Treatment of bone infection often includes a burdensome two-stage revision. After debridement, contaminated implants are removed and replaced with a non-absorbable cement spacer loaded with antibiotics. Weeks later, the spacer is exchanged with a bone graft aiding bone healing. However, even with this two-stage approach infection persists. In this study, we investigated whether a novel 3D-printed, antibiotic-loaded, osteoinductive calcium phosphate scaffold (CPS) is effective in single-stage revision of an infected non-union with segmental bone loss in rabbits. A 5 mm defect was created in the radius of female New Zealand White rabbits. The bone fragment was replaced, stabilized with cerclage wire and inoculated with Staphylococcus aureus (MSSA). After 4 weeks, the infected bone fragment was removed, the site debrided and a spacer implanted. Depending on group allocation, rabbits received: 1) PMMA spacer with gentamycin; 2) CPS loaded with rifampin and vancomycin and 3) Non-loaded CPS. These groups received systemic cefazolin for 4 weeks after revision. Group 4 received a loaded CPS without any adjunctive systemic therapy (n=12 group1-3, n=11 group 4). All animals were euthanized 8 weeks after revision and assessed by quantitative bacteriology or histology. Covariance analysis (ANCOVA) and multiple regression were performed. All animals were culture positive at revision surgery. Half of the animals in all groups had eliminated the infection by end of study. In a historical control group with empty defect and no systemic antibiotic treatment, all animals were infected at euthanasia. There was no significant difference in CFU counts between groups at euthanasia. Our results show that treating an osteomyelitis with segmental bone loss either with CPS or PMMA has a similar cure rate of infection. However, by not requiring a second surgery, the use of CPS may offer advantages over non-resorbable equivalents such as PMMA.
Cauda equina syndrome represents the constellation of symptoms and signs resulting from compression of lumbosacral nerve routes. Combined with subjective neurological findings, a reduction in anal tone is an important sign deeming further imaging necessary. Our main objective was to investigate the validity of DRE for assessment of anal tone. 75 doctors completed a questionnaire documenting their grade, speciality and experience in performing DRE. A model anus, using a pressure transducer surrounding an artificial canal, was assembled and calibrated. Participants performed 4 DREs on the model and predicted tone as ‘reduced’ or ‘normal’ (35 and 60 mmHg respectively), followed by a ‘squeeze’ test. 30 healthcare assistants (HCAs) with no training in DRE partook as a control group.Introduction
Method
Centre Hospitalo-Universitaire de Bordeaux, Service de Pathologie du la Colonne Vertébrale, Bordeaux, France. Assessment of cervical lordosis using a standardised digital acquisition procedure in the normal population Three independent reviewers measured static lordosis. The EOS¯ system, which utilises low dose radiation and provides reliable standardized digital 2D acquisition with 3D reconstruction was employed. Measurements were carried out twice by every examiner on two different occasions. Cohort of the general public of 180 subjects divided into 4 groups (both sexes individually, age less than 40 and greater than 50 individually). None had any previous history of spinal disorders or sagittal imbalance. General cervical lordosis (C2 to C7) as well as upper and lower cervical lordosis were assessed. Cervical lordosis in the general population has a very wide range in both sexes. Overall cervical lordosis was 37 degrees. Lower cervical lordosis (superior endplate of C4 to inferior endplate of C7) demonstrated an average of 16 degrees, and upper cervical lordosis was found to be 21 degrees. No particular age group or sex was more prone to having lesser/greater lordosis. Current literature is sparse and provides large ranges, different standards and variable methods for assessing standard cervical lordosis. Overall cervical lordosis is very variable amongst the sexes and age groups. We provide a standard set of values which help to provide the spinal surgeon with values to aim for when seeking to restore cervical lordosis.
Centre Hospitalo-Universitaire de Lille, Service de Neurochirurgie et Chirurgie du Rachis, Lille, France. Assessment of current thoughts regarding spinal fellowships amongst spinal fellows in the United Kingdom and abroad Qualitative analysis provides rich and contextual detail that cannot be borne out by quantitative research. We undertook detailed interviews amongst fellows who have varying fellowship experience both in the United Kingdom and abroad. Ten fellows, all of whom were approaching their Certificate of Completion of Training (or equivalent) in Trauma and Orthopaedic surgery, or just awarded the certificate. All undertaking/undertaken at least one 12-month fellowship. Qualitative experiences A large unit provides a breadth of pathology that may is usually not encountered in smaller units. Fellows who worked in such units felt confident that they would recognise a variety of pathologies, but did not necessarily feel confident in their surgical management. Operative exposure to deformity surgery, whilst not necessarily a future part of practice, was felt useful for the added technical skills it provides. Fellows attending a smaller unit, where they may have been the sole ‘spinal fellow’, reported greater satisfaction in operative experience. Interestingly, there was felt to be a ‘saturation point’, where a fellow perceived no further educational benefit from remaining in one particular unit. A fellowship in spinal surgery is useful in preparing for independent practice as a spinal surgeon. Large units provide skills that are applicable to several aspects of spinal surgery. There appears to be a difference in breadth and complexity of pathology versus operative experience.
Competency levels of AOSpine members (Europe) based on whether or not they had undertaken a full 12 month fellowship in spinal surgery Self-assessment questionnaire distributed to members (60 questions relating to: previous surgical training, fellowships and their nature, and both theoretical and practical competency amongst basic and advanced spinal conditions) 289 completed responses Competency levels with(out) fellowship; differences in fellowship training; overall competence in spinal surgery as neurosurgeons versus those trained as orthopaedic surgeons. Competency defined as those able to deal with complications or able to perform without supervision. 28% (n=80) undertook a full 12 month fellowship Notable differences between groups were identified (fellowship vs no fellowship): spinal deformity (58% vs 26%), cervical trauma (83% vs 59%), cervical stabilisation (78% vs 53%), lumbar and thoracic trauma (85% vs 57%) and anterior surgery (66% vs 41%) and its complications (46% vs 23%). Interestingly of the whole group only 43% were competent in the actual practice of conservative management of spinal conditions. There was no significant difference in theoretical knowledge or practical skills between orthopaedics surgeons and neurosurgeons. Fellowship training is effective, but there are deficiencies in areas. In order to provide a routine and emergency service as a spinal surgeon, competency at relatively common procedures must be reached. Our data demonstrates a lack of uniformity in such competencies, and we believe efforts towards a formal curriculum for spinal training should be embarked upon.
The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC. Retrospective analysis All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15. Neurological outcome and survival A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery. The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%. There was no difference in neurological outcome between the 3 groups. There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score.
To assess whether the timing of surgery is an important factor in neurological outcome in patients with MSCC. Retrospective review All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups - those who underwent surgery within 24 hours (Group 1), those 24 hours to 48 hours (Group 2) and those greater than 48 hours (Group 3). Neurological outcome (improvement in Frankel score), complication rate and survival were assessed in all groups. A total of 109 patients with MSCC were operated on in our unit during this time. Mean age of patients was 61 years (range 7 - 86). The number that had at least one grade of Frankel improvement was 21 /37 (57%) in group 1; 11/17 (65%) in group 2 and 20/49 (41%) in group 3, p=0.03. When patients treated less than 24 hours were compared with those greater than 24 hours, the Frankel grade improvement approached significance (p=0.05). When we compared those who had surgery within 48 hours and those greater than 48 hours, the Frankel grade improvement was highly significant (p=0.009). There was no difference in survival or complications between the groups. Our results suggest that early surgical treatment in patients with MSCC gives a better neurological outcome but has no influence on survival or complication rates.
There is currently wide variation in the management of patients who are anticoagulated with Warfarin and require urgent orthopaedic surgery. These form an important and significant group of patients, in terms of real numbers (at least 5,600 per annum in the UK). A study was initiated with an audit of 34 patients presenting to the West Wales unit who were warfarinised at admission and required trauma surgery. Observations were recorded about their pre-operative management and the delay this caused in taking the patient to theatre. 6 months later, a similar group of patients were re-audited. The mean delay to surgery in those patients in whom the INR was left to fall spontaneously was 5.5 days. Following administration of 1mg i.v. Vitamin K in those patients without cardiac valves, re-audit showed the mean delay reduced to 2.2 days. Representations from at least 6 major specialties were considered and a consensus statement was derived. Standardised protocols, which hinge on whether or not the patient has or does not have a cardiac valve were devised. Vitamin K should not be given to those patients with a cardiac valve and early consultation with cardiology and anaesthetics is recommended, with consideration of referral to a specialist cardiothoracic unit. For those patients without a cardiac valve, 1mg of Vitamin K may be administered, repeated as necessary until the INR is less than 1.8. Intravenous Heparin should be provided in the interim whilst the patient is waiting for surgery. This is discontinued the morning of surgery and subcutaneous Heparin reinstated post-operatively. These recommendations have been trialled in the two units involved in the study and have been relatively safe and easy to implement.
Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift. In recent years various surgical morphoplastic techniques have been employed in an attempt to improve on the disappointing natural history of this manifestation of biological failure. Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies. We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining Visual Analogue Pain Score (VAS), vertebral height, vertebral and kyphosis angles, Oswestry Disability Index and Hospital Anxiety and Depression Score (HADS). 50 patients in our kyphoplasty group have undergone 91 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.8 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.3 and 2.7 respectively (p<
0.001). Functional status ODI scoring improved from a pre-operative score of 54 to 47 post-operatively, to 40 at 6 weeks, and further, to 39 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.0, 11.2, 11.1 and 11.7 respectively. Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle (p<
0.01) with increases in the anterior, middle and posterior vertebral body heights of 19, 31 and 9% respectively (p<
0.001). No significant improvement of kyphosis angle was identified. The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures. Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.
Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift. Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies. These published case series report the use of several end points, variously including Visual analogue score (VAS), Vertebral height, kyphosis angle and Oswestry disability index (ODI). We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining VAS, vertebral height, vertebral and kyphosis angles, ODI and hospital anxiety and depression score (HADS). 40 patients in our kyphoplasty group have undergone 70 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.9 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.7 and 3.8 respectively. Functional status ODI scoring improved from a pre-operative score of 53 to 48 post-operatively, to 42 at 6 weeks, and further, to 41 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.3, 12.0, 10.1 and 11.3 respectively. Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle with increases in the anterior, middle and posterior vertebral body heights of 26, 40 and 11 % respectively. Kyphosis angle has been improved by a mean angle of 2 degrees. The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures. Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.
