Aims

The aims of this study were to evaluate the clinical and radiological outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients with rheumatoid arthritis.

The use of serial casting in the management of early onset scoliosis (EOS) has been well described. Our aim was to evaluate outcomes of plaster jacket therapy in patients with EOS from a tertiary referral centre.

A retrospective review of hospital records and PACS images of 27 patients to identify patients treated with serial casting over a five year period. The primary outcome measure was the need for surgical intervention, with change in Cobb angle used as a secondary outcome measure

Mean age at presentation was 14 months (range 10 – 42), including 14 male and 13 female patients, with an average follow-up of 34 months. Curves were categorised according to aetiology: 16 idiopathic, 6 syndromic, 3 congenital and 2 neuromuscular curves. The mean Cobb angle at diagnosis was 43.7° (range 22 – 115) and mean rib vertebral angle difference (RVAD) was 22.2° (8 – 70). Duration of treatment was 9.9 months (range 3 – 27), with an average of two plaster jacket changes per child. At the time of review, patients fell into one of three groups. Group one (10 patients) failed conservative treatment due no improvement in Cobb angle (mean 48.4° compared with pre-op 53.9°, p value 0.55) and either had insertion of growing rods or had been listed for this procedure, at a mean age of 51.8 months. Group two (12 patients) had a mean Cobb angle of 38.9° pre-treatment which improved to 23.5° (p value <0.05) and were either treated in a brace or had discontinued treatment. The mean RVAD at initial diagnosis was 36.6° in group 1 compared with 13.8° in group 2 (p<0.05). All patients in group one requiring surgical treatment had an RVAD of greater than 20°. Serial casting is on-going for five patients (group three). Complications occurred in 30% of patients including pressure sores, chest infection and respiratory compromise requiring intubation.

Current NICE guidance recognises that serial casting ‘rarely corrects scoliosis’ but recommends it may be used ‘to allow growth before a more permanent treatment is offered’. In our experience, serial casting did not allow any patients with a progressive scoliosis (determined by an RVAD of greater than 20°), to reach a single definitive fusion. However serial casting appeared to halt to curve progression until the child was suitable for the insertion of a growing rod system.

Introduction

Negative remodelling of the femoral cortex in the form of calcar resorption due to stress shielding and cortical hypertrophy at the level of the tip of the implant, due to distal load transfer, is frequently noted following cemented total hip replacement, most commonly with composite beam implants, but also with polished double tapers. The C-stem polished femoral component was designed with a third taper running from lateral to medial across and along the entire length of the implant, with the aim of achieving more proximal and therefore more natural loading of the femur. The hoop stresses generated in the cement mantle are transferred to the proximal bone starting at the calcar, which should theoretically minimise stress-shielding and calcar resorption, as well as reducing distal load transfer, as signified by the development of distal femoral cortical hypertrophy.

Introduction

Traditionally the use of small diameter femoral head (22mm) with the posterior approach has been perceived as an increased risk of dislocation. We present this prospective study of 400 consecutive total hip replacements performed using a 22mm femoral head and the posterior approach.

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma.

Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system.

Recurrence of spinal metastasis and radiological failure of reconstruction

All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications.

Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.

Ultrasound imaging has become an essential adjunct to clinical examination when assessing a patient with suspected rotator cuff pathology. With the new high-resolution portable machines it has become feasible for the shoulder surgeon to perform the scans himself in the clinic and save a great deal of time. This study was conducted to examine the accuracy of the ultrasound scans performed by a single surgeon over a period of four years (2001-2004).

The ultrasound findings were uniformly documented and collected prospectively. Out of a total of 364 scanned patients we selected 143 who ultimately received an operation and we compared the surgical findings with the ultrasound reports. The intra-operative findings included 77 full thickness supraspinatus tears, 24 partial thickness tears and 42 normal cuffs. Three full thickness tears were missed on ultrasound and reported as normal/ partially torn. Four normal/ partially torn cuffs were thought to have a full thickness tear. This presents 96.3% sensitivity and 94.3% specificity for full thickness tears. Three partial thickness tears were reported normal on ultrasound and eight normal cuffs were thought to have partial thickness tears. This presents 89% sensitivity and 93.7% specificity for partial thickness tears. The size estimation of full thickness tears was more accurate for large/massive tears (96%) than moderate (82%) and small/pinhole tears (75%). The tear sizes were more often underestimated which may partly reflect disease progression during the unavoidable time lag between scan and surgery.

We conclude that shoulder ultrasound performed by a sufficiently trained orthopaedic surgeon is a safe and reliable practice to identify rotator cuff tears.

Introduction: Between June 2005 and September 2007, ten male athletes underwent repair of the pectoralis major tendon using a new double row surgical technique whereby employing three bone anchors to produce a large foot print of the pectoralis major tendon. Here, we present our new surgical technique for the repair of the pectoralis major tendon with the results.

Patients: The mean age was 33.9 years (23–46 years) and the average follow up was 20.3 months (12–39). The mean time between surgery and the original injury was 11.6 weeks (1–48 weeks). We used the visual analogue scale for determining the level of satisfaction with regards to cosmesis and pain. Also, the patients were asked them about their subjective loss of strength.

Results: Eight patients were in pain prior to surgery and all patients were unsatisfied with the appearance of their chest. The average loss of strength was 75% pre-operatively. At the final follow up, none of the patients complained of any pain while pushing things away from their body; nine patients had no pain on moving their arm across the chest whilst one patient reported mild pain. Nine were satisfied with the appearance and the average regain in strength was around 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst our patients. Hence, we conclude that satisfactory results can be achieved with this new technique.

Introduction: Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and show longer survival rates compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radio resistant tumour, which can often present with both back pain and neurological deficit. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma.

Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy.

Results: All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. The other three are alive and well at 33, 40 and 54 months post-op with no radiological evidence of tumour recurrence in the spine. There were no major surgical complications.

Discussion: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.

Conclusion: TES can improve symptomatic control of isolated solitary spinal metastases of the thoracolumbar spine in Renal Cell Carcinoma.

Study Design: Descriptive case series.

Objective: To report on the outcome of 4 patients treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to hypernephroma.

Summary of background data: Patients with solitary spinal metastases from renal cell carcinoma (RCC) have better prognosis and show longer survival rates as compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radioresistant tumour, which can often present with both back pain and neurological deficit.

Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. 3 of the 4 had pre-operative embolization and all had radical resection of the primary tumour.

Results: All patients reported significant pain relief and demonstrated neurological improvement. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. 3 were alive and well at 18, 26 and 39 months post-op with no radiological evidence of tumour recurrence. There were no major surgical complications.

Conclusions: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.

Objective: To assess the effectiveness of total disc replacement (TDR) (Charité SB III) for treatment of lumbar discopathy and to report the preliminary clinical results after a minimum follow-up period of two years

Materials and Methods: From 49 patients who underwent lumbar TDR, 31 patients fulfilled the criteria for clinical evaluation at least 2 years after surgery. The mean age was 39ys (range 29 – 48). Preoperative diagnosis included degenerative disc disease in 27 patients and 4 patients had post discectomy back pain. 44 disc prosthesis were implanted, 18 patients had a single level disc replacement and 13 patients had two level replacement. All patients were studied prospectively and clinical results evaluated by assessing preoperative and postoperative Oswestry Disability Index questionnaire and Visual Analogue Scale for back pain. Pre and postoperative patients’ work status as well as patient satisfaction were also assessed. The mean postoperative follow up was 3.3years (range 2 – 8 years). Statistical analysis of the results was done with the Wilcoxon Signed Ranks Test.

Results: There were significant improvements of the clinical outcome measures. Mean post operative ODI compared to mean preoperative scores of 19 and 53 respectively (p< 0.0001) and mean postoperative VAS compared to mean preoperative scores of 2.5 and 7.5 respectively (p< 0.0001). Success rates showed 51.6% of patients had an excellent result (relative improvement of ODI score, > 75%), 19.4% had a good result (relative improvement of ODI score, 60% to74%), and 29% had a fair and poor results (relative improvement of ODI score, < 60%). No major or approach related complications were encountered.

Conclusions: TDR is an effective method of treating discopathic low back pain. The medium term results are comparable to those obtained following traditional lumbar arthrodesis. Yet longer term results are still needed to comment on adjacent segment load transfer and progression of degenerative changes.

Introduction: The conventional approach to spinal malignancy is via intralesional piecemeal resection but the incidence of local recurrence after surgery has been increasing as survival of patients getting prolonged due to advance adjuvant treatment TES is devised to minimize the incidence of local recurrence in malignant spinal tumours. The purpose of this study is to analyse whether the radical procedure like TES is justifiable in solitary metastasis or not

Material & Methods: We analysed 6 patients who undergone surgery for metastases of spine secondary to renal cell carcinoma between1996 and 2005 out of which 4 had TES for solitary intraosseous thoracolumbar lesion. They include three men and one woman ranging an age from 51 to 64 years. Common presenting complaints were intractable back pain dependent on opiates and progressive neural deficit. Four patients had localised intraosseous thoraco-lumbar lesion. The extent of spinal lesion was assessed with X-rays, CT scans and MRI for all patients. All patient’s prognosis was analysed by Tokuhasi Scoring System.3 patients had pre-op embolisation.4 patients with solitary intra-osseous metastasis underwent radical surgery in the form of total vertebrectomy and 3- column stabilisation of spine. Total surgical time was between 9–13 hrs and total blood loss between 4–11 Litres.

Results: None of the patients had surgery related major complication. No external brace used for mobilisation. The surgical outcome assessed by the pain, severity of paresis and the ability to walk before and after surgery. All patients followed up regularly to detect local tumour recurrences and position of implant. None of the patients with TES shown signs of local recurrence The follow up period for the surviving patients ranged from 9 to 32 months after TES. One patient died 9 month post-op due to widespread metastasis.

Conclusion: TES offers the most aggressive mode of treatment for the solitary metastasis of Thoraco-Lumbar spine secondary to Renal Cell Carcinoma. Considering the technical demands and potential risks of TES, the indication for TES with spinal metastasis should be limited to the cases with solitary intra-osseous lesions in malignancies with good prognosis.

We have examined the accuracy of 143 consecutive ultrasound scans of patients who subsequently underwent shoulder arthroscopy for rotator-cuff disease. All the scans and subsequent surgery were performed by an orthopaedic surgeon using a portable ultrasound scanner in a one-stop clinic. There were 78 full thickness tears which we confirmed by surgery or MRI. Three moderate-size tears were assessed as partial-thickness at ultrasound scan (false negative) giving a sensitivity of 96.2%. One partially torn and two intact cuffs were over-diagnosed as small full-thickness tears by ultrasound scan (false positive) giving a specificity of 95.4%. This gave a positive predictive value of 96.2% and a negative predictive value of 95.4%. Estimation of tear size was more accurate for large and massive tears at 96.5% than for moderate (88.8%) and small tears (91.6%). These results are equivalent to those obtained by several studies undertaken by experienced radiologists.

We conclude that ultrasound imaging of the shoulder performed by a sufficiently-trained orthopaedic surgeon is a reliable time-saving practice to identify rotator-cuff integrity.

Posterior lumbar interbody fusion is a well established method of treatment in spinal disorders. It is particularly useful in situations in which neural decompression and simultaneous interbody fusion is indicated. The interbody fusion is generally done using various cage designs which are often sizeable and difficult to insert into the limited space available in the spinal canal. The B twin device is inserted collapsed and expands in the disc space to provide interbody support.

We present our experience with the use of this device and present our clinical and radiological results.