Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers.

This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median.

A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS.

In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS.

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship.

The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed.

Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday.

Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor.

Up to 20 percent of patients remain dissatisfied after primary total knee arthroplasty (TKA) surgery. Understanding the reasons for dissatisfaction post TKA may allow for better patient selection and optimized treatment for those who remain dissatisfied. The association between function, mobility and satisfaction are not well understood. The purpose of this study was to investigate the association between post-TKA satisfaction and i) pre-operative, ii) post-operative, and iii) change in knee joint function during gait.

Thirty-one patients scheduled to receive primary TKA for knee osteoarthritis (OA) diagnosis were recruited and visited the Dynamics of Human Motion laboratory for instrumented walking gait analysis (using a synchronized NDI Optotrak motion capture system and AMTI force platforms in the walkway) at two time points, first within the week prior to their surgery, and second at approximately one year after surgery. At their post-operative visit, patients were asked to indicate their satisfaction with their knee prosthesis on a scale from zero to 100, with zero being totally unsatisfied and 100 being completely satisfied. Knee joint mechanics during gait at both time points were characterized by discriminant scores, the projection of their three-dimensional knee angles and moments during gait onto an existing discriminant model that was created to optimize separation of severe knee OA and healthy asymptomatic gait patterns. This discriminant model was created using data from 73 healthy participants and 73 with severe knee OA, and includes the magnitude and pattern features (captured with principal component analysis) of the knee adduction and flexion moment, and the magnitude of the knee flexion angle during gait. Larger discriminant scores indicate improved function toward healthy patterns, and smaller scores indicate more severe function. Associations between post-operative satisfaction and pre, post and change in discriminant scores were examined using Pearson correlation analyses. We also examined associations between satisfaction and pre-operative BMI, EQ5D and Oxford 12 scores, as well as changes in these scores from pre to post-TKA.

Discriminant scores representing knee joint function during gait significantly improved on average after surgery (P =0.05).

While overall knee joint function improved after primary TKA surgery, the amount of improvement in function was not reflected in post-operative patient satisfaction. However, the pre-operative function of the patient was negatively associated with satisfaction, indicating that patients with higher pre-operative function are overall less satisfied with their TKA surgery, regardless of any functional improvement due to the surgery. Interestingly, the only significant association with post-operative satisfaction was knee joint function, and the relationship between function and patient satisfaction following TKA appears to relate only to the baseline functional state of the patient, and not with functional improvement. This suggests that dissatisfaction post-surgery is more likely reflecting the unmet expectations of a higher functioning patient, and has implications for the need for improved understanding of pre-operative patient functional variability in TKA triage and expectation management.

Introduction

Lateral epicondylitis, also known as “tennis elbow,” is a degenerative disorder of the common extensor origin of the lateral humeral epicondyle. The mainstay of treatment is non-operative and includes physiotherapy, activity modification, bracing, nonsteroidal anti-inflammatory drugs, and injections. There is a subgroup of patients however who do not respond to non-operative measures and require operative intervention.

Total knee arthroplasty (TKA) has been shown to improve knee joint function during gait post-operatively. However, there is considerable patient to patient variability, with most gait mechanics metrics not reaching asymptomatic levels. To understand how to target functional improvements with TKA, it is important to identify an optimal set of functional metrics that remain deficient post-TKA. The purpose of this study was to identify which combination of knee joint kinematics and kinetics during gait best discriminate pre-operative gait from postoperative gait, as well as post-operative from asymptomatic.

Seventy-three patients scheduled to receive a TKA for severe knee osteoarthritis underwent 3D gait analysis 1 week before and 1 year after surgery. Sixty asymptomatic individuals also underwent analysis. Eleven discrete gait parameters were extracted from the gait kinematic and kinetic waveforms, as previously defined (Astephen et al., J Orthop Res., 2008). Stepwise linear discriminant analyses were used to determine the sets of parameters that optimally separated pre-operative from post-operative gait, and post-operative from asymptomatic gait. Cross-validation was used to quantify group classification error.

Knee flexion angle range, knee adduction moment first peak, and gait velocity were included in the optimal discriminant function between the pre- and post-operative groups (P<0.05), with relatively equal standardised canonical coefficients (0.567, −0.501, 0.565 respectively), and a total classification rate of 74%. A number of metrics were included in the discriminant function to optimally separate post-operative and asymptomatic gait function, including the knee flexion angle range, peak stance knee flexion angle, minimum late stance knee extension moment, minimum mid-stance knee adduction moment, and peak knee internal rotation moment (P<0.05). The mid-stance knee adduction moment had the largest standardised canonical coefficients in the function, and 89.5% of cases were correctly classified.

Separation of pre and post-operative gait patterns included only three parameters, suggesting that current standard of care TKA significantly improves only walking velocity, knee flexion angle range, and the peak value of the knee adduction moment. A number of gait metrics, which were included in the discriminant function between post-operative and asymptomatic gait, could benefit from further improvement either through rehabilitation or design. With almost 90% classification, separation of post-operative gait function from asymptomatic levels is significant. The consolidation of knee joint function during gait into single, discrete discriminant scores allows for an efficient summary representation of patient-specific (or implant-specific) improvement in gait function from TKA surgery.

Background

Controversy persists regarding preference between Herbert and Acutrak screw for internal fixation of scaphoid non-union. Acutrak screw has been shown to have better biomechanical compression properties than Herbert screw in the laboratory setting. The aim of this study was to assess the clinical, radiological and functional outcome of patients treated with the two different screw systems.

The indication for rotator cuff repair in elderly patients is controversial.

Introduction

It is well established that non-union of the scaphoid requires operative intervention to achieve stable union, restore scaphoid anatomy and prevent further degenerative change. Acutrak screw has been shown to have better biomechanical compression properties than the Herbert screw in the laboratory setting. The aims of the study were to assess the rate of union, the functional outcome and post- operative complications of patients with the two different screw systems.

To determine extent of correction in spinal osteotomy for fixed sagittal plane deformity

Radiographic retrospective cohort analysis using standardised standing whole spine radiographs. Level III evidence

24 patients (14 females/10 males, av. 53.6 yrs) with sagittal plane deformity due to either ankylosing spondylitis (4), idiopathic (12), congenital (1), tumour (2), infectious (1), or posttraumatic (4) aetiologies. Max. 4 yrs follow up

Sagittal balance, lumbar lordosis correction, osteotomy angle, pelvic indices

Chevron (3), pedicle subtraction (17), and vertebral column resection (4) osteotomies were performed with the majority at L3 (9) and L2 (8). The C7-S1 sagittal vertical axis demonstrated a preoperative decompensation averaging 12.0 cm (range -7 to 37) with 55% of patients achieving normal sagittal balance postoperatively. Lumbar lordosis increased from 28.9° (range -28 to 63) to 48.9° (range 12 to 69) (22.3° av. correction). L3 osteotomy angle was largest, average 31° (range, 16 to 47). There were 11 complications comprising; major (1) and minor (1) neurological, junctional kyphosis (3), metalwork problems (2), dural tear (2) and infection (2). Four patients required additional surgery at latest follow-up. Technical outcome was good 11(50%), fair 8(36%), poor 3(14%).

Spinal osteotomy is a very effective technique to correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio before undertaking what is a major reconstructive procedure. Most patients are satisfied, particularly when sagittal balance is achieved.

To compare the effect of intraoperative red cell salvage on blood transfusion and cost in patients undergoing idiopathic scoliosis surgery.

Retrospective

37 patients (36 females, 1 male) underwent scoliosis surgery from February 2007 to October 2008. Intraoperative red cell salvage (Group 1) was used. They were compared with 28 patients (23 females, 5 males) operated from January 2005 to December 2006 without the use of cell salvage (Group 2). 36 patients in group 1 had posterior surgery and 1 had anterior surgery. In Group 2, 20 patients had posterior surgery, 7 anterior and 1 patient had anterior and posterior surgery. Both groups were comparable for age, number of levels fused, preoperative haemoglobin and haematocrit values.

Amount of perioperative blood transfusion, costs

14 patients (50%) in group 2 had blood transfusion whereas only 6 (16%) were transfused blood in group 1. Average blood loss in group 1 was 1076 mls (range 315-3000) and 1626mls (419-4275) in group 2. An average of 2 units of packed red blood cells per patient was processed by the cell salvage system. Postoperative haemoglobin, haematocrit and hospital stay were comparable in both groups. Cost analysis shows the use of cell salvage is cost beneficial by £116.60 per case.

The use of red blood cell salvage reduces the amount of blood transfusion and is cost beneficial.

A literature review of bone graft substitutes for spinal fusion was undertaken from peer reviewed journals to form a basis for guidelines on their clinical use.

A PubMed search of peer reviewed journals between Jan 1960 and Dec 2009 for clinical trials of bone graft substitutes in spinal fusion was performed. Emphasis was placed on RCTs. Small and duplicated RCTs were excluded. If no RCTs were available the next best clinical evidence was assessed. Data were extracted for fusion rates and complications.

Of 929 potential spinal fusion studies, 7 RCTs met the inclusion criteria for BMP-2, 3 for BMP-7, 2 for Tricalcium Phosphate and 1 for Tricalcium Phosphate/Hydroxyapatite (TCP/HA). No clinical RCTs were found for Demineralised Bone Matrix (DBM), Calcium Sulphate or Calcium Silicate. There is strong evidence that BMP-2 with TCP/HA achieves similar or higher spinal fusion rates than autograft alone. BMP-7 achieved similar results to autograft. 3 RCTs support the use of TCP or TCP/HA and autograft as a graft extender with similar results to autograft alone. The best clinical evidence to support the use of DBMs are case control studies. The osteoinductive potential of DBM appears to be very low however. There are no clinical studies to support the use of Calcium Silicate.

The current literature supports the use of BMP-2 with HA/TCP as a graft substitute. TCP or HA/TCP with Autograft is supported as a graft extender. There is not enough clinical evidence to support other bone graft substitutes.

This study did not require ethics approval and no financial support was received.

To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation.

Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008).

Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group.

Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms

NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows

The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel.

MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder.

Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory.

Aim

We report our ten year experience of primary haematogenous non-tuberculous spinal infection.

Twenty-two patients with piriformis syndrome underwent surgery between October 1995 and February 2002. The mean age was 56 years (range 28-90). Only 2 patients (9%) gave a history of trauma to the ipsilateral buttock. All the patients complained of deep buttock pain, which radiated to the ankle in 14 (63%), the calf in 4 (18%) and the thigh in 3 patients (13.6%). The symptoms were chronic, with a mean of 70 months (range 12-192) and patients had been previously seen by a mean of 2.6 specialists (range 1-6). There was associated neurosensory loss in 11 patients (50%). The symptoms were exacerbated by passive stretching and active contraction of the piriformis muscle. MRI of the lumbar spine (every case) and gluteal region (8 cases) were negative, while NCV tests (20 cases) were positive in 11 patients (55%). Previous conservative measures such as physiotherapy (59%) and epidural (40%) had failed. Every patient had surgical division of the piriformis tendon at the greater trochanter by the senior author. Abnormal anatomy was identified in 6 cases (29%).

At 6 weeks (n=22), the symptoms had resolved in 6 patients (27%), were better in 8 (36%), no different in 7 (32%) and worse in 1 (4.5%). After a mean follow-up of 52 months (range 11-86), seven (35%) of patients were cured, 3 (15%) were better, 8 (40%) were no different, 2 (10%) were worse than pre-operatively and 2 had died of unrelated causes. Seventy-five percent of patients said that with hindsight they would undergo surgery again. One patient suffered a post-operative below knee DVT requiring no treatment.

Surgery for piriformis syndrome in this selected group of patients led to an improvement or resolution of chronic symptoms in 64% of patients at 6 weeks, and 50% of patients after a mean follow-up of 52 months with minimal associated morbidity.

Performance evaluation in specialist orthopaedic hospitals was reviewed in comparison to district general hospitals (DGHs) using a variety of outcome measures, including surgical activity, length of stay and infection rates.

Data regarding admission rates, operations performed or cancelled, outpatient activity and waiting times were obtained from the Hospital Episode Statistics department of the Department of Health. Surgical site infection (SSI) and MRSA infection rates from the Royal National Orthopaedic Hospital (RNOH) are compared to national data supplied by the Health Protection Agency.

In comparison with DGHs, specialist orthopaedic hospitals admit fewer patients, with fewer emergencies; have a higher ratio of waiting list patients to number of patients admitted; have longer waiting list times on average; perform more primary joint arthroplasty surgery; undertake more revision procedures; discharge patients home following joint arthroplasty surgery on average one day earlier; have a lower total hip arthroplasty SSI rate (0.8%) compared with 2.3% in 146 DGHs and from RNOH data, provide a service with a lower surgical site infection and MRSA rate.

Specialist orthopaedic hospitals in England provide a unique, efficient and effective service compared to DGHs. However, short-term performance measures, though simpler to collate, may not be as valuable as longer-term outcome measures, thus making direct comparisons between DGHs, specialist orthopaedic hospitals and independent treatment centres difficult.

We aimed to collate guidelines for preoperative marking in orthopaedic surgery, identify areas of convergence and difference and relate them to previous work on guideline effectiveness.

We performed a systematic search of Medline and Google using ‘correct site’, ‘wrong site’, ‘marking’, ‘surgery’, ‘orthopaedics’ and ‘guidelines’. Orthopaedic societies and bodies, personal knowledge and unindexed conference abstracts were also used.

We found nine guidelines from ten institutions in seven different countries; UK National Patient Safety Agency/Royal College of Surgeons of England, Australian College of Surgeons, JCAHO (USA), Canadian Orthopaedic Association, Veterans Health Association (USA), Copenhagen Hospital Corporation, German Coalition for Patient Safety, American Academy of Orthopaedic Surgeons and the New Zealand Orthopaedic Association.

We identified four ‘core-steps’ common to the majority of guidelines. Firstly, using indelible pen. Secondly, the operating surgeon should mark the patient. Thirdly, the patient should be involved in confirming side/site. Finally, a ‘time-out’ before starting the procedure. Only one of the ‘core steps’ is carried out in theatre. The others are carried out before theatre emphasising the importance of accurately identifying and marking early in the patient’s journey.

Common sense suggests guidelines should be simple, user friendly and quick to complete. Making guidelines compatible with existing values and not deviating from existing routines are recognised to increase their use. Guidelines issued by practitioners’ own professional bodies are likely to have more impact than those from outside the profession. However increasing the number of items a guideline contains does not necessarily make it better or safer.

The four core steps we identified are the basis for any marking guideline. It is reasonable to assume that incorporating the guidance into clinical orthopaedic practice will further improve safety. Future work should focus on establishing the relative impact of each guideline aspect.

Background: Clonidine is an 2 adrenoreceptor and imidazoline receptor agonist which has analgesic, sedative and MAC sparing effects. It has been used orally, intravenously (including as an additive to morphine in PCA devices) and epidurally in combination with local anaesthetics and alone. We hypothesised that epidural administration of clonidine without local anaesthesia might provide adequate postoperative analgesia following spinal surgery without centroneuraxial block, and that if the drug’s effect site is spinal then this might be achieved with smaller doses and with fewer side effects than if given systemically.

Method: This randomised controlled trial evaluated the effect of epidural clonidine versus saline on analgesia requirement and pain scores following spinal decompressive surgery. 66 patients were recruited and received a standardized general anaesthetic. At the end of surgery group C received a bolus of 1.5 mcg/kg of epidural clonidine followed by an infusion of 25 mcg/h for 36 to 48 hours. Patients in group P received a similar bolus and infusion of saline. Verbal pain scores, morphine consumption by patient-controlled device (PCA), sedation score, haemodynamic variables and the incidence of PONV were recorded for up to 48 hours.

Results: Pain scores in both groups were low, but significantly lower for the first 6 hours in the clonidine group. Cumulative morphine consumption, used as a proxy for pain perception, was significantly lower in the morphine group throughout the whole period; mean (SEM) at 48 hours 62 (7) mg vs 35 (7) mg.

Conclusion: Epidural clonidine has a useful effect in post operative pain relief following spinal surgery with few side effects.

Aim: To report our ten year experience of primary haematogenous spinal infection.

Method: Retrospective case note review of 42 patients presented to our unit with primary spinal infection between 1995–2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. Information with regard to Mobility, Domestic circumstances, Oswestry disability index(ODI), Hospital Anxiety and depression score(HAD), Visual Analogue Score (VAS) for pain and coping were obtained. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated.

Results: Mean age was 59.9 years (1–85) with almost equal gender distribution (M 20: F 22). Axial pain was universal. Pyrexia was seen in 62%. Time from presentation to diagnosis averaged 19days (range 0–172). Sensitivity for MRI and plain x-ray was 100% and 46% respectively. Treatment ranged from intravenous antibiotics alone to combined anterior and posterior surgery depending on the presence or absence of significant collection, neurological deficit and structural threat. Mean duration of intravenous antibiotics was 54 days (range 13–240). At mean follow up of 5.4 years (0.6–10.5) there was no mortality directly related to the infection. Recurrence rate was 14%. Significant past medical history(P=0.001), constitutional symptoms(p=0.001) and pyrexia at presentation(0.001) were positively associated with recurrence.

Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9).

Overall it was calculated that HIAS had saved a total of 940 in-patient days.

Conclusion: Primary spinal infection is a treatable condition. Disease and patient characteristics dictate the management strategy. Although most patients can regain their pre infection mobility and go back to their pre morbid domestic circumstances with little or no pain and psychological sequel, a proportion of patients end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection. Finally, HIAS was cost effective.

Aim: In this study we present our ten year experience of primary spinal infection.

Method: Retrospective case note review of 42 patients who presented to our institution with primary spinal infection between 1995–2005 was carried out. Demographic data and information with regard to timing and modes of presentation, results of radiological and laboratory investigations, and methods of treatment were collected. The financial impact of Home Intravenous Antibiotics Service (HIAS) was also investigated.

Results: Axial pain was the most consistent symptom seen in 100% of the patients. Only 62% had pyrexia at presentation. Major neurological deficit was seen in 10.2%.

Mean duration of symptoms was 25 days (range 1–202). Mean time from presentation to diagnosis was 19 days (range 0–172). Staphylococcus Aureus was the most common organism. Mean duration of Intravenous antibiotics was 60 days (range 13–240) followed by oral antibiotics for mean duration of 65 days (range 0–161). CRP was more reliable in monitoring the disease over time. At mean follow up of 5.4 years (0.6–10.5) there has been no mortality directly related to the infection. With our management there has been 14% recurrence rate. All re- presenting within the first year after initial presentation (Mean 5.5 Months, range 1–11).

HIAS saved a total of 940 in-patient days with a total cost saving of approximately £350,000.00.

Conclusion: In the majority of patients spinal infection can be successfully treated. Disease severity dictates the duration of antibiotic treatment and whether surgery is required. Recurrent infection occurred in a number of patients with more significant past medical history and pre-existing risk factors. Finally, HIAS is extremely cost effective in this group of patients.

Aim: To assess the functional outcome following spinal infection.

Method: 42 patients who had been treated in our unit for primary spinal infection between 1995–2005 were identified. 33 who were still alive at the time of study, were sent postal questionnaires. Average length of follow up was 5.4 years (rang 0.6–10.5). The non-respondents were contacted by phone two weeks later. Overall 29 (88%) were traced.

Results: Mobility score dropped in 10 (34%) patients whilst domestic circumstances’ score dropped only in 1 (3.4%). Oswestry disability score averaged 18% (range 0–53%). 16 (62%) had mild or no disability, 7(27%) had moderate and 3 (12%) had severe disability. Neck disability index in all those with cervical spine infection was between 10–20% indicating mild disability. Hospital anxiety and depression score for anxiety was normal for 25 (86%) and that for depression was normal for 27(93%) patients. Ten point Visual Analogue Score (VAS) for pain intensity when doing the questionnaire averaged 1.3 (range 0–9) with 19 (66%) having no pain, 9 (31%) mild to moderate (1–5 score) and 1 (3%) having severe pain (6–10 score). Mean VAS over one week was 1.8(range 0–9) with 14(48%) having no pain, 13(45%) mild to moderate and 2 (7%) having severe pain. VAS for distress averaged at 1.8 (range 0–9), 22 (76%) patients were coping very well (8–10 score) and poor coping (0–4 score) was seen in 1 (3%).

Conclusion: Most patients after spinal infection return to activities of daily living with little or no pain and psychological sequelae. A proportion of patients however end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection.

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.