Current evidence on the indications for and efficacy of non-rigid lumbar stabilisation remains unclear. The aim of this study was to review the outcome of the DYNESYS system (Zimmer, Inc.) in a consecutive series of 34 patients undergoing this procedure between 2001 and 2006.

Prospectively collected outcome measure data obtained pre-operatively and at 1 year post-operatively was analysed using the Wilcoxon Signed Rank Test. Kaplan Meier survival analysis was performed using revision surgery as the end point. Cox Regression was utilised to identify variables that were related to implant survival.

Pain rating on the visual analogue scale improved from a mean of 7 pre-op to 4 at 1 year (p=0.009), Roland Morris Disability Questionnaire scores from 13 to 9 (p=0.02), Modified Somatic Perception Questionnaire from 13 to 9 (p=0.03). When reporting subjective outcome, 54% of patients reported “better” or “much better” outcomes at last followup (12–69 months post op). Eight patients (25%) required removal of the implant and conversion to fusion, one of whom had deep infection. Kaplan Meier survival analysis revealed a survival of 78% at 5 years (95% CI, 60 – 96%). Previous spinal surgery was significantly related to the time of survival of the implant (p=0.008).

Our study has demonstrated a high revision rate for this implant and 54% patient satisfaction. We recommend that patients be counseled regarding these risks and further use of this implant should be subject to the outcome of larger studies and randomised controlled trials.

We aim to assess the clinical and radiological outcome following cartilage repair in the knee using the TruFit plug (Smith & Nephew). Eleven active sporting patients underwent cartilage repair using TruFit plugs between February 2006 and August 2007. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks.

Data was collected prospectively, patients underwent clinical review and completed Lysholm, IKDC subjective, Tegner, KOOS and SF-36 scores pre-operatively and at 6 monthly intervals. One patient has been excluded from the analysis as she emigrated and was lost to follow up. The remaining 10 patients (mean age 35 years (21–49)) had defects on the medial femoral condyle (n=6), lateral femoral condyle (n=3), and lateral trochlea (n=1). Patients received one (n=5), two (n=3) or three (n=2) plugs and four were primary procedures, and six revision procedures (1 failed OATS, 5 failed microfracture). Eight implantations were performed arthroscopically and, and two were mini-open. All patients were reviewed at 12 months, five were reviewed at 18 months and four have also been reviewed at 24 months.

Statistically significant improvements from mean pre-operative scores are seen at 12 months; Lysholm (48.3 to 71), IKDC Subjective (37.7 to 65.1), Tegner (2.4 to 4.6), SF36 physical (39.5 to 50.3) and all components of KOOS. These improvements are maintained at the latest follow up. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina, resorption of the graft and a similar signal from neo-cartilage as that of adjacent native cartilage.

TruFit plugs offer an exciting novel solution for cartilage repair in the knee with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing. The implant may be suitable for small lesions only and further prospective study is required to establish long-term outcome.

Peri-prosthetic fracture after joint replacement in the lower limb is associated with significant morbidity. The primary aim of this study was to investigate the incidence of peri-prosthetic fracture after total hip replacement (THR) and total knee replacement (TKR) over a ten-year period using a population-based linked dataset.

Between 1 April 1997 and 31 March 2008, 52 136 primary THRs, 8726 revision THRs, 44 511 primary TKRs, and 3222 revision TKRs were performed. Five years post-operatively, the rate of fracture was 0.9% after primary THR, 4.2% after revision THR, 0.6% after primary TKR and 1.7% after revision TKR. Comparison of survival analysis for all primary and revision arthroplasties showed peri-prosthetic fractures were more likely in females, patients aged > 70 and after revision arthroplasty.

Female patients aged > 70 should be warned of a significantly increased risk of peri-prosthetic fracture after hip or knee replacement. The use of adjuvant medical treatment to reduce the effect of peri-prosthetic osteoporosis may be a direction of research for these patients.

Introduction: Current evidence on the indications for and efficacy of non-rigid lumbar stabilisation remains unclear. The aim of this study was to review the results of this system in thirty four patients who underwent this procedure between 2002 and 2006.

Methods & Results: Validated outcome measures including Visual Analog Score (VAS), Roland Morris Disability Questionnaire (RMDQ), Modified Zung Score and Modified Somatic Perception Questionnaire (MSPQ) were evaluated preoperatively and at 1 year post operatively. Subjective patient outcome (much better, better, same, worse) was assessed at final followup Kaplan-Meier Survival analysis was performed using need for revision surgery as endpoint. The indications for surgery in thirty patients was radicular pain and back pain, these patients underwent discectomy (12 patients) or decompression (18 patients) in addition to Dynesys. Two patients who had only back pain underwent Dynesys alone. There were statistically significant improvements in VAS, RMDQ, Modified Zung and MSPQ scores at 1 year. However at final followup 46% of patients had a unsatisfactory subjective patient outcome (worse or the same). 25% of patients required revision surgery (posterolateral fusion) for ongoing pain (seven patients) or infection (one patient).

Conclusion: We recommend that all patients undergoing this procedure are counselled regarding the high rate of revision surgery and patient dissatisfaction. Routine use of this implant should be subject to the findings of larger studies and randomised controlled trials.

Ethics approval: None

Interest Statement: None

We investigated the excess mortality risk associated with fractures of the hip. Data related to 29 134 patients who underwent surgery following a fracture of the hip were obtained from the Scottish Hip Fracture Audit database. Fractures due to primary or metastatic malignancy were excluded. An independent database (General Register Office (Scotland)) was used to validate dates of death. The observed deaths per 100 000 of the population were then calculated for each group (gender, age and fracture type) at various time intervals up to eight years. A second database (Interim Life Tables for Scotland, Scottish Government) was then used to create standardised mortality ratios. Analysis showed that mortality in patients aged > 85 years with a fracture of the hip tended to return to the level of the background population between two and five years after the fracture. In those patients aged < 85 years excess mortality associated with hip fracture persisted beyond eight years. Extracapsular hip fractures and male gender also conferred increased risk.

We have investigated how medical postponement, the time to surgery and the correction of medical abnormalities, according to McLaughlin criteria, before operation affected peri-operative mortality after fracture of the hip. From February to December 2007, in addition to core data, the Scottish Hip Fracture Audit collected information relating to surgical delay. Data were available for 4284 patients which allowed 30-day survival analysis to be performed. Multivariable logistic regression models were used to control for differences in case-mix.

Patients with major clinical abnormalities were more likely to have a postponement and had a lower unadjusted 30-day survival. The time to operation and postponement were not associated with higher mortality after adjustment for case-mix. Correction of major clinical abnormalities before surgery improved the adjusted survival, but this improvement was not significant (p = 0.10). Postponement without correction of a medical abnormality before surgery was associated with a significantly lower (p = 0.006) 30-day adjusted survival. The possible benefits of postponement need to be weighed against prolonged discomfort for the patient and the possibility of the development of other complications.

Introduction: Treatment of dual compartment osteoarthritis remains controversial, with conjecture over whether Uni-Compartmental (‘UKA’) or Total Knee Arthroplasty (‘TKA’) is more appropriate for patients with patello-femoral disease. The ‘Journey Deuce’ 2/3 Knee Arthroplasty (‘2/3 Knee’) (Smith & Nephew) is a bi-cruciate retaining prosthesis designed to treat this subgroup of patients with both antero-medial and patello-femoral disease.

We have conducted a prospective, observational clinical trial of 34 patients with dual compartment osteoarthritis of the knee treated with a 2/3 Knee.

Aims: To assess the safety and clinical efficacy outcomes of the 2/3 Knee.

Method: All patients pre-op leg alignment films, as well as MRI or arthroscopy to confirm the inclusion criteria of dual compartment osteoarthritis with a preserved lateral compartment and intact cruciate ligaments. All operations were performed by a single surgeon (DW) using computer assisted surgery (CAS) and a minimally invasive technique (MIS) at a local university affiliated private hospital (HPH).

Exclusion criteria included obesity, inflammatory arthritis and a fixed flexion deformity > 10 degrees.

Subjective outcome measures included Oxford Knee Scores (OKS) and EQ-5D Scores. RSA beads were implanted at surgery to detect loosening, micro-motion and prosthesis wear. Gait analysis was conducted at 1 year post op in a subgroup of patients.

Results: Follow up ranged from 6 months to 2 years. There have been no early failures requiring complete revision. The first 23 knees (18 patients) did not have primary resurfacing of the patella. Some of these patients suffered palpable and audible patello-femoral crepitus, with a subgroup (17%, 4 knees-3 patients) having associated anterior knee pain. This subgroup had revision procedures to resurface their patellae with resolution of their symptoms. All subsequent patients have had primary patella resurfacing with no incidence of Significant crepitus or anterior knee pain.

The patients have recorded Significant improvement in their Oxford Knee Scores at 6 months (mean reduction all patients: 17.3, resurfaced 20).

Early RSA results have not detected Significant migration to indicate early loosening. Gait analysis has shown that patients return to approximate normal rather than pre-operative gait.

Conclusions: Although longer follow up is required the 2/3 Knee appears a safe and effective treatment option for patients with dual-compartment osteoarthritis; with rehabilitation, function and gait tending towards that seen in UKA rather than TKA.

It is essential that patients undergo primary patella resurfacing to prevent crepitus and associated anterior knee pain.

A study comparing clinical outcomes of 2/3 Knee vs TKA is underway at our institution.

Introduction: Current evidence on the indications for and efficacy of non-rigid lumbar stabilisation remains unclear. The aim of this study was to review the results of this system in thirty four patients who underwent this procedure between 2002 and 2006.

Methods & Results: Validated outcome measures including Visual Analog Score (VAS), Roland Morris Disability Questionnaire (RMDQ), Modified Zung Score and Modified Somatic Perception Questionnaire (MSPQ) were evaluated preoperatively and at 1 year post operatively. Subjective patient outcome (much better, better, same, worse) was assessed at final followup Kaplan-Meier Survival analysis was performed using need for revision surgery as endpoint. The indications for surgery in thirty patients was radicular pain and back pain, these patients underwent discectomy (12 patients) or decompression (18 patients) in addition to Dynesys. Two patients who had only back pain underwent Dynesys alone. There were statistically significant improvements in VAS, RMDQ, Modified Zung and MSPQ scores at 1 year. However at final followup 46% of patients had a unsatisfactory subjective patient outcome (worse or the same). 25% of patients required revision surgery (posterolateral fusion) for ongoing pain (seven patients) or infection (one patient).

Conclusion: We recommend that all patients undergoing this procedure are counselled regarding the high rate of revision surgery and patient dissatisfaction. Routine use of this implant should be subject to the findings of larger studies and randomised controlled trials.

The purpose of this study was to assess the accuracy of a modified version of the pivot shift test in detecting ruptures of the anterior cruciate (ACL) ligament.

Methods: Two groups of patients aged 18 to 50 years were recruited from operating theatre lists examined at a check and consent clinic. One of the groups had ACL deficient knees and the control group had intact ACL, later proven at arthroscopy. A total of 48 independent examinations, 26 with ACL rupture and 22 without, were undertaken by a consultant or registrar proficient in the modified version of the pivot shift test. At the start of the consultation the examiner, who was blinded to the operation that the patient was listed for and to the patient’s history, performed the modified pivot shift test only. The result of the test was reported as positive or negative for ACL rupture to the study co-ordinator before the examiner continued with the consultation.

Results: Of the 26 examinations of ACL deficient knees, 22 were reported as positive and four negative for ACL rupture using the pivot shift test only. Of the 22 examinations of ACL intact knees one was reported as positive for ACL rupture and 21 as negative. This gives a specificity and sensitivity of the modified version of the pivot shift test as 95.5% (95% CI 75.1–99.8%) and 84.6% (95%CI 64.3–95.0%) respectively.

Conclusion: The modified pivot shift test is an accurate test for the detection of ACL rupture. Our modified pivot shift test compares favourably with data from previous accuracy studies of previously described versions of the pivot shift test. We now plan to assess the accuracy of the modified pivot shift test when carried out by medical students and junior doctors.

Objectives: To compare the results of various surgical approaches to the knee in primary arthroplasty surgery.

Design: Systematic review with meta-analysis

Data Sources: Cochrane Bone, Joint, and Muscle Trauma group trials register (2007), Cochrane central register of controlled trials (Cochrane Library issue 2, 2007), Medline (1950 to February 2007), Embase (1974 to February 2007), CINAHL (1982 to February 2007), Pubmed, SCOPUS and ZETOC. If data was insufficient trialists were contacted via telephone, email or letter.

Review methods: Randomised and quasi-randomised controlled trials comparing surgical approaches to the knee in patients undergoing primary arthroplasty surgery.

Results: Twenty-three randomised, controlled trials (1282 patients, 1490 TKAs) were included.

Midvastus vs Medial Parapatellar approach: Quadriceps function in the early post operative period was better preserved in the MV group. Post operative pain, blood loss and the need for LRR tended to be lower in the MV group. There was no difference in ROM, hospital stay, knee scores, complications or radiological alignment.

Conclusions: Approaches preserving the quadriceps tendon improve the early extensor mechanism function and tend to decrease the need for LRR. Combined with a decrease blood loss and postoperative pain, these approaches improve early rehabilitation and allow for a more rapid recovery of knee function. However, these early improvements fail to provide any long term benefit, do not improve knee scores, or decrease the length of hospital stay.

Introduction: Tendon injury is an important cause of injury in racehorses, with flexor tendon and suspensory ligament injuries accounting for 46% of all musculoskeletal injuries at British racecourses (1). In the galloping horse the superficial digital flexor tendon (SDFT) undergoes strains that are close to the functional limit of the tendon (2) and it is hypothesised that exercise induces cumulative microdamage in the SDFT of skeletally mature horses which may predispose to clinical disease. We hypothesised that matrix metalloproteinases (MMPs) play a role in the process of tendon degeneration induced by cyclical loading and investigated this using an in vitro model.

Methods: Mid-metacarpal SDFTs were harvested from Thoroughbred horses that were euthanased for non-orthopaedic reasons. Tendon explants (2mm x 2mm x 60mm) were maintained in DMEM and placed in custom designed loading cassettes which were cyclically loaded in an incubator using a Dartec materials testing device for 24 hours with 5% strain and at a frequency of 1Hz. Control explants were placed in similar cassettes but were not loaded. The ultimate tensile strength (UTS) of the tendon was assessed using a destructive test at the end of the 24 hour loading period. The experiments were repeated using non-viable tendon explants, or in the presence of a pan-MMP specific inhibitor (Illomastat, 25 μM).

Results: Cyclical loading induced a 30% decrease in the UTS of tendons of immature and young mature (< 10 years of age) horses but this increased to a 50% reduction in older (10–30 years of age) horses compared to controls. This loss of UTS was prevented in tendon explants with non-viable cells or with a pan-MMP inhibitor applied to the live explants prior to cyclical loading.

Conclusions: The results suggest that an MMP mediated mechanism plays a pivotal role in tendon degeneration following cyclical loading in vitro. Current work including analysis of gene expression and quantification of MMPs within the tendon tissue aims to identify the key MMPs responsible for the loss of tendon UTS following cyclical loading. This will hopefully enable therapeutic strategies to be developed to slow or stop the age-associated tendon degeneration that predisposes to overstrain injury, and thereby help prevent this common orthopaedic disease in horses.

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18 817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique).

Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions.

Objective: To challenge the validity of using biomarker concentrations in synovial fluid for the assessment of joint pathology.

Hypothesis: Synovial fluid biomarker concentrations are influenced by both cartilage and synovial fluid volumes.

Methods: Synovial fluid volumes were determined from the equine metacarpophalangeal (MCP), proximal inter-phalangeal (PIP) and distal interphalangeal (DIP) joints, which have different disease prevalences.

Chondrocyte density was calculated from a defined site in each joint.

Cartilage volume was measured by novel application of Peripheral Quantitative Computed Tomography (pQCT).

Cartilage oligomeric matrix protein (COMP), glycos-aminoglycans (GAG) and total protein (TP) concentrations were measured and then adjusted for cartilage and synovial fluid volume and compared between joints.

Results: Mean synovial fluid volume was significantly greater in the MCP than the distal joints (p< 0.0001) (3.2 ±0.5ml, 0.5 ±0.1ml and 0.6 ±0.1ml respectively). In contrast, the DIP had the greatest cartilage volume compared to the proximal joints (5360 ±667mm3 2640mm3, 1940 ±331mm3 respectively). There was no significant difference in the cartilage cellularity between all joints.

The DIP had higher TP, COMP and GAG concentrations, however, when values were expressed per unit cartilage volume the opposite was found, with the MCP then exhibiting significantly higher concentrations.

Conclusions: These data show the joint with the highest prevalence to osteoarthritis has the lowest biomarker synovial fluid concentrations but the highest biomarker levels per unit cartilage, suggesting a higher release. These results indicate that meaningful interpretation of biomarkers in synovial fluid require consideration of both fluid and cartilage volume.

We aim to assess the outcome of ankle arthrodesis performed for painful osteoarthritis in the presence of a coronal plane deformity of 20 degrees or more. To our knowledge this is the first reported series of such a cohort of patients. We have a consecutive and complete series of 24 patients with 26 ankle arthrodeses which were all performed for painful osteoarthritis in the presence of large coronal plane deformity. These patients have a minimum of twelve months clinical follow up. The results showed a low non union rate of 8% (2 ankles). These have subsequently been refused satisfactorily, and were excluded from further analysis. The results of the remaining 24 ankles which united primarily show that they were very pleased with the outcome of their surgery. AOFAS scores were used to measure pain and function both pre operatively and post operatively. These scores showed large improvements for both pain and function, and had a high statistical significance (p< 0.0005). All patients improved in their walking distance and many patients reduced their need for walking aids. Stair climbing ability was also improved in some patients. It is recognised that an ankle arthrodesis usually relieves pain but does not result in a normal gait and full function. We feel that the high level of patient satisfaction in this series was due to the combination of deformity correction, restoring a functional foot position, and achieving a painless ankle. Arthroplasty of the ankle is a good procedure for relief of pain and restoration of function. However In the presence of a large coronal plane deformity ankle arthroplasty is known to fare badly with early failure. Therefore for patients with painful osteoarthritis and a coronal plane deformity of 20 degrees or more, we recommend ankle arthrodesis as the procedure of choice.

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders.

Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered.

We prospectively studied 29 patients with distal femoral fractures stabilised using the less invasive stabilisation system [LISS]. Four patients were excluded from the final follow up [3 deaths and 1 case of quadriplegia]. The mean age of the remaining 25 patients [9 males] was 60.9 years and the mean follow up 18 months [12–24]. Eleven patients were tertiary referrals from other hospitals [7 cases were referred due to failure of primary fixation]. Overall, there were 12 cases of high-energy trauma [7 open fractures]. According to the AO classification there were 5 Type 33A, 2 Type 33B and 12 Type 33C fractures and 4 Type 32A, 1 Type 32B, 1 Type 32C fractures. Functional assessment was performed using the Modified HSS and the Schatzker and Lambert scores. The average time to union in 22 cases was 3.5 months [range, 2–5]. None of the acute cases required bone grafting with a 100% union rate. There were 3/7 cases of non-union in the salvage group still undergoing treatment. The overall results in the acute cases were good and in the salvage cases fair. While this is a small series of patients, our preliminary data indicate favourable results using the LISS in stabilizing acute distal femoral fractures. However, when the LISS is used as a revision tool despite the concept of preserving the bone biology, the results seem to be less satisfactory. The system appears to be user friendly and no technical difficulties were encountered.

The application and interpretation of the impact factor of a journal is fraught with problems, some of which are explored in this editorial.

A consecutive series of 23 patients (25 ankles) with osteoarthritis of the ankle and severe varus or valgus deformity were treated by open arthrodesis using compression screws. Primary union was achieved in 24 ankles one required further surgery to obtain a solid fusion. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis.

Introduction: Energy storing tendons, such as the human Achilles tendon, suffer a much higher incidence of rupture than non- energy storing positional tendons, such as the anterior tibialis tendon. Similarly, in the horse partial rupture of the energy storing superficial digital flexor tendon (SDFT) and suspensory ligament (SL) occurs much more frequently than to the deep digital flexor tendon (DDFT) and common digital extensor tendon (CDET) which are not involved in energy storage. In order to function effectively, energy storing tendons experience strains during high speed locomotion which are much closer to failure strain than non-energy storing tendons. Therefore, these tendons are likely to sustain high levels of microdamage, hence cell metabolism may also be higher in order to repair damage and maintain matrix integrity. Maintenance of the matrix requires not only synthesis of new matrix components but also degradation of matrix macromolecules which is achieved, in part, by a family of matrix metalloproteinase enzymes (MMPs). In this study we test the hypothesis that the energy storing equine SDFT and SL which are prone to degenerative changes have higher levels of MMP2 and MMP9 than the positional DDFT and CDET that are rarely injured.

Methods: Tendons (SDFT, DDFT, SL, CDET) were harvested from the distal part of the forelimbs of 18 month old Thoroughbred horses (n = 12). Tissue from the mid-metacarpal region of each tendon was snap frozen, lyophilised, powdered and MMPs extracted. Gelatin zymography was used to determine levels of the pro and active forms of the gelatinase enzymes, MMP2 and MMP 9. Proteolytic activity (units per mg dry weight tissue) was quantified based on densitometry measurements and standardised between gels using an equine neutrophil MMP extract. Statistical significance was evaluated using a general linear model (SPSS software).

Results: The main activity observed in all tendon samples was that of proMMP2. Quantification showed that the energy storing SDFT (23.4 ± 10.95) and SL (18.9 ± 5.3) had significantly higher levels than the non-energy storing DDFT (2.90 ± 0.99) and CDET (4.06 ± 2.06). Active MMP2 levels were lower than the pro form and were not sufficient to quantify. However, there appeared to be more in the energy storing structures compared with the non energy storing structures. MMP9 activity was detected in some samples. A higher number of the CDET extracts contained MMP9 activity compared to extracts from the other structures.

Discussion: The results of this study show higher levels of MMPs in energy storing structures than in non-energy storing structures. This suggests that there may be an increased demand for repair of micro-damage in these tendons and hence an increased capacity for matrix degradation. Previous studies on energy storing structures in the horse have shown that they do not undergo adaptive hypertrophy or a change in structural architecture in response to mechanical demand, unlike non-energy storing structures. The results of this study indicate that this lack of adaptation in energy storing structures is not due to a general deficiency in cell activity but may be a means of preventing increase in tendon stiffness and a subsequent decrease in efficiency. In order to maintain tendon integrity MMP activity must be matched by mechanisms to inhibit activity and/or to synthesize new matrix components. Degeneration may therefore occur when there is an imbalance between these processes.

Background: To assess the cosmetic advantage of costotomy at the angle of the ribs on the convexity of a curve in the management of Adolescent Idiopathic scoliosis. Whilst modem segmental correction produces gratifying improvement in Cobb-angle and, to some extent rotation, rib asymmetry often remains as a concern for patients. Performing costotomy at the angle of the rib at the same time as corrective surgery can improve the cosmetic appearance significantly. It avoids any further scars or surgery, and is associated with minimal complications, the main one being pneumothorax and the requirement of a chest drain.

Methods: Retrospective review of 50 patients. This has been a standard practice and this presentation reports on 50 patients treated in Preston with a variety of corrective devices; we have assessed results radiologically, with cosmetic acceptability by the patient and surface topographical analysis.

Results: Significant improvement occurs at the time of costotomy as the ribs drop from their arched position after the coronal deformity has been improved

Conclusion: The addition of costotomy at the time of primary surgery for Adolescent Idiopathic Scoliosis leads to minimal complications. Significant improvement occurs at the time of costotomy as the ribs drop from their arched position after the coronal deformity has been improved. This is maintained in the post-operative period by moulding of the brace.