Predictive value of post-void residual volume as an adjunctive tool in the clinical evaluation of cauda equina syndrome.

The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected. The search strategy used electronic databases (PubMed, Medline, EMBASE, and AMED) for publications between January 1996 and November 2021. All studies that reported mPVR in patients in whom the diagnosis of CES was suspected, followed by MRI, were included. A total of 2,115 studies were retrieved from the search. Seven fulfilled the inclusion criteria. These included 1,083 patients, with data available from 734 being available for meta-analysis. In 125 patients, CES was confirmed by MRI. The threshold value of mPVR reported in each study varied and could be categorized into 100 ml, 200 ml, 300 ml, and 500 ml. From the meta-analysis, 200 ml had the highest diagnostic accuracy, with 82% sensitivity (95% confidence interval (CI) 0.72 to 0.90) and 65% specificity (95% CI 0.70 to 0.90). When compared using summative receiver operating characteristic curves, mPVR of 200 ml was superior to other values in predicting the radiological confirmation of CES. mPVR is a useful tool when assessing patients in whom the diagnosis of CES is suspected. Compared with other values a mPVR of 200 ml had superior sensitivity, specificity, and positive and negative predictive values. In a patient with a suggestive history and clinical findings, a mPVR of > 200 ml should further raise the suspicion of CES. Caution is recommended when considering the mPVR in isolation and using it as an 'exclusion tool', and it should only be used as an adjunct to a full clinical assessment.

Surgeon-Directed Neuromonitoring in Adolescent Spinal Deformity Surgery Safely Assesses Neurological Function.

Background Spinal deformity correction is associated with the risk of intra-operative neurological injury. Surgeon-directed monitoring (SDM) of transcranial motor-evoked potentials (TcMEP) is an option to monitor intra-operative spinal cord function. We report a retrospective analysis of a prospective database to assess the safety of this technique in spinal deformity correction in adolescent patients. Methods Surgeon-directed neuro-monitoring was utilised in 142 consecutive deformity correction surgeries (2012-2017). Surgeons were responsible for electrode placement, intra-operative stimulation, and interpretation of TcMEP data. If waveform disappearance occurred in the lower limb (LL), the surgeon would re-stimulate after excluding technical or anaesthetic factors. Failure to return normal waveforms led to maneuver reversal and reducing distractive force and ensuring subsequent return to baseline. Wake up test and ankle clonus followed by staging surgery was considered if the LL waveforms failed to return indicating potential motor injury. Results Of 142 patients, three cases (2.11%) had a complete visual loss of LL signals that did not resolve with anaesthetic stabilisation, leading to reversed surgical manoeuvre and staged surgery. No cases with permanent neurological dysfunction were recorded. This outcome supports surgeon-directed monitoring as a safe monitoring option, as an alternative to neurophysiologist-led monitoring. It also provides evidence in support of the waveform disappearance criteria as a safe TcMEP warning criterion with a 100% negative predictive value. Conclusions Where there is a lack of availability of trained neurophysiologists, surgeon-directed neuro-monitoring is a safe and reliable method of preventing intra-operative neurological injury amongst adolescent patients undergoing deformity correction.

A Systematic Review of the Value of a Bladder Scan in Cauda Equina Syndrome Diagnosis.

Cauda equina syndrome (CES) is one of the emergency conditions that can lead to devastating permanent functional disabilities, if misdiagnosed. Multiple studies have questioned the reliability of clinical assessment in diagnosing CES, whether some of the features should be considered to be potential red flags. Bladder dysfunction can reflect CE compromise. The post-void residual (PVR) volume bladder scan is useful in CES diagnosis, but to date there has been no single systematic review supporting its use. Furthermore, there is no clear cut-off point to consider PVR statistically significant. The aim of the study is to perform a systematic review of the current evidence behind the use of the PVR bladder scan as a diagnostic tool for CES diagnosis. This was a comprehensive search using Medline, PubMed and Embase. All articles included post-void bladder scans with the mentioned clear cut-off volume as a diagnostic parameter. A total of five study articles from 1955 fit with our inclusion and exclusion criteria. The total number of patients who had a bladder scan was 531. CES was confirmed in 85 cases. Bladder scan diagnosed 70 cases and excluded 327. The best results for both sensitivity and specificity in correlation with the sample of the study were for PVR more than 200 ml. Measuring the post-void urine volume using a bladder scan is an essential tool in the diagnosis of CES. There is a significant correlation between the PVR volume more than 200 ml and higher sensitivity and specificity.

CT scans to exclude spine fractures in children after negative radiographs may lead to increase in future cancer risk.

INTRODUCTION: National Institute for Health and Care Excellence guidelines recommend computed tomography (CT) scanning for children who fulfill the criteria of significant mechanism or focal spinal pathology. Resulting radiation might subsequently increase the risk of cancer. METHODS: Children with spinal CT scans and radiographs from August 2015 to July 2017 were reviewed retrospectively. Data were obtained from the formal radiology reports and case notes. The radiation exposure and risk of cancer were estimated. RESULTS: Thirty-five children had spine CT scans, and 757 spine radiographs were undertaken. Nine (25%) children had their spines scanned as a part of trauma series due to a severe mechanism of injury. Two patients (6%) had abnormalities in their radiographs prior to CT scans, and the rest were obtained to exclude injuries with negative radiographs. The mean radiation dose from CT scan was 20.3 (SD: 11.3) mSV. The relative risk of missing a spine fracture in a child with a normal radiograph was not statistically significant (RR1.14 95% CI 0.3-4.3 and P = 0.8), and the NNT for detecting a spine fracture with a normal radiograph with further CT scan was 56. The mean lifetime additional cancer risk with CT scan in this group was 0.37%. A significant (P < 0.0001) positive correlation between the radiation dose and increased cancer risk was found. CONCLUSION: Children with clinically suspected spinal fracture in the absence of red flag signs/symptoms and negative radiographs might be considered for alternative assessments or investigations to reduce the risk of CT-related radiation hazards.

Systematic review of high-volume multimodal wound infiltration in total knee arthroplasty.

Pain relief following total knee arthroplasty (TKA) is challenging because early mobilization and rehabilitation are essential for a successful outcome. Postoperative pain can limit recovery, leading to reduced mobility and prolonged hospitalization. There are potential benefits of infiltrating high volumes of local anesthetics around the soft tissues of replaced hip and knee joints. The risk of systemic toxicity is minimized with diluted local anesthetic solution, which also allows a high volume to be used. One of the principal advantages is that analgesia agents are administered intraoperatively by the surgeon, thereby minimizing the need for additional invasive procedures. The authors conducted a systematic review to evaluate whether high-volume multimodal wound infiltration reduces pain and opiate intake while enhancing early rehabilitation and discharge when used in patients undergoing TKA. Only randomized controlled studies were included. Although better pain relief in the immediate postoperative period with wound infiltration is gained after TKA, there is no definite evidence that this leads to a reduction in opiate consumption, the achievement of early milestones, or a reduction in hospital stay. The roles of individual agents in achieving pain relief and the use of percutaneous wound catheter for postoperative doses are also unclear. There are few reports of complications, including falls and delayed mobilization, when femoral nerve blocks are used. Wound infiltration analgesia should be used at the preference of the surgeon and anesthetist provided regular review of their practice is undertaken to identify any untoward side effects. Further randomized trials with sufficient sample size comparing each outcome, including pain scores, opiate consumption, and length of hospital stay, should be undertaken.

Consenting operative orthopaedic trauma patients: challenges and solutions.

Guidelines exist to obtain informed consent before any operative procedure. We completed an audit cycle starting with retrospective review of 50 orthopaedic trauma procedures (Phase 1 over three months to determine the quality of consenting documentation). The results were conveyed and adequate training of the staff was arranged according to guidelines from BOA, DoH, and GMC. Compliance in filling consent forms was then prospectively assessed on 50 consecutive trauma surgeries over further three months (Phase 2). Use of abbreviations was significantly reduced (P = 0.03) in Phase 2 (none) compared to 10 (20%) in Phase 1 with odds ratio of 0.04. Initially, allocation of patient's copy was dispensed in three (6% in Phase 1) cases compared to 100% in Phase 2, when appropriate. Senior doctors (registrars or consultant) filled most consent forms. However, 7 (14%) consent forms in Phase 1 and eleven (22%) in Phase 2 were signed by Core Surgical Trainees year 2, which reflects the difference in seniority amongst junior doctors. The requirement for blood transfusion was addressed in 40% of cases where relevant and 100% cases in Phase 2. Consenting patients for trauma surgery improved in Phase 2. Regular audit is essential to maintain expected national standards.

The efficacy of multimodal high-volume wound infiltration in primary total knee replacement in facilitating immediate post-operative pain relief and attainment of early rehabilitation milestones.

Inadequate pain relief after lower limb joint replacement surgery has been a well-recognised limiting factor affecting post-operative mobilisation and length of hospital stay. Multimodal local wound infiltration with local anaesthetics, adrenaline and non-steroidal anti-inflammatory agents can lower the opiate intake, reduce the length of stay and enhance early mobilisation in knee replacement patients. A retrospective review of 64 patients undergoing primary total knee replacement was undertaken. Thirty-two patients (cases) had their wounds infiltrated with ropivacaine, adrenaline and ketorolac by the operating surgeon, intraoperatively. Subsequently, a 19G wound catheter placed into the knee joint. They received two further top-up doses of the same combination at 10 and 20 h post-operatively. This group was compared with a control group of 32 patients who did not receive any local infiltration. Both groups were comparable in terms of BMI and age. Post-operative opiate drug consumption in first 48 h after surgery, length of hospital stays and time taken to mobilise after surgery were recorded. There was significant reduction in opiate consumption in the treatment group with an average consumption of 49.35 mg of morphine compared to 71.48 mg in the control group (p = 0.004). The median length of hospital stay was significantly reduced from 5 days in the control group to 4 days in the treatment group (p = 0.03). The patients in the treatment group mobilised around 19 h earlier (p = 0.001). No major post-operative complications were encountered in either group. Wound infiltration is an effective and safe technique that promotes early rehabilitation and discharge of patients following primary total knee replacement.

Intraoperative radiation use by trainees during ankle fracture fixation.

Orthopedic trainees are assessed during training regarding their use of radiological screening during operative procedures. The authors investigated whether orthopedic trainees' use of fluoroscopic screening during ankle fixation operations varied with the 2 variables of consultant supervision and trainee experience. Data from operative fixation of isolated Weber B ankle fractures were reviewed. The intraoperative radiation dose was retrieved from radiographers' data. Operations performed by consultants were used as a control group (n=25 patients). Trainee supervision was assessed as "trainer in operating room (OR)" and "trainer out of OR." Regarding experience, the patients were divided into those operated on primarily by trainees in their first (n=36 patients) and in their last (n=34 patients) 3 years of formal specialist training. All trainee groups used more radiation than consultants. Supervision did not affect the radiation use of senior trainees (P<.05). Senior trainees used less radiation than their junior peers (P<.02). Junior trainees supervised by a trainer in the OR used less radiation than junior trainees supervised by a trainer outside of the OR (P<.05). During open reduction and internal fixation of ankle fractures, junior orthopedic trainees use less intraoperative radiation when they are supervised by a trainer in the OR. The more experience a surgeon has, the less fluoroscopic screening is used during operative ankle fixation.

The efficacy of multimodal high-volume wound infiltration in primary total hip replacement.

Multimodal wound infiltration with local anesthetics, adrenaline, and nonsteroidal anti-inflammatory agents can lower the opiate intake, reduce the length of stay, and enhance early mobilization after total hip arthroplasty (THA). A retrospective review of 204 patients undergoing primary THA was undertaken. One hundred two patients had their wounds infiltrated with ropivacaine, adrenaline, and ketorolac by the operating surgeon intraoperatively. Subsequently, a 19-gauge wound catheter was inserted percutaneously into the hip joint. Patients received 2 further top-up doses of 20 mL of ropivacaine (7.5 mg/mL) at 10 and 20 hours postoperatively. These patients were compared to a control group of 102 patients who received no local infiltration. Both groups were comparable in terms of body mass index and age. Opiate consumption in the first 48 hours after surgery and length of hospital stay were recorded. The mean consumption of morphine in the treatment group was 42.3 mg (standard deviation [SD], 31.2 mg) compared to 60.9 mg (SD, 33.8 mg) in the control group (P<.0001). The mean length of stay was significantly reduced from 5.2 days (SD, 1.6 days) in the control group to 4 days (SD, 1.3 days) in the treatment group (P<.0001). The time needed by the patients to walk for 3 meters after surgery was significantly reduced in the treatment group (median, 25 vs 46.1 hours; interquartile range, 20.7- 45.1 vs 27.2- 50.9; P<.0001). This is the largest series to demonstrate that a multimodal perioperative wound infiltration technique in primary THA surgery leads to early attainment of immediate postoperative rehabilitation milestones and reduced length of stay along with reduction in postoperative opiate consumption.

Chronic exertional compartment syndrome with medial tibial stress syndrome in twins.

Chronic exertional compartment syndrome and medial tibial stress syndrome are uncommon conditions that affect long-distance runners or players involved in team sports that require extensive running. We report 2 cases of bilateral chronic exertional compartment syndrome, with medial tibial stress syndrome in identical twins diagnosed with the use of a Kodiag monitor (B. Braun Medical, Sheffield, United Kingdom) fulfilling the modified diagnostic criteria for chronic exertional compartment syndrome as described by Pedowitz et al, which includes: (1) pre-exercise compartment pressure level >15 mm Hg; (2) 1 minute post-exercise pressure >30 mm Hg; and (3) 5 minutes post-exercise pressure >20 mm Hg in the presence of clinical features. Both patients were treated with bilateral anterior fasciotomies through minimal incision and deep posterior fasciotomies with tibial periosteal stripping performed through longer anteromedial incisions under direct vision followed by intensive physiotherapy resulting in complete symptomatic recovery. The etiology of chronic exertional compartment syndrome is not fully understood, but it is postulated abnormal increases in intramuscular pressure during exercise impair local perfusion, causing ischemic muscle pain. No familial predisposition has been reported to date. However, some authors have found that no significant difference exists in the relative perfusion, in patients, diagnosed with chronic exertional compartment syndrome. Magnetic resonance images of affected compartments have indicated that the pain is not due to ischemia, but rather from a disproportionate oxygen supply versus demand. We believe this is the first report of chronic exertional compartment syndrome with medial tibial stress syndrome in twins, raising the question of whether there is a genetic predisposition to the causation of these conditions.

Femoroacetabular impingement: a review of diagnosis and management.

Hip pain in adults has traditionally been associated with osteoarthritis in the joint. However, many young patients with hip pain do get referred to orthopaedic surgeons without arthritis. Subtle bony and soft tissues abnormalities can present with hip pain in the active young adult. These abnormalities can lead to premature arthritis. With the improvements in clinical examination for hip impingement, radiological imaging using magnetic resonance arthrography (MRA) and or computed tomograms (CT) Scans, these lesions are being detected early. Though the cause of primary osteoarthritis is unknown, it is suggested that femoro-acetabular impingement (FAI) may be responsible for the progression of the disease in these patients. FAI is a pathological condition leading to abutment between the proximal femur and the acetabular rim. Two different mechanisms are described, although a combination of both is seen in clinical practice. Cam impingement is a result of reduced anterior femoral head neck offset. Pincer lesion is caused by abnormalities on the acetabular side. FAI due to either mechanism can lead to chondral lesions and labral pathology. Patients present with groin pain and investigated with radiographs, CT and MRA. Surgery is the treatment of choice. Open or arthroscopic exploration of the hip is undertaken with bony resection to improve the femoral head neck junction with resection or repair of the damaged labrum. This may involve femoral osteochondroplasty for the cam lesion and acetabular rim resection for pincer lesion. There is no difference in outcome between open and arthroscopic surgery for FAI.