should lead to improved outcomes.
    • Elastic intramedullary nailing in unstable fractures of the paediatric tibial diaphysis: a systematic review.

      Swindells, Mark; Rajan, Rohan (2010-02)
      PURPOSE: The majority of paediatric tibial fractures can be managed conservatively. However, there is a small but significant group of patients that require surgical intervention for several indications, most notably, unstable fractures. There are various surgical options, each with its own advantages and risks. This review establishes the current available evidence for the use of elastic intramedullary nails in this group. METHODS: A systematic review of the currently available literature was performed. The relevant studies were then critically appraised. RESULTS: Seven applicable retrospective case series were identified, with the outcomes from a total of 210 (range 16-60) patients considered. The mean time to union ranged from 7 to 21 weeks. Reported complications included small numbers each of delayed union, non-union, malunion, leg length discrepancy and infection. CONCLUSIONS: There is only a small body of evidence currently published on this topic. The evidence published so far concludes that elastic intramedullary nailing represents an effective and reliable method to treat an unstable fracture of the tibial diaphysis in the paediatric patient, where conservative management is not appropriate.
    • Pigmented villonodular synovitis of second toe interphalangeal joint: Methods of imaging.

      Edwards, Claire; Milner, Stephen (2010-06)
      Pigmented villonodular synovitis is a rare proliferative disorder of the synovium of unknown aetiology. We present a case of pigmented villonodular synovitis in an unusual location, the interphalangeal joint of a toe, diagnosed by ultrasound with colour Doppler. The role of various imaging modalities in the diagnosis of pigmented villonodular synovitis is discussed.
    • Neutropenia in patients receiving anti-tumor necrosis factor therapy.

      Hastings, Richard; Ding, Tina; Butt, Sayqa; Gadsby, Kate; Deighton, Chris (2010-06)
      OBJECTIVE: To examine the rates of and risk factors for neutropenia together with the dynamics of neutrophil and other white cell subset counts in a cohort of patients treated with a tumor necrosis factor (TNF) inhibitor for inflammatory arthritis. METHODS: We performed a retrospective cohort study examining the association between baseline demographics, clinical features, medications used, and development of neutropenia, and behavior of neutrophil and other white cell subset counts during TNF inhibitor therapy. RESULTS: In 367 patients (298 [81.2%] with rheumatoid arthritis, 38 [10.4%] with ankylosing spondylitis, and 31 [8.4%] with psoriatic arthritis), 69 (18.8%) had at least one episode of neutropenia (<2.0 x 10(9)/liter) during TNF inhibitor therapy, and of these, 6% developed serious infections secondary to neutropenia. There was no significant difference in disease, demographic, or drug variables between patients with and without neutropenia. However, patients with neutropenia had significantly lower baseline neutrophil counts (4.2 x 10(9)/liter; 95% confidence interval [95% CI] 3.8, 4.6 versus 6.2 x 10(9)/liter; 95% CI 6.0, 6.5), and a previous history of neutropenia while receiving disease-modifying antirheumatic drugs increased the risk while receiving TNF inhibitors (hazard ratio 2.97; 95% CI 1.69, 5.25). A significant drop in mean neutrophil count (1.12 x 10(9)/liter; 95% CI 0.92, 1.32) was observed after 2 weeks of TNF inhibitor therapy. Other white cell subsets tended to significantly increase. CONCLUSION: TNF inhibitor therapy is associated with a significant reduction in peripheral blood neutrophil count, leading to 19% of patients becoming neutropenic. Risk of neutropenia is significantly higher in patients with a low baseline neutrophil count or previous history of neutropenia. We suggest that patients receiving TNF inhibitor therapy would benefit from regular complete blood cell count monitoring.
    • The benefit of radiologically-guided steroid injections for trapeziometacarpal osteoarthritis.

      Swindells, Mark; Logan, AJ; Armstrong, D; Chan, P; Burke, Frank; Lindau, Tommy (2010-11)
      INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint (TMJ) is a common condition causing significant disability. Conservative treatments include intra-articular steroid injections. PATIENTS AND METHODS: This clinical, observational study prospectively reviewed the longevity of benefit of steroid injections into the TMJ. Eighty-three patients were recruited with a median age of 62 years and injected with steroid and local anaesthetic under radioscopic guidance. They were followed up until the analgesic effects ceased with a questionnaire including visual analogue scores. RESULTS: Two-thirds of patients were improved at 2 months, with nearly half having a 3-month improvement. One in six patients had a 6-month benefit, with some patients still improved 2 years after injection. Previously injected patients had a reduced duration of benefit compared to their previous injection. Severity of osteoarthritis did not affect the injection efficacy. CONCLUSIONS: Based on this study, we recommend steroid injections in all degrees of TMJ osteoarthritis.
    • Wrist denervation in isolation: a prospective outcome study with patient selection by wrist blockade.

      Storey, Phil; Lindau, Tommy; Jansen, Victoria; Woodbridge, Sarah; Bainbridge, Chris; Burke, Frank (2011-01)
      Surgical wrist denervation involves division of the anterior and posterior interosseous nerves and articular branches of the superficial radial nerve. In this outcome study, 37 patients were individually assessed and deemed suitable for denervation surgery due to appreciable symptom resolution following a local anesthetic wrist block. At a mean of 18 months following denervation surgery, median activity pain scores had decreased by 60% (p < 0.001) from initial assessment levels, and more than three quarters (30/37) of patients reported continued improvement in their activity pain (p < 0.001). More than two thirds of patients had a satisfaction VAS of greater than 50, with less postoperative resting pain and a greater reduction in postoperative activity pain as the important predictors of patient satisfaction. Thirty-one out of the 37 patients had not represented to our department for revision wrist surgery by a mean of 10.3 years follow-up. We have found this procedure useful in ameliorating symptoms for some patients who would conventionally have required partial or total wrist fusions with greater residual functional limitation.
    • Impact of kyphoplasty treatment for vertebral compression fractures on pain and function in 105 patients.

      Klezl, Zdenek; Bommireddy, Rajendranadh; Clamp, J; Jones, M; Calthorpe, D (2011-01)
      PURPOSE OF THE STUDY: Vertebral compression fractures are very common. Symptomatic relief with conservative therapy is often difficult to achieve. Balloon kyphoplasty is a relatively new technique which stabilises the vertebral body and restores spinal alignment in recent fractures, it achieves significant pain relief and improved functional outcome is reported. The aim of this prospective study was to determine the level of pain relief and functional outcome in patients who were initially treated conservatively for 4-6 weeks and if symptoms did not have tendency to resolve, then had kyphoplasty surgery. MATERIAL AND METHODS: 105 patients underwent balloon kyphoplasty between April 2006 and August 2010 and had 1 year follow up. Total 170 levels were augmented, 65% (n=68) of patients were female and the average age was 74 years. Pain relief was assessed using visual analogue score (VAS) and functional outcome using Oswestry Disability Index (ODI). RESULTS: Results showed decrease of the average pre-operative VAS from 8.2 to 4.4 in the immediate postoperative period (p=0.000). This dramatic improvement remained and was 4.1 at 6 weeks, 3.3 at 6 months and 3.6 at 1 year. The average pre-operative ODI was 58. This improved to 47 in the immediate post-operative period (p=0.002). At 6 weeks this had improved further to 40 and further improvements were seen at 6 months (ODI 37) and 1 year (ODI 38). The average screening time was 2 minutes and 20 seconds. The average volume of cement used per level was 5.5 cm3. Radiographic measurements were performed by independent radiologist. The average pre-operative vertebral angle was 11.6° and 10.9° postoperatively. This was maintained throughout the follow up. This represented a negligible 6% improvement in vertebral body angle. We did not experience any clinically significant complications, we have encountered 11 minor complications which did not require any additional measures (cement leaks, penetration of the vertebral body margins by balloons or K wires and rib fractures). DISCUSSION: Pain relief and improvement of functional outcome was sustained after one year. Limited number of patients who had 2 year follow up showed trend of minimal deterioration of both parameters (VAS and ODI). This can be explained by incidence of few adjacent segment fractures and progressive overall osteoarthritic changes in this aging population. Radiological evaluation showed maintenance of achieved alignment which did not deteriorate over time. Complication rate was low and did not require any further surgical interventions and did not have any effect on final good clinical outcome. CONCLUSION: Balloon kyphoplasty proved to be safe surgical technique and should be considered in patients with ongoing pain following an acute vertebral compression fracture that does not improve with initial conservative treatment. It significantly improves pain and functional status in elderly patients.
    • The rheumatoid metacarpophalangeal joint.

      Burke, Frank (2011-02)
      Rheumatoid metacarpophalangeal joint deformities remain an important cause of disability. Surgical intervention in carefully selected patients improves function and prolongs independence. This article discusses the commonly used reconstructive techniques and their benefits. Case selection through a combined clinic with rheumatologists and hand therapists is recommended.
    • Unicompartmental knee replacements with Miller-Galante prosthesis: two to 16-year follow-up of a single surgeon series.

      John, Joby (2011-04)
      We report the outcome of 94 Miller-Galante unicompartmental knee replacements done by a single surgeon over 16 years in a district general hospital in the UK. Patellofemoral arthritis was considered a contraindication only if symptomatic and confirmed on radiography and surgery. Deformity when present was correctable. The mean age at surgery was 66.54 years. The mean follow-up was 10.8 years (2-16 years). The mean Bristol knee score was 43.1 (28-50); 86% of the patients had good or excellent scores. The average range of flexion was 110.6° (80-130°); 89% of the knees had an appropriate alignment. Using revision as the endpoint, outcome for every knee was established. The survival rate for medial unicompartmental knee replacements was 94% at ten years and 87% at 15 years. Although the survival rate for the lateral unicompartmental knee replacement was 97% at five years, it dropped to 41% at eight years. Lateral unicompartmental knee replacements formed only 9.6% of all the replacements in this series. The results for medial unicompartmental knee replacements are similar to reports by other authors for similar and mobile bearing designs. Unicompartmental knee replacement results in a more kinematic knee and produces good functional results.
    • The use of the mini C-arm in the outpatient setting: evolving practice.

      Swindells, Mark; O'Brien, C; Armstrong, D; Arundell, M; Quinton, David; Burke, Frank (2011-05)
      The mini C-arm image intensifier (mini C-arm) has now become an established diagnostic tool in the hand surgery outpatient department. This study reviews the use of the mini C-arm and formal radiographs (X-rays) in the outpatient hand surgery setting. X-rays provide a standard image whereas the mini C-arm can obtain non-standard images to aid diagnosis and treatment. The mini C-arm enables the clinician to obtain dynamic images and perform interventions such as manipulations or injections. The mini C-arm results in a significantly lower radiation exposure for the patients than a formal X-ray. Use of the mini C-arm may be cheaper, and can lead to a shorter outpatient visit with less travel between hospital departments.
    • Early results after vertebral body stenting for fractures of the anterior column of the thoracolumbar spine.

      Klezl, Zdenek; Majeed, H; Bommireddy, Rajendranadh; John, Joby (2011-10)
      INTRODUCTION: Vertebroplasty and balloon kyphoplasty have shown to improve pain and functional outcome in cases with symptomatic vertebral fractures. Although restoration of the vertebral body height and kyphosis seemed to be easier with balloon kyphoplasty, it became clear that some of the correction achieved by the balloon is lost once it was deflated. Vertebral body stent was developed to eliminate this phenomenon. To our knowledge this is the first study in describing this technique in clinical settings. MATERIALS AND METHODS: Seventeen patients with 20 fractured vertebral bodies were included. All fractures were Type A1.3 or A3.1 (incomplete burst). Information about pain (visual analogue scale-VAS) and function (Oswestry disability index-ODI) and vertebral body deformity (vertebral angle-VA) was recorded in a prospective way at regular intervals. Patients were classified into osteoporotic group (7 patients) and traumatic groups (10 patients, younger than 60 years). RESULTS: There were 6 male and 11 female patients with mean age of 58.1 years (31-88 years). Mean follow up was 12 months. The preoperative pain level showed a mean VAS score of 8.9 in osteoporotic group and 9.7 in traumatic group. Postoperatively, in osteoporotic group, mean VAS was 4.8 at 6 weeks, 4.0 at 6 months and 2.5 at 12 months compared with traumatic fracture group where it was 2.7 at 6 weeks, 2.2 at 6 months and 1.6 at 12 months. Mean ODI in osteoporotic group was 41.7% (14-58%) and in traumatic group it was 20.4% (6-33%). Mean vertebral body angle prior to surgery in osteoporotic group was 9.7 whilst postoperatively it was 5.2°; so the mean correction achieved was 4.5°. In traumatic group preoperative VA was 13° whilst postoperatively it was 5.7°; therefore the mean correction achieved was 7.3°. None of the patients lost reduction at their last follow up. CONCLUSION: Vertebral body stenting leads to satisfactory improvement in pain, function and kyphosis correction in the treatment of osteoporotic and traumatic fractures. Anterior spinal column, especially the fragmented superior endplate is nicely reconstructed by the stent provided it is inserted accurately. With addition of posterior transpedicular instrumentation, indications for this technique may be wider covering some Type B and C fractures with similar vertebral body damage.
    • Rheumatoid hand surgery: differing perceptions amongst surgeons, rheumatologists and therapists in the UK.

      Burke, Frank; Miranda, S; Owen, V; Bradley, M; Sinha, S (2011-10)
      Rheumatoid arthritis is a systemic disease that requires coordinated management by rheumatologists, surgical specialists and therapists working in a multidisciplinary team. Differences of opinion within the team may adversely affect patient care. Our aim was to assess differences in perception about rheumatoid hand surgery between rheumatologists, hand surgeons and hand therapists in the UK. We used a postal questionnaire to assess commonly performed rheumatoid hand operations. For each procedure, respondents rated the most important indication for surgery and scored effectiveness at reducing pain, improving function and aesthetics, and preventing deformity. Statistically significant differences were found between all three groups with regards to expected outcome and main indications for surgery. We concluded that significant differences do exist in the perceptions of rheumatologists, surgeons and therapists. Rheumatoid hand operations require more detailed study, clarifying indications and outcome to allow consistent advice to patients from all members of the multidisciplinary team.
    • A simple and safe technique for reconstruction of the acromioclavicular joint.

      Rushton, Paul; Gray, James; Cresswell, Timothy (2012-01)
      Surgical reconstruction of the dislocated acromioclavicular joint often requires exposure and instrumentation of the coracoid. This carries risks to the surrounding neurovascular structures. We present a safe and simple technique of primary fixation of the acromioclavicular joint, relying on mechanical principles and biological repair, without the need for metalwork. By avoiding the coracoid we hope this approach will appeal to the general orthopedic surgeon. We have found that this technique is suited to both acute and chronic acromioclavicular joint dislocation.
    • Accuracy of prognostic scores in decision making and predicting outcomes in metastatic spine disease.

      Majeed, H; Bommireddy, Rajendranadh; Klezl, Zdenek; Calthorpe, D (2012-01)
      INTRODUCTION: Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease. METHODS: Retrospectively, four years of data were collected (2007-2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction. RESULTS: A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age. CONCLUSIONS: The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.
    • Endovascular treatment of a Superior Mesenteric Artery Syndrome variant secondary to traumatic pseudoaneurysm.

      Watson, Nicholas (2012-03)
      Pseudoaneurysms related to the superior mesenteric artery (SMA) are a recognised complication of trauma to the vessel, and successful treatment with stenting has been previously described. We report the case of a patient who presented with obstruction of the fourth part of the duodenum secondary to a traumatic pseudoaneurysm, a hitherto unreported variant of superior mesenteric artery syndrome. Exclusion of the pseudoaneurysm and relief of the duodenal obstruction were simultaneously achieved by placement of a covered stent.
    • Trapezoid fractures: report of 11 cases.

      Kain, Nakul (2012-06)
      PURPOSE: Trapezoid fractures are rare. Mostly single cases reports appear in the literature. The purpose of this study was to review 11 patients treated for trapezoid fractures at our center. METHODS: We reviewed all trapezoid fractures that presented over the past 10 years at our institution. We reviewed case notes regarding mechanism of injury, fracture pattern, mode of diagnosis, and time to diagnosis and treatment. RESULTS: We treated 11 patients for trapezoid fractures over the 10-year period. A correct diagnosis was made in 5 cases on initial evaluation. Most trapezoid fractures were diagnosed on computed tomographic scan. The fracture plane was predominantly sagittal. Coronal fractures could not be diagnosed on plain radiographs. CONCLUSIONS: Fractures of the trapezoid should be suspected from the mechanism of injury, in particular, axial force, and from local tenderness. These fractures may be underdiagnosed. We recommend computed tomography rather than plain radiography alone in case of clinical suspicion. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.