BackgroundThe study determined the one year incidence of post operative cognitive decline (POCD) and evaluated the effectiveness of an intra-operative anaesthetic intervention in reducing post-operative cognitive impairment in older adults (over 60 years of age) undergoing elective orthopaedic or abdominal surgery.Methods and Trial DesignThe design was a prospective cohort study with a nested randomised, controlled intervention trial, using intra-operative BiSpectral index and cerebral oxygen saturation monitoring to enable optimisation of anaesthesia depth and cerebral oxygen saturation in older adults undergoing surgery.ResultsIn the 52 week prospective cohort study (192 surgical patients and 138 controls), mild (χ2 = 17.9 p<0.0001), moderate (χ2 = 7.8 p = 0.005) and severe (χ2 = 5.1 p = 0.02) POCD were all significantly higher after 52 weeks in the surgical patients than among the age matched controls. In the nested RCT, 81 patients were randomized, 73 contributing to the data analysis (34 intervention, 39 control). In the intervention group mild POCD was significantly reduced at 1, 12 and 52 weeks (Fisher’s Exact Test p = 0.018, χ2 = 5.1 p = 0.02 and χ2 = 5.9 p = 0.015), and moderate POCD was reduced at 1 and 52 weeks (χ2 = 4.4 p = 0·037 and χ2 = 5.4 p = 0.02). In addition there was significant improvement in reaction time at all time-points (Vigilance Reaction Time MWU Z =  −2.1 p = 0.03, MWU Z = −2.7 p = 0.004, MWU Z = −3.0 p = 0.005), in MMSE at one and 52 weeks (MWU Z = −2.9 p = 0.003, MWU Z = −3.3 p = 0.001), and in executive function at 12 and 52 weeks (Trail Making MWU Z = −2.4 p = .0.018, MWU Z = −2.4 p = 0.019).ConclusionPOCD is common and persistent in older adults following surgery. The results of the nested RCT indicate the potential benefits of intra-operative monitoring of anaesthetic depth and cerebral oxygenation as a pragmatic intervention to reduce post-operative cognitive impairment.Trial RegistrationControlled-Trials.com ISRCTN39503939

The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP). A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion.

Chronic patellar dislocation is a rare condition where the patella remains dislocated throughout knee range of motion during flexion and extension. In adults, the delayed presentation of this condition is often due to symptoms caused by the onset of severe secondary osteoarthritis. To the authors' knowledge, all of the cases reported in the literature have been treated by patellofemoral or total knee replacements depending on patient age and the extent of the arthritis. This article describes a rare case of a 22-year-old woman who sustained a traumatic chronic patellar dislocation for 5 months. Clinical examination revealed a valgus deformity of the left leg secondary to childhood injury and that the patella lay lateral to the lateral femoral condyle throughout flexion and extension. Radiographs of the knee revealed patellar dislocation. Long-leg radiographs of the left leg showed an anatomic tibiofemoral angle of 17° valgus. The anatomical (74°) and mechanical (80°) lateral distal femoral angles were abnormal, whereas the medial proximal tibial angle (87°) was normal, confirming that the valgus deformity was due to the abnormal distal femur. The authors performed a distal femoral osteotomy to correct the valgus deformity. Medial patellofemoral ligament reconstruction using a hamstring autograft was performed to stabilize the patella.

47% of patients with chronic back pain had insomnia. The ODI was more reliable than the NRS for back pain to detect insomnia. Back pain should be treated early to avoid serious health problems associated with insomnia.

Summary of background data The sagittal profile of lumbar endplates is discrepant from current simplified disc replacement and fusion device design. Endplate concavity is symmetrical in the coronal plane but shows considerable variability in the sagittal plane, which may lead to implantendplate mismatch. Objective The aim of this investigation is to provide further analysis of the sagittal endplate morphology of the mid to lower lumbar spine study (L3-S1), thereby identifying the presence of common endplate shape patterns across these levels and providing morphological reference values complementing the findings of previous studies. Study design Observational study Methods A total of 174 magnetic resonance imaging (MRI) scans of the adult lumbar spine from the digital archive of our centre, which met the inclusion criteria, were studied. Superior (SEP) and inferior (IEP) endplate shape was divided into flat (no concavity), oblong (homogeneous concavity) and ex-centric (inhomogeneous concavity). The concavity depth (ECD) and location of concavity apex (ECA) relative to endplate diameter of the vertebrae L3-S1 were determined. Results Flat endplates were only predominant at the sacrum SEP (84.5%). The L5 SEP was flat in 24.7% and all other endplates in less than 10%. The majority of endplates were concave with a clear trend of endplate shape becoming more ex-centric from L3 IEP (56.9% oblong vs. 37.4% ex-centric) to L5 IEP (4% oblong vs. 94.3% ex-centric). Ex-centric ECA were always found in the posterior half of the lumbar endplates. Both the oblong and ex-centric ECD was 2-3 mm on average with the IEP of a motion segment regularly possessing the greater depth. A sex-or age-related difference could not be found. Conclusion The majority of lumbar endplates are concave, while the majority of sacral endplates are flat. An oblong and an ex-centric endplate shape can be distinguished, whereby the latter is more common at the lower lumbar levels. The apex of the concavity of ex-centric discs is located in the posterior half of the endplate and the concavity of the inferior endplate is deeper than that of the superior endplate. Based on the above, the current TDR and ALIF implant design does not sufficiently match the morphology of lumbar endplates in the sagittal plane.

Patients taking clopidogrel who sustain a fractured neck of femur pose a challenge to orthopaedic surgeons. The aim of this study was to determine whether delay to theatre for these patients affects drop in haemoglobin levels, need for blood transfusion, length of hospital stay and 30-day mortality. A retrospective review of all neck of femur patients admitted at two centres in the North East of England over 3 years revealed 85 patients.Patients were divided into two groups depending on whether they were taking clopidogrel alone (C) or with aspirin (CA). Haemoglobin drop was significantly different in the CA group that was operated on early (CA1) versus the group for which surgery was delayed by over 48 hours (CA2): 3.3g/dl and 1.9g/dl respectively (p=0.01). The mean inpatient stay in group C was 35.9 days while in group CA it was 19.9 days (p=0.002). The mean length of stay in group CA2 (26.7 days) was significantly longer than for CA1 patients (14.1 days) (p=0.01). There were no significant differences in mortality or wound complications.Hip fracture patients on clopidogrel can be safely operated on early provided they are medically stable. Bleeding risk should be borne in mind in those patients on dual therapy with aspirin. KEYWORDSHip fracture -Clopidogrel -Aspirin -Delay to surgery Clopidogrel is a thienopyridine that irreversibly binds to platelets inhibiting aggregation. It is used commonly with or without aspirin for primary and secondary prevention of cardio and cerebrovascular disease. Given the prevalence of coronary disease, advances in coronary intervention for stable and unstable cardiac as well as stroke disease, it is no surprise that the number of patients admitted to hospital on dual antiplatelet therapy (DAPT) as well as other newer anticoagulant agents is rising. The timing of operative intervention for hip fracture patients on antiplatelet agents poses a significant challenge to the multidisciplinary team managing these complex patients. Hip fracture patients tend to be older with co-morbidities. There is consensus in the orthopaedic community that if feasible and indicated, surgery should be carried out at the earliest opportunity followed by early mobilisation. Patients taking DAPT, clopidogrel alone or other anticoagulants have an elevated bleeding risk in the perioperative period. These patients have a higher risk of bleeding if operated on early while delaying surgery is associated with increased risk of morbidity and mortality. There is a lack of consensus among orthopaedic teams for timing of operation, with some surgeons choosing to stop their patients' antiplatelet treatment and delay operative management. 3,4 There is a paucity of literature reporting the risks and benefits of operating on these patients. 5,6 This study sought to determine whether time to surgery influenced factors including drop in haemoglobin (Hb) levels, need for blood transfusion, duration of inpatient stay and 30-day mortality for patients who were admitted with a neck of femur fracture while taking cl...

Compression of the ulnar nerve in Guyon's canal is an uncommon phenomenon. Reports of ulnar nerve palsy secondary to ulnar artery pseudoaneurysm at this anatomical location are very rare and equivalent pathology just distal to this site is unheard of.Here we present such a case, which featured a delayed onset of symptoms. This followed penetrating trauma to the hand. Our methods for diagnosis, operative planning and surgical treatment are included.Compression of the ulnar nerve in Guyon's canal is an uncommon phenomenon, described as early as 1908 by Hunt. 1Reports of ulnar nerve palsy secondary to ulnar artery pseudoaneurysm at this anatomical location are very rare. Case historyA 33-year-old man presented to our clinic 3 weeks after a penetrating glass laceration to the hypothenar eminence of his non-dominant right hand. He had attended casualty at the time of his injury while on holiday abroad where the wound was treated with adhesive strips. He reported that there were no functional problems with the hand at the time of the injury but motor and sensory symptoms developed progressively over the subsequent weeks.At the time of our assessment, ulnar clawing of the hand was apparent; the ring and little metacarpophalangeal joints were held in hyperextension with flexion at the interphalangeal joints of the corresponding fingers. Clinically, a sensory deficit was apparent (light touch, 2 point discrimination) in a well demarcated medial one and a half digit ulnar distribution. There was weakness of the interosseous muscles, abductor digiti minimi and lumbricals to the ring and little fingers (Medical Research Council score 3/5). Froment's sign was positive. A pulsatile mass was palpable over the hypothenar eminence. A clinical diagnosis of pseudoaneurysm of the ulnar artery causing neurapraxia of the ulnar nerve was made. The patient underwent ultrasonography and magnetic resonance angiography provided further clarity, demonstrating a pseudoaneurysm measuring 24mm of the ulnar artery as it coursed into the palm, immediately prior to its continuation as the superficial palmar arch (Fig 1).There was no evidence of ulnar nerve transection. Maximal ulnar nerve compression was at a site just distal and

Background/Aims: Post-operative cognitive decline is frequent in older individuals following major surgery; however, biomarkers of this decline are less clearly defined. Methods: Sixty-eight participants over the age of 60 provided blood samples at baseline and 24 h post-surgery. Cognitive decline was measured at baseline and 52 weeks post-surgery using the Cambridge Assessment for Mental Disorder in the Elderly, section B (CAMCOG) score. Plasma levels of neuron-specific enolase (NSE) and S100B were measured by ELISA. Results: Baseline NSE and the change in NSE levels between baseline and 24 h were correlated with the change in CAMCOG score between baseline and 52 weeks. Conclusion: NSE concentrations may be a useful predictor of individuals at risk of more severe long-term cognitive decline.