Background

Cauda Equina Syndrome (CES) needs to be diagnosed and managed promptly to ensure the best outcome for patients. Our current spinal service has been centralised, with referrals currently delivered via an online system. This means that patients aren't seen by spinal specialists until confirmed radiological diagnosis. To ensure patient safety, we must make sure that our CES pathway is as robust as possible.

Purpose of study and background

Spinal surgery is a high-risk surgical speciality, a patient's understanding of surgical interventions, alternative treatment options, and the benefits and risks must be ascertained to gain informed consent. This pilot study aims to evaluate if the provision of a digital recording of a patient's consultation enhances patient satisfaction, improves recall of clinical diagnosis, recall of treatment options and the risks and benefits of Spinal Surgery.

Purpose of Study and Background

Degenerative cervical myelopathy resulting in cord compromise is a progressive condition that results in significant quality of life limitations. Surgical treatment options available are anterior and/or posterior decompression of the affected levels. Patients are counselled pre-operatively that the aim of surgical intervention is to help prevent deterioration of neurology. Anecdotal evidence suggested improvements in both EMS and PROMs in this cohort of patients. A 2-year prospective study tested this hypothesis.

Background

Advances in surgical and anesthetic technique have resulted in a reducing length of stay for lumbar decompression, with the first day case procedure published in the literature in 1980. Current evidence suggests day case surgery is associated with improved patient satisfaction, faster recovery, reduced infection rates and financial savings. Following the introduction of a locally agreed day case protocol for lumbar microdiscectomy, we reviewed our 30-day postoperative complication rates.

Background

PROMs have become an integral assessment tool of clinical effectiveness and patient satisfaction. To date, PROMs for lumbar discectomy are not an NHS requirement, although voluntary collection via the British Spine Registry is encouraged. Despite this, PROMs for day case microdiscectomy is scarcely reported. We present PROMs for day case microdiscectomy at Lancashire Teaching Hospitals.

Purpose of Study/Background

To identify whether patients were satisfied with the overall educational component of the specialist nurse (CNS)/occupational therapist (OT) led pre-operative assessment clinic in order to identify areas which required improvement.

The pre-operative specialist nurse led clinic was set up in 2002. The aim was to provide high quality information to patients undergoing elective spinal surgery in order to manage expectations and optimise post-operative recovery. Initially the clinic was specialist nurse led however, in 2006 occupational therapy input was introduced in order to provide an increased depth of information in regard to function and activities of daily living post operatively. In addition this has allowed assistive equipment to be provided pre-operatively. The format of this clinic has enhanced the patient's journey by facilitating reduced length of stay and more timely discharge.

Aim

To assess the safety of day case lumbar decompressive surgery

Aim

To assess the safety of Zero Profile Interbody fusion (Zero P) device in Anterior Cervical Decompression and fusion (ACDF) for degenerative cervical stenosis.

Introduction

Orthopaedic Spinal Rapid Access Service (OSRAS) was developed in our institute to provide a structured pathway for management of urgent spinal pathologies during working hours of Monday to Friday. It was delivered through a published rota by a multi displinary team of Extended Scope Practitioner carrying a bleep and a Spinal Surgeon.

Introduction

Spinal conditions commonly cause pain and disability. Various non-operative treatments including acupuncture are practiced for these conditions.

Introduction

Both intra- and post-operative radiographs are traditionally obtained after instrumented lumbar spinal surgery; however the clinical advantage of routine post operative images has not been demonstrated.

Aim

To investigate the role of websites in enhancing patients' understanding of reason and risk of surgery as a part of informed consent for elective un-instrumented lumbar spine surgery (EULSS).

Aim

The aim of this study is to evaluate the causes of litigation in spinal surgery and to identify preventable causes.

Aim

Assess efficacy of caudal epidural injection with epidurogram with validated outcome measures.

Aim: To evaluate patient satisfaction between telephone and traditional outpatient appointments following un-instrumented spinal surgery.

Material and Methods: The study was approved by the local audit committee. Fifty seven patients who underwent un-instrumented lumbar spinal micro-decompressive surgery in 2008 were identified from Bluespiers database and were contacted by telephone. A predesigned proforma was used to collect data. Ten patients had not yet had follow-up at the time of study and were excluded. Results of 47 patients were analysed and are described. No loss to follow up was encountered.

Results: Average age was 60 (Range 23 to 89 years) with 21 male (45%) and 26 female (55%). Majority (77%) of patients rated telephone follow-up as good or excellent. Average delay between scheduled appointment time and contact with the clinician was 47 minutes in traditional clinic. Majority (84%) of patients were contacted in time in telephonic clinic with minority (16%) experienced an average delay of 28 minutes. Majority (93%) of patients would recommend telephone follow up clinic and (70%) reported telephone follow-up was better or much better than traditional clinic. Reasons for preferring telephone follow-up included delay in the clinic, saving travel time and no need to find parking space. Six percent were dissatisfied with telephone clinic the reason being hearing impairment and desire to discuss their condition face-to-face.

Conclusion: Telephone follow-up clinic for un-instrumented spinal surgery appears to be a safe cost effective satisfactory alternative for the majority of patients. However traditional clinical follow up may be required for a proportion of patients.

Conflict of Interest: None

Source of Funding: None

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

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

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

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

Sub-optimal positioning of the implant is thought to be related to poor outcome after Lumbar Disc Replacement. Our aim was to analyse the impact of implant position in the outcome of Charite III Disc Replacement implants.

160 Charite III Lumbar Disc Replacements that were implanted between 1990 and 2000. The average age was 46 years with 62 Males and 98 Female subjects. An independent observer (HN) administered Pain score (VAS 1–10) for Low Back Pain (LBP) and Oswestry Disability Index (ODI). These clinical outcome parameters were compared with coronal and sagittal position of the implants from the latest available radiographs. Those with operation at L3L4 (small numbers = 20) and inadequate radiographs were excluded.

48 implants were optimally placed and 70 implants were placed sub optimally. Both the groups were in similar age groups (45.02 years, SD 7.61 and 48.31 years, SD 8.04). Clinical: No statistical or clinically significant difference was observed in LBP on VAS (4.92 V/S 4.41), ODI (42.8 V/S 38.0) and in Patient Satisfaction at an average follow up of 70 months. Average movement at optimally placed discs at L4L5 was 4.4o(95% CI 2.3 – 6.7) and at L5S1 was 5.9o(95% CI 4.2 – 7.5) and at sub optimally placed disc at L4L5 was 3.8o(95% CI 2.4 – 5.1) and at L5S1 was 3.8o(95% CI 2.3 – 5.3).

Clinical and radiological results after Charite III Disc Replacement is NOT dependent on positioning of implants. Movements at optimally placed implants are better but is of questionable clinical relevance.

Aim: To analyse the impact of implant position in the outcome of Charite III Disc Replacement implants.

Methodology: 160 Charite III Lumbar Disc Replacements that were implanted between 1990 and 2000. The average age was 46 years with 62 Males and 98 Female subjects. An independent observer (HN) administered Pain score (VAS 1–10) for Low Back Pain (LBP) and Oswestry Disability Index (ODI). These clinical outcome parameters were compared with coronal and sagittal position of the implants from the latest available radiographs. Those with operation at L3L4 (small numbers = 20) and inadequate radiographs were excluded.

Results: 48 implants were optimally placed and 70 implants were placed sub optimally. Both the groups were in similar age groups (45.02 years, SD 7.61 and 48.31 years, SD 8.04). Clinical: No statistical or clinically significant difference was observed in LBP on VAS (4.92 V/S 4.41), ODI (42.8 V/S 38.0) and in Patient Satisfaction at an average follow up of 70 months. Movements: Average movement at optimally placed discs at L4L5 was 4.4o(95% CI 2.3–6.7) and at L5S1 was 5.9o(95% CI4.2–7.5) and at sub optimally placed disc at L4L5 was 3.8o(95% CI 2.4–5.1) and at L5S1 was 3.8o(95%CI 2.3–5.3).

Conclusions: Clinical and radiological results after Charite III Disc Replacement is NOT dependent on positioning of implants.

Ethics approval: None

Interest Statement: None

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

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

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

Ethics approval: None

Interest Statement: None

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

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

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

Between January 1990 and December 2000 we carried out 226 SB Charité III disc replacements for lumbar disc degeneration in 160 patients. They were reviewed at a mean follow-up of 79 months (31 to 161) to determine the clinical and radiological outcome. The clinical results were collected by an independent observer, who was not involved in patient selection, treatment or follow-up, using a combination of outcome measures, including the Oswestry Disability Index. Pain was recorded using a visual analogue score, and the most recent radiographs were reviewed.

Survival of the device was analysed by the Kaplan-Meier method and showed a cumulative survival of 35% at 156 months when radiological failure was taken as the endpoint. The mean improvement in the Oswestry disability index scores after disc replacement was 14% (6% to 21%) and the mean improvement in the pain score was 1.6 (0.46 to 2.73), both falling below the clinically significant threshold. Removal of the implant was required in 12 patients, four because of implant failure.

These poor results indicate that further use of this implant is not justified.

Introduction: Disc Replacement has been described as 21st Century revolution in spinal surgery that preserves mobility and prevents adjacent segment degeneration. Numerous short-term studies are available on clinical outcome but to date there are no published long term clinical, radiological and survival data on disc replacement.

Aim: To analyse clinical, radiological & survival results of Charite III Disc Replacement.

Study Design: Ethical committee approved retrospective study.

Methodology: 160 patients (Av. Age 46yrs; Std.Dev 8.06; 62 Males & 98 Females) underwent disc replacement surgery between Jan1990 and Dec2000. An independent observer reviewed case notes, radiographs and administered a questionnaire that included Oswestry Disability Index, and Pain Score.

Results: Clinical: At an average follow up of 79 (range 31 to 161) months, mean improvement in ODI and pain score were 18.01(p< 0.001) and 1.69(p< 0.001) respectively.

Radiological: average movement at replaced disc, defined as greater than 4 degrees on flexion-extension lateral view was 1.5 degrees for L3L4, 4.01 degrees for L4L5 and 4.8 degrees for L5S1 disc replacement.

Survival: A mean survival time of 147(95% C.I. 140 to 154) months was observed with cumulative survival of 55% with implant removal as an endpoint. A mean survival time of 124(95% C.I. 116 to 133) months with cumulative survival of 35% was observed with all radiological failures as an endpoint.

Complications: were post-operative incisional hernia seen in 17(10.6%), wound infection 9(5.6%) and retrograde ejaculation in 5(3.1%) patients.

Conclusion: Charite III Disc Replacement results in clinically significant (> 15, p< 0.001) improvement in ODI, but does not result in clinical significant (> 2 points) improvement in back pain. Motion is preserved at L4L5 and L5S1 level. It has low survival rate and does not seem to prevent onset of facet arthritis. This study does not support the use of this device for management of back pain.

Introduction: The Less Invasive Stabilisation System (L.I.S.S.) is a new internal fixator for the treatment of complex distal femoral and proximal tibial fractures. Traditional treatment of these injuries is associated with recognised complications and fixation failure.

The LISS is designed to preserve periosteal perfusion and to facilitate a minimally invasive application. Self drilling unicortical screws provide angular stability with the implant giving it a mechanical and biological advantage over conventional fixation methods.

Aim: To evaluate clinical & radiological results of our experience with the LISS in the stabilisation of distal femoral and proximal tibial fractures

Method: Twenty two patients (12 male & 10 female), mean age 60.7 years (range 12–95 years) were treated in our institution over a 29 month period. Nine patients treated with proximal tibial fractures included 4 tibial plateau fractures (AO 41-B, 41-C) and 5 metaphyseal fractures (AO 41-A). Thirteen distal femoral fractures (AO-33) were treated of which 3 were periprosthetic. There were 15 low energy and 7 high energy fractures. Three open fractures of which two required soft tissue cover. Nineteen primary procedures performed following acute fractures and 3 revisions. Quality of life score was measured with SF12.

Results: Follow up rate of 91% (20/22; one died and the other left the country). Union was seen in 90% (18/20) of cases. Mean time to union was17 weeks (range 12–26) for low energy fractures and 27 weeks (range 13–52) for high energy fractures. Complications included: 2 delayed union, 2 late infections, 1 implant failure and 1 varus malunion.

Conclusion: This study demonstrates the LISS system is a useful implant for the treatment of complex fractures of the distal femur and proximal tibia, especially when bone quality is poor.

Aim: To test the hypothesis that the number of admissions in an orthopaedic trauma ward are related to weather conditions.

Materials and Methods: Details of all admissions to the orthopaedic trauma ward over one complete year were retrieved from a computerised data base. Fractures were classified according to the AO classification.

Meteorological data correlated with trauma admissions and data analysis using SPSS version 10.1

Results: Total number of admissions = 1390 [mean age: male=44.2, female=67.6 years]. Commonest fractures in descending order: neck of femur, distal tibia and distal humerus. Overall correlation: significantly +ve (p=0.013) with sunshine (more sunshine = more fractures) and significantly –ve (p=0.001) with rain (less rain = more fractures). 34.5% of admissions were non trauma related.

Conclusion: Females were significantly older than men probably reflecting hazardous activities by younger males and the presence of osteopaenia in females. No significant monthly (seasonal) variations were seen. Influence of weather conditions:

Proximal femoral fracture incidence increase with fall in temperature (freezing conditions does NOT further increase the risk) and rain (but NOT dependent on the amount of rain).

A long term prospective study is required to further support the above findings if clinical trauma resources are to be planned based on predicted weather forecast.

We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total score (maximum 100) before the operation was 47.21 and improved to 79.92 (p < 0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p < 0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p < 0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124° to 136° was noted (p < 0.001).

Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing relief from pain and functional improvement in rheumatoid patients.

Aim: To analyse clinical, radiological & survival results of Charite III Disc Replacement.

Study Design: Ethical committee approved retrospective study.

Methodology: 160 patients (Av. Age 46yrs; Std.Dev 8.06; 62 Males & 98 Females) who underwent disc replacement surgery through transperitoneal approach using a midline incision, between Jan1990 and Dec2000 were identified from hospital records. An independent observer administered Oswestry Disability Index, Pain Score by telephone at the time of review (Aug2003) and reviewed Clinical and radiographic features that were recorded in pre designed form.

Results: Clinical: At an average follow up of 79 (range 31 to 161) months, mean improvement in ODI and pain score were 18.01(p< 0.001) and 1.69(p< 0.001) respectively. Radiological: Movement between the disc spaces, defined as greater than 4 degree on flexion-extension lateral view was preserved after surgery at L4L5 (4.01 degree) & L5S1(4.8 degree) level but not at L3L4( 1.5 degree) level. Average disc height was 19.7mm, and gross radiological loosening was observed after 04, Facet osteoarthritis after 65 and Heterotrophic ossification after 23 operations. Survival: Kaplan-Meier survival analysis showed mean survival time of 147(95% C.I. 140 to 154) months with cumulative survival of 55% at 156 months with implant removal as an endpoint. A mean survival time of 124(95% C.I. 116 to 133) months with cumulative survival of 35% was observed with all radiological failures as an endpoint. Complications: Commonest complication was post-operative incisional hernia seen in 17(10.6%) patients. Other complications were: post-operative ileus 4(2.5%), wound infection 9(5.6%) and retrograde ejaculation in 5(3.1%) patients.

Conclusion: Charite III Disc Replacement results in a clinical significant (> 15, p< 0.001) improvement in ODI, it however does not result in clinical significant (> 2 points) improvement in back pain.Preservation of motion is of questionable clinical significance and it has low survival. Prospective studies are required to confirm the efficacy of this technique

Introduction: the NHS places emphasis on outcomes and patient partnerships but measuring these factors is problematic. In 2003 the Spinal Assessment Clinic (SAC) moved from an old style hospital to a new PFI building providing an opportunity to audit the influence of environment on operational activity.

Objective: Does environment influence satisfaction with care and objective outcome in patients with LBP?

Method: Patients attending the SAC two months prior to relocation and two months following completed a Low Back Outcome Score (LBOS) and a satisfaction survey.

Results: The analysis of the satisfaction surveys demonstrated that the patients did not perceive any real difference in the two locations despite the significant age difference, layout and internal standards of the buildings.

The satisfaction of patients at both sites was analysed using a number of factors- the care provided was 79% before the move and 82% afterwards, their understanding of a nurse led service was rated as 73% and 85% respectively. Evaluation of the quality of information demonstrated that their questions had been answered well 78% and 75% respectively and the confidence and trust in the person providing the care was 91% and 89%.

Failure by the IT department in delivering effective links to hospital computer system resulted in the LBOS data not being completed in the period following the move with logistical difficulties in clinic organisation.

Conclusion: despite the difficulty of moving and problems encountered by staff from the SAC the patient did not perceive any alteration in quality.

Introduction : The ultimate aim of any treatment for low back ache is to improve the quality of life as perceived by the patient. Changes in the condition specific disability measures like the Low Back Outcome Score are used as a measure for this purpose and the results interpreted in terms of statistical significance. It is not known, however, if these changes are considered to be clinically significant by the patients.

Objective: To quantifies the Minimum Clinically Important Difference (MCID) of Low Back Outcome Score in patient’s treated conservatively for Mechanical Low Back Pain.

Design & Subject: Postal questionnaire was sent to a randomly selected cohort of 300 individuals who were treated in the Spinal Assessment Clinic (SAC) for low back pain.

Outcome measures: Patient’s perception of the outcome of the rehabilitation programme was compared with the changes in LBOS from the time of initial presentation to the postal questionnaire.

Results: 186 forms (62 % response rate) were returned. Data from 170 forms were analysed, as 16 forms were incomplete. An average improvement of 17.96(p=0.001) in 75-point LBOS was noticed in those (n = 61) who reported complete recovery. Those who reported Good but incomplete recovery ( n =61) improved their LBOS by 12.37 points( p=0.001). LBOS improvement of 7.52 points ( p = 0.002) was noticed in patients reporting a minimal improvement( n= 38). Ten patients had no change in their clinical condition ( LBOS change 2.8, p =0.485).Age and gender distribution of four groups remained same ( chi square = 1.39, df = 3,p > 0.5).

Conclusions: The Minimum Clinically Important Difference for patients with Low Back Pain is a 7.5 (10%) change in the 75 point LBOS. An average change of 12 (16%) and 18(24%) can be considered to be Good and Excellent responses respectively to the treatment as perceived by the patients. This data will help to determine whether a statistically significant result is clinically meaningful.

Introduction: The ultimate aim of any treatment for low back ache is to improve the quality of life as perceived by the patients. Changes in the condition specific disability measures like the Low Back Outcome Score are used as a measure for this purpose and the results interpreted in terms of statistical significance. It is not known, however, if these changes are considered to be clinically significant by the patients. This study quantifies the Minimum Clinically Important Difference (MCID) of Low Back Outcome Score from the patient’s perspective that were treated conservatively for Mechanical Low Back Pain.

Method: In August and September 1999, a postal questionnaire was sent to a randomly selected cohort of 300 individuals who were treated in the Spinal Assessment Clinic (SAC) for low back pain.

Patient’s perception of the outcome of the rehabilitation programme was compared with the changes in LBOS from the time of initial presentation to the postal questionnaire.

Results: 186 forms (62 % response rate) were returned. Data from 170 forms were analysed, as 16 forms were incomplete. An average improvement of 17.96(p=0.001) in 75-point LBOS was noticed in those (n = 61) who reported complete recovery. Those who reported Good but incomplete recovery ( n =61) improved their LBOS by 12.37 points( p=0.001). LBOS improvement of 7.52 points ( p = 0.002) was noticed in patients reporting a minimal improvement( n= 38). Ten patients had no change in their clinical condition ( LBOS change 2.8, p =0.485).Age and gender distribution of four groups remained same ( chi square = 1.39, df = 3,p > 0.5).

Conclusion: The Minimum Clinically Important Difference for patients with Low Back Pain is a 7.5 (10%) change in the 75 point LBOS. An average change of 12 (16%) and 18(24%) can be considered to be Good and Excellent responses respectively to the treatment as perceived by the patients. This data will help to determine whether a statistically significant result is clinically meaningful.

Thirty-four patients with an average age of 64 years had forty consecutive total elbow replacements done using Souter-Strathclyde prostheses between 1991 & 1994. Six patients had died, however useful data was available in three that were included in the series, two patients failed to attend review clinic due to other medical problems and were excluded from this study. The results of thirty-five elbows were analysed and are presented in this paper. Mean follow up at the final evaluation was 79 months.

All patients were evaluated before and after the operation using Modified Mayo’s Performance index with maximum score of 100. An independent observer performed the latest clinical evaluation.

The average score before the operation was 51. 4, this improved to 82. 4 (p< 0. 001), pain score (maximum 50) improved from 23. 4 before the operation to 47. 1 (p< 0. 001) and the functional component of the score (maximum 30) also improved from 12. 5 to 18. 57 at the time of follow up. The range of motion score (maximum 20) showed least improvement with slight improvement in flexion from 127. 57 before the operation to 134. 34 (p=0. 387) at the time of last follow up.

Four elbows were removed, one due to early and three due to late onset deep infection; there has been no incidence of aseptic loosening requiring revision. Other complications were ulnar nerve dysthesia (two), minor intra-operative fracture (two), dislocation (one).

The Souter-Strathclyde elbow provides sustained pain relief, and functional improvement in the upper extremity. Motion remains unaffected, with some improvement in flexion. We believe that the Souter-Strathclyde elbow replacement can help patients with rheumatoid elbow disease, and we continue to evaluate prospectively a larger series of patients.