Cement Augmentation of the Cervical Spine - a Technique Enhancing Stability of Anterior Cervical Plating.

PURPOSE OF THE STUDY The aim of this study is to describe a new technique for cement augmentation of primary anterior cervical screw fixation in the sub-axial cervical spine. MATERIAL AND METHODS Seven patients underwent anterior cervical spine surgery for trauma (two) or tumor infiltration (five) between 2008 and 2015. The tumor cases underwent corpectomy and anterior plating, with the trauma cases undergoing anterior cervical decompression and fusion using iliac crest bone graft. All surgeries were performed through the standard anterior approach. 0.2-0.25 ml of Kyphon cement were introduced into the screw holes before the screws were locked into the plate of the anterior construct. Karnofsky Index, Spinal Instability Neoplastic score (SINS) were calculated and radiographic follow-up performed. RESULTS Median follow-up was 7 months (range 7 weeks-39 months). There were no complications from cement leakage or construct failure during the follow-up period. There were no wound infections or approach-related complications. We did not have to re-operate on any patient, cervical spine remained stable until the end of follow up. DISCUSSION Until now a limited number of papers on cement augmentation of cervical spine mainly dealt with revision surgeries, when cement was used as rescue technique to re-establish stability of previous fixation or cement augmentation was performed in form of vertebroplasty following plate fixation. Our technique intends to prevent revision surgeries and to anchor all screws in holes which are evenly filled with bone cement. CONCLUSIONS This technique of cement augmentation is a useful adjunct in those few patients where a secondary posterior surgery would be high-risk due to the general health of the patient, or when life expectancy is limited. We have shown that anterior alone reconstruction of the cervical spine with cement augmentation of screws did provide sufficient and sufficiently long stability of the cervical spine which prevented catastrophic collapse and quadriplegia in patients in poor general condition. Key words: cement augmentation, cervical spine, corpectomy, tumor, stabilization, fusion.

The direct anterior approach to the thoracolumbar junction: an anatomical feasibility study.

INTRODUCTION: The thoracolumbar junction (TJ) is traditionally exposed by lateral or posterior approaches. This usually requires splitting of the diaphragm, or extensile removal of the posterior elements. A circumferential exposure (i.e. simultaneous anterior and bilateral exposure) of the vertebral body is not possible. Direct anterior access would allow circumferential exposure of the vertebral body, with adjacent disc levels, and would avoid splitting the diaphragm or extensive removal of the posterior bony structures. MATERIALS AND METHODS: Twelve Thiel cadavers (8 f/4 m) were dissected to access T12 or L1 via a midline laparotomy. Supra- and infragastric laparatomy techniques were investigated. Six cadavers were used to reach T12 through the lesser omentum, six to reach L1 through the greater omentum. RESULTS: T12 after bluntly dissecting the lesser omentum, the lesser gastric curvature and the caudate lobe of the liver were utilised as landmarks. A small retroperitoneal incision was performed to mobilise the aorta allowing exposure of the T12 vertebra and its adjacent discs. Discectomy, corpectomy and insertion of an anterior column support were possible. The L1 level can be reached through the greater omentum by mobilising the pancreas as a single retroperitoneal structure, leaving the aorta and celiac trunk as landmarks. Retraction of the great vessels is necessary to expose L1 with its adjacent discs. Implantation of an anterior column support was possible utilising this approach. CONCLUSION: Direct anterior access to the TJ is feasible in a reproducible manner. This approach would avoid splitting the diaphragm, or dissection of the erector spinae muscles, and is likely to be less invasive than standard lateral or posterior approaches. This technique may offer a significant time reduction to surgery, especially in exposing the spine. Anterior column support can easily be performed, offering a better avoidance of kyphotic deformities.

Antibiotic-associated complications following lower limb arthroplasty: a comparison of two prophylactic regimes.

INTRODUCTION: As part of a wider drive to reduce Clostridium difficile rates (CDAD), our trust switched from cefuroxime to gentamicin and flucloxacillin prophylaxis for joint replacement surgery. Anecdotal evidence suggested that we were seeing an increased incidence of acute kidney injury (AKI) following elective total hip replacement (THR) and total knee replacement (TKR) since this change. The aim of this study was to compare rates of AKI and post-operative infection between the two antibiotic regimes. METHODS: We carried out a single-centre retrospective cohort study comparing 200 patients (100 THR and 100 TKR) who received cefuroxime with another age and procedure-matched group who received gentamicin and flucloxacillin (gentamicin 3 mg/kg and 5 g flucloxacillin in total). We compared rates of AKI, haemofiltration, CDAD, surgical site infection (SSI) and return to theatre for infection (RTT). RESULTS: Gentamicin was associated with a significant increase in AKI (1 vs. 8%, p < 0.01). More patients needed haemofiltration (0 vs. 1.5%) although this was not significant. Interestingly, when the groups were subdivided into THR and TKR, significantly more TKR patients receiving gentamicin developed AKI (0 vs. 11, p < 0.01). This difference was not significant following THR (2 vs. 5, p = 0.44). This may be related to tourniquet use in TKR. SSI and RTT were comparable. No patient developed CDAD. CONCLUSIONS: Gentamicin with flucloxacillin is comparable with cefuroxime in rates of SSI and RTT but is associated with a significant increase in AKI. AKI is associated with additional morbidity and mortality. This association should be considered when choosing a suitable prophylactic regime.

Fatal pulmonary embolism following elective total knee replacement using aspirin in multi-modal prophylaxis - A 12year study.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) has issued guidelines on which thromboprophylaxis regimens are suitable following lower limb arthroplasty. Aspirin is not a recommended agent despite being accepted in orthopaedic guidelines elsewhere. We assessed the incidence of fatal pulmonary embolism (PE) and all-cause mortality following elective primary total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching district general hospital. METHODS: We utilised a prospective audit database to identify those that had died within 42 and 90days postoperatively. Data from April 2000 to 2012 were analysed for 42 and 90day mortality rates. There were a total of 8277 elective primary TKR performed over the 12year period. The multi-modal prophylaxis regimen used unless contraindicated for all patients included 75mg aspirin once daily for four weeks. Case note review ascertained the causes of death. Where a patient had been referred to the coroner, they were contacted for post mortem results. RESULTS: The mortality rates at 42 and 90days were 0.36 and 0.46%. There was one fatal PE within 42days of surgery (0.01%) who was taking enoxaparin because of aspirin intolerance. Two fatal PE's occurred at 48 and 57days post-operatively (0.02%). The leading cause of death was myocardial infarction (0.13%). CONCLUSIONS: Fatal PE following elective TKR with a multi-modal prophylaxis regime is a very rare cause of mortality.

Fatal pulmonary embolism following elective total hip arthroplasty: a 12-year study.

AIMS: The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime. PATIENTS AND METHODS: A prospective audit database was used to identify patients who had died within 42 and 90 days of surgery respectively between April 2000 and December 2012. A case note review was performed to ascertain the causes of death. RESULTS: During this period 7983 THAs were performed. The rate of mortality was 0.43% and 0.58% at 42 and 90 days respectively. The groups comprised 1571 patients (19.7%) on warfarin, 1838 (23.0%) on LMWH and 4574 (57.3%) on aspirin. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. The higher mortality rate for LMWH was significant (p < 0.05). There were six fatal pulmonary emboli (PEs) (0.08%). A total of three occurred within 42 days, all in the LMWH group. A total of three occurred between 42 and 90 days; one on warfarin, two on LMWH. The leading causes of death in all three groups were lower respiratory tract infections and myocardial infarction. CONCLUSION: We confirmed that fatal PE following elective THA with a multi-modal prophylaxis regime is rare. We further found that LMWH conferred no benefit over aspirin in this context, and is associated with a higher all-cause rate of mortality. TAKE HOME MESSAGE: This study proposes that aspirin may be an appropriate thromboprophylaxis agent when used as part of a multi-modal regimen, suggesting current guidelines should be reviewed. Cite this article: Bone Joint J 2016;98-B:585-8.

Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients.

AIM: Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals. PATIENTS AND METHODS: All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%). RESULTS: Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries. TAKE HOME MESSAGE: There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care. Cite this article: Bone Joint J 2016;98-B:825-8.

A Delphi study on research priorities for trauma nursing.

OBJECTIVES: To identify and prioritize research questions of importance to trauma patient care and of interest to trauma nurses. METHOD: A three-round Delphi technique was used to solicit, identify, and prioritize problems for trauma nursing research. In round 1, experienced trauma nurses (N = 208) generated 513 problems, which were analyzed, categorized, and collapsed into 111 items for subsequent rounds. Round 2 participants rated each research question on a 1 to 7 scale on two criteria: impact on patient welfare and value for practicing nurses. Group median scores provided by 166 round 2 respondents and respondents' individual round 2 scores were indicated on the round 3 questionnaire. Subjects rated the questions again on the same criteria and indicated whether nurses, independently or in collaboration with other health professionals, should assume responsibility for that research. Median and mean scores and rank order were determined for each item. RESULTS: Respondents who completed all three rounds (n = 137) had a mean of 8.3 years of trauma experience. Nine research questions ranked within the top 20 on both criteria. The two research questions that ranked highest on both criteria were: What are the most effective nursing interventions in the prevention of pulmonary and circulatory complications in trauma patients? and What are the most effective methods for preventing aspiration in trauma patients during the postoperative phase? The third-ranked question regarding patient welfare was: What psychological and lifestyle changes result from traumatic injury? Regarding value for practicing nurses, What are the most effective educational methods to prepare and maintain proficiency in trauma care providers? ranked third. CONCLUSION: These research priorities provide impetus and direction for nursing and collaborative investigation in trauma care.

Research priorities for burn nursing: report of the psychosocial issues group.

This study was designed to identify nursing research priorities in burn care. The Delphi technique of sequential questionnaires was used for data collection. Ninety-four participants completed four rounds of questionnaires. One hundred and one research questions were identified, and priorities were assigned according to their impact on patient welfare and on the profession of burn nursing. Twenty-two of these research questions concerned psychosocial issues. This group of questions was then analyzed for priority research issues. The top five ranked questions in the psychosocial issues group for impact on patient welfare concerned: (1) stress reduction techniques, (2) social reentry strategies, (3) management of psychosis and post-traumatic stress disorder, (4) strategies to assist patients with impaired communication capabilities, and (5) the role of recovered burn survivors in encouraging patient compliance with treatments. Similarly, the top five ranked questions for impact on the profession of burn nursing concerned: (1) stress reduction strategies, (2) coping techniques for burn survivors, (3) management of psychosis and post-traumatic stress disorder, (4) nursing's supportive role in regard to "do not resuscitate" orders, and (5) coping strategies to be used with patients who express a desire to die.

Research priorities for burn nursing: report on physiologic issues.

This Delphi study was designed and conducted to identify the issues of greatest concern to care of patients with burns and to the profession of burn nursing, so that nursing research could be directed toward these ends. One hundred and one questions were prioritized by the 94 participants who completed the four sequential rounds of questionnaires. A total of 11 questions (10.9%), which addressed physiologic-based issues, were identified.

Research priorities for burn nursing. Report of the Wound Care and Infection Control Group.

This study was designed to identify research priorities in burn nursing. The Delphi technique of sequential questionnaires was used for data collection. Ninety-four participants completed four rounds of questionnaires. One hundred one research questions were identified and prioritized according to impact on the welfare of patients with burns and impact on the profession of burn nursing. Twenty-three of these research questions concerned issues of wound care or infection control. This group of questions was further analyzed to determine priority research issues. The five most highly ranked questions in the category of wound care/infection control with regard to impact on patient welfare concerned healing of donor sites and skin grafts, wound cleansing, and the effect of pressure garments on wound healing. Similarly, the five most highly ranked questions with regard to impact on the profession of burn nursing concerned the impact of combining patients with burns and patients without burns in the same unit, healing of donor sites and skin grafts, care of the patient with burns who also has acquired immune deficiency syndrome, infection control, and dressing of the burn wound.

Research priorities for burn nursing: patient, nurse, and burn prevention education.

Fifteen of the 101 research questions that were assigned priorities in the Burn Nursing Delphi study by Marvin et al. (Marvin JA, Carrougher GJ, Bayley EW, Weber B, Knighton J, Rutan RL. Burn nursing Delphi study: setting research priorities. J BURN CARE REHABIL 1991;12:190-7) addressed education from the perspectives of patients, their families, and burn nurses; the study also addressed the issue of burn prevention education. Questions concerning patient education were assigned the highest priority in this education subgroup with respect to the potential for research that would have an impact on patient welfare. The question that rated highest as a priority for its potential impact on the profession of burn nursing addressed the core competencies needed for safe and effective burn nursing practice. Prevention education was generally found to be a low priority in the Delphi study. Many of the questions in the education subgroup can best be answered by comparative or experimental studies designed to explain and predict the effects of various teaching strategies on behavioral outcomes. Research on patient, nurse, and burn prevention education provides a fertile ground for nurse researchers and an opportunity to contribute knowledge of vital importance to clinicians, educators, managers, and the public.

Burn nursing Delphi study: pain management.

In 1989 a Delphi study was undertaken to identify the nursing priorities in burn research. The Delphi technique is a series of questionnaires used to reach consensus. Ninety-four nurses involved in burn care completed four rounds of questionnaires containing 101 research questions. This, the seventh and final report, concerns a significant area of burn research, which is pain management. Eleven (10%) of the 101 questions dealt with pain, whereas five were rated among the top 20 priority questions. As a category the questions concerning pain management had a mean score of 5.91 on a 0 to 7 Likert scale. The questions collectively were cited as having the most impact on the welfare of the patient with burns.

Research priorities for burn nursing: nursing recruitment, retention, and other administrative issues.

This Delphi study was designed to identify nursing research priorities. Ninety-four participants completed four rounds of questionnaires that contained 101 potential research questions. Twenty questions addressed nursing administrative issues. In this category, the highest priority for potential impact on patient welfare related to the cost-effectiveness of various infection control measures. Questions concerning recruitment, retention, staffing, and cost/quality issues had the highest priority for research that could have an impact on the profession of nursing.

Research priorities for burn nursing: rehabilitation, discharge planning, and follow-up care.

Fourteen of the 101 research questions that were proposed in the Burn Nursing Delphi study by Marvin et al. (J Burn Care Rehabil 1991;12:190-7) were concerned with the rehabilitation, discharge planning, and follow-up care of patients with burns. Questions that were ranked as top priorities for patient welfare related to control of postburn itching, prevention of contractures, and effective means of community-based follow-up to meet physical, social, and emotional needs of patients and families. Burn nurses identified the study of nursing interventions that are the most effective means for preparing patients, families, and community nurses for posthospitalization care as the research priority that has the greatest potential impact on the profession of burn nursing. Respondents to the Delphi study favored a collaborative approach to research for most of the questions in the rehabilitation subgroup. Suggestions are made for nurses who wish to take the lead in designing and implementing qualitative and quantitative studies that relate to the increasingly prevalent problems that are encountered by survivors of burn injury.

Wound healing in the patient with burns.

The burn wound presents many unique challenges to the nurse who promotes optimal wound healing. Nursing care includes meticulous attention to the prevention of infection, wound cleansing and debridement, and application of topical antibacterial agents. Preparation of graft recipient sites, care of graft and donor sites, and use of various biologic and synthetic wound coverings are required. An interdisciplinary approach that provides for adequate nutrition, fosters physical function, and supports psychologic adjustment to altered self-concept is required for holistic healing of the burn wound.

Nurses preparing for change: their needs and concerns.

As a result of decreased lengths of stay and cost-containment initiatives, fewer nurses are needed in acute care settings. The trend for community-based health care is broadening employment opportunities for nurses to work in community settings. As nurses are considering options to base their practice in community settings, it is important to understand their concerns about making this transition. The results of a qualitative study conducted to examine the concerns and educational needs of acute care nurses related to working in the community are reported. Clinical, professional, and intrapersonal skills important for a successful transition to community-based practice are identified and discussed.

The use of locking plates in complex midfoot fractures.

INTRODUCTION: Complex fracture dislocations of the midfoot are uncommon. Improved outcomes have been demonstrated where it has been possible to restore and maintain the length and alignment of the medial column as well as the congruity of the articular surfaces. We present our experience with the use of angle-stable locking plates in the stabilisation of complex midfoot fracture dislocations. METHODS: Twelve patients were identified on a prospective trauma database between 2003 and 2009. All fractures involved the medial column with four associated fracture subluxations of the lateral column also. Patients underwent open reduction internal fixation (ORIF) with restoration of the medial column axis, reduction of the articular surface congruity and stabilisation with angle-stable locking plates. RESULTS: There were no post-operative infections or neurological injuries. Ten of the twelve patients required metalwork removal. There were no implant failures prior to removal of the metalwork. At a mean follow-up of 12.4 months (range: 4-32 months), 11 patients had minimal symptoms of swelling, discomfort or stiffness in the midfoot. This did not restrict their daily activities. One patient developed post-traumatic arthritis and collapse of the medial longitudinal arch. Two patients declined removal of the metalwork. CONCLUSIONS: Angle-stable locking plates provide satisfactory stabilisation following ORIF of complex midfoot fracture dislocations. Most patients will require removal of the metalwork. Following removal of metalwork, the majority of patients will maintain the length, alignment and stability of the midfoot.