The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP).

A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion.

Cite this article: Bone Joint J 2015;97-B:1395–1404.

Introduction

The majority of spine patients present with discogenic low back pain, originating from either degenerative disc disease (DDD) or internal disc disruption (IDD). Successful treatment of this patient population relies on obtaining precision diagnosis and careful patient selection, as well as matching the pathology with reliable technology. Total disc replacement (TDR), as an alternative to spinal fusion in the treatment of DDD or IDD, has been studied and reported for several decades in long-term follow-up studies and in several randomized control trials. This prospective study presents a single surgeon experience with two-level CHARITÉ® TDR in 84 consecutive patients, with minimum follow-up of 5 years. The aims of the study were to assess the clinical outcomes of two-level TDR in patients with DDD/IDD. Based on the literature review conducted, this study is considered the largest single surgeon series experience with the two-level CHARITÉ® TDR in the treatment of lumbar DDD, with a minimum follow-up of 5 years reported to date.

Introduction: There is an increasing interest in the concept of motion preservation in cervical disc degeneration surgery. There is still a controversy regarding the effect of posterior placement of the disc on the segmental motion of the treated level.

The objective of this study is to assess the effect (if any) of posterior placement of the LP Prestige disc on the motion.

To our knowledge this is the first study to assess the relation of posterior placement on the motion.

Material and Methods: We retrospectively reviewed 186 prosthesis implanted in 130 patients who underwent an LP Prestige cervical disc replacement and decompression. The distance between the posterior edge of the lower plate of the LP Prestige disc and the posterior wall of the corresponding vertebra was measured. The measurement was performed on a digitalized lateral view x-rays. The posterior placement measurement was correlated to the range of motion of the device on the same level and also on the level above and bellow.

Results: The average age was 46.7 years (range 33–66). The mean posterior placement was 2.96 mm (range 0–6 mm). Range of motion (full flexion to full extension) of the prosthesis was 9.41 degrees (range 0.2–22). Average followup was 2.3 years.

Statistical analysis showed no statistical significant correlation between the posterior placement of the disc and the motion of disc (flexion to extension, flexion to neural and neutral to extension). The p value was 0.259, 0.379 and 0.623 respectively. There was no correlation between the placement of the disc and the motion of the level above and bellow the operated level.

Conclusion: We conclude from our study that there is no correlation between the posterior placement of the Prestige LP and the segmental motion of the prosthesis and the level above and bellow.

Introduction: Cervical disc replacement has emerged as an alternative to the gold standard ACDF in ordered to preserve the motion of the cervical spine, and reduce the risk of adjacent degenerative changes. However, little data actually exists to support or refute the effect of symptoms chronicity on TDA for the treatment of degenerative cervical spine.

Material and Methods: We prospectively investigated 130 consecutive patients who have undergone a Prestige LP cervical disc replacement for degenerative disease causing chronic neck pain and radiculopathy.

The pre and post-operative NDI, SF-36, Visual Analogue Score (VAS), HDS and HAS were recorded.

Results: There were 130 patients in total. There were 66 males and 64 females, with an mean age at surgery was 51.12 +/− 0.84. Seventy five patients had one level disc replacement, and 56 had 2 levels.

The mean follow up was 28+/−0.35 months, and the mean duration of symptoms was 34.46 +/−3.8 months. Mean length of stay 1.75+/−0.11 (1–4)

There was no correlation between the DOS and any of the functional outcome:

Improvement Neck disability index (r=−0.181, p=0.134)

Dividing the DOS into more or less than 12 months shows significant improvement only in the NDI: less than 12 months DOS (31.85±3.209) and in patients with more than 12 months DOS (19.71±2.164), p=0.002

While there was no statistical difference in the other outcomes.

Dividing the DOS into more or less than 24 months showed significant improvement the out come in patients with less than 24 months in the following outcomes:

Improvement in NDI: less than 24 months (27.35±2.714), more thank 24 months (19.72+2.435), p=0.04

While there was no significant difference in the other outcomes

Dividing the DOS into less or more than 36 months showed no statistical difference in any of the outcome,

That was also the case when the DOS was divided into more or less than 48 months.

Conclusion: Duration of symptoms of more that 24 months was associated with less favorable outcome, that was evident in improvement in NDI, HDS, HAS and VAS arm pain. Patients should be counseled when they present with DOS more than 24 months.

Purpose: To assess the outcomes in consecutive 32 patients of two level cervical disc replacement

Methods: In this article, we report 2-year results of anterior cervical decompression and two level cervical disc replacements (prestige) in 32 patients with a diagnosis of symptomatic cervical spondylosis. Dynamic assessment with lateral radiographs of the cervical spine in flexion/extension was done pre and post op. All of them had partial uni/bilateral uncinectomy, which adds in lateral bending. The median age of all patients was 46 years (range 32–61). Levels of surgery included between seven C3–C7, most common were C5–6, C6–7.

Results: Neck and arm pain as well as disability scores (VAS, ODI and SF36) were significantly improved by 3 months and remained improved at 2 years. Radiography revealed the complete motion (From flexion to extension) at upper disc replacement level of 11% and 9.6% at the lower level. There is a significant decrease of the facet joint articulation overlap in the sagittal plane. As the diameter of socket is slightly larger than the ball in prestige disc replacement, it helps in additional axial movement. There was reduction in motion at the adjacent segments above and below, preventing adjacent segment problems.

Conclusion: Twenty-four months after surgery, patients who underwent two level cervical disc replacements demonstrated greater improvement in neurologic function and neck pain. It helps in restoring sagittal balance, functional outcome of patient because of increased lateral bending, axial rotations and flexion-extension.

Ethics approval: done from appropriate authorities

Interest Statement: There is no local grant, national grant, commercial/industry support for this article. There are no interest or gain from any source for this article.

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus.

Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an antero-posterior and a lateral weight bearing radiograph

The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision.

All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46).

The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear.

The functional outcome as assessed using the SF-36 health score was compatible with an age matched population.

The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores.

Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome.

We retrospectively reviewed 31 patients who underwent reconstruction procedure for PTT D (Type II Johnson). The surgery was mostly performed by the senior author.

Fifty patients underwent 55 procedures, 31 patients were available for review (34 procedures)

Clinical and functional outcome were assessed using AOFAS hindfoot score, and the SF-36 health assessment score.

The patients had a calcaneal medialising (chevron) osteotomy to correct heel valgus, with or without a calcaneal lengthening osteotomy, and transfer of the FDL tendon to the navicular. All patients were immobilized in non-weight (to partial) bearing POP for 5 weeks, followed by CAM for 6 weeks.

There were 7 males and 24 female, with an average age of 60.5 years. The average follow up was 54 months (range 11.5–111.2). The average hindfoot valgus deformity was 15 degrees preoperatively.

Eight patients had and additional procedures including (TA lengthening, Lapidus). Four patients required bone graft for calcaneal column lengthening, and in 5 patients the posterior screw was removed due to continuous discomfort.

The average AOFAS hindfoot score was 74 (47–100), the average pain score was 31/40 and the average subscore of the heel alignment was 7.9/10.

Nineteen patients (61%) were able to perform single heel raise, and 27 patients (87%) were able to perform bilateral heel raise. 26 patients (83.8%) had no lateral impingement pain post operatively.

The SF-36 health assessment showed similar functional outcome with age matched population. Two patients had superficial wound infection required oral antibiotics.

Hindfoot and midfoot reconstructive surgery for type II PTTD after failed orthotic treatment is well established. However, the post operative care and rehabilitation period is lengthy and protracted. This must be emphasized during informed consent in order to fulfil realistic expectations.

Aim: To review the results of tibial lengthening and deformities correction in children using the Sheffield Ring Fixator.

Materials and methods: We have reviewed, retrospectively, 25 patients (average 12.2 years old) who underwent predominantly lengthening of the tibia using the Sheffield Ring fixator.

The average follow up was 25.7 months. For logistic regression analysis the patients were binary coded into two groups: those with a good outcome (BHI< 45 days/cm) and those with a poor outcome (BHI> 45 days/cm). Various factors which may influence the out come were then analysed.

Results: The most common indication for tibial lengthening in our series was for fibular hemimelia in 6 patients and achondroplasia in 4 and growth arrest secondary to trauma in 3. The mean lengthening of 48.1 mm (25–76). The mean accuracy of lengthening achieved was 85%.

11 patients had foot plate extension, and 5 had cross knee extension for unstable knee. 10 patients had bifocal osteotomy, and 8 patients had spontaneous SLR for femoral lengthening or correction.

The mean bone healing index was 49 days/cm (20–95). The mean maximum correction in any one plane was 150 (3–40), the site of the osteotomy was mainly metaphyseal at an average of 25% of the tibial length.

There were 5 grade II complications, 9 grades I complications and one type III complication. Thirteen patients had grade I pin site infection, three had grade II and 12 had no pin site problems.

A moderately strong relationship was identified between the BHI and a number of variables such as complications, maximum correction and pin site infection grade.

The analysis of the factors which may influence the BHI suggested a correlation between increasing angular correction and poor out come BHI.

Conclusion: In tibial lengthening in children there is a correlation between increasing angular correction and poor out come BHI

Aim: To review the outcome following growth plate arrest in distal femur and proximal tibia of different aetiology in adults.

Materials and methods: We have reviewed, retrospectively, eight adult patients with lower leg deformity in the distal femur and proximal tibia, as a sequelae of growth plate arrest of different aetiology. These patients underwent tibial and femoral, correction and lengthening. The total number was 8 patients, there were 6 male and 2 female, with an average age of 22.8 years (17–34.8) The average follow up was 32.9 months (7.9–51.4)

Results: Four patients had growth plate arrest following trauma (two patients were involved in road traffic accidents, one had Salter-Harris type V fracture of the proximal tibia and one had sport injury), two patients had iatrogenic growth plate arrest after internal fixation of tibial spine in one patient and after internal fixation of a popliteal muscle rupture in the other, one patient had Osgood Schlater disease, one patient had childhood osteomyelitis and one unknown pathology.

The average shortening was 34.8 mm (8–60), the average maximum deformity in any one plane was 19.8 degree (6–40).

All the patient underwent corrective surgery and lengthening, five patients had Sheffield Ring Fixator, two had Limb Reconstruction System and one had percutaneous osteotomy on Albizzia nail. The patients who underwent SRF and LRS stayed in the frame for an average 258 days (150–435)

The residual leg length discrepancy was 5.5 mm (0–12). There was three grade one complications, three grade two complications, and one patient had grade IV complication following compartment syndrome. Four patients had grade two pin site infection and three patients had grade one.

Conclusion: Growth plate arrest of the distal femur and proximal tibia can cause severe deformity and shortening of the lower limb in adult, and this deformity is amenable to correction in the end of growth using different techniques. We used Sheffield ring fixator in complex cases, to address both deformities and lengthening, while other techniques were used in less complex cases.

We reviewed 35 patients who underwent a medial unicondylar knee replacement, with an average follow up of 4 years (for functional assessment). All patents had a weight bearing AP and lateral X rays and were clinically assessed using Hospital for Special surgery score, Bristol Knee Score and SF 36 health assessment form. Five angles were measured on the x-rays to assess the alignment of the tibial and femoral alignment. There was a significant relation between the femoral component varus/valgus angle and three sub scores (fixed flexion contracture, maximum valgus/varus and range of movement) in Bristol Knee scores. The best functional out come correlated with femoral components of 4–8 degrees of valgus.

We present a series of 88 non-unions in which non-union, infection, bony alignment and length were addressed simultaneously, by using the Sheffield Ring Fixator.

The mean follow up was 50 months (range 6–110) after union, which was achieved in 90.5% of the patients. The mean deformity correction was 16.80 (range 60–320), and mean length gain was 12.5 mm (range 2–40 mm).

Smoking and infection had a statistical significant association with the time of healing, as healing of the non-union in over 18 months was more common in smoker and patients with infected non-union.

There was no statistical difference between the functional score (SF-36) between these patients and normal population, at a follow up of minimum 2 years, but that was significant between pre operative and less than one year follow up on one side, and more than 2 years follow up on the other.

We report 10 cases of supracondylar periprotheitc fractures following TKR; all were treated using a retrograde intramedualry nailing. There were 7 females and 3 males, the mean age at surgery was 76 years (range from 68–85). The average time since the primary TKR to surgery was 5.3 years (range 2–9.4). All patients had locked intramedualry nail, and knee was immobilized in a splint for few months post op. Partial weight bearing was started 2 weeks post op. There was no intraoperative complication. One patient had superficial infection, which was treated by IV antibiotics. There was no cases of septic arthritis.

One patient was lost for follow up and one patient died from myocardial infarction 8 months post op.

Eight patients were reviewed and assessed clinically and radiologicaly. The average range of movement in the knee was 97 (range 75–110) and all patient achieved clinical and radiological healing.