Aims: to evaluate the outcome following internal þxation of olecranon fractures using the techniques of tension band wiring and plating with a minimum follow up of two years. Methods:Design: retrospective evaluation and clinical review. Setting: regional trauma centre. Patients and participants: 48 consecutive patients with fractures of the olecranon were treated over a twenty month period (may 1993 to december 1994). 25 fractures were þxed using a tension band wiring technique and 23 underwent plating; the selection of method was based on agreed radiological fracture pattern criteria. Main outcome measurements: radiographic evaluation of the quality of reduction. Clinical outcome (broberg and morrey functional rating index). Results: clinical evaluation of 39 patients was carried out. In the tension band wiring group 17 (85 percent) patients had an excellent or good outcome and 11 (55 percent) patients underwent a second procedure for symptomatic metalwork. In the plating group 16 (84 percent) patients had an excellent or good outcome and 2 (11 percent) patients underwent a second procedure for symptomatic metalwork. The latter group had more complex and associated fractures and included the only poor result. Conclusion: internal þxation of fractures of the olecranon results in good functional outcome. Fixation with a plate is effective and produces good outcome even though selected for the more complex olecranon fractures. Patients who have tension band wiring more often require a second procedure for removal of symptomatic metalwork.

INTRODUCTION: To audit the workload of an Orthopaedic Surgeon sent on deployment to the Middle East. The cases seen and treated are discussed. The audit was to determine the lessons for the future.

DISCUSSION: 86 in patient admissions occurred between 12.01.2002 and 10.04.2002. A break up of speciality was a follows: Orthopaedic 38, Medical 27, General Surgical 16 and Psychiatric 5. A breakdown of the Orthopaedic cases were as follows: Ankle Injury 5, Arthralgia 3, Closed Fracture 4, Elbow Injury 1, Knee Injury 5, Low Back Pain 5, Multiple Soft Tissue Injury 3, Open Injury 3, Sciatica 1, Shoulder Injury 2, Soft Tissue Injury 3, and Stress Fracture 3. The 3 suspected stress fractures and the 2 gun shot wounds required special mention. 31 of 38 Orthopaedic patients were sent back to the UK through the Aeromedical chain. These patients were subclassified according to the requirement of evacuation through the Aeromedical chain. Seventeen patients, though not fit for theatre were able to undertake their own flight back. A trial of sending them back on unaccompanied flights failed. All patients were then evacuated through the Aeromedical chain. On average this meant one medical attendant per 2 patients. If civilian flights were taken this would have meant an extra expenditure of £4,800 (£600 x 8).

Illness behaviour was noted in 10 of the 38 Orthopaedic patients. All these patients were evacuated to the UK. Malingering as tested by the Burns bench test, modified Schobers test, Hoover test and Inappropriate Waddells signs were positive in 4 of these patients whose initial complaint was of low back pain.

CONCLUSION: It is proposed that the category of patients who are unfit for theatre but fit to fly unaccompanied should be recognised. It is also proposed that patients potentially deployable but showing illness behaviour should be discharged from the services earlier as it causes unnecessary expenditure and enforces extra work on other sincere and fit personnel.

This study was designed to determine the point prevalence of musculoskeletal pain among deployed personnel.

150 questionnaires were randomly distributed through the cashier and the mess at RAF Thumrait. 112 questionnaires were returned. The questionnaire, although a general musculoskeletal one, focused mainly on spine pain and also contained the Short Form 36.

107 males and 5 females responded. 85 (75.89%) personnel reported presence of some pain either in their spine and/ or limbs. There was no difference in the report of pain between the various age groups mentioned (p=0.76). There were significant differences among the different occupational branches (p=0.0023). There was no correlation however between spinal pain and lifting (p=0.79), standing (p=0.28), sitting (p=0.98), or running / jumping/ climbing (p=0.77). Though the 22 smokers reported higher pain than non-smokers this did not show statistical significance. There was negative correlation between the VAS report of pain and the Physical Component of Health (p=0.0001) and between stress at work and the Mental Component of Health (p=0.001) and between stress at work and the Mental component of health (p=0.001).

85 (75.9%) of the 112 personnel who had completed the questionnaire had some pain either in the spine or limbs. The lower back was the single anatomical region where pain was reported (n=68,60.7%) most frequently. It is interesting to note that all these personnel were on active duty in the armed forces and considered medically fit to deploy. It only shows to reinforce that low back pain in particular and musculoskeletal pain in general is common and normal and does not always imply disease and disability.

Recent years have seen the popularization of minimally invasive approaches to the spine.

However, the use of the balloon assisted retroperitoneal approach has not been widely described, moreover there has been no direct comparison between this mini-ALIF (anterior lumbar interbody fusion) and the conventional open method in the literature.

Comparison of peri and intra-operative parameters between the rnini-ALIF (using the balloon assisted dissector and Synframe retractor system) and the open midline approach for single and double level anterior lumbar interbody fusions in order to assess the efficacy of this procedure.

An independent retrospective evaluation of 35 patients who underwent single or double level ALIF under the care of the senior author at the University Hospital, Nottingham during the period from 1997 to 2000. The patients were split between those undergoing a mini-ALIF (balloon assisted retroperitoneal dissection) or the conventional approach via a larger midline incision. The groups were matched for age, sex and number of levels. Data was collated from the medical notes with regards to intra-operative blood loss, operative time, intra-operative complications, PCA requirements, time to mobilisation and length of hospital stay.

A statistically significant (p=0. 01) reduction in time to mobilisation (mean 2. 1 days vs 3. 9 days) and operative time (mean 175mins vs 265mins) was found for the single level mini-ALIF. This reflects the greater number of L5/SI fusions in this group. The number of vascular injuries was also greater in the approach to L4/5.

No difference was found between the two groups for double level procedures.

The immediate advantages of a less invasive approach both to the patient and hospital do not appear to be borne out by this study. Cosmesis was not assessed and the long term functional outcome awaits later confirmation.

Objective: A clear definition of cauda equina syndrome (CES) following herniated discs was not available from the literature. Some define CES as a total paralysis of the pelvic viscera1 while others consider any dysfunction as sufficient evidence of CES2. An extensive search of the literature also demonstrated a lack of a disease specific outcome measure for CES. We aimed to classify CES in the above spectrum and validate a new outcome score for CES.

Design and subjects: We present a retrospective study of 38 patients with a minimum of one-year follow up who presented with an acute cauda equina syndrome. We categorized the patients as complete or incomplete and further sub-classified them as acute or chronic. A total paralysis of the pelvic viscera was considered as complete. Presence of only dysfunction of the pelvic viscera was considered as incomplete. If the presenting episode plateaued within 24 hours or less of onset it was classified as acute and if it plateaued later than 24 hours it was considered as chronic.

Outcome measures: The new 17-item disease specific questionnaire was compared with the Oswestry Disability Index, SF36 and Urodynamic studies.

Results and conclusion: Of the patients studied, 44.7% were complete with acute onset, 21.1% were complete with chronic onset, 10.5% were incomplete with acute onset and 23.7% were incomplete with chronic onset. Outcome score matched the spectrum of our suggested classification.

Objective: To determine if a porous, coralline-derived hydroxyapatite block (ProOsteon 500^TM, Interpore, Irvine, CA) is a suitable substitute for tricortical iliac crest autograft in cervical interbody fusion.

Design: A prospective randomised trial with two-year follow-up comparing clinical and radiographic outcomes in patients receiving either iliac crest or hydroxyapatite grafts in cervical interbody fusion.

Subjects: Twenty-nine patients undergoing cervical fusion and anterior plating were randomised to receive either iliac crest (Group I) or hydroxyapatite (Group II) interbody grafts. Fourteen patients (19 grafts) in Group I and twelve patients (18 grafts) in Group II were available for final analysis. Both groups were similar with respect to age, sex, diagnosis and levels fused.

Outcome Measures: The SF-36 and Oswestry Disability Index were used to measure clinical outcome. Post-op and final follow-up radiographs were analysed for graft fragmentation, loss of height, loss of angular alignment and hardware failure to assess structural integrity of the graft. Computed or plain tomography was used to evaluate fusion.

Results: Groups I and II demonstrated improvement in preoperative scores for bodily pain (p=. 016 and. 016 respectively) and physical functioning (p=. 050 and. 016 respectively) at final follow-up. There was no significant difference in SF-36 and Oswestry scores between the two groups. Successful radiographic fusion was similar in both groups (79% in Group I and 76% in Group II). Graft fragmentation occurred in 89% of the hydroxyapatite grafts and 11% of the autografts (p=. 001). Greater than 2mm of graft height and 3° of segmental lordosis were lost in 55% of hydroxyapatite grafts vs. 11% of autografts (p=. 009). One patient in Group II and none in Group I required revision surgery for graft failure. The high rate of early radiographic failure in the hydroxyapatite grafts prompted suspension of further enrolment in the clinical trial.

Conclusions: ProOsteon 500 coralline hydroxyapatite blocks do not possess adequate structural integrity to resist axial loading and maintain disc height or segmental lordosis during cervical interbody fusion.

Objectives: Comparison of peri and intraoperative parameters between mini-ALIF (using balloon assisted dissector and Synframe retractor) and open midline approach for single and double level ALIF.

Methods: Independent, retrospective evaluation of 35 patients split between those undergoing the mini-ALIF or the conventional approach via larger midline incision. Groups matched for age, sex and number of levels. Operations performed at University Hospital, Nottingham between 1997 and 2000.

Outcome measures: Data collated for operative time, intraoperative blood loss, complications, PCA requirements, time to mobilisation and hospital stay.

Results: Statistically significant (p=0.01) reduction in operative time (175 vs 265mins) and time to mobilization (2.1 vs 3.9 days) found for single level mini-ALIF. Complications namely vascular injuries were almost equal in both groups. No difference was found between the two groups for double level procedures.

Conclusion: The immediate advantages of a less invasive approach both to the patient and the hospital do not appear to be borne out by this study. Cosmesis was not assessed and long term functional outcome awaits later review.

Objective: To assess the clinical outcome and return to sport following surgical treatment of spondylolysis in young sporting individuals.

Design: A prospective outcome analysis of consecutive surgically treated cases of lumbar spondylolysis in young sporting individuals.

Subjects: Twenty-two young sports persons (15M: 7F) with a mean age of 20.2 years (range 15–34 years) were surgically treated for radiographically confirmed spondylolysis between 1994 and 1999. Eleven patients were professional footballers and four were professional cricketers. Pre operative assessment included plain X-rays, SPECT imaging with planar bone scan and reverse gantry CT scans. All subjects had pre-operative Oswestry Disability Index (ODI) and SF36 scores recorded. Eighteen patients underwent Buck’s fusion and four patients underwent Scott’s fusion. A graduated exercise regime was commenced at 12 weeks. At two year follow-up nineteen patients had ODI and SF36 scores recorded.

Outcome Measures: The clinical outcome in individual patients supported by statistical analysis of the pre operative and post-operative data was performed using SPSS (ver 10). Return to the sporting activity at the previous level was regarded as a successful outcome.

Results: Eleven patients had bilateral spondylolysis at L5. Twenty patients had positive uptake on SPECT imaging and the remaining two were diagnosed to have lysis on CT scans alone. The average duration of back pain before the patients underwent surgery were 8.4 months (range 3–36 months). The mean lysis defect determined by CT was 3.5 mm (range 1–8 mm). The mean pre-operative and post-operative ODIs were 40.5 and 12.4 respectively (SEpreop = 2.06 and SEpostop = 3.05). The mean scores of physical health component of SF36 improved from 27.1 to 47.8 (SEmean = 1.1 and 1.7 respectively). The mean scores of mental health component of SF36 improved from 39.1 to 55.3 (SEmean = 0.9 and 1.4 respectively) [P < 0.001]. Eighteen patients returned to their previous active sporting career following an average of seven months of rehabilitation (range 4–10 months).

Conclusions: The surgical repair of bilateral spondylolysis with Buck’s fusion in professional sportsmen and women results in a significant improvement in Oswestry Disability scores (P< . 001) and in all domains of SF36 health questionnaire (P< . 001). 90% return to active sport seven months following surgery.

Objective: To study the long term operative and non-operative outcome in patients with diastematomyelia (DM).

Design: A prospectively acquired database of all spinal patients seen jointly by the senior authors (JKW, JLF), was searched for patients with DM. Their notes and the database were then reviewed.

Subjects: Thirty-six patients were identified; twenty-one (58%) had associated scoliosis. There were 60 associated abnormalities in the 36 patients, most common being ten (27%) with leg length inequality. Twelve patients (33%) had no radiological bony abnormality. Twenty-four (66%) had neurosurgery, eleven (31%) untethering of filum alone and eleven (31%) with removal of a spur and closure of the DM as well. Nineteen (53%) underwent some sort of neuraxial shortening scoliosis correction/surgery. Twenty-eight (78%) were deemed to have a normal/independent neurological outcome, seventeen (61%) having neurosurgery and twelve (43%) scoliosis surgery.

Conclusions: Patients with DM have been followed up for many years. Good neurological outcomes can be anticipated in cases with untethering and with scoliosis correction alone. This series raises the question as to whether any unthethering procedure is necessary in these cases when neuraxial shortening is carried out for scoliosis cases.

Advances in laparoscopic technology have popularised minimally invasive approaches to the anterior lumbar spine. The use of the balloon assisted retroperitoneal approach however has not been widely described; moreover there has been no direct comparison between this mini anterior lumbar interbody fusion (ALIF) and the conventional open method in the literature.

Comparison of peri and intra-operative parameters between the mini-ALIF (using the balloon assisted dissector) and the open midline approach for single and double level anterior lumbar interbody fusions in order to assess the efficacy of this procedure.

An independent retrospective evaluation of 35 patients who underwent single or double level ALIF. A single surgeon at the University Hospital, Nottingham, performed the procedures during the period from 1997 to 2000. The patients were split between those undergoing a mini-ALIF (balloon assisted retroperitoneal dissection) and the conventional approach via a larger midline incision. The groups were matched for age, sex and number of levels. Data was collated from the medical notes with regards to intra-operative blood loss, operative time, intra-operative complications, Patient Controlled Analgesic (PCA) requirements, time to mobilisation and length of hospital stay.

A statistically significant reduction in operative time (mean 178mins Vs 255mins) and time to mobilisation (mean 2.2 days Vs 3.7days) was found for the single level mini-ALIF. No other significant difference was detected for the other criteria between the two groups for either single or double level procedures. Complications in the form of vascular injuries were almost equal in both groups.

Although operating time was significantly shortened using the balloon-assisted dissector other perioperative parameters were not. The question of cosmesis of the surgical scar was not explored in this study, this may have been more favorable in the mini-ALIF group but given the above results one must question whether the added expense of this innovative device is justified when there was no detected difference in all other measured criteria.

To determine the current practice and to review the literature regarding administration of high dose Methylprednisolone for acute spinal cord injury (SCI).

Administration of high dose Methylprednisolone for Acute Spinal Cord Injury has been widely practised following the publication of the three National Acute Spinal Cord Injury Studies (NASCIS). NASCIS recommends a bolus intravenous dose of 30mg/kg of Methylprednisolone in 15 minutes, followed by a 45 min pause and then followed by a maintenance dose of 5.4 mg / kg / hr for 23 hours. This regime has been recommended by the Advanced Trauma Life Support. The Cochrane reviews also extol the three NASCIS randomised controlled trials. The mechanism of neuroprotection by Methylprednisolone is based on its inhibition of lipid peroxidation. Three hundred questionnaires were sent to Consultants practising Spinal surgery, Neurosurgery and Accident & Emergency to determine the popular thought regarding the use of Methylprednisolone for Acute SCI. A thorough review of current medical literature was also performed. The literature search showed contradictory evidence regarding the use of high dose Methylprednisolone.

The current popular thought, the diversity of responses between the three groups, the results of the 3 NASCIS trials and a recent review of literature is presented.