Osteoporotic fracture admissions compared to other major medical admissions in Irish public hospitals.

Multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis. Hospital care represents the costliest portion of health services. We found public hospital bed days for fragility fractures in Ireland increased by 43% between 2008 and 2017 which exceeded those for other common diseases. INTRODUCTION: Recent multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis, manifesting clinically as fragility fractures (FF). International reports show that FF incidence, rate of hospital admission and cost are similar or greater than those for breast cancer, myocardial infarction and stroke. Studies addressing the illness burden of osteoporosis in Ireland are few, and none compares fragility fractures to other common chronic diseases. METHODS: A retrospective analysis of national administrative data for all public hospital admissions was performed on adults aged 50 years and older from January 2008 to December 2017. RESULTS: In 2017, public hospital bed days for FF totalled 249,887 outnumbering Chronic Obstructive Pulmonary Disease (COPD): 131,897; 6 solid cancers (CA): 118,098; myocardial infarction (MI): 83,477; and diabetes mellitus (DM): 31,044. Bed days for FF increased by 43% between 2008 and 2017, in contrast to a 32%, 28% and 31% reduction for CA, MI and DM, respectively, and a 12% increase for COPD. Public hospital bed days for FF in 2016 were greater than MI, stroke, atrial fibrillation and chest pain combined but less than a combination of COPD, pneumonia and lower respiratory tract infection. CONCLUSION: Osteoporotic fractures represent a large and rapidly increasing illness burden amongst older Irish adults, with substantial care requirements and the resulting onus on our healthcare system. Urgent action is needed to address this public health issue and the services for those at risk of fracture.

Signs of Nature in Spine Radiology.

As medical science developed over time, we have relied on natural imagery to help us recognise and remember things. In this review article, we will be discussing some radiological signs named because of their resemblance to the occurrences in the natural world.

Sprain of the Subaxial Cervical Spine in Childhood.

Posterior atlantoaxial ligament disruption in children is a rare diagnosis. We present a case of a young girl with cervical spine posterior atlantoaxial ligament disruption post a fall from a climbing frame. Presenting with minimal symptoms other than neck pain, this case highlights the diagnostic difficulty and need for further radiological imaging in paediatric patients with neck pain post trauma.

The Evolution of Spinal Surgery in the West of Ireland, 2005-2013.

The aim of this study was to determine the changes in both the short and long term, in the trends within the practice of spinal surgery in Galway University Hospitals (GUH) over a seven year period, January 2005 to January 2013. The absolute number of spinal surgery cases has increased from 147 in 2005, to 257 cases by 2013. Multiple level spine surgery accounts for 51% (131) of all cases by 2013, which is an increase from 31% (45) in 2005. On analysis of the trends within spinal surgery during the study period, a statistically significant (p<0.05) increase in all aspects of spinal surgery was noted, with the exception of surgeries for single level, lumbar and infection pathology respectively. The average waiting time for lumbar decompression and instrumentation climbed for an average of 1.3 months in 2008 to 12.1 months by 2012.The volume and complexity of spinal surgery has increased during the study period, in the West of Ireland.

Medical record weight (MRW): a new reliable predictor of hospital stay, morbidity and mortality in the hip fracture population?

We sought to compare the weight of patient's medical records (MRW) to that of standardised surgical risk scoring systems in predicting postoperative hospital stay, morbidity, and mortality in patients with hip fracture. Patients admitted for surgical treatment of a newly diagnosed hip fracture over a 3-month period were enrolled. Patients with documented morbidity or mortality had significantly heavier medical records. The MRW was equivalent to the age-adjusted Charlson co-morbidity index and better than the American Society of Anaesthesiologists physical status score (ASA), the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM,) and Portsmouth-POSSUM score (P-POSSUM) in correlation with length of hospital admission, p = .003, 95% CI [.15 to .65]. Using logistic regression analysis MRW was as good as, if not better, than the other scoring systems at predicting postoperative morbidity and 90-day mortality. Medical record weight is as good as, or better than, validated surgical risk scoring methods. Larger, multicentre studies are required to validate its use as a surgical risk prediction tool, and it may in future be supplanted by a digital measure of electronic record size. Given its ease of use and low cost, it could easily be used in trauma units globally.

Optimal patient positioning for ligamentotaxis during balloon kyphoplasty of the thoracolumbar and lumbar spine.

Percutaneous balloon kyphoplasty aims to restore vertebral height, correct angular deformity and stabilize the spine in the setting of vertebral compression fractures. The patient is positioned prone with supports under the iliac crests and upper thorax to allow gravity to extend the spine. In the treatment of lumbar fractures, we evaluated patient positioning with the contribution of hip extension to increase anterior ligamentotaxis, thus facilitating restoration of vertebral height. Our positioning technique created a mean anterior height increase from 72% to 78% of the average height of the cranial and caudal vertebrae (p=0.037). Balloon inflation did not significantly further increase anterior or posterior vertebral height, or Cobb angle.

The 100 classic papers of orthopaedic surgery: a bibliometric analysis.

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 qualities, characteristics and clinical innovations required for a paper to attain 'classic' status.

Recent onset neck pain with associated neurological deficit--Pott's disease remains an important differential diagnosis.

The incidence of spinal tuberculosis is increasing in developed nations. In Ireland, half of all cases seen in the most recent decade for which figures are available were diagnosed in 2005-2007, the three most recent years for which there is complete data. We discuss a patient who presented with neurological complications due to destructive spinal tuberculous disease affecting the sixth cervical vertebra.

Development and testing of the Gait Assessment and Intervention Tool (G.A.I.T.): a measure of coordinated gait components.

Recent neuroscience methods have provided the basis upon which to develop effective gait training methods for recovery of the coordinated components of gait after neural injury. We determined that there was not an existing observational measure that was, at once, adequately comprehensive, scored in an objectively-based manner, and capable of assessing incremental improvements in the coordinated components of gait. Therefore, the purpose of this work was to use content valid procedures in order to develop a relatively inexpensive, more comprehensive measure, scored with an objectively-based system, capable of incrementally scoring improvements in given items, and that was both reliable and capable of discriminating treatment response for those who had a stroke. Eight neurorehabilitation specialists developed criteria for the gait measure, item content, and scoring method. In subjects following stroke (>12 months), the new measure was tested for intra- and inter-rater reliability using the Intraclass Correlation Coefficient; capability to detect treatment response using Wilcoxon Signed Ranks Test; and discrimination between treatment groups, using the Plum Ordinal Regression. The Gait Assessment and Intervention Tool (G.A.I.T.) is a 31-item measure of the coordinated movement components of gait and associated gait deficits. It exhibited the following advantages: comprehensive, objective-based scoring method, incremental measurement of improvement within given items. The G.A.I.T. had good intra- and inter-rater reliability (ICC=.98, p=.0001, 95% CI=.95, .99; ICC=.83, p=.007, 95% CI=.32, .96, respectively. The inexperienced clinician who had training, had an inter-rater reliability with an experienced rater of ICC=.99 (p=.0001, CI=.97, .999). The G.A.I.T. detected improvement in response to gait training for two types of interventions: comprehensive gait training (z=-2.93, p=.003); and comprehensive gait training plus functional electrical stimulation (FES; z=-3.3, p=.001). The G.A.I.T. was capable of discriminating between two gait training interventions, showing an additive advantage of FES to otherwise comparable comprehensive gait training (parameter estimate=1.72, p=.021; CI, .25, 3.1).

Surgical site infection with methicillin-resistant Staphylococcus aureus after primary total hip replacement.

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.

Epidemiology of spine trauma in an Irish regional trauma unit: a 4-year study.

Currently there is a lack of information on the full spectrum of spine trauma presenting to medical services in a defined geographic area. This study analyses the aetiology and demographics of a cohort of spine trauma in the West of Ireland. A regional trauma unit has been investigated for a 51-month period. Two hundred and eighty-five cases admitted with spine trauma were documented. The annual incidence of traumatic spinal injury was 19.54 cases/100,000 persons per year. Falls and low-energy trauma are shown to constitute a significant proportion of all cases (60.35%). Injury at greater than one level is frequently present. The highest peak of injury occurred in the 20-24-year-old age group (11.58%). A second peak occurred at 75-79 years of age (7.37%). The commonest cause of neurological injury was falls (n=9; 64.3%). This spine trauma register has provided valuable insights into the patterns of injury encountered in spine trauma patients in this region. It may act as a blueprint for a national spine trauma register and highlights the importance of patient education and injury prevention strategies.

Diathermy versus scalpel incisions for hemiarthroplasty for hip fracture: a randomised prospective trial.

As the age profile of our population expands, we can expect subsequent increase in patients presenting with intracapsular fracture. The onus remains on the surgeon to make all reasonable efforts to find new and innovative means of reducing associated morbidity and mortality of the treatment of these injuries. This challenge is particularly relevant in the elderly and in patients with multiple co-morbidities. In this study, 100 patients were randomly allocated into two groups. One group had dissection to the level of the hip joint under direct diathermy control; the other group had dissection using a scalpel with supplementary electrocautery. Intraoperative total blood loss prior to dissection of the abductors was measured by collecting blood using wound swabs using a local protocol and results were statistically analysed using PROC GLM SAS. We demonstrate a clear advantage in the use of diathermy to create a hip incision showing a significant reduction in wound-related blood loss and a reduction, whilst not statistically significant, in total operative blood loss using diathermy incision. Larger randomised prospective trials are necessary to study the effects of this intervention in a larger patient population so that these end-points can be adequately assessed.

Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre: a five-year analysis.

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.

Strain on the human sciatic nerve in vivo during movement of the hip and knee.

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.

Functional outcome study of patients after surgical decompression for lumbar spinal stenosis: effects of concomitant pathology.

The aim of this study is to identify factors associated with poor outcome in the medium (2-5 years) postoperative period following lumbar stenosis surgery. Fifty-six consecutive patients who underwent decompression for lumbar spinal stenosis were retrospectively analyzed using chart and radiologic review, questionnaire using American Association of Orthopaedic Surgeon's MODEM questionnaire containing disability, symptoms, and illness rating, as well as Short Form-36 questionnaires. Postoperatively, there was 98% partial or total relief in leg pain, 85% had partial or total relief in back pain, and 69% had partial or total recovery of neurologic deficit. Functional outcome according to the Short Form-36 was comparable with the age-adjusted population when other comorbidities were taken into account. We found a direct relationship between poor outcome and coexisting medical conditions (p <0.001). Accompanying comorbid conditions have a significant impact on outcome after surgical decompression for lumbar spinal stenosis.

Occipital fixation: effect of inner occipital protuberance alignment on screw position.

Previous authors have demonstrated that the optimum position for screw placement in the occiput is in the inner occipital crest. The position of this structure is usually taken as being in the midline; however, this has not been previously validated. Computerized tomography (CT) of the occipital region was performed prospectively according to a standard protocol. The study included 100 patients (53 female and 47 male, 18-75 years of age). CT images were analyzed to determine the position of the inner occipital crest in relation to the midline. The inner occipital crest is located off the midline (> or = 2 degrees ) in 48% of patients. Preoperative CT evaluation may be helpful prior to occipitocervical fixation on the basis of this study.

Primary angiosarcoma of the femur: a diagnostic dilemma with a rare bone tumour.

We describe a rare case of high-grade primary angiosarcoma of the proximal femur in a 66-year-old man that proved fatal secondary to pulmonary metastases. The difficulties experienced in histological and immunohistochemical diagnosis of these tumours, and the resultant need for a high index of suspicion by surgeons in general and orthopaedists dealing with bone tumours in particular, is emphasized, as is the need for multidisciplinary management.

Postoperative spinal wound infection: a review of 2,391 consecutive index procedures.

Postoperative infection remains a troublesome but not uncommon complication after spinal surgery. Most previous reports, however, are small or involve cases with more than one surgeon often at different institutions. This study represents a single surgeon's 9-year experience with postoperative infection at one institution. The authors describe the features of wound infection after spinal surgery with reference to diagnosis, microbiology, and treatment and they describe a protocol for effective management of postoperative spinal wound infection. The records of the senior author (F.P.C.) during a 9-year period for cases of postoperative wound infection were reviewed. Of 2,391 operative procedures, 46 cases of wound infection were identified, yielding an overall infection rate of 1.9%. Patients' preoperative risk factors, original diagnosis prompting the surgery, onset of infection, presentation, treatment, and outcome were analyzed. The mean age of the 23 men and 23 women was 57.2 years. The preoperative diagnoses included lumbar degenerative scoliosis or spinal stenosis in 28 cases, disk prolapse in 8 cases, metastatic disease in 4 cases, degenerative disk disease in 1 case, and a group of 5 miscellaneous cases. Seventeen (37%) of the patients underwent at least one previous spinal surgery at the same site. Twenty-three patients had a fusion, of whom 22 also had instrumentation. Forty-three (93%) of the patients had significant wound drainage after an average of 15 days (range, 5-80 days). The other three patients were examined approximately 2 years after the surgery. Fourteen of the patients also had pyrexia (temperature >37.5 degrees C) at presentation. Staphylococcus aureus alone was cultured in 29 patients, whereas another six patients had a different single organism. In nine patients, more than one organism was cultured during their hospital stay. Surgical treatment included primary closure in only seven patients, with most undergoing wound drainage and debridement followed by delayed closure. Instruments were removed in the three patients with late presentation who had solid fusion at operation. Viable bone graft and instrumentation were left in situ in all patients who were seen before fusion. All wounds healed without sequelae, except for three that required flap closure. Pseudarthrosis was noted in three patients after more than 1 year of follow-up in this series. Postoperative spinal wound infection is a potentially devastating problem. In this series, infection was more common in patients undergoing fusion with instrumentation and in patients with cancer metastatic to the spine. An aggressive surgical approach, including repeated debridement followed by delayed closure, is justified. Instrumentation may be safely left in situ to provide stability for fusion.

The safety and efficacy of intraoperative heparin in total hip arthroplasty.

A single dose of unfractionated heparin (15 U/kg), administered intravenously before surgery on the femur suppresses thrombogenesis during total hip replacement. Nine hundred eighty-nine patients (1021 hips) who received one dose of intraoperative heparin with hypotensive epidural anesthesia were followed up prospectively for 3 months. Asymptomatic deep vein thrombosis assessed by ultrasound in the first 198 consecutive patients showed an incidence of 7.1% (14 of 198). The incidence of clinical deep vein thrombosis in the subsequent 791 patients was 0.88% (seven of 791). Symptomatic pulmonary embolism occurred in 0.5% (five of 989). No patients died and there was one major bleeding episode. Based on this favorable experience, intraoperative heparin appears safe and efficacious as thromboembolic prophylaxis.