Publications by authors named "Darren F Lui"

28 Publications

  • Page 1 of 1

Integrated Custom Composite Polyetheretherketone/Carbon fiber (PEEK/CF) Vertebral Body Replacement (VBR) in the treatment of Bone Tumors of the Spine: A Preliminary Report From a Multicenter Study.

Spine (Phila Pa 1976) 2021 Jul 23. Epub 2021 Jul 23.

University of Virginia, Charlottesville, Virginia (USA) IRCSS, Istituto Ortopedico Rizzoli, Bologna (Italy) St. George's University Hospital, London, (UK) Oxford Spinal Unit, Oxford University Hospitals, Oxford, (UK) Memorial Medical Center, Los Banos, California, (USA) IRCCS, Istituto Ortopedico Galeazzi, Milano (Italy).

Study Design: Retrospective, multi-center chart and radiologic review.

Objective: To present the first case series of bone tumors of the spine surgically reconstructed with a new custom, fully radiolucent, Polyetheretherketone/Carbon fiber (PEEK/CF) vertebral body replacement (VBR) integrated system.

Summary Of Background Data: Surgical resections of spinal tumors result in large defects and local recurrence remains a concern. Current titanium-based implants adversely affects postoperative imaging, directly affects ability to identify tumor recurrence, and for delivery of radiotherapy treatments. PEEK/CF spinal implants allows for improved tumor surveillance, precise pre-radiation CT planning, and reduces interference with post-reconstructive adjuvant radiotherapy.

Method: Thirteen patients with spinal tumors underwent vertebral body resection and reconstruction with an integrated, fully radiolucent, custom PEEK/CF vertebral body replacement and radiolucent posterior PEEK/CF screw-rod system and/or radiolucent anterior PEEK/CF plate system. Clinical and radiographic data were tabulated. Need for adjuvant radiotherapy determined based on final tissue histology and extent of surgical margins. Postoperative surveillance imaging were reviewed for local tumor recurrence.

Results: The ability to integrate the PEEK/CF VBR connected to either the posterior screw-rod system, or anterior plate system provided immediate stability. The VBR was placed directly on cancellous vertebral body surface in 46.2% of cases. Loosening of the distal, or proximal, aspect of posterior system was seen in 15.4% of cases. There was no clinical or radiographic evidence of VBR migration and subsidence at latest follow up. Local recurrence occurred in 1 (7.7%) patient.

Conclusions: This is the first series to describe the use of a fully-radiolucent, integrated, PEEK/CF implant system for spinal tumor reconstruction. The use of a PEEK/CF VBR system integrated to either the anterior plate, or posterior screw-rod system is feasible and allows for superior postoperative surveillance imaging and effective delivery of postoperative adjuvant radiotherapy.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000004177DOI Listing
July 2021

Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review.

Acta Orthop Belg 2021 Mar;87(1):181-190

Controversy surrounding the classification of thoracolumbar injuries has given rise to various classification systems over the years, including the most recent AOSpine Thoracolumbar Injury Classification System (ATLICS). This systematic review aims to provide an up-to-date evaluation of the literature, including assessment of a further three studies not analysed in previous reviews. In doing so, this is the first systematic review to include the reliability among non-spine subspecialty professionals and to document the wide variety between reliability across studies, particularly with regard to sub-type classification. Relevant studies were found via a systematic search of PubMed, EBESCO, Cochrane and Web of Science. Data extraction and quality assessment were conducted in line with Cochrane Collaboration guidelines. Twelve articles assessing the reliability of ATLICS were included in this review. The overall inter-observer reliability varied from fair to substantial, but the three additional studies in this review, compared to previous reviews, presented on average only fair reliability. The greatest variation of results was seen in A1 and B3 subtypes. Least reliably classified on average was A4 subtype. This systematic review concludes that ATLICS is reliable for the majority of injuries, but the variability within subtypes suggests the need for further research in assessing the needs of users in order to increase familiarity with ATLICS or perhaps the necessity to include more subtype-specific criteria into the system. Further research is also recommended on the reliability of modifiers, neurological classification and the application of ATLICS in a paediatric context.
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March 2021

A Hybrid Virtual Fracture Clinic is Safe and Efficacious in the COVID-19 Era: Stay at Home and Save Lives.

Cureus 2021 May 5;13(5):e14849. Epub 2021 May 5.

Trauma and Orthopaedics, St. George's University Hospitals NHS Foundation Trust, London, GBR.

Introduction The coronavirus disease 2019 (COVID-19) pandemic necessitated a change in the manner outpatient fracture clinics are conducted due to the need to reduce footfall in hospitals. While studies regarding virtual fracture clinics have shown these to be useful and effective, they focus exclusively on remote consultations. However, our service was bespoke to the patient - either a face-to-face, a telephone consultation or both, depending on patient need - a 'hybrid virtual fracture clinic' (HVFC). We report patient satisfaction and outcomes with this service from the first wave of the pandemic. Methods We retrospectively interviewed patients who availed of the HVFC service at our institution during the first two weeks of national lockdown in England from March 23 to April 5, 2020. The number and type of consultations, patient vulnerability to COVID-19, and type of management (surgical vs non-surgical) were among the factors taken into consideration. Patient experience was assessed using the Net Promoter Score (NPS), Customer Effort Score (CES), and Customer Satisfaction Score (CSS) on a scale of 0-10. Patient-reported outcomes were assessed using the EuroQol-5D-5L score (including EQ Visual Analogue Scale {EQ-VAS} scoring on a scale of 0-100). Results The mean overall NPS, CES, and CSS for the service were 7.32, 7.24, and 7.49, respectively. The mean self-reported EQ-VAS rating was 77.5. Of 442 consultations, 246 were conducted virtually; 10% were face-to-face, 29% virtual, and 61% were hybrid consultations. The HVFC resulted in a 55.65% reduction in footfall. Statistical analysis showed no significant difference across any outcome measure when compared between hybrid, virtual, and face-to-face consultations. Patients vulnerable to COVID-19 and those who did not require surgery tended to report better overall scores. Conclusion Our study indicates that the HVFC format can reduce patient footfall significantly (>50%) while providing effective and satisfactory outpatient care. There appears to be no difference in patient-reported outcomes between face-to-face consultations and hybrid or virtual consultations. Patients would recommend HVFC to family and friends, found it was easy to use, and reported good satisfaction with the service.
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http://dx.doi.org/10.7759/cureus.14849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174398PMC
May 2021

Reproducibility and reliability analysis of the Luk Distal Radius and Ulna Classification for European patients with adolescent idiopathic scoliosis.

J Child Orthop 2021 Apr;15(2):166-170

St Georges University Hospitals NHS Foundation Trust, London, UK.

Purpose: Current clinical and radiological methods of predicting a patient's growth potential are limited in terms of practicality, accuracy and known to differ in different races. This information influences optimal timing of bracing and surgical intervention in adolescent idiopathic scoliosis (AIS). The Luk classification was developed to mitigate limitations of existing tools. Few reliability studies are available and are limited to certain geographical regions with varying results. This study was performed to analyze reproducibility and reliability of the Luk Distal Radius and Ulna Classification in European patients.

Methods: This is a radiological study of 50 randomly selected left hand and wrist radiographs of patients with AIS referred to a tertiary referral centre. They were assessed for bone maturity using the Luk Distal Radius and Ulna Classification. Assessment was performed twice by four examiners at an interval of one month. Statistical analysis was performed using the intraclass correlation (ICC) method to determine the reliabilities within and between the examiners.

Results: In total, 50 radiographs (M:F = 13:37) with a mean age of 13.7 years (10 to 18) were assessed for reliability. The inter-rater ICC value was 0.918 for radius assessment and 0.939 for ulna assessment. The intra-rater ICC values for radius assessment ranged between 0.897 and 0.769 and between 0.948 and 0.786 for ulna assessment. There was near perfect correlation for both assessments.

Conclusion: This study provides independent evidence that the Luk Distal Radius and Ulna Classification is a reliable tool for assessment of skeletal maturity for European patients. Minimal clinical experience is required to reliably utilize it.

Level Of Evidence: IV.
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http://dx.doi.org/10.1302/1863-2548.15.200251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138788PMC
April 2021

The rising burden of penetrating knife injuries.

Inj Prev 2021 Feb 11. Epub 2021 Feb 11.

Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK.

Introduction: Knife crime remains an area of public health concern. In order to tackle this problem and reduce its burden, the epidemiology of penetrating knife injuries needs to be understood. The aim of this study is to analyse the pattern of knife injuries at a major trauma centre (MTC) in London.

Methods: An analysis of cases from the prospectively collected Trauma Audit and Research Network database of patients attending the emergency department with violent intentional knife injuries from January 2014 to December 2018 was performed. Registry data were analysed for mechanism of injury, number of stabbings, month/date/time of admission, patient demographics, anatomical pattern of injury, hospital length of stay, intervention, ethnicity, repeat victims and fatality.

Results: 1373 penetrating knife injuries activated the major trauma call representing 11.7% of all major trauma alerts. 44% occurred in the 16-25 years age group and 85.6% were male. 67.2% required hospital admission. 14.1% required surgery. 50.3% required intervention from multiple specialities. 39.4% had thoracic injuries and 25.8% abdominal injuries. Fatality rate was 0.9% (n=12). 3.6% were repeat victims. 26.8% were multiple stabbings. 5.2% were deliberate self-harm. 23.2% were of white ethnic background. Injury incidence peaked on a Saturday. A significant peak in injuries occurred between 22:00 and 00:00.

Conclusion: This study shows an increase in the incidence of knife crime per year. These cases contribute approximately 12% of major trauma calls. Female assaults increased from 8.4% to 14.3%. Approximately 2/3 injuries occur in the thorax and abdomen with high frequencies at weekends and evenings. These facts can help allocate resources more efficiently.
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http://dx.doi.org/10.1136/injuryprev-2020-044016DOI Listing
February 2021

Tranexamic acid use in a patient with sickle cell disease undergoing posterior scoliosis correction surgery: safely mitigating bleeding and vaso-occlusive crises.

J Surg Case Rep 2021 Jan 29;2021(1):rjaa559. Epub 2021 Jan 29.

St George's University Hospital NHS Foundation Trust, London.

A 15-year-old female with 2-year post-menarchal adolescent idiopathic scoliosis and sickle cell disease (SCD) underwent posterior scoliosis correction surgery. SCD is associated with higher rates of surgical complications, and these patients require careful management to prevent vaso-occlusive sickle cell crises (VOSCC); scoliosis correction surgery can be associated with high morbidity and mortality, including significant blood loss. Multiple techniques were employed to successfully prevent VOSCC in this patient including a preoperative transfusion, meticulous haemostasis at osteotomy sites, not performing a costoplasty despite presence of a rib hump, maintenance of intraoperative mean arterial pressure below 70 mmHg, aggressive postoperative hydration and the use of intraoperative tranexamic acid (TXA). This is the first reported case of the use of TXA in a patient with SCD and scoliosis correction surgery. A satisfactory correction was achieved with a longer than average inpatient stay due to non-sickle cell pain and protracted wound ooze.
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http://dx.doi.org/10.1093/jscr/rjaa559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850132PMC
January 2021

40 days and 40 nights: Clinical characteristics of major trauma and orthopaedic injury comparing the incubation and lockdown phases of COVID-19 infection.

Bone Jt Open 2020 Jul 2;1(7):330-338. Epub 2020 Nov 2.

Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK.

Aims: The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era.

Methods: A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after.

Results: A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis).

Conclusion: Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%.Cite this article: 2020;1-7:330-338.
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http://dx.doi.org/10.1302/2633-1462.17.BJO-2020-0068.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7659656PMC
July 2020

Two-stage anterior and posterior fusion versus one-stage posterior fusion in patients with Scheuermann's kyphosis.

Bone Joint J 2020 Oct;102-B(10):1368-1374

Spinal Deformity Unit, Royal National Orthopaedic Hospital, Stanmore, UK.

Aims: Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann's kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

Methods: A retrospective review of patients treated surgically for Scheuermann's kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples -tests, and z-tests of proportions analyses where applicable.

Results: There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches.

Conclusion: A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: 2020;102-B(10):1368-1374.
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http://dx.doi.org/10.1302/0301-620X.102B10.BJJ-2020-0273.R3DOI Listing
October 2020

Spinal-Pelvic Dissociation in Pregnancy: Surgical Fixation of Culture-Negative Extrapulmonary Tuberculosis.

Case Rep Orthop 2020 10;2020:9769076. Epub 2020 Apr 10.

St. George's Hospital, University of London, UK.

A 33-year-old gravid female from Pakistan presented to the Emergency Department with persistent, intractable low back pain and neuropathic left L5 leg pain, associated with a left foot drop. There was a notable history of weight loss for 1 year. Investigations revealed a large collection in the right posterior paraspinal muscles tracking from a large bony defect in the right half of her sacrum extending into the pelvis. The collection was suggestive of an abscess and underwent US-guided aspiration. Culture, PCR examination, and bone biopsy were culture-negative for tuberculosis (TB). Samples taken from the placenta showed two small granulomata in the chorionic villi only. A multidisciplinary approach commenced with initiation of empirical TB treatment and attempted normal vaginal delivery. An urgent caesarean section for the delivery of the baby was required for failure to proceed. Spinal-pelvic stabilization in two stages was performed for the unstable fracture pattern, followed by pharmacotherapy and physiotherapy rehabilitation. At 12-month follow-up, the patient showed resolving TB and eradication of the paraspinal abscess. There was bony union and stability of the spinal-pelvic reconstruction. Back pain and sciatica can be common in pregnancy. However, this case highlights a rare occurrence of culture-negative extrapulmonary TB leading to an unstable spinal-pelvic fracture requiring a multidisciplinary approach for careful obstetric and orthopaedic treatment with empirical treatment by the infectious disease team and microbiology.
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http://dx.doi.org/10.1155/2020/9769076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171626PMC
April 2020

360-Degree Complex Primary Reconstruction Using Porous Tantalum Cages for Adult Degenerative Spinal Deformity.

Global Spine J 2019 Sep 21;9(6):613-618. Epub 2018 Nov 21.

Royal National Orthopaedic Hospital, Stanmore, UK.

Study Design: Retrospective cohort study.

Objective: To assess both implant performance and the amount of correction that can be achieved using multilevel anterior lumbar interbody fusion (ALIF).

Methods: Retrospective cohort study (n = 178) performed over a 4-year period. Surgical variables examined included blood loss, operative time, perioperative complications, and secondary/revision procedures. Follow-up radiographic assessment was performed to record implant-related problems. Radiographic parameters were examined pre- and postoperatively. Health-related quality of life (HRQOL) outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Descriptive and comparative statistical analysis, using paired-sample test and repeated-measures analysis of variance (rANOVA), was performed.

Results: Lumbar lordosis increased from 42° ± 17° preoperatively to 55° ± 11° postoperatively ( < .001). The visual analog scale back pain mean score improved from 8.3 ± 1.5 preoperatively to 2.6 ± 2.4 at 2 years ( < .001). The mean Oswestry Disability Index improved from 69.5 ± 21.5 preoperatively to 19.9 ± 15.2 at 2 years ( < .001). The EQ-5D mean score improved from 0.2 ± 0.2 preoperatively to 0.8 ± 0.1 at 2 years ( = .02). There were no neurological, vascular, or visceral approach-related injuries reported. No rod breakages and no symptomatic nonunions occurred. There was one revision procedure performed for fracture.

Conclusions: The use of porous tantalum cages as part of a 360-degree fusion to treat adult degenerative spinal deformity has been demonstrated to be a safe and effective strategy, leading to good clinical, functional, and radiographic outcomes in the short term.
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http://dx.doi.org/10.1177/2192568218814531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693065PMC
September 2019

Neurologic Injury in Complex Adult Spinal Deformity Surgery: Staged Multilevel Oblique Lumbar Interbody Fusion (MOLIF) Using Hyperlordotic Tantalum Cages and Posterior Fusion Versus Pedicle Subtraction Osteotomy (PSO).

Spine (Phila Pa 1976) 2019 Aug;44(16):E939-E949

Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, London, UK.

Study Design: A retrospective review of prospectively collected data.

Objective: The aim of this study was to determine the safety of MOLIF versus PSO.

Summary Of Background Data: Complex adult spinal deformity (CASD) represents a challenging cohort of patients. The Scoli-RISK-1 study has shown a 22.18% perioperative risk of neurological injury. Restoration of sagittal parameters is associated with good outcome in ASD. Pedicle subtraction osteotomies (PSO) is an important technique for sagittal balance in ASD but is associated with significant morbidity. The multilevel oblique lumbar interbody fusion (MOLIF) is an extensile approach from L1 to S1.

Methods: Single surgeon series from 2007 to 2015. Prospectively collected data. Scoli-RISK-1 criteria were refined to only include stiff or fused spines otherwise requiring a PSO. Roentograms were examined preoperatively and 2 year postoperatively. Primary outcome measure was the motor decline in American Spinal Injury Association (ASIA) at hospital discharge, 6 weeks, 6 months, and 2 years. Demographics, blood loss, operative time, spinopelvic parameters, and spinal cord monitoring (SCM) events.

Results: Sixty-eight consecutive patients were included in this study, with 34 patients in each Group. Group 1 (MOLIF) had a mean age 62.9 (45-81) and Group 2 (PSO) had a mean age of 66.76 years (47-79); 64.7% female versus PSO 76.5%; Body Mass Index (BMI) Group 1 (MOLIF) 28.05 and Group 2 (PSO) 27.17. Group 1 (MOLIF) perioperative neurological injury was 2.94% at discharge but resolved by 6 weeks. Group 2 (PSO) had five neurological deficits (14.7%) with no recovery by 2 years. There were four SCM events (SCM). In Group 1 (MOLIF), there was one event (2.94%) versus three events (8.88%) in Group 2 (PSO).

Conclusion: Staged MOLIF avoids passing neurological structures or retraction of psoas and lumbar plexus. It is safer than PSO in CASD with stiff or fused spines with a lower perioperative neurological injury profile. MOLIF have less SCM events, blood loss, and number of levels fused.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003034DOI Listing
August 2019

Effect of body mass index on functional outcome in primary total knee arthroplasty - a single institution analysis of 2180 primary total knee replacements.

World J Orthop 2016 Oct 18;7(10):664-669. Epub 2016 Oct 18.

Shane C O'Neill, Joseph S Butler, Adam Daly, Darren F Lui, Patrick Kenny, Department of Orthopaedics, Cappagh National Orthopaedic Hospital, Dublin 11, Ireland.

Aim: To evaluate the effect of body mass index (BMI) on short-term functional outcome and complications in primary total knee arthroplasty.

Methods: All patients undergoing primary total knee arthroplasty at a single institution between 2007 and 2013 were identified from a prospective arthroplasty database. 2180 patients were included in the study. Age, gender, BMI, pre- and post-operative functional scores [Western Ontario and McMaster University Arthritis Index (WOMAC) and SF-36], complications and revision rate were recorded. Patients were grouped according to the WHO BMI classification. The functional outcome of the normal weight cohort (BMI < 25) was compared to the overweight and obese (BMI ≥ 25) cohort. A separate sub-group analysis was performed comparing all five WHO BMI groups; Normal weight, overweight, class 1 obese, class 2 obese and class 3 obese.

Results: With a mean age of 67.89 (28-92), 2180 primary total knee replacements were included. 64.36% (1403) were female. The mean BMI was 31.86 (18-52). Ninty-three percent of patients were either overweight or obese. Mean follow-up 19.33 mo (6-60 mo). There was no significant difference in pre or post-operative WOMAC score in the normal weight (BMI < 25) cohort compared to patients with a BMI ≥ 25 ( > 0.05). Sub-group analysis revealed significantly worse WOMAC scores in class 2 obese 30.80 compared to overweight 25.80 ( < 0.01) and class 1 obese 25.50 ( < 0.01). Similarly, there were significantly worse SF-36 scores in class 2 obese 58.16 compared to overweight 63.93 ( < 0.01) and class 1 obese 63.65 ( < 0.01) There were 32 (1.47%) superficial infections, 9 (0.41%) deep infections and 19 (0.87%) revisions overall with no complications or revisions in the normal weight cohort (BMI < 25).

Conclusion: Post-operative functional outcome was not influenced by BMI comparing normal weight individuals with BMI > 25. Patients should not be denied total knee arthroplasty based solely on weight alone.
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http://dx.doi.org/10.5312/wjo.v7.i10.664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5065673PMC
October 2016

Successful nonsurgical treatment for highly unstable fracture subluxation of the spine secondary to myeloma.

Spine J 2016 08 9;16(8):e547-51. Epub 2016 Mar 9.

Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.

Background Context: In multiple myeloma, patients may develop rapidly progressive, lytic, spinal lesions. These may result in spinal instability, but instrumented stabilization may fail because of poor bone quality. In addition, patients are immunocompromised and are therefore at increased risk of deep infection.

Purpose: The aim was to describe a patient presenting with an unstable fracture subluxation of the thoracic spine secondary to myeloma, successfully treated with non-surgical management.

Study Design/setting: This is a case report of a patient seen in a specialist spinal myeloma service.

Methods: A 74-year-old Caucasian woman presented with destructive myelomatous lesions of T9 and T10. Greater than 50% of the T9 vertebral body was involved, and there was subluxation and translation of T9 on T10 (Spinal Instability Neoplastic Score of 14). There was a single episode of transient paresthesia of both lower limbs. The patient was in considerable pain, requiring large quantities of opioid analgesia. She was treated non-surgically in a thoracolumbar sacral orthosis for a period of 3 months (strict bed rest for the first 3 weeks).

Results: A computed tomography scan at 3 months demonstrated bony fusion and the brace was removed. The patient returned to her normal activities 5 months posttreatment. Her pain and patient-reported outcome scores were significantly improved.

Conclusions: We present a successful non-surgical management of an unstable myelomatous vertebral fracture without neurologic deficit. However, surgical stabilization remains the treatment of choice in unstable vertebral fractures and spinal surgical opinion should be sought in all cases.
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http://dx.doi.org/10.1016/j.spinee.2016.03.008DOI Listing
August 2016

Eliminating the use of allogeneic blood products in adolescent idiopathic scoliosis surgery.

Eur J Orthop Surg Traumatol 2015 Jul 27;25 Suppl 1:S219-23. Epub 2015 Mar 27.

Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland,

Purpose: The aim of this study was to compare transfusion requirements in patients before and after the introduction of tranexamic acid as standard in patients undergoing spinal surgery for idiopathic scoliosis in a national orthopaedic hospital.

Methods: A retrospective chart review of 56 idiopathic scoliosis patients who underwent posterior spinal instrumentation and fusion between 2009 and 2013 at our institution. Preoperative, intraoperative, and postoperative data were measured.

Results: Patients who received tranexamic acid as standard (n = 31) showed a trend towards a decrease in transfusion requirements compared with those who received no tranexamic acid (n = 25). These patients had a statistically significant decrease in operative time (223 vs 188 min, p = 0.005), and estimated intraoperative blood loss was reduced by nearly 50% in the tranexamic acid group. They also had an associated reduced decrease in haemoglobin between preoperative and postoperative levels (4 vs 5 g/dL, p = 0.01).

Conclusions: Since February 2012, no patient has required intraoperative or postoperative allogeneic blood product transfusion in this hospital. The routine use of antifibrinolytic medications in patients undergoing surgery for adolescent idiopathic scoliosis has effectively eliminated the need for allogeneic blood products.
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http://dx.doi.org/10.1007/s00590-015-1624-3DOI Listing
July 2015

Lower leg compartment syndrome after appendicectomy.

Case Rep Orthop 2015 10;2015:585986. Epub 2015 Feb 10.

Department of Paediatric Trauma and Orthopaedics, Our Lady's Children's Hospital Crumlin, Dublin 12, Ireland.

A 10-year-old boy presented with severe left lower leg pain, uncontrolled with increasing analgesia after appendicectomy. A diagnosis of acute compartment syndrome was made after a delayed referral to the orthopaedic service. The patient subsequently underwent an emergency fasciotomy and made a good functional recovery. To the best of our knowledge this is the first reported case of paediatric lower leg compartment syndrome after appendicectomy in the literature. The case report serves to highlight the importance of maintaining a high index of suspicion for compartment syndrome.
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http://dx.doi.org/10.1155/2015/585986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4338393PMC
March 2015

Paediatric spinal trauma. When in doubt, scan again.

BMJ Case Rep 2014 Mar 7;2014. Epub 2014 Mar 7.

Department of Trauma & Orthopaedics, Our Lady's Children's Hospital, Dublin, Ireland.

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http://dx.doi.org/10.1136/bcr-2014-203760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948149PMC
March 2014

Fibroma of the peroneus longus tendon sheath in a child: a case report.

J Orthop Surg (Hong Kong) 2013 Dec;21(3):387-90

Department of Paediatric Orthopaedics, Our Lady's Children's Hospital, Dublin, Ireland.

Tendon sheath fibromas are rare, benign soft-tissue tumours and usually involve tendons of the upper extremities, particularly the fingers. The most common presentation is a painless, slow-growing swelling. Tendon sheath fibromas are composed of dense fibrocollagenous stromas with scattered, spindle-shaped fibroblasts and narrow, slit-like vascular spaces. Ultrasonography and magnetic resonance imaging are useful diagnostic tools. We report on an 11-year-old boy with a fibroma involving the right peroneus longus tendon sheath.
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http://dx.doi.org/10.1177/230949901302100326DOI Listing
December 2013

Acute nontraumatic spinal intradural hematoma in a patient on warfarin.

J Emerg Med 2013 Nov 26;45(5):695-7. Epub 2013 Aug 26.

Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.

Background: Nontraumatic spinal intradural extramedullary hematomas are extremely rare. When they occur, they can rapidly lead to spinal cord or cauda equina compression and have devastating consequences.

Objective: The aim here was to report a case of this rare phenomenon and discuss the etiology, imaging, management, and outcome of intradural hematomas.

Case Report: We describe the case of a 76-year-old man on warfarin therapy who presented with severe lower back pain and flaccid paraparesis. Blood tests revealed an international normalized ratio of 6.0. A magnetic resonance imaging result suggested an intradural hematoma extending from L1 to L4 and compressing the spinal cord and cauda equina. Emergency surgical decompression revealed an extensive intradural extramedullary hematoma, which was evacuated. The patient showed only minor neurologic improvement 6 months postoperatively.

Conclusions: Coagulopathy-induced spinal hemorrhage should be included in the differential diagnosis for patients presenting with signs of acute spinal cord compression.
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http://dx.doi.org/10.1016/j.jemermed.2013.04.048DOI Listing
November 2013

Preoperative comorbidity and modes of failure in revision hip arthroplasty: a single-surgeon series in a tertiary referral centre.

Eur J Orthop Surg Traumatol 2013 Apr 16;23(3):329-33. Epub 2012 Mar 16.

Department of Trauma and Orthopaedic, Mayo General Hospital, Castlebar, Co. Mayo, Ireland.

Revision hip arthroplasty is associated with higher morbidity post-operatively than primary surgery. We reviewed data on 102 consecutive patients (124 procedures) undergoing revision hip arthroplasty by a single surgeon from January 2005 to June 2009 in 2 institutions. Indications of failure: 62% aseptic loosening, 15% infection, 11.5% fracture, 10.6% dislocation or instability and 0.9% implant failure. Preoperative comorbidities: 28.4% cardiac, 4% respiratory and 6.8% diabetic. Morbidity: 3.9% complication rate (5 of 124 procedures). 73.5 median age and 46% over 75 years old. Modes of failure in our population leading to revision hip arthroplasty are similar to other studies. We showed a low morbidity following revision hip arthroplasty despite significant preoperative comorbidities and a high proportion of elderly patients. In conclusion, gender, age (>75) and preoperative comorbidities should not deter from revision surgery.
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http://dx.doi.org/10.1007/s00590-012-0964-5DOI Listing
April 2013

Total joint arthroplasty in nonagenarians--a retrospective review of complications and resource use.

Acta Orthop Belg 2012 Dec;78(6):745-50

Cappagh National Orthopaedic Hospital, Dublin, Ireland.

Increased age brings with it the potential for increased surgical risk. Assessment of specific age cohorts is necessary to plan future service provision and this is the case in hip and knee arthroplasty as the demand for these procedures is anticipated to increase. We retrospectively reviewed the outcomes, including complications, length of stay and blood transfusion rate, in a cohort of 35 nonagenarians undergoing primary or revision total hip and knee arthroplasty. All patients were pre-assessed by anaesthetists before being deemed suitable to undergo surgery in the unit. The mean length of hospital stay was 13.7 +/- 10 days (range 2-56). Thirty-one percent of patients required a blood transfusion. Patients who underwent primary total hip arthroplasty reported improved joint specific functional scores. In this appropriately selected group of nonagenarians, we found no evidence to suggest surgery be withheld on the basis of age alone. However, patients with multiple medical comorbidities warrant appropriate assessment and surgical intervention in an institution with appropriate support. Future planning needs to take into account the predicted increase in demand for arthroplasty surgery in this age group.
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December 2012

Hand dominance in orthopaedic surgeons.

Acta Orthop Belg 2012 Aug;78(4):531-7

Department of Trauma and Orthopaedics, Cappagh, National Orthopaedic Hospital, Finglas, Dublin, Ireland.

Handedness is perhaps the most studied human asymmetry. Laterality is the preference shown for one side and it has been studied in many aspects of medicine. Studies have shown that some orthopaedic procedures had poorer outcomes and identified laterality as a contributing factor. We developed a questionnaire to assess laterality in orthopaedic surgery and compared this to an established scoring system. Sixty-two orthopaedic surgeons surveyed with the validated Waterloo Handedness Questionnaire (WHQ) were compared with the self developed Orthopaedic Handedness Questionnaire (OHQ). Fifty-eight were found to be right hand dominant (RHD) and 4 left hand dominant (LHD). In RHD surgeons, the average WHQ score was 44.9% and OHQ 15%. For LHD surgeons the WHQ score was 30.2% and OHQ 9.4%. This represents a significant amount of time using the non dominant hand but does not necessarily determine satisfactory or successful dexterity transferable to the operating room. Training may be required for the non dominant side.
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August 2012

Skype: a tool for functional assessment in orthopaedic research.

J Telemed Telecare 2012 Mar 13;18(2):94-8. Epub 2012 Jan 13.

Department of Trauma, Orthopaedics, Pelvic and Acetabular Reconstructive Surgery, Adelaide and Meath Incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland.

Skype is a free program which enables PC users to make video calls to other users with Internet access. We carried out a prospective review of all acromioclavicular joint hook plates for lateral-third clavicle fractures over a five-year period. Functional assessment with Oxford and Constant shoulder scores were carried out using Skype and compared to outpatient review using the Bland-Altman method. Of 36 patients (mean age 36 years), 33 had a computer with a video camera, all 33 had Internet access and 22 were already users of Skype. In total 29 patients were happy to take part in Skype assessment (83%). In comparison with outpatient review, there was a mean difference in the Oxford score of -0.48 (95% confidence interval -0.84, -0.12); the mean difference for the Constant score was -0.68 (95% confidence interval -1.08, -0.29). These differences were not clinically significant, confirming that Skype can be used as an alternative to goniometry in this clinical setting. A survey showed that 93% of 29 patients surveyed preferred the use of Skype for follow-up, mainly due to the convenience and cost-saving involved. The study demonstrates the potential for this new technique in providing patients with more options for follow-up.
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http://dx.doi.org/10.1258/jtt.2011.110814DOI Listing
March 2012

Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study.

J Shoulder Elbow Surg 2012 Aug 20;21(8):1045-8. Epub 2011 Oct 20.

Department of Trauma Orthopaedics, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin, Ireland.

Background: Controversy exists with the use of the acromioclavicular hook plate for the treatment of lateral-third clavicle fractures (Neer type II). This is thought to stem from problems associated with the hook plate causing impingement symptoms, which can cause long-term limitation of movement and pain. Our aim was to evaluate the functional outcomes of patients with lateral-third clavicle fractures treated with the hook plate.

Methods: We prospectively reviewed all patients who underwent surgery from July 2005 to August 2009 using our prospectively recorded electronic patient information database. All patients were assessed in the clinic to determine both Oxford and Constant shoulder scores.

Results: We identified 36 patients who underwent surgery with the hook plate, 26 men and 10 women. The mean age was 36.2 years (range, 22-60 years). Of the patients, 46% were smokers. The median length of hospital stay was 2 days (interquartile range [IQR], 1-3). The median follow-up was 28 months (IQR, 23-37). The median time from date of injury to surgery was 7 days (IQR, 4-76). The mean time to union was 3 months (IQR, 2-4), and the union rate was 95%. In total, 92% of plates were removed. The median time to removal was 4.5 months (IQR, 3-8.75). There were no complications. Two patients presented months later after falls with fractures around the medial end of the hook plate.

Conclusion: Hook plates are an effective form of treatment for lateral third clavicle fractures. The best outcomes occur with plate removal before 6 months postoperatively, provided that the fracture has healed.
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http://dx.doi.org/10.1016/j.jse.2011.07.020DOI Listing
August 2012

Inflammatory myofibroblastic tumour of the tibia.

Joint Bone Spine 2010 Oct 15;77(5):488-9. Epub 2010 May 15.

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http://dx.doi.org/10.1016/j.jbspin.2010.02.038DOI Listing
October 2010

The evaluation of the inverted supinator reflex in asymptomatic patients.

Spine (Phila Pa 1976) 2010 Apr;35(9):955-7

National Spinal Injuries Unit, Department of Trauma and Orthopaedic Surgery, Mater Misericordiae Univeristy Hospital, Eccles Street, Dublin 7, Ireland.

Study Design: A prospective study was undertaken over a 6-month period to determine the incidence of the inverted supinator reflex in asymptomatic, neurologically normal individuals.

Objective: The objective of our study is to assess asymptomatic patients for the presence of the inverted radial reflex and to determine its clinical relevance.

Summary Of Background Data: The inverted radial reflex sign is commonly used in clinical practice to assess cervical myelopathy. It is unknown whether the sign correlates with the presence or severity of myelopathy, and no consensus exists regarding the significance of a positive sign in asymptomatic individuals.

Methods: Patients attending the Trauma Clinic at our institution were invited to participate. Each patient was examined neurologically and specifically for the presence or absence of the Babinski test, Hoffman's sign, the finger escape sign, static and dynamic Romberg's test, and the inverted supinator reflex. Patients were excluded if they had any history of neck pain, any history of neurosurgical procedure or spinal surgery, any known neurologic disorder or deficit, or if there was any outstanding medicolegal case.

Results: We examined 277 patients in 6-month period. The male to female ratio was 1.1:1. The mean age was 27 years (range, 16-78). The incidence of the inverted supinator reflex was 27.6% (75/271). Of the 75 positive patients, the inverted supinator reflex was present bilaterally in 39% (29/75). Nine of 75 patients (10%) had an associated positive Hoffman's sign but had no other signs suggestive of myelopathy. The proportion of patients with a positive inverted supinator reflex reduced with increasing age (Pearson correlation coefficient > 0.80).

Conclusion: This study demonstrates that an isolated, inverted supinator reflex may be a variation of normal clinical examination. We believe that an isolated inverted supinator reflex, in the absence of other clinical findings, is not a reliable sign of cervical myelopathy; however, it must be interpreted with caution in the older patient.
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http://dx.doi.org/10.1097/BRS.0b013e3181bccf0fDOI Listing
April 2010

Giant cell tumour in the foot of a skeletally immature girl: a case report.

J Orthop Surg (Hong Kong) 2009 Aug;17(2):248-50

Cappagh National Orthopaedic Hospital, Cappagh Road, Finglas, Dublin 11, Ireland.

We present a case of delayed diagnosis of a benign giant cell tumour (GCT) of the third metatarsal in a skeletally immature girl. The patient underwent en bloc excision of the tumour. The tumour had replaced the third metatarsal and had infiltrated the surrounding soft tissue and the second and fourth metatarsal bases. Deep, lateral and medial margins were all involved. A high index of suspicion is needed when evaluating any tumours of the foot, because the compact structure of the foot may delay diagnosis. Early detection is important for avoiding amputation, as the hindfoot and midfoot are classified as one compartment and radical resection is impossible to achieve. Tumours grow faster in the foot than in other bones. GCT in this location and age-group are rare and should be considered in the differential diagnosis of a destructive bony lesion in skeletally immature patients.
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http://dx.doi.org/10.1177/230949900901700230DOI Listing
August 2009

Foot drop--an unusual presentation of exertional compartment syndrome.

Clin J Sport Med 2009 May;19(3):236-7

Mater Misericordiae Hospital, Dublin, Ireland.

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http://dx.doi.org/10.1097/JSM.0b013e3181a39b04DOI Listing
May 2009
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