Objective

Full-thickness cartilage defects are commonly found in symptomatic knee patients, and are associated with progressive cartilage degeneration. Although the risk of defect progression to degenerative osteoarthritis is multifactorial, articular cartilage defects change contact mechanics and the mechanical response of tissue adjacent to the defect. The objective of this study was to quantify changes in intra-tissue strain patterns occurring at the defect rim and opposing tissue in an experimental model mimicking in vivo cartilage-on-cartilage contact conditions.

Study Design

Single surgeon prospective cohort with radiological follow-up.

Introduction

The cause of adolescent idiopathic scoliosis (AIS) is still not known. Although several candidate gene studies and linkage analyses have been done, no causal relationship has yet been established. To our knowledge, we report the first case-control based genome-wide association study (GWAS) for this trait.

Purposes of the study

The most common fracture of the cervical spine in the elderly population is a fracture of the odontoid peg. Such fractures are usually not displaced and these are commonly treated non-operatively. Rarely though, peg fractures are displaced and then their management is less straightforward. This is in part because the group of patients who sustain them frequently have complex and pre-existing medical co-morbidities and in part because a new neurological injury may have been sustained as a result of the peg fracture itself.

Many options for the management of displaced peg fractures, both operative and non-operative have been described in the literature and discussion continues as to which technique is superior and in which patient population. The purpose of this study was to follow-up those patients who were managed operatively in our unit between 2007 and 2009.

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.

AIM

We aim to identify whether meniscal repair at the time of ACL reconstruction was associated with a better outcome than meniscectomy.

Fractures of the odontoid peg are relatively common in elderly people. Often they are minimally displaced and can be treated with a collar. However, a fracture which is displaced significantly may be difficult to manage. We describe the case of an 80-year-old man with a fracture of the odontoid peg which was completely displaced and caused respiratory distress. After initial closed reduction and application of a halo jacket, open and internal fixation was undertaken and relieved his symptoms. It is a safe and effective way to manage this injury.

Purpose: The optimal autograft choice for ACL reconstruction remains controversial. Twelve recently published reviews comparing Patellar Tendon (PT) to Hamstring Tendon (HT) autografts in ACL reconstruction vary in their methodology, quality and application of sensitivity analyses. The present review and meta-analysis follows the rigorous methodology of the Cochrane Collaboration of Systematic Reviews and includes more recent trials that utilize modern surgical techniques and concealed randomization.

Method: Randomized Clinical Trials (RCT) and Quasi-randomized Trials (QRCT) with a minimum 2-year follow-up comparing PT with HT autografts in patients undergoing primary ACL reconstruction were included. Non-English articles were professionally translated. Four electronic databases were searched from 1969-present. Bibliographies and proceedings of major orthopaedic meetings were handsearched. Two teams of investigators independently reviewed all citations, selected relevant studies, extracted the data and assigned quality scores. Consensus was achieved within and between each team for all stages of the review process.

Results: Three hundred and twenty-six citations were originally identified with the search criteria. Following rigorous review, 26 relevant studies were identified. Nine were excluded due to missing information, inadequate follow-up, ongoing trials or low quality scores, leaving 17 studies included in the final analysis. Outcomes related to stability (Lachman test, instrumented laxity, and pivot shift) showed trends towards improved stability with PT reconstruction. When QRCTs were excluded there was a significant difference favoring PT reconstructions only with respect to the pivot shift test. All other outcomes were similar between the PT and HT reconstructions including IKDC categories, anterior knee pain (trend in favor of HT), re-rupture rate, and activity levels. No information was available to distinguish between the outcome of acute and chronic reconstructions, long term information or validated patient based outcomes.

Conclusion: The current literature fails to demonstrate significant differences in multiple outcomes comparing PT to HT reconstruction of the ACL. The overall quality of trials is questionable and fails to use validated patient based outcomes or sufficiently long-term results to assess the development of osteoarthritis.

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.

ACL deficiency can have detrimental pathological effects on the menisci in the knee. A database review in Quebec over a three-year period was previously reported (Canadian Academy of Sport Medicine, Winnipeg, 2003), which examined the relationship between waiting times for ACL surgery and the requirement of a meniscal procedure. The purpose of this study is to determine if the length of time between an index injury and ACL reconstruction (ACLR) surgery correlates with the incidence of meniscal repair and meniscectomy in Alberta, and to compare the results to those of the Quebec study.

Retrospective study, using procedure and billing codes to search the Alberta Health and Wellness databases for knees undergoing primary ACLR surgery between 2002–2005. Inclusion: Patients sixteen years or older at time of reconstruction. Exclusion: Revision ACLR, duplicate billing and coding, and insufficient database information. For each reconstructed knee, databases were searched for initial injury evaluation date with primary care physician, dates of meniscectomy or meniscal repair procedures, and date of ACLR.

Over a three-year period, there were 3382 primary ACL reconstructions performed in Alberta, 3812 ACLR in Quebec. Of these patients, 2583 in Alberta (76%) and 1722 in Quebec (45%) required a meniscal procedure. On average, Albertans waited 1389 days from injury to ACLR compared to 422 days in Quebec. In Alberta, patients not requiring a meniscal procedure waited 1212 days, patients requiring meniscal repair waited 1143 days, and patients requiring meniscectomy waited 1519 days, compared to 251, 413 and 676 days in Quebec, respectively. Three percent of patients in Alberta had ACLR < three months after injury (114 patients), with 45% requiring meniscectomy. Overall, 61% of patients in Alberta required a meniscectomy for significant meniscal injury, compared to 48% of patients in Quebec. The proportions for each province were statistically significant.

Compared to Quebec, patients in Alberta are waiting longer for ACLR, with only a small proportion of cases being treated acutely. The proportion of patients requiring surgery for significant meniscal injury is also greater in Alberta. The higher proportion of patients in Alberta requiring meniscectomy may be due to the delay in ACLR.

The current standard of care in Calgary, Alberta for management of a ruptured Achilles tendon is surgical repair, typically performed following admission to hospital. The primary objective of this study was to compare the costs of hospital treatment and complications associated with the surgical repair of Achilles tendon ruptures between two groups of patients: Group One = patients enrolled in the randomised clinical trial (RCT) Multicentre Achilles Tendon Treatment Study (MATTS), Group Two = all other non-study patients.

This observational cohort study analyzed all patients surgically treated for Achilles tendon ruptures at Calgary area hospitals over a three-year period (October 2002–September 2005). Inclusion criteria: age eighteen to seventy years, acute rupture.

A total of two hundred and eighty-two patients met the inclusion criteria; thirty-three patients were included in Group One, two hundred and forty-nine patients in Group Two. In Group One, twenty-seven patients (82%) were treated as outpatients, five patients (15%) were ADOP-24hr, and one patient (3%) was admitted. In Group Two, twenty-seven patients (11%) were treated as outpatients, ninety-five patients (38%) were ADOP-24hr, and one hundred and twenty-seven patients (51%) were admitted. The total costs for patients treated as outpatients and requiring overnight stays in Group One were $18,408 and $7,419, respectively. In Group Two, the total cost for outpatients was $18,071 compared to $379,496 for non-study patients requiring overnight stay. If all overnight patients in each group were treated as outpatients, the total savings would be $235,545. There were no serious complications in Group One. In Group Two, complications included two cases of pulmonary embolus, and one case of compartment syndrome requiring readmission. All complications resolved.

Surgical treatment of Achilles tendon rupture can be performed safely and at less cost on an outpatient basis. Participation in this RCT has allowed us to recommend a change in the standard of care in Calgary.

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.

Collecting outcome scores in paper form is fraught with difficulty. We have assessed the feasibility of and patient’s attitude towards entering scores using a touchscreen.

A touchscreen was installed in the orthopaedic outpatient clinic. If relevant, patients were asked to complete either an Oswestry Disability Index (ODI) or Oxford Shoulder Score (OSS) using the screen. Patients were given written instructions and their hospital number by the receptionist who had no further input. Scores were completed with two identifiers. A paper questionnaire was used to assess computer experience and attitude towards the touchscreen.

Results: 1377 patients, average age 51 successfully completed a score in the first 12 months. 1/3 were over 60. 93% correctly entered their hospital number and date of birth, falling to 85% in patients over 70. All patients were identifiable. The average time to complete the scores was 4 minutes rising with age.

Of 170 patients completing the questionnaire, 1/3 had little or no experience of computers and 1/3 were over 60. 93% of patients were willing to repeat the score using the touchscreen to monitor progress. 2/3 found it easier to use than expected. Only 10% would prefer a paper score. These results were maintained among patients over 60. Only 2 were unable to complete the score and 80 % of those potentially eligible did so. The remainder were called to clinic before the touchscreen was free.

Conclusion: Orthopaedic outcome scores can be collected in very large volumes using a touchscreen. Data is then in an immediately usable form. The method is acceptable to the patients, independent of age and computer experience. Even in the oldest patients the accuracy is higher than for paper versions of the score. Combined with operative data, this simple method has the potential to provide a very powerful audit tool indeed.

Introduction We have evaluated the early outcome of arthroscopic excision of the distal clavicle (Mumford procedure) for acromioclavicular joint pathology.

Method Forty-one patients with acromioclavicular joint pathology underwent arthroscopic distal clavicle resections between 2002 and 2004. Preoperatively, all patients had acromioclavicular joint tenderness, 90% had a positive horizontal adduction test and 62% had a positive O’Brien’s AC compression test. All provocative signs were abolished on re-examination after acromio-clavicular joint injection. Surgery was indicated with failure of conservative management. Surgery was performed through a subacromial approach to the acromio-clavicular joint, using a Acromionizer (Smith-Nephew Dyonics, Andover, MA) burr through the anterosuperior portal. A supplementary Neviaser portal was used in 9 cases. Patients were clinically assessed at average of 18 months post surgery (range; 9–36). Functional rating was obtained with the Constant Score, WORC score and the Oxford Score. Results

Thirty-five patients (85%) reported none or minimal pain. 81% were negative for provocative AC signs. Internal rotation increased by average of 5 vertebrae levels. The Constant, the WORC and Oxford Scores were improved by 23 points, 674 points and 16 points respectively (p< 0.05). 71% reported good or excellent function by the 3^rd post-operative month.

Conclusion The arthroscopic Mumford procedure effectively treats acromioclavicular joint pathology. The procedure has low associated morbidity and high patient satisfaction.

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.

To provide short- term follow-up data on the surgical success and patient outcome following early anterior cervical fusion in this particular type of injury. A prospective study of 10 consecutive patients.

Stage I compressive extension injury of the cervical spine, as described by Allen and Ferguson, is not always a stable injury. The combined unilateral failure of the posterior structures under compression together with failure of the anterior structure under tension will lead to a rotationally unstable segment. Various treatment options are available including halo vest immobilization, posterior stabilization with plating and anterior fusion and plating.

10 consecutive patients diagnosed with stage I compressive extension injury (fracture subluxation of the cervical spine). All subjects presented with a neurological deficit and vertebral subluxation. All patients were investigated with CT scan of the involved segment; in addition 2 patients had MRI scans.

The surgical protocol consisted of early reduction followed by anterior cervical fusion using a tricortical iliac graft, and stabilization, using locking plate fixation. Follow-up was by radiographs and clinical examination.

Intraoperative assessment revealed disc injury in all patients. Anatomical realignment was achieved together with a solid fusion in all of the patients. All patients showed improvement in the neurological deficit. One patient remains with some residual weakness in his triceps and another patient required removal of a prominent screw.

Early anterior fusion and plating for this type of injury is a safe procedure

Objectives: Is to present the short term outcome of lumbar Artificial Disc Replacement in the Royal Devon and Exeter Hospital, UK.

Design: Review of literature and the short term outcome.

Summary of background data: The mainstay of surgical treatment for discogenic low back pain has been spinal fusion for many decades. The outcome of fusion procedures has been somewhat unpredictable and is linked with some limitation in the activities related to spinal motion.

Recently and in the last few years a relatively new procedure was introduced to spinal surgery practice which is the artificial disc replacement, the potential benefit of which is to relief back pain as well as keeping the spinal motion.

In this study, we are reporting our early experience in the results and short term outcome of lumbar artificial disc replacement done on 26 patients in The Royal Devon and Exeter Hospital

Methods: The 26 cases were operated upon in the duration between 1996 and 2003. We used artificial disc replacement.

Results: Our results based on ODSS and the VAS were good to excellent with patient satisfaction of about 87%

Conclusion: The Artificial disc replacement procedure in the lumbar and lumbosacral region is promising in short term outcome , however the long term results should be carefully evaluated.

Background: We report on the surgical treatment of a case spinal neuroarthropathy, where surgical fusion of the pathological level was achieved by a shortening osteotomy and apposition of the adjacent vertebral bodies. Neuropathic (Charcot) arthropathy of the spine is relatively an uncommon problem. Spinal neuroarthropathy has been described to occur after traumatic paralysis as well as other causes of neuropathic arthropathy. Surgery has been recommended for the treatment of painful or unstable neuropathic joints of the spine. From the few cases that have been reported in the literature, surgical management included extensive debridement, bridging of the defect with autogenous graft as well as instrumentation to achieve an anterior and posterior fusion. To the knowledge of the authors, the technique of spine shortening and vertebral apposition was reported only once in the literature, however the patient had to be kept recumbent in a cast for six months. (1)

Methods: Literature review and a case of spinal neuroarthropathy successfully treated by a shortening osteotomy and instrumented arthrodesis is presented.

Results: Patient was allowed to mobilize in his wheelchair by the second week post operation with a support of a TLSO, which was used for five months. Roentgenograms and CT scan done at thirteen months showed good position of the spine and evidence of solid bone arthrodesis. This matched marked clinical improvement in the preoperative symptoms.

Conclusion: Treatment of a Charcot affection of the spine should be directed toward vertebral stabilization to eliminate the pathological effects and complications secondary to instability. Sound arthrodesis in our case could be achieved with resection of the affected level(s), shortening of the spine and good apposition of fresh bleeding bone surfaces. Careful attention to the demanding surgical technique is required. Yet, any fusion procedure poses additional stresses to the adjacent levels. So long term monitoring of the rehabilitation is mandatory to detect the possibility of developing secondary levels of Charcot joints below a previously successful fusion.

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.