Introduction

“No routine post-operative follow up appointments” policy has been implemented in NHS hospitals in different specialties for uncomplicated surgical procedures. In trauma and orthopaedics few studies to date reviewed this practice and reflected on the patients' opinions.

Background: Intramedullary spinal cord tumours (ISCT) are rare with an annual incidence of less than 1 per 100,000 population. This makes assessing the efficacy of any treatment regimen difficult. Goals of management currently focus on obtaining a histological diagnosis for prognostic and therapeutic planning, and long-term tumour control. However, current outcome measures are crude and the quality of life outcome after surgery for intramedullary spinal cord tumours remains uncertain.

Aim: The aims of this study are to assess disability and outcome in patients undergoing surgery for ISCT. We aim to provide prospective quality of life data on patients with spinal cord tumours.

Patients and Methods: Data was collected prospectively on patients undergoing surgery for ISCT between 1995–2006 under the care of the senior author. The Short Form 36 (SF36) Health Survey Questionnaire was self-administered prior to surgery and again at 3, 12 and 24 months after surgery. All patients were also classified using the Frankel disability score. SF36 data were analysed using the Friedman test with Dunn’s post-test for multiple comparisons and the Wilcoxon signed rank test for matched pairs.

Results: Sixty-five patients (35 men, 30 women) had surgical interventions for ISCT. The mean age at first operation was 43y and median follow-up time was 60 months. 15% had astrocytomas, 45% ependymomas, 7 haemangioblastomas and 19 miscellaneous tumours.

Seventy-two percent of patients (47/65) were graded Frankel D pre-operatively and 65% (42/65) remained so after surgery. SF36 data were obtained for 17 patients. Pre-operatively, patients with ISCT had significantly lower SF36 physical domain scores when compared with normative data from age-matched population controls (p=0.0096). There was no difference between post-operative scores and those of normal controls. Matched pairs analysis on the patients with complete SF36 data sets (n=12) demonstrated a significant improvement in physical function post-operatively. Eleven of these 12 did not show an improvement in their Frankel grade, remaining Grade D pre- and post-operatively.

Conclusion: From this preliminary study it appears that patients with spinal cord tumours have significantly impaired physical function compared to the normal population. More importantly, we have demonstrated that the SF36 can detect changes in function associated with spinal cord tumour surgery that other, cruder measures, cannot.

BACKGROUND: Physical outcomes following surgery for degenerative spine disease have been well studied. It is only relatively recently however that the importance of psychological factors in determining outcome from spine surgery has been addressed. Previous studies suggest that pre-operative psychological distress is a predictor of poor outcome. In the drive to identify patients who will not benefit from spine surgery these patients may in future be denied surgery.

AIM: The aim of the current study was to examine the relationship between the severity of physical symptoms, levels of pre-operative psychological distress and out-come in patients with degenerative spine disease undergoing elective spinal surgery.

PATIENTS & METHODS: The study was a prospective cohort study. Health status and psychological distress were measured pre-operatively and at 12 months or more post-operatively using the Short Form 36 (SF36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale (HADS). We compared levels of physical disability (SF-36 physical domain scores) and psychological distress (HADS scores) before and after surgery in this group. Comparisons of pre- and post-operative scores were made using the Kruskal-Wallis, Wilcoxon Signed Rank Test and Mann Whitney U tests as appropriate.

RESULTS: A total of 333 patients were included (178 men, 155 women, mean age 54y). Pre-operatively patients with severe levels of anxiety and depression (higher HADS score) had worse (lower) SF-36 physical domain (SF-36 PD) scores compared to those with normal HADS scores (median 181.5 vs 109, p< 0.0001). Both HADS and SF-36 PD scores improved post-operatively (HADS 13 vs 6 p< 0.0001; SF-36 PD 134 vs 250.5 p< 0.0001). Greater reduction in HADS score was observed in patients with severe pre-operative HADS scores compared to those with normal pre-operative HADS scores (p< 0.0001). Patients with severe HADS scores also had greater improvement in SF36 PD scores when compared to patients with normal pre-operative HADS scores (77.24 vs 53.87 p=0.03).

CONCLUSION: Poor physical function pre-operatively correlates with severe psychological distress. Both physical and psychological symptoms improve after surgery. Severe levels of anxiety and depression pre-operatively are associated with the greatest symptomatic improvement and psychological morbidity does not worsen outcome.

To determine whether the Dynamic Condylar Screw, DCS, is suitable in treating pathological subtrochanteric fractures of the femur and the incidence of failure with this device.

Nineteen sequential and unselected patients with twenty femurs with pathological subtrochanteric fractures, or impending fractures, were identified, which had been treated with DCS. Mean age was seventy. Follow up was until functional union (minimum follow up 18 months) or until death. Primary tumour was identified in seventeen of the nineteen cases.

Grade of surgeon was recorded as was the use of adjunctive measures at the time of surgery (PMMA). Subsequent failure, cause and need for revision was noted.

Operative morbidity was low and initial pain relief good in all cases. Two fractures went on to unite. Eight original implants survived until the patient died (mean survival time 24 days). Ten implants failed (50%). Failure resulted from fracture through the DCS plate in eight cases and cut out of the screw in the other two. Of these, five patients (6 femurs) went on to further operative procedures. The others were either deemed unfit (3 cases) or refused further surgery (1 case).

In the light of newer intramedullary techniques we feel the DCS should be used with caution in this type of fracture. DCS in this fracture is associated with a high degree of failure.

In the reconstruction of the exstrophy/epispadias complex pelvic osteotomy has a role in helping the urologist close the anterior defect thereby improving appearance and helping to achieve continence. In the neonate and infant, we have traditionally used an oblique osteotomy coupled with plastering of the legs until the osteotomy shows signs of healing. Plastering has significant disadvantages in respect of nursing care. We have therefore looked to external fixation in this age group.

In the past year we have used the A.O. wrist fixator to stabilise the osteotomised pelvis of ten babies with bladder exstrophy ranging in age from neonates to two years. All have achieved soft tissue closure with improved appearance. However, because of the foreshortened anterior pelvis in the exstrophy patients, it is not possible to reconstruct to normality. The results to date are promising and the patients remain under follow up.

We report on four cases in which the diagnosis of compartment syndrome was delayed by the administration of patient controlled opiate analgesia ( PCA ) following intramedullary nailing of tibial shaft fractures. We believe that this poses a diagnostic problem and can lead to lasting sequelae as decompression is delayed. We present the 4 cases and a review of the literature. We recommend that the use of PCA in patients with intramedullary nailing following tibial shaft fractures be discontinued or used in conjunction with continuous intracompartmental pressure monitoring.