Abstract

Abstract

Abstract

Aims

Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected.

Abstract

Abstract

Introduction

Thoracic wall surgery can cause severe pain and inhibition of coughing with effects. (1) Various local anaesthetic (LA) techniques have been tried successfully to mitigate the use of opioids alone. We believe this is the first time that a serratus plane block using an epidural catheter (SABER)has been studied in anterior spinal fusion (ASF) procedures. Our aim was to ascertain how it would affect ASF compared to gold standard posterior spinal fusion (PSF) surgery.

Adolescent Idiopathic Scoliosis (AIS) patients were subjected to four weeks of Physiotherapy Scoliosis Specific Exercise (PSSE). 124 (Exclusion = 3) Patients were enrolled and assigned to either complete their treatment in one 4-week bout (4WC) (63 patients, M_age = 14.52), or to complete their treatment in two separate fortnightly bouts (2X2WC) (63 patients, M_age = 14.26). Clinical exam, surface topography and Scoliometer readings were compared. The SRS-30 questionnaire before and after treatment was conducted at 6, 12, 18 and 24 months.

Group 1 (4WC) showed significant improvements from baseline (Pre-3.73 – Post 3.9; p=0.026) after the course of treatment, and showed significant improvements at 12 months follow up in Mental Health (p=0.006), Aggregate score (p= 0.005) and Satisfaction score (p=0.011). Satisfaction score remained statistically significant at 18 months follow up (p=0.016). Group 2 (2X2WC) did not record a significant improvement from baseline (p=0.058); however, showed significant improvements in self-image (p=0.013). There was no statically significant difference in SRS scores with respect to follow up time.

We conclude that Physiotherapy Scoliosis Specific Exercise (PSSE) is a successful non-invasive therapy for AIS. The modified Schroth technique (ScolioGold) shows significant improvement in SRS30 scores with the 4-week intensive course that are sustained at a 2 year follow up.

Introduction: Ankle diastasis injury occurs in up to 20% of ankle fractures. Various techniques have been used to treat syndesmosis injuries, but controversy remains and outcome is variable. In light of some recent cases of substandard syndesmosis fixations requiring revision, an audit of our results was undertaken.

Method: Study type: Retrospective audit of radiographs and patient records

Data collection: patients were selected using an orthopaedic database search for operations coded as distal tib/fib ORIF or ankle ORIF.

Study period: 12 months, July 2008 to July 2009 (currently data has been analyzed on the first 6 months only, the remaining 6 months will follow)

Audit questions to be answered: How is ankle diastasis injury being managed? Are we reducing syndesmosis correctly? Should there be a revision to local policy?

Audit standard: Syndesmoses should be adequately reduced and fixation techniques employed should be in accordance with recommendations in standard Orthopaedic reference texts (Rockwood & Green, AO fixation manual 3)

Results: 76 ankle ORIFs in July to December 2008 inclusive. Out of these, 16 had diastasis fixation (21%). 2 of the patients had a syndesmosis width over 6 mm indicating an inadequate reduction of the syndesmosis 1. Both of these required revision surgery. In total 70% of the post operative x-rays showed inadequate syndesmosis fixation or reduction.

Discussion: The single most predictive indicator of a favourable function is accurate reduction of the syndesmosis 2. Substandard fixations are associated with poor long term outcomes. This raises the potential for litigation and the requirement for education and policy change. We have produced policy guidelines for theatre and circulated the information to all surgeons. A further audit will be carried out to assess the effectiveness of this in 6 months time. (The data will be available from this re-audit for presentation at the conference.)

Purpose: Pigmented Villonodular Synovitis (PVNS) is an uncommon presentation characterised by hyperplastic synovium, bloody effusions and bone erosions. Incompletely resected localised and diffuse lesions have a high recurrence rate. The management of recurrent lesions depends on the expertise of the surgeon and severity of the lesion. The imaging characteristics of PVNS and experience of British knee surgeons in managing these lesions is presented in our study.

Methods: A postal questionnaire was sent to 100 knee surgeons of the British Association of Surgeons of the Knee (BASK) with questions relating to their experience in managing localised and recurrent PVNS. The options included either arthroscopic or open synovectomy with or without radiotherapy, radical excision or referral.

Results: 74 responses were included in the study. 73 out of the total cohort of 74 surgeons (98.7%) had seen less than 5 presentations in their career.

Localised lesions were treated primarily by arthroscopic synovectomy [N=58(78.4%)] or open synovectomy [N=12(16.2%)] with radiotherapy being utilised in 4 lesions (5.4%).

For local recurrence the management was arthroscopic [N=26(35.1%)] and open [N= 19(25.7%)] synovectomy. Radiotherapy was used in 18 (24.3%) of patients with localised recurrence and 8 (10.8%) of were referred to specialist units.

Infiltrating lesions were treated with open synovectomy and radiotherapy [N=22(29.7%)] and 20 cases [27.02%] were referred to specialist units.

Imaging of PVNS and Conclusions: The role of imaging is invaluable in early diagnosis and treatment due to limited experience in managing such presentations. Routine radiography and Computerised Axial Tomography (CT scan) often demonstrate non-marginal pressure erosions with sclerotic margins as well as nodular soft tissue masses. Sonography shows non-specific focal or nodular synovial thickening with increased flow on colour doppler. Magnetic Resonance imaging characteristics of PVNS are nodular, synovial masses which are low signal on T1-weighted and T2-weighted imaging.

Introduction: Fractures of the neck of femurs in amputees have been reported sporadically in literature. We reviewed a series of 19 amputees who presented with a fracture neck of femur to analyse their mobility and pain scores at the end of one year and compared them with other patients presenting with the same condition.

Methods: We retrospectively analysed prospectively collected data for fractures of the proximal femur on all patients with amputations of the lower limb. Details on admission of all consecutive admission to one hospital were recorded from 1989 onwards including age, sex, type of amputation, fracture type, mechanism of injury, peri-operative mobility and rehabilitative status up to 1 year post operatively.

Results: Nineteen (19) patients with 22 amputations, sustaining 20 fractures of the neck of femurs were treated among approximately 6500 neck of femur fractures in our hip fracture database. Of these 7 were male and 12 were female. The mean age was 79 years with a range of 50–89 years. 17 patients had undergone below knee amputations (BKA) and 5 above knee amputations (AKA). Thirteen patients came from their own homes with thirteen patients being mobile pre-operatively while 6 were bed bound. All patients were alert and scored well on mental test scores. Intracapsular fractures were the most common type with AO Screw fixation being the most common operative management. Hospital stay was an average of 7 days with a range of 1–90 days. Thirteen of our cohort of patients survived more than a year after the fracture operation. Post operative mobility scoring revealed that most of our patients returned to their preoperative mobility level except for those that did not survive for the first year.

Discussion: Fractures of the neck of femurs have an increasing incidence in an expanding aging population with nearly 60000 fractures treated in the United Kingdom every year. Amputees suffer from accelerated bone density loss and are at an increased risk for osteoporosis and fragility fractures in the hip. The future prospect with an increasing population of amputees with fracture neck of femurs must be addressed so that appropriate management plans can be implemented to allow such patients to return to full mobility and active lifestyle. This also decreases other co-morbidities such as pressure sores and infection.

Approximately one third of our patients survived between 1 to 4 years and another third survived between 5 to 10 years with one patient surviving over 10 years with nearly returning to their pre-injury status. We suggest that satisfactory post operative function is achievable with either internal fixation or hemiarthroplasty.

We conclude that these fractures should be treated with the same urgency and expertise as similar fractures in non-amputees as long term survival and good quality of life can be expected.

Background: Numerous researchers have documented posterior comminution to confer an increased incidence of non-union and avascular necrosis after internal fixation of both displaced and undisplaced intracpasular hip fractures. This prospective study of 1247 patients questions this association and shows that comminution does not cause a statistically significant increase in these complications of fracture healing.

Methods: Twelve hundred and forty-seven patients with 1247 intracapsular hip fractures (568 undisplaced and 679 displaced fractures) were treated with open reduction and internal fixation. All these had preoperative radiographs, which were evaluated for posterior comminution. All of them were followed up post-operatively for clinical and radiographic evidence of non-union and avascular necrosis. The incidence of complications in comminuted versus non-comminuted fractures was calculated in both undisplaced and displaced groups. These rates were then compared for statistical significance (p value =0.05).

Results: The undisplaced cases (n=568) comprised 557 non-comminuted and 11 comminuted fractures. The complication rates were 10.9% and 18.2% respectively. The difference was not significant, with a p value of 0.38. Displaced fractures (n=679) consisted of 588 non-comminuted and 91 comminuted cases. In this group, complication rates were 33% and 35% respectively, with a p value of 0.82.

Conclusions: For the 1247 patients studied, there was no association between the observation of comminution of the fracture on the pre-operative x-rays and the later development of fracture healing complications.

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores by analysing prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas.

Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (4.65 versus 5.76), diabetes mellitus (pressure sore incidence 10.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor.

While the time interval between fall and admission was not significant, the time interval between admission and surgery was found to be an extremely significant risk factor. A fall in blood pressure during surgery (5.6%) was found to increase risk. Patients who underwent a dynamic hip screw were more likely to develop pressure sores (incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery or type of anaesthesia. Our incidence of pressure sores is lower than previously reported (30%). Whilst determining factors that increase the risk of pressure sores may not be sufficiently reliable to be used for the individual patient, taking appropriate preventative measures can reduce the incidence, particularly with reference to (optimising the patient pre-operatively and) reducing delays to surgery.

It is unclear which length of thread may be most advantageous for the internal fixation of an intracapsular fracture with cancellous screws. We have compared the 16mm versus the 32mm threads on cancellous screws within a randomised trial for 432 patients. All fractures were fixed with three screws and patients followed-up for a minimum of one year from injury.

The characteristics of the patients in the two groups was similar with a mean age of 76 years. 23% were male. The most common complication encountered was non-union of the fracture which for undisplaced fractures occurred in 7/107(6.5%) of short threaded screws versus 11/133(8.3%) of long threaded screws. For displaced fractures the figures were 29/104(27.9%) versus 24/89(27.0%). Other complications for the short versus long threaded group were avascular necrosis (two cases versus five cases) and fracture below the implant (two cases in each group). Elective removal of the screws for discomfort was undertaken in five and three cases respectively. None of these differences between groups was statistically significant. In summary there is no difference in fracture healing complications related to the length of the screw threads.

Introduction: In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of “Halo zone” surrounding the screw.

Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.

Method: Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).

Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.

Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.

Results: Kappa Index among three experts was 0.2198 at 95% CI (−0.0520, 0.4916) while for all 7 assessors (3 Experts & 4 SpR), KI was 0.1462 at 95% CI (0.0332, 0.2592)

Discussion & Conclusion: Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.

We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.

Introduction: We report a series of 10 cases from a cohort of 421 Dynesys procedures in which evidence of Accelerated Adjacent Disc Disease (AASDD).

Spinal fusion for degenerative disc disease is known to have inconsistent outcomes. One concern is the possibility of AASDD as a result of the altered kinematics. The Dynamic Neutralisation System (Dynesys) appears to offer an advantage in that it restricts, rather than abolishes movement at the treated segment, and should thereby reduce the problem of AASDD, In the event of failure, it can in addition be removed, returning the spine to the former status quo. Various biomechanical studies confirmed flexibility of Dynesys.

Method: Ten patients developed new and symptomatic disc disease within segments adjacent to Dynesys. The average age of patients was 49 year with range between 36–70 years. Average post Dynesys to secondary surgery for ASD was 24.7 months. Previous discography and MRI in all cases had shown no evidence of disc disease within these adjacent segements prior to Dynesys. All patients were evaluated preoperatively using Oswestry Disability Index, SF 36 and Visual Analogue Scores together with plain x ray imaging, MRI scanning and discography. Of this cohort Dynesys was indicated to treat single disc level in 7 and two levels in 3

Results: Incidence of AASDD associated with Dynesys was 2.1%. Further surgical intervention included:

Extension of Dynesys10

There was no caudal ASD in our cohort.

Discussion & Conclusions: Dyensys did not prevent the development of accelerated ASD. Evidence from Aylott cadaver studies suggests that Dynesys instrumentation alters the Kinematics of the adjacent segment and increases the excursion. It is unclear whether the small number of AASDD reported here is other than the natural progression of degenerative change. 95.7 cases did not progress.

Introduction: The results of the FDA trial for Dynesys stabilisation implied that the procedure was effective as a method of treatment for this condition. However, all the American cases had adjunct decompressive treatment. In this study we report the outcome of the first two years following DYNESYS for Spondylolisthesis in two groups of patients; Dynesys alone and Dynesys with fusion.

Method: Fifty five patients had Dynesys for symptomatic Spondylolisthesis which was indicated for surgical treatment. Average age for group 1 was 51 years with range of 36–85 years whereas in group 2, average age was 59 years with range of 31–79 years. Patients were evaluated preoperatively using ODI, SF36, VAS, plain x-ray, MRI scanning & discography. 33 of the patients underwent Dynesys alone (group 1) while 22 underwent dynesys with fusion (group 2). Previous decompression surgery was noted in 10 in group 1 and 8 in group 2.

Results: In the first year following Dynesys, both groups did show significant improvement in all the four parameters; VAS (back and leg), ODI and SF36. In group 2 slight deterioration was noted in year 2 and while group 1 continued to improve, Subsequently 3 group 1 patients underwent fusion and 12 required removal/revision of Dynesys (40%).

Discussion & Conclusions: Dynesys alone in the treatment of spondylolysthesis resulted in a 45% re-operation rate, and we believe it should not be recommended as an indication.

Introduction: We report the outcome two years following Dynesys for the treatment of Spinal Canal Stenosis. In both the FDA trial and the European multicentre study, stenosis was invariably combined with decompression, invalidating conclusions on the results of Dynesys alone.

Method: Eighteen patients had symptomatic Spinal Canal Stenosis with root claudication sufficient to justify surgical intervention. Average age of patients was 68 with a range between 44–86 years. Dynesys was applied for the treatment of a single level in 4, two levels in 8, and more than two levels in 6.

Patients were evaluated preoperatively using ODI, SF36, VAS, plain x-ray, MRI scanning & discography. Questionnaires were evaluated at the first and second years.

Results: 2 patients had undergone previous spinal decompression, and decompression at the time of Dynesys surgery in 7. In the remaining 9 cases, no decompression was used, relying on distraction alone as in the X stop system. In this latter group, stenotic symptoms failed to resolve. Removal of Dynesys was indicated in 3 (16.6%).

Discussion & Conclusions: Dynesys alone is not recommended as a treatment for symptomatic spinal stenosis. A separate study is required to address the question of whether Dynesys adjunct improves the back pain outcome compared with decompression alone.

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores

We have analysed prospectively collected data of 4654 consecutive patients (1003 males/3473 females).

3.8% developed pressure sores in the sacral, buttock or heel areas. Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (5.7 versus 6.7), diabetes mellitus (pressure sore incidence 9.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor. Among surgical factors related to an increased risk was a fall in blood pressure during surgery (5.6%). Patients who underwent a dynamic hip screw were more likely to develop pressure sores (pressure sore incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery of type of anaesthesia.

Our study indicates that the current incidence of pressure sores is lower that that previously reported (30%). Whilst it is possible in a large population of patients to determine factors that increase the risk of pressure sores, these are not sufficiently reliable to be used for an individual patient.

Two of commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. We performed this trial to determine if any difference in outcome exist between these implants.

We undertook a prospective randomised controlled trial of four hundred patients with a displaced intra-capsular hip fracture. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility.

The average age of the patients was eighty-three years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups. Pain scores were less for those treated by a cemented prosthesis (p value < 0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay, implant related complications, re-operations or post-operative medical complications between the two groups. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group.

In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to the uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.