Success treating AIS with bracing is related to time worn and scoliosis severity. Temperature monitoring can help patients comply with their orthotic prescription. Routinely collected temperature data from the start of first brace treatment was reviewed for 14 patients. All were female with an average age of 12.4 years (range 10.3–14.6) and average 49o Cobb angle (30–64).

Our current service recommendation is brace wear for 20 hours a day. Patients complied with this prescription 38.0% of the time, with four patients averaging this or more. Average brace wear was 16.3 hours per day (3.5–22.2).

There were 13 patients who had completed brace treatment. The majority had surgery (7/13; 54%) or were considering surgery (1/13; 8%). There were 5 who did not wish surgery at discharge (5/13; 38%); 1 achieved a 40o Cobb angle, with 4 larger (53o;53o;54o;68o). The Bracing in AIS Trial (BrAIST) study measured “success” as less than a 50o Cobb angle, so using this metric our cohort has had a single “success”.

Temperature monitors allowed an analysis of when patients were achieving their brace wear. When comparing daywear (8am-8pm) to nightwear (8pm-8am), patients wore their brace an average of 7.6 hours a day (2.5–11.2) and 8.7 hours a night (0.4–11.5).

We conclude the minority of our patients comply with our current 20 hour orthotic prescription. The “success” of brace treatment is lower than comparison studies despite higher average compliance but starting with a larger scoliosis. Brace wear is achieved during both the day and night.

Study Design

Prospective cohort study.

INTRODUCTION: We have previously demonstrated the efficacy of a modified Ti-surface tethered with antibiotics in preventing bacterial colonization. It is not known if coverage of this surface with serum or other physiological material may hinder the bactericidal properties of such a surface.. The in vitro activity and efficacy of such a surface against S. aureus and S. epidermidis was tested following coverage of the surface with serum.

METHODS: Vancomycin was coupled to Ti6Al4V pins by aminopropylation, linker addition, and vancomycin coupling (VancTi). Bactericidal activity was tested in solutions of bacteria (Ci=1×104cfu/ml) incubated with pins±pre-incubation with fetal bovine serum (FBS). Anti fibronectin and anti-vancomycin antibodies were used to detect surface coating or modification. Bacteria were detected by fluorescent labeling (Syto9) or by direct counting after solubilization.

RESULTS: By immunofluorescence, pins were extensively covered with serum fibronectin which did not interfere with the diffuse, intense vancomycin staining. When incubated with S. epidermidis or S. aureus, VancTi showed little colonization compared to control pins (> 95% reduction in cfu).

DISCUSSION: In a physiological environment, implants will be coated with serum proteins. Activity of the VancTi was unaffected by this coating and maintained potent inhibition of bacterial colonization. We have described a surface modification that allows Ti implants to resist colonization and subsequent periprosthetic infection. Such surfaces hold great promise for the prevention and treatment of periprosthetic infections.

Introduction: We have previously described modification of Ti that renders the implant surface bactericidal and prevents bacterial colonization in vitro. This study evaluates the efficacy of the same surface in preventing periprosthetic infection in a small mammal model.

Methods: Control or VancTi rods were incubated with S. aureus (Ci=104CFU/mL) in TSB containing 0, 5×10-3, 4, or 100 μg/mL vancomycin at 37°C for 24h. Bacteria were detected by fluorescence (Live/Dead BacLight) and imaged by confocal microscopy. Resistance was tested by incubating control or VancTi rods with S. aureus for 0–8 weeks. Adherent bacteria were tested every 7 days on vancomycin screening agar (6μg/mL).

Results: Using a percutanous approach, the intercondylar region of the knee in rats were identified. The intrameduallry canal of the femur was retrograde reamed using an 18-gauge needle. Infection was induced by injection of 103 CFU S. aureus in 150uL of saline into the femoral canal followed by insertion of a 20 mm Ti implant. Animals were harvested at various time points. At harvest, animals were euthanized with CO2.. Detailed analysis including radiographic, micro-CT, histological, bacteriological, and clinical evaluation was performed.

Results: All animals showed signs of infection within the first few post-operative days with increased soft tissue swelling and limited mobility. At 1 week 75% of the animals showed radiographic signs of periprosthetic infection including periosteal reaction, abscess formation, widened canal, bone destruction, and formation of involucrum. PPI could be prevented in 92% of cases when modified Ti-Van was used. In one animal despite the use of antibiotic-tethered implant, PPI occurred partially due to the pin insertion penetrating the bone cortex.

Discussion: Biologically modified implants with bactericidal surface can have a promising role in management of periprosthetic infection. The modified implant described herein contains a nanoscale surface of covalently linked antibiotics that can potentially confer bactericidal properties throughout the life of the implant

Background: To analyse the effects of surgery on sagittal alignment¹ in patients with severe Scheuermann’s kyphosis. To assess the ability of two surgical techniques to prevent loss of correction in the thoracic kyphosis. To assess factors of patient’s Body Mass Index (BMI) and instrumentation level on the risk of adjacent level kyphosis or pullout.

Methods: A retrospective study of 13 consecutive cases of rigid Scheuermann’s kyphosis. Group A: 6 patients with anterior interbody cages. GroupB: 7 patients with interbody autogenous rib graft. All patients were instrumented posteriorly from T2 to L2. Radiographs from initial presentation, pre-operatively, post-operatively and at final follow –up were assessed. The thoracic kyphosis, lumbar lordosis, sagittal balance² and sacral inclination were measured.

Results: There were 7 males and 6 females with a mean age of 22 years (range 15 to 38yrs). The mean follow-up was 26 months (range 7 to 53 mths). In Group A: the mean preoperative kyphosis was 87° (range 82° to 92° ) and postoperative kyphosis was 45° (range 38° to 60°). The mean loss of correction was 0.3° (range 0° to2°). In Group B: the mean preoperative kyphosis was 83° (range 70° to 100°) while the postoperative kyphosis was 43° (range 30° to 60°). The mean loss of correction was 1.1° (range 0°to 2°) at final follow-up. The mean lumbar lordosis pre-operatively for all patients was 66° (range 62° to 84°) reducing to 48° (range 34° to 82°) following surgery. The mean sacral inclination pre-operatively was 41° (range 18° to 80°) reducing to 32 °(range 14°to 40°) following surgery. The mean sagittal balance preoperatively was −1.1 cm (range +0.1 to −3.5). It reduced postoperatively to −2.2 cm (range +1.5 to −4 cm) and was −1.6cm (range +0.2 to – 3.5cm) at final follow- up. Three patients with BMI greater than 25 had an increased lumbar lordosis at final follow up, with one case of implant failure and 2 cases with lower junctional kyphosis. No patient had an upper thoracic junctional kyphosis. There was no evidence of neurological compromise.

Conclusion: Patients had a mean thoracic kyphosis correction of 41° (49%). This was maintained during follow-up with no significant difference between autograft and cages. Cranially, all patients had instrumentation to T2 and there was no junctional kyphosis. Caudally, three obese patients (BMI > 25) suffered screw pullout (1 patient) or junctional kyphosis (2 patients). Instrumentation to L3 may avoid this complication in this patient group. The lumbar lordosis and sacral inclination reduced immediately postoperatively, with further correction at final follow –up.

Study Design: A consecutive retrospective cohort including all patients treated by a single consultant spinal surgeon (BJCF) with targeted foraminal epidural steroid injection (FESI) for radicular pain.

Objective: To assess the efficacy of targeted foraminal epidural steroid injection (FESI) for radicular pain in preventing surgical intervention.

Summary of Background Data: 90% of sciatica resolves within 90 days. Beyond this period, decompresssive surgery for pain relief maybe considered. Open surgery however carries attendant risk including nerve root injury, dural laceration, cauda equina syndrome, deep infection, recurrent disc prolapse, epidural fibrosis and post-discectomy lumbar instability. Peri-radicular infiltration of local anaesthetic and steroid has been shown to reduce pain, at least in the short term. We were interested in whether FESI could obviate the need for surgery in refractory cases of nerve root pain.

Methods: 83 consecutive patients (45 female, 38 male) with a mean age of 51 years (range 24 to 87) presenting between November 2000 and February 2003 with radicular pain were treated with targeted FESI. 55 patients had a principal diagnosis of disc prolapse, 20 had lateral canal stenosis and 8 had degenerative spondylolisthesis. Fourteen had previous surgery and 38 had previous caudal or lumbar epidural injections.

Outcome Measures: Pain was assessed using the Visual Analogue Score and disability by the Oswestry Disability Index. The product-limit method of Kaplan Meier was used to assess the time to further procedure or the date of last review.

Results: 21 of 83 patients (25.3%) underwent an open procedure (discectomy/decompression) within the designated time period (median 20 months). Median time to open procedure was 6.5 months (mean 8.2 months). Repeat FESI was required in 16 patients (19.2%). The remaining 46 (55.4%) patients avoided any further procedure at a median of 20 months (range 13 to 36). No complications resulted from these procedures.

Conclusions: Targeted foraminal epidural steroid injection can resolve radicular pain caused by varying pathologies. Surgical procedures (decompression/discectomy) can be avoided in 74.7% of cases up to a median of 20 months thereby avoiding unnecessary surgical risk.

Objective: Idiopathic scoliosis is a complex, three-dimensional deformity. Surgical correction has been assessed by radiographic measurements in the coronal and sagittal planes and vertebral rotation. However the primary concern for the patient is the transverse plane deformity at the skin surface. The purpose of this study was to correlate the surface and radiographic measurements of transverse plane deformity in idiopathic thoracolumbar scoliosis before and after single stage anterior fusion with instrumentation.

Design: A consecutive, prospective study of patients operated upon by a single surgeon.

Subjects: 24 patients (23 female) with idiopathic thoracolumbar scoliosis operated on between 1990 and 1999. Mean age at surgery 14.8 yrs (range 10.9 to 17.5). All had single stage surgery through an anterior thoraco-abdominal approach with anterior release of a mean of 4 discs (range 3 to 6). Anterior instrumentation was inserted using vertebral body screws secured to a single contoured rod with interbody bone grafting using strips of rib autograft.

Outcome measures: All patients were assessed both radiographically and by surface topography using the Integrated Shape Imaging System (ISIS) pre-operatively, post-operatively and during each follow-up visit for a mean 3.1 years (range 1.8–9.1).

Results: Radiographically the mean pre-operative coronal Cobb angle of 49 degrees (range 30 to 74) was reduced to 13 degrees (range 0 to 32) following surgery with a mean 2 degree loss (range −5 to 10) at final follow-up. The Perdriolle rotation was reduced by a mean of 19 degrees (range 5 to 30) with a mean 1 degree loss (range −6 to 6) of correction at final follow-up.

ISIS showed the mean pre-operative Standing Angle of Trunk Inclination (sATI) of 15 degrees (range 7 to 25) was reduced to 5 degrees (range 0 to 15) post-operatively with a further mean improvement of 2 degrees during the follow-up period. The final sATI was within the range of normality for 21 patients (87 percent). Spinal balance in the coronal plane improved from a mean of 24mm to 11mm. Spinal balance in the sagittal plane was unchanged.

Conclusions: Anterior surgery for idiopathic thoracolumbar scoliosis is effective in reducing transverse plane deformity. The Standing Angle of Trunk Inclination is returned to the normal range in 87% of cases. Coronal plane balance is improved by surgery. These corrections occur mainly due to surgery but also continue on follow up (growth).

Objective: To demonstrate the safety, surgical efficacy and advantages of the Posterior Lumbar Interbody Fusion (PLIF) technique using posterior elements as graft material when combined with pedicle screw fixation.

Design: Retrospective study assessing the Oswestry Score and Pain Intensity Score pre and post-operatively in patients undergoing disc excision and PLIF with the above technique.

Subjects: Eighteen patients (6 male), mean age 44 years (range 24 – 59) with a mean follow-up of 11 months (range 9 – 14). Four subjects had undergone previous lumbar surgery. All subjects had a history of back pain with or without sciatica.

Outcome measures: Pre and post-operative assessment of functional ability and pain using the Oswestry Score and Pain Intensity Score.

Results: Following surgery there was marked improvement in the Oswestry Score from a mean score of 36 (+/−12) to 19 (+/−9), P< 0.0001. Likewise there was an improvement in the Pain Intensity Score from a pre-operative mean score of 4 (+/−1) to a post-operative score of 1 (+/−1), P< 0.0001. Seventeen of the eighteen patients indicated that they would have the operation again.

Conclusion: Our technique is safe, effective and the results are comparable with published data. This technique provides the added benefit of utilisation of posterior elements of the spine as bone graft and hence avoids donor site problems and the risks associated with insertion of block grafts.