John F. Quinlan

Serum albumin and total lymphocyte count as predictors of outcome in hip fractures

BACKGROUND & AIMS Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a significant contributor to this, however no consensus exists as to the detection or management of this condition. We hypothesise that results of admission serum albumin and total lymphocyte count (TLC), as markers of Protein Energy Malnutrition (PEM) can help predict clinical outcome in hip fracture patients aged over 60 years. METHODS This retrospective study evaluated the nutritional status of patients with hip fractures using albumin and TLC assays and analysed their prognostic relevance. Clinical outcome parameters studied were delay to operation, duration of in-patient stay, re-admission and in-patient, 3- and 12-month mortality. RESULTS Four hundred and fifteen hip fracture patients were evaluated. Survival data were available for 377 patients at 12 months. In-hospital mortality for PEM patients was 9.8%, compared with 0% for patients without. Patients with PEM had a higher 12-month mortality compared to patients who had normal values of both laboratory parameters (Odds Ratio 4.6; 95% CI: 1.0-21.3). Serum albumin (Hazard Ratio 0.932, 95% CI: 0.9-1.0) and age (Hazard Ratio 1.04, 95% CI: 1.0-1.1) were found to be significant independent prognostic factors of mortality by Cox regression analysis. CONCLUSIONS These results highlight the relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the correlation between PEM and outcome in these patients.

Three-dimensional Motion Analysis of the Lumbar Spine during “Free Squat” Weight Lift Training

Background Heavy weight lifting using a squat bar is a commonly used athletic training exercise. Previous in vivo motion studies have concentrated on lifting of everyday objects and not on the vastly increased loads that athletes subject themselves to when performing this exercise. Hypothesis Athletes significantly alter their lumbar spinal motion when performing squat lifting at heavy weights. Study Design Controlled laboratory study. Methods Forty-eight athletes (28 men, 20 women) performed 6 lifts at 40% maximum, 4 lifts at 60% maximum, and 2 lifts at 80% maximum. The Zebris 3D motion analysis system was used to measure lumbar spine motion. Exercise was performed as a “free” squat and repeated with a weight lifting support belt. Data obtained were analyzed using SAS. Results A significant decrease (P < .05) was seen in flexion in all groups studied when lifting at 40% maximum compared with lifting at 60% and 80% of maximum lift. Flexion from calibrated 0 point ranged from 24.7° (40% group) to 6.8° (80% group). A significant increase (P < .05) was seen in extension when lifting at 40% maximum was compared with lifting at 60% and 80% maximum lift. Extension from calibrated 0 point ranged from —1.5° (40% group) to —20.3° (80% group). No statistically significant difference was found between motion seen when exercise was performed as a free squat or when lifting using a support belt in any of the groups studied. Conclusion Weight lifting using a squat bar causes athletes to significantly hyperextend their lumbar spines at heavier weights. The use of a weight lifting support belt does not significantly alter spinal motion during lifting.

The effect of acetabular inclination on metal ion levels following metal-on-metal hip arthroplasty.

Acetabular inclination angles have been suggested as a principal determinant of circulating metal ion levels in metal-on-metal hip arthroplasties. We aimed to determine whether inclination angle correlates with ion levels in arthroplasties using the Articular Surface Replacement (ASR) system. Patients undergoing ASR arthroplasties had blood metal ion levels and radiograph analysis performed a mean of 3.2 years after surgery. Inclination angle showed only a weak correlation with cobalt (r=0.21) and chromium (r=0.15) levels. The correlation between inclination angle and cobalt levels was significant only with small femoral components, although it was still weak. Multiple regression showed a complex interaction of factors influencing ion levels but inclination angle accounted for little of this variation. We conclude that the acetabular inclination angle is not a meaningful determinant of metal ion levels in ASR arthroplasties.

INTER AND INTRA-OBSERVER VARIABILITY ASSOCIATED WITH THE USE OF THE MIRELS’ SCORING SYSTEM FOR METASTATIC BONE LESIONS

Metastatic bone disease is increasing in association with ever-improving medical management of osteophylic malignant conditions. The precise timing of surgical intervention for secondary lesions in long bones can be difficult to determine. This paper aims to evaluate a classic scoring system. All radiographs were examined twice by three orthopaedic oncologists and scored according to the Mirels’ scoring system. The Kappa statistic was used for the purpose of statistical analysis. The results show agreement between observers (κ = 0.35–0.61) for overall scores at the two time intervals. Inter-observer agreement was also seen with subset analysis of size (κ = 0.27–0.60), site (κ = 0.77–1.0) and nature of the lesion (κ = 0.55–0.81). Similarly, low levels of intra-observer variability were noted for each of the three surgeons (κ= 0.34, 0.39, and 0.78, respectively). These results indicate a reliable, repeatable assessment of bony metastases. We continue to advocate its use in the management of patients with long bone metastases.

The use of the Zebris motion analysis system for measuring cervical spine movements in vivo.

Abstract The cervical spine exhibits the greatest range of motion among the spinal segments due to the complex interaction of its triplanar components of movement. As a result, measurement of movements of the cervical spine and of the various orthoses used in cervical spine injuries has proved difficult with no one method proving satisfactory. This paper uses the Zebris ultrasonic three-dimensional motion analysis system to measure flexion, extension, range of lateral bending, and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested unrestrained and in soft and hard collars, as well as in Philadelphia, Miami J, and Minerva orthoses. Results show that the Minerva is the most stable construct for restriction of movement in all planes in both groups. Looking at these results allows ranking of the measured orthoses in order of their three-dimensional stability. Furthermore, by presenting reproducible data incorporating the composite triplanar movements of the cervical spine, thus allowing comparative analysis of the studied orthoses, they propose the Zebris as a reliable, repeatable, and safe method of measurement of cervical spine motion with low intersubject variability.

Withholding clopidogrel for 3 to 6 versus 7 days or more before surgery in hip fracture patients.

Purpose. To compare morbidity and mortality after hip fracture surgery in patients withholding clopidogrel for 3 to 6 days versus ≥7 days. Methods. Records of 16 men and 31 women aged 49 to 92 (mean, 80.2) years who underwent hip fracture surgery after withholding clopidogrel for 3 to 6 days (n=24) versus ≥7 days (n=23) were compared. The patients were taking clopidogrel owing to ischaemic heart disease (n=37), cerebrovascular disease (n=7), and intolerance to aspirin (n=3). Patient demographics, American Society of Anesthesiologists status, preoperative delay, length of hospital stay, perioperative haemoglobin reduction, receipt of blood and platelet transfusions, morbidity, and mortality were recorded. Results. Respectively in the early-surgery and delayed-surgery groups, the mean surgical delay was 4.2 and 8.0 days, the mean length of hospital stay was 21.1 and 28.7 days, the mean peri-operative haemoglobin reduction was 1.5 and 1.1 g/dl, the mean units of blood transfusion per patient was 0.8 and 0.7. No severe intra-operative bleeding or wound haematoma was encountered in either group. Two patients in each group died within one month, and 2 more in the delayed-surgery group died within 3 months. The main cause of death was cardiovascular. Conclusion. Withholding clopidogrel for <7 days before surgery conferred no increased risk in hip fracture patients.

MRI Findings Following Metal on Metal Hip Arthroplasty and Their Relationship With Metal Ion Levels and Acetabular Inclination Angles

Following the global recall of all ASR metal on metal hip products, our aim was to correlate MRI findings with acetabular inclination angles and metal ion levels in patients with these implants. Both cobalt and chromium levels were significantly higher in the presence of a periprosthetic fluid collection. There was no association between the presence of a periprosthetic mass, bone marrow oedema, trochanteric bursitis or greater levels of abductor muscle destruction for cobalt or chromium. There was no association between the level of periprosthetic tissue reaction and the acetabular inclination angle with any of the pathologies identified on MRI. The relationship between MRI pathology, metal ion levels and acetabular inclination angles in patients with ASR implants remains unclear adding to the complexity of managing patients.

Factors Associated with Persistent Sequelae after Fasciotomy for Acute Compartment Syndrome

Purpose. To determine factors associated with persistent sequelae after fasciotomy for acute compartment syndrome. Methods. Records of 57 men and 3 women aged 8 to 84 (mean, 31.9) years who underwent fasciotomy of the lower (n=48) or upper (n=12) limbs for acute compartment syndrome following limb trauma were retrospectively reviewed. 58 of the fasciotomies were therapeutic and 2 were prophylactic. The mean follow-up was 3.9 (range, 1–8) years. Patients were assessed through a telephone survey for persistent sequelae (parasthaesia, dysasthaesia, and/or motor weakness), using a scale of one to 4 to indicate asymptomatic, mild, moderate, and severe, respectively. Associations of persistent sequelae with the aetiology, mechanism of injury, site of fasciotomy, time to fasciotomy (from admission to anaesthesia induction), number of operations, method of closure, time to closure, and perioperative complications were assessed. Results. 18 patients were asymptomatic and 42 reported having persistent sequelae including motor weakness (n=26), parasthaesia (n=28), and dysasthaesia (n=30). In terms of severity, these sequelae were mild (n=10), moderate (n=12), or severe (n=20). Persistent sequelae were associated with higher number of operations, post-fasciotomy complications, closures with skin grafting, and increased time to closure. Conclusion. To reduce the risk of persistent sequelae after fasciotomy, careful preoperative planning and meticulous perioperative care is needed to avoid multiple operations and post-fasciotomy complications. Patients whose wounds healed by secondary intention showed the best outcome.

Quantification of the coupled motion that occurs with axial rotation and lateral bending of the head-neck complex: An experimental examination

Abstract The vertebrae of the cervical spine exhibit out-of-plane or coupled motion during axial rotation and lateral bending. Quantifying the range of motion (ROM) of this occurrence can aid the understanding of cervical spine injury mechanisms and disorders, as well as the development of new treatment methods. Previous studies have formulated ratios to describe coupled motion obtained from in-vitro examinations. The aim of the present study was to use in-vivo test data to develop mathematical relationships to quantify the coupled motion that occurs with axial rotation and lateral bending of the head-neck complex. Using a three-dimensional motion analyser it was possible to trace the coupling effect throughout the full range of unrestricted head-neck motion. Values for primary and coupled ROMs were obtained, showing no significant difference between male and female primary ROMs but a small disparity between male and female coupled ROMs. Regression equations were found to quantify coupled motion throughout the range of axial rotation and lateral bending. The present experimental study also examines the range of horizontally fixed axial rotation of the head to determine the minimum amount of coupled lateral bending that takes place, which has not been measured previously.

Co-existent medial collateral ligament injury seen following transient patellar dislocation: observations at magnetic resonance imaging

This study reports on a series of patients who were diagnosed as having had a transient lateral patellar dislocation by magnetic resonance imaging (MRI). The images were reviewed with specific reference to the medial collateral ligament (MCL), a heretofore undescribed concomitant injury. Eighty patients were diagnosed on MRI as having had transient lateral patellar dislocation. Their mean age was 23.9 years (SD 7.5). Forty patients (50.0%) had co-existent MCL injuries. These injuries were classified as grade 1 (n = 20), grade 2 (n = 17) and grade 3 (n = 3). These results suggest that MCL injury commonly accompanies transient lateral patella dislocation, most likely due to a shared valgus injury. It appears to occur more commonly in male patients and if unidentified may explain both delayed recovery and persistent morbidity in more severe cases. In this setting, without specifically excluding co-existent MCL injury, the current vogue for early rehabilitation should be adopted with caution.