Aims

Bone is a common site of metastatic disease. Skeletal complications include disabling pain and pathological fractures. Palliative surgery for incurable metastatic bone lesions aims to preserve quality of life and function by providing pain relief and stable mobility with fixation or replacement.

Current literature has few treatment studies. We present a 5 year longitudinal cohort study of surgery for metastatic bone disease at our large teaching hospital reviewing our complication and mortality rates.

To audit the routine measurement of Vitamin B12 levels prior to cervical decompressive surgery

Retrospective analysis of medical records and pathology results of patients who underwent decompressive cervical surgery for myelopathy over a 6 month period

26 patients were identified from theatre records.

21 out of 26 patients did not have vitamin B12 levels checked prior to their decompressive surgery

The reports in the literature of co-existent B12 deficient myelopathy and mechanical compression are a cause for concern. Although the incidence of this is unknown and unlikely to be common, good clinical practice would suggest that we should be routinely monitoring B12 levels in myelopathic patients.

We have introduced new standards for routinely checking B12 levels pre-operatively and intend to re-audit the effectiveness of these in six months time.

To establish the current practice of spinal cord monitoring in units carrying out scoliosis surgery in the UK.

To illustrate the benefit of routinely monitoring motor evoked potentials (MEPs).

Questionaire: Nationwide survey of spinal monitoring modalities used by spinal units carrying out deformity surgery.

10 out of 27 units routinely measure motor evoked potentials (MEPs), the remainder use only sensory potentials (SEPs). There is significant variability in use of monitoring around the UK and we have compared this to the practice elsewhere in the world.

We report the case of a thirteen year old girl who underwent posterior instrumentation for correction of an idiopathic scoliosis. Intra-operatively there was a significant reduction in the amplitude of the MEPs without any corresponding change in the SEPs. These changes reversed when the correction was released. The surgery was abandoned and was carried out as a staged procedure, initially anteriorly then posteriorly. There was no loss of motor potentials during either operation and no post operative neurological abnormalities.

We propose that the changes noted initially were due to transient ischaemia of the cord which would not have been detected without MEPs and may have led to long term sequelae. This highlights the safety benefit of routinely using MEPs in scoliosis surgery.

Nationally there is wide variation in the monitoring of spinal cord function during scoliosis surgery. We feel that monitoring of motor potentials is a vital component in ensuring scoliosis surgery is as safe as possible.

The CMI pyrocarbon implant is a unipolar arthroplasty for trapeziometacarpal joint arthritis which is implanted in to the thumb metacarpal. Previous case series have shown these implants provide significant pain relief and good patient satisfaction. We report the first cases of pyrocarbon hemiarthroplasty from Peterborough.

Seventeen cases in fifteen patients were retrospectively reviewed. The average patient age was 59.7 years (range 47–72). 7 patients were men and 8 were women. Five were discharged with good outcome at a mean of 11.5 months (range 6–19). One failed to attend follow up.

Most patients in whom the implant survived were afforded good pain relief by the procedure and had a good functional range of thumb movement. Radiologically 8 implants were subluxed by at least 50%. One implant was revised after dislocation and loosening of the prosthesis which was associated with trauma. She made excellent clinical progress after revision of the prosthesis. One of the thirteen cases dislocated and was revised to a trapeziumectomy after 11 months.

Preliminary results suggest that this implant affords good pain relief and functional improvement in managing OA at the TMC joint. Longer term follow up will be required to correlate clinical and radiological outcomes.

Aim: We studied the payments received by our hospital for 109 elective lower limb arthroplasty cases to see if this was fair and consistent under Payment by Results.

Methods: A cohort of patients who had Total Hip Replacement (THR), Total Knee Replacement (TKR), Resurfacing Hip Arthroplasty and Unicompartmental Knee Replacements were taken from the departmental database. Their diagnostic codes, operation details and comorbidities were established and compared with the payment the trust received using the Dr Foster database. This was confirmed with their hospital notes and the finance department.

Results: Twenty THRs and twenty TKRs were paid the standard tariff with one exception. Fifteen Hip Resurfacing arthroplasties showed variable payment from £4690 to £6673 per case. Most interesting were the Unicompartmental Knee Replacements. Despite having almost the same operative and diagnostic codes 46 out of 54 cases were significantly underpaid. During one financial year the trust lost more than £70,000 from this operation alone. This does not meet the Department of Health’s stated aim of being fair and consistent. Out of 109 cases reviewed 51 could have been coded differently and 47 of these were “underpaid”.

Conclusion: In an NHS increasingly driven by financial pressures it is vital that surgeons understand how Payment by Results works. There are significant financial gains to be made by those trusts who pay attention to the small print.