The False Security of Pelvic Binders: 2 Cases of Missed Injuries due to Anatomical Reduction.

INTRODUCTION: Pelvic injuries are common in high energy trauma. It is now a standard practice to reduce the potential space for haemorrhage with the use of pelvic binders and slings in the resuscitative scenario as this has been shown to reduce mortality. Most trauma centres have CT based trauma protocols so that alongside increased awareness of pelvic injuries, there is a higher detection rate of pelvic fractures. CASE REPORT: We present two cases of high energy pelvic injuries that were missed on initial presentation. In both the instances, pelvic binders were applied with the level of anatomical reduction being achieved meaning that pelvic injuries were missed on the initial CT scan reports. CONCLUSION: CT scans continue to be an essential tool in the management of trauma, especially with regards to pelvic injuries. The increased availability and improvements in imaging techniques has confirmed CT scans as an important tool in the detection of life threatening injuries, resulting in a marked reduction in the overall number of pelvic fractures missed. However, these cases highlight the fact that the orthopaedic surgeon should not reply on an essentially 'normal' CT scan report and when possible, one must perform an accurate clinical assessment of the patient with the involvement of a pelvic specialist at an early stage if there is any suspicion of a pelvic injury. Repeated reporting of the initial CT scan additionally reduces the incidence of missed injuries.

The development and nature of femoral head cam lesions following acetabular fractures.

The aim of acetabular fracture fixation is to restore joint congruity with restoration of the articular surface. Poor outcomes are seen where this has not been achieved. Letournel reported a collarette osteophyte seen postoperatively in a proportion of patients, which he suggested was an early precursor to the development of osteoarthritis. This is a retrospective study of patients treated at a tertiary referral unit who developed this lesion. The triangular index was measured in 48 of these patients and then correlated with their clinical findings, Oxford Hip Score and the presence of osteoarthritis. Length of follow-up, fracture classification, and joint congruency were also recorded. Results showed a statistically significant relationship between cam lesion size and the development of osteoarthritis (P = 0.008), cam lesion size and length of follow-up (P = 0.01), and between groin pain and postoperative joint congruency (LR = 0.035). These findings suggest that the appearance of a cam lesion is a poor long-term prognostic marker for the development of osteoarthritis in patients with an acetabular fracture.

The safety of direct primary excision of low-grade chondral lesions based on radiological diagnosis alone.

The safety of treating low-grade chondral tumours by primary surgery without a pre- operative diagnostic needle biopsy was assessed by looking at the concordance between radiological and histological diagnoses. A retrospective review of the departmental histopathology registry from 2005 to 2009 was performed to identify cases of intramedullary chondral lesions in the appendicular skeleton. Cases with a pre-operative needle biopsy and with recurrence were excluded. Correlation between radiological and histological diagnosis was investigated with kappa analysis. Of 53 patients, bone expansion was seen in 18.4%, endosteal scalloping in 42.9% and extraosseous extension in 143%. Concordance was 100% between the radiological and histological diagnoses (Kappa score = 1.0). If a radiological diagnosis of an enchondroma or low-grade chondrosarcoma is made, then direct surgical treatment without needle biopsy is safe. A biopsy should be considered if any atypical radiological features suggesting a high-grade chondrosarcoma exist. This increases the certainty of diagnosis and allows planning of surgical treatment.

Malignant proximal fibular tumours: a case series of 17 patients.

The aim of this study was to establish whether the proximity of significant neurovascular structures around the surgical excision results in higher rates of recurrence and poorer survival outcomes. A retrospective study of all patients treated at a regional bone tumour unit for proximal fibula Ewing's tumours and osteosarcomas was conducted, and in total 17 patients were identified. The recurrence rate of all cases was 29.4% and the overall 5 year survival was 70.5%. The recurrence rate just for osteosarcoma was 50%, which compared poorly to published recurrence rates throughout the appendicular skeleton. The 5-year survival for proximal fibula osteosarcoma of 50% was also worse than generalised survivorship data reported in non-metastatic osteosarcoma. This series demonstrates that malignant proximal fibula tumours are a difficult entity to manage and recurrence rates and patient survival are poor for osteosarcoma.

The impact of intermittent retraction on paraspinal muscle function during lumbar surgery.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To study the effect of surgical retraction on paraspinal muscle function and investigate the effect of intermittent muscle retraction. SUMMARY OF BACKGROUND DATA: Paraspinal muscle retraction leads to increased intramuscular pressure with a reduction in local blood flow resulting in ischemic damage. This may lead to muscle dysfunction and increased back pain after surgery. METHODS: Two groups of 20 patients underwent one-level decompressive lumbar surgery. Group A underwent continuous muscle retraction, group B underwent intermittent muscle retraction. All patients completed pain questionnaires and underwent spinal strength assessment, paraspinal needle electromyography (EMG) before and after surgery, and had intraoperative muscle biopsy analysis using the technique of birefringence. RESULTS: Pain questionnaires revealed a reduction in back pain in all patients following surgery; patients with shorter retraction times had less pain (P < 0.05). Paraspinal muscle histochemistry revealed patients with shorter muscle retraction times and patients who underwent intermittent muscle retraction has less damage (P < 0.05). Isometric strength testing revealed patients in the intermittent retraction group had a less profound reduction in strength after surgery (P < 0.05). Needle EMG data and pain questionnaires showed no differences between the continuous and intermittent groups, although EMG data did show that muscle shows evidence of reinnervation after surgery. CONCLUSION: Although histologically there was a reduction in muscle damage in patients that underwent intermittent retraction, there was no benefit on clinical outcome. Paraspinal muscle shows evidence of reinnervation after surgery.

Back pain and disability after lumbar laminectomy: is there a relationship to muscle retraction?

OBJECTIVE: Preliminary studies have suggested that prolonged retraction of the paraspinal muscle during spinal surgery may produce ischemic damage. We report the continuous measurement of intramuscular pressure (IMP) during decompressive lumbar laminectomy and its relationship to subsequent back pain and disability. METHODS: Twenty patients undergoing two-level decompressive lumbar laminectomy for lumbar canal stenosis were recruited. Back pain and disability were assessed by use of the Visual Analog Score (VAS), Oswestry Disability Index (ODI), and Short-Form 36 (SF-36) Health Survey. During surgery, IMP was recorded continuously from the multifidus muscle by use of a pressure transducer. The intramuscular perfusion pressure (IPP) was estimated as the difference between the patient's mean arterial pressure and IMP. RESULTS: Two muscle retractors were used: the Norfolk and Norwich (n = 10) and the McCulloch (n = 10). The mean duration of deep muscle retraction was 62.7 +/- 8 minutes (range, 19-133 min). On application of deep muscle retraction, there was a rapid and sustained increase in IMP (P < 0.001), and overall, the calculated mean IPP approached 0 mm Hg or less during this period (P < 0.001). On release of deep muscle retraction, there was a rapid decrease in IMP to preoperative levels. The IPP was greater with the Norfolk and Norwich than the McCulloch retractor (P < 0.001). Compared with preoperative values, there was a decrease in ODI (P < 0.001) and VAS for back pain (P < 0.001) at discharge and 4 to 6 weeks and 6 months after surgery. In addition, there was a decrease in SF-36 scores at 6 months compared with preoperative values (P < 0.001). Total duration of muscle retraction greater than 60 minutes was associated with worse VAS scores for back pain and ODI and SF-36 scores for disability at 6 months after surgery (P < 0.05). There was no relationship between the VAS, ODI, and SF-36 scores and other parameters measured, including the mean IPP, retractor type, operating surgeon, and wound length. CONCLUSION: The McCulloch retractor generates a higher IMP than the Norfolk and Norwich retractor. However, postoperative improvement in VAS, ODI, and SF-36 scores in these patients was associated with a shorter duration of muscle retraction and not the degree of IMP or IPP generated. In this respect, periodic relaxation of the paraspinal muscle retractors during surgery to allow muscle perfusion may help to reduce postoperative back pain and disability.