Background: Surgery in adolescent idiopathic scoliosis is done mainly for cosmesis and outcomes are reported in terms of radiological measurements (Cobb angle), outcome questionnaires (SRS-22) and back surface measurements (Scoliometer & Quantec). Previous studies have shown correlations between SRS-22 and objective radiological and back surface measures at a point in time (Asher et al 2003 & 2004).

Aim: of the study was to evaluate the association between subjective and objective outcomes in posterior instrumented scoliosis correction.

Patients and Methods: 43 patients with late-onset thoracic idiopathic scoliosis were included in the study with 39 girls and 4 boys with a mean age 13.2 years. Mean pre-operative Cobb angle was 71o. The objective assessment of back surface was done using a scoliometer and the POTSI & Suzuki Hump Sum scores. The subjective assessment was done using the Scoliosis Research Society (SRS)-22 score. The assessments were done pre-operatively and then post-operatively at 8-weeks and one year.

Results: The average percentage improvement in various outcomes after surgery was as follows: Cobb angle (71%), Maximum Angle of Trunk Inclination (Max. ATI) (52 % at 8 weeks and 39 % at 1 year), POTSI (57%), Hump Sum (24%), SRS-Total (14%), SRS-self image (14%). Pre-operatively, there were good inter-correlations (r= 0.4–0.7) between the objective measures (Max. ATI, POTSI and Hump Sum). Significant correlation was found between SRS-22 total versus Cobb angle (p-0.001, r=0.41). No significant correlation was found between the SRS-22 (total & domains) versus the Max. ATI, POTSI or the Hump Sum scores. Post-operatively, good correlation (r=0.6) was again found between the objective measures (Max. ATI, POTSI and Hump Sum) of back surface measurements (absolute and percentage). No significant correlation was found between SRS-22 (domains & total) versus Cobb angle correction, Max. ATI, POTSI, or Hump Sum.

Conclusion: In this study SRS-22 was found to be responsive to change with surgery, especially the self-image/appearance domain. However the SRS-22 score after surgery and the change in this score did not correlate with the change in objective measures of back surface deformity after surgery.

Purpose: To assess quality of life in quadriplegic cerebral palsy (CP) after scoliosis surgery.

Methods: This is a study of 43 consecutive patients undergoing instrumented scoliosis correction for quadriplegic CP (2003–2008). The parents completed (telephone) the original DuPont questionnaire (Tsirikos et al 2004, JPO) and 4 additional questions. Each of the 17 items scores from 1 (best) to 5 (worst) with 3 being no change. Retrospective case note and radiograph review was performed.

Two patients had died by the time of follow-up (1 perioperative, 1 unrelated) leaving 41 patients (23 female, 18 male) for analysis. Mean age was 14.0 at surgery, mean follow-up of 2.6 years (0.25–5.3). GMFCS types 2–4 (8), 5 (31). Mean preoperative Cobb angle 78° and pelvic obliquity 18°. There were 34 posterior and 7 anterior and posterior instrumentations.

Results: Mean DuPont score for the original 13 questions was 2.00 compared with 1.75 in the DuPont study. The scores for individual questions ranged from 1.35 to 2.76. The mean score of the 4 additional questions was 2.43, related to transfer ability, reflux and communication. 95% of parents would recommend the surgery again. 75.6% reported an improvement in their child’s ability to sit. Cobb angle correction was 53%, pelvic obliquity correction was 47%. The mean DuPont score is not significantly correlated with Cobb angle or pelvic obliquity correction.

Conclusions: This is the first UK study evaluating the parental view of outcome for scoliosis surgery in quadriplegic CP. Outcome does not seem to be related to radiographic correction. 39 of 41 parents would recommend the surgery.

Ethics approval: none – Clinical Effectiveness Department & PALS

Interest Statement: None

Purpose of study: There is a controversy in the surgical treatment of unstable thoracolumbar burst fractures scoring high on the Load Sharing Classification (LSC). We have been treating unstable thoracolumbar fractures with postero-lateral fusion using short segment instrumentation and in this study we investigated our complication rate.

Methods and results: We retrospectively reviewed notes and radiographs of patients presenting with thoracolumbar burst fractures and stabilised with a short-segment instrumented postero-lateral fusion between 1998 and 2007. We identified 31 patients who had adequate documentation and radiographs. Twenty patients had a high (> =7) LSC score and none of these fixations failed. Overall early and late complication rate was low (one wound infection, one dehiscence and four unrelated infections), the one metalwork failure related to infection. Fifty-five percent of patients returned to full-time work. Approximately 50% of correction of kyphosis was lost but the average kyphosis at final follow-up was 11 degrees that we thought was acceptable.

Conclusion: We concluded that treating unstable burst fractures with posterior instrumented fusion alone using a pedicle screw construct does not result in late instrumentation failure, high complication rate or unacceptable final deformity.

Ethics approval: None

Interest Statement: None

Introduction: Blood conservation is important in surgery for adolescent idiopathic scoliosis due to the potential for significant blood loss and need to avoid allogeneic transfusion in young, commonly female, patients. Previous studies have shown that a combination of blood conservation methods may be effective in reducing the need for allogeneic blood transfusion. We have carried out a study to investigate if the sole use of intraoperative red cell salvage in surgery for adolescent idiopathic scoliosis is effective and can lead to a reduced rate of allogeneic transfusion.

Patients and Methods: 56 patients aged between 10 and 17 underwent posterior spinal surgery for correction of idiopathic scoliosis. In 34 patients intraoperative cell salvage was used and salvaged blood re-infused perioperatively. This group was compared with a control group of 22 patients in whom only allogeneic blood transfusion was used. All patients underwent hypotensive anaesthesia. Other forms of blood conservation, such as predonation, were not used. Data was gathered on patient demographics, operative details, quantity of blood reinfused, pre and post operative haemoglobin levels and total allogeneic transfusion requirement. Operative data was gathered prospectively and blood transfusion data provided by the transfusion centre.

Results: In the cell salvage group an average of 309mls of blood was reinfused and these patients were transfused an average of 1.8 units less allogeneic blood in the peri-and post-operative period (p< 0.001). 74% of these patients required no allogeneic blood compared with 27% in the control group. There were no complications related to the use of intraoperative red cell salvage.

Conclusion: Intraoperative red cell salvage is effective in reducing the need for allogeneic transfusion in children undergoing posterior surgery for scoliosis correction.

Background: To assess the potential for Quantec imaging to save radiographs in the follow-up of patients with early onset scoliosis. This is a group of patients who often have many radiographs due their age at diagnosis.

Methods: This is a prospective cohort study. Twenty-four children with early onset scoliosis are identified. They all have a minimum of three simultaneous radiographs and Quantec scans as part of routine follow up for their scoliosis curves. There are 15 males and 9 females (22 thoracic, 1 thoracolumbar, 1 lumbar). Mean age at diagnosis is 3 years (range 1–4.8 years). The Cobb angle of the major curve is measured from each radiograph and compared with the Q-angle using Bland-Altman plots and linear regression analysis.

Results: The mean Cobb angle was 30° and the mean Q-angle 19°. The correlation coefficient was 0.68 (p< 0.05). In curves with Cobb angle < 30°, The Bland-Altman plots show a close scatter with a mean difference of 3.4°. It was calculated that this could have safely saved 18 radiographs in 14 patients. In curves > 30°, there was a large scatter and a mean difference between Cobb angle and Q-angle of 20.1°.

Conclusion: In early onset scoliosis, curves with Cobb angle less than 30° can be safely followed clinically and with the Q-scan reducing the number of radiographs required. Curves with Cobb angle greater than 30° cannot be reliably observed with Quantec scans alone.

Background: It is generally accepted that surgical correction in adolescent idiopathic scoliosis (AIS) is largely for cosmesis. Scoliometer measurements of back surface asymmetry and rasterstereographic methods are used to attempt to quantify the surface deformity, These methods are also used to determine the ‘success’ of surgery. This study objectively evaluates trunk cosmesis from pre-operative photographs.

Methods: This is a prospective cohort study. Twelve pre-operative girls with thoracic AIS had standard photographs taken in the standing and forward bending positions. The mean Cobb angle is 74°, mean age 13.7 years. Twenty observers were selected by their profession (3 Spinal Consultants, 4 Orthopaedic Specialist Registrars, 4 nurses, 4 medical illustrators and 5 lay-people). Each patient’s photographs were arranged on a single sheet and the observer was asked to arrange the patients in order of cosmesis and having done this to give a score between 0 (best) and 100 (worst) for overall cosmesis.

Results: There was no good agreement either in the ranking or the scoring for any of the groups of observers. Some observers agreed quite well whilst others ranked and scored much differently to the ‘mean’.

Conclusion: Cosmesis is a spectrum and is most definitely in the eye of the beholder with wide disagreement between individuals both for ranking and scoring cosmesis. We must identify the components of trunk cosmesis (for the majority of observers) so that we can quantify these and produce a score to reflect what we are trying to treat. Only then will we be able to assess the results of our treatments.

Diagnosis of infective discitis may be difficult as presentation is usually non-specific with little symptomatology and few signs in the early stages. This dilemma is further complicated by the fact there is a long latent period between the onset of symptoms and plain radiograph changes and a high index of suspicion must be maintained. We reviewed 30 cases referred to our unit for treatment between 1996 and 2001 with an emphasis on time to diagnosis.

90% of patients complained of some degree of back pain at initial presentation and 70% had symptoms of active infection. 60% had a history of recent sepsis and a further 23% had been extensively investigated for pyrexia of unknown origin (PUO).

The mean time to diagnosis from first presentation to a member of the medical profession was 54 days (range 0–183 days). 35% of patients were diagnosed incidentally on a CT scan while investigating abdominal and chest symptoms or PUO so these diagnoses could potentially have been delayed further.

23% of patients required acute surgical treatment and in this sub-group the mean time to diagnosis was 61 days (range 14–91 days).

16% of patients died as a result of discitis. In this subgroup the mean time to diagnosis was 74 days (range 56–183 days).

Many patients were extensively investigated for PUO or sepsis of unknown cause despite having persistent back pain. Although a small sample, delay in diagnosis seems to increase death rates. Many of these patients had first presented to their general practitioner or a physician for investigation, however discitis is rarely cited as a differential diagnosis of PUO in medical textbooks.

A high index of suspicion must be maintained in patients with back pain, especially that of a non-mechanical nature. Discitis should be considered early in such patients especially those with evidence of infection. Discitis must always be included in the differential diagnosis of pyrexia of unknown origin.

Meticulous haemostasis not only improves the operative field facilitating spinal surgery, but also diminishes chances of post-operative neurological complications from a compressive haematoma. Since being introduced in the 1940’s, implantable haemostats have proven a useful adjunct in achieving haemostasis with relatively few complications. However, their use in spaces bounded by bony architecture can lead to compressive effects on neurological structures.

We present three cases of post-operative cauda equina syndrome – two cases following surgery for lumbar disc herniation and one case following surgery for lumbar canal stenosis. In each case, implantable haemostats were utilised to control haemorrhage for complications during the surgery. All three patients underwent urgent exploration, which revealed cauda equina compression from clot organised around the haemostat. Neurological recovery was variable.

We recommend careful attention to intra-operative haemostasis. Although haemostats can assist in achieving haemostasis, we caution against leaving them in situ.

The Charnley total hip replacement has had favourable long-term survival results. On the strength of these results orthopaedic companies have introduced “Charnley Copies” incorporating identical design parameters.

The objective of the study was to determine whether the acetabular cups provided as DePuy Charnley copies by different manufacturers are identical with regards to their geometry. To analyze how any differences present may affect the motion characteristics of the arthroplasty.

A jig was designed which allowed the measurements of: i) range of movement free from impingement, ii) the arc of movement during which the femoral neck is impinging on the cup, iii) point of subluxation and dislocation of the femoral head from the cup. The cups obtained for analysis where the Standard and Long Posterior Wall models of the DePuy Charnley, Aesculap ALFA, Corin Cenator and Avatar LFA. The Aesculap Plasma Symmetrical and Asymmetrical were analyzed for comparison.

The Alfa has a greater free range of movement compared to the Charnley cup and the other copies. The Charnley cup, the Cenator and the LFA differed in their pattern of impingement. The Alfa had the earliest point of dislocation. Long Posterior Wall: The Avatar had the greatest free ROM. The Charnley and the Alfa dislocated in an anterior direction latest. The Avatar and Cenator dislocated latest in the posterior direction. Plasma Cup: Compared to the Charnley and its copies its free range of movement was greater, it had only one point of impingement and impinged through the smallest arc before dislocating. It did, however, dislocate easiest.

Charnley copies are not identical. Differences in geometry exist and these alter important motion characteristics. Long term outcome may be affected. Surgeons should be aware of these differences when choosing implants.

We studied nine patients with Paget's disease affecting the skull or facial bones, who were subsequently treated with either dichloromethylene diphosphonate (clodronate) or ethylene-1-hydroxy-1,1-diphosphonate (etidronate). Long-term treatment induced a clinical and biochemical improvement in eight, and this was associated with a reduction in maxillary or skull volume as assessed by quantitative stereophotogrammetry. The one patient whose disease was resistant to treatment with diphosphonate, showed no change in maxillary shape. These studies suggest that the long-term control of disease activity attained with diphosphonates, results in the improvement of skeletal deformity.

There are many operations for hallux valgus and hallux rigidus, but Keller's operation remains one of the most popular, particularly for the older patient. A prospective trial was carried out to compare the results of Keller's operation modified by Kirschner-wire distraction with those of the standard operation. The results suggest that there is no advantage in using temporary Kirschner-wire distraction; indeed, degenerative changes in the interphalangeal joint and a subjectively worse result may result from its use.

The medical treatment of eight patients with paraparesis associated with Paget's disease of the vertebrae is described. Treatment, for 3 to 87 months, with calcitonin or with diphosphonates produced marked clinical improvement in seven of these patients. From this series and a review of 19 additional case reports it is concluded that favourable clinical response is seen in about 90 per cent of patients, and that this may occur very rapidly. Results are as good or better than those obtained by surgical decompression. It seems possible that paraparesis in some cases may be due to diversion of blood supply from the spinal cord to the highly vascular Pagetic bone giving rise to a vascular "steal" syndrome. It is suggested that medical treatment should be used more widely to avoid or delay the need for operation and reduce the risks of recurrence. These patients, however treated, require lifelong follow-up because relapses are common.