Mid-term follow-up of whiplash with Bournemouth Questionnaire: the significance of the initial depression to pain ratio.

INTRODUCTION: The Bournemouth Questionnaire (BQ) was used to report the short to mid-term outcome of a prospective cohort of patients who had sustained Whiplash Associated Disorder (WAD), and establish whether outcome could be predicted on initial assessment. METHODS: One hundred patients with WAD grades I-III on the Quebec Task Force Classification were referred for physiotherapy (neck posture advice, initially practised under the direct supervision of a therapist). BQ scores were recorded on the first visit, at six weeks, then at final follow-up. RESULTS: Seventy-six percent of patients were available at final follow-up, 58% women. The mean age was 43.2 years old and follow-up time 38 months (28-48). Symptoms plateaued after six weeks in the majority and improved gradually thereafter. When the individual BQ components on initial presentation were reassessed, patients who score disproportionately highly in BQ Question 5 (Depression) had a worse outcome. To quantify this, the ratio of BQ Questions 5 (Depression)/1 (Pain) was calculated. BQ5/1 ratio greater than 1 on initial presentation had an odds ratio of 2 for poor outcome (p= 0.02). CONCLUSION: The BQ can therefore be used to identify patients with a disproportionately high depression score (BQ5) who are highly likely to clinically deteriorate in the medium term.

Post-traumatic immunosuppression is reversed by anti-coagulated salvaged blood transfusion: deductions from studying immune status after knee arthroplasty.

Major trauma increases vulnerability to systemic infections due to poorly defined immunosuppressive mechanisms. It confers no evolutionary advantage. Our objective was to develop better biomarkers of post-traumatic immunosuppression (PTI) and to extend our observation that PTI was reversed by anti-coagulated salvaged blood transfusion, in the knowledge that others have shown that non-anti-coagulated (fibrinolysed) salvaged blood was immunosuppressive. A prospective non-randomized cohort study of patients undergoing primary total knee arthroplasty included 25 who received salvaged blood transfusions collected post-operatively into acid-citrate-dextrose anti-coagulant (ASBT cohort), and 18 non-transfused patients (NSBT cohort). Biomarkers of sterile trauma included haematological values, damage-associated molecular patterns (DAMPs), cytokines and chemokines. Salvaged blood was analysed within 1 and 6 h after commencing collection. Biomarkers were expressed as fold-changes over preoperative values. Certain biomarkers of sterile trauma were common to all 43 patients, including supranormal levels of: interleukin (IL)-6, IL-1-receptor-antagonist, IL-8, heat shock protein-70 and calgranulin-S100-A8/9. Other proinflammatory biomarkers which were subnormal in NSBT became supranormal in ASBT patients, including IL-1ß, IL-2, IL-17A, interferon (IFN)-γ, tumour necrosis factor (TNF)-α and annexin-A2. Furthermore, ASBT exhibited subnormal levels of anti-inflammatory biomarkers: IL-4, IL-5, IL-10 and IL-13. Salvaged blood analyses revealed sustained high levels of IL-9, IL-10 and certain DAMPs, including calgranulin-S100-A8/9, alpha-defensin and heat shock proteins 27, 60 and 70. Active synthesis during salvaged blood collection yielded increasingly elevated levels of annexin-A2, IL-1ß, Il-1-receptor-antagonist, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IFN-γ, TNF-α, transforming growth factor (TGF)-ß1, monocyte chemotactic protein-1 and macrophage inflammatory protein-1α. Elevated levels of high-mobility group-box protein-1 decreased. In conclusion, we demonstrated that anti-coagulated salvaged blood reversed PTI, and was attributed to immune stimulants generated during salvaged blood collection.

Osteonecrosis with the use of polymethylmethacrylate cement for hip replacement: thermal-induced damage evidenced in vivo by decreased osteocyte viability.

Thermal damage to host bone is a possible source of compromise of fixation in patients undergoing cemented total hip replacement (THR). Data on the subject to date are derived from mathematical modelling powered by animal studies. The aim of this study was to assess the effect of cement thickness on osteocyte viability in a population of patients undergoing cemented THR. An in vivo model was designed and validated by means of a finite element analysis. During standard hip joint replacement in 14 patients, the femoral necks were exposed before final resection to the heat of a curing cement mantle equivalent to 2.5 (Group 1) or 5 mm (Group 2) in vivo in the cemented acetabulum. Matched controls were collected for each patient. Osteocyte counts and viability were assessed by means of haematoxylin and eosin (H&E) stain and lactate dehydrogenase (LDH) assay. Ex vivo experiments were performed to determine the extent of thermal insult. H&E staining proved unreliable for assessing thermal insult in the short term. The LDH assay was reliable and demonstrated a significant reduction in osteocyte viability to a depth of 2.19 mm in group 1 and 9.19 mm in group 2. There was a significant difference between the groups at all depths. The ex vivo experiments revealed thermoclines indicating that host bone in the population undergoing cemented THR is more sensitive to the thermal insult delivered by curing polymethylmethacrylate cement than previously believed. This thermal insult may weaken the fixation between bone and cement and contribute towards aseptic loosening, the commonest cause of failure of THRs.

Clinical and radiological results of the collarless polished tapered stem at 15 years follow-up.

We prospectively followed 191 consecutive collarless polished tapered (CPT) femoral stems, implanted in 175 patients who had a mean age at operation of 64.5 years (21 to 85). At a mean follow-up of 15.9 years (14 to 17.5), 86 patients (95 hips) were still alive. The fate of all original stems is known. The 16-year survivorship with re-operation for any reason was 80.7% (95% confidence interval 72 to 89.4). There was no loss to follow-up, with clinical data available on all 95 hips and radiological assessment performed on 90 hips (95%). At latest follow-up, the mean Harris hip score was 78 (28 to 100) and the mean Oxford hip score was 36 (15 to 48). Stems subsided within the cement mantle, with a mean subsidence of 2.1 mm (0.4 to 19.2). Among the original cohort, only one stem (0.5%) has been revised due to aseptic loosening. In total seven stems were revised for any cause, of which four revisions were required for infection following revision of the acetabular component. A total of 21 patients (11%) required some sort of revision procedure; all except three of these resulted from failure of the acetabular component. Cemented acetabular components had a significantly lower revision burden (three hips, 2.7%) than Harris Galante uncemented components (17 hips, 21.8%) (p < 0.001). The CPT stem continues to provide excellent radiological and clinical outcomes at 15 years following implantation. Its results are consistent with other polished tapered stem designs.

Often atypical? The distribution of sensory disturbance in carpal tunnel syndrome.

This study aimed to examine the disturbance of hand sensation in patients with carpal tunnel syndrome (CTS) and assess the usefulness of objective and subjective measures. The study included 64 patients with CTS confirmed by electrophysiological testing. Sensory assessment was made by objective (pressure aesthesiometry) and subjective (hand symptom diagram) measures in different anatomical areas. The results of the subjective and objective testing were correlated with nerve conduction studies by a kappa analysis. Sensory disturbance occurred more frequently in areas innervated by the median nerve (index finger, 94%) but also with great frequency in other areas (little finger, 39%). Pain occurred frequently in anticipated areas (wrist crease, 33%) but also in other areas (little finger, 11%). There was very poor correlation between objective measures and electrophysiological testing or subjective measures. This study does therefore not support the use of objective sensory assessment for the initial diagnosis of CTS. An atypical distribution of symptoms is a common occurrence and should not discourage diagnosis of CTS. The patient's description of symptoms remains the most important tool in diagnosis.

Role of early intravenous to oral antibiotic switch therapy in the management of prosthetic hip infection treated with one- or two-stage replacement.

OBJECTIVES: To determine outcomes for an antibiotic regimen using early switch to oral antibiotics for treatment of infected total hip replacement (THR) treated by either a one-stage or two-stage procedure. METHODS: Cases of infected THR were identified from the microbiology records on all orthopaedic infections in a 24 month period. Diagnosis was made by microbiological culture of theatre specimens and findings at the time of surgery. A standard approach of 10-14 days intravenous (iv) antibiotic followed by a switch to oral antibiotics either for 6-8 weeks until second-stage re-implantation or for up to 3 months following a one-stage procedure was used. The exact date of oral switch and antibiotic duration was determined by clinical resolution and C-reactive protein (CRP). Outcome was recorded as no microbiological or clinical evidence of relapse of infection or relapse after completing the antibiotic course. Follow-up duration for all cases at the time of study was 24-36 months after completion of antibiotic treatment. RESULTS: In 24 months, 19 patients underwent two-stage THR for infection, of which 17 were treated with oral antibiotics after a median of 14 days initial iv antibiotics. None relapsed. Four patients underwent one-stage THR and had 12-20 days iv then 6-26 weeks oral antibiotics with no relapse. CONCLUSIONS: Early oral antibiotic switch therapy was effective in patients treated at the Avon Orthopaedic Centre with infected THR and plays an important role in enabling patients to return to independence after revision surgery and avoid complications of prolonged iv access.

Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial.

We reviewed the seven- to ten-year results of our previously reported prospective randomised controlled trial comparing total hip replacement and hemiarthroplasty for the treatment of displaced intracapsular fracture of the femoral neck. Of our original study group of 81 patients, 47 were still alive. After a mean follow up of nine years (7 to 10) overall mortality was 32.5% and 51.2% after total hip replacement and hemiarthroplasty, respectively (p = 0.09). At 100 months postoperatively a significantly greater proportion of hemiarthroplasty patients had died (p = 0.026). Three hips dislocated following total hip replacement and none after hemiarthroplasty. In both the total hip replacement and hemiarthroplasty groups a deterioration had occurred in walking distance (p = 0.02 and p < 0.001, respectively). One total hip replacement required revision compared with four hemiarthroplasties which were revised to total hip replacements. All surviving patients with a total hip replacement demonstrated wear of the cemented polyethylene component and all hemiarthroplasties had produced acetabular erosion. There was lower mortality (p = 0.013) and a trend towards superior function in patients with a total hip replacement in the medium term.

A medium-term comparison of hybrid hip replacement and Birmingham hip resurfacing in active young patients.

We compared the medium-term clinical and radiological results of hybrid total hip replacement (THR) with metal-on-metal Birmingham hip resurfacing (BHR) in two groups of 54 young patients matched for age, gender, body mass index and pre-operative levels of activity. The clinical outcome was assessed by the University of California, Los Angeles (UCLA) activity score, the Oxford Hip Score (OHS) and the EuroQol scores. Radiologically, all hips were assessed for migration and osteolysis, the hybrid THRs for polyethylene wear and the BHRs for a pedestal sign. The mean follow-up of the patients with a hybrid THR was ten years and for those with a BHR, nine years. Four patients with a hybrid THR and one with a BHR had died. In each group five were lost to follow-up. The revision rate of the hybrid THRs was 16.7% (9 of 54) and of the BHRs 9.3% (5 of 54) (p = 0.195). Radiographs of a further eight hybrid THRs demonstrated wear and osteolysis, and they await revision (p = 0.008). Of the unrevised BHRs 90% had radiological changes, of which approximately 50% had progressed over the previous four years. All hybrid THRs demonstrated linear polyethylene wear with a mean of 1.24 mm (0.06 to 3.03). The BHRs recorded superior OHS (p = 0.013), UCLA (p = 0.008), and EuroQol visual analogue scores (p = 0.009). After nine years, patients with BHRs remained more active and had a lower rate of revision than those with hybrid THRs. Both groups demonstrated progressive radiological changes at medium-term follow-up.

Factors affecting wound ooze in total knee replacement.

INTRODUCTION: Wound ooze is common following total knee arthroplasty (TKA) and persistent wound infection is a risk factor for infection, and increased length and cost of hospitalisation. PATIENTS AND METHODS: We undertook a prospective study to assess the effect of tourniquet time, peri-articular local anaesthesia and surgical approach on wound oozing after TKA. RESULTS: The medial parapatellar approach was used in 59 patients (77%) and subvastus in 18 patients (23%). Peri-articular local anaesthesia (0.25% Bupivacaine with 1:1,000,000 adrenalin) was used in 34 patients (44%). The mean tourniquet time was 83 min (range, 38-125 min). We found a significant association between cessation of oozing and peri-articular local anaesthesia (P = 0.003), length of the tourniquet time (P = 0.03) and the subvastus approach (P = 0.01). CONCLUSIONS: Peri-articular local anaesthesia, the subvastus approach and shorter tourniquet time were all associated with less wound oozing after total knee arthroplasty.

Whiplash injury: 30-year follow-up of a single series.

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.

Whiplash injury.

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately pound 3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.

Skin closure after total hip replacement: a randomised controlled trial of skin adhesive versus surgical staples.

We undertook a randomised controlled trial to compare the outcomes of skin adhesive and staples for skin closure in total hip replacement. The primary outcome was the cosmetic appearance of the scar at three months using a surgeon-rated visual analogue scale. In all, 90 patients were randomised to skin closure using either skin adhesive (n = 45) or staples (n = 45). Data on demographics, surgical details, infection and oozing were collected during the in-patient stay. Further data on complications, patient satisfaction and evaluation of cosmesis were collected at three-month follow-up, and a photograph of the scar was taken. An orthopaedic and a plastic surgeon independently evaluated the cosmetic appearance of the scars from the photographs. No significant difference was found between groups in the cosmetic appearance of scars at three months (p = 0.172), the occurrence of complications (p = 0.3), or patient satisfaction (p = 0.42). Staples were quicker and easier to use than skin adhesive and also less expensive. Skin adhesive and surgical staples are both effective skin closure methods in total hip replacement.

Cervical range of movement in relation to neck dimension.

The authors investigated the effect of neck dimension upon cervical range of motion. Data relating to 100 healthy subjects, aged between 20 and 40 years, were recorded with respect to age, gender and range of motion in three planes. Additionally, two widely used methods of measuring neck motion, chin-sternal distance and uniplanar goniometer, were assessed against a validated measurement tool, the 'CROM goniometer'. Using multiple linear regression analysis it was determined that sagittal flexion (P = 0.002) and lateral rotation (P < 0.0001) were most closely related to neck circumference alone whereas lateral flexion (P < 0.0001) was most closely related to a ratio of circumference and length of neck. Hence, assessing cervical range of motion as outcome variable or as a measure at posttreatment follow-up, neck circumference was shown to be one of the factors influencing total neck motion, particularly sagittal flexion and lateral tilt. Comparison of cervical range of motion assessed with a validated measurement tool, the CROM goniometer, with results of both frequently applied clinician's instruments, the uniplanar goniometer and measurement of chin-sternal distance, showed low reliability with the latter techniques, and motion values measured with these techniques should be interpreted with caution if using them for comparison of cervical range of motion of alike groups. We demonstrated that neck dimension should be incorporated into cervical functional outcome assessment and one should be wary about recorded values for neck motion from non-validated measurement tools.

Prevalence and functional impact of patient-perceived leg length discrepancy after hip replacement.

The aim of this postal survey was to determine the prevalence and impact of patient-perceived leg length discrepancy (LLD) at 5-8 years after primary total hip replacement (THR). A postal audit survey was undertaken of all consecutive patients who had a primary unilateral THR at one elective orthopaedic centre between April 1993 and April 1996. The questionnaire included the Oxford hip score (OHS) and questions about LLD. Questionnaires were received from 1,114 patients. In total, 329 THR patients (30%) reported an LLD, although radiographic analysis revealed that only 36% of these patients had anatomical LLD. Patients with a perceived LLD had a significantly poorer OHS (p < 0.001) and reported more limping than those patients without a perceived LLD. This study found that a third of patients perceived an LLD after THR and that perceived LLD was associated with a significantly poorer midterm functional outcome.

The Harris-Galante porous-coated, hemispherical, polyethylene-lined acetabular component in patients under 50 years of age: a 12- to 16-year review.

We have reviewed 70 Harris-Galante uncemented acetabular components implanted as hybrid hip replacements with cemented stems between 1991 and 1995 in 53 patients whose mean age was 40 years (19 to 49). The mean follow-up was for 13.6 years (12 to 16) with no loss to follow-up. We assessed the patients both clinically and radiologically. The mean Oxford hip score was 20 (12 to 46) and the mean Harris hip score 81 (37 to 100) at the final review. Radiologically, 27 hips (39%) had femoral osteolysis, 13 (19%) acetabular osteolysis, and 31 (44%) radiolucent lines around the acetabular component. Kaplan-Meier survival curves were constructed for the outcomes of revision of the acetabular component, revision of the component and polyethylene liner, and impending revision for progressive osteolysis. The cumulative survival for revision of the acetabular component was 94% (95% confidence interval 88.4 to 99.7), for the component and liner 84% (95% confidence interval 74.5 to 93.5) and for impending revision 55.3% (95% confidence interval 40.6 to 70) at 16 years. Uncemented acetabular components with polyethylene liners undergo silent lysis and merit regular long-term radiological review.

Collarless polished tapered stem: clinical and radiological results at a minimum of ten years' follow-up.

We retrospectively reviewed 175 patients (191 hips) who had undergone primary cemented total hip replacement between November 1992 and November 1995 using a collarless polished double-tapered femoral component after a minimum of ten years (mean 11.08; 10 to 12.8). All stems were implanted using contemporary cementing techniques with a distal cement restrictor, pressurised lavage, retrograde cementing with a gun and proximal pressurisation. Clinical outcome was assessed using the Harris Hip score. Radiological analysis was performed on calibrated plain radiographs taken in two planes. Complete radiological data on 110 patients (120 hips) and clinical follow-up on all the surviving 111 patients (122 hips) was available. The fate of all the hips was known. At final follow-up, the mean Harris Hip score was 86 (47 to 100), and 87 of 116 patients (75%) had good or excellent scores. Survival with revision of the stem for aseptic loosening as the endpoint was 100%; and survival with revision of the stem for any reason was 95.9% (95% confidence interval 87.8 to 96.8) at ten years. All the stems subsided vertically at the stem-cement interface in a predictable pattern, at an overall mean rate of 0.18 mm per year (0.02 to 2.16), but with a mean rate of 0.80 mm (0.02 to 2.5) during the first year. The mean total subsidence was 1.95 mm (0.21 to 24). Only three stems loosened at the cement-bone interface. There was excellent preservation of proximal femoral bone stock. There was a high incidence of Brooker III and IV heterotopic ossification affecting 25 patients (22%). The collarless polished tapered stem has an excellent clinical and radiological outcome at a minimum of ten years' follow-up. The pattern and magnitude of subsidence of the stem within the cement mantle occurred in a predictable pattern, consistent with the design philosophy.

Ten-year life expectancy after primary total hip replacement.

We determined the ten-year life expectancy of 5831 patients who had undergone 6653 elective primary total hip replacements at a regional orthopaedic centre between April 1993 and October 2004. Using hospital, general practitioner and the local health authority records, we recorded the dates of death for those who died following surgery. The mean age at operation was 67 years (13 to 96) with a male:female ratio of 2:3. Of 1154 patients with a ten-year follow-up 340 (29.5%) had died a mean of 5.6 years (0 to 10) after surgery. Using Kaplan-Meier curves, the ten-year survival was 89% in patients under 65 years at surgery, 75% in patients aged between 65 and 74 years, and 51% in patients over 75. The standardised mortality rates were considerably higher for patients under 45 years, 20% higher for those between 45 and 64 years, and steadily reduced in patients aged 65 and over. The survival of cemented hip replacement derived from the Swedish Hip Arthroplasty Register Annual Report 2004 exceeds the life expectancy of patients over the age of 60 in our area, suggesting that cemented hip replacement is the procedure of choice in this population.