Background

Advanced spinal practitioner physiotherapists (ASPPs) assess and manage spinal referrals, as advocated by the National Low Back Pain Pathway in the United Kingdom. The ASPP pathway relies on multi-disciplinary team (MDT) meetings where potential surgically appropriate or complex cases can be discussed. Meetings were held with two different Consultant Spinal Neurosurgeons (total 2 meetings per month). The aim of this service evaluation was to assess MDT meeting outcomes and surgical listing.

Introduction

Degenerative cervical myelopathy (DCM) is associated with progressive neurological deterioration. Surgical decompression can halt but not reverse this progression. The Modified Japanese Orthopaedic Assessment (MJOA) tool is recommended by international guidelines to grade disease severity into mild, moderate and severe, where moderate and severe are both recommended to undergo surgical intervention. During Covid-19 Nottingham University Hospitals (NUH) NHS Trust, identified DCM patients as high risk for sustaining permanent neurological damage due to surgical delay. The Advanced Spinal Practitioner (ASP) team implemented a surveillance project to evaluate those at risk.

Success treating AIS with bracing is related to time worn and scoliosis severity. Temperature monitoring can help patients comply with their orthotic prescription. Routinely collected temperature data from the start of first brace treatment was reviewed for 14 patients. All were female with an average age of 12.4 years (range 10.3–14.6) and average 49o Cobb angle (30–64).

Our current service recommendation is brace wear for 20 hours a day. Patients complied with this prescription 38.0% of the time, with four patients averaging this or more. Average brace wear was 16.3 hours per day (3.5–22.2).

There were 13 patients who had completed brace treatment. The majority had surgery (7/13; 54%) or were considering surgery (1/13; 8%). There were 5 who did not wish surgery at discharge (5/13; 38%); 1 achieved a 40o Cobb angle, with 4 larger (53o;53o;54o;68o). The Bracing in AIS Trial (BrAIST) study measured “success” as less than a 50o Cobb angle, so using this metric our cohort has had a single “success”.

Temperature monitors allowed an analysis of when patients were achieving their brace wear. When comparing daywear (8am-8pm) to nightwear (8pm-8am), patients wore their brace an average of 7.6 hours a day (2.5–11.2) and 8.7 hours a night (0.4–11.5).

We conclude the minority of our patients comply with our current 20 hour orthotic prescription. The “success” of brace treatment is lower than comparison studies despite higher average compliance but starting with a larger scoliosis. Brace wear is achieved during both the day and night.

There are only a limited number of long term studies of total knee arthroplasty and few with a minimum fifteen year survivorship of a modular fixed bearing posterior cruciate-retaining prosthesis. This consecutive series of 139 total knee arthroplasties (109 patients), using the non-conforming posterior cruciate-retaining Press Fit Condylar (PFC®) system was followed for a minimum of 15 years (range 15.0 to 16.9 years). The patella were resurfaced with an all-polyethylene component in 83% of knees. The tibial component was always cemented, while a porous-coated femoral component was used in 84% of knees. Fifty-nine knees (45 patients) were followed up for a minimum of 15 years. Fifty-seven patients (70 knees) had died and five (8 knees) were too ill to assess. Survivorship of the prosthesis was confirmed for 98.6% of the prosthesis, as only two patients (2 knees) were lost to follow-up.

The mean Knee Society Score and Function Score were 96 and 78 respectively. The total incidence of radiolucent lines was 13%, with 2% around the femur, 11% around the tibia, and 0% around the patella. None of these lines were of any clinical relevance. There was no evidence of progressive radiolucent lines or component loosening, and one case of zone 4 femoral osteolysis.

There were five re-operations for any indication, of which four were for polyethylene insert wear. There was also one loose cemented femoral component after more than 15 years. The survival without need for revision for any reason was 99% at 10 years and 95.6% (worst-case scenario of 94.2%) at 15 years.

This single-surgeon series with a minimum 15 year follow-up shows that the modular fixed bearing posterior cruciate retaining total knee arthroplasty of the PFC system can provide excellent and predictable long term results in tri-compartmental arthritis of the knee.

A consecutive series of 139 total knee arthroplasties (109 patients, average age 67 years), using a non-conforming posterior cruciate-retaining prosthesis was followed for 15 years (range, 15.0 to 16.9 years).

Forty-five patients (59 knees) were clinically and radiographically evaluated, 57 (70 knees) had died, five patients (8 knees) were too ill to assess, two patients (2 knees) were considered lost to follow-up. Survivorship analysis was performed using worst case scenario analysis and failure defined as re-operation for any reason.

Results: In this series there were five re-operations for any indication, four of which were for polyethylene insert wear. One loose cemented femoral component was revised at 15 years. The survival without revision or need for any re-operation was 92.6% at 15 years. The mean Knee Society Score and Function Score at 15 year follow-up are 96 and 78 respectively. The prevalence of radiolucent lines was 13%. None of these lines were clinically relevant. There was no evidence of progressive radiolucent lines, and one case of asymptomatic femoral osteolysis.

Conclusions: This single-surgeon series with a minimum 15 year follow-up shows good clinical and radiological results with excellent survivorship of a modular fixed bearing posterior cruciate retaining total knee arthroplasty system.

Introduction In an attempt to decrease the incidence of posterior hip dislocation following a posterior approach, a simple capsulorrhaphy was utilized in 255 consecutive primary total hip arthroplasties performed by one surgeon.

Methods All patients were reviewed at a minimum of two years post-operatively and no patient was lost to follow-up. One patient sustained a posterior hip dislocation, while there were no anterior hip dislocations. The dislocation rate of 0.39 is equal to or less than the rates of dislocation reported in the literature using a direct lateral approach.

Conclusions We postulate that this capsular repair creates not only a static restraint but also a capsule and gluteus medius mediated proprioceptive feedback to guard against extremes of internal rotation of the hip.

Introduction There are only a limited number of long term studies of total knee arthroplasty but none with a minimum 15 year survivorship of a modular fixed bearing posterior cruciate-retaining prosthesis.

Methods We present a consecutive series of 139 total knee arthroplasties (109 patients, average age 67 years), using a non-conforming posterior cruciate-retaining prosthesis, followed for a minimum of 15 years (range, 15.0 to 16.9 years). The patella was resurfaced with an all-polyethylene component in 83% of knees. The tibial component was always cemented, while a porous coated femoral component was used in 84% of knees. Fortyfive patients (59 knees) were followed-up for a minimum of 15 years, 57 (70 knees) had died, five patients (8 knees) were too ill to assess, two patients (two knees) were considered lost to follow-up.

Results In this series there were five re-operations, four of which were for polyethylene insert wear. At two of these, the patella was exchanged for early surface wear and one patella was resurfaced for the first time. There was one loose cemented femoral component after more than 15 years. The survival without revision or need for revision for any reason was 99% at 10 years and 95.6% (worst case scenario of 94.2%) at 15 years. The mean Knee Society Score and Function Score at 15 year follow-up was 96 and 78 respectively. The total incidence of radiolucent lines was 13%, with two percent around the femur, 11% around the tibia and zero percent around the patella. None of these lines were of any clinical relevance. There was no evidence of progressive radiolucent lines or component loosening, and one case of zone four femoral osteolysis.

Conclusions This single-surgeon series with a minimum 15 year follow-up, and excellent clinical, radiological and survivorship results provides a benchmark upon which other long term studies of modular fixed bearing posterior cruciate retaining total knee arthroplasty can be compared.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.