Microdiscectomy is the most commonly performed spine surgery in the world. Due to its technical simplicity and low complication rate, this was the first spine surgical procedure transitioning for one-day surgery. However, the economic assessment of this outpatient transition was never performed and the question on the real impact in the burden of spine care remains.

This economic study aims to access the cost-utility of outpatient lumbar microdiscectomy when compared with the inpatient procedure.

To do so, a cost-utility study was performed, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy, from a in a Portuguese NHS hospital. Utilities were calculated with quality-adjusted life-years were derived from Oswestry Disability Index values (ODI). ODI was assessed prospectively in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. both probabilistic and deterministic sensitivity analyses were performed and incremental cost-effectiveness ratio (ICER) calculated. A willingness to pay (WTP) threshold of €60000/QALY gained with inpatient procedure was defined.

Out results showed that inpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135753 to €345755/QALY, higher than the predefined WTP. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group. The mean admission time in inpatient group was 2.5 days. Since there is an overall agreement among spine surgeons that an uncomplicated inpatient MD would only need a one-day admission, an analysis reducing inpatient admission time for one day was also performed and outpatient remained cost-effective.

In conclusion, as the first economic study on cost-utility of outpatient lumbar microdiscectomy, this study showed a significant reduction in costs, with a similar clinical outcome, proving this outpatient transition as cost-effective

Objectives

This systematic review aimed to assess the in vivo and clinical effect of strontium (Sr)-enriched biomaterials in bone formation and/or remodelling.

Purpose of the study: Proximal fractures of the humerus account for 10% of fractures in persons aged over 65 years. There is no optimal treatment. The goal of surgery is to restore joint congruency, preserve vascular supply, and allow functional recovery. We describe the results obtained with a surgical technique designed to meet these goals.

Material and methods: Fifteen 3-fragment fractures of the proximal humerus were treated with transosseous suture. Mean age of patients was 58 years. Eighty-six percent of the patients were female. Follow-up was 18 months on average. The patients were placed in a lounge chair position for the deltopectoral or transdeltoid approach. For this type of fracture, the humeral head is displaced medially or laterally, so that care must be taken to ensure the realignment in the sagittal and coronal planes. The DASH and Constant scores were noted for the operated and non-operated shoulders. Signs of bone healing were noted on the plain x-rays.

Results: The mean DASH was 12, mean Constant score for the operated shoulder was 80 versus 90 for the other shoulder. The mean neck-shaft angle was 139°. There was one case of lost reduction but with a good final result. There was one case converted to arthroplasty.

Discussion: This technique is in line with the current trend for biological preservation minimising the aggression to the humeral head blood supply. There was no risk of migration with the fixation material used and no need to remove implants.

Conclusion: Transosseous suture of proximal fractures of the humerus is a mini-invasive method which provides good functional results avoiding voluminous metal implants, known to be costly and source of complications. The incidence of avascular necrosis of the humeral head is low, in agreement with the international literature.

Cervical Spondylotic Mielopathy (CSM) is the most common cause of spinal cord dysfunction in the adult population. Treatment implies surgical decompression as soon as possible after the diagnosis. In this study the authors present the long term results of minimal 10 years follow up of a prospective study of 98 patients that underwent anterior decompression and arthrodesis surgery for CSM.

Patients that underwent surgery for CSM between January 1990 and December 1994 were evaluated for sex, age, number of levels operated, functional evaluation with Nurick Scale pre operatively, 1 year after surgery and at the final the revision that took place in 2007 and 2008, evidence of consolidation and complications. All the patients were operated by anterior approach. T-Student Test was performed with SPSS for statistical analysis.

99 patients were evaluated during the study, 73 male, 26 female, with a mean age of 56, 6 years (42–86) and mean follow up time of 14,4 years. 3 patients died in the immediate pos op period, 1 in the first year, 8 during the 15 year evaluation period. 16 patients were operated for 1 level, 22 for two levels, 36 for 3 levels and 22 for four levels (mean on 2,7±1,0 levels for patient).

Pre op Nurick was 3,8±0,9. There was a significant improvement in neurological condition after one year surgery (Nurick 2,2±1,1; p< 0,001), and between pre op and final evaluation (2,3±1,2; p< 0,001). The degradation between the first year and the final evaluation was statistically significant (p=0,004).

There was a strong correlation between age and the number of operated levels (r=0,391, p=0,01), age and initial neurologic status (r=0,238, p=0,05), initial neurological status and number of operated levels (r=0,251, p=0,05) and sex and number of operated levels, with women being operated for more levels (r=0,208, p=0,05). There was also e stronger neurological deterioration between year 1 and year 15 in young patients when compared to older ones (r=0,250, p=0,05). There is a strong clinical relation between first year recuperation and final recuperation (r=0,838, p=0,01). There was a 100% rate of consolidation.

Surgical treatment for decompression and arthrodesis is considered for us the best option for the treatment of CSM in terms of improvement of pain, alignment and neurological function. A significant neurological improvement comes from surgery, and despite a significant clinical deterioration between the first year and the final evaluation, the benefits of surgery are still evident 15 years after, with a better neurological status when compared to the pre operative period.

Treatment of patellar instability in adolescents is controversial. Some investigators have advocated early repair of the medial structures, whereas others have treated this injury nonoperatively. The medial patellofemoral ligament, is a primary restrictor and stabilizer of the patella, and has acquired a significant role in the treatment of instability in children and adolescents.

The authors present a prospective study of 39 consecutive patients (45 knees), without physeal closure, who underwent plasty of the medial patellofemoral ligament for the treatment of symptomatic patellofemoral instability with autologous Gracilis tendon, according to Chassaing’s technique. There were 26 female and 13 male patients with an average age of 15, 9 years. Mean follow-up was 44 months (6–65). All patients presented with clinical evident patellar tilt. This population presented a TA-GT within a normal range (12+/− 5 mm), but presented in 80% of cases a trochlear dysplasia

Clinical functional results were evaluated using the Kujala scale. Arthroscopic evaluation was systematically performed searching for intra articular injuries or patellar tilt. Early rehabilitation protocols were used in all cases.

At the last follow up evaluation, 90% of the patients presented good or very good results. Kujala Score was 84, 5 +/−9,7 after surgery compared with 54,9+/−11,8 before surgery (p< 0,0001). There were 3 minor complications: 2 hematomas and 1 superficial infection that resolved without complications.

Four patients kept complaining of residual anterior knee pain as result of patellar chondropathy that was diagnosed intra operatively. Three patients complained of graft donor site pain. One patient presented with a patellar dislocation three years after the surgery, and two patients still present clinical instability two years after the procedure. There was no stiffness in the knee in any patient.

The technique presented in this study has allowed very good clinical results, with few complications, using a small incision to reconstruct in an isometric fashion, this important patellar stabilizer.

Our objective is to perform a prospective study on the efficiency and durability of pain reduction through percutaneous PMMA vertebroplasty in patients with vertebral osteoporotic fractures.

We started in March 2002, and up to January 2005 we have performed this technique in 43 patients, 42 female and 1 male, with osteoporotic vertebral fractures. We performed a total of 56 vertebroplasties, 36 lumbar and 20 thoracic. The majority is for the thoracolumbar junction. Patient age went from 56 to 85, with an average of 70,7 years.

Cryteria for inclusion in this study have been the following:patients with osteoporosis, preferably with one or two collapsed vertebral bodies, with intractable pain for over 3 months. Exclusion cryteria have been: infection, blood coagulation deficits and mieloradicular compression. Relative exclusion criteria are Fractures over 70% body collapse, Posterior wall fragmentation and Young patient fracture with no prior disease.

We perform our PV under local anesthaesia with sedation and in a lateral decubitus position. We preferably use a parapedicular approach for both thoracic and lumbar fractured vertebrae.

The material we prefer are the LP2 system or the LCO and we chose Exolent spine for PMMA.

We follow a protocol that consists in:bed rest for 2 hours, allowing the patient to sit and have small walks afterwards;Dismissal the following day, with a mild analgesic for the effects of the skin incision;Maintain drug treatment for osteoporosis;Revision on the 2nd and 7th day;New revision at 3, 6 and 12 months.

Evaluation of the results was made by defining a pain score: Score 1 corresponds to minor or no improvement in pain.

Score 2 corresponds to a medium improvement in pain, with 25 to 50% less drugs required.

Score 3 corresponds to a better improvement in pain, with 75 % less drugs required.

Score 4 corresponds to complete relief of pain. In our revision, we had a minimum follow-up of 12 months, maximum of 44, and an average of 28 months. We have observed the following results:

- 2 patients with score 1

We can resume this by stating that 90 % of the patients had a relief in pain, and a good result was observed in 75 %.

We have had some complications, which consisted in:

- PMMA leakage into the disc in 1 case

In conclusion, and up to now, we have obtained pain reduction in 90% of the cases; we have prevented collapse of the treated vertebrae, and we have not had collapse of any adjacent vertebrae.

It is a technique that may have complications, but results depend on a correct selection of patients.