Aim

To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap.

Backpain is a common cause of patient referral to pain clinics. Around 120 000 patients with back pain are seen in UK Pain Clinics every year. Facet joint injections are a commonly used treatment modality. However there is considerable controversy regarding their efficacy. Most of the evidence supporting the use of injections is anecdotal, rather than being based on randomised studies.

We carried out a prospective study to assess the efficacy of facet joint injections in relieving chronic low back pain. Our study group comprised 41 patients (57% females, 43% males). Patients completed the Oswestry Disability Index (ODI) and marked their pain levels on a Visual Analogue Scale (1 to 10).

We found that though the pain score improved from 6.9 to 4.3, there was only a marginal improvement in the ODI from 52.5 to 50.8. Overall 85 % of patients experienced some improvement, while 15% felt their symptoms had worsened after the injections. One of the most significant findings of this study was the fact that the improvement in most patients lasted only for an average of three weeks. This is significantly less than most previous studies indicate. Interestingly, inspite of this limited improvement, almost all patients expressed the desire to be placed back on the list for repeat injections.

Our study demonstrated a beneficial short term effect of facet joint injections. In our opinion, they are a reasonable adjunct to non operative treatment of chronic backpain.

Objective: We prospectively compared the techniques of skip laminectomy and laminoplasty for the treatment of cervical spondolytic myelopathy in terms extent of decompression achieved, axial pain, postoperative range of cervical motion, patient and surgical outcomes.

Methods and results: We studied fifty consecutive patients operated on for cervical spondolytic myelopathy and spinal cord compression as demonstrated on MRI between the levels C3–4 to C6–7. Each patient had a minimum follow-up of two years (2.2 – 4.3 years). Twenty-five patients underwent skip laminectomy and twenty-five patients underwent laminoplasty. Decompression was assessed by pre- and post-operative MRI. Cervical range of motion was assessed by pre- and postoperative flexion and extension radiographs. Patient outcomes were assessed by evaluation of pre-and postoperative neurology and SF12 scores for mental health, physical health and axial pain.

Less blood loss and operative times were found with skip laminectomy. Similar degrees of decompression with both techniques. Significantly improved axial pain scores with skip laminectomy. Significantly improved preservation of range of movement with skip laminectomy.

Conclusion: Skip laminectomy is an effective procedure for reducing the incidence of postoperative morbidities, such as persisting axial pain, and restriction of neck motion often seen after laminoplasty, and provides adequate decompression of the spinal cord as demonstrated on MRI for a minimum follow-up of two years.

The objective of this study was to assess the clinical outcome and efficacy of the X-Stop™ interspinous implant.

67 patients (36 male, 31 female) with mean age of 62.4 years (range 50–94 years) and radiologically proven lumbar stenosis, underwent X-Stop™ implantation during the period of June 2004 to June 2007. Patients were assessed pre-operatively and post-operatively at 3, 6 and 12 months using the Back and Sciatica Questionnaire, the Oswestry Disability and the SF12 questionnaire. Patient’s satisfaction was assessed in each visit. Minimum follow up 2 years in 45 patients and 1 year in 22 patients.

70% had significant improvement in the walking distance following the operation.

With the Back and Sciatica Questionnaire the average preoperative VAS of back and leg pain was 7.1 and 6.7 and improved to 2.5 and 2.6 postoperatively.

86% patient had improvement in their ODI score by 14% and more with average pre and postoperative score 44% (range18%–84%) and 15.8% (range 0%–61%) respectively.

With the SF12 questionnaire 68% patients had significant improvement in physical score and 77% in the mental score. Complications included five superficial wound infections and one wound haematoma. One patient required revision surgery.

This new surgical technique for the treatment of lumbar spinal stenosis, is simple and effective with minimum complications.

Introduction: Although there are several accepted methods of surgical treatment for single level cervical radiculopathy, the choice depends on the surgeon’s preference. The techniques may vary in perioperative morbidity, short and long term outcome, but no study so far has analysed their cost-effectiveness. To compare the outcome and cost-effectiveness of four techniques commonly used for degenerative cervical disc pathology.

Methods: We conducted a observational cohort study from two spinal units. Between 1999 and 2004, 60 patients underwent surgery for single level anterior cervical disc pathology. Out of this 30 patients underwent their surgery in centre A the other 30 in centre B. Centre A used two ACDF techniques-group 1- plate and tricortical graft, group 2- plate, cage and bone substitute (BCP granules). Centre B used two other techniques- group 3- cage alone with autologous locally harvested graft, group 4- disc arthroplasty. We had 15 patients in each of the above four groups. Operating time, blood loss, duration of stay, donor site morbidity, analgesia requirements, and total cost incurred per patient were recorded. All patients were followed up at 6 weeks, 3 months, 6 months, 1 year and 2 years. The clinical outcome and pain assessment were done using the SF12 and VAS.

Results: The three Fusion groups had a similar radiological outcome. With appropriate statistical analysis, there were no differences in physical and mental domains of the SF12 or pain scores between the groups. The average operative time in the group 1 was 160 minutes, group 2 was 100 minutes, group 3 was 90 minutes and group 4 was 105 minutes. Average blood loss was minimal in all groups. The average hospital stay was of 5, 2.7, 2.5, 2 days for groups 1–4 respectively. The average total cost per patient in the group 1 (surgery+stay+plate) was £2790, group 2 (surgery+stay+plate+cage+BCP) was £2400, group 3 (surgery+stay+cage) was £1900, and group 4(surgery+stay+disc implant) was £2350.

Conclusion: All the techniques gave similarly satisfactory clinical outcomes but using cages alone could be more cost-effective than using iliac crest auto-graft for fusion. The disc arthroplasty was comparable to cage with bone substitute and plate in terms of outcome and may giev the surgeon an alternative choice in patients who are not keen on/ unfit for fusion.

Introduction: Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. We performed two separate studies:

1) observational study to analyse surgeon’s and anaesthetist’s attitude to transfusion

Method: 500 orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty.

200 patients (88 THR, 99 TKR, 13 hip resurfacing) were evaluated. Blood Hb, hand grip strength and vigour scores using fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. POMS and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia.

Results: In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below Hb of 8g/dL. Mean transfusion threshold in surgeons was 8.3g/dL compared to 7.9g/dL for anaesthetists (p< 0.01). 97% of surgeons transfused two or more units compared to 78% anaesthetists (p< 0.01). This threshold Hb increased if patient was symptomatic (surgeons 9.3g/dL, anaesthetists 8.8g/dL, p< 0.05), or if known to have pre-existing ischaemic heart disease (surgeons 9.0g/dL, anaesthetists 9.2g/dL, p< 0.05).

A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09).

A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or duration of in-patient physiotherapy (p=0.20).

A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02).

Conclusion: Haemoglobin level below 9g/dL is the most common ‘trigger’ for blood transfusion. Surgeons tend to be more aggressive in their attitude to transfusion. A fall in Hb of more than 4 g/dL has a detrimental effect on post-operative rehabilitation. Pre-operative grip strength measurements are valuable in predicting the rehabilitation potential of patients undergoing lower limb arthroplasty.

AIM: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty).

METHODS: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation.

We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression.

RESULTS & CONCLUSION: There was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation.

46 Sacral chordoma patients treated between 1987 and 2004 are reviewed. The importance of early diagnosis, adequate surgical margin and post operative radiotherapy for optimum outcome and survival is stressed.

There were 33 male and 13 female patients, with a mean age of 61 years (38–73 years). The surgical approach depended on the level and extent of the lesion, with an anteroposterior approach used in 23 and posterior approach in 17 patients. 20 had partial sacrectomy, 17 had subtotal sacrectomy and 3 underwent total sacrectomy. 6 patients were deemed inoperable and received palliative therapy. 14 patients received radiotherapy post-operatively. The length of average follow up was 4.27 years (range 2–15.7 years).

Low back pain was the most common presenting symptom (80%), and 50% patients had a palpable mass. The mean duration of symptoms prior to diagnosis was 2 years (range 1 month–10 years). Examination revealed a palpable mass in 7 both externally and on rectal examination. 10 had a palpable mass on rectal examination but not externally. 2 patients presented with multiple metastases and another 2 with widespread local disease. Excision was complete in 23 patients and incomplete in 17. Histology revealed dedifferentiation in 4. Complete excision margin was achieved in 69.6% through combined approach and 52.9% through posterior approach only. 24 patients (52%) had local recurrence. Without adjuvant radiotherapy the mean disease free period following complete excision was 3.5 years, compared to 0.9 years following incomplete excision. Adjuvant radiotherapy extended the mean disease free period following incomplete excision to 1.8 years.

The authors conclude that an early diagnosis and careful examination is important. Wide excision remains the mainstay of treatment. If excision is incomplete radiotherapy increases the disease free period although local recurrence is inevitable. The use of a combined approach increases the likelihood of complete excision.

Aim: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty).

Methods: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation.

We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression.

Results and Conclusion: here was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation.

Purpose: To report the genetic correlation of familial chordoma, a rare tumour of embryonic notochordal remnant.

Method: We present two patients with a family history of chordoma. Both patients had surgery at our unit, one for a clival and one for a sacral tumour. These two cases comprise 1.14% (2 out of total 175 chordoma cases) of our unit’s surgical experience with chordoma (79 cases involving craniocervical junction, 4 cases involving thoracolumbar spine, 92 cases involving sacral region) over the period of 15 years (1990– 2005). Patient1 had clival chordoma and Patient2 had sacral chordoma. Both the patients had excision of the tumour followed by postoperative radiotherapy and annual follow up. There was no recurrence eight years later in Patient 1 and Patient 2 died three years after the surgery.

Results: Patient 1 had ten other family members affected by chordoma (mostly clival) and Patient 2 had two other family members affected by clival chordoma. Genetic analysis for the Patient 1 and of her relatives (National Cancer Institute, Bethesda) showed that there was loss of heterozygosity on chromosome 7q 33. None of the affected members of the Patient 2 were alive to do the genetic study.

A literature search on genetic studies was performed using the key term as familial chordoma and following studies have been found-

Kelly et al- the study had 10 affected members and showed linkage to chromosome 7q 33.

Conclusion : Familial chordoma is a very rare tumour. Further genetic studies will hopefully reveal valuable insight into the pathogenesis and possible therapeutic measures of this tumour.

Purpose: To report the importance of early diagnosis, adequate surgical margin and postoperative radiotherapy for optimum outcome and survival.

Study Design: A retrospective review of 46 sacral chordoma patients treated between 1987 and 2004.

Methods: There were 33 male and 13 female patients, with mean age of 61 years (38 to 73 year). The surgical approach depended on the level and extent of the lesion, with an anteroposterior approach used in 23 and posterior approach in 17 patients. 20 had partial sacrectomy, 17 had subtotal sacrectomy and 3 underwent total sacrectomy. 6 patients were deemed inoperable and received palliative therapy. 14 patients received radiotherapy postoperatively. The length of average follow up was 4.27 years (range 2–15.7 years).

Results: Low back pain was the most common presenting symptom (80%), and 50% patients had a palpable mass. The mean duration of symptoms prior to diagnosis was 2 years (range 1 month–10 years). Examination revealed a palpable mass in 7 both externally and on rectal examination. 10 had palpable mass on rectal examination but not externally. 2 patients presented with multiple metastases and another 2 with widespread local disease.

Excision was complete in 23 patients and incomplete in 17. Histology revealed dedifferentiation in 4. Complete excision margin was achieved in 69.6% through combined approach and 52.9% through posterior approach only. 24 patients (52%) had local recurrence. Without adjuvant radiotherapy the mean disease-free period following complete excision was 3.5 years, compared to 0.9 years following incomplete excision. Adjuvant radiotherapy extended the mean disease-free period following incomplete excision to 1.8 years.

Conclusion: An early diagnosis and careful examination is important. Wide excision remains the mainstay of treatment. If excision is incomplete radiotherapy increases the disease free period although local recurrence is inevitable. Use of combined approach increases the likelihood of complete excision.

Introduction and Aims: Allogenic blood transfusion is often required in lower-limb arthroplasty. The aims of this study were (1) to analyze the influence of anaemia on post-operative fatigue, hand grip strength, duration of in-patient physiotherapy and post-operative morbidity score (POMS) and (2) to investigate for prognostic factors to predict functional recovery following primary arthroplasty of the lower limb.

Patients and methods: This study was approved by the regional ethics committee. Two hundred patients (88 THR, 99 TKR and 13 hip resurfacing) were evaluated in this prospective trial. Blood haemoglobin concentration (Hb), hand grip strength and vigour scores using a validated fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. Postoperative morbidity score (POMS) and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia.

Results: A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09).

A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or required duration of in-patient physiotherapy (p=0.20).

A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02).

Conclusion: We conclude that a fall in Hb of more than 4 g/dL has a detrimental effect on post-operative rehabilitation. Pre-operative grip strength measurements are valuable in predicting the rehabilitation potential of patients undergoing lower limb arthroplasty.