To describe complications and reoperation rates associated with degenerative spinal deformity surgery

A retrospective review of prospectively collected data from a single spinal surgeon in the United Kingdom. A total of 107 patients who underwent surgery, of 5 or more levels, for primary degenerative kyphoscoliosis between 2006 and 2012 were identified. Clinical notes were reviewed and post-operative complications, reoperation rates, length of follow up and mortality were analysed.

A total of 107 patients, average aged 66.5 years (range 52 – 85), with 80% women. 105 patients underwent posterior surgery, two patients required both anterior and posterior surgery. The average number of instrumented levels was 8.3; 10% 5 levels, 15% 6 levels, 11% 7 levels, 14% 8 levels, 15% 9 levels and 35% had fusions of 10 levels and above. 58% included fixation to sacrum or pelvis. 93% had a decompression performed and 30% had an osteotomy. There were 40 complications recorded within the follow-up period. Infection occurred in 7 patients (6.5%). All were successfully managed with debridement, antibiotic therapy and retention of implants. There were 4 dural tears (3.7%). One patient developed a post-operative DVT (0.9%). No patients sustained cord level deficits. Prevalence of mechanical complications requiring re-operation was 26% (28 patients). 5 patients (4.7) required revision surgery for symptomatic pseudarthrosis, 7 patients (6.5%) underwent revision fixation for metal work failure (broken rods/screw pull-out) and 16 patients (14.9%) underwent revision surgery to extend fixation proximally or distally due to adjacent segment disease (symptomatic proximal junction kyphosis 4.7%; osteoporotic fracture 3.7% and junctional/nerve root pain 6.5%). Overall reoperation rate was 32.5% at an average of 1.9 years following primary surgery (range 1 week–6 years). 37% patients remain on regular outpatient review (average 3.8 years following first surgery; range 2–6 years). 52% have been discharged after a mean follow-up of 2.3 years. 11 patients had died since their surgery (10.2%) at an average 4.1 years following their spinal surgery (range 1 –5.9 years).

Overall complication rate was 37.3%. 32.5% of patients were re-operated for infective or mechanical complications. 52% of patients had been discharged at an average of 2.3 years following their surgery. 10.2% of patients had died within 6 years of surgery.

The prevalence of degenerative spondylolisthesis (DS) increases with age. With an ageing population there will be increasing demands for adult deformity surgery, with associated significant financial and complication costs. The prevalence of lytic spondylolisthesis (LS) is 6–8%. Our clinical observation is that it is extremely rare to see LS in the presence of DS and therefore the objective was to formally describe the prevalence of LS in combination with DS to assess the hypothesis that 6–8% of patients with DS should also have LS. If this is not the case it may further our understanding of the pathogenesis of DS, which could aid in future prevention or treatment.

A retrospective review of erect lateral lumbar radiographs demonstrating lumbar spondylolisthesis was performed. Radiographs were identified and analysed on the hospital Synapse Picture Archiving and Communication System (PACS). Search criteria were radiographs requested by primary care and patients aged over 60.

101 patients with spondylolisthesis were identified. 89% were requested for back or leg pain. There were 89 patients with DS (69.7% women) and 12 with LS (83% men). The average age of DS and LS patient was 75 and 70 respectively (not significant). There were no cases found with both DS and LS. This was significantly different to the expected amount of 6% (p=0.03). The level of DS was at L3/4 in 11.2% (n=10), L4/5 in 79.8% (n=71) and L5/S1 in 16.9% (n=15). 2 levels were involved in 7 patients. 94.4% (n=84) demonstrated a Meyerding grade 1 slip and 5.6% (n=5) grade 2 slip. For LS the slipped level was at L5/S1 in all cases. 66.7% (n=8) had a grade 1 slip and 33.3% (n=4) a grade 2 slip.

We found no cases of lytic spondylolisthesis in the presence of degenerative spondylolisthesis. We hypothesis that the presence of spondylolysis or lytic spondylolisthesis may be protective against development of degenerative spondylolisthesis. More work is needed to explore this further.

Ensuring correct rotation of the femoral component is a challenging aspect of patellofemoral replacement surgery. Rotation equal to the epicondylar axis or marginally more external rotation is acceptable. Internal rotation is associated with poor outcomes. This paper comprises two studies evaluating the use of the medial malleolus as a landmark to guide rotation.

We used 100 lower-leg anteroposterior radiographs to evaluate the reliability of the medial malleolus as a landmark. Assessment was made of the angle between the tibial shaft and a line from the intramedullary rod entry site to the medial malleolus. The femoral cut was made in ten cadaver knees using the inferior tip of the medial malleolus as a landmark for rotation. Rotation of the cut relative to the anatomical epicondylar axis was assessed using CT. The study of radiographs found the position of the medial malleolus relative to the tibial axis is consistent. Using the inferior tip of the medial malleolus in the cadaver study produced a mean external rotation of 1.6° (0.1° to 3.7°) from the anatomical epicondylar axis. Using the inferior tip of the medial malleolus to guide the femoral cutting jig avoids internal rotation and introduces an acceptable amount of external rotation of the femoral component.

Informed consent is vital to good surgical practice. Pain, sedative medication and psychological distress resulting from trauma are likely to adversely affect a patient's ability to understand and retain information thus impairing the quality of the consent process. This study aims to assess whether provision of written information improves trauma patient's recall of the risks associated with their surgery.

121 consecutive trauma patients were randomised to receive structured verbal information or structured verbal information with the addition of supplementary written information at the time of obtaining consent for their surgery. Patients were followed up post-operatively (mean 3.2 days) with a questionnaire to assess recall of risks discussed during the consent interview and satisfaction with the consent process.

Recall of risks discussed in the consent interview was found to be significantly improved in the group receiving written and verbal information compared to verbal information alone (mean questionnaire score 41% vs. 64%), p=0.0014 using the Mann-Whitney U test. Patient satisfaction with the consent process was significantly improved in the group receiving written and verbal information, 97.9% of patients reported that they understood the risks of surgery when they signed the consent form compared to 83.2% who received verbal information alone (p=0.01). The majority of patients who received written information reported finding it helpful (93.8%) and most of the patients who did not receive written information reported they would have found it useful had it been offered (66%).

Patients awaiting surgery following trauma can pose a challenge to adequately inform about benefits conferred, the likely post operative course and potential risks. Written information is a simple and cost-effective means to improve the consent process and was popular with patients.

Surgery for spinal deformity was previously carried out only in teaching hospitals in the United Kingdom. With increasing numbers of patients especially adults, seeking treatment for spinal deformity, the number of centres offering treatment for spinal deformity is going to have to increase.

The deformity part of the Spinal Surgical Service in the District General Hospital in Taunton started in 2005. This paper is an audit of this deformity service. It looks at two key areas – that of patient satisfaction and patient reported outcomes of surgery. Patient satisfaction was assessed by a validated questionnaire that evaluated a patient's perception of consultations, consent, preoperative assessment, operative and post operative experience and follows up visits. Patient reported outcomes were evaluated using the SRS 30 questionnaire. 104 patients were contacted and 95 patients (91%) responded. The overall patient satisfaction rate was 96%, with 87% very pleased with the result of surgery, 80% felt that their body shape had improved considerably, 62% had an increased ability to carry out day to day activities to a much higher level and 78% had significantly decreased pain after surgery. The results of the different domains of the SRS questionnaire also supported this.

The authors believe that this audit proves that it is possible to provide a spinal deformity service in a District General Hospital in the United Kingdom safely and effectively with a high degree of patient satisfaction. Audits of this kind are required to compare results of treatment between different centres and establish standards.

Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. We prospectively evaluated a new protocol for DVT prophylaxis using fondaparinux.

Without thromboprophalaxis, the recorded incidence of deep venous thrombosis (DVT) in pelvic fracture varies between 35% and 61%. The incidence of pulmonary embolism (PE) is reported to be 2–10% and death subsequently occurs in 0.5–4% of patients. With preventative measures the incidence of clinically significant DVT has been reported as low as 0.5%. The primary aim of this study is to look into the efficacy of Enoxaparin in preventing clinically significant DVT and PE in patients with pelvic and acetabular fracture. The secondary aim is to investigate the effect of prolonged pre-operative exposure to Enoxaparin on operative and post-operative bleeding. Sixty-four patients with pelvic and acetabular fractures were reviewed retrospectively between 2000–2005. Patients with coagulopathies were excluded. 40mg Enoxaparin was administered daily following haemodynamic evaluation and continued thereafter until discharge. Blood loss was measured using 3 indicators: volume of blood transfused, difference in pre and post operative Hb, and amount of blood collected in surgical drains. The incidence of clinically significant DVT was 2.9% (2 cases). There was no confirmed incidence of PE. 47% of patients were operated on within a week of admission (Group A), 40% within 1–2 weeks (Group B) and 13% in over 2 weeks (Group C). The group with the most prolonged pre-operative exposure to Enoxaparin: Group C, required the least transfused blood (A: 4.8units, B: 2.0units C: 1.3units), bled the least into drains (A:310ml, B:253ml and C:212ml) and had the smallest post-operative fall in Hb (A:2.2, B:2.0, C:1.9). The low incidence of clinically detectable DVT in the study confirms that Enoxaparin is an effective method for reducing the incidence of significant thrombotic events. Prolonged pre-operative administration of Enoxaparin does not pre-dispose patients to an increased risk of operative and post-operative bleeding.

Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.

Introduction: Anterior cruciate ligament (ACL) rupture impairs knee stability. Reconstruction of the ACL is therefore performed to restore knee stability and avert risk of subsequent ligament and meniscal injury. Bone-patellar tendon-bone autograft is the most commonly employed technique for ACL reconstruction and considered the “gold standard”. Although 10% postoperative patellar tendon shortening has been reported with this technique, there are no systematic studies assessing the effect of this shortening on patellofemoral joint (PFJ) biomechanics under loading conditions simulating normal physiologic activity. The purpose of this study was to determine if 10% shortening of the patellar tendon affected PFJ biomechanics.

Methods: Patellofemoral contact characteristics were evaluated in cadaveric knees before and after patellar tendon shortening. Tendon shortening was performed using a specifically designed device that shortened the tendon without interfering with its anatomic and physiologic integrity. Conditions simulating light physical activity such as level walking were recreated by applying physiological quadriceps loads and corresponding angles of tibial rotation to the PFJ at 15°, 30° and 60° of knee flexion. PFJ contact areas were measured at each position of knee flexion before and after patellar tendon shortening using the silicone oil-carbon black powder suspension squeeze technique (3S technique, Yao & Seedhom, Proc Instn Mech Engrs1991;205:69–72). Differences were compared using the Wilcoxon signed rank t-test, with p< 0.05 required for statistical significance.

Results: Twelve unembalmed cadaveric knees (median age 81.8 years, 8 female: 4 male) were available for study. Five knees had evidence of osteoarthritic changes, and were rejected. The remaining 7 knees were macroscopically intact and were considered adequate for the experimental procedure. The mean patellofemoral contact areas and stresses determined preoperatively were comparable to those reported in normal knees in previous studies. Following patellar tendon shortening, PFJ contact areas were displaced superiorly on the patellar articular surface and distally on the femoral articular surface. Although the PFJ contact area increased by 17% at 15° of knee flexion (p=0.04), no significant change occurred at 30° or 60° of knee flexion (p> 0.05). Patellofemoral contact stress did not differ before and after patellar tendon shortening (p> 0.05) at any angle of knee flexion.

Conclusions: Our results suggest that with light activity such as level walking, a 10% postoperative shortening of the patellar tendon does not alter patellar tracking (in particular contact stresses) and therefore may not impact biomechanics of the patellofemoral joint. Extrapolating these results to the clinical scenario, deleterious consequences on the patellofemoral joint are unlikely after bone-patellar tendon-bone autograft reconstruction of the ACL despite the possibility of postoperative patellar tendon shortening.

Introduction: Isolated PCL ruptures are most frequently treated non-operatively, although PCL deficiency may ultimately lead to degenerative changes within the patellofemoral compartment. This study investigated, for the first time under physiological loading conditions, the change in patellar tracking as a result of PCL deficiency, hoping to further understand the clinical consequences in situations where such an injury is treated conservatively.

Method: Using eight fresh cadaveric knees, physiological axial tibiofemoral loads and rotatory torques occurring during level walking, were applied to determine tibial rotation angles. These were then used under dynamic Quadriceps femoris loading to determine contact areas and stresses within the patellofemoral joint at 15°, 30°, 60° and 90° of knee flexion. The PCL was then severed, and the procedure repeated under the same loading conditions.

Results: Significant increases in patellofemoral contact stress in the PCL deficient knees were observed at 15° and 30° knee flexion, both in internal and external rotation of the tibia (TABLE I). For these respective rotation positions the increases were 23% and 20% at 15°, and 19% and 28% at 30°, (in all cases p≤0.05). These significantly increased stresses coincided with unchanged contact patterns on the inferior third of the patella, spanning both its medial and lateral facets.

Conclusions: The increased stresses were due to increased patellofemoral joint reaction force, caused by a decreased angle between the quadriceps and patellar tendons due directly to posterior tibial translation in the PCL deficient knees. Significantly increased patellofemoral contact stresses at 15° and 30° of knee flexion, may be implicated in the degeneration of articular cartilage, on both the medial and lateral facets of the inferior third of the patella. These results point out the need for further biomechanical studies to investigate the effects of more strenuous loading conditions. There is also need for clinical studies to investigate focal lesions associated with long-term PCL deficiency.