To assess whether epidural steroid injection [ESI] is effective in the treatment of nerve root pathology caused by compression in the lumbar spine secondary to either spinal stenosis or disc prolapse, we carried out a prospective randomised controlled trial; patients were randomised either to ESI or Intramuscular steroid injection, with minimum two year follow-up.

Ninety two patients with symptoms, signs and radiological findings consistent with lumbar nerve root compression suitable for surgical decompression.

The main outcome measures were the Oxford Pain Chart over the first month, Oswestry Disability Index, and the need for surgery.

There was a significant reduction in pain early on after ESI compared with controls [p=< 0.004] between 10 and 35 days. There was no difference in the long term between the two groups and the rate of surgery in the two groups was not significantly different. Indeed the rate of surgery was higher in the ESI group than the control group [41% vs.31%] but this was not significant. A second ESI did not change the likelihood that surgery would be required.

Conclusion: ESI is effective for early pain relief for lumbar nerve root compression. However it does not change the natural history of the condition and does not reduce the ultimate need for surgery. It is probably effect to “buy time” in acute sciatica until improvement occurs naturally.

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation.

Objective: To investigate consistency between radiologists interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment.

Background: MRI has assumed a preeminent position in the diagnosis of lumbar disc prolapse.

Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy.

Results: Reliability tests show only fair agreement (k=0.36) between the radiologists and at best only moderate agreement (k=0.41) between the radiologists and surgical findings.

Conclusions: MRI is an excellent tool for diagnosis of a disc prolapse but does not appear to help in classifying discs suitable for percutaneous treatment.

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation.

Objective: To investigate consistency between Radiologists’ interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment.

Background: MRI has assumed a pre-eminent position in the diagnosis of lumbar disc prolapse.

Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy.

Results Reliability tests show only fair agreement (k=0.36) between the Radiologists and at best only moderate agreement (=0.41) between the Radiologists and surgical findings.

Conclusion: MRI is an excellent tool for diagnosis of a disc prolapse. MRI is poor at defining the character of a disc prolapse, and does not appear to help in classifying discs suitable for percutaneous treatment.

Study Design: A six-year retrospective analysis of all instrumented spinal fusions performed in the Nuffield Orthopaedic Centre and the John Radcliffe Hospital.

Objective: To assess the incidence of infection following instrumented spinal fusion, the nature of the infecting organisms and their subsequent management.

Subjects: All patients who had undergone removal of spinal metalwork were analysed for evidence of infection. The indications for removal of metalwork included proven deep infection, refractory postoperative pain or planned removal after thoraco-lumbar fracture.

Outcome Measures: Successful treatment of infection was documented when the patient was asymptomatic and inflammatory markers remained within normal limits following cessation of antibiotic therapy. Failure was documented when the patient had recurrent sepsis, refractory pain following removal of metalwork or died.

Results: 80 spinal infections following instrumented fusions were found between 1997 and 2003. 34 of the infecting organisms were propionibacteria, 19 were coagulase negative staphylococcus, 10 were staphylococcus aureus, 8 were methicillin resistant staphylococcus aureus, 3 were coliforms, 2 were proteus, 2 were diphtheroids, 1 was alpha haemolytic streptococcus and 1 was anaerobic streptococcus. 29 of these infections were polymicrobial. Of 55 patients who had metalwork removed secondary to pain, 20 patients had proven infection postoperatively (36.3%). Preoperative inflammatory markers failed to accurately predict the presence of infection for trauma patients. Our management of infection is removal of metalwork with six intraoperative samples sent for culture and histology specimens, followed by administration of at least six weeks of intravenous or oral antibiotic, depending on the organism and its antibiotic sensitivity. Prolonged treatment is used where inflammatory markers remain raised.

Conclusions: Infection of spinal implants presents different management problems to those which follow infected total joint replacement. The lack of specific clinical, laboratory and radiological findings in patients who are subsequently diagnosed as having infections associated with spinal instrumentation presents a challenging clinical problem. We found the most predictive sign of infection following instrumented fusion of scoliotic spines was postoperative pain. CRP and ESR were unreliable as predictors of infection.

Introduction and Aims: A multicentre trial of 349 patients of candidates for spinal fusion (where both patient and surgeon were uncertain of the outcome) were randomised to either an operation or to an intensive rehabilitation program. Rehabilitation was based on a three-week (15-day) model of exercise therapy and education using cognitive behavioural principles.

Method: The main outcome measures were the Oswestry Disability Index (ODI); Shuttle Walking Test; SF-36 and EuroQol EQ-5D recorded at baseline and six, 12 and 24 months after randomisation. The trial was 90%-powered to show a four-point ODI difference between groups at a= 0.05. Full economic analysis is available.

Results: Patients in both treatment arms made statistically significant improvements on all outcome measures between baseline and two-year follow-up. There was a small difference between the treatment arms favouring surgery on one of the main outcome measures, the Oswestry Disability Index; there were no statistically significant differences between the two treatment strategies for the rest. The difference in the change of score for the ODI was a decrease of 3.2 (C.I -7.3 – 0.9) in favour of surgery (p< 0.1), an improvement of 30 metres on the shuttle walking test in favour of the surgery group (p< 0.2), a difference of 0.01 on the Euroqol (p< 0.9) and an increase of 2.7 points on the SF-36 (p< 0.4).

The surgery results parallel those reported in other trials. At two years, the treatment costs of the surgery arm were approximately twice those of the rehabilitation arm. The costs of the rehabilitation strategy depend on how many patients opt to have surgery after rehabilitation (22% in this trial). This is a comparison of treatment strategies: there was no clinical or statistical difference in outcome between the strategy of spinal fusion and rehabilitation.

Conclusion: Patients randomised to both surgery (spinal stabilisation) and rehabilitation have indicated a treatment effect, but this may be due to natural history. ‘Failed’ non-operative treatment is commonly listed as an indication for surgery, this should only be considered once an intensive rehabilitation program backed by the treating surgeon has been tried.

Aims: Data collected on knee replacements from 93 hospitals in England were analysed to identify risk factors for surgical site infection. Methods: Prospective surveillance data collected from hospitals in England to calculate surgical site infection rates and potential risk factors Results: There were 242 (1.6%) infections in 15427 primary TKR, with a 0.11% joint infection rate, and 36 (3.6%) infections in 988 revisions, with a signiþcantly higher joint infection rate of 0.35%. There was considerable variation between hospitals. Multivariable logistic regression found signiþcant association between risk of SSI and type of procedure (p< 0.01), the hospital where the procedure was performed, male sex (p< 0.001), age (p< 0.001) and wound class (p< 0.05). The mean length of stay in primary TKRñs increased from 9 days to 18 days with an infection; and in revision procedures from 12 to 24 days. The median time to diagnosis for SSI was 7.5 days. Staphylococcus aureus accounted for 33%, 66% of which were methicillin resistant (MRSA). Conclusions: There is signiþcant inter-hospital variation in the incidence of SSI following knee replacements in England. Signiþcant risk factors include revision procedures. Male sex, age and wound class. SSIñs doubled the length of post-operative stay and MRSA accounted for 21% of organisms.

Aims: To calculate SSI rates and potential risk factors for primary total hip replacements (THR), hip hemiarthroplasties (HH), revision THR’s, and revision HH’s in England. Methods: Demographic, operative, and infection data was collected prospectively from 104 hospitals in England over 4 years to calculate SSI rates and potential risk factors. Results: There were 353 (2.3%) infections in 15697 THR’s with a 0.2% joint infection rate; 248 (4.6%) infections in 5456 HH procedures (0.9% joint). For revision THRs there were 92 (3.6%) infections in 2563 procedures, and 11 (5.6%) infections in 197 revision HH’s. Staphylococcus Aureus was identified in 52%; 58% were MRSA. With multivariable analysis, only inter-hospital variation (p< 0.001) and ASA score (p< 0.001) remained significant. Mean time to detection of infection varied from 9.2 days (superficial) to 11.3 days (joint). Mean length of stay increased from 9 to 14 days in THR’s; from 14 to 30 days for revision THR’s; from 19 to 34 days for HH’s and from 20 to 28 days for revision HH’s with an infection.

Conclusions: Infection rates are within acceptable levels, however there is a significant inter-hospital variation in infections following hip prosthesis in England. ASA score remains a significant risk factor and MRSA accounted for 30% of organisms.

Objective: To assess whether Webb Morley Instrumentation had satisfactory long term results.

Design: A retrospective review of 52 patients who underwent fusion and instrumentation with Webb Morley Instrumentation between 1991–1997.

Subjects: 52 patients were reviewed, 32 patients with idiopathic scoliosis who underwent isolated anterior fusion, 19 patients with neuromuscular scoliosis who underwent anterior and posterior surgery.

Outcome measures: Preoperative and postoperative radiographs, ISIS scans, and patient review. The in-patient notes were assessed for duration of surgery, blood loss, hospital stay and complications. Correction of Cobb angle and union were assessed.

Results: In the idiopathic group Cobb angle improved by 57%, apical rotation by 36% and tilt angle by 56%. There were no major complications and all united. The implant has a tendency to kyphose the spine, and an average of 7 degrees of kyphosis was seen across the implant. In the neuromuscular group Cobb angle improved by 52%, apical rotation by 21% and tilt angle by 57%. There was one asymptomatic pseudarthrosis, two rod breakages and two posterior rod dissociations. Only one patient complained of significant back pain.

Conclusions: Webb Morley instrumentation offers results as good as most other anterior implant systems. The flexibility of the rods may be a relative advantage, with a high union rate. Although the implant tends to kyphose the spine this has not been a problem clinically at follow-up of 4-11 years. This may help in design of future implants.

Objective: To assess the Universal Spine System and Kaneda Anterior Scoliosis System. Does one system have particular advantages over another?

Design: A retrospective review of patients with idiopathic scoliosis undergoing anterior fusion and instrumentation. The patients undergoing USS instrumentation were treated between 1994–1998, KASS patients 1997–2001.

Subjects: Thirty two consecutive patients were reviewed. Seventeen patients were in the USS group and 15 in the KASS group, 28/32 were female.

Outcome measures: Preoperative and postoperative radiographs, ISIS scans, and patient review. The in-patient notes were assessed for duration of surgery, blood loss, hospital stay and complications. Correction of Cobb angle and union were assessed.

Results: The patients in the KASS group had less flexible curves (correctability 45% vs. 53%). Despite this correction of Cobb angle was better in patients undergoing KASS instrumentation (38.0 degrees vs. 27.8 degrees, P=< 0.05). The secondary curves also improved more in the KASS group (55% vs. 29%, p=< 0.05). Complications occurred in 30%, but there was no difference between the two groups. There were no non-unions. In every other respect there was no difference between the groups for surgery time, blood loss, loss of correction or progression of secondary curve.

Conclusions: KASS instrumentation has better ability to correct spinal deformity in the short term. Further follow-up is required to assess long term results.

One of the major long term problems of total shoulder replacement is loosening of the glenoid component. Since 1997 we have been using atmospheric pressure to drive cement into the interstices of the glenoid trabecular bone by lowering the intraosseous pressure. This is achieved by introducing a wide bore needle into the base of the coracoid process and attaching it to surgical suction. During this period approximately 200 Tornier Aequalis shoulder replacements were performed by the senior author. For the purpose of this detailed study 20 consecutive cases were studied.

Good exposure of the glenoid is achieved using an extended approach and aggressive surgical releases. The surface is prepared according to the manufacturers recommendation. The base of the coracoid is now exposed and drilled with a 3.5mm AO drill bit, angled so as not to collide with the keel of the glenoid component. A Verres needle is hammered into the glenoid at this point and connected to a separate, second suction apparatus, placed on high suction during final lavage, cement insertion and cement curing. Blood and lavage fluid can be seen to be sucked from the glenoid during preparation and cementation.

Standard true antero-posterior radiographs were taken by the same experienced radiographer in the plane of the glenoid face two days following surgery, and at 3 months and one year. A Mitotoyu digital microcalliper with a resolution of 0.1mm was used to determine the depth of cement intrusion and presence of lucent lines. Three independent observers measured each radiograph. Analysis of interobserver error shows agreement between observers. For assessment the glenoid was divided into five zones – Superior flange; superior slope of keel; base of keel; inferior slope of keel; inferior flange.

No patient had a complete lucent line around the glenoid component. Four patients had a single zone lucent line (ranging from 1.1mm to 1.7mm) None of these patients had a lucent line around the keel, and those four areas of lucency under the superior or inferior flange were more likely due to incomplete removal of articular cartilage than a failure of cement technique.

The reported prevalence of glenoid lucent lines varies from 22% to 89%. The significance of glenoid lucent lines is controversial but several studies have reported a direct relationship between the presence of radiolucent lines and the development of loosening of cemented components.

Secure cement technique is more difficult in the shoulder than in the knee or hip. Access is tighter, bleeding more difficult to control and peroxide should not be contemplated because of close proximity of the axillary nerve to the glenoid. Classic socket pressurisers can not fit into such a small space. We have found that the second sucker technique is extremely effective in establishing a secure cement-bone interface during glenoid replacement.

Data collected on total knee replacements (TKR) from 77 hospitals in England were analysed to identify risk factors for surgical site infection (SSI).

Demographic, operative, and infection data were collected prospectively over a four-year period by the Nosocomial Infection National Surveillance Scheme.

There were 213 (1.8%) infections reported in 11552 primary TKR of which 82% were superficial, 10% deep incisional, and 8% joint/bone infections. The incidence of SSI in 687 revision of TKRs was 4.1% (71% superficial incisional, 18% deep incisional and 11% joint/bone). In the single variable analysis of primary TKRs, significant risk factors were male sex (p< 0.01), age (p< 0.001), ASA score (p< 0.001), wound class (p< 0.001) and NNIS risk index (p< 0.001). In revision of TKRs, only age (p< 0.01) and pre-operative hospital stay of more than one day (p< 0.02) were found to be significant. Significant risk factors with multi-variable logistic regression were type of procedure (TKR or revision TKR), hospital where the procedure was performed, male sex, and age. The mean length of stay in primary TKRs was 10 days (19 days with SSI) and 12 days in revision TKR (22 days with SSI). The median time to diagnosis for superficial SSI was 7 days for superficial SSIs, 9 days for deep incisional SSIs and 7.5 days for joint/bone infections. Staphylococcus aureus accounted for 35% of the infections and nearly one third of these were methicillin resistant (MRSA).

There is significant inter-hospital variation in the incidence of SSI following total knee replacement. Revision TKR procedures are associated with a significantly higher incidence of SSI than primary TKRs (p< 0.001). Male sex and age are also important risk factors. Patients with SSI had a length of post-operative stay approximately twice that of those without SSI.

Objective: To assess early results with the KASS system for scoliosis correction. To assess lateral curvature, rotational correction and complications.

Design: The first 22 patients requiring anterior correction of scoliotic curves were retrospectively reviewed. Pre- and post-operative curve measurements were made with a Cobbometer. Topographical assessment (ISIS) scan was used to assess rotation and correction of the rib hump. The notes were reviewed to determine complications and time to discharge.

Subjects: Twenty-two patients: 18 idiopathic scoliosis (4 others); average age 15.4 years; 5 King One, 10 King Two, 6 King Three and one non-definable; 5 thoracic curves

Results: Average pre-op scoliosis 54.85 degrees

Average post-op scoliosis 19.4 degrees. Average correction 65%. One patient required second operation for long screws. Four self limiting rninor complications. Average time to discharge eight days

Conclusion: KASS instrurnentation is a safe, effective and reliable method to correct scoliotic curves including rotational deformities. It was not possible to correct the Cobb angle of purely thoracic curves as much as thoracolumbar curves. Cosmetic correction however has been excellent as demonstrated with ISIS. Long term review will be necessary to confirm that correction is maintained.