Total disc replacement (TDR) is the gold standard for lumbar degenerative disc disease in selected patient groups. Traditional TDR designs benefit from a wealth of literature and use a polyethylene inlay pseudo-disc between two metal endplates. There is scarce literature for novel monomodular implants that form an artificial construct of woven annulus and central nucleus, providing physiological motion preservation. The aim was to compare the evolving changes to radiological position between monomodular and traditional implants and assess the relationship of migration with bone densitometry. This retrospective series of consecutive patients undergoing TDR under a single surgeon recorded demographics, co-morbidities, previous surgery and clinical outcomes. Measurements of endplate subsidence, lordosis and spondylolisthesis taken from weight-bearing erect x-rays at 0, 3, 6 and 12 months. Radiological outcomes were compared against CT bone densitometry. 33 monomodular and 13 traditional implants. Mean age 40 years. All patients had degenerative disc disease. Monomodular and traditional implants were as likely to develop lordosis (p=0.32), endplate subsidence (p=0.78) or spondylolisthesis (p=0.98). Comparison between endplate subsidence and low bone densitometry were insignificant (p=0.47). Developing lordosis in the monomodular implant was related to low bone density; mean 134vs.184mg/cm3 (p=0.018). Three monomodular implants developed a posterior hinge after migrating into lordosis. One traditional implant dislocated, requiring emergency fusion. Radiological outcomes are comparable between traditional and monomodular implants. The larger endplate-footprint of the monomodular implant did reduce subsidence. Monomodular implants pivoting on a posterior hinge may fail early. Bone densitometry may identify patients who will drift into lordosis.
Neuromuscular scoliosis is a difficult condition to treat. Curve severity, secondary pelvic obliquity and poor respiratory function can make operative treatment and post operative care challenging. The benefits to the child in terms of improved sitting position and trunk posture can be considerable. We present a large consecutive series of patients with neuromuscular scoliosis treated surgically at our institution. The aim of this work was to study the clinical and radiographic impact of surgery for neuromuscular scoliosis. Data was gathered from patient records and radiographs for all cases of neuromuscular scoliosis treated surgically between April 2002 and Feb 2005. 52 cases were identified. They fell into 2 surgical groups: single stage posterior correction and two stage anterior and posterior correction. All posterior instrumentation was transpedicular. Complications, length of stay, and change in severity of sagittal and coronal plane deformity were recorded. Average pre-operative Cobb angle was 85°. There were 16 patients with additional sagittal plane deformity. Average percentage improvement of Cobb angle was 59%. The correction was better in two stage procedures. Pelvic obliquity was improved in those who were obligatory sitters. Fusion rate was 83% for those followed up more than 1 year. ITU stay was longer in single stage procedures. Complication rate was 58%. We have shown that with appropriate patient selection the correction of neuromuscular scoliosis can achieve good results with high fusion rates. Two stage correction confers correctional advantage on those who have sufficient respiratory reserve to tolerate it.
Treatment regimes for malignant disease have improved significantly in recent years leading to improved survival after diagnosis of primary and Metastatic disease. Against this background we have reviewed the activity in a district general hospital offering a spinal service to evaluate the efficacy of surgery in metastatic disease. Materials and Methods: Retrospective casenote review of patients identified through theatre records over a 3 year period. 27 patients were identified as having surgery for spinal tumours, of whom 24 were for metastatic disease. All presented with pain and/or signs of acute cord compression and had an intervention on an urgent or emergency basis by one of three spinal surgeons. Results: Of the 24 patients with metastases, the primary tumours were breast (7), lung(7), prostate(2), renal(2), bladder(1), clear cell (1), colon(1), thyroid(1) and unknown (2). The operations performed were: spinal decompression or vertebrectomy and stabilisation(18), stabilisation without decompression(4), decompression alone (1), biopsy only (1). Mean survival after surgery was 9.4 months (range 0–42 months) with a poorer outcome in those with pulmonary and renal disease. 7 patients remain alive with a mean follow up of 21 months. Symptomatic improvement was recorded in 19 / 24 patients in terms of pain control and/or restoration of function. There were 4 perioperative deaths of which none were due to complications of surgery. Discussion: Patients with terminal diseases are challenging to treat as they require multidisciplinary input both in hospital and in the community. Good results can be achieved for both symptom control and pain relief by surgical intervention for spinal metastases if appropriate early referral is made to a spinal surgeon. We have found that with the general improvements in survival with malignancy an aggressive surgical regime of decompression or vertebrectomy with spinal stabilisation can be supported.
Free osteocutaneous fibular grafts, revascularised by microvascular anastomoses, have been used for one-stage reconstruction of extensive bone and skin loss in the lower leg in seven patients. The addition of an integral skin flap to a vascularised fibular graft makes reconstruction of bone defects with significant skin loss possible, and the technique for designing and raising such a flap is presented. The advantages of this transfer over other microvascular osteocutaneous flaps are the available length of straight cortical bone, the large thin skin flap, the good diameter of the vascular pedicle and the fact that dissection is carried out under a tourniquet.
