We aimed to audit the results of one stop fragility fracture risk assessment service at fracture clinic for non-hip fractures in 50–75 years old patients at Newcastle General Hospital. Currently, fewer than 30% of patients with fragility fractures benefit from secondary prevention in the form of comprehensive risk assessment and bone protection because of multifactorial reasons. We have a fragility fracture risk assessment service staffed by an Osteoporosis Specialist Nurse equipped with a DEXA scanner located at the fracture clinic itself.

We carried out a retrospective audit of 349 patients of 50–75 years with suspected non-hip fractures referred from A& E Department from October 2006 to September 2007. Patients over 75 years were excluded because as per NICE guidelines, they should receive bone protection without need of a DEXA scan.

Out of these 349 patients with suspected fractures, 171 had fragility fractures. Median age was 64 years. 69 patients had humerus fracture, 65 had forearm fracture and 23 patients had ankle fracture and 14 had metatarsal fractures. Fracture risk assessment was carried out in 120 (70%) patients. Thirty Seven (31%) patients had osteoporosis and bone protection was recommended to GP. 38 (32%) had osteopenia and lifestyle advice was provided. 45 (37%) had normal axial bone densitometry. 90% patients had DEXA scan at the same time of fracture clinic appointment. Patients with male gender, undisplaced fracture and fewer fracture clinic appointments were more likely to miss fracture risk assessment.

Our experience suggests that locating fragility fracture risk assessment service co-ordinated by an Osteoporosis Specialist Nurse at fracture clinic is an efficient way of providing secondary prevention for patients with fragility fractures. This can improve team communication, eliminate delay and improve patient compliance because of ‘One Stop Shop’ service at the time of fracture clinic appointment.

Introduction: Schober’s test, along with the modified version have long been used to assess lumbar flexion. The modified Schobers test, as described by McRae et al, is now the more commonly used. Both these tests rely on the assumption that movement of skin over the lumbar spine represents the degree of lumbar spine flexion. To our knowledge neither of these tests have been validated. Our aim is to validate the modified Schobers test as a method for measuring lumbar flexion.

Materials and Methods: Our inclusion criteria were:

normal subjects with no known structural abnormalities in spine or pelvis.

Accurate measurement of lumbar spine flexion is possible using a machine made by a Finnish company called Data Based Care (DBC). The machines accurately measure ranges of spine movement by isolating the movement being measured and immobilising any other muscle groups which may interfere with the movement being measured.

We measured lumbar spine flexion as described by Mc Rae et al ie. The modified Schobers test and isolated lumbar spine flexion using the DBC machine.

Two researchers were involved in measuring subjects. One set the subject on the DBC machine and took the measurement, whilst the other assessed when the pelvis began to tilt. Thus only isolated forward lumbar flexion was measured. DBC measurements were carried out in a standardised way. The results were then tabulated and correlated.

Results: Our study included 100 people of whom 54 were male and 46 female. Average age was 38. The median measurements for modified schober’s test and DBC were 5 and 44 cm respectively. The measurements of both modified schober’s test and actual lumbar flexion using DBC were correlated with spearman’s rank correlation test showed no correlation.

Conclusion: Our results show no correlation at all between the actual range of lumbar flexion and the modified Schobers test. We state that this test is invalid and its place in clinical practice unjustified.

Purposes: To assess the influence of patients’ positioning following caudal epidural injections on the outcome.

Methods and Results: 58 patients with low back pain and sciatica undergoing caudal epidural injection were prospectively and randomly allocated into 2 groups. 28 patients (Group 1) were positioned on the side (same side of sciatica) following the injection while 29 patients (group 2) were laid on the back. Patients were assessed using Oswestry disability index and the leg pain intensity was scored using Numerical pain intensity scale before surgery and after 6 weeks following the procedure. Pre-and postoperative pain scores were reviewed for each individual patient and the rate of improvement or worsening was noted. In group 1, 92.8 % of patients had their leg pain improved and 7.2 % remained unchanged. In group 2 however, 77% of patients did improve whereas 13.7% failed to do so and 6.8 deteriorated on the pain scale. There was a statistically significant difference in the degree of pain score improvement in favour of Group1 (Mean: 2.75 points on the scale for group 1 versus mean: 1.31 for group 2, P< 0.001, Mann-Whitney test). No difference was noted between the two groups in the improvement in the disability index (P< 0.14).

Conclusions: Lying on the symptomatic side following caudal epidural injection has improved the result in terms of pain control. Such a simple manoeuvre could add benefit to the injection in terms of pain for which the procedure is mainly indicated. The longstanding functional disability remained unchanged.

Ethics approval: None

Interest Statement: None

Background: Falls are a major concern in the elderly population both from a clinical perspective and that of health resource provision. This study evaluates the incidence of falls in patients awaiting hip or knee replacement and the impact of joint replacement surgery 2 years later.

Method: Patients aged 65-80 years listed for primary hip or knee arthroplasty for osteoarthritis (OA) were invited to participate. Patients completed a questionnaire including Western Ontario and McMaster University OA Index (WOMAC) scores 0-100, 100 best, history of falls and fractures. Function was measured using Timed Up and Go (TUG) walk test. All tests were repeated at two years.

Results: One hundred and ninety-nine patients (84 hips, 115 knees) were recruited with a mean age of 72 years (standard deviation 4.0) and predominantly female (57 %). At two years 144 patients were reviewed of whom 128 had undergone arthroplasty. After surgery, 29/128 (23%) reported falling compared to 55 of these 128 (43%) falling at baseline; only 13/128 (11%) had fallen more than once. Fifteen patients sustained minor injuries and one patient reported a fractured wrist. Of the patients who had undergone joint replacement and fell at baseline 36/55 (66%) patients reported no falls at follow-up, whilst there were 11 new fallers. Patients reporting falls had significantly lower WOMAC pain and function scores, and slower TUG scores at both baseline and two-year review.

Conclusion: Patients with severe hip and knee OA awaiting arthroplasty reported a higher incidence of falls compared to the normal population but reported fewer falls after surgery. However, almost one in four patients were still reporting falling at the two-year review. Injury including periprosthetic fractures can have serious clinical and economic consequences. This study highlights the need to evaluate a falls prevention programme in arthroplasty management.

This study aimed to determine the prevalence of osteoporosis in patients awaiting hip and knee replacement for osteoarthritis and to review them two years later to determine the changes in bone density following joint replacement.

Patients aged between 65 and 80 years awaiting total hip or knee replacement were invited to participate. Lumbar spine, bilateral femoral and forearm bone mineral density (BMD) measurements were obtained using dual energy x-ray absorptiometry. BMD values were standardised using previously published T-scores and Z-scores. To assess clinical status, patients completed a questionnaire including the Western Ontario and McMaster University OA Index (WOMAC). All measurements were repeated at two-years.

Participants included 199 patients (84 hips and 115 knees) with a mean age of 72 years (SD 4.0) and were predominantly female (hips 67%, knees 50%). At baseline 46/199 (23%) patients (39 females) had evidence of osteoporosis (WHO definition) at one or more sites with the highest prevalence at the forearm (14%). At two-years 144 patients attended for review with 128 having undergone hip (56) or knee (72) replacement. At this review 39/144 (27%) patients (33 females) had evidence of osteoporosis at one or more sites with the highest prevalence at the forearm (22%). The greatest bone loss occurred at the forearm with median BMD change of minus 4% for females (25th percentile minus 7.3%, 75th percentile minus 1.9%) and minus 2.9% for males (25th percentile minus 4.6%, 75th percentile minus 1.1%). There was a significant difference in WOMAC Pain scores at follow-up between the osteo-porotic and non-osteoporotic knee patients (67 versus 81, p=0.002) indicating that osteoporotic patients had greater knee pain.

We have identified the forearm as not only the site with the highest prevalence of osteoporosis but also the greatest bone loss at follow-up. Further evaluation of forearm bone density measurements in the preopera-tive assessment and follow-up of patients awaiting joint replacement for hip and knee OA is required. Larger studies are needed to confirm our finding that the presence of osteoporosis is predictive of worse patient-reported outcomes of knee replacement.

Study Design: Prospective study with a 2-year follow-up.

Background: Intradiscal electrothermal therapy (IDET) was developed as an intermediate stage between conservative measures (analgesia, physiotherapy and injections) and radical surgery (fusion and disc replacement) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this treatment.

Objective: To assess the long-term outcome of patients with discogenic low back pain (≥ 6 months duration) treated with IDET who had previously failed to improve with nonoperative treatment

Methods: Forty patients with IDD determined by pre-operative provocative discography and MRI were treated with IDET. VAS pain scores, SF-36 scores, analgesic usage and sitting tolerance (mins) were collected pre-treatment and at 12 and 24 months. Subsequent treatments were recorded. The differences in the outcome scores were tested by Wilcoxon signed rank tests.

Results: Average age was 46 years (range 25–62 years) with 44% males and 56% females. No significant improvement was seen in pain intensity as measured by VAS and bodily pain SF-36 scores pre treatment and at 12 and 24 months post IDET. There were no significant differences in the remaining SF-36 subscales. Only 11% used less pain medication. Sitting tolerance improved between pre and 1-year post IDET, the difference was not significant. Eight (20%) patients underwent further surgery; 5 disc replacement and 3 fusions at 1-year post treatment.

Conclusion: The patients with IDD did not show any improvement at 1-year or 2-year post IDET. A significant proportion of patients required further surgery. We believe that the efficacy of IDET is doubtful.

Study Design: Prospective longitudinal study with a 2-year follow-up.

Background: Intradiscal electrothermal therapy (IDET) was introduced to bridge the gap between conservative measures (analgesia, physiotherapy and standard injection therapy) and radical surgery (disc replacement and fusion) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this so called less invasive treatment technology.

Objective: To assess the long-term outcome of patients with chronic discogenic low back pain (< 6 months duration) treated with IDET who had previously failed to improve with comprehensive nonoperative treatment.

Methods: Forty patients with IDD determined by provocative discography and pre-operative MRI were treated with IDET. VAS pain scores, SF-36 scores, analgesic usage and sitting tolerance times (mins) were collected pre-treatment and at 12 and 24 months. Subsequent treatments were recorded. Statistical analysis was performed using Wilcoxon signed rank tests to test for differences in the outcome parameter scores.

Results: Average age was 46 years (range 25–62 years) with 44% males and 56% females. The study group demonstrated no significant improvement in pain intensity as measured by VAS and bodily pain SF-36 scores pre treatment and at 12 and 24 months post IDET. There were no significant differences in the remaining SF-36 subscale scores at 0, 12 and 24 months after treatment. Analgesia requirement remained the same in 77% of the patients; 12% required stronger analgesia and only 11% used less pain medication. Although sitting tolerance improved between pre and 1-year post IDET, the difference was not significant. Eight (20%) patients underwent further surgery in the form of a disc replacement or fusion at 1-year post treatment.

Conclusion: The patients with chronic discogenic low back pain in this study did not show any improvement at 1-year or 2-year post IDET treatment. A significant proportion of patients underwent further surgery for persisting low back pain. We believe that the efficacy of IDET in the treatment of chronic discogenic low back pain is doubtful.