Sarkhell Radha

Evaluation of perifacet injections and paraspinal muscle rehabilitation in treatment of low back pain. A randomised controlled trial.

BACKGROUND Lumbar paraspinal muscle dysfunction and Low Back Pain are strongly correlated. The best treatment for non-specific Low Back Pain is still controversial. OBJECTIVE To evaluate the efficacy of lumbar multifidus muscle retraining exercises and perifacet multifidus injections in the treatment of Low Back Pain. MATERIAL AND METHODS 63 patients with non-specific LBP, with or without leg pain, and magnetic resonance images of paraspinal muscle degeneration only, were randomised to one of three treatment groups: A- Back education and standard physiotherapy for 10 weeks, B- Back education and gym ball exercise for 10 weeks or C- Perifacet injection into the lumbar multifidus muscle with methylprednisolone. The Oswestry Disability Index was used as the primary outcome measure and the SF-36, modified Zung depression index, modified somatic perception and McGill pain questionnaires were used as secondary outcome measures. RESULTS 56 patients completed the trial. The Oswestry Disability Index improved in general from a mean of 29.9 to 25.9, but there were no statistically significant differences between the groups. Low back pain improved most in group C (P<0.02), while physical activities and social functioning were improved the most in group B (P<0.03). CONCLUSION Perifacet injection and back education including a gym ball exercise program may be more effective than back education alone in relieving pain and improving physical capacity respectively. Back education including gym ball exercise could be used for non-specific Low Back Pain, as the ultimate goal should be to restore function.

Common peroneal nerve schwannoma: an unusual differential for a symptomatic knee lump

A 60-year-old woman with no medical history presented to the emergency department with worsening knee pain after a short-haul flight. She had a 2 year history of intermittent left knee pain, made worse by crouching and a lump at the back of her leg, which was gradually increasing in size. On examination, she was found to have a 3×4 cm lump behind the posterolateral aspect of the left knee. …

Can patients really make an informed choice? An evaluation of the availability of online information about consultant surgeons in the United Kingdom

Objectives The National Health Service (NHS) ‘Choose and Book’ online scheme, which allows patients to select the location and time of hospital appointments, has now been extended to include the option for patients to select a specific consultant to carry out any necessary treatment. The aim of this study was to determine whether there is sufficient online information about consultants or consultant-led teams for patients to make an informed choice regarding a specific consultant. Design A web-based analysis of the availability of information. Setting North of England. Participants Two hundred websites of orthopaedic surgeons. Main outcome measures The websites were analysed using a bespoke template that took into account recommendations of the 2010 UK Government white paper. Each website was scored in relation to the availability of specific content relating to each surgeon. Results The majority of websites detailed authorship information (73.2%), level of professional qualification (98.5%) and area of general (73.7%) and specialist (93.3%) interest. However, approximately 50% of websites provided no information in relation to update cycle, involvement in teaching or research and patient satisfaction. Only five (2.6%) of the websites presented death rates, and none indicated morbidity rates. Conclusions For patients to be able to make informed choices about their healthcare, surgeons need to ensure that sufficient information is available online, according to the identified limitations of the websites investigated in this study.

Gym ball exercise leads to recruitment and increased water content of the paraspinal muscles: An MRI pilot study

Study design: Cross-sectional pilot study on 24 healthy volunteers. Objectives: Investigate the value of stabilization exercises using a gym ball in paraspinal muscle activation by measuring changes in muscle signal intensity on MRI before and after exercise. Background: The gym ball is commonly used for rehabilitating spinal dysfunction. It is thought to rehabilitate some key muscle groups in the trunk. Methods: Twenty-four healthy volunteers (aged 21–50, 13 female and 11 male) had special sequence MR images of the lumbar spine showing an axial section of the paraspinal muscles at L4/5 level. Afterwards all were subjected to 10 minutes of exercise on the gym ball followed by repeat MRI scans immediately, 5 and 10 minutes post exercise. Changes in the mean signal intensity at the same region of interest in multifidus, erector spinae and psoas muscles were evaluated using MRI software. Results: The mean signal intensity in the MR images of the same region in the multifidus (P < 0.03) and erector spinae (P < 0.005) muscles significantly increased after gym ball exercise. There was no statistically significant change in the signal intensity of the psoas muscle (P < 0.086). Conclusions: The multifidus and erector spinae muscles of a healthy individual can be activated by performing certain exercises

The Introduction of a Multidisciplinary Hip Fracture Pathway to Optimise Patient Care and Reduce Mortality: A Prospective Audit of 161 Patients

Introduction: Hip fractures are a major cause of morbidity and mortality in the elderly. A new patient pathway was introduced in our institution to facilitate rapid preoperative assessment, acute physician involvement and early surgery for patients with hip fractures. We sought to assess its impact on patient care and outcomes. Materials and Methods: Prospective audit of 161 patients admitted with a proximal femoral fracture in the six months before (92 patients) and after (69 patients) implementation of the pathway. Data included: time to orthogeriatric assessment (TtG); time to surgery (TtS); length of hospital stay (LOS); return to original accommodation; inpatient mortality rate. Results: In the six months after introduction of the pathway, there was an increase in patients who received pre-operative medical assessment (85% after vs. 19% before, p=0.0001). Average TtG decreased (19 vs. 91 hours, p=0.0001), as did LOS (19.5 vs. 24.8 days, p=0.029) and mortality (4 vs. 14%, p=0.0336). There was an increase in patients returning to their original place of accommodation (80% vs. 57%, p=0.0069). There was a reduction in mean TtS (31 vs. 37 hours, p=0.0663), although this was not statistically significant. Discussion and Conclusions: Rapid medical optimisation and prompt surgery significantly improve outcomes in patients with hip fractures. By involving an acute medical team in patient care from the point of admission, we have significantly improved our inpatient mortality and increased the proportion of patients returning to their preoperative place of accommodation, thereby maintaining patient independence and reducing the financial and logistical burden on social care.

Effects of 1 week of unilateral ankle immobilization on plantar-flexor strength, balance, and walking speed: a pilot study in asymptomatic volunteers.

CONTEXT Ankle immobilization is often used after ankle injury. OBJECTIVE To determine the influence of 1 weeks unilateral ankle immobilization on plantar-flexor strength, balance, and walking gait in asymptomatic volunteers. DESIGN Repeated-measures laboratory study. SETTING University laboratory. PARTICIPANTS 6 physically active male participants with no recent history of lower-limb injury. INTERVENTIONS Participants completed a 1-wk period of ankle immobilization achieved through wearing a below-knee ankle cast. Before the cast was applied, as well as immediately, 24 h, and 48 h after cast removal, their plantar-flexor strength was assessed isokinetically, and they completed a single-leg balance task as a measure of proprioceptive function. An analysis of their walking gait was also completed Main Outcome Measures: Peak plantar-flexor torque and balance were used to determine any effect on muscle strength and proprioception after cast removal. Ranges of motion (3D) of the ankle, knee, and hip, as well as walking speed, were used to assess any influence on walking gait. RESULTS After cast removal, plantar-flexor strength was reduced for the majority of participants (P = .063, CI = -33.98 to 1.31) and balance performance was reduced in the immobilized limb (P < .05, CI = 0.84-5.16). Both strength and balance were not significantly different from baseline levels by 48 h. Walking speed was not significantly different immediately after cast removal but increased progressively above baseline walking speed over the following 48 h. Joint ranges of motion were not significantly different at any time point. CONCLUSIONS The reduction in strength and balance after such a short period of immobilization suggested compromised central and peripheral neural mechanisms. This suggestion appeared consistent with the delayed increase in walking speed that could occur as a result of the excitability of the neural pathways increasing toward baseline levels.

Successful Treatment of Painful Synchondrosis of Bipartite Patella after Direct Trauma by Operative Fixation: A Series of Six Cases

Introduction: The patella is the largest sesamoid bone in the body and may have one (77%) or multiple (23%) ossification centres. Patellar and patellofemoral joint abnormalities are a common cause of anterior knee pain but symptomatic bipartite patella is an uncommon problem. Case Series: We report a series of six cases of painful synchondrosis in bipartite patellae, all in keen athletes following a direct blow to the anterior aspect of the knee. A complete rupture of the synchondrosis with evidence of retropatellar chondral separation was seen on MRI scan in all cases. Successful surgical fixation was undertaken with complete resolution of symptoms in all patients at an average of three months post-operatively. Conclusion: Painful synchondrosis of a bipartite patella in young and active individuals following direct trauma is a relatively rare cause of anterior knee pain, but may be associated with significant morbidity. In cases refractory to non-operative management, successful symptomatic treatment can be achieved by operative fixation.

Leg length discrepancy: the importance of a complete history and examination

A 26-year-old woman with a 1-year history of right knee pain had failed to respond to analgesia and activity modification in the community. Her general practitioner referred her to the orthopaedic department for specialist review. A thorough history revealed that she had multiple orthopaedic interventions as a child. The patient had significant postoperative infection of the left knee following knee surgery at 7 years of age. Examination demonstrated the presence of a limp, scoliosis and suspected leg length discrepancy. Plain film radiography confirmed the presence of leg length discrepancy, with the right limb measuring 30 mm longer than the left. The leg length discrepancy was likely secondary to a growth arrest of the left knee following the postoperative infection in childhood. The patient was managed with physiotherapy and heel raises and received regular orthopaedic follow-up.

A hot, swollen joint without trauma: septic arthritis until proven otherwise

A 71-year-old man with a history of rheumatoid arthritis presented to the accident and emergency department with a hot, swollen and painful right knee. The patient had been seen by his primary care physician several times in the preceding 4 months, and each time oral antibiotics and non-steroidal anti-inflammatory drugs were prescribed for presumed pre-patella bursitis. There was no history of joint surgery or intra-articular steroid injection and rheumatoid disease was currently well controlled with sulfasalazine. At presentation, the patients temperature was 38.4°C, and there was a moderate effusion and …

Fractured Inferior Pubic Ramus with Ipsilateral Total Hip Replacement: A Case Report and Review of the Literature

Pubic rami fractures are common. They are associated with significant morbidity and mortality. These fractures are usually classified as stable injuries and traditionally receive limited orthopaedic input. Management typically involves hospital admission and early input from physiotherapists and occupational therapists. Early mobilisation is advocated as a central part of managing these patients, with emphasis on secondary prevention. We report a case diagnosed as minimally displaced inferior pubic ramus fracture in a patient with an ipsilateral total hip replacement (THR). The patient was mobilised early and despite analgesia continued to complain of groin pain. Repeat radiographs showed a fracture of the acetabulum with displacement of the acetabular component of the hip replacement. We advocate early orthopaedic input for all pubic rami fractures, particularly in patients with hip arthroplasty, and thorough investigation including a CT scan of the pelvis to exclude acetabular extension prior to mobilisation.