Metal-on-metal (MoM) hip resurfacing was developed in the 1990s by surgeons in Birmingham, UK, as a surgical solution to the problem of osteoarthritis in younger, more active patients. Early results were promising and the procedure gained in popularity. However, adverse reports of soft-tissue reaction and failure started to appear from 2008 onwards. Surgeons may be asked to write
This short contribution aims to explain how intervertebral disc ‘degeneration’ differs from normal ageing, and to suggest how mechanical loading and constitutional factors interact to cause disc degeneration and prolapse. We suggest that disagreement on these matters in
Mechanical function and failure of intervertebral discs. In a healthy disc, the nucleus pulposus acts like a pressurised fluid which is restrained by tensile stress within the annulus. With increasing age, the nucleus becomes more fibrous, and biochemical changes cause the whole disc to become less elastic, and more yellow in colour. Mechanically, the hydrostatic nucleus shrinks with age, and concentrations of compressive stress appear in the posterior annulus. Experiments on cadaveric spines have shown that healthy discs can prolapse when loaded severely or repetitively in bending and compression, and that internal disruption of the disc probably follows damage to the vertebral endplates. However, mechanical loading is not necessarily harmful to living discs: on the contrary, moderate repetitive loading may lead to disc hypertrophy rather than injury. Disc degeneration. Degeneration represents some mechanical or biological “insult” superimposed on normal ageing. A defining feature of “degeneration” should be structural failure of the annulus or endplate, because all degenerated discs exhibit structural failure whereas many old discs do not. Degeneration creates high stress concentrations within the annulus. Paradoxically, severe degeneration can lead to gross disc narrowing and reduced stresses in the annulus, presumably because it is “stress shielded” by the apophyseal joints. Animal experiments show that disc degeneration always follows mechanical disruption. In some cases, it may possibly precede it. Disc degeneration and back pain. Pain-provocation studies have shown that severe and chronic back pain often originates in the posterior annulus fibrosus, and can be elicited by relatively moderate mechanical pressure. Anatomical studies indicate that the outer annulus is supplied with complex and free nerve endings from the mixed sinuvertebral nerve. MRI and discographic studies show that back pain is closely correlated with structural features of disc degeneration such as radial fissures and prolapse, although age-related changes in composition are clinically irrelevant. The stress-shielding of severely degenerated discs (see above) suggests that discogenic pain may be most closely associated with intermediate stages of degeneration. The localised stress concentrations found in degenerated cadaveric discs have been directly linked to low back pain in living people.
The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines. Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively. Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time. Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK. In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated.
Despite tendencies for Claims against medical practitioners around Australia to fall, litigation continues to be a burden on individual practitioners and the system. Unlike Claims frequency, Claims costs are not falling and indemnity insurance remains a significant practice cost. Data is presented to illustrate some trends in litigation and illustrative cases are also presented to outline some of the difficulties in defending Claims. Particular emphasis on the degree of difficulty is made in respect of Epidural Abscess.
Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant
Introduction. Video recording to teach and assess both technical and non-technical skills is well-established within medical education. Trainees’ clinical and practical competencies are evaluated using Procedure-Based Assessments (PBAs). However, there is limited research describing how these PBAs truly reflect trainee performance. We sought to:. 1). assess the duration between the procedure and PBA completion. 2). assess the perceived viability of supplementing assessments using intra-operative camera footage and. 3). clarify
Acute post-operative urinary retention (POUR) is a recognized complication following lower limb arthroplasty. Its occurrence may have patient and ultimately
Introduction. Appropriate consenting is part of good medical practice and is a
The aim of this study was to investigate the long-term outcome of isolated, displaced Lisfranc injuries requiring operative intervention and identify whether results of treatment are influenced by workers compensation. This retrospective study reviewed all patients who underwent operative intervention for Lisfranc injuries. Patients with concomitant injuries were excluded from further investigation so that the outcome of purely isolated Lisfranc injuries could be assessed. The minimum follow-up was two years and the senior author performed all the operations. Patients were contacted and their employment status recorded. Ordinal regression analysis was performed to identify which factors influenced the outcome. Forty-six patients were studied and 24 had pursued
Purpose: Litigation continues to be a concern in orthopaedic surgery despite suggestions on how to contain liability. The purpose of this study was to characterize orthopaedic litigation in Canada from 1997–2006. Method: This study reviewed all closed claims reported to the Canadian Medical Protective Association (CMPA) for 1997–2006 in which orthopaedic surgeons were named. There were 11,983 closed legal actions involving CMPA members (>
73,000 physicians), and 1,353 involved orthopaedic surgeons. A careful review of closed legal actions is a recognized tool for risk identification, assessment and management. The CMPA identifies any critical incidents within the closed legal files. A critical incident is defined as any omission or commission in the evaluation or management which led to the problem(s) that triggered the legal action. Each closed legal action can have more than one critical incident. Results: Performance, diagnostic and communication issues were the most frequently identified problems. These three areas account for 55% of the critical incidents identified. Performance related issues accounted for 395 critical incidents (29%). Diagnostic issues, including deficient histories and general evaluations, were identified in 281 cases (21%). Communication-related critical incidents included those concerning informed consent. The lack of informed consent was a common allegation, proven in 71 cases. In 439 cases (32%) there was no identifiable critical incident for the orthopaedic surgeon involved. Seventy-eight per cent of patients experienced minor or no disability and 22% experienced major disability or death. Events related to tibia trauma and knee arthroscopy formed the two major categories of claims. Patient care areas of high risk include the operating room and outpatient clinic. Overall, 31% of legal actions against orthopaedic surgeons had outcomes in favour of the plaintiffs, compared with 33% of all CMPA members’ claims. Conclusion: Although the likelihood for an orthopaedic surgeon to be sued in Canada has decreased over the last 10 years, the percentage of legal cases resolved in favour of plaintiffs has remained stable. Performance-related deficiencies, delays in diagnosis, and failures in communication represent areas of high
