Neuroleptic Malignant Syndrome Following Bilateral Cemented Total Hip Replacements.

Neuroleptic malignant syndrome (NMS) is a rare, serious complication caused by neuroleptic medications. It is characterized by rigidity, hyperthermia, tachycardia, leukocytosis, and an elevated creatine kinase (CK). We present a case of a 50-year-old male who underwent bilateral total hip replacements and subsequently developed NMS. This condition is typically triggered by the sudden introduction, omission, or change in dose of a neuroleptic; in contrast with previous case reports of post-surgical NMS, however, no such trigger was identifiable for our patient. Moreover, this is the first reported case of NMS after single-stage bilateral hip arthroplasty. Consequently, by presenting this case report we hope to make clinicians aware of the possibility of NMS occurring after hip arthroplasty in any patient taking longterm neuroleptics.

Assessment of Range of Movement, Pain and Disability Following a Whiplash Injury.

BACKGROUND: Whiplash has been suggested to cause chronic symptoms and long term disability. This study was designed to assess long term function after whiplash injury. MATERIAL & METHODS: A random sample of patients in the outpatient clinic was interviewed, questionnaire completed and clinical examination performed. Assessment was made of passive cervical range of movement and Visual Analogue Scale pain scores. One hundred and sixty-four patients were divided into four different groups including patients with no whiplash injury but long-standing neck pain (Group A), previous symptomatic whiplash injury and long-standing neck pain (Group B), previous symptomatic whiplash injury and no neck symptoms (Group C), and a control group of patients with no history of whiplash injury or neck symptoms (Group D). RESULTS: Data was analyzed by performing an Independent samples t-test and ANOVA, with level of significance taken as p<0.05. Comparing the four groups using a one-way ANOVA showed a significant difference between the groups (p<0.001). There were significant differences when comparing mean ranges of movement between Group A and Group D, and between Group B and Group D. There was no significant difference between Group C and Group D. similar differences were also seen in the pain scores. CONCLUSION: We conclude that osteoarthritis in the cervical spine, and whiplash injury with chronic problems cause a significantly decreased cervical range of movement with a higher pain score. Patients with shorter duration of whiplash symptoms appear to do better in the long-term.

Has the introduction of an admissions lounge affected theatre start times in a busy teaching hospital environment?

The Admissions Lounge (AL) was introduced with the aims of reducing the number of late starts, improving the patient experience and reducing preoperative length of stay to save bed days. To determine whether a reduction in number of late starts was achieved, 237 start times from pre and post introduction of the AL were collected and analysed. There was no statistically significant difference (p > 0.05) between the percentage of lists delayed or the mean delay between pre and post introduction of the AL (mean delay for post AL was 10.17 minutes compared to 9.85 minutes pre AL). The AL had no impact on theatre start times, neither improving nor reducing the operating theatre efficiency in this respect.

Total hip arthroplasty after ipsilateral intra-articular steroid injection: 8 years follow up.

The purpose of the study was to assess the safety of Intra-articular steroid hip injections (IASHI), prior to ipsilateral total hip arthroplasty (THA). We investigated whether there was an excess of infection in such a group 7-10 years after total hip arthroplasty. A database of 49 patients who had undergone IASHI followed by ipsilateral THA was reviewed. The mean length of time between injection and arthroplasty was 12.1 months (5.1-19 months). We found 7 major complications. Ten patients died with no further hip surgery at a mean of 28 months from surgery ; 3 were lost to follow-up. The remaining group (36) were contacted by telephone at a mean of 97.8 (85-117) months from their surgery. No objective signs of joint infection were found. We believe our results show that ipsilateral steroid injection does not confer an increased risk of complications following subsequent THA, over an extended follow up.

Can patients with low energy whiplash associated disorder develop low back pain?

800 consecutive claimant generated medicolegal reports were analysed for symptomatology of whiplash associated disorder (WAD) including the presence of mid and low back pain. We aimed to establish whether the two were linked and if so if there were correlations between accident vector and severity. We also aimed to establish if a low back injury could result from a vehicular accident in the absence of a neck injury. In addition we examined if occupant bracing and occupant neutral position at the time of the accident affected symptom patterns. We found that a claimed back injury following WAD was independent of both accident severity and accident vectors, approximately 40% claiming injury in low, medium and high violence groups and with rear, frontal and side impact. We established that it was unusual to have a back injury in the absence of a neck injury (18 out of 325, 5.5%) without a past medical history of back pain (72.2% of this group having previous back pain). Occupant bracing was not protective. We also showed that occupant neutral position was not protective against a back injury. We were surprised that patients with next to no car damage had the same incidence of back pain as those involved in more violent crashes when biomechanically unlikely. The complex biopsychosocial response and the relationship to constitutional factors are discussed. The literature concerning forces across the lumbar spine and possibilities of injury is reviewed.

The effect of increasing age on nocturnal joint pain in patients about to undergo hip or knee joint arthroplasty.

Many hip and knee joint scores rate nocturnal symptoms as important in their scoring systems. The aim of this study was to determine if being woken up with pain disappears with advancing age in patients with arthritic hip or knee joints. Data was collected from 60 patients with an average of age of 69.0 years through a questionnaire conducted at the time of their pre-operative assessment, 36 of them were awaiting hip replacements, 24 knee replacement surgery. There was a positive correlation between age and the loss of nocturnal pain symptoms (p<0.05), this was seen more strongly for hips rather than knees. The average ages of those patients reporting night pain was 65.7 years and of those who did not report night pain 75.5 years. This is almost certainly because of a change in sleep pattern and nociceptive inputs. Although elderly patients may score more highly on other areas of a joint score they may be under assessed if nocturnal symptoms are relied upon.

An unusual presentation of a popliteal arteriovenous fistula after primary total knee arthroplasty.

Iatrogenic popliteal arteriovenous fistula after total knee arthroplasty is extremely rare (Int Surg. 1998 Jul-Sep;83(3):198-201). We report this complication in a 78-year-old female patient 3 years after total knee arthroplasty. She presented with symptoms of persistent swelling and recurrent cellulitis of the operated leg. A fistula was detected between the popliteal artery and vein by vascular duplex scan and confirmed by peripheral arteriography. This was successfully treated by resection of the fistula and direct repair of the artery and vein.

Surgery for fractured neck of femur - are patients adequately consented?

INTRODUCTION: Obtaining valid consent is a legal and ethical obligation when performing any procedure in clinical practice. This study was performed to identify the validity and effectiveness of the new consent form and any potential improvement that could be made when taking consent. PATIENTS AND METHODS: Case notes of 173 patients undergoing surgery for fractured neck of femur were retrospectively reviewed. Risks and complications of the surgery as listed on the consent form were noted. Sixty-five cases were excluded from the study as they had either old consent forms with no risks recorded or a consent form signed by a consultant due to patient inability to consent. Six of the consent forms could not be located in the notes. This left 102 consent forms to be analysed. RESULTS: The number of risks documented on each form ranged from 0-8 (mean, 3.92). No risks were recorded in 2 of these 102 forms. Most commonly recorded risks were infection (95.1%), DVT/PE (81.4%) and failure of procedure (59.8%). It was shown that many of the consent forms analysed did not have all the serious or frequently occurring risks recorded on them and that a large proportion of the forms had acronyms or phrases that may mean nothing to the patient. Comparison of documented risks for different hip surgery were made using Fisher's exact test showing no significant difference between the risks recorded on the forms for each type of procedure. CONCLUSIONS: Although documentation of risks has been improved compared to old consent forms, patients are not necessarily given the most appropriate information to ensure consent is valid. Further refining of consent forms may be necessary to ensure that all major risks are explained and understood by patients and that there is satisfactory recording of this information.

Minimal surgical approach for recurrent hip dislocation using the posterior lip augmentation device for the Charnley hip arthroplasty.

We present the management of recurrent posterior dislocations in cemented Charnley total hip arthroplasties treated with acetabular augmentation. Certain patients are elderly with comorbid conditions and diminished reserves. We have used a minimal surgical approach to implant 21 posterior lip augmentation devices in elderly patients. Ninety percent of the hips are stable with follow-up of 1 to 3 years (mean, 1.9 years). Eighty-four percent of the patients were satisfied with the outcome. Two cases, which redislocated, were further stabilized by changing the position of the posterior lip augmentation device and are stable. Because of a minimal surgical approach, the time duration of surgery, blood loss, transfusion requirement, inpatient stay, and morbidity are reduced. Posterior lip augmentation device surgery with a minimal approach is a safe and effective procedure for elderly patients who do not have any obvious cause for dislocation.

Extra help required by litigants after simple fractures--a questionnaire based study.

A questionnaire based interview of 100 patients under fracture clinic review was undertaken to assess the help required with the activities of daily living (ADL) in the first 2 weeks following fractures of the hand, wrist, neck of humerus, foot or ankle. The amount of help patients required was correlated with whether or not the patients were claiming compensation for their injuries. Twenty-five percent were litigating and this was shown to influence the amount of help a patient reported having received with dressing, shopping, cooking, housework, personal hygiene and travelling (p<0.0001) and feeding (p<0.0022), but not with getting in/out of bed (p=0.52). Complications of the fracture were not shown to increase litigation. On average litigants required over 3 h extra help per day compared with non-litigants (6.4 h versus 2.75 h).

A prospective study of injuries sustained during competitive Muay Thai kickboxing.

OBJECTIVE: To investigate prospectively the type and rate of injuries sustained during amateur Muay Thai competition. DESIGN: Prospective cohort study collection of data following clinical examination. SETTING: Amateur Muay Thai competitions in the United Kingdom organized by the International Amateur Muay Thai Federation. PARTICIPANTS: Amateur Muay Thai boxers. Both sexes. Lightweight to super heavyweight. RESULTS: There were 92 participants, 12 females and 82 males. The average age was 17.3 years, and the average previous number of bouts was 3.9. A total of 588.5 minutes of competition time was assessed during a total of 10 events. Injury rates were 1.3 injuries per 100 minutes of competition in the lightweight category, 2.25 per 100 minutes of competition in the middleweight category, 30 per 100 minutes of competition in the heavyweight category, and 2.54 per 100 minutes of competition in the super heavyweight category. CONCLUSIONS: Compared with other reported martial arts, the injury rates are higher in Muay Thai. The head was shown to be the most common site of injury in amateur fighters, but there was an almost complete absence of lower limb injuries, which again is at variance with reported figures for other martial arts.

Annual review of fractured neck of femur mortality rates: is this a true picture?

BACKGROUND: Annual fractured neck of femur death rates within a region are used by the Department of Health (DoH) as a clinical performance indicator of hospital trusts. Presently trusts and DoH publish performance figures annually but there is significant variability year to year. OBJECTIVE: Does a 5-year mortality review reflect a truer picture? METHODS: Hospital information services were used to provide the details for all patients who died within 30 days of admission. These were analysed to determine the true fractured neck of femur mortality. RESULTS: The variations in fractured neck of femur mortality rates between years within the same and between different trusts shows that annual scrutiny is an inappropriate, often skewed, analysis of performance. CONCLUSIONS: A 5-year mortality review would seem more appropriate to visualise true trends and should be performed to remove anomalous results.

Soft tissue neck symptoms following high-energy road traffic accidents.

STUDY DESIGN: A single-blinded prospective study was performed into the occurrence and frequency of soft tissue neck symptoms of patients involved in high-energy road traffic accidents. OBJECTIVES: We studied the occurrence of incidental soft tissue neck symptoms in victims of high energy (defined as those severe enough to cause major trauma leading to an injury severity score >16) vehicular collisions causing significant musculoskeletal trauma requiring operative intervention. SUMMARY BACKGROUND DATA: Whiplash is considered to be a soft tissue injury of the neck sustained by occupants of motor vehicles. Use of the term in the past had been restricted to hyperextension injuries following a rear impact, but is commonly now used for all types of impact. No relationship has been found between velocity or force of injury and incidence or outcome of whiplash. The preponderance of whiplash after relatively minor vehicular accidents, the unpredictability of who will develop chronic symptoms and the lack of clinical and radiological evidence of a pathological mechanism suggests that psychosocial variables are important factors in determining the development of persistent neck pain. METHODS: A total of 36 consecutive patients were recruited who had been involved in high-energy road traffic accidents and had chest, musculoskeletal, or abdominal injuries (ISS > 16) requiring admission for treatment, but who had no diagnosed injury of the cervical spine. Patients were asked in a nonspecific or leading manner at the time of admission and again at least 6 to 8 weeks postinjury if they had any neck symptoms, headaches, or paresthesiae. RESULTS: Only 2 of the patients interviewed described any whiplash symptoms. All symptoms were resolved at the time of second interview. CONCLUSIONS: Our study demonstrates a surprisingly low incidence of neck symptoms following high-energy road traffic accidents in which patients sustained unrelated injuries requiring treatment.