Modern cemented Furlong hemiarthroplasty: Are dislocations rates better?

BACKGROUND: Dislocation following hip hemiarthroplasty is a major complication with increased mortality and morbidity. Data looking at dislocation following contemporary bipolar stems are lacking in literature. METHODS: Retrospective review of our prospective national hip fracture database over a two-year period. Group 1 comprised of consecutive patients receiving bipolar Furlong prosthesis (N222) while Group 2 was made up of a historical cohort (uncemented; N254). Clinical and radiological records were reviewed to determine dislocation rates, causes and associative factors of dislocations. Data were analysed using SPSS. RESULTS: Following 476 hemiarthroplasties performed during the study period, 12 (2.5%) dislocations were reported (eight in Group 1; four in Group 2). There was no significant difference in dislocation rates (3.6% vs 1.6%) between groups (p = 0.159). Subgroup analysis of Group 1 demonstrated a significant difference in dislocations with Furlong cemented (6%) as compared with Furlong uncemented (0%) hemiarthroplasties (p = 0.024). Following dislocation, death rates increased to 8.3% from 1.7% in both groups. CONCLUSION: There is a statistically significant increase in dislocation rate following use of cemented Furlong prosthesis when compared to similar uncemented prosthesis at the same treatment period. However, when compared to traditional uncemented prosthesis, there is no difference in dislocation rates.

Neurosurgery and Neurology Practices during the Novel COVID-19 Pandemic: A Consensus Statement from India.

BACKGROUND: The COVID-19 infection outbreak has aroused increasing attention and affected thousands of people nationwide. The long incubation period, high infectious rate, varied manifestation, and absence of effective treatment make it difficult to manage the disease transmission. OBJECTIVE: The intended goals are to encourage efficient management of neurological and neurosurgical patients, resource utilization, and protecting the healthcare provider during the COVID-19 epidemic. Herein, we present a consensus statement from various centers in India. METHODOLOGY: In addition to the literature review, recommendations were included from neurologists and neurosurgeons from various centers in India. RESULTS: Every patient presenting for treatment should be treated as a potential asymptomatic infected case. Patients should be categorized based upon the priority as acute (require immediate treatment/surgery within 24 h), sub-acute (requiring treatment within a maximum of 7-10 days), or chronic (requiring treatment within a month). Non-essential elective surgeries and outpatient clinics should be avoided after informing the patient(s). There is a high risk of aerosol dispersion during intubation and certain neurosurgical procedures particularly those involving drills and endoscopes. These procedures should be performed wearing full personal protective equipment. The workflow of the operating rooms should also be modified significantly. Minor modifications in personal and professional lifestyles and routine training to use the PPE will ensure efficient management of resources. CONCLUSION: These recommendations could be used to mitigate the risks and reduce exposure to other patients, public, and healthcare staff.

Chronic Recurrent Multifocal Osteomyelitis: A Diagnostic Dilemma: A Case Report and Review of the Literature.

CASE: Chronic recurrent multifocal osteomyelitis, a misnomer in itself, is a rare disorder that presents infrequently to orthopaedic units. The differential diagnosis is wide, including neoplastic lesions and infection, which may lead to unnecessary interventional and surgical procedures. We present a case that exhibited the hallmark features of this condition-recurrent, multifocal, aseptic osteitis in a 9-year-old girl-and our rationalized management including imaging, nonsteroidal anti-inflammatory drugs, and bisphosphonates. CONCLUSION: With increased awareness by orthopaedic surgeons, patients may be diagnosed and managed appropriately, enabling a benign course and limiting morbidity.

Patient evaluation of outpatient venous thromboembolism prophylaxis service following lower limb injuries using a developed validated questionnaire.

This paper explores patients' perceptions of a new service and protocol for managing outpatient venous thromboembolism (VTE) prophylaxis, using either subcutaneous Dalteparin or oral off-license Dabigatran in patients with lower limb injury requiring immobilisation. Establishing a patient's perspective is part of good practice as, when this is positive, it aids patient compliance and protocol dissemination. A questionnaire consisting of fifty questions was given at random to one hundred patients over a six month period when they attended the trauma clinic. Each question was scored on a five point Likert scale (1 = poor, 5 = excellent) by the patient. The internal consistency of the questionnaire (Cronbach's alpha reliability coefficient) was more than 0.9 in all domains. Qualitative analysis was done for open-ended questions. One hundred respondents completed the questionnaire, two were void due to significant amounts of incomplete data. The gender split was 54 females, 43 males, and one did not answer the question. The average age was 43 (range 18-72). Sixty seven respondents were first-time attenders, 22 were follow-up patients and nine did not complete this section. The overall average score was 4.26 (range 1-5), with 90% of the patients recommending the service. The overall patient satisfaction for a VTE prophylaxis service is high although there is room for improvement as demonstrated by the range of the scores.

The cost of outpatient venous thromboembolism prophylaxis following lower limb injuries.

This paper reports the cost of outpatient venous thromboembolism (VTE) prophylaxis following 388 injuries of the lower limb requiring immobilisation in our institution, from a total of 7408 new patients presenting between May and November 2011. Prophylaxis was by either self-administered subcutaneous dalteparin (n = 128) or oral dabigatran (n = 260). The mean duration of prophylaxis per patient was 46 days (6 to 168). The total cost (pay and non-pay) for prophylaxis with dalteparin was £107.54 and with dabigatran was £143.99. However, five patients in the dalteparin group required nurse administration (£23 per home visit), increasing the cost of dalteparin to £1142.54 per patient. The annual cost of VTE prophylaxis in a busy trauma clinic treating 12 700 new patients (2010/11), would be £92 526.33 in the context of an income for trauma of £1.82 million, which represents 5.3% of the outpatient tariff. Outpatient prophylaxis in a busy trauma clinic is achievable and affordable in the context of the clinical and financial risks involved.

Surgical management of cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) is emerging as the most common cause of spinal cord dysfunction in the elderly worldwide. In the past decade, our understanding of the biomechanics of the spine has improved along with advances in spinal instrumentation and this has led to significant changes in the surgical management of CSM. This review will discuss the indications, advantages and limitations of different operative approaches as well as the complications and prognosis of surgery for cervical spondylotic myelopathy. Choice of surgical approach for CSM should be based on the clinical and radiological characteristics of the individual patient and not on the preferences of the surgeon.

Causes and predictors of early re-admission after surgery for a fracture of the hip.

The aim of this study was to examine the rates and potential risk factors for 28-day re-admission following a fracture of the hip at a high-volume tertiary care hospital. We retrospectively reviewed 467 consecutive patients with a fracture of the hip treated in the course of one year. Causes and risk factors for unplanned 28-day re-admissions were examined using univariate and multivariate analysis, including the difference in one-year mortality. A total of 55 patients (11.8%) were re-admitted within 28 days of discharge. The most common causes were pneumonia in 15 patients (27.3%), dehydration and renal dysfunction in ten (18.2%) and deteriorating mobility in ten (18.2%). A moderate correlation was found between chest infection during the initial admission and subsequent re-admission with pneumonia (r = 0.44, p < 0.001). A significantly higher mortality rate at one year was seen in the re-admission group (41.8% (23 of 55) vs. 18.7% (77 of 412), p < 0.001). Logistic regression analysis identified advancing age, admission source, and the comorbidities of diabetes and neurological disorders as the strongest predictors for re-admission. Early re-admission following hip fracture surgery is predominantly due to medical causes and is associated with higher one-year mortality. The risk factors for re-admission can have implications for performance-based pay initiatives in the NHS. Multidisciplinary management in reducing post-operative active clinical problems may reduce early re-admission.

Concurrent syringomyelia and intradural extramedullary tuberculoma as late complications of tuberculous meningitis.

Tuberculous meningitis (TBM) is a common presentation of extrapulmonary tuberculosis. TBM is associated with many complications. However, concurrent syringomyelia and intradural extramedullary tuberculoma occurring in a patient treated for TBM is rare. Only one such case has been reported earlier. A 27-year-old woman presented with paraparesis of 2 months duration. She had been treated for TBM 8 months earlier. She was found to have an extensive syringomyelia from C2 to the conus medullaris and an intradural extramedullary tuberculoma at the lower thoracic levels. At surgery, a thick, granulomatous lesion was found in the intradural extramedullary plane. Following excision of the granulomatous lesion, a syringostomy was done. The patient was treated with antituberculous drugs and steroids. Six months after treatment, there was no significant change in her neurological status. Concurrent syringomyelia and intradural extramedullary tuberculoma should be entertained in the differential diagnosis when a patient presents with myelopathy following TBM. The pathogenesis of syringomyelia in this condition is discussed.

Influence of an oil soluble inhibitor on microbiologically influenced corrosion in a diesel transporting pipeline.

Microbial degradation of the oil soluble corrosion inhibitor (OSCI) Baker NC 351 contributed to a decrease in inhibitor efficiency. Corrosion inhibition efficiency was studied by the rotating cage and flow loop methods. The nature of the biodegradation of the corrosion inhibitor was also analysed using Fourier transform infrared spectroscopy, nuclear magnetic resonance spectroscopy and gas chromatography-mass spectrometry. The influence of bacterial activity on the degradation of the corrosion inhibitor and its influence on corrosion of API 5LX were evaluated using a weight loss technique and impedance studies. Serratia marcescens ACE2 and Bacillus cereus ACE4 can degrade aromatic and aliphatic hydrocarbons present in the corrosion inhibitor. The present study also discusses the demerits of the oil soluble corrosion inhibitors used in petroleum product pipeline.

Intramedullary dermoid in a low lying conus tethered by a fatty filum - embryological implications.

Intramedullary dermoids arising within the conus medullaris are rare. We report a rare association of an intramedullary dermoid cyst located in a low lying conus tethered by a thickened, fatty filum terminale and discuss the embryological implications of this association.

Role of cationic and nonionic surfactants on biocidal efficiency in diesel-water interface.

Biodegradation occurs at the interface between diesel and water. The microbial contamination can result in inhibitor/fuel degradation that leads to the unacceptable level of turbidity, filter plugging, corrosion of storage tanks, pipeline and souring of stored products. Hence, selection of biocides/inhibitors is an important aspect in petroleum product transporting pipeline. Three biocides (cationic and nonionic) were employed to study the biodegradation of diesel in diesel-water interface. The biocidal efficiency on biodegradation of diesel was examined using Fourier transform infrared spectroscopy (FTIR), nuclear magnetic resonance spectroscopy (NMR) and gas chromatography mass spectrometry (GC-MS). Polyoxyethyleneglycol dodecyl ether [BRIJ-35] and polyethylene glycol-p-isooctylphenyl ether [TRITON-X-100] had higher bactericidal efficiency than Dodecyl ethyl dimethyl ammonium bromide [DDAB]. But the cationic biocide (DDAB) gave good biocidal efficiency at the interface. The data are explained in terms of a model that postulates the formation of "micelle" at the diesel-water interface.

Water-soluble inhibitor on microbiologically influenced corrosion in diesel pipeline.

The effect of water-soluble corrosion inhibitor on the growth of bacteria and its corrosion inhibition efficiency were investigated. Corrosion inhibition efficiency was studied by rotating cage test and flow loop techniques. The nature of biodegradation of corrosion inhibitor was also analyzed by using Fourier transform infrared spectroscopy (FT-IR), nuclear magnetic resonance spectroscopy (NMR) and Gas chromatography and mass spectrometer (GC-MS). The bacterial isolates (Serratia marcescens ACE2, Bacillus cereus ACE4) have the capacity to degrade the aromatic and aliphatic hydrocarbon present in the corrosion inhibitor. The degraded products of corrosion inhibitor and bacterial activity determine the electrochemical behaviour of API 5LX steel. The influence of bacterial activity on degradation of corrosion inhibitor and its influence on corrosion of API 5LX have been evaluated by employing weight loss techniques and electrochemical studies. The main finding of this paper is that the water-soluble corrosion inhibitor is consumed by the microbial action, which contributes to the decrease in inhibitor efficiency. The present study also emphasis the importance of evaluation of water-soluble corrosion inhibitor in stagnant model (flow loop test) and discusses the demerits of the water-soluble corrosion inhibitors in petroleum product pipeline.

Rib impingement in first class cricketers: case reports of two patients who underwent rib resection.

Two first class cricket bowlers presented with costoiliac pain secondary to rib impingement. In both patients, conservative management of the injury had failed to improve symptoms. Surgical resection of the affected rib was undertaken. At follow up, both patients had made a good recovery and had returned to competitive cricket.

Thoracic myelocystoceles--two variants.

Myelocystoceles are rare lesions. Rarer still are thoracic myelocystoceles. Two patients with thoracic myelocystoceles are being reported. The first patient presented with swelling in the thoracic region with paraplegia and incontinence. MR with MR myelography revealed the malformation to be a thoracic myelocystocele. The second patient presented with a midline cutaneous mass lesion without neurological deficit. MRI revealed a Type I split cord malformation, a CSF containing sac in the thoracic region that communicated through a stalk-like structure to the hydromyelic hemicord. Surgery in both these patients did not produce any change in the neurological status. The importance of recognizing thoracic myelocystoceles, their clinical presentation, embryology, value of MR myelography in the diagnosis and role of surgery are discussed. The differences between terminal myelocystoceles and thoracic myelocystoceles are also highlighted.

Idiopathic hypertrophic cranial pachymeningitis masquerading as Tolosa-Hunt syndrome.

Idiopathic hypertrophic cranial pachymeningitis is a rare condition. A case of idiopathic hypertrophic cranial pachymeningitis presenting as Tolosa-Hunt syndrome is being reported. The importance of neuroimaging in patients with suspected Tolosa-Hunt syndrome is discussed. Tolosa-Hunt syndrome might represent a focal manifestation of Idiopathic hypertrophic cranial pachymeningitis. Future studies are necessary to further clarify the relationship between these two conditions.

A morphometric analysis of the foramen magnum region as it relates to the transcondylar approach.

BACKGROUND: The transcondylar approach is being increasingly used to access lesions ventral to the brainstem and cervicomedullary junction. Understanding the bony anatomy of this region is important for this approach. The purpose of this study was to conduct a morphometric analysis of the hypoglossal canal (HC), occipital condyle (OC) and the foramen magnum (FM) as it pertains to the transcondylar approach. METHODS: 50 dry skulls provided 100 hypoglossal canals, 100 occipital condyles and 50 foramina magna. Twenty one parameters were analyzed. They were: length of the HC, diameter of the intra- and extracranial ends of the HC, angle of the HC to the sagittal plane, distance of the HC from the posterior, anterior and inferior margins of the OC, antero-posterior and transverse diameter of the OC, presence of condylar foramen, distance of HC from the jugular foramen intra- and extracranially, distance of HC from basion, opisthion, carotid canal and jugular tubercle. The anteroposterior and transverse diameters of the FM were measured and a FM index was calculated by dividing the AP diameter of the FM by the transverse diameter. The angle of the long axis of the occipital condyles to the sagittal plane was measured. Protrusion of the occipital condyle into the foramen magnum was noted. Where applicable, the measurements were made separately for the right and left side. FINDINGS: The average length of the hypoglossal canal in this study was 12.6 mms. The hypoglossal canal makes an angle of 49 degrees to the sagittal plane. In 30% of the dry skulls studied, the HC was divided into two by a bony septum. The distance of the intracranial end of the HC from the posterior margin of the OC was 12.2 mms. The average anteroposterior length of the occipital condyle was 23.6 mms and the transverse diameter was 14.72 mms. The occipital condyle made an angle of 60 degrees to the sagittal plane. In 20% of the skulls studied the occipital condyle protruded into the foramen magnum. The condylar foramen was absent on the right side in 4 skulls and on the left side in 16 skulls. The average anteroposterior length of the foramen magnum was 33.3 mms and the width was 27.9 mms. When the foramen magnum index was > 1.2, the foramen was found to be ovoid. Forty six percent of the skulls studied exhibited an ovoid foramen magnum. CONCLUSIONS: The occipital condyle is frequently being drilled to expose lesions ventral to the brainstem. From our study, it is evident that the occipital condyle can be safely drilled for a distance of 12 mms from the posterior margin before encountering the hypoglossal canal. In 20% of the skulls the occipital condyle protrudes significantly into the foramen magnum. Wide and sagittally inclined occipital condyles, medially protruberant occipital condyles along with a foramen magnum index of more than 1.2 will require much more extensive bony resection than otherwise. With the availability of recent imaging techniques, it is possible to anticipate the extent of bony resection required in an individual case by using the above mentioned morphometric features.

Cerebral venous sinus thrombosis and thrombophilia presenting as pseudo-tumour syndrome following mild head injury.

Cerebral venous sinus thrombosis (CVT) after mild head injury is infrequent. A 38-year-old patient presented with a Glasgow Coma score (GCS) of 15 after a road traffic accident. CT scan revealed a temporal contusion. He was treated with measures to prevent cerebral oedema and anticonvulsants. Three weeks later he presented with features of pseudo-tumour syndrome. Investigations revealed the presence of cerebral venous sinus thrombosis, protein C deficiency and elevated titres of antiphospholipid antibodies. He was treated with anticoagulants and showed improvement. This case report highlights that multiple "hits" may lead to CVT and hence laboratory screening of patients with CVT is necessary even if the clinical situation seemingly provides sufficient explanation for a thrombotic event. The presence of acquired and inherited causes of thrombophilia need not always lead to symptomatic thrombosis. As illustrated by this case, a second hit, such as trauma, may be the precipitating factor that unmasks the prothrombotic state.

Patellar fracture following surgery for patellar instability.

We present a case of patellar fracture in a teenager that followed a soft tissue realignment surgery for patellar instability. We propose that this fracture was due to disruption of the blood supply to the patella as a result of the procedure. To our knowledge this complication, which has been documented following Total Knee Arthroplasty, has not been documented in the English literature before.