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.

Generally, it is considered to be safe in preventing iatrogenic instability if half of the facet joint is left intact during decompression surgeries.

By removing half of the facets can we get adequate decompression of the nerve roots? Is there a difference at different levels in the lower lumbar spine? What is the inclination of the facet joint at each level and how does it affect the stability?

Retrospective study

We analysed 200 consecutive magnetic reasonance imaging (MRI) scans of the lumbosacral spine at L3/4, L4/5, and L5/S1 levels. We measured the difference in the distance from midline to the lateral border of the foramen and from midline to the middle of the facet joint at each level on either sides. The angle of the facet joint was also noted.

The distance to the foramen from the level of the middle of the facet joints seem to be between 5-6mm lateral at every level. The angle of the facet joints at L3/4 is 35.9°+/−7.4°, while at L4/5 it is 43.2°+/−8.0°, and at L5/S1 it is 49.4°+/−10.1°.

In lumbar spine decompression surgeries, after the midline decompression extending up to half of the facet joints, a further undercutting of the facet joints to 5-6mm is therefore required to completely decompress the nerve root in the foramen. The more coronal orientation of the facet joint at L5/S1 conforms better stability than that at L3/4level. Therefore, stabilisation of the spine should be considered if more than 2cm of the posterior elements are removed from midline at L3/4 level.

We described a technique of measuring the flexibility of the rib prominence clinically before surgery, and aimed to analyse the results in patients with adolescent idiopathic scoliosis who underwent posterior correction with pedicle screw instrumentation.

This prospective study investigated the magnitude of rib humps before and after the operation when the patient was in Adam's forward bending posture. Also preoperatively, a flexion and derotation manoeuvre was performed and the corrected rib prominence was measured. This is compared to the magnitude of the rib hump present postoperatively at three months' follow up.

Seven consecutive patients with adolescent idiopathic scoliosis that underwent posterior surgical correction.

Clinical measurement of rib prominence using scoliometer.

The magnitude of the curve improved from a mean preoperative Cobb angle of 53.6+/−11.2° (range 45.3–72.5°) to a mean postoperative Cobb angle of 7.8+/−9.3° (range 0.4–17.6°). The mean preoperative magnitude of the rib hump was 12.3+/−6.9° (range 5-20°) which was then corrected to a mean magnitude of 1.3+/−2.2° (range 0-5°) by performing the above described flexion derotation manoeuvre. The mean postoperative magnitude of the rib hump was 3.0+/−3.1° (range 0-8°) with the patient in Adam's forward bend position. There was positive correlation between the postoperative residual rib hump and the reduced rib hump measured preoperatively using our described technique (r=0.8,p=0.05).

This flexion derotation test is a useful in assessing the amount of postoperative persistent rib hump after posterior correction of adolescent idiopathic scoliosis using pedicle screw instrumentation with derotation technique.

The footplate in the current available TDR is flat without any allowance for endplate concavity in the sagittal plane.

To assess the morphology of the endplates of the lower lumbosacral in the sagittal plane, and to identify the frequently occurring shape patterns of the end plates at each level.

Retrospective Study

200 consecutive magnetic reasonance imaging (MRI) scans of patients between the age of 30 and 60 years were analysed. In each endplate, the anteroposterior width, the height of concavity of the endplate, and the distance of the summit from the anterior vertebral body margin were noted. The shape of the endplate was noted as oblong (o) if the curve was uniform starting from the anterior margin and finishing at the posterior margin, eccentric (e) if the curve started after a flat portion at the anterior border and then curving backwards, and flat (f) if there is no curve in the sagittal plane.

The shape of the end plate is mostly oblong at L3 IEP(59%), equally distributed between oblong and eccentric at L4 SEP (o=43.5%, e=46.5%), eccentric at L4 IEP (e=62.5%), eccentric at L5 SEP (e = 59.0%), eccentric at L5 IEP (e=94.0%), and flat at S1 SEP (f=82.5%).

As there is a difference in the shape of the endplate at each level and they are not uniform, there is a need to focus on the sagittal shape of the footplate to avoid subsidence and mismatch of the footplate in cases of endplate concavity.

Northumbria Healthcare NHS Trust, Ashington, UK

To assess if a pain diary is useful in assessment and management of patients who undergo diagnostic nerve root block (NRB) for lumbar radicular pain.

Prospective study

23 patients who underwent diagnostic NRB for lumbar radicular pain were given a pain diary. They recorded their response to one of four options from Day 0 to Day 14 (good relief, partial satisfactory, partial unsatisfactory, and no relief of leg pain) and could also add additional comments. A Consultant Spinal Surgeon reviewed the diary with the patient at 6-week follow up appointment to formulate a management plan.

Patient response, completion of the pain diary and final clinical outcome (surgical or non surgical treatment).

The response rate was 91% (21/23). The pain diary was very useful in 43% (9/21), useful in 33% (7/21) and not useful in 24% (5/21) of patients in formulating further management. There was a tendency for patients with complex problems and poor response to add descriptive notes and comments (9/ 23).

Patient compliance with pain diary was good and it has been valuable in making further management decisions. We found the pain diary to be a useful and inexpensive adjunct in the assessment of patients who underwent diagnostic NRB.

Background

Percutaneous K-wire fixation is a well-recognised and often performed method of stabilisation for distal radius fractures. However, there is paucity in the literature regarding the infection rate after percutaneous K-wire fixation for distal radius fractures.

Introduction: There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

Aim: To assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility total ankle replacement.

Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 and 12 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

Results: The mean preoperative BMD within the medial malleolus improved from 0.58g/cm2 to mean 6 months postoperative BMD of 0.59g/cm2 and 0.60g/cm2 at 12 months. The mean preoperative BMD within the lateral malleolus decreased from 0.40g/cm2 to a mean 6 months postoperative BMD of 0.34g/cm2. However the BMD over the lateral malleolus increased to 0.36g/cm2 at 12 months. The mean alignment of the tibial component was 88.5° varus (85° varus to 94° valgus). There was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

Conclusion: The absence of stress shielding around the medial malleolus indicates that TAR implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.

Background: Iatrogenic instability can be produced by lumbar spine decompression surgery not only if decompression extends beyond the lateral border of pars but also if there is insufficient pars left at the end of the procedure resulting in its fracture and hence instability on weight bearing. Generally, it is considered to be safe in preventing iatrogenic instability if half of the facet joint is left intact during decompression surgeries.

Purpose: We aimed to answer the following questions. By removing half of the facets can we get adequate decompression of the nerve roots? Is there a difference at different levels in the lower lumbar spine? What is the inclination of the facet joint at each level and how does it affect the stability?

Material and Methods: We analysed 200 consecutive magnetic reasonance imaging (MRI) scans of the lumbosacral spine at L3/4, L4/5, and L5/S1 levels. We measured the difference in the distance from midline to the lateral border of the foramen and from midline to the middle of the facet joint at each level on either sides. The angle of the facet joint was also noted. The vertebral body diameters in both the sagittal and coronal plane were noted.

Results: At L3/4, the mean distance from the midline to the middle of facet joint was 15.5 +/−1.9 mm (11–23mm), while the mean distance from the midline to the foramen was 21.2 +/− 2.6 mm (13–28mm). At L4/5, the mean distance from the midline to the middle of facet joint was 18.1 +/−2.3 mm (13–25mm), while the mean distance from the midline to the foramen was 23.6 +/− 2.9 mm (16–34mm). At L5/S1, the mean distance from the mid-line to the middle of facet joint was 15.5 +/−1.9 mm (11–23mm), while the mean distance from the midline to the foramen was 26.8 +/− 2.9 mm (20–34mm). The angle of the facet joints at L3/4 is 35.90 +/− 7.40, while at L4/5 it is 43.20 +/− 8.00, and at L5/S1 it is 49.40 +/− 10.10.

Conclusion: The distance to the foramen from the level of the middle of the facet joints seem to be between 5–6mm at every level with the lateral border of the foramen being lateral to the middle of the facet joint. Hence, in lumbar spine decompression surgeries, after the mid-line decompression extending up to half of the facet joints, a further undercutting of the facet joints to 5–6mm is therefore required to completely decompress the nerve root in the foramen. The more coronal orientation of the facet joint at L5/S1 conforms better stability than that at L3/4level. Therefore, stabilisation of the spine should be considered if more than 2cm of the posterior elements are removed from midline at L3/4 level.

There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

We aimed to assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the Bone Mineral Density (BMD) of the medial and lateral malleoli before and after Mobility total ankle replacement.

Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and postoperative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

The mean preoperative BMD within the medial malleolus improved from 0.57g/cm2 to mean 6 months postoperative BMD of 0.62g/cm2. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to a mean 6 months postoperative of 0.33g/cm2. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). However, there was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.

Introduction: There is limited literature looking into the circumstances surrounding the development of stress fractures of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD) and the phenomenon of stress shielding.

Aim: To assess the effect of TAR loading othe medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility TAR.

Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 and 12 months after surgery. The bone mineral density of a 2 cm square area within the medial and lateral malleoli was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

Results: The mean preoperative BMD within the medial malleolus increased from a mean of 0.57g/cm2 to 0.58g/cm2 at six months and 0.60g/cm2 at 12 months postoperatively. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to 0.34g/cm2 at six months postoperatively. However the BMD over the lateral malleolus increased to 0.356g/cm2 at 12 months. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). There was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

Conclusion: The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.

Introduction: There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

Aim: To assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility total ankle replacement.

Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

Results: The mean preoperative BMD within the medial malleolus improved from 0.57g/cm2 to mean 6 months postoperative BMD of 0.62g/cm2. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to a mean 6 months postoperative BMD of 0.33g/cm2. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). However, there was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

Conclusion: The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.

Introduction: Avulsion fractures of the anterior tibial spine are not so common. The best form of treatment for displaced fractures is still debatable.

Aims: We aimed to analyze the results of different forms of internal fixation for avulsion fractures of the anterior tibial spine.

Material and Methods: Twenty-five patients with avulsion fractures of the anterior tibial spine had open reduction and internal fixation with different implants (AO screw, Herbert screw, stainless steel wire loop and absorbable stitch) and techniques. The mean follow up period was 3.66 years. They were evaluated clinically and radiologically, using KT 1000 arthrometer for ACL laxity and goniometer for range of movements. The outcome was measured using Lysholm Knee Score.

Results: Significant residual anterior laxity despite adequate fracture union was a common finding. Maximum ACL laxity was seen in adults in whom absorbable stitches had been used and they had a corresponding lower Lysholm score. Significant migration of the Herbert screws was noted in two of five patients in which it was used. Five of the eight patients with higher Lysholm score had AO screw fixation. Three patients with steel wire loop for stabilization of the fracture also had better results comparatively. Three individuals who had their knee immobilised in 25°–50° of flexion developed fixed flexion deformities, which took 12–18 months to recover.

Conclusions: The use of absorbable stitches as the primary method of fixation for avulsion fractures of the tibial spine should be avoided in adults. Herbert screw in this situation has a tendency to migrate. AO screws and non-absorbable loop yields better functional outcome. Immobilization of the knee in excessive flexion leads to prolonged fixed flexion deformity. Early range of movements can be achieved by replacing cast with a brace allowing flexion up to 90 degrees.

Introduction: The Two Week Waiting Time (2wwt) Standard, which requires that patients with suspected cancer referred by general practitioners should be seen within 2 weeks, was introduced in 2000. We reviewed the performance of this standard with regards to proportion of patients seen and tumour detection rates.

Methods and Results: We reviewed all the referrals sent as “two week waiters” from January 2004 to December 2005, to our bone and soft tissue sarcoma service. These referrals were evaluated for

Whether or not the referral met established referral guidelines for bone and soft tissue tumours

This was compared with the total number of referrals to the unit and their tumour detection rates.

A total of 40 patients were referred as “two week waiters” in the given time period. They were seen on an average of 8 days following the referral. Of the 40 patients, four patients had soft tissue metastasis from a primary tumour elsewhere, and six had primary malignant soft tissue tumours. 12 had a benign bone/ soft tissue tumour. 18 (45%) patients had a non neoplastic pathology (6 Muscle tear/ herniation; 4 ganglion/bursa; 2 lumps that disappeared)

During the same period a total of 515 patients were referred by other routes.

Conclusion: Only 10 of 40 patients referred under the 2-week rule had malignant tumours. The majority of referrals to our service do not fall under this rule. Significant numbers of referral under the 2wwt standard are not in line with the referral guidelines. It is our impression that the 2-week rule, whilst highlighting the need of these patients to be seen urgently may distort clinical priorities and disadvantage patients referred from other sources.

Introduction: Short term pain or discomfort after a knee replacement (TKR) is not uncommon, and is usually attributed to the surgical procedure. In this case report, we describe an unusual cause of knee pain following total knee replacement, and remind the reader of the need for a thorough assessment.

Case Report: A 76 year-old male presented with pain in the knee and shin seven months following a TKR on the same side. The pain was dull, aching and constant in nature. There was no other significant past medical history. Pre-operative and immediate postoperative radiographs did not reveal any other abnormality. Clinical examination revealed no evidence of infection, and the motion in the knee ranged from 0–100 degrees. Radiographs revealed a lytic lesion in the proximal tibia just distal to the tibial prosthesis. Further investigations confirmed a diagnosis of renal carcinoma with bone metastases, with one of the lesions appearing in the proximal tibia. The lesion was treated with intralesional curettage, cementing and plate osteosynthesis. The knee pain improved and the mobility was restored. Follow-up radiographs at 6 months showed no evidence of local recurrence.

Discussion: Knee pain following TKR may be attributed to the surgery or the knee implant. However, it is important to keep an open mind about the diagnosis. Local hyperaemia in the metaphysis of proximal tibia following TKR may have resulted in the seeding of metastasis. We elected for primary stabilization of the metastasis with cement and plate, rather than revision of the tibial component with a long intramedullary stem. As a result, rehabilitation was rapid and the risks of revision of the knee prosthesis were avoided.

Introduction and aims: Despite advances in local therapy, there is an ongoing risk of local recurrence after treatment for soft tissue sarcoma. Early detection of local recurrence with MRI scanning may improve outcomes for patients. The purpose of this retrospective study was to evaluate the usefulness of routine postoperative MRI scans in diagnosing clinically occult local recurrence after surgery for trunk and extremity soft tissue sarcomas.

Material and Methods: We reviewed the clinical and radiology records of all patients who underwent surgery for trunk or extremity soft tissue sarcoma in our service with the potential for 3 years of follow up. We looked at the number of postoperative MRI scans performed, the indications for the scans (routine or clinical suspicion of recurrence) and the scan results.

Results: Between 1998 and 2003, 151 patients met the inclusion criteria. The mean age was 59 (17 – 94) years. The diagnosis was liposarcoma in 37%, malignant fibrous histiocytoma in 17%, and leiomyosarcoma in 15%. Reflecting differences in practice between consultants, 79 patients had routine postoperative MRI scans, 8 patients had MRI scans following clinical suspicion of a local recurrence, and 64 patients did not have a postoperative MRI scan. Of 79 patients undergoing a total of 354 routine postoperative scans, 2 had detection of a local recurrence not suspected clinically. This represents a cost of £55,224 per recurrence detected. Of the 8 patients who underwent MRI scanning for a clinical suspicion of local recurrence, 4 had a local recurrence confirmed on scanning.

Conclusions: Most local recurrences are detected clinically. The cost of detecting local recurrence of a trunk or extremity soft tissue sarcoma by MRI scanning is high. The benefit of earlier detection over clinical examination is not known.

Introduction: Brown tumours occur as a complication in patients with renal failure, due to secondary hyperparathyrodism. In these patients brown tumours commonly regress if the primary cause is treated. We present a rare case of recalcitrant brown tumour with unusual presentation and symptom complex requiring surgical intervention.

Case Report: 14-year-old girl with blindness presented with pain in the proximal tibia. Radiographs revealed a lytic lesion in the proximal tibia. Biopsy of the lesion showed osteoclast rich stroma. Blood investigations indicated renal impairment, and secondary hyperparathyroidism. She underwent repeated dialysis treatment, and her renal parameters and parathormone levels were brought back to within normal limits. However, there was no evidence of regression of the lesion. Hence, intralesional curettage of the brown tumour was performed while still maintaining her on regular dialysis. This resulted in complete healing of the brown tumour with no recurrence at latest follow-up. She recently had a renal transplant as a definitive treatment for her renal failure.

Conclusion: The patient in our case has got renal retinal dysplasia which resulted in juvenile renal failure and retinal pigmentary degeneration. The renal failure resulted in secondary hyperparathyroidism leading to the formation of bone tumour in the proximal tibia. Eventhough temporarily the renal parameters were restored to within normal limits, this tumour did not regress in size, and hence required surgical intervention. This case highlights the importance of detailed thorough investigations to find the primary cause and syndrome associated with juvenile renal failure which presented with only a bony abnormality.

Background: Giant-cell tumour (GCT) of bone is a benign but aggressive tumour, usually treated by radical surgical curettage. Surgical treatment of GCT involving the ischium is associated with a high local recurrence rate. We describe a case in which serial arterial embolisation and bisphosphonate treatment resulted in radiological healing of the tumour. So far we have avoided surgical treatment.

Case Report: A 40-year-old lady was referred to the bone tumour unit following a fall. A plain radiograph of the pelvis revealed a lytic lesion in the ischium, extending into the posterior column of the acetabulum and associated with a pathological fracture. Biopsy confirmed a diagnosis of GCT. Given the anatomic location, the tumour was treated with serial arterial embolisation and intravenous zoledronate infusions. Follow up at one-year shows healing of the lesion, with no radiological evidence of recurrence. The patient has so far avoided surgery.

Discussion: Serial arterial embolisation has been described in the treatment of giant cell tumours in anatomical regions where surgery is likely to be associated with significant morbidity, such as the sacrum. There is a sound theoretical basis for the use of bisphosphonates in this disease; they have been shown to cause apoptosis of the osteoclast-like giant cells and interfere with osteoclast recruitment. As far as we are aware this is the first case described in which embolisation and bisphosphonate treatment appears to have led to healing and stabilisation of the lesion. The durability of this response remains uncertain.

Background The magnitude of the medial offset and the limb length discrepancy after a total hip replacement (THR) significantly alters the biomechanics of the hip. If both these components are not properly restored, the rate of dislocation may increase. Further decreased offset may result in impingement at the extremes of movement, and also results in soft-tissue laxity, while increased offset increases stress within the stem that may lead to stem fracture or loosening. In addition to affecting the clinical outcome, limb length discrepancy may also cause legal problems.

Aim To find out whether intraoperative assessment and restoration of desired offset, and correction of limb length discrepancy actually corrects these two components as assessed by postoperative radiographs.

Material and Methods We evaluated 39 consecutive THRs in 37 patients who had the surgery performed via the posterior approach. Intraoperatively the medial offset was measured using a ruler from the tubercle in the trochanteric fossa to the centre of rotation of the head, and then check again after the seating of the femoral prosthesis. The size of the head was then accordingly altered. The limb length was measured using the ruler parallel from the lesser trochanter, and taking it upto the tip of the greater trochanter. The preoperative and the postoperative radiographs were evaluated for the medial offset and limb length discrepancy. The medial offset was calculated as a ratio in reference to the opposite side.

Results The median medial offset was 93.9 (85–100) preoperatively and 94.2 (85–110) postoperatively. The median limb length discrepancy was improved from a preoperative −4.84mm (0 to −30mm) to a postoperative −0.06mm (−9 to +16mm).

Discussion Preoperative templating may be a way of obtaining the correct medial offset and limb length in THRs. However, varus or valgus placement, and sinking or protrusion of the prosthesis may alter both these components significantly. Hence, intraoperative measurement and thus changing the components and the position of the stem accordingly may be the best method in addition to preoperative templating, in achieving the required offset and minimising limb length discrepancy in THRs.

Purpose Of The Study: Avulsion fractures of the anterior tibial spine are uncommon injury and we have evaluated the results in-patients who have undergone arthrotomy and fixation of the fracture.

Material & Method: Twenty five patients were followed up between 21–108 months (mean 44 months) after the operation. They were evaluated clinically, radiologically and the residual ACL laxity was measured with KT 1000. Lysholm scoring scale has been used to assess the outcome.

Eight fractures were fixed with a single AO screw; 5 with Herbert screws; 4 with a steel wire loop and 8 with absorbable stitch.

Results: Significant residual anterior laxity despite adequate fracture union was a common finding. The ACL laxity was maximum in adults in whom absorbable stitch had been used to fix the fracture and they had a corresponding lower Lysholm score.

In 2 out of the 5 patients where Herbert screws had been used there was significant migration of the screws.

Additional articular damage was observed in 3 patients who were pedestrians hit by a car. All 3 ended up with restricted knee movements and poor results. Three individuals who had their knee immobilised in 250–500 of flexion developed flexion deformities, which took 12–18 months to recover.

Conclusions: We recommend that use of absorbable stitches as a method of fixation be avoided in adults. Herbert screws in this situation have a tendency to migrate. AO screws or a non-absorbable loop should be used were possible. Immobilisation of the knee in excessive flexion leads to prolonged flexion deformity and we recommend immobilising the knee in no more than 100 of flexion.

Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging.

Purpose The aim of this study is to find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who were diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level while it was in two patients in Group II (L4/5 or L5/S1). Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score(p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. There is no significant difference in the duration of the procedure as well between the two techniques. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.