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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 25 - 25
2 May 2024
Ajula R Mayne A Cecchi S Ebert J Edwards P Davies P Ricciardo B Annear P D'Alessandro P
Full Access

Proximal hamstring tendon avulsion from the ischial tuberosity is a significant injury, with surgical repair shown to have superior functional outcomes compared to non-surgical treatment. However, limited data exists regarding the optimal rehabilitation regime following surgical repair. The aim of this study was to investigate patient outcomes following repair of proximal hamstring tendon avulsions between a conservative (CR) versus an accelerated rehabilitation (AR) regimen.

This prospective randomized controlled trial (RCT) randomised 50 patients undergoing proximal hamstring tendon repair to either a braced, partial weight-bearing rehabilitation regime (CR=25) or an accelerated, unbraced regime, that permitted full weight-bearing as tolerated (AR=25).

Patients were evaluated pre-operatively and at 3 and 6 months post-surgery, via patient-reported outcome measures (PROMs) including the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT) and 12-item Short Form Health Survey (SF-12). Primary analysis was per protocol and based on linear mixed models.

Both groups were matched at baseline with respect to patient characteristics. All PROMs improved (p>0.05) and, while the AR group reported a significantly better Physical Component Score for the SF-12 at 3 months (p=0.022), there were no other group differences. Peak isometric hamstrings strength and peak isokinetic quadriceps and hamstrings torque symmetry were all comparable between groups (p>0.05). Three re-injuries have been observed (CR=2, AR=1).

After proximal hamstring repair surgery, post-operative outcomes following an accelerated rehabilitation regimen demonstrate comparable outcomes to a traditionally conservative rehabilitation pathway, albeit demonstrating better early physical health-related quality of life scores, without an increased incidence of early re-injury.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 24 - 24
7 Aug 2023
Myers P Goldberg M Davies P
Full Access

Abstract

Introduction

Augmentation of meniscus repairs with fibrin clot may enhance the healing capacity. Pulling the clot into the tear with a suture ensures that it stays in position. This paper aims to assess the outcome of this technique.

Methods

52 patients over 4 years undergoing suture repair of a meniscus tear with blood clot augmentation were collected from a prospective database. Follow up included outcome scores and a questionnaire. Failure was defined as pain or further surgery secondary to meniscal pathology.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_5 | Pages 12 - 12
13 Mar 2023
Harding T Dunn J Haddon A Fraser E Sinnerton R Davies P Clift B
Full Access

COVID 19 led to massive disruption of elective services across Scotland. This study was designed to assess the impact on elective service that the COVID-19 pandemic had, to what extent services have been restarted and the associated risks are in doing so.

This is a retrospective observational study. The primary outcomes are the number of operations completed, 30-day mortality, 30-day complication rates and nosocomial infection with COVID-19 compared to previous years. Data was collected from 4 regions across Scotland from 27th March 2020 - 26th March 2021. This was compared to the same time period the previous year.

3431 elective operations were completed in the year post-pandemic compared with 12255, demonstrating a reduction of 72%. Both groups had comparable demographics. Major joint arthroplasty saw a 72% reduction, with TKR seeing a reduction of 82%. Each of the 4 health boards were affected in a similar fashion. Nosocomial COVID-19 infection was 0.4% in the post covid group. 30 day mortality was the same at 0.1%. Total complications rose from 5.7% to 10.1% post covid.

This study shows that there has been a substantial reduction in elective activity across Scotland that is disproportionate to the level of COVID-19. The risk of developing COVID-19 from elective surgery is low at 0.4%, however all complications saw a significant rise. This is likely multifactorial. This study will inform decision makers in future pandemics, that it is safe to continue elective orthopaedic surgery and of the potential impact of cessation of services.


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_4 | Pages 9 - 9
1 Mar 2020
Gannon M Downie S Aggarwal I Parcell B Davies P
Full Access

Gram staining is used as an initial indicator of synovial joint infection but has widely varied false negative rates in the literature. Clinical decisions are often made on the basis of gram stain results, such as whether a patient requires urgent surgery, and therefore it is important to understand the tests efficacy.

A retrospective review of synovial fluid aspirates in NHS Tayside for the years 2017 and 2018 was performed from the departmental microbiology database. Aspirates of large joints were included (hip, knee, shoulder, wrist, elbow, ankle). Any joints with prosthesis were excluded, including fixation metalwork. Any abscess overlying a joint that was not proven to penetrate the joint was also excluded. Initial gram stain results and formal culture results were reviewed. Final culture results were considered to be the gold standard to compare gram stain results to.

2167 samples were reviewed. Of these 1552 were excluded base on inclusion criteria. Of the remaining 615, 120 (19.5%) were culture positive. There were 33 positive gram stain results, 1 false positive and 32 true positive results. The sensitivity was 26.67% with a specificity of 99.80% (p=0.0001). The negative predictive value is 84.88% (CI 83.44% – 86.21%).

These results show that gram stain tests of native joints have a low sensitivity and poor negative predictive value. This is reflected in the current literature with prosthetic joints. Based on this study caution should be used when interpreting a negative gram stain result with appropriate safety netting and follow up required alongside clinical assessment.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_6 | Pages 12 - 12
1 May 2019
Davies P Mayne A Milton J Kelly K Mackinnon F Simpson J
Full Access

Introduction

The number of hip fracture admissions is rising; with reduced hospital bed capacity and increasing patient numbers, care pathways must be optimised to maximise inpatient bed efficiency. There is currently significant interest in improving healthcare services across all 7 days in the United Kingdom. It is unclear whether lack of allied healthcare professional review at the weekend is detrimental to hip fracture patient care. This study aims to examine whether providing 7-day physiotherapy and occupational therapy (7DPOT) service improves outcomes for fractured neck of femur patients compared to a 5-day service (5DPOT).

Methods

All patients admitted with an acute neck of femur fracture were grouped into three cohorts, depending on provision of 7DPOT services: the initial cohort received 5DPOT between December 2012 and March 2013. Seven-day physiotherapy and occupational therapy was introduced for one year from October 2014 until September 2015 (2nd cohort). The service then reverted to 5DPOT between January to June 2016 (3rd cohort). The third cohort was utilised to nullify changes in the overall service which had occurred which were not attributable to 7DPOT. Data was collected prospectively using a specially designed audit tool.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_11 | Pages 48 - 48
1 Jun 2016
Mayne A Davies P Simpson J
Full Access

Introduction

Patients with asymptomatic bacteriuria (ASB) have a significantly increased risk of both superficial wound infection and deep infection following arthroplasty. Debate continues as to whether treatment of pre-operative ASB reduces the risk of subsequent prosthetic joint infection.

Patients/Materials & Methods

All arthroplasty units in Scotland were contacted by telephone and asked a standard series of questions regarding pre-operative urine testing in arthroplasty patients. A review of the literature was also performed.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_12 | Pages 6 - 6
1 Jun 2016
Davies P Mayne A Faulkner A Mackinnon F Simpson J
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The availability of seven-day NHS services for patients is currently receiving widespread national attention. Rehabilitation services including physiotherapy and occupational therapy are not routinely available at the weekend. The aim of this pilot study was to determine if seven-day rehabilitation services led to improved outcomes for hip fracture patients.

All proximal femur fractures were included and formed into two cohorts. Data were collected prospectively in each cohort. Cohort one underwent standard five-day rehabilitation (n=79). Cohort two received seven-day rehabilitation (n=338). Both groups were followed up to 120 days.

No significant differences were observed between the cohorts for pre-fracture place of residence, ASA score or age. Combined median length-of-stay in hospital and rehabilitation improved from 28 to 21 days (p=0.054) Combined median length of stay for patients admitted from home improved from 26 to 19 days (p=0.016).

This pilot study suggests that a seven-day physiotherapy and occupational therapy service may result in decreased total length-of-stay in hospital and subsequent rehabilitation. This is a clear benefit for our patients but also for our hospitals and rehabilitation units where beds are at such a premium. A wider study across multiple institutions within NHS Scotland is now needed to investigate this further.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 21 - 21
1 Oct 2014
Masud S James S Jones A Davies P
Full Access

The K2M MESA Rail is a new implant with a unique beam-like design which provides increased rigidity compared with a standard circular rod of equivalent diameter potentially allowing greater control and maintenance of correction. The aim of this study was to review our early experience of this implant.

We retrospectively reviewed the case notes and radiographs of all consecutive cases of spinal deformity correction in which at least one rail was used. All radiological measurements were made according to the Scoliosis Research Society definitions.

Since June 2012 thirty-three cases of spinal deformity correction were performed using the K2M Rail system. One case was excluded as there were no pre-operative radiographs. Median age was 15 years; there were 23 females. There were 26 scoliosis cases of which two had associated Chiari malformation, three were neuromuscular, and the remainder were adolescent idiopathic cases. Six patients had kyphotic deformity secondary to Scheuermann's disease. Mean length of follow-up was 16 months. In the scoliosis cases the mean pre-operative Cobb angle of the major curve was 58.6° with a mean correction of 35.6°. The mean post-operative thoracic kyphosis was 21.1°. The median number of levels included in the correction was 13. Bilateral rails were used in four cases, the remainder had one rail on the concave side and a contralateral rod. No patients required an anterior release or staged surgery. All kyphosis cases had posterior apical corrective osteotomies. The mean pre-operative thoracic kyphosis was 75.5° with a mean correction of 31°. The median number of levels included in the correction was 11. Four patients had bilateral rails. No patients required anterior release. Complications: two patients had prominent hardware. One patient had a malpositioned screw causing nerve root irritation, which was removed. There were three superficial infections, which settled with antibiotics. There were no cases of implant breakage, screw pull-out, or loss of correction.

The K2M MESA Rail is a powerful new implant design which helps to achieve and maintain satisfactory correction of complex spinal deformity, and is particularly strong at correcting kyphotic deformity. It also enables restoration of normal thoracic kyphosis, particularly in idiopathic thoracic curves, which tend to be lordosing. This may prevent thoracic flat back and potential long-term sequelae. Early results show that the system is as safe and effective as other posterior deformity correction implants on the market, however, it requires further prospective follow-up to ascertain its outcomes in the long-term.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_6 | Pages 16 - 16
1 Apr 2014
Yasso S Towriss C Baxter G Hickey B James S Jones A Howes J Davies P Ahuja S
Full Access

Aim:

To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS).

Methods:

In 2011, 6 males and 2 females had Magec rods, with an average age of 8.5 years (2.9–12.7 years), 7 patients had dual rods, and 1 had single. The main cause of EOS was idiopathic scoliosis (n=6), followed by Congenital (n=1), and Syndromic (n=1). Average follow up was 19.4 months (14–26 months). 4 of these patients had their previous Paediatric Isola growing rods exchanged to Magec, and 1 patient had an exchange from single to Dual Magec rods.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_6 | Pages 18 - 18
1 Apr 2014
Towriss C Baxter G Yasso S James S Jones A Howes J Davies P Ahuja S
Full Access

Aim:

To measure truncal parameters for patients treated with growing rod systems for early onset scoliosis (EOS).

Methods:

44 patients underwent growth rod surgery for EOS between 1999 and 2013 (24 females and 20 males). 27 patients had idiopathic scoliosis, 13 congenital, 3 syndromic and 1 neuromuscular. 26 patients had Paediatric Isola, 8 had Paediatric Expedium, 4 had dual growth rods with domino's and 9 each had VEPTR and MAGEC rods systems. Medical records and radiographs were analysed. Cobb angle, T1-T12 and T1-S1 length, coronal and sagittal balance, apical vertical translation (AVT), space available for the lung (SAL) and shoulder balance were measured.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 22 - 22
1 Jul 2012
Bhagat S Lau S Singh S James S Jones A Howes J Davies P Ahuja S
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Purpose

Retrospective review of growth sparing spinal instrumentation.

Methods and results

Medical records of 30 children with spinal deformity treated were evaluated. There were 14 male and 16 female patients at an average age of 4.9 years (1-14) at the time of presentation. These included 18 idiopathic, 11 congenital and a 14 year old with delayed growth having GH treatment. All patients underwent dual growing rod construct using hook and pedicle screw instrumentation. Extensions were carried out at approximately 6 monthly intervals. Average follow up was 4.2 years (2-8.5) with an average of 7.3(3-15) extension/exchange procedures per patient. Average immediate postoperative Cobb angle was 29(15-55) from a preoperative Cobb of 68(55-100) and this was maintained to a final mean Cobb angle of 30(15-60). Average gain in T1-S1 length was 5.7(3.5-9.8) cm. Five patients had final fusion at an average age of 15.5 years.

There were no infections following primary operation. Out of 249 procedures including extensions/exchange, there were 9(4.5%) episodes of deep infection in 7 patients requiring debridement. Four patients (13%) had revisions for rod breakage/screw loosening/hook pullout/junctional kyphosis and three(10%) had prominent implants.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 24 - 24
1 Jul 2012
Guha A Khurana A Bhagat S Pugh S Jones A Howes J Davies P Ahuja S
Full Access

Purpose

To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching.

Methods and Results

Retrospective review of 50 consecutive adult scoliosis patients treated using anterior only(14,28%), posterior only(19,38%) or combined(17,34%) approaches. All patients were anaesthetised by the same anaesthetist implementing a standard protocol using cell salvage, controlled hypotension and antifibrinolytics.

Mean age was 24.6 years. BMI was 21.9. On an average 9.5(6-15) levels were fused, with an average duration of surgery of 284.6(130-550) minutes. Antifibrinolytics were used in 31(62%) of the patients which included Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Patients on antifibrinolytics had a significantly (p<0.05) lower blood loss (530ml) as compared to other patients (672ml). Mean volume of the cell saved blood re-transfused was 693.8 ml and mean postoperative HB level dropped to 10.7 g/dl(7.7-15) from a mean preoperative of 13.3 g/dl(10-17).

7(42%) with combined approaches and 3(15.8%) with posterior only approach required blood transfusion, 4/50(8%) of which required intra while 6/50(12%) required intra and postoperative transfusion. None of the patients having anterior surgery alone required blood transfusion.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 78 - 78
1 Apr 2012
Dhir J James S Davies P Jones A
Full Access

To assess adverse events related to XLIF approach in lumbar degenerative disease.

Recently novel minimally disruptive spine procedure eXtreme lateral Interbody Fusion i.e XLIF has been developed. It is 90 (off the midline true lateral approach, which allows large graft placement, excellent disc height restoration and indirect decompression at the stenotic motion segment. We describe our experience in 28 patients.

Retrospective review of records of patients undergoing surgery between July 2008- Jan 2010. Presenting complaints, number of levels performed and complications (medical, approach, or implant related) were audited.

Results: 28 patients (17 female: 11 male) with median age of 47 yrs, range (38-75) formed the study group. Average stay was 4 days. All patients had MRI of lumbar spine. 2/3 rd patients had low back pain as their presenting complaint. All patients had nerve monitoring through out the procedure. There were 12 single, 15 two level and 1 three level cases (total 45 levels). 14/28 patients underwent plating at the same time. EBL was 100ml. There were 11/45 adverse events (24.4%). 6 events were approach, 4 were implant bone interface and 1 medical related. Major complication occurred in 1 patient (3.6%).

2/3 rd of patients, were better after the surgery. Almost negligible blood loss, low infection rate and short average stay seemed to work in favour of this approach. Complications are there as (with any new procedure) our results indicate, but these are manageable and less common with this technique.

This did not require Ethics approval and there was no grant or industry support for the above.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 27 - 28
1 Jan 2011
Guha A Khurana A Saxena N Pugh S Jones A Howes J Rhys-Davies P Ahuja S
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We aimed to evaluate the effects of implementing blood conservation strategies on transfusion requirements in adult patients undergoing scoliosis correction surgery. We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients had a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, anti-fibrinolytics used and blood transfused was noted.

50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Antifibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10 (20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

In conclusion, the use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures. In our unit we do not have blood cross matched for anterior surgery alone.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 569 - 569
1 Oct 2010
Vannet N Ahuja S Davies P Hammer K Howes J James S Jones A
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Background: The simultaneous occurrence of spina bifida occulta (SBO) and spondylolysis has been noted previously. The occurrence of SBO and spondylolysis are approximately 17% and 5% respectively.

Aims: The aim of this study was to determine the incidence of SBO when a symptomatic spondylolysis has been proven.

Method: Analysis of four years of lumbar spine CT scans was performed. Patients with spondylolysis or spondylolisthesis caused by a pars defect were identified. These patients’ CT images were then reviewed to establish the patients who also had SBO.

Results: In this unit 650 CT scans of lumbar spines were performed in the last five years. Of these scans 100 (15%) were found to have a pars defect. The average age was 34.6. On CT 30 (30%) patients were shown to have SBO. Of the total 23 were under 18 years old and 13 (56%) of these patients had SBO associated with the spondylolysis. In the over 18 year olds 21 (27%) patients had SBO associated with spondylolysis.

On review of the 550 other scans the average age was 51.9 years old. The incidence of SBO within this group is 10%. Only 6% of these patients were under 18. Out of these 33 patients 30.3% (10 patients) had SBO. Over 18 the incidence of SBO was only 8.5%.

Conclusions: Our results indicate that the occurrence of SBO within the group with a spondylolysis is much higher than in the group where no spondylolysis is present. There is higher incidence of SBO in the younger patients with spondylolysis. 56% of paediatric patients with symptomatic spondylolysis will have SBO. Clinicians should be aware of this fact preoperatively to decide on the technique of repair of the symptomatic lysis.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 383 - 383
1 Jul 2010
Kempshall P Jemmett P Evans S Davies P Jones D Howes J Ahuja S
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This study aims to evaluate the accuracy of sheer off self limiting screw drivers and to assess repeatability with age.

It has been reported that overzealous tightening of halo pins is associated with co-morbidity. Our unit has recently received a tertiary referral where the patient over tightened a pin leading to intracranial haematoma, hence our interest in this subject. The torque produced by six new and nine old screw drivers was tested using an Avery Torque Gauge and a Picotech data recorder. These devices are designed to produce a torque of 0.68 Nm, any greater than this is potentially hazardous. Accepted error for each device was +/− 10%. The average torque produced by the new screw drivers was 0.56 Nm with a range of 0.35–0.64 Nm (SD 0.120). The older screw drivers produced an average torque of 0.67 Nm ranging from 0.52–0.85 Nm (SD 0.123).

In conclusion, sheer off self limiting screw drivers are not accurate devices. The older devices are more likely to produce a torque exceeding a safe range and therefore we would recommend the use of new devices only.

Ethics approval: none audit.

Interest statement: none local grant.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 427 - 427
1 Jul 2010
Foulkes R James S Jones A Howes J Davies P Ahuja S
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Background: It remains unclear and controversial whether preoperative magnetic resonance imaging (MRI) in patients with adolescent idiopathic scoliosis (AIS) should be mandatory.

Aim: (1) To review our own practice, (2) conduct a national survey of United Kingdom Consultants, and (3) to perform a literature review.

Methods: Our own practice was established by identifying patients with AIS and examining whether an MRI scan was performed preoperatively. A survey of Consultants practice in the UK (British Scoliosis Members) was conducted by either an e-mail or telephone conversation. Finally, a literature survey was performed to establish current views.

Results: 118 patients with AIS were identified between 2003 and 2007. 78% of these patients underwent pre-operative MRI scans. Neural axis abnormalities were found in 8% of these patients. They included syrinx’s, chiari malformations, tonsillar herniation, cord tethering, central canal dilatation and undiagnosed spina bifida. Only 1 patient required intervention by the neurosurgeons. 92% of respondents to the national survey routinely performed preoperative MRI scans. The literature was not conclusive with regards to mandatory preoperative imaging.

Conclusion: Despite the literature showing little evidence, our survey shows a widespread consensus in clinical practice across the UK that routine preoperative MRI should be performed from a risk management viewpoint. It is mandatory in our unit to perform pre-operative MRI scans on all patients with AIS and would recommend that this becomes standard practice in all other units.

Ethics Approval: None/Audit

Interest Statement: None


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 494 - 494
1 Sep 2009
Batra S Ahuja S Jones D Jones A Howes J Davies P
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In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to

Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia.

Patients’ experiences of information regarding the risk of such complications and how the information affects the patients.

Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction.

The study had a non-randomized design and patients divided into TWO groups Group A and group B.

The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.

For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.

Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 482 - 482
1 Sep 2009
Guha A Khurana A Saxena N Pugh S Jones A Howes J Davies P Ahuja S
Full Access

Introduction: Scoliosis surgery involves major blood loss, at times exceeding estimated blood volume.

Aim: To evaluate the effects of implementing blood conservation strategies (including cell salvage, controlled hypotension and anti-fibrinolytic drugs) on transfusion requirements in adult patients undergoing scoliosis correction surgery. To establish a protocol for cross matching of blood.

Study Design: We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients were anaesthetised by the same anaesthetist who implemented a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, antifibrinolytics used and blood transfused was noted.

Results: 50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Anti-fibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

Conclusion: Use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures.

In our unit we do not have blood cross matched for anterior surgery alone.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 495 - 495
1 Sep 2009
Khurana A Guha A Howes J Jones A Davies P Mohanty K Ahuja A
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Introduction: Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following the arthrodesis.

Aims and Objectives: To evaluate the functional and radiological outcome following percutaneous technique for SIJ fusion with HMA (Hollow modular anchor-age) screws.

Materials and Methods: 15 consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The Hollow modular anchorage (HMA) screws (Aesculap Ltd, Tuttlingen) packed with bone substitute were implanted percutaneous under fluoroscopic guidance

Results: The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p < 0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p< 0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post operative or radiological complications in any patient.

Conclusion: Percutaneous HMA screws are a satisfactory way to achieve sacro-iliac stabilisation.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 483 - 483
1 Sep 2009
Mehta J Paul I Hammer K Jones A Howes J Davies P Ahuja S
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Background: Radicular pain has been reported even in the absence of a compressive lesion. It has been postulated that annular tears provide a conduit for pro-inflammatory substances, which can leak around the nerve root causing radiculitis. A link between the side of back pain and the side of the annular tear has been reported.

Objective: To establish whether the side of the annular tear may influence the side of the leg in a non-compressive setting.

Methods and patients: We identified 121 patients from the patients referred to our unit with back and radicular leg pain. The mean age of the cohort was 50 yrs and 49% were male. All these patients were investigated with an MRI scan that demonstrated no compression of the nerve root. We used strict exclusion criteria to exclude the patients with any neural compression, previous lumbar operation, degenerative deformity or an associated pathology such as peripheral neuropathy.

Results: The annular pathology was described as annular tears (47 patients) and non compressive disc bulges (106 patients). The odds ratio for the concurrence of an annular tear causing ipsilateral leg pain is 1.05 and for a non-compressive disc bulge causing ipsilateral leg pain is 2.14

Conclusion: A non-compressive disc bulge is more likey to cause radicular symptoms than an annular tear. Though, both these annular lesions can cause ipsilateral nerve root symptoms.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 479 - 479
1 Aug 2008
Shanbhag V Ahuja S Jones A Davies P
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Anterior Lumbar Interbody Cages are used to recreate the lumbar lordosis in scoliosis surgery as anterior instrumentation is usually kyphogenic. We report two cases in which an anterior release was performed and interbody cages were used.In both these patients the cage was displaced anteriorly by an incorrectly positioned pedicle screw during posterior instrumentaion. In one case the cage was retrieved and correctly repositioned from the back using a TLIF approach, in the other this was noticed only post-operatively and patient needed another anterior surgery. We recommend a lateral Image Intensifier screening for combined anterior and posterior cases in which anterior cages are used in addition to posterior pedicle screws to prevent this complication.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 483 - 483
1 Aug 2008
Mehta J Hammer K Khan S Paul I Jones A Howes J Davies P Ahuja S
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Objective: To assess the correlation between the side of the annular pathology and the radicular symptoms, in the absence of a compressive root lesion.

Materials and Methods: 121 patients underwent MRI scan fro axial back and radicular symptoms. The mean age was 49.9 yrs (24–80). The sex distribution was equal. We excluded the patients that had a compressive lesion, previous operations, spinal deformity, spondylolyses, an underlying pathology (tumour, trauma or infection) or a peripheral neuropathy. Annular pathology was documented as annular tear or a non-compressive disc bulge with its location and side. We also recorded marrow endplate changes and facet arthrosis.

Results: Bilateral radicular symptoms were reported in 16 (13.2%): right side in 33 (27.3%) and left in 47 (38.8%) patients. Additionally, 82 patients (67.8%) had axial back pain. 33 patients (27.3%) were noted to have a right sided annular pathology (tear or bulge) and 72 (59.5%) had a left sided annular lesion. 21 patients (17.4%) had a central annular tear and 43 (35.5%) had a generalised disc bulge. 14 patients (11.6%) with right sided symptoms also had annular pathology, while 38 patients (31.4%) with left sided symptoms had a left sided annular lesion. There was no statistical correlation between the side of symptoms and the side of the lesion (r = −0.00066, p=0.994), any particular annular pathology (annular tear r=0.085, p=0.35; disc bulge r-0.083, p=0.36). There was no correlation between the axial back pain and the annular pathology (r=0.004; p=0.97) and facet joint or marrow end plate changes (r= −,29, p=0.76).

Conclusions: Although annular pathology can cause the radicular symptoms, our results suggest that they do not influence the side of the symptoms.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 482 - 482
1 Aug 2008
Mehta JS Hipp J Fagan D Shanbhag V Jones A Howes J Davies P Ahuja S
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Objective: To assess the temporal geometric sagittal profile changes on serial radiographs of fractures of the thoracic and thoraco-lumbar spine.

Materials and methods: We have included 103 patients with thoracic or lumbar fractures were treated at our unit between June 2003 and May 2006. The patients were suitable for non-operative treatment. The mean age of the cohort was 46.9±2.4 (16–90). The sex distribution was equal. 94 patients had a single level lesion. 19 fractures were in the thoracic spine; 64 in the thoraco-lumbar (T11-L1) and 29 between L2 and L5. The radiographs were scored using the AO classification by 2 senior orthopaedic trainees. The radiographs were analysed at the Spine Research Laboratory. The results were computed using Stat, a statistical software.

Results: The changes were assessed over a mean period of 5.6 mo (range 1–49 mo; 95% CI 4.1–7.1 mo). Weighted kappa score of 0.58 was computed for the primary fracture type and 0.22 for the fracture sub-types. The inter-observer rater agreement was similar to that reported in literature. 7 patients showed a significant collapse. We report the association between the fracture types and the extent of collapse. We have also assessed the association between the medium to long term symptoms, the fracture types and the extent of collapse at the fracture sites and the adjacent disc.

Conclusion: Some fracture sub-types are more likely to collapse and cause long term symptoms. Identifying these fractures at the outset would help clarify surgical indications.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 480 - 480
1 Aug 2008
Mehta JS Sharma H Jones A Howes J Davies P Ahuja S
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Objective: To do assess changes in patients’ symptoms and the operative plan.

Materials and methods: 147 patients on a spinal surgery waiting list were assessed at a mean wait of 15.8 ± 1.3 months. 89 (61%) were male and 58 (39%) were female at a mean age of 49.7 yrs (16–78). 123 patients had a degenerative condition (20 cervical; 03 lumbar); 20 patients were seen for scoliosis; 2 with a post-traumatic kyphosis and 1 each with ankylosing spondylitis and a psudarthrosis.

Outcomes assessed: Changes in patients symptoms; changes from the initial operative plan when listed; requirement for re-imaging due to the wait.

Results: 31 patients reported improved symptoms at the re-assessment, while 96 were worse off and 20 were unchanged. 137 had axial pain when listed which changed to 116 at review (p=0.0018). 130 had radicular pain when listed which improved to 80 on re-assessment (p< 0.0001). However 19 reported an increase in the axial and 17 in the radicular symptoms. 71 patients (48.3%) required to be re-imaged at the re-assessment due to changes in the clinical picture. 42 patients received the procedure as originally listed. 30 patients were taken off the list, 24 received a different operation, and 38 had an interim or a definitive needling procedure while 13 await a re-assessment.

Conclusions: On the basis of the observations on our cohort, 1 in 5 operations were cancelled; 65% had an increased severity of the symptoms and just 1 in 3 patients were operated as planned while 48% required re-imaging. A long wait inevitably leads to changed symptoms and a review of these patients is mandatory. The review and the re-imaging adds to the burden on the already over-loaded system.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 458 - 459
1 Aug 2008
Shanbhag V Ghandour A Lyons K Jones A Howes J Ahuja S Davies P
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Introduction: Sacroiliac joint pathology can contribute to lowback pain and sciatica. Its frequency and significance is controversial.

Aims: The purpose of this study is to evaluate the incidence and clinical significance of positive SI joint pathology on MRI scans.

Methodology: 353 MRI reports and scans carried out over a one year period for backpain and sciatica were reviewed. Demographic data and clinical notes of patients who had positive SI joint pathology on MRI scans were analysed. Correlation between clinical suspicion of SI joint pathology and MRI findings was studied.

Results: 12 scans showed pathology in the SI joint, an overall incidence of 3.3%.8(66%) were males and 4(33%) females. Only 4(33%) of these patients had Plain Film abnormality. Average age of 41.2 years (33–54). One patient was known case of Ankylosing Spondylitis. Other positive pathology included oedema, sclerois and bridging osteophytes. Clinicians requested inclusion of SI joint in 43 patients. 8 of these were positive, an incidence of 18.6%. In 130 patients, the SI joints were imaged as routine. This yielded positive pathology in 4 patients (3%).

Conclusion: Our study concludes that 18.6% of patients who are suspected to have SI joint involvement clinically have positive pathology on MRI scans.

Routine inclusion of imaging of the SI joint as part of lumbosacral spine MRI for back pain and sciatica shows only 3% positive results.

SI joint should be imaged only if clinically suspected.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 480 - 480
1 Aug 2008
Shanbhag V Paul I Joshy S Jones A Howes J Davies P Ahuja S
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Aim: To assess if commonly used scoliosis instrumentation activates metal detectors at airport security gates.

Methods: 20 patientswho had travelled by air following scoliosis surgery were included. The type of instrumentation, number of journeys, body mass index and whether the alarm was triggered off by the airport security detector was recorded. We asked the patients opinion regarding provision of documentary evidence of surgery.

Results: 10 patients had posterior instrumentation, 5 patients -Paediatric ISOLA,4 patients had anterior instrumentation and one patient, anterior and posterior instrumentation. 12 patients (60%) had travelled more than four times by air following surgery corresponding to 48 passes through an airport archway detector.5 patients out of 20 had set off the alarm while passing through the metal detector everytime of which 4 had posterior instrumentation and 1 anterior instrumentation. None of the patients with ISOLA instrumentation set of the alarm. Two patients had set off the alarm every time they passed through the metal detector and both of them had posterior instrumentation. 14 patients(70%) suggested that we should provide documentary evidence of surgery to avoid delays in the airport security check. 25 % of patients set of the metal detector alarm following scoliosis instrumentation.

Conclusion: Patients with posterior instrumentation are more likely to set off the alarm compared to patients with ISOLA instrumentation. It is important to be aware that scoliosis instrumentation can activate airport archway detectors in our present security climate and to provide documentation to patients in order to avoid embarassment and delays.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 480 - 480
1 Aug 2008
Turner B Shanbhag V Jones A Howes J Davies P Ahuja S
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Introduction: Scoliosis Nursing service was introduced at the Cardiff Spinal Unit in 2003 as part of a multi-disciplinary team to improve quality of care for the patients and their families.

Background: This nurse is a point of contact at pre-admission and discharge. She co-ordinates the peri operative care and liases with other team-members including physiotherapists, occupational therapists and dieticians. Information regarding type of surgery, pain management, wounds/dressings, investigations is offered.

Aims and Objectives: To assess patients’ and families perception and satisfaction with the various aspects of care provided by the Scoliosis Nurse.

Methods and Materials: From 2005 to 2006, 30 consecutive patients and families who had seen the Scoliosis Nurse filled a questionnaire. 25 questionnaires were completed. Response was collated by an independent observer.

Results: All (100%) respondents felt that the presence of a nurse in clinic was beneficial. (100%) reported that they had received adequate information and literature. 66% of the patients felt a pre admission ward visit would be beneficial. 63% felt that further information about discharge and aftercare would be helpful.

Conclusion: Thus the Scoliosis Nurse was perceived to be beneficial by the patients and the family. Based on the abovefeedback the patient Information booklet has been updated.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 478 - 478
1 Aug 2008
Roberts D Shanbhag V Coakley M Jones A Davies P Howes J Ahuja S
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Paravertebral anaesthesia is a particularly effective, safe and reliable option in scoliosis patients undergoing anterior release in whom percutaneous epidural placement may be difficult to perform. A recent systematic review and meta-analysis of randomized trials has demonstrated that whilst paravertebral block and thoracic epidural insertion provide comparable pain relief after thoracic surgery, paravertebral block placement is associated with a better side effect profile, including a reduction in pulmonary complications, hypotension, nausea and vomiting and urinary retention. We describe a case of a 16 year old female patient who underwent staged correction of her thoracolumbar scoliosis. A paravertebral catheter was inserted under direct vision for continuous infusion post operative analgesia following the anterior release. 48 hours after surgery a swelling was noted in the groin, which was confirmed with ultrasonography as a fluid collection. The swelling resolved upon removing the paravertebral catheter. This suggests that it was caused by the local anaesthetic fluid tracking along the psoas muscle. Retroperitoneal infections, venous thrombosis, femoral hernia, femoral artery aneurysm and inguinal lymphadenopathy are other differentials. Ultrasonography was a fast and sensitive investigation to rule out these differentials and determined that fluid communicating with the abdominal cavity was the cause for this swelling. The infused local anaesthetic had tracked down into the femoral triangle and the swelling resolved upon cessation of the infusion.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 480 - 480
1 Aug 2008
Shanbhag V Roberts D Turner B Jones A Howes J Davies P Ahuja S
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Background data: Previous studies have questioned the quality of information available on the internet. Internet research has proven to more prevalent among scoliosis patients as compared to other orthopaedic conditions.

Aim: Scoliosis websites identified by commonly used search engines were assessed for quality and medical accuracy.

Methods: The word scoliosis was entered into top six search engines and Websites ranked according to frequency. Five websites from the worldwide web and five from the UK only search were evaluated by medical professionals – 4 spinal consultants, 2 registrars, 3 nurses and 1 physiotherapist. 10 patients/carers who had scoliosis surgery also assessed these sites. A scale of 1 to 5 was used for ease of understanding, reliability, clinical correlation, adequacy and links and average score calculated.

Results: None of the top five UK websites figured in the top 5 WWW searchs. Scoliosis research society (SRS) and American Academy of Orthopaedic Surgeons (AAOS) website scored the highest by clinicians and patients in the www list. From the UK list, SAUK website scored the highest with both groups followed by Great Ormond Street Hospital (GOSH) website. We compared the assessment of websites by a healthcare professionals and by patients who had undergone treatment and showed no statistical difference in the scoring.

Conclusion: As treating clinicians it is necessary to educate patients by guiding them to reliable internet sites like SAUK and SRS.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 480 - 480
1 Aug 2008
Mehta JS Acharya A Jones A Howes J Davies P Ahuja S
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Objective: Prolonged waiting time after being referred for a specialist opinion has plagued the NHS despite pressures to deliver optimum healthcare. We have assessed changes in clinical situation in patients referred to a spinal service while awaiting the first assessment.

Materials & Results: 89 patients were referred to our unit between Jan 2001 and December 2004. The gender distribution in this cohort was equal and the mean age was 50.7 yrs. The mean delay for being seen in the clinic was 28.4 mo (16–58 mo). Significant changes in the symptom pattern were noted in 46 patients, of which 8 patients reported radicular symptoms on a different side. In addition, 7 patients experienced an increased severity in the existing symptoms. 43 patients had been referred to us with an MRI. However due to the delay, 20 of these patients required re-scanning. Following the clinical assessment 25 patients were referred for Physiotherapy, 4 patients required a further clinical review and 44 patients were referred for further imaging.

Conclusion: The problem of excessive out-patient waiting time results in changes in symptom patterns and an increase in the severity of existing symptoms. The changes frequently results in an increased requirement of re-imaging.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 481 - 481
1 Aug 2008
Shanbhag V Gough J Khan S Jones A Howes J Davies P Ahuja S
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Background data: The Paediatric Isola system uses the philosophy of torsion-countertorsion force as a means of scoliosis correction. It aims to maintain this correction till such time that definitive fusion can be carried out.

Aim: This is a retrospective case series of our experience with the Paediatric Isola system and we evaluated the results of this system in the treatment of Scoliosis of various etiologies.

Methods: Twenty –one children,5 with neuromuscular,1 with Ehler-Danlos,5 with idiopathic,3 syndromic and 7 congenital treated with the Isola Instrumentation were studied.

Average age was 6.5 years(2–12). Average follow-up was 24 months (6m-36m).

Results: The average Cobb angle was 52° before surgery, 33.7° after surgery (64 % correction) and 32.5° (62.5% correction) at latest follow-up. The mean apical vertebral translation was 86% and 84% at post-op and latest follow-up. Stabilisation was most commonly perfomed from T2 to L4/L5. Three patients had implant complications, two had deep seated wound infections which necesssiated removal of implants in one case. Five of these patients have gone on to definitive fusions. Curve correction was best for primary thoracolumbar curves and lumbar curves. 2 patients with thoracic curves did not maintain correction.

Conclusion: The Paediatric Isola system is a safe and effective instrumentation in early management of a difficult and challenging sub group of scoliosis patients.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 459 - 459
1 Aug 2008
Dillon D Jones A Ahuja S Hunt C Evans S Holt C Howes J Davies P
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Introduction: Restoration of vertebral height for burst fractures can be achieved either anteriorly, posteriorly or combined.

Aim: To biomechanically assess and compare stiffness of 1) posterior pedicle screws with Synex, 2) Synex+ Double screw+rod Ventrofix 3) Synex+ Double screw+ Single rod and 4) Synex+ Single screw+ Single rod in reconstructing an unstable burst fracture following anterior corpectomy.

Method: Fresh frozen calf lumbar spines (L3–L5) were dissected and L4 corpectomy performed. L3 and L5 were mounted on a plate and fixed. Loads were applied as a dead weight of 2Nm. The range of movement was measured using the Qualisys motion analysis system using external marker clusters attached to L3 and L5. Bony landmarks were identified with marker clusters as baseline. The movement was measured between the 2 marker clusters.

Five specimens were implanted for each group 1) with pedicle screw (into L3 and L5) and tested with/without Synex (expandable) cage anteriorly, 2) implanted with a Synex cage and Double screw+rod Ventrofix system, 3) Synex cage and Double screw+ Single rod Ventrofix construct and 4) Synex cage and Single screw+ Single rod Ventrofix system.

Results: Reconstruction of the anterior column with the combination of Synex and double rod Ventrofix produces a stiffer construct than the pedicle screw system in all planes of movement (p= 0.001 in rotation).

The double screw/ single rod system is less effective than the Ventrofix System but is comparable to the pedicle screw construct.

The single screw/ single rod construct leads to unacceptable movement about the axis of the inferior screw particularly in extension with a ROM much greater than the intact spine (p< 0.001)

Conclusion: Thus biomechanically we recommend Synex and double rod Ventrofix construct to reconstruct the anterior vertebral column following corpectomy for unstable burst fractures.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 447 - 447
1 Aug 2008
Manoj-Thomas A Shanbhag V Vafadis J Jones A Howes J Davies P Ahuja S
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Aim: To determine the incidence of adjacent level osteophytes in patients who have had anterior cervical fusion using an anterior cervical plate as compared to those who are fused without an anterior cervical plate.

Design: We retrospectively reviewed the lateral radiograms of sixty two patients who have had an anterior cervical fusion with a minimum follow up of twelve months.

Materials and methods: We looked for the development of adjacent level osteophytes in these patients at their final follow up, which was generally at the time radiological fusion. There were 27 patients in the first group who had an anterior cervical plate used to fix the vertebrae in addition to the Cervios cage, while the 35 patients in the second group in whom only a Rabea cage was used for the fusion. The mean follow-up was 20.6 months (range 12–48).

Results: 64.3% of the patients who had an anterior cervical plate developed adjacent level osteophytes while none of the patients who have had the fusion without the cage developed the osteophytes.

Conclusion: We found the patients who had an anterior cervical interbody fusion using a plate had a significant risk of developing adjacent level osteophytes while this is not seen in patients who do not have the plate for the fixation.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 233 - 233
1 May 2006
Williams T Williams D Ahuja S Jones A Howes J Davies P
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Background: More patients are turning to the Internet for health-related information. Studies indicate that this information is being used to make decisions about their management. The aim of this study was to assess the information available specific to scoliosis on the Web using four common search engines.

Methods: Four search engines (Google, Yahoo, Hotmail and Ask Jeeves) were used in scanning the Web for the following key word- “Scoliosis”. Both U.K. only and World Wide sites were accessed. Four Spinal Surgery Consultants independently graded each site for layout, content, relevance to patients as opposed to medical professionals, ease of use and links to other sites. Each point was marked on a scale of 0–2 and a total of 10 points available. Web sites were assessed via U.K. search engines and forty via World Wide search engines. Good was awarded to a site with a score of 7–10; an average awarded for a score of 4–7 and poor was given to a site with a score of 0–4.

Results: For the U.K. search engines, twenty sites were evaluated and five common sites identified (spineuniverse.com, S.A.U.K.org, orthoteers.co.uk, B.O.A.ac. uk and scoilosis.info). From these sites only two were given a rating of good. For the World Wide Web search engines eighteen sites evaluated and seven common sites identified (SRS, spineuniverse.com, scoliosis.org, orthinfo.aaos.org, iscoliosis.com, scoliosisrx.com and scoliosis-world.com). From these sites four were given a rating of good. It was evident that the Scoliosis Association of United Kingdom did not appear in three of the search engines but only in Hotmail.

Conclusion: These results suggest that there are good sites available for patients to access information with regards to their condition and treatment options but there are also very poor sites available where incorrect information is available. Commonly, unfamiliar users of the Web will not search U.K. sites specifically and could easily miss the S.A.U.K. site, which is an excellent site and was one of the two sites via the U.K. search engine awarded a good score. Obviously, there were more good sites via the World Wide Web due to the American healthcare system. We recommend that leaflets should be available to parents and patients with scoliosis with information from the BSS of the condition and available Web sites with good ratings. Also we recommend that these sites be linked to the Royal College of General Practitioners Web site to provide reference on good practice.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 218 - 218
1 May 2006
Lakshmanan P Ahuja S Davies P Howes J
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Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging.

Purpose The aim of this study is to find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who were diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level while it was in two patients in Group II (L4/5 or L5/S1). Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score(p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. There is no significant difference in the duration of the procedure as well between the two techniques. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 153 - 153
1 Mar 2006
Lakshmanan P Ahuja S Davies P Howes J
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Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging. The entry point and the direction of the needle entering into the facet joint are different in these techniques. Further the difficulties encountered in both the techniques are different.

Purpose To find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who was diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level (L4/5 or L5/S1) while it was in two patients in Group II. Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score (p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 154 - 154
1 Mar 2006
Lakshmanan P Jones A Lyons K Ahuja S Davies P Howes J
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Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The severity was graded into none, mild, moderate and severe, depending on the cortical thickness, trabecular pattern, and the size of holes (absence of trabeculae) using sagittal, coronal and transverse sections of CT scan pictures. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearsons Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (Chi-square value = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_II | Pages 120 - 120
1 Feb 2004
Ahuja S Howes J Davies P
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Objective: Surgical correction of scoliosis in small stature children is challenging due to the profile of the posterior instrumentation traditionally available. Concerns are also raised with the use of 5 mm rods for posterior correction. The Paediatric USS is a small stature System.

We studied the correction achieved and the maintenance of the correction at a minimum 15 months follow up using the Paediatric USS.

Design: 20 patients with a minimum 15 months follow up were included in the study. Measurements were made for the initial correction of the Cobb angle to assess correction. At 15 months follow up the cobb angle was measured to assess maintenance of correction.

Results: The average age of the patients was 12 ½ years. The average weight was 32 kgs. The commonest etiology was paralytic(40%) followed by congenital (30%), idiopathic (25%) and collagen disorder (5%). King type II (45%) and type IV (35%) were the commonest type of curves. Combined anterior release and posterior stabilization and fusion was the commonest procedure performed. The average pre op Cobb angle was 77.7°, which corrected to 37.6° i.e. 49%. There was no significant loss of correction at 15 months follow-up.

Conclusions: Thus the Paediatric USS allows adequate correction of the curve and does maintain the correction achieved at a minimum 15 months follow up


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_II | Pages 112 - 112
1 Feb 2004
Ahuja A Ahuja S Howes J Davies P
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Objectives: Quantitative research methods have highlighted the psychological implications of spinal deformities in adolescence. However these methods are limited in exploring the adolescent’s perception of the illness and the expectations from treatment. Hence we carried out detailed qualitative interviews with these adolescents and where applicable with their families to examine these issues

Design: Individual contact was made with the adolescents attending the spinal deformity clinic in a specialist centre in Cardiff. Following their consent an interview was carried out using a qualitative semistructured format

Subjects: A total of 10 adolescents and their families attending the spinal clinic for treatment were interviewed

Results All the adolescents and their families had sufficient information and fairly good understanding of their condition and of the treatments available. The impact the deformity had on the individual’s life was variable. Social impairment was higher in these individuals and this was reflected in their interaction with their peers. Most of the families desired an expected timetable of treatemnt and sequence of events. They also felt the lack of buddy or self help gropus. It also gave a better understanding into these teenagers perception of their condition and their attitude towards treatment

Conclusions: These issues probably need to be understood while dealing with these individuals and their families and as health professionals we need to be sensitive to these issues.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_I | Pages 15 - 15
1 Jan 2003
Dillon D Ahuja S Evans S Holt C Howes J Davies P
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Controversy exists as to whether the biomechanical properties of a 360 lumbar fusion are influenced by the order in which the anterior and posterior components of the procedure are performed.

The fusion technique used Magerl screws to effect the posterior fusion and a Syncage implant (Stratec) to effect the anterior component of the fusion.

Isolated motion segments from calf spines were tested in each of two groups of five. In the first group the posterior fusion was performed first and in the second group the anterior fusion was performed first. Loads were applied as a dead weight of 2Nm in each range of movement of the spine (flexion/extension, lateral flexion and rotation). The range of movement was measured using the Qualisys motion analysis software linked to a set of five cameras, using external marker clusters attached to the vertebral bodies. Each motion segment was tested prior to instrumentation, post anterior or posterior instrumentation and with both anterior and posterior instrumentation.

Ranges of movement following 360 instrumentation were increased in all planes tested when posterior fixation was performed first; flexion/extension 26% v 55% (p=0.020), lateral flexion 18% v 34% (p=0.382), and rotation 18% v 73% (p=0.034).

It was concluded that posterior fixation should not be performed prior to anterior fixation as this results in a significant loss of stability in both flexion/extension and rotation


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_I | Pages 4 - 4
1 Mar 2002
Evans S Bose D Jones L Pullin R O’Doherty D Holford K Davies P
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Interbody fusion is increasingly widely used as a treatment for intervertebral disc disorders, but the biomechanics of the procedure are not well understood. The compressive loads through the spine are largely carried by the implant or bone graft, which typically rests on a relatively small area of the vertebral body. As the compressive strength of the bone is very low, subsidence of the implants into the vertebral bodies is a common clinical complication.

Previous biomechanical studies of spinal fusion have concentrated on the stiffness of the constructs, which is important in promoting fusion. Preliminary studies have shown that there are large differences in compressive strength between different implant systems, and gave an insight into the biomechanical factors that are important in determining the strength of spinal fusion constructs. This paper reports part of a larger on going study comparing anterior and posterior fusion systems, with various methods of fixation.

A major problem in interpreting the results of these tests is to distinguish between initial settling of the implants and the onset of failure to construct. We have developed a novel technique using acoustic emission monitoring to detect microcracking in the bones, which allows the onset of failure to be distinguished from initial bedding in of the implants.

Two implant systems were tested, the Syncage and the Contact fusion cage. The cages were implanted into porcine lumbar spines at L4-L5, and the implanted motion segment was then dissected out. Steel plates were mounted on each end using bone cement to ensure an even distribution of load through the vertebral body. The complete constructs were then loaded in compression, using acoustic emission sensors to detect microcracking in the bones. The load was cyclically increased in o.5kN steps until failure occurred.

The acoustic emission technique gave a sensitive indication of the onset of damage in the bones and allowed the initial settling of the implant under load to be identified. Using cyclic unloading and reloading, it was possible to accurately identify whether this damage had weakened the construct or increased its strength by redistributing stress concentrations. Initial results indicate that the Contact fusion cage fails at a much lower load than the Syncage in this model; this is ascribed to the very small contact areas between the cage and the vertebral body, which results in high compressive stresses in the bone. Under large compressive loads it appears that the constructs become unstable, and fail by buckling and plastic collapse of the vertebral bodies. Various failure models are therefore possible depending on which part of the vertebral body starts to collapse first.


The Journal of Bone & Joint Surgery British Volume
Vol. 66-B, Issue 3 | Pages 326 - 330
1 May 1984
Davies P Humphries M Byfield S Nunn A Darbyshire J Citron K Fox W

Of the 4172 patients in a survey of all cases of tuberculosis notified in a six-month period in England and Wales in 1978-79, 198 had a bone or joint lesion; 79 were white and 108 were of Indian subcontinent (Indian, Pakistani or Bangladeshi) ethnic origin. The estimated annual notification rates for orthopaedic tuberculosis were 29 per 100 000 for the Indian subcontinent group and 0.34 per 100 000 in the white group, a ratio of 85 to 1. Rates increased with age in both groups. The spine was the most common site, and was affected in 30% of the white patients and 43% of the Indian subcontinent patients; the distribution of other sites was similar in both groups. Positive culture from a bone or joint lesion was obtained in 99 (50%) of the 198 patients (58% of white patients and 47% of the Indian subcontinent patients). Bacteriological or histological confirmation of tuberculosis either from a bone or joint lesion or from another site was obtained in 68% of the patients. Mycobacterium tuberculosis was isolated from the orthopaedic lesions in 79 of the 82 patients with identification test results and M. bovis in the 3 remaining patients. Of the 61 patients with M. tuberculosis and with no history of previous chemotherapy, 5 had resistant strains compared with 1 of the 18 patients who had previously received chemotherapy. All 6 patients with resistant strains were of Indian subcontinent ethnic origin.