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Volume 85-B, Issue SUPP_III March 2003

H. Singh C. Soo-lin B.A. Kareem K. Selvakumar O. Kim-Soon M.B.T. Abdullah

Introduction: Understanding the factors in progression of curves in spinal deformities are crucial to the planning of treatment. While clinical and genetic parameters appear to be involved in the progression of adolescent idiopathic scoliosis, it remains very difficult to objectively study this as it is difficult to find pedigree cohorts. We wish to report the difference in progression of adolescent idiopathic scoliosis curves in two essentially homogenous racial groups that utilise our Scoliosis service.

Methods and Results: Three hundred and twenty-four patients were treated at the Scoliosis service of our Institute from 1985 to 1998. The aetiology of the curves were as follows: 218 AIS, 37 Neuromuscular, 48 Congenital, 21 other diagnostic type, and 11 aetiology not known. The racial distribution of utilisation of service: 44% Malay, 44.7% Chinese, 2.0% Indian and 9.3% not known or mixed race. The Malay and Chines groups were matched and studied. There was no difference in the menarchal age, curve size at presentation and age at presentation to the service (P=0.3). Patients were analysed in two groups: below 10 years, and above 10 years at presentation.

The rate of progress of the AIS curves > 50° were fastest in the Chinese patients with a rate of 14.7°/year; with Malay patients progressing at 8.4°/year. Rates of progression of curves 30–50° were the same for both groups with Chinese at 7.7°/year, and Malays at 6.7°/year. Curves < 30° progressed at the same rate also with Chinese at 5.0°/year and Malays at 7.0°/year.

Conclusion: From our data, it appears that race (genetics) does influence the rate of progression of AIS curves.

F.M. Smith G. Latchford R.M. Hall P.A. Millner R.A. Dickson

Introduction: Given the timing and nature of adolescent-onset idiopathic scoliosis (AIS), this progressively deforming condition is highly likely to have a significant psychosocial impact. Body image dissatisfaction is a frequent finding in AIS patients, which is of concern, as there is a well-documented causative link between body image disturbance and the formation of disordered eating behaviour, reflected in the theoretical models for this area of psychopathology.

However, although AIS patients have frequently been observed to exhibit disturbed body image, there has been no previous attempt to assess indications of disordered eating behaviour. Given the prevalence of AIS in adolescent females and the possible medical consequences of disordered eating, this study aimed to investigate whether AIS patients have an increased likelihood of low body weight.

Methods and Results: Patients were recruited over a four month period from the regional scoliosis out-patient clinic at St James’ University Hospital; 44 female scoliosis patients participated, with a mean age of 16 (range 13 to 19). All those meeting the inclusion criteria (diagnosed with AIS, not diagnosed with any other serious medical condition), and attending clinic over the data collection period were asked to participate.

Weight, height, and BMI (weight (kg)/height(m)2) measurements taken from AIS participants were compared to age and gender-adjusted normative data. No uncoiling correction was made for the scoliosis in terms of body height. The International Classification of Diseases (ICD-10) body mass criterion for eating pathology was used to determine how many AIS participants were within the range considered eating disordered.

Independent-sample t-tests revealed that, when compared to the normative data, the AIS group did not differ significantly in terms of height (p=0.646). However, they were significantly lighter (p< 0.001), and had significantly lower BMI scores (p< 0.001); 25% of the sample had a BMI score within the range considered anorectic. Of these low-BMI patients, the mean index score was 15.6 (range 12.9–17.5). The mean weight was 40.25 kg (6st 4lbs), with a range from 31.5 to 49 kg (4st 13lbs – 7st 11lbs). The body mass data for this low-BMI group, both in terms of range and severity, is not within ‘normal’ body shape variation, and would not be expected in healthy adolescent females.

Conclusion: The relationship between a diagnosis of AIS and low body weight may indicate disordered eating behaviour and is thus a cause for considerable concern. This is of particular relevance in the light of the well-established relationship between eating psychopathology and osteoporosis, which may result if disordered eating produces a reduced peak bone mass. Organic health consequences may need to be added to a matter previously considered to be one of cosmetic deformation.

K.P. Muralikuttan D.S. Marks A.J. Stirling

Introduction: Percutaneous or semi-open needle biopsy is recommended to obtain histological or bacteriological diagnosis prior to definitive treatment of destructive vertebral lesions. The clinical efficacy of repeating biopsies when initial samples have been inconclusive has not been established. We have examined the accuracy of repeat biopsy in these cases.

Materials and Methods: 103 patients with destructive vertebral lesions underwent percutaneous trans-pedicular or open vertebral biopsy. Eighty-two were available for analysis, and in 33 (39%) the initial biopsy failed to establish a histological or microbiological diagnosis. Thirteen patients underwent a repeat biopsy. The remaining 20 patients underwent a definitive surgical procedure or were treated empirically.

Results: Repeat biopsy was inconclusive in six patients, two were confirmed as infection (one TB and one Staph Aureus) and five malignancy (four lymphoma and one chordoma).

There was no significant association between the type of biopsy (open or percutaneous), the vertebral level of the lesion or the use of adjuvant therapy in the malignant cases. As has already been shown from this unit, the commencement of ‘blind’ antibiotic therapy reduces the success of bacteriological culture but does not affect the histological appearance.

Conclusion: Repeat vertebral biopsy is indicated if the initial biopsy is inconclusive, especially if antibiotics have not been commenced or a diagnosis of lymphoma is suspected. It should be performed promptly so as not to compromise the definitive treatment.

C.J. Goldberg D.P. Moore E.E. Fogarty F.E. Dowling

Introduction: The arguments for and against school screening for scoliosis are long since over, and centres have continued or ceased as they thought best and as funding allowed. However, the programmes did amass considerable volumes of observations that, being part of the over-all epidemiological picture, could advance our understanding of adolescent idiopathic scoliosis and of minor asymmetries of back shape.

Methods and Results: A retrospective examination of the records from the school screening programme at this centre concentrated on subjects with minor asymmetry, those who at first review did not qualify as ‘scoliosis’ yet were noted to have failed the forward bend test. There were 91,811 examinations on 55,484 girls: 2170 were classified as ‘non-scoliosis asymmetry’. Of these, 1574 were noted but not referred; 360 were reviewed in clinic without radiograph,; 107 had straight spines on radiograph and 221 had Cobb angles < 10°. Eleven are known to have progressed to 10° or more, three passed 25°, two passed 40° and one underwent surgery. This gives an incidence in this subgroup of 0.51% for defined scoliosis. For scoliosis => 25°, it was 0.14%; for scoliosis => 40°, 0.092%; and 0.046% for surgery, none of which shows a significant difference from the equivalent rates for the population as a whole. (0.6% Cobb angle => 10°, 0.2% Cobb angle => 25°, 0.08% Cobb angle => 40°, 0.045% surgery. (Goldberg CJ et al. (1995). Spine. 20(12):1368–1374).

Conclusion: These findings are in accordance with previous reports on school screening, and it is not proposed to re-open the discussion. Their relevance is their relationship to significant scoliosis: since these children are not at increased risk of developing deformity, they cannot be, as has been proposed (Nissinen et al (2000) Spine. 25:570–574) instances of mild or early scoliosis, and they do not need intensive investigation, follow-up or treatment. Non-scoliosis asymmetry is closer to the increased fluctuating asymmetry displayed by this age group (Wilson and Manning. (1996) Journal of Human Evolution. 30:529–537) and begs a more biological approach to spinal deformity, asymmetry and back shape.

J.A. Bettany Saltikov P. van Schaik J. Warren S.L. Papastefanou

Introduction: The clinically significant threshold above which a scoliotic curve could be abnormal remains arbitrary. Data on normal adolescent and adult back shape are scarce. However clinical decision making based on subjective, visual criteria influences management. We aimed to produce measurable values of normal back shape, against which deformity could be defined. Method: 48 volunteering young adults perceiving themselves as “normal” participated in the study. All have been cleared previously by school screening. Their age (18–28 years old) precluded curve deterioration, but was close enough to adolescent measurements at the end of growth. Back shape was assessed with the ISIS system.

Results: A minority of 8% showed no curve, with 54% a single curve and the rest a double one. Right spinal asymmetry (77%) was more frequent than the left (52%). Mean values and 95% confidence intervals were 16.1° (14.0°–18.2°) for upper spinal asymmetry, 13.4° (10.1°–16.6°) for lower lateral asymmetry, 24.9 mm (20.6 mm–29.2 mm) for thoracic kyphosis and 14.9 mm (12.5 mm–17.2 mm) for lumbar lordosis. Increasing upper lateral asymmetry correlated with decreasing thoracic kyphosis (p< 0.01). Maximum skin surface angle correlated positively with only upper lateral asymmetry (p< 0.001).

Conclusion: Normal spines comprise of lateral asymmetries, where straight is the exception more than the rule. Scoliosis seems to be an exacerbation of this lateral asymmetry beyond 18° for the upper and 16° for the lower spinal asymmetry. Hypokyphosis is related to upper lateral spinal asymmetry. Skin surface angle is a very good indicator of only the upper lateral asymmetry.

M.A. Asher S.M. Lai D.C. Burton B.J. Manna

Introduction: It is now well recognised that the patient’s perception of the medical problem and the treatment for the medical problem are not always the same as the facts of the diagnosis and treatment process. The study being reported was conducted to determine the validity of the SRS-22 patient questionnaire for the discrimination of scoliosis patients based on curve pattern and curve size.

Materials: Three study groups were developed. The first or control group consisted of patients who had been referred for evaluation of suspected scoliosis but documented by X-ray not to have structural scoliosis of 10° or more. The second group, a non surgical group (NS) consisted of patients with documented idiopathic scoliosis who were either being evaluated and discharged, observed either short or long term, or who had been or would be braced. The third or surgical group (S) were being seen prior to primary idiopathic scoliosis surgery. Patients with comorbidities were excluded.

Methods: Deformity pattern and Cobb measurement were determined from standing frontal and sagittal plane radiographs. Each patient completed a SRS-22 outcomes questionnaire leaving off the satisfaction with management domain. Thus there were four domains: pain; self image; function; and mental health, five questions per domain. Scoring is 5 best and 1 lowest. Case series: Patients were gathered between October 1999 and September 2000. The control group consisted of 17 patients average age 13 years. Non surgical group included 72 patients of average age 16 years and average scoliosis of 33°. The surgical group consisted of 33 patients of average age 16 years with an average curve size of 64°.

Statistical analysis: The effect of curve pattern was studied with ANOVA and the effect of curve size by the Pearson correlation coefficient.

Results: There were 69 patients with single, 33 with double and three with triple curves. There was no difference in SRS domain or total scores based on curve pattern. There was a very significant correlation between curve size and SRS-22 score, p> 0.001 for pain; self image, function; and a total of these domains. For mental health there was also a significant relationship at p=0.0124.

Conclusion: The SRS-22 questionnaire successfully discriminates among persons with no scoliosis, moderate scoliosis, and large scoliosis by curve size. It does not discriminate among patients with single, double or triple curves.

K.M. Bagnall T. Rajwani R. Bhargava M. Moreau J. Raso J. Mahood A. Elander

Introduction: Although there are several known causes of scoliosis, most are of unknown cause and develop during adolescence, making adolescent idiopathic scoliosis (AIS) the most common form. It has long been hypothesised that unilateral closure of the neurocentral junction accompanied by continued growth on the opposite side could lead to vertebral rotation and subsequent lateral curvature. However, autopsy studies of neurocentral junction closure in children has revealed that these joints close at approximately six years of age consequently excluding this hypothesis as a cause of AIS. In contrast, a recent MRI study has suggested that in some children at least, the NCJ does not close until much later in development around the time of puberty thereby resurrecting this hypothesis as a potential cause of AIS. This study was designed to investigate closure time and pattern of closure of the NCJ in normal patients to determine whether further examination of this hypothesis might be warranted.

Methods and results: The morphology of the NCJs in 20 patients between the ages of 3 and 15 were observed in MR images taken for purposes other than spinal anomaly. The structure of individual NCJs were observed and reconstructed in 3-dimensions. The age at which NCJs became closed was determined and pattern of closure of a typical NCJ was created using the reconstructed images. The pattern of closure of the NCJs along the vertebral column was also determined and any differences between right and left sides at the same level was also noted.

The results showed that there was a sequence of closure along the vertebral column for the NCJs with those in the cervical and lumbar regions being the first to close and those at the approximate level of T8 being the last to close. While the NCJs in the cervical and lumbar regions close at 5–6 years of age, those in the thoracic region, that are the last to close, do so at approximately 12 years of age. No significant difference between the stage of closure of the left and right sides was seen at any level.

Conclusion: The results of this study have shown that the closure of the NCJs in those vertebrae that form at approximately the most common level for the apical vertebra associated with AIS (midthoracic) does not occur until the time of puberty. This contrasts sharply with previously held views on the age of closure. Although no significant difference in closure between left and right sides was seen among these particular patients it does not exclude unilateral closure as a cause of AIS at least in some patients. These results suggest that examination of this hypothesis should be resurrected and that further study is well warranted. MR examination of young patients with small, initial curves could be well worthwhile.

R. G. Burwell P. H. Dangerfield

Nachemson (1996), drawing upon the theses of Sahlstrand (1977) and Lidström (1988), articulated the view there are more girls than boys with progressive AIS for the following reason. The maturation of postural mechanisms in the nervous system is complete about the same time in boys and girls. Girls enter their skeletal adolescent growth spurt with immature postural mechanisms – so that if they have a predisposition to develop a scoliosis curve, the spine deforms. In contrast boys enter their adolescent growth spurt with mature postural mechanisms so that they are protected from developing a scoliosis curve. There is evidence that postural sway improves with age in boys and girls until about 10 years of age after which it is similar between the sexes (Hirashawa 1973, Odenrick and Sandstedt 1984) findings which need further evaluation. We term Nachemson’s concept the neuro-ossesous timing of maturation (NOTOM) hypothesis. It may have an evolutionary basis through natural selection towards sexual and skeletal development during adolescence being earlier in girls and later in boys.

The NOTOM hypothesis suggests a treatment to prevent progression of late-juvenile idiopathic scoliosis, early-AIS, and some secondary scolioses based on delaying the onset of puberty used therapeutically in girls with idiopathic precocious puberty (IPP, Grumbach and Styne 1998). The proposal is to administer a gonadorelin analogue which in the pituitary down-regulates the receptors to hypothalamic gonadotropin-releasing hormone (GnRH) causing a fall in both luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which in turn causes a fall in oestrogens and androgens, and thereby delays or stops menarche and slows bone growth – as in girls and boys with IPP (Galluzzi et al 1998). Expert scrutiny of this therapeutic proposal is currently in progress.

C.H. Rivard C. Coillard M.A. Leroux J. Badeaux

Introduction: Until now, the non-surgical therapeutic approach for idiopathic scoliosis (IS) was based on rigid brace using three points pressure and distraction technique. For the first time we wanted to use a dynamic approach for the treatment of IS. For this goal we have developed a Dynamic Correction Brace (DCB) or SpineCor to use the forces of the dynamic spine to optimise the reduction of spinal curves and permit neuromuscular integration during the period of correction.

Methods and results: The effectiveness of the treatment depends on the reducibility of the curve with the brace. The goal of this study is to quantify the reducibility of scoliosis curves through a study of the variation of Cobb angle, during and after treatment.

Between 1993 and 1999, 113 adolescents with classic indications of idiopathic scoliosis were treated by the same orthopaedist with the DCB. The mean age at the beginning of the treatment is 12.9 years old. The potential reducibility (PR) of the curves was estimated by the percentage of reduction of the initial Cobb’s angle corresponding to the maximum correction obtained during the course of treatment and after the treatment for the patient at maturity. Fifty patients have completed their treatment and are at maturity.

From this cohort of patients treated by the DCB, 73.4% had a reduction of 5° or more than their principal Cobb angle; 22.8% were stable, but non-reducible, with a change of less than 5°; and 3.8% conserved an evolutive potential, with an increase in the Cobb angle of 5° or more. A significant difference was evident for PR between the group presenting an initial Cobb angle < 30° and those presenting an initial Cobb angle > 30° (p< 0.05). 65.8 per cent of the patients presented with an initial Cobb angle < 30° for a mean PR of 40.6% and were categorised according to the following: a) 26% of the patients had a PR ≤20%; b) 41% obtained a PR between 20% and 50%; and c) 33% had a PR > 50%. The other patients (34.2%) with an initial Cobb > 30° and a mean PR 22% were also categorised: 39% had a PR ≤20%; b) 48% had a PR between 20% and 50% and c) 13% > 50%. For patients who have completed their treatment 85% have a correction or are stabilised, 15% are worse or needed surgery during the treatment. For these patients, 53% have a correction of < 20%, 31% have a correction between 20 and 50%, and 16% have a correction of > 50%.

Conclusion: The reducibility of the curve during the treatment is very informative concerning the prognosis treatment. The effectiveness of a DCB is comparable to effectiveness of other rigid braces for which the results have been published.

K.M. Bagnall D. Demianczuk X. Wang M. Moreau J. Raso J. Mahood

Introduction: No appropriate animal model for studying adolescent idiopathic scoliosis (AIS) exists and this hampers research. In recent years, we have been examining a model in which scoliosis consistently develops in young chickens following pinealectomy and which has been shown to have many characteristics similar to those seen in AIS. Not all of the pinealectomised chickens develop scoliosis following the pinealectomy and so we have the opportunity to examine differences between the two groups. The obvious candidate for study of the mechanism underlying this phenomenon is melatonin which is the principal product of the pineal gland. In this study we have measured the serum melatonin levels of pinealectomised chickens that have developed scoliosis and compared these with similar measurements taken from chickens that have developed scoliosis.

Methods and results: Newly-hatched chickens were obtained from a local hatchery and kept in a single pen with standard heating and lighting. A 12:12 light dark cycle was introduced immediately and the two-thirds of the chickens were pinealectomised three days later. The remainder acted as controls. At weekly intervals following surgery, the chickens were radiographed in a supine position while anaesthetised and the presence of scoliosis was determined from the radiographs. Three weeks after surgery the chickens were euthanised and blood samples were collected and analysed using radioimmunological techniques to determine levels of serum melatonin. The samples were collected in the presence of red light in the middle of the dark cycle when melatonin levels have been shown to be at their highest.

Approximately 55% of the pinealectomised chickens developed scoliosis within the three weeks following surgery whereas none of the control chickens developed scoliosis. The results showed that the serum melatonin levels of pinealectomised chickens were significantly lower than the normal controls and were in fact all close to zero. However, there was no significant difference in serum melatonin levels between those chickens that developed scoliosis and those that did not.

Conclusion: The results of this study have shown that pinealectomy significantly reduces serum melatonin levels close to zero in all chickens. The results also show that there is no significant difference in serum melatonin levels between those pinealectomised chickens that develop scoliosis and those that do not. Unless there is a subtle threshold level that is unable to be detected using our methodology or that melatonin levels in the days immediately after surgery are of critical importance, these results suggest that other causes for this phenomenon need to be examined. An understanding of the underlying cause would be of great importance and might represent a significant breakthrough in the study of AIS.

V.J. Raso M.J Moreau E. Lou D.L. Hill J.K. Mahood N. Durdle

Introduction: Braces are the most generally accepted form of non surgical treatment for adolescent idiopathic scoliosis (AIS). Despite decades of usage controversy still exists regarding the efficacy of this treatment. We believe this controversy continues in part because there are few studies describing the mechanical effect of bracing and linking mechanically effective bracing to changes in the natural history of AIS. If braces are effective, is it because they apply significant mechanical support to a collapsing spine or are they effective for other reasons? A first step towards answering this question is to document the mechanical action of braces during activities of daily living. This would enable researchers to examine the effect of mechanical support on progression of the scoliosis. The objective of this study was to determine the temporal pattern of forces exerted by the pressure pad in Boston braces prescribed for the treatment of AIS.

Methods and results: A force transducer and a programmable data logger were designed to measure loads exerted by the pressure pad over extended periods of time. The loads were recorded at one minute intervals. Braces were adjusted to a prescribed load level and the patients were asked to set the brace tightness to match this target any time the brace was donned. Brace wear data were stratified into: not worn, worn at less than 80% of target, 80–120% of target and greater than 120% of target. Bracing was considered mechanically effective if the load was at least 80% of the prescribed level. Patients were aware of the study and consented to participate.

Thirteen patients were followed from 1 to 16 days, average was 9±5 days. Nine patients were asked to wear their braces 23 hours per day, two for 20 and two for 16 hours per day. Braces were not worn 34±27% of the time logged. When they were worn, patients adjusted the tightness of the brace such that it was < 80% of the target 29±20% of the time, within 20% of target 19±19% and over 120% of target 18±13% of the time. Patients wore their braces at or above the target levels 33% of the time logged or 8 hours in a typical day. Subjects had no difficulties using the data logger and none complained that it interfered with brace wear. Reviewing individual histories suggested that subjects did not alter their brace wear pattern because of the data logger.

Conclusion: The mechanical effectiveness of the brace varies considerably over the normal course of wear but seldom does it provide the support intended. While patients wear their braces for about 16 hours per day, it is mechanically effective for 8 hours only.

G. Nicholson M. Ferguson-Pell K. Smith M. Edgar T. Morley

Introduction: The clinical effectiveness of spinal bracing for the conservative treatment of adolescent idiopathic scoliosis is still not fully understood. Cohort studies on clinical effectiveness fail to adequately measure and control for confounding variables including spine flexibility, curve type, magnitude and maturity, distribution of corrective forces and compliance. This paper presents intermediate findings from a longitudinal study to objectively measure brace wear patterns and compliance in users of custom fitted TLSOs in the UK. Braces are fitted with data logging devices to measure temperature and humidity at the skin/brace interface. Previously reported measures of compliance have been in adolescents wearing Boston Braces using questionnaires, strap tension, interface pressure and skin temperature. They have shown compliance reported by the user can significantly over estimate actual compliance.

Methods and results: 20 patients are being studied over 18 months. TLSOs are fitted with data logging devices to measure temperature and humidity at the skin/brace interface. They are discrete sensors inserted into a pocket formed on the posterior of the brace. Measurements are recorded at 16 minute intervals and data downloaded every three to four months. Results clearly demonstrate compliance and daily wear routines. Temperature and humidity at the skin/brace interface during periods of wear are 35°C and > 80%RH respectively. Compliance ranges from 60–98%. Users who stick rigidly to their regime only remove their brace in the evening. Where poorer compliance is evident, the brace is worn sporadically during the day and evening, and worn full time at night.

Conclusion: Measurement of temperature and humidity at the skin/brace interface clearly demonstrates compliance and daily wear routines. Compliance varies from 60–98%. Where poor compliance is an issue it is intended to re-interview these individuals and obtain more detailed information about the reasons why they failed to use the brace.

A.J. Stirling M. Rafiq K. Mathur T.S.J. Elliott T. Worthington P.A. Lambert

Introduction: We have previously demonstrated significantly elevated IgG titres (ELISA) to a glycolipid antigen found in the cell wall of most gram positive bacteria in patients with discogenic radiculitis (sciatica).

This raised the possibility that the inflammation associated with disc protrusion might be initiated or accelerated by the presence of bacteria.

Aim of the study: To confirm whether bacteria were present in the disc material harvested at the time of discectomy. To determine whether the presence of bacteria correlated with elevation of Anti Lipid S antibody levels. To compare these results with Antibody levels and disc specimens from patients undergoing surgery for indications other than radiculitis.

Methods: This was a prospective study. Recognising the frequency of contamination in clean wound culture stringent aseptic precautions were taken. Disc material was harvested from 108 microdiscectomy patients with sciatica.

Disc material was also obtained from 11 patients undergoing discectomy for other indications (trauma, tumour scoliosis). Serology was obtained for all these patients.

Results: In the microdiscectomy group 50/112 (45%) had positive cultures after seven days incubation, of which 15 (30%) had positive serology. Thirty-one patients had Propionibacteria, nine Coagulase negative Staphylococci (CNS), six Propionibacteria and CNS, one Corynebacterium and three mixed growth.

Sixty-two (55%) patients had negative cultures and all except one had negative serology. There was a significant difference between patients with positive serology and culture compared with those with negative serology and culture (Fischer exact test P< 0.01). In some patients organisms were visible on microscopy prior to culture.

Thirteen of those with postive cultures and 25 of those with negative cultures had had one or more epidural injections prior to surgery. Epidural injection was not found to be significantly associated with postive culture.

None of the patients undergoing surgery for other indications had positive serology or positive cultures.

Conclusion: A significant proportion of patients with discogenic radiculitis have positive cultures with low virulence Gram positive organisms (predominantly Propionibacteria) and in a proportion a corresponding appropriate antibody response.

W.I. El Assuity M.A. El Masry Y.K. El Hawary C.R. Weatherley

Introduction: Spondylolytic spondylolisthesis is a not uncommon cause of back pain in adults. The initial management, especially for the low grade slips, is usually conservative. When this fails or is deemed inadequate surgical options are considered. The principles of surgical treatment involve a fusion of the painful segment or segments (usually with instrumentation), with an associated decompression if there is radicular leg pain. Some authors also propose a simultaneous reduction of the slip. Most reports in the literature on adults have a short follow-up.

Materials and method: This paper reports the results of surgery from two centres carried out between 1993 and 1998 on 75 adult patients using the same indication for surgery and the same surgical technique. The indication for surgery was a significant reduction in the quality of life with persistent low back and/or leg pain after conservative treatment for a minimum of six months. The surgery involved an in situ posterolateral fusion with pedicular fixation (Oswestry system) with a simultaneous decompression for radicular involvement. The average operating time was 2.5 hours (range 2–4) and the average blood loss 850 mls (range 300–2300). The mean follow-up was 61 months (range 24 to 95).

Results and conclusion: A solid fusion was considered to be present in 71 of the 75 cases (95%) using the Lenke and Bridwell (1997) criteria for radiological union. Seventy-two of the 75 cases (96%) had a very satisfactory clinical outcome (Ricciardi et al 1995). The complications were limited – two superficial wound infections and one deep wound infection which resolved after debridement of the wound. There were no neurological complications.

The authors believe that with careful patient selection an instrumented in-situ posterolateral fusion is a safe and effective operation for symptomatic low grade slips providing good long term results.

M. Rafiq D.S. Marks A.G. Thompson

Introduction: The long term integrity of the intervertebral disc following repair of pars interarticularis defects in the lumbar spine is uncertain. This study was undertaken to clarify this issue.

Materials and Methods: 26 patients with symptomatic lumbar spondylolyis underwent a modified Scott repair of the defects, between 1979 and 1993. The early results of these patients were presented to the British Scoliosis Society in 1998. Ten patients have been recalled and reviewed clinically and by MRI investigation at a mean follow-up of 10 years.

Results: Eight of the 10 patients are completely asymptomatic and the MRI appearances are normal. The remaining two patients are symptomatic; one has MRI evidence of disc degeneration and the other has normal MRI appearances.

Conclusion: Repair of the pars interarticularis defect in symptomatic spondylolysis gives excellent symptomatic relief following surgery. This long term review indicates that it protects the integrity of the adjacent intervertebral disc.

C. Bünger E.S. Hansen K. Høy P. Neumann B. Niedermann B.E. Lindblad P. Helmig M. Laursen F.B. Christensen

Introduction: Lumbar spine fusion is now an evidence based treatment principle of low back pain. However, much controversy still exists on the choice of surgical technique. Since the source of pain may be located in the intervertebral disc, a disc removal seems logical. Instrumented and non-instrumented fusion as well as PLIF have failed to restore lumbar lordosis.

Aim: The aim of the present study was to study fusion rates, functional outcome, lumbar lordosis and complications in a RCT design using radiolucent cages and titanium instrumentation.

Materials and methods: 148 patients were bloc randomised to either PLF (72) or ALIF + PLF (76) from April 1996 to February 2000. Inclusion criteria were disc degeneration or spondylolisthesis groups 1 and 2; Age> 20 years and < 65 years. Life quality was assessed pre-operatively, one and two years post-operatively by Dallas Pain Questionnaires and by Back and Leg Pain rating scales from 0 to 10.

Results and discussion: A preliminary follow-up at one year post-op of 56 patients in each group showed no difference in admission or blood loss (921/1008 ml) and peroperative morbidity, although the operation time was significantly longer in the ALIF+ group (mean 219/344 minutes). Sagittal lordosis was restored and maintained in the ALIF+ group (p< 0.01), in contrast to the PLF group. There was no difference in functional outcome. Average back pain lasting 14 days scored 4.5 in each group, and leg pain 3.2 in the ALIF+ group versus 4 in the PLF group (NS). The re-operation rate was significantly higher in PLF after both one and two years with 9% refusion versus no refusion in the ALIF+ group. Global patient satisfaction was equal in both groups: 78% versus 76% at one year and at two years 75% versus 80% in PLF and ALIF+ groups.

Conclusion: ALIF+ fusion demands higher operative resources compared to PLF, however ALIF+ restores lordosis and provides the highest union rate and significantly fewer reoperations. A cost/effectiveness analysis after long-term follow-up may also favour the ALIF+ treatment due to improved lordosis and perhaps less degeneration of adjacent motion segments.

S. Mohammad R. Shah B.A. Taylor

Aim: To test the null hypothesis that interbody cage fusion does not improve clinical outcome.

Methods and materials: This is a prospective study of 87 patients. Seventy-one of the 87 patients followed to the conclusion of the study at two years. Inclusion criteria: Patients undergoing interbody cage fusion with the Ray threaded cage, made of Titanium, and posterior stabilisation with Diapason pedicle screw instrumentation, all operated by the same surgeon. Exclusions: Surgery for infection, or tumour. Tools used for assessment: Oswestry low back pain questionnaire; Visual analogue pain score (VAS); SF36 general health questionnaire. Assessment time points were 1) Pre-op, and post-operatively at 2) 3 months, 3) 6 months, 4) 1 year and 5) 2 years. SF 36 was introduced later recruiting 71 of the 87 patients.

Results: There were 31 males and 56 females. Average age was 46 years (range 14–76) Fifty-one of the patients had no previous surgery, while 36 had previous surgery.

There was a significant, gradual improvement in symptoms of an average of 20 points (p< .001) over the first year on the Oswestry score. However, this plateaued between the first and second years. Over two years there was a greater than 20 point increase in all but three concepts of SF36, general health, reported health and mental health improving around 15 points (p< .001). Sixty-five per cent of the patients reported an overall improvement and 12% were worse, with most changes occurring in the first year.

In assessing the symptoms with Oswestry questionnaire there was a significant difference between first time and revision surgical groups. The revision group showed an improvement of 11 points (p< .001) at two years, most occurring in the latter part of the first year followed by some deterioration between the first and second years. In the primary surgery group there is a 28 point (p< .0001) improvement by two years. Most of the improvement in the primary group is achieved by the first six months.

Conclusions: Interbody fusion can significantly improve health and function assessed by Oswestry and SF36 outcome tools. Additional observations – unsatisfactory outcome in 12% of patients; expected progress at fixed times after surgery can assist planned rehabilitation. This paper introduces the concept of time staged assessment of symptoms in spinal fusion.

J.P. O’Brien P. Renton A. Sarwat

This paper presents radiological changes in femoral cortical allograft used to replace the disc in low back and leg pain syndromes. The technique originated with the use of patient’s own iliac crest but donor site pain and lack of rotational control with removal of the annulus resulted in a) femoral cortical allograft supplemented with b) posterior fixation, more recently of the trans-laminar screw variety.

Experience with over 200 patients with femoral cortical allograft indicated that the rejection rate is virtually nil. Early changes include the loss of line between donor and host bone as early as three to four weeks after surgery.

There is radiological evidence in some cases that radiological healing has taken place by four weeks. There is no radiological difference whether the patient’s own bone or allograft chips are used to pack the allograft cavity. At one year and beyond, the gap behind the allograft in the interbody space fills with host bone, thus avoiding any posterior migration of the allograft plug. There is some subsidence, over the first 12 months, into host bone. Attention to detail in surgical treatment of the end-plate is an important part of the technique.

Axial views show dramatic changes up to 10 years after surgery. Gradual erosion of allograft by host bone, both at the external and internal diameter, occurs. Finally, there is the merest shell of donor bone identified, the rest clearly replaced by host bone. Unfortunately, biopsy samples to corelate with the radiological films are not available.

Allograft bone in surgery was original with MacEwen of Glasgow (1880). Its use 30 years ago in scoliosis surgery was generally not successful. The interbody femoral cortical allograft succeeds by reason of the surgical principles involved: 1) Thorough clearance of all avascular (disc) tissue – thus, the provision of a thoroughly vascularised bed; 2) Rigid fixation (provided by the translaminar screw fixation). For reasons of cost, mechanics, biological behaviour and ease of shaping before insertion, femoral cortical allograft has provided an excellent long-term disc replacement.

S. Mohammad R. Shah A. Saifuddin B.A. Taylor

Aim: To test the null hypothesis that plain X-rays can provide the same assessment of sacral screw placement as CT.

Introduction: Engaging the anterior cortex of the sacrum provides additional strength to fixation and is a goal of surgery. The sacrum with its unique anatomy makes it a difficult bone to assess screw placement radiologically. This study examines the positioning of sacral screws as seen on X-rays and compares the result with spiral CT “gold standard”.

Materials and methods: Inclusion criteria: Sacral fixation using Diapason (Stryker) Titanium pedicle screws by one surgeon. Spiral CT, plain AP and lateral X-rays of the sacrum. Exclusion criteria: X-rays with more than three level fixation.

There were 66 patients (132 S1 screws). Surgical technique engaged the anterior cortex to enhance fixation. Two independent observers (a musculoskeletal radiologist and spinal fellow) who were blinded to outcome, reported findings in forms with constrained fields. Assessment of plain X-ray and CT was at separate times not less than three weeks apart. Variables noted: Screw position in pedicle, screw tip position, and angle of screw (sagittal on axial CT scans).

AP X-ray was divided, for each screw, into nine zones based on the first sacral foramina. The position of the screw tip in the zones was noted. The lateral X-ray was divided into three zones to note the tip of the screw in relation to the cortex. The extent of screw protrusion was measured. X-ray technique: Supine AP centred on fusion and lateral X-ray standing, X-ray source 200 cm from the film. CT: Images acquired on Picker PQ 6000 spiral CT with collimated thickness of 3 mm, pitch 1.25 and reconstructive index of 1.Para-sagittal and coronal reconstructions. Spiral CT was used to note the position of the screw within the pedicle and the relation of the screw tip to the anterior cortex. For screws within the pelvis any structure in close proximity was noted.

Results: On CT 10% of the screws had breached the pedicle compared with 2% on the plain X-rays. Anterior cortical perforation had been achieved in 48 out of 132 screws on CT. The sensitivity of the plain X-rays to perforation was 40% with a specificity of 92%. There was an average under estimation of the extent of screw perforation by 4.4 mm (95% confidence ±1 mm). There was a correlation between the position of the screw tip on the AP X-ray and the sensitivity of the lateral X-ray to detect a perforation. The sensitivity ranged from 52% for zone 1 to 15% in zone 8. 15/31 perforations were missed in zone 1, compared with 11/13 in zone 8. For screws penetrating 5 mm or more, in zone 8, 9 out of 10 were missed on lateral X-rays.

Eighty-five screws were placed at an angle of less than or equal to 25° to the sagittal; this included 28 out of 34 screws placed in zone 8. The inter-observer variance of screw angle measurement was 1.1° and intra-observer difference 1.7°. Overall 95% confidence of a single measurement was ±3.3°.

Conclusion: Plain X-rays and CT do not provide the same assessment of sacral screw placement. This is particularly true for sagitally placed screws with screw tips in zones 7–8.

M. Laursen F.B. Christensen E.S. Hansen K. Høy J. Gelineck B. Niedermann P. Helmig C. Bünger

Introduction: In the attempt to improve fusion rates in spondylodesis surgery, focus has been applied on numerous factors, including surgical strategies, instrumentation-devices and –material, technical preparation of the fusion bed, stringency of radiological outcome criteria, patient-related factors such as age, sex, tobacco consumption, and severity of underlying pathology. In recent years the development of new techniques for exploring mechanisms in cellular and molecular biology have further directed focus toward more advanced biological techniques and considerations. To the authors’ knowledge, little or no attention has been focused on one of the basic and important factors in the attempt to achieve fusion, ie the impact of bone graft quantity placed at the fusion bed.

The aim of this study was to investigate the influence of autologous bone graft quantity in posterolateral instrumented spinal fusion (PLF) in respect to fusion rates.

Methods and results: A prospective clinical study in 76 patients, in which CD-instrumented posterolateral lumbar or lumbosacral spine fusion surgery was performed. The quantity of autologous bone graft applied at the fusion bed was recorded peroperatively. Spinal fusion rates were assessed by AP/lateral radiographs at one-year follow-up by two independent observers, according to our strict classification system. The impact of bone graft quantity, tobacco consumption, age and sex of the patients were analysed in respect to fusion-rates by logistic regression.

According to our classification “fusion” was seen in 76% of the patients, “non-union” in 12.7% and “doubtful”fusion in 11.3%. In “fusion” segments, the median amount of bone used was 24.4 (13–53) g and 14.7 (12.5–23.4) g in “non-union” segments. The “non-union” rate was 7.1% for non-smokers in contrast to 21.4% for patients who smoked during the first six post-operative months. The impact on fusion rates by graft quantity and cigarette smoking were significant, p< 0.006 respectively 0.035. Age and gender did not influence fusion rates. Thirty-three percent of patients with “non-union” had a corresponding failure of the implant.

Conclusions: The quantity of graft used at the fusion bed is critical for successful fusion. Based on the results presented here, we recommend a minimum of 24 g of autogenous bone graft at each intervention segment in auto-grafted posterolateral spinal spondylodesis surgery. In addition, this study underlines the importance of tobacco arrest, in at least the first six post-operative months. The data presented here strongly support the importance of quantifying or optimally standardising the amount of graft placed at each intervention segment.

J. Dubousset P. Wicart V. Pomero A. Barois B. Estournet

Methods and results: From the last 15 years, we have observed 18 cases from various aetiologies of compression of the airway by the “billot” created by the protrusion of the vertebral bodies inside the thoracic cage. This status lead to atelectasia intermittent or permanent with subsequent recurrent lung infection and sometimes abscesses with impairment of the respiratory function perfectly demonstrated by CT scan as well as with bronchoscopy showing extrinsic bronchi stenosis. Such pathology necessitates an anterior vertebral body resection for decompression of the airway done in 15 patients and sometimes partial lung removal lobectomy done in 4 cases. Subsequently repeated lung infection disappeared in all cases but vital capacity only improved by 2%.

Discussion: This pushed us to study this point and to propose a new 3D entity called spinal penetration index seen as well on regular CT scan cut of the chest as on 3D volumetric reconstruction representing the amount of vertebral, rib, soft tissues and sometimes empty space protruding inside the thoracic cage. This presented as an endothoracic vertebral hump compared to the exothoracic classical rib hump. Compared to normal subject where the amount is less than 10%, it can reach 50% in some severe scoliotic cases. The deformity is evident and can be quantified easily with a computer programme. Done today with regular CT scan cuts at rest, in the near future this will be obtained with regular stereographic X-rays in a much less invasive manner with low dose radiation.

Conclusion: The spinal penetration index measure in 3D is the amount of protrusion of the spine and surrounding tissues inside the thoracic cage. It is an anatomical parameter entering into the measurement on the useful thoracic volume for breathing given by the thoracic skeleton. It is very different from vital capacity where diaphragm, joints, muscle function play an important role. This concept allows to quantify in 3D the results of surgery of the spine in a much better way for 3D consideration than the classical Cobb angle. It helps also for analysis of the chest for example before and after thoracoplasty and allows to classify the rib hump and the vertebral hump in a logical way with their therapeutic consequences.

S.H. Kamath D.K. Sengupta S. H. Mehdian J.K. Webb

Introduction: Surgical treatment is indicated in Scheuermann’s disease with severe kyphotic deformity, and/or unremitting pain. Proximal or distal junctional kyphosis and loss of correction have been reported in the literature, due to short fusion level, overcorrection, or posterior only surgery with failure to release anterior tethering. We reviewed surgically treated Scheuermann’s kyphosis cases, to evaluate the factors affecting the sagittal balance.

Methods and results: 35 cases (22 male, 13 female) of Scheuermann’s kyphosis were treated surgically in this centre during 1993–1999. Mean age at operation was 21.5 years (14–53 years). The kyphosis was high thoracic (Gennari Type I) in two cases, mid thoracic (Type II) in 11 cases, low thoracic or thoraco-lumbar (Type III) in eight cases, and whole thoracic (Type IV) in 14 cases. Mean pre-operative kyphosis (Cobb angle) was 81° (range 70° to 110°). Ten cases (mean kyphosis 77°) had one stage posterior operation only with segmental instrumentation. Twenty-five cases had combined anterior and posterior (A-P) surgery. Fifteen cases (mean kyphosis 81°) had one stage thoracoscopic release and posterior instrumentation, and 10 cases (mean kyphosis 89°) had open anterior release, followed by second stage posterior instrumentation. Minimum follow-up was 14 months (mean 45 months, range 14–140 months). The mean post-operative kyphosis was 47.2°. Kyphosis correction achieved ranged from 39% after posterior surgery only, to 42% after thoracoscopic A-P surgery, and 48% after open A-P surgery. Mean loss of correction was 12° after posterior only surgery, 9.5° after thoracoscopic A-P surgery, and 6° after open A-P surgery. Four cases of open A-P surgery had additional anterior cages to stabilise the kyphosis before posterior instrumentation; a mean 55% kyphosis correction was achieved in this group, and there was no loss of correction. Younger cases, under 25 years (n=16) had significantly better kyphosis correction (p< 0.05). Two cases (6%) developed distal junctional kyphosis due to fusion short of the first lordotic segment, requiring extension of fusion. Four cases (12%) developed proximal junctional kyphosis requiring extension of fusion; all of them had primary posterior surgery only. Location of the curve (Gennari Type) had no significant influence on the initial curve, degree of immediate correction, or loss of correction. Complications included infection (4 cases), pneumothorax (1 case), haemothorax (1 case), instrumentation failure (3 cases); 3 cases had persistent back pain.

Conclusion: Combined anterior release and posterior surgery achieves and maintains better correction of Scheuermann’s kyphosis. Loss of correction, and proximal junctional kyphosis are more frequent after posterior surgery only, and short fusion. Use of cages anteriorly prevents loss of correction. Correction is better achieved in younger patients, but is not influenced by the location of the curve.

K. Ravi Sankar J.B. Williamson P. Heaton A. Wills D. Jones

Introduction: Complications of homologous blood transfusion include transmission of infection and development of antibodies. Autologous pre-donation, acute normo-volaemic haemodilution and cell salvage have been used to reduce the use of homologous transfusions.

Surgery for spinal deformities often requires blood transfusion. In February 1999, we started an autologous pre-donation programme for children undergoing spinal deformity surgery.

Methods and results: The case records of the first 15 patients who took part in the programme have been scrutinised and data about pre-donation, haemoglobin, pre- and post-operative hameoglobin, blood loss, blood transfusions, use of blood products, and complications related to pre-donation of blood were obtained and analysed. Similar data from case records of 15 patients, who had surgery for spinal deformities before start of the programme, were used as control.

In the autologous pre-donation group, four received homologous transfusion and 11 escaped exposure to homologous blood or blood products. In comparison in control group 14 out of 15 received homologous transfusion. There was no significant difference between the two groups in terms of diagnosis, operating time, postoperative haemoglobin, body weight and age. Mean operative blood loss in autologous group was less (1190 mls) than in that of the control group (1529 mls).

Of the four patients who received homologous transfusion, two were transfused outside the hospital protocol.

Complications from pre-donation of blood occurred in three patients and were minor. They included minor bruising in two and difficult and painful venous cannulation in one.

Conclusion: In our practice autologous pre-donation resulted in avoidance of homologous blood transfusion in three quarters of patients undergoing spinal deformity surgery. By adopting strategies such as acute normo-volaemic haemodilution, cell salvage and strictly adhering to protocols for prescribing transfusion, we believe that the need for homologous transfusion could be obviated except in extreme cases.

M.A. Asher S.M. Lai D.C. Burton B.J. Manna

Introduction: The SRS-22 questionnaire is a disease specific instrument developed to assess the effect of idiopathic scoliosis on the patient from their vantage point. This study is being conducted to determine the responsiveness of the SRS-22 questionnaire to patient change associated with surgery.

Material and methods: This is a prospective study of surgically treated patients. The SRS-22 outcomes questionnaire consists of five domains: Pain; self image; function; mental health and satisfaction with management/surgery. There are five questions in each of the first four domains and two in the last. The scoring scale is 5 best and 1 lowest. Patients were tested pre-operatively and then at 3, 6 and 12 months post-operatively. Statistical analysis was done using the paired t-test. Comparisons were only performed on individuals with domain scores at the follow-up interval being tested. There were 33 patients (6 male and 27 female) average age 15.7 years with average Cobb size of 64°.

Results: Self image was significantly improved at three months and remained improved; Pre-operative 3.3; 3 months 4.2 p< 0.0001); 6 months 4.0 (p=0.079); and 12 months 4.2 (p> 0.0425). Function was significantly decreased at three months but returned to baseline at 6 and 12 months: Pre-operative 3.9; 3 months post-operative 3.3 (p=0.0024); 6 months 3.8 (ns) and 12 months 4.0 (ns). Surprisingly pain did not show significant change being 3.9 pre-operatively; 3.6 at 3 months; 3.5 at 6 months, and 4.1 at 12 months.

Conclusion: Based on these very preliminary data the SRS-22 questionnaire has been found to be responsive to self image and function changes in the post-surgical period. The function change was anticipated. The self image improvement occurred earlier than had been anticipated. The questionnaire was not responsive to pain change and did not reflect the substantial pain the patients had gone through at the time of the surgery. As anticipated the mental health domain was unchanged overall.

A. Gardner

Introduction: In 1998 the British Scoliosis Society was asked by the Board of Affiliated Societies to the BOA to provide information concerning the activity, numbers and training implications for specialists in our field. We had no systematic data so with the valuable assistance of the BOA a survey of spinal surgery activity was undertaken amongst 187 Orthopaedic Surgeons who had declared spinal surgery as a main interest in a previous BOA survey. One hundred and fifty questionnaires were returned (80.2%). This data was collated and analysed by the Statistical Department of the British Orthopaedic Association.

As a result of the information obtained a template for the organisation of management of spinal disorders in UK and its manpower implications was developed. This template was then circulated to the Presidents of all the British Spine Societies for consideration at their AGMs in 1999. There was widespread support. It is understood that the BOA have also discussed these proposals along with those from other affiliated societies and it is perhaps time for further action.

Methods and results: The results from the postal questionnaires were analysed along with information from other sources. Fifty-five surgeons were identified as being Specialist Spinal Surgeons (greater than 70% of their time), 120 Surgeons were designated Surgeons With An Interest (greater than 30% of their time), 25 Surgeons spent less than 30% of their time on spines. Sixty-two per cent (93 Surgeons) considered their facilities for spinal work were adequate, 34.7% (52) considered that they were inadequate and 3.3% (5) said that they were unacceptable. Forty-nine per cent (73) of those responding employed a triage system with 58.5% using a physiotherapist and 16.2% using a nurse. Five point nine per cent used a clinical assistant and 19.1% of triage was done by the Spinal Surgeon.

Regarding outpatient waiting times, 31% of Surgeons had a waiting time of three to six weeks for urgent appointments with 20% longer than six weeks. Sixty per cent had a waiting time of over six months for non urgent consultations. For urgent but not emergency surgery 70% had a waiting time of over three weeks and half of those were over six weeks. For non urgent spinal surgery 70% were waiting more than six months with 50% waiting more than nine months.

Conclusion: Our limited manpower and resources must be used with maximum efficiency while we wait for the inevitably slow build up to international best practice which is likely to take at least ten years with a fair wind.

The Template: 20 Regional Spine Centres each with at least five Specialist Spinal Surgoens (SSS) including one or two Neurosurgeons, total 100 Surgeons.

Sixty-five District Spine Centres (at least three per Region) with at least two Surgeons With An Interest (SWI) (Orthopaedic or Neuro), total 130 Surgeons. At present we have 55 SSS of whom 18 will be retired by 2005. We have around 120 SWI of whom only nine will be retired in 2005 taking retirement age at 65. We therefore have a shortfall of 63 SSS and perhaps 10 SWI a number of whom may wish to upgrade to SSS. According to Okafor and Sullivan (1998) the average European country of our size would have 150 SSS compared with our 55.

1.There is an urgent need for more Orthopaedic Surgeons and in particular Spinal Surgeons.

2.Surgeons need adequate facilities and infrastructure to allow them to work efficiently. Finance is required.

3. Until the training base for future Specialists involved in the management of spinal disorders is steadily expanded from bottom to top, little progress can be expected.

K.S. Conn D.J. Sharp A.D.H. Gardner

Introduction: In order to improve the provision of Spinal Surgery in the United Kingdom, the number of Specialist Spinal Surgeons and Surgeons with an Interest in Spinal Surgery needs to increase by 25% from the existing 175 surgeons. There is an expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery not only to maintain the status quo, with one third of Specialist Spinal Surgeons due to retire in the next three years, but also to provide the needed expansion in numbers.

Methods and results: A postal survey of the 528 SpRs was performed with a response rate fo 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery.

Sixty-nine per cent indicated that they intended to avoid all Spinal Surgery. Thirty-five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only nine (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first two years of training, to 70% in the middle two years, and to 75% in the final two years and post C.C.S.T. fellowships. There should be 24 newly accredited Specialist Spinal Surgeons based on a projection of the 4.3% response intending to become Specialist Spinal Surgeons. This leaves a shortfall of 34 Specialist Spinal Surgeons by 2005.

The survey has revealed three main features of Spinal Surgery which appear to have a negative effect on the attitude of the SpRs to Spinal Surgery and overwhelm the potentially attractive features. These are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to Spinal Surgery during their training.

Conclusion: It is clear from the response of SpRs that there are important misconceptions concerning Spinal Surgery, together with the shortcomings of training and of the provision of services within the NHS. These have to be addressed urgently if the speciality is to become more attractive to them. Areas where positive action can be taken include the modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and above all the need for Spinal Surgeons to be encouraging and enthusiastic about a field of surgery which provides some of the exciting challenges in Orthopaedic Surgery.

R. Pollock J. Lehovsky T. Morley H. El Sebaie

Introduction: The aim of this study is to compare the efficacy of the AO Universal Spine System (AO USS) with Harrington-Luque instrumentation for the treatment of King type II idiopathic scoliosis.

Methods/Results: A retrospective analysis was performed on two groups of patients with King II adolescent idiopathic scoliosis. The first group consisted of 40 consecutive patients treated with Harrington-Luque instrumentation between 1990 and 1993. The second group consisted of 25 consecutive patients treated with AO USS instrumentation between 1994 and 1996. The groups were well matched with respect to age, sex and curve severity. Inclusion criteria were patients over the age of 12 years with a King II curve pattern and a Cobb angle of greater than 40°. Half of the patients in each group underwent anterior release prior to posterior fusion. All patients were followed up six monthly for 18 months. The thoracic curve, lumbar curve, kyphosis and lordosis were measured using the Cobb method.

The mean pre-operative thoracic and lumbar curves were 62° and 43.9° respectively in the Harrington group and 57.5° and 35.9° in the AO USS group. On average 11.4 levels were fused in the Harrington group compared to 10.9 levels in the AO USS group. The mean post-operative correction of the thoracic curve in the AO USS group of 64% was significantly greater than the 51% achieved in the Harrington group (p< 0.005). At 18 months there was a 7% loss of correction in the Harrington group and 9% in the AO USS group. The correction of lumbar curve of 41% in the Harrington group and 46% in the AO USS group at 18 months was not significantly different. In the sagittal plane the AO USS group had significantly better preservation of the lumbar lordosis but there was no difference in kyphosis correction. Blood loss was similar in both groups. Mean operative time of 132 minutes in the AO USS group was shorter than the mean time of 153 minutes in the Harrington group (p< 0.05). Two hooks in the Harrington group became dislodged and two in the AO group. There were no neurological complications in either group. All the patients in both groups achieved a solid fusion.

Conclusion: AO USS is a safe and effective instrumentation system for the treatment of King type II adolescent idiopathic scoliosis. Correction of the thoracic curve is superior to that achieved with Harrington-Luque instrumentation and operative time is shorter. AO USS enables better preservation of the lumbar lordosis than Harrington-Luque. There is no difference in blood loss, complication rate and fusion rates between the two techniques. It has become our instrumentation system of choice for this group of patients.

R.N. Dunn M.A. Edgar

Twenty-eight patients undergoing correction of thoraco-lumbar deformity were randomised to either the USS or Colorado 2 spinal instrumentation. Scoliosis was the deformity in 24 cases. Only once the surgical plan was decided upon was the instrumentation randomised, thus not influencing the use of anterior release or not.

Of the scoliotics, seven underwent anterior releases. The average duration was 107 minutes, blood loss 325 ml and number of levels 4.6 discs.

The USS group had 11 scoliosis cases. Nine were idiopathic, one neurofibromatosis and one neuromuscular. The average age at surgery was 18.7 years. The average number of levels fused was 11.4±1.6 (9–14). The average duration of surgery was 237±43.9 (180–330) minutes. The average blood loss was 2460±2204 (500–7500) ml. If the extreme blood loss of 7500 ml was excluded, then the average was 1900±1392 (500–4500). Costoplasties were performed in five cases. Only one case braced.

The Colorado 2 group had 13 scoliosis cases. Ten were idiopathic and three neuormuscular. The average age at surgery was 21.9 years. The average number of levels fused was 11±1.52 (9–14). The average duration of surgery was 198.3±34.9 (150–255) minutes. The average blood loss was 1766.7±863 (850–3800). Costoplasties were performed in five cases. Only one case braced.

Results: There was similar correction between the groups with Colorado 2 having an average of 52±16 (17–67)% and USS 62±17 (38–93)%. As regards instrumentation related failure, one USS hook cut out intra-operatively and needed to be replaced a level lower. In the Colorado group, there was also a laminar fracture. There were two screw cut outs, a hook pull out and two misplaced hooks in the Colorado group.

Conclusions: Both systems provided a similar amount of correction. There were more fixation point problems with the Colorado 2 group than the USS group. Some of these problems were related to insertion errors, but may have been due to migration during the correction process. This may indicate a benefit of the USS hook-screw fixation system.

C. Salanova J.F. Dubousset P. Moreno J. Boulot

Purpose of the study: To analyse post-operative imbalance after C.D.I. (Cotrel Dubousset Instrumentation) for idiopathic scoliosis according to the fused area, particularly the lower level of fusion. To recall a classification for determination of fusion area based on pre-operative standing coronal radiograph.

Patients and methods: To be included in this study the patients had to have an adolescent idiopathic scoliosis, at least two years of post-operative follow up. One hundred and twenty-two patients met the criteria; mean follow-up was three years, five months (minimum two years, maximum nine years). Scoliotic curves were classified as single structural (81), double structural (41). Balance was clinically analysed by plumbline, radiographically by a plumbline dropped from C7 to the sacrum and measuring deviation from the midpoint of the sacrum in centimetres. A curve with a deviation of 10 mms or less was considered as balanced.

Results: Imbalance in single structural curves was 70% when using stable vertebra (King) or “other vertebra” (beyond stable vertebra or one or two levels upper stable vertebra). Using end vertebra (J.MOE), (elected vertebra – C. Salanova) imbalance was 10%. In double structural (41 cases) imbalance was 50% using stable, or “other vertebra” 10% when elected vertebra was fused.

Conclusion: In this study there was a strong statistical relationship between the lower level of fusion and imbalance.

S. Mohammad T. Ursu A. Singh M.A. Edgar

Aim: To test the null hypothesis that older instrumentations with their complications do not produce a clinical improvement.

Introduction: Surgical treatment of adult scoliosis is difficult with a high incidence of complications. The presenting complaints and expectations from the surgery are different to those in adolescent scoliosis.

Methods and results: Inclusion: All cases of adult idiopathic scoliosis presenting at or after the age of 20 and requiring surgical treatment. Exclusions: Revisions. Average age of follow-up is 6 years (range 2 to 14 years) with 107 patients. For analysis three groups were decided on the basis of the age. A number of different instrumentation systems were used with time. Treatment varied according to senior author’s planning for the individual patient, ranging from posterior instrumentation, anterior release and posterior instrumentation, and combined anterior and posterior instrumentation.

Group I: Age 20–30 years, consisted of 64 patients. Average pre-operative primary curve was 56° with post-operative correction 50%. Deformity was the most common presenting complaint. Seventy-one per cent felt an overall improvement, the rest noticed no benefit.Twenty-two per cent would prefer not to have the surgery. Complications included four pseudoarthrosis, nine required further surgery, and one late infection.

Group II: Age 31–40 years, 20 patients with an average primary curve of 63°, and a correction of 56%. Fifteen per cent had significant pain at presentation. Seventy per cent felt an overall benefit although all noticed a cosmetic improvement. Complications: two pseudarthrosis, three subsequent surgical procedures.

Group III: Age > 41 years, 23 patients, an average primary curve of 72° with a correction of 39%. Eleven out of 23 had significant pain on presentation. Complications: four pseudoarthrosis, metal pull out in one. Further surgery was performed in nine. All felt some benefit from the treatment and despite the high proportion of complications, would have the surgery again.

Conclusions: There is a clinical benefit from surgical treatment of adult idiopathic scoliosis. There is a higher number of complications in the older age group.

P. Parisini T. Greggi M. Di Silvestre A. Miglietta

Introduction: Pedicle screw instrumentation as a part of scoliosis surgery has been shown to provide a better correction in lumbar deformities. The purpose of this retrospective study was to verify if segmental screw fixation has the same efficacy in correcting hypokyphotic thoracic deformities.

Methods and results: We considered 40 cases with AIS treated posteriorly by segmental fixation (CDI, Colorado or similar instrumentations) from 1987 to 1998. All patients presented with a predominant hypokyphotic thoracic curve and were divided into two groups (20 cases each) according to the fixation method selected: multiple, hook fixation (MHF) or segmental pedicle screw fixation (SPSF). In the PSF group, the pedicle screws were inserted at every other or every third vertebra in lumbar and thoracic areas, and correction was achieved by translation technique and derotation manoeuvre without distraction and compression on the concavity and convexity of the curve, respectively. At a follow-up longer than two years and in all of the cases, the average frontal correction in the PSF group decreased from 61.3° to 27.6°, and in the MHF group from 57.5° to 28°; the average hypokyphosis value improved from 12.9° to 25.6° in the PSF group, and from 15.3° to 17° in the MHF group. There were no major, visceral or neurological complications related to hook or pedicle screw placement.

Conclusion: According to the present results, segmental pedicle screws are more effective than multiple hooks in restoring thoracic kyphosis in AIS: pedicle screw fixation may play a role in reducing the need for the two-stage surgery.

B. Salanova P. Moreno J. Boulot

Study design: To analyse the long term effect of Harrington Instrumentation and fusion to the lumbar spine in the treatment of idiopathic scoliosis.

Objectives: To demonstrate there is a relationship between the strategy used (determination of fusion area) and pain or degenerative changes.

Summary of background data: The literature has been fairly controversial in terms of pain and degenerative changes beyond a fusion for idiopathic scoliosis according as the lower level of fusion. This is the first study in which the results are analysed according as the “strategy used” and not the sole level of fusion.

Methods: 250 patients operated on by Harrington instrumentation were clinically and radiographically reviewed. Pain was classified (as Moskowitz and Moe). To be included they should have an idiopathic scoliosis, a minimum follow up of 20 years (mean 26, max 36), 37% over 30 years, had to have been under 20 years at the time of surgery, and should have a full set of radiographs.

Curves were classified according to our own classification (Salanova et al) 1973–2000 in single structural. Thoracic 114, thoraco-lumbar 21 and double structural thoracic and lumbar, true double major (52), false D.M. (45). The double thoracic was identified with permanent T1 tilt (18). On P.OP standing the lower level of fusion was identified: E.V. (Salanova et al 1973–2000) SV (King) other vertebra. On follow up radiographs standing coronal and sagittal, lumbar coronal and sagittal degenerative changes were evaluated, slipping lateral and sagittal, discopathy over 50% and classified as none, moderate, complete.

Results: Mean age at surgery 15 years + 6. Mean age at follow up 49 years. Ten patients were reoperated on for various reasons. Overall results: Pain none 70, episodic 82, frequent 42, permanent 46. Degenerative changes none 155, moderate 62, complete 23. These data were evaluated according to the strategy used; there is a strong statistical relationship between strategy and final results. Our study proves that King’s classification for so-called King II curves is misleading.

Conclusion: This study is the most important ever published in terms of patients, methodology, and follow up. It shows that if a clear analysis of curve(s) before surgery is effectuated for determination of fusion area, if for single curves the lower level of fusion is the good one and for double structural the choice between selective thoracic fusion and double fusion is correctly determinated the long term results are not so bad.

FE. Dowling C.J. Goldberg D.P. Moore E.E. Fogarty

Introduction: Historically, the spinal curvature of adolescent idiopathic scoliosis was considered a life-threatening occurrence, which would result in early death from cardio-respiratory compromise. Consequently, corrective surgery had the primary intention of preventing this unacceptable outcome: cosmetic improvement was considered to be certainly important, but not the prime objective of the treatment. More recent work (e.g. Branthwaite MA. (1986) Br.J.Dis.Chest. 80:360–369) has shown that, while significant deformity presenting in early childhood does carry this outlook, those with an adolescent onset should not be significantly affected in this way. Consequently, any surgery recommended is primarily cosmetic, to improve the deformity when it is unacceptable to the patient and her parents. This, of necessity, changes the criteria by which treatment outcome should be assessed. Scoliosis surgery has generally been judged by the correction in Cobb angle and, more recently, the derotation of vertebrae. However, it is well known that neither factor accurately expresses cosmesis, the criterion by which the patient will judge the operation. Surface topography attempts to quantify the external appearance of a patient and so the cosmetic effect of surgery. Since 1995, when a surface topographic system (Quantec) was acquired by this department, 61 patients were operated for adolescent idiopathic scoliosis, of whom 35 underwent anterior release and posterior fusion for rigid thoracic curves.

Methods and Results: Pre- and post-operative radiographs were compared with topographic results from the same periods and with the latest scan at last review. The mean pre-operative Cobb angle was 74.5° and, postoperatively was 40.7°, a mean correction of 45.4% and was statistically significant (p< .001). This was accompanied by statistically significant reductions in upper and middle topographic spinal angles (p=0.001), an increase in thoracic kyphosis (p< 0.05), a decrease in lumbar lordosis (p=0.001), lower rib hump (p< 0.05), Suzuki hump sum (a measure of back asymmetry, p=0.001) and posterior trunk asymmetry score (POTSI, a measure of trunk balance, p=0.003). At final follow-up a mean of 2.2 years later, topographic spinal angles and POTSI maintained their improvement, still being statistically significantly less than their pre-operative values. Thoracic kyphosis, lumbar lordosis, rib hump and Suzuki hump sum had returned towards pre-operative levels and no longer showed statistically significant differences.

Conclusions:This confirms previous reports of the recurrence of the rib-hump. In conclusion, after two-stage spinal fusion for adolescent idiopathic scoliosis, significant improvement in cosmetic appearance can be achieved. However, over time certain aspects of the original deformity, particularly distortion of the back surface (rib hump or asymmetry) recurs.

N R Boeree

No matter what form of anterior scoliosis instrumentation a spinal surgeon chooses to use it is generally accepted that complete clearance of the intervertebral discs over the levels being instrumented should be undertaken. This improves the flexibility of the curve, potentially enhancing the correction that can be achieved but, perhaps more importantly, reduces the forces that must be exerted on the spine through the instrumentation, particularly at the upper and lower levels. Complete disc clearance may also facilitate intervertebral fusion.

The most challenging aspect of disc clearance is removal of the posterior aspect of the annulus and the posterior longitudinal ligament The standard surgical technique involves initial excision of the convex lateral and anterior annulus, followed by the gelatinous nuclear material. This is relatively easily and quickly achieved. However, careful, patient and painstaking piecemeal removal of the posterior annulus is then necessary and this is more time consuming. Care is clearly required to avoid injury to the adjacent dura and neurological structures. Access to the posterior annulus with a ronger becomes more difficult towards the far concave aspect of the disc.

Little information is published concerning the time required for standard disc clearance. However, in the author’s experience, and from personal information provided by other surgeons, 30 minutes per level is generally required.

Coblation is a relatively new surgical technology by which tissue is removed by vaporisation achieved through the production of an ionized plasma vapour. The depth of vaporisation is very limited and is achieved with virtually no heat production, resulting in minimal thermal damage to adjacent tissue.

The author has used coblation in anterior correction of scoliosis, and in his view the technique allows simpler, more controlled and thus ultimately safer clearance of the posterior annulus. Clearance is also achieved more quickly, the time required for each level undertaken being reduced to approximately 15 minutes.

The technique involves standard exposure and then excision of the bulk of the disc. The disc must be exposed back to the neural foramen and the convex lateral annulus cleared to this point The anterior annulus is also exposed in the usual manner and excised together with the nuclear material and as much of the posterior annulus that can be easily removed with a ronger. At this point a blunt dissector is introduced into the neural foramen and held in position. Starting at the convex aspect of the posterior annulus and working towards the concave side a ‘Versitor’ coblator wand is then used to remove the posterior annulus, working back to the tip of the dissector . The dissector is not particularly required for safety , the depth of vaporisation being only 0.5 mm, but to establish the posterior extent of the annulus. As this is vaporised the dissector is advanced as necessary .

No complications have been observed in the small number of cases undertaken thus far. Current generated by the sodium plasma can result in local neurological stimulation causing muscle twitching, similar to that seen with the use of diathermy, but this has not been associated with any neurological deficit

J.A. Ouellet J.K. Webb

Introduction: Historically, anterior spinal surgery for scoliosis has led to better coronal correction, though at the expense of sagittal alignment specifically at the thoracolumbar junction. The purpose of the study was to ascertain the effectiveness in maintenance of coronal and sagittal balance of anterior spinal surgery and instrumentation for AIS.

Methods: 17 patients with idiopathic scoliosis treated with anterior spinal fusion using a single rod AO USS construct were reviewed in a retrospective fashion. Inclusion in study group required a minimum two years follow-up with complete radiographic and clinical follow up.

Results: There were 14 lumbar curves of which seven were King I and seven thoracolumbar / lumbar curves. Seven patients had supplemental structural anterior support in the lumbar spine. Four had femoral allograft rings and three had cages (2 Harms, 1 Synex cages). Three thoracic curves were operated on of which two were King III, and one King II. The mean pre-operative Cobb angle was corrected from 48° to 14° post-op and 16° on the last follow-up (24 to 53 months) representing 71% of correction. Apical vertebral translation was corrected to 70%, comparable to the 60% correction of trunk shift at last follow-up.

Sagittal contour of instrumented segment for the thoracic curve did not change. The pre-operative sagittal contour across the instrumented levels for the 14 1umbar was 5.6° of lordosis which changed to 0.5° of lordosis post-operatively. At last follow-up it was 2° of kyphosis. Specifically there were 7 of 14 that had greater that 10° of surgically induced kyphosis across the fusion mass. At last follow-up three patients had further kyphosis across the instrumented levels. The overall sagittal vertical axis did not change irrespective of the focal sagittal alignment. There was a net increase in lumbar lordosis below the fusion mass. Three patients had asymptomatic pseudoarthroses. There was no failure of instrumentation and no patient required further surgery.

Conclusion: The authors conclude that single rod anterior spinal instrumentation for AIS is effective in maintaining coronal and sagittal alignment though one needs to pay particular attention to sagittal contour. The increase in lumbar lordosis below the fusion may well explain the maintained sagittal balance.

A. Nachemson A. Danielsson I. Wiklund K. Pehrsson

Introduction: A consecutive series of patients with adolescent idiopathic scoliosis, treated between 1968 and 1977 before 21 years of age, either with distraction and fusion using Harrington rods (ST, n=156; 145 females and 11 males) or with brace (BT, n=127; 122 females and 5 males) were followed at least twenty years after completion of the treatment to determine the long-term outcome in terms of health related quality of life (HRQL) in patients treated for adolescent idiopathic scoliosis. No results on long term outcome of HRQL have previously been presented for this group of patients.

Methods and Results: Ninety-four per cent of ST and 91% of BT patients filled in a questionnaire comprising the SF-36, Psychological General Well-Being Index (PGWB), Oswestry Disability Back Pain Questionnaire, parts of SRS/MODEM’s questionnaire and study-specific questions concerning the treatment, as a part of an unbiased personal follow-up examination. An age and sex-matched control group of 100 persons was randomly selected and subjected to the same examinations. There were no differences in terms of sociodemographic data between the groups. Both ST and BT patients had a slightly, but significantly reduced physical function using the SF-36 subscales, SF-36/Physical Component Summary (PCS) score as well as the Oswestry Disability Back Pain Questionnaire compared to the controls. Neither the mental subscales and the Mental Component Summary (MCS) score of SF-36 nor the PGWB index showed any significant difference between the groups. Forty-nine per cent of ST, 34% of BT and 15% of controls admitted limitation of social activities due to their back, (p< 0.001 ST vs. controls, BT vs. controls p= 0.010, and p=0.024 n.s. ST vs. BT), mostly due to difficulties to physically participate in activities or selfconsciousness about appearance. Pain was a minor reason for limitation. No correlation could be found between the outcome scores and curve size after treatment, curve type, total treatment time or age at completed treatment.

Conclusions: Patients treated for adolescent idiopathic scoliosis were found to have approximately the same HRQL as the general population. A minority of the patients (4%) had a severely decreased psychological well-being and a few (1.5%) were physically severely disabled due to the back.

V.J. Raso J.K. Mahood D. L. Hill M.J. Moreau

Introduction: Trunk asymmetry has been acknowledged as an important aspect of scoliosis that is difficult to treat. Recent innovations in the surgical management of idiopathic scoliosis have attempted to improve trunk symmetry as well as spine curvature. But there have been few reports in the literature describing the effectiveness of these procedures on trunk alignment. The objective of this study was to determine the long-term changes in spine and trunk alignment after surgery for scoliosis.

Methods and Results: 38 subjects were identified as candidates for this study. Fifteen were lost to follow-up. Of the remaining 23 subjects, 20 (15 female, 5 male; age at surgery 16±5 years) agreed to participate and had posterior-anterior radiographs and surface topography prior to derotational surgery, within six months of surgery, at two years post-operatively and 5-10 years after surgery. Three subjects had anterior instrumentation and 17 had posterior instrumentation. Cobb angles, surface trunk rotations, and cosmetic scores were measured at each visit. A questionnaire assessed back appearance and pain at the 5–10 year follow-up and the results compared to a group who had recently undergone surgery. A paired two tailed Student’s t-test with p=0.01 was used to compare the deformity between visits.

The Cobb angle and cosmetic score improved after surgery; the initial Cobb angle improved to 35±11° (42%). Trunk rotation change was insignificant (p=0.25).

Between the two and seven year reviews, the Cobb angle had significantly increased while the cosmetic score (p=0.07) and surface trunk rotation (p=0.10) were unchanged. The mean back appearance and pain scores were 4.3 for both compared to 4.2 and 4.0 for the control group where 1 is worst and 6 is best.

Imperfect surgical correction of spinal curvature leads to continued changes to spine alignment as well as to cosmesis and trunk alignment, although the increases were not all statistically significant. Responses to the patient questionnaire suggest that these changes are not clinically significant.

Conclusion: Surgery significantly improves trunk symmetry but not trunk rotation. There is mild deterioration of the deformities associated with scoliosis after surgery but these changes do not appear to be clinically significant.

M.A. Asher S.M. Lai D.C. Burton B.J. Manna

Introduction: Spine and trunk deformity are different; trunk deformity is probably more important to the patient, and trunk deformity has received much less attention. This study was designed to determine the extent and stability of trunk deformity correction and is part of an ongoing effort to study trunk deformity.

Material and methods: This is a prospective case series the inclusion criteria being pre-, post- and follow-up surface topography evaluation of idiopathic scoliosis patients undergoing posterior instrumentation and arthrodesis. Twenty-eight patients (25 female, 3 male) met these inclusion criteria. The average age at surgery was 15 years 3 months (11 years 3 months – 38 years 2 months). Spine deformity measurement and classification were done from standing 36” PA and lateral scoliosis radiographs. Trunk asymmetry was determined from standing posterior rastersterography. Coronal plane asymmetry was calculated utilising the Posterior Trunk Symmetry Index (POTSI), threshold for change being ±8. Transverse plane asymmetry was determined by the Suzuki Hump Sum (SHS), threshold for change being ±3.5. Curve classification and number in each category were King Moe I – three; IIA – two; IIB – three; III – ten; IV – four;V – five and Triple – one. Initial follow-up averaged 2.3 months (±7) and latest follow-up 15.8 months (±8.1).

Results: Pre-operative; post-operative; and 1atest follow-up spine deformity measurements with percent correction (for spine and trunk deformity) were as follows: Major scoliosis-63°, 19° (69%) and 21° (66%); POTSI 52, 26 (50%), and 24 (54%); and SHS 18, 11 (38%), and 12 (37%). Thus, spine deformity (Cobb) and trunk deformity (POTSI and SHS) correction appeared to be stable over the follow-up period. Spine deformity correction was better than coronal trunk plane asymmetry correction which was better than transverse plane asymmetry correction. At latest follow-up, spine deformity correction for single curves was similar to multiple curve, 69% versus 64% as was transverse plane trunk asymmetry correction 34% versus 37%. However, coronal plane trunk asymmetry correction was better for single curves than double curves 63% versus 42%. At follow-up POTSI was better in all patients with single curves whereas in double curves it was better in nine, same in three, and worse in two. Transverse plane trunk asymmetry for single curves was better in ten, same in three, and worse in one, whereas for double curves it was better in eight, same in four and worse in two.

Discussion and conclusion: The obvious weaknesses in this study are the small numbers and relative short follow-up. However, the trend seems clear. Trunk deformity correction is not as good as spine deformity correction. This is especially true for the transverse plane for all curves and the coronal plane for double curves in comparison to single curves.

B.A. Taylor G. Etherington

Introduction: There have been reports of anterior fusion surgery advocating the routine use of interbody spacers in the lumbar and low thoracic spine. In contrast to these, many surgeons feel that the routine use of inter-body spacers is not warranted, provided appropriate surgical technique is used for discectomy, screw placement, and solid rod contouring. Rather, the insertion of spacers may, in fact, hinder correction of the overall deformity. Our hypothesis was that it is possible to create a satisfactory sagittal profile without the use of interbody spacers.

Methods and results: Study design: Retrospective examination of X-rays and appropriate notes. Patients of the senior author who had undergone an instrumented anterior fusion for scoliosis were reviewed. Some of these patients underwent a second stage posterior fusion to the same level distally. Analysis of the X-rays and notes was performed on a group of 27 patients who had undergone their surgery from July 1996 to December 2000. Follow-up varied from six months to three years.

Inclusion criteria: Diagnosis was adolescent idiopathic scoliosis. All surgery carried out by the one surgeon (BT). Anterior fusion, with a solid rod, extending into the lumbar spine. There were 15 who had anterior fusion only, and 12 who also underwent posterior fusion. The difference between the groups was that of the nature of the curves. One of the patients had the posterior fusion on a second admission for thoracic curve progression after anterior lumbar fusion. Lowest instrumented levels were 6 to L2, 15 to L3, and 6 to L4.

Variables measured: Assessment of AP and sagittal alignment was made, as was fusion across the levels. Methods and problems encountered with data collection will be discussed. Variables were AP Cobb; Sagittal angle variables were 1) L1-S1 2) TIV-LIV 3) LIV-S1 4) L4 5) S1. These were compared with previously published data; difficulties in comparison to ‘Normal’ will be discussed.

Results: There was no incidence of metalware failure, and no bone/screw interface problems. There was no loss of correction in those cases where follow-up was possible. Union was slow compared to some previously published series. Despite a tendency for a relative loss of lordosis across the fusion, overall lumbar lordosis was maintained within accepted values, and the fusion construct angle was within accepted limits. There was minimal change in Cobb angle of the fusion construct with time.

There have been four cases of < 25% retro-listhesis at the upper end of the constructs. These have not produced neurological symptoms, but as yet the significance clinically is unknown.

Conclusion: At this stage the authors feel that routine use of interbody spacers is not justified, as complications without their use have not been forthcoming.

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J. Ouellett B.J. Freeman P. Twining J.K. Webb

Introduction: Although the ultrasound diagnosis of neural tube defects has been described extensively, anomalies of the fetal vertebral bodies have received little attention. This study aims to document the incidence of congenital hemivertebrae, the association with defects of other organ systems and discuss the outcome.

Methods: All fetuses with ultrasonographically detected vertebral anomalies presenting to the above institution over a four year period were included in the study. Those with open neural tube defects were excluded. The level and Cobb angle (where possible) were estimated from the 18 week scan. Associated congenital anomalies were noted. Radiographs were taken soon after birth and checked for accuracy of original diagnosis and patients were monitored for curve progression.

Results: Fourteen fetuses with congenital hemivertebrae were found from a total of 12,000 routine antenatal scans. Maternal age ranged from 22–32 years (mean 26.8 years) with an average term of 36.3 weeks (range 29–40). Only two fetuses were born prematurely: one at 33 weeks as part of a twin gestation (only one of the twins had an isolated hemivertebrae) and the other at 29 weeks via emergency caesarian section for fetal distress. This pregnancy was complicated by the oligohydramnios sequence (Potter syndrome). Ten of 14 fetuses had an isolated hemivertebrae. Two had VATER association (oesophageal and anal atresia) and two had multiple mosaic type congenital scoliosis, one of which had associated rib and abdominal wall malformation. All pregnancies resulted in live births. All except one child remain well at latest follow-up (average 25 months). The infant born at 29 weeks has had multiple complications of prematurity. Vertebral anomalies appeared in the thoracic spine in five, the lumbar spine in eight and the sacrum in one resulting in scoliosis in 13 and kyphosis in one. The average antenatal Cobb angle was 30°. The average postnatal Cobb angle was 32° (range 18–42). Accuracy of localisation (level and type) was good with only one error due to inability to see the S1 hemivertebrae. Six of the 14 had surgery before the age of 24 months, with the youngest aged three months. In this group the average pre-operative Cobb angle was 35° (range 25–42°). Three patients had anterior and posterior fusion in-situ without instrumentation. Three patients had hemivertebrectomy with correction and posterior instrumentation of the spine.

Conclusion: In general sonographically detected isolated fetal hemivertebrae carry a good prognosis. If associated with the oligohydramnios syndrome the fetus is at high risk. Ultrasound appears accurate in the diagnosis of both the level and type of congenital malformation. The value of early surgical management needs continued assessment.

N. Suzuki K. Kohno

Introduction: One of the important goals of scoliosis surgery is to improve or to prevent deterioration of pulmonary function. There have been many reports on this subject, yet there are a few reports on cases that had surgery by modern multi-hook system. Modern instrumentation can provide better correction; therefore better results on pulmonary function can be expected.

The purpose of this study is to analyse post-operative pulmonary function in cases that underwent Isola instrumentarion to scoliosis.

Method and Results: There are 130 cases (Male 23, Female 107) who underwent Isola instrumentation to scoliosis from December 1991 to December 1998 and had pulmonary function test pre-operatively and at the time of two-years follow-up. Aetiologies were Idiopathic 119, Congenital 3, Neurofibromatosis 2, Marfan 4, and Others 2. Average age is 15 at the time of operation ranging 10 to 26. One hundred and twenty-six cases had single operation and four cases had two-staged anterior-posterior surgery.

VC, %VC, Fev.l.0, % Fev.1.0 were measured pre-operatively and two years post-operatively. Body height correction was done using Kohno’ s equation to obtain % VC.

The pre-operative average VC, %VC, Fev.l.0, and %Fev.l.0 were 2.4l, 84.2%. 2.1l, and 85.5% respectively. They were 2.6l, 83.0%. 2.3l, and 87.2% at 2 years postoperatively. Cases were diagnosed according to the change of % VC using a threshold of 10% change. If the change of the %VC is less than 10%. it is diagnosed as unchanged. Thirty cases (23.1%) had decreased %VC, 70 cases (53.8%) unchanged and 21 cases (16.1%) had increased %VC.

The cases were divided into four groups according to the pre-operative % VC. Group 1; the pre-operative %VC was less than 60%. Group 2; 60% to 69%, Group3; 70% to 79%. and Group 4; 80% or more. The average pre- and post-operative %VC were 50% and 54% in Group 1, 65.5% and 67.5% in Group 2, 75.4% and 80.5% in Group 3, 94.8% and 90.6% in Group 4.

Conclusion: The results showed that a patient can expect to have normal or almost normal VC post-operatively when the pre-operative % VC is larger than 70%. On the other hand, if the pre-operative % VC is less than 60% the chance to have normal or almost normal VC . post-operatively is very little. Therefore, surgery must be done before % VC deteriorates to less than 60%. The goal of scoliosis treatment is three fold; 1) to restore stable, balanced, and stable spine, 2) to have normal pulmonary function, 3) to be emotionally stable. In 61% of the cases the surgical technique applied was conventional method which gave average % correction of 68%. From 1997, a new correction technique using Isola system has been applied. Results at one-year follow-up showed better results. It is my opinion that the treatment of scoliosis should be focused not only to the correction of coronal and sagittal curvature but to the correction of thoracic cage deformity.

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H. Elsebaie P. Basu M.H.H. Noordeen

Background: The incidence of intra-spinal abnormality in congenital scoliosis is high. McMaster et al found an 18% incidence of myelographic abnormality in a series of 251 patients. Our objective was to report the MRI findings in a large series of patients with congenital scoliosis.

Method: The notes, X-rays and MRI of 126 congenital scoliosis patients were reviewed to note the vertebral abnormality, curve progression, MRI findings and the presence of non-spinal congenital abnormality. These findings were then correlated to detect any association between them.

Result: Forty-six patients (37%) had intra-spinal abnormalities detected on MRI. Sixty-six patients had failure of formation, 10 had failure of segmentation, 34 had mixed vertebral anomaly and 16 had congenital kyphosis or dislocation. MRI abnormality was significantly higher among patients with mixed anomaly (41%), congenital kyphosis (57%) and segmentation anomaly (40%) than those with failure of formation (29%). Presence of MRI abnormality did not correlate with curve progression or the presence of congenital abnormality affecting other organs.

Conclusion: Intra-spinal abnormality in congenital scoliosis occurred in 37% cases. The incidence of such abnormality is higher in patients with congenital kyphosis, failure of segmentation and mixed vertebral anomalies.

H. Elsebaie P. Basu M.H.H. Noordeen

Background: Surgical treatments described for congenital spinal deformity are i) convex growth arrest, ii) posterior or combined anterior and posterior fusion and iii) hemivertebrectomy. Posterior instrumentation is used as an adjunct to fusion, whenever possible.

Anterior instrumentation for correction of congenital scoliosis has not been described. A preliminary report of the use of anterior instrumentation following hemi-vertebrectomy for correction of congenital spinal deformity is reported.

Method: 15 patients with congenital scoliosis and 5 patients with congenital kyphosis underwent hemiverte-brectomy and anterior instrumentation with fusion for single-stage correction of deformity . The average age of the patients at the time of surgery was 31 months and at last follow-up 59 months. All patients had pre-operative MRI. Twelve patients had normal and 8 had abnormal MRI. The average operating time was 135 minutes and average blood loss was 462 ml. Implants used were downsize Synergy, Orion Colorado and AO Cervifix.

Average sagittal Cobb angle for the scoliosis patients was 45.5° pre-operatively and 16.8° post-operatively. Average coronal Cobb angle in patients with congenital kyphosis was 61° pre-operatively and 21° postoperatively. At an average follow-up of 17 months, the correction is well maintained in all except one. This patient developed pseudarthrosis at 19 months post-operatively. This was treated with posterior instrumented fusion. There were no cases of neurologic compromise or deep wound infection.

Conclusion: Because of the young age at which hemiver-tebrectomy is performed in congenital scoliosis patients, instrumentation is difficult. Posterior instrumentation has been well described in literature. Our early experience with anterior instrumentation after hemivertebrectomy shows promising results with very good correction of the deformity and no increase in complication rate.

D.C. Mackay M.J. Gibson

Late wound infection is a recognised complication of instrumented spinal deformity surgery. In most cases it is a benign complication which usually resolves after implant removal. However, some of our patients with late infection developed a pseudoarthrosis.

To investigate this further we undertook a retrospective review of all patients undergoing implant removal for deep infection between 1991 and 2000.

Twenty-one patients were identified, representing a late infection rate of at least 6%. They showed no specific pre- or intra-operative risk factors. Nine had some problems with early post-operative wound healing, which settled with minimal treatment. Late infection presented as localised swelling or a discharging sinus between 4 and 84 months (average 31 months) post-surgery. Blood parameters were abnormal in 15 cases, frank infection demonstrated in 19 cases, loosening of the implant in four cases and positive bacteriology culture in 14 cases. Wounds healed within 2 to 17 weeks (average 5 weeks) following implant removal, wound debridement and antibiotic therapy lasting 2 to 20 weeks (average 6 weeks). This was delayed until one year post-surgery in the three cases presenting early. Follow-up of between 6 and 92 months (average 38 months) revealed no persistent infection. Pseudoarthrosis developed in seven patients (33%). Four of these patients had progressive deformity warranting refusion and three produced minimal symptoms. Patients developing a pseudoarthrosis had an excess of post-operative wound problems, presented much earlier and had more severe infections compared to those without sequelae.

Late infection is confirmed as a relatively common complication of scoliosis surgery. Implant removal, aggressive debridement and primary closure is confirmed as effective treatment to eradicate the infection. A high rate of pseudoarthrosis is the only sequelae. The excess of early infections in these cases may indicate interference with a critical stage of the fusion process. Preservation of the implants until one year post surgery was unsuccessful at preventing a pseudoarthrosis.

J. Aderinto H. EIsebaie M.H.H. Noordeen

Introduction: Somatosensory evoked potentials are monitored during the surgical treatment of spinal disorders to reduce the risk of cord injury. Whilst studies have examined its role in patients undergoing correction of idiopathic and neuromuscular scoliotic curves, its effectiveness in patients undergoing operative treatment for spinal injury is less certain.

Methods and Results: We reviewed the medical records of patients who underwent surgery for spinal trauma. between 1995 and 2000. There were 82 patients with adequate data for analysis who underwent 83 spinal reconstructive procedures. We recorded the age at injury, diagnosis, time of operation, levels instrumented, systolic and diastolic blood pressures and surgical approach. The intraoperative somatosensory evoked potential (SSEP) traces were examined. The SSEP at insertion of electrode was taken as the control level. The highest and lowest intraoperative somatosensory evoked potentials and SSEP at closure were noted and expressed as a percentage of the control value.

Forty patients (48%) had a pre-operative neurological deficit. Neurological deterioration occurred postoperatively in three patients. Eighty-three traces from 82 patients were available for analysis. Fifty-seven patients had a fall in trace amplitude by more than 25% of the control, 25 by more than 50% and eight by more than 75%.

With an SSEP amplitude loss of 60%, both sensitivity and specificity for the prediction of post-operative neurological injury were optimised at 67 and 81% respectively, with one false negative result.

SSEP rise at completion of spinal reconstruction and highest intraoperative SSEP rise was compared with neurological outcome in the 40 patients with abnormal pre-operative neurology. Neurology improved in all patients in this group who had a trace amplitude more than 60% above the control value at end of operation. None had neurological deterioration. There was no correlation between intraoperative SSEP rise and neurological outcome.

Conclusion: Loss of trace amplitude more than 50% is common during spinal reconstructive surgery after trauma, however a 60% threshold for SSEP fall improves specificity by reducing the rate of false positive results. A trace amplitude 60% above the control value at completion of operation is specific but not sensitive for postoperative neurological improvement.

M. O’Malley J.C. Dorgan C. Bruce C.J. Roche

Introduction: Atlanto-axial rotatory fixation is a rare condition which occurs more. commonly in children than in adults. The terminology can be confusing and the condition is also known as. ‘ atlanto-axial rotatory sub-luxation’ and ‘atlanto-axial rotary dislocation’ . Rotatory fixation is the preferred term however , as in most cases the fixation occurs within the normal range of rotation of the joint and by definition therefore the joint is neither subluxed nor dislocated. Atlanto-axial rotatory fixation is a cause of acquired torticollis. Diagnosis can be difficult and is often delayed. The classification. system proposed by Fielding in 1977 is most frequently used and will be discussed in detail. Given that this classification system was devised in the days before CT, as well as the fact that combined atlanto-axial and atlanto-occipital rotatory subluxation is omitted from the classification, we propose a modification to the classification of this rare but significant disorder.

Methods and Results: The radiological findings in six cases of atlanto-axial rotatory fixation will be illustrated, including a case with associated atlanto-occipital sub-luxation. The pertinent literature will be reviewed and a more comprehensive classification system proposed. The imaging approach to diagnosis and the orthopaedic approach to management will be discussed.

Conclusion: In general, children who present with a traumatic torticollis should be treated conservatively with cervical collar and anti-inflammatory medication for one week. Those children whose torticollis fails to resolve after one week require aggressive investigation by ‘dynamic’ computed tomography to assess whether the joint is fixed. If however there is a history of significant trauma then immediate radiological assessment is advised. This approach will avoid over-investigation and over-treatment yet will still detect atlanto-axial rotatory fixation early enough to achieve a good outcome.

V. Lykomitros J.B. Wllliamson J.B. Spilsbury R.R.S. Ross

Introduction: Treatment of thoracolumbar fractures remains controversial. The treatment options are conservative management or operative treatment, either through a posterior or anterior approach. Surgery through an anterior approach provides excellent decompression through vertebrectomy and the ability to correct the deformity. Stabilisation with Moss cage and Kaneda device remains unproven.

Methods and Results: This is a retrospective study of 55 consecutive patients with thoracolumbar fractures operated on between 1993–99. Indications for surgery were: neurological deficit, two or three column injury causing instability or significant kyphotic deformity .

There were 34 male and 21 female patients, mean age 33 years old. Trauma was caused by a fall from a height, either due to accident (30 patients) or suicide attempt (5), RTAs (14), sporting injury (6). Other injuries included multiple level spinal fractures (9 patients), pelvic (5), calcaneal (3), talar (1) and malleolar (1) fractures.

Surgery was performed on the next available list unless there was an indication for emergency intervention, (mean 5 days post injury, range 1–19). Post-operative hospital stay averaged 17 days (7–59).

Forty-seven patients underwent an anterior procedure alone, whilst eight patients had combined anterior and posterior instrumentation and fusion. Mean operative time was 207 minutes (150–360) and blood loss 2670 ml (985– 7000).

Nineteen patients (35% of all) had neurological deficit. Neurological status improved post-op in 85% of these patients, remained the same in nine per cent and there was a nerve root injury in one patient (revision case) which has almost recovered. Other complications included five chest infections, three UTIs, one incisional hernia, four implant problems and eight patients with thigh pain.

Results were analysed according to return to work and the Oswestry Disability Score with a mean follow-up of three years. Thirty-eight patients (69%) returned to the same occupation held before the injury, 11 patients (20% ) had a lighter job and six patients ( 11% ) are not working with litigation going on. Oswestry Disability Score post-op was 24% (4%–72%).

Conclusion: Compared to the natural history of conservatively treated thoracolumbar fractures, surgical treatment with anterior decompression and stabilisation with Moss cage and Kaneda device offers considerable advantages. It enables a thorough decompression and has the advantage of providing greater deformity correction than the traditional posterior approach while instrumenting fewer vertebrae, thus preserving spinal motion segments. Early mobilization of the patients is a major advantage.

M. Reed J. McVie P.L. Sanderson

Introduction: The threshold for internal fixation of thoracolumbar junction fractures is controversial. Most authorities would agree that indications would include neurological deficit and severe deformity. The definition of severe deformity many would regard as a kyphus angle of 20° or more and/or compression of more than 50% of the anterior body height. Patients are only assessed on supine films alone. The aim of this study was to ascertain whether weight-bearing films altered the deformity and if so did this subsequently alter management.

Methods: A prospective study of patients who had suffered a fracture of the thoracolumbar junction (T11- L2). All patients who had a neurological deficit or a kyphus angle of greater than 20° and/or greater than 50% anterior body collapse were excluded. Only patients with a deformity less than the above were entered into the study. These patients then had weight-bearing views (standing or sitting) as soon as they had developed trunk control. A kyphus angle of greater than 20° or more than 50% body collapse were used as a criteria for fixation.

Results: 16 patients were entered into the study over a one year period. Five (31% ) of the 16 patients had a significant increase in their deformity on weight-bearing films that caused them to pass the threshold for fixation, and subsequently had surgery .

Conclusion: The authors recommend that weight-bearing views should always be taken on fractures of the thoracolumbar spine if conservative treatment is being considered.

M. El Masry I. W. El Assuity D. Chan

Introduction: Allen and Ferguson in 1982 described five stages of compression extension injury to the cervical spine; the first stage that was considered as a stable injury involves fracture of the articular process, pedicle or lamina which may be associated with a rotary spondylolisthesis. This fracture pattern, which is not uncommonly missed on the initial X-rays, can be diagnosed using CT scanning especially if patients present with root symptoms. This fracture will be usually treated conservatively as a stable injury. In practice we found out that this type of bony fracture might present later on with subluxation and/or persistence of symptoms even if treated in rigid immobilisation devices including halo jacket. The hypothesis around this fracture pattern will be a hyperextension mechanism combined with a degree of lateral tilt and rotation producing an anterior annular disruption under tension and a unilateral posterolateral mass or laminar fracture under compression with a resultant rotational instability around the intact lateral mass.

Material and Methods: Ten patients with stage I compression extension injury who presented with subluxation were studied prospectively aiming for addressing the patho-anatomy and define a method for treatment. All the cases presented with neurological manifestations, nine cases with root symptoms and one case with incomplete cord injury. The treatment consisted of early closed reduction followed by anterior fusion and fixation.

Results and Conclusion: All patients showed neurological improvement. Radiological union was achieved in all the patients with maintenance of the alignment. In conclusion, extension compression injury type I (fracture of the bony posterior elements) is usually a stable injury but if there is additional failure of the disc this segment will be rendered rotationally unstable. Despite the limited number of patients in this series the results of early anterior fusion with fixation were very satisfactory encouraging the recommendation for using this type of treatment.

R.E. McCall

Introduction: Since 1989 vertebral resection with modified Luque fixation has been the procedure of choice for correction of myelomeningocele kyphotic deformity at this institution. The purpose of this study was to evaluate long-term results with this technique.

Treatment or congenital kyphosis in myelomeningocele is a difficult problem. Current thinking supports kyphectomy and post-operative internal fixation.

The majority of authors agree that kyphotic deformity in myelomeningocele should be treated with vertebral resection. There is less uniform consensus as to postoperative fixation. Literature reports appear to support fixation with modified segmental instrumentation.

Methods and Results: 16 patients, followed for an average of 57.2 months (36–94 months), underwent vertebral resection from the proximal aspect of the apical vertebra cephalad into the compensatory lordotic curve. Fixation was segmental instrumentation wired to the thoracic spine and anterior to the sacrum.

The average blood loss was 1121 cc (450–2580 cc.). Pre-operative kyphotic deformity averaged 111° (75–157°), postoperative 15° (−18° –36°) and latest follow-up of 20° (−17° –83°), with loss of correction of 6° (0–27°). Post-operative immobilisation was with a TLSO for 18 months. Complications occurred in eight of the 16 patients: (1) transient headache (2), superficial wound breakdown (2), supracondylar femur fractures (2), and one late infection secondary to skin breakdown necessitating early rod removal and some loss of correction.

Conclusions: Kyphectomy is an excellent method of correcting rigid kyphotic deformity in the myelodys-plastic patient. Segmental spinal instrumentation provides three distinct advantages: rigidity of the construct, greater correction of the deformity and low-profile instrumentation.

P. Basu H. Elsebaie M.H.H. Noordeen

Introduction: Pelvic obliquity is a constant problem in neuromuscular scoliosis. Galveston and Luque L rod techniques are well described and achieve good correction of pelvic obliquity. We describe a sacral and iliac screw construct integrated with double-rod, pedicle screws and hook system, for correction of pelvic obliquity.

Method: 44 patients underwent posterior or combined anterior and posterior fusion to pelvis, for correction of neuromuscular scoliosis and pelvic obliquity. Average age at the time of surgery was 13.8 years. All patients were wheelchair-bound and nine of them were therapeutic walkers. Average follow-up was 44 months (range 24–69 months). Twenty-six patients had combined anterior and posterior surgery. All patients had posterior instrumentation to pelvis and 18 had anterior instrumentation as well. Eighteen patients had posterior instrumented fusion alone. Anterior instrumentation (when used) was Synergy and posterior instrumentation was Synergy or Colorado for all patients.

Result: Average time for surgery was 5 hours and 20 minutes and average blood loss 3600 ml. The average pre-operative Cobb angle was 69° and pelvic obliquity 23°. Post-operative average Cobb angle was 29° and pelvic obliquity 7.5°. At the latest follow-up the average Cobb angle was 36° and pelvic obliquity 10°. There were three deep wound infections. Two of the sacral screws have become prominent and two patients had de-linking of the iliac screw with the rod on one side. None showed significant loss of correction.

Conclusion: The sacraliliac screw construct with double rod segmental instrumentation achieved good correction of pelvic obliquity in patients with neuromuscular scoliosis. Implant related problems were infrequent

J. Dove

Introduction: It is the accepted dogma that should paralysis complicate spinal deformity surgery, then the internal fixation should be removed within three hours. This dogma is based on MacEwen’s paper in 1975 which related to the Harrington system and which did not contain statistical analysis (MacEwen G.D. et al, JBJS 557A, 1975,404-8). Since that time spinal cord monitoring systems have been developed and internal fixation systems have become considerably more complex. Does the accepted dogma need to be reviewed?

Methods and results: The author has reviewed the literature which contains statistical analysis of risk factors and results in relation to major neurological complications of spinal deformity surgery (Dove J. Résonance Européenes du Rachis 1999, 7[23]961–66). The risk factors are adult scoliosis, congenital and neuromuscular curves, kyphosis, combined anterior and posterior surgery, intra-operative hypertension, distraction and certain types of segmental fixation. Furthermore these risks are additive. MacEwen’s 1975 paper did not include statistical analysis and its conclusions are not borne out by the information within the paper. The only statistical analysis of the management of neurological complications has shown that surgical removal of the internal fixation was not related to neurological recovery (Paonessa K.G., Hutching F. Scoliosis Research Society Meeting. New York. Sept 1998).

Conclusion: Based on an analysis of the relevant literature and current clinical practice, the author suggests an algorithm to be followed by the surgeon faced with a major neurological complication of spinal deformity surgery. The author also raises the question as to whether the British Scoliosis Society should make a statement regarding “best practice” in such cases.

J.M. Trivedi D.C. Jaffray

Introduction: The incidence of scoliosis in patients with myelomeningocele has been reported to be as high as 80 to 90% in some studies. However these studies included patients with both congenital and developmental curves. The purpose of this study is to identify clinical and radiological factors, which may predict the development of scoliosis in patients with myelomeningocele.

Methods: A retrospective review of the charts and radiographs of all patients with myelomeningocele seen in our clinic between 1990 and 1995 was performed. Selection criteria for the study included: a diagnosis of myelo-meningocele or lipomeningocele, age greater than 10 years, serial documentation of motor power testing, and a radiographic documentation of spinal deformity primarily in the coronal plane.

Statistical analysis was performed to obtain predictive values, specificity and sensitivity for each of the following factors: clinical motor level, functional status, motor asymmetry and hip instability.

Radiographs were examined to obtain the last intact laminar arch in these patients. The relationship between the last intact laminar arch and scoliosis was evaluated.

Results: 141 patients satisfied the inclusion criteria. Seventy-four patients (53%) developed scoliosis. The mean follow-up was 9.4 years (range 3–30 years). The average age of the patient population was 19 (range 10–42 years). Forty-three patients developed scoliosis before nine years of age. New curves continued to develop until 15 years of age. Curves less than 20° often resolved. Clinical motor level, functional status, motor asymmetry and the last intact laminar arch were all found to be predictive for scoliosis in these patients. The presence of spasticity and hip instability had no definite influence on the development of scoliosis.

Conclusion: The term scoliosis should be reserved for curves greater than 20° in patients with myelomeningocele. New curves may continue to develop until 15 years of age. The last laminar arch is a useful early indicator of scoliosis in these patients.

R.E. McCall

Introduction: The study was to evaluate the effectiveness using a new type of instrumentation, a U-rod, in the treatment of neuromuscular scoliosis. This technique provides a method of secure fixation and excellent correction in neuromuscular curves, including correction of pelvic obliquity by terminating the rod construct in pedicle screws at Lumbar 5 without crossing the lumbosacral joint.

The need for surgery for progressive neuromuscular scoliosis is not controversial. However, often the type of instrumentation to be used is. Initially, Luque rods provided strong segmental fixation and the advent of the unit rod allowed strong segmental fixation with excellent fixation to the pelvis. However, there are cases where instrumentation to the pelvis is neither feasible nor necessary.

The U-rod offers the structural stability of a unit rod, being one continuous rod, avoiding the instability often seen with linked Luque rods, but without the need to invade the pelvis. The U-rod terminates in pedicle screws at Lumbar 4 or 5, is fixed segmentally to the remainder of the spine, and connects pelvic obliquity through the pull of the iliolumbar ligaments

Methods and Results: 11 patients have been treated with the U-rod, all for neuromuscular curves. Minimum follow-up is two years. Primary indications for use of the U-rod are: 1) ambulatory neuromuscular patient, 2) a lumbar curve with less than 15° tilt of Lumbar 5 on Sacral 1, despite the degree of pelvic obliquity, 3) a non-ambulatory neuromuscular patient meeting the above criteria for lumbar tilt/and/or pelvic obliquity.

Correction of curves has been excellent, accomplished either by posterior instrumentation alone or posterior instrumentation following anterior discectomy. The greater the degree of correction of the lumbar curve, the greater the correction of the pelvic obliquity Pelvic obliquity of up to 45° has been corrected with instrumentation to Lumbar 5 and the correction has been maintained.

Conclusions: In selected patients, the U-rod offers the ability to correct neuromuscular curves, including those with significant pelvic obliquity , without the necessity to invade the pelvis or cross the Lumbar 5 Sacral 1 joint. This is important in ambulatory neuromuscular patients. In non-ambulatory patients the unit rod offers convenience, decreased operative time, blood loss, and preserving the iliac crest for bone grafting.

V. Pai

The author reviewed 10 patients with irreducible or unstable Total Hip Arthroplasty (THA) dislocation. After clinical and radiological assessment an attempt was made to classify these cases based on the radiological findings and anatomical derangement and review of the literature. The purpose of this study was to correlate the cause of dislocation and the treatment.

The material consisted of ten cases of irreducible or unstable THA dislocation seen in the Healthcare Hawke’s Bay Hospital, Hastings, between 1995 and 2000. The mechanism of dislocation was either bending to put on socks or shoes, twisting injury pivoting on the leg or slipping in the shower. These patients had been treated by different surgeons and had various types of implants. All 10 were female and presented with pain, limp, shortening or deformity. Patients were categorised into:

Irreducible dislocation:

Dislodgement of the stem

Dislodgement of the cup

Disassociation of the liner or head in a modular system

Soft tissue interposition: Capsule, tendon

Miscellaneous: Cement interposition; Pseudoaneurysm, Myositis ossificans

Unstable Dislocation:

Subsidence of the stem

Cup migration

The incidence of dislocation, not an uncommon complication, has been reported to be 1.5% following primary THA. One-third may develop recurrent dislocation. Most of the reports in the literature are on the incidence and causes of dislocation. They include cup malposition, trochanteric migration, decreased femoral offset, inappropriate head size, leg length discrepancy, surgical approach and postoperative mobilization. Closed reduction can usually be easily achieved under sedation or general anesthesia. Very rarely, the hip joint cannot be reduced.

The author discusses his experience with irreducible dislocation and tries to classify its different causes and to the best of his knowledge, there is no classification of irreducible dislocation according to the anatomic-radiological findings in the literature. The treatment depends on the type of dislocation and is discussed under the specific types of irreducible dislocation.

N. Strick J.G. Horne P.A. Devane V. Stevanovic

There is controversy regarding the best way to manage fit, independent patients with acute hip fractures. The aim of this study was to compare, nationally, the early complication rates of total hip arthroplasty (THA) in those patients with an acute fractured neck of femur (NOF) with a similar group of THA’s performed in patients with a diagnosis of osteoarthritis.

Using the National Hip Joint Register and the New Zealand Health Information Service Database, 200 patients with acute hip fractures undergoing THA were identified and compared to 1102 THA’s performed on osteoarthritis patients. The mortality, revision, dislocation and infection rates were analysed at a minimum of one year.

Acute THA had a 7.5% one-year mortality rate compared with 2.5% in the OA group (p < 0.01). The revision rate was 2.5% vs 1.8% in the acute and OA groups respectively. The dislocation rate was 4.3% for the whole group with a 8.5% for the acute group and 3.5% for the OA group (p< 0.01). In the acute group the dislocation rate using the posterior approach was 17.1 % compared to 3.1% for the lateral approach (p< 0.01).

We conclude that acute THA is a useful procedure in fit patients with a fracture of the neck of the femur but that a posterior approach should be avoided.

S. Crampton J. McKie

This study reviews Total Hip Arthroplasty (THA) in the subcapital femoral neck fracture population looking at early complications.

Primary THA’s performed in our institution for femoral neck fractures between 1999 and 2001 were reviewed. The case records were obtained from the hospital patient information database. Medical charts, including operation and outpatient notes, were used to obtain information on the level of experience of the surgeon, supervision and complications.

Sixty five THA’s were performed on 65 patients with the average age of 77. Trainee Registrars performed 62%, 15% with a consultant assistant and consultants performed 38%. There were 19 (30%) medical complications giving a total complication incidence of 38%. All of the procedures were performed via the Hardinge direct lateral approach. There were 6 (9%) surgical complications, including one deep infection requiring revision. There were no dislocations or peri-operative deaths. The one-year mortality was 9% (equal to expected mortality of age related population without fracture).

Primary THA’s for displaced subcapital fracture in “community ambulators” is a safe and reliable procedure with an acceptable rate of surgical complications. Although there were a large number of minor medical complications documented, the 12-month mortality for this group remained the same as the population normal.

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E.F. Newman

Between June 1986 and 1993, 208 Protek CLS total hip replacements were inserted in 174 patients. These have been reviewed clinically and radiologically by independent observers at 3 yearly intervals.

One hundred and sixty six hips in 137 patients were available for review 9 to 15.5 years from insertion (mean just over 10.5 years). There has been no significant clinical or radiological change when compared to reviews three and six years ago with regard to the Harris Hip Score and the pain and function components of this. There has also been no change in subsidence, heterotopic ossification or lucencies. There has been no significant difference in results between males or females, nor between other factors such as pre-operative diagnosis, the use of metal or ceramic heads, age at time of operation or length of follow up. The failure rate remains low, less than 4%, i.e. survival rate greater than 96%. The reasons for failure in general do not relate to the fixation of either the acetabular or femoral components.

The results of this long-term follow up of a large group of relatively young patients at time of insertion of arthroplasty remain very satisfactory.

P.C. Turner R.O. Lander L. Rees

The purpose of this paper was to review the 8 to 11 year follow-up results of the Exeter Universal Hip in primary joint replacement in Palmerston North, New Zealand, where the prosthesis has been in use since 1989.

The first 216 Exeter Hips implanted in Palmerston North by six Orthopaedic surgeons, across four hospitals, were analysed. Each surgeon had varying experience with the implant used. A total of 88 primary hips were available for clinical evaluation, functional assessment and radiological review. The Orthowave software programme was used to collect data. Survivorship was determined by using revision as an endpoint.

Ninety percent of patients had an excellent functional outcome at time of follow-up. Infection rates were 2.3%. Dislocation rates were high at 14.7%. The survivorship of the Exeter Universal stem at 8–11 years was 95.5%. The overall survivorship of the hips including acetabular revisions was 92%.

We have found an excellent survivorship of the Exeter Universal stem at eight to eleven years. The most significant complication was dislocation. The small numbers of this study, and the large numbers lost to follow-up, influence the final results.

A. Wickham J.G. Horne J. Fielden P. Devane

The purpose of this study was to determine if the incidence of heterotopic ossification following total hip replacement decreases with increasing experience of the surgeon. A comparison of the incidence of heterotopic ossification between 196 patients having primary total hip replacement in 1989–1990 and a second group of 180 patients between 1999–2000 was performed. The surgery was done by one surgeon. Radiographs taken at least six months post operatively were assessed, and graded using both the Hamblen and Brooker classification systems. No patients were given specific prophylaxis. The groups were well matched. There was a statistically significant reduction in the incidence of Grade 2 and 3 heterotopic ossification in the 1999–2000 patient group.

There did not appear to be any identifiable reason for this except increased surgeon experience. The incidence in the 1999–2000 group was well below reported figures from other studies. The incidence of heterotopic ossification following total hip replacement is falling and the fall may be related to improved surgical technique.

J.M. Fielden J.M. Cumming J.G. Horne P.A. Devane L.M. Gallagher A. Slack

The purpose was to define the economic and health costs of waiting for total hip joint replacement surgery. A prospective cohort of 122 patients requiring primary hip arthroplasty (HA) was recruited from four hospitals in the lower North Island. Health related quality of life (HRQL), using self-completed WOMAC questionnaires, was assessed monthly from enrolment pre-operatively to six months post surgery. Monthly cost diaries were used to record medical, personal and other costs. Data was analysed using PC-SAS to test the strength of associations between costs and waiting times, and changes in HRQL pre- and post-surgery.

The mean waiting time was 5.2 months and mean cost of waiting for surgery was $1,376 per person per month (pp pm) with medical, personal and social costs contributing $404, $399, and $573, respectively. Waiting more than 6 months was associated with an increased cost of $730 pp pm for a total cost of $2177 pp pm (p< 0.003). Age was correlated with greater loss of income (< 65 years) (p=0.001) and higher medical costs (< 65 years) (p=0.08). An incremental improvement over time in WOMAC scores post-operatively was identified (p=0.0001). Older age (p=0.01), community services card use (p=0.003) and a greater number of months waiting (p=0.1) were negatively correlated with post-surgical improvement after adjusting for other variables. Longer waits for HA incur greater economic costs and impact on patient recovery. This lends weight to the view that a shorter waiting time for HA significantly reduces costs to individuals and society and improves health outcomes.

G. Singh E.W. Jamieson

A review of total hip replacements (THR) performed in Palmerston North between 1991–2000 has identified a group of postoperative patients in whom recurrent dislocation has been previously deemed untreatable because of medical co-morbidity. From 1998 to 2001, 47 patients underwent THR utilizing a semi-constrained “Kasselt” cup to reduce the risk of dislocation. Indications for use of this cup were: Recurrent dislocation following primary or revision THR (3 or more dislocations) or perceived greater risk of recurrent dislocation eg. elderly, mental confusion, neurological compromise or fracture neck of femur.

This paper presents the early results in these 47 patients (49 hips). Clinical records and radiographs of all hip replacement patients were retrospectively reviewed to identify the “Kasselt” group and telephone contact was made for permission to participate in the study. All living patients were sent a self-evaluation questionnaire and invitation to attend clinic for physical examination and radiographs of the hip joint. Twenty-one patients were recurrent dislocators and 24 were at risk patients. Out of 45 living patients 36 were physically examined between 6 and 36 months following surgery. All collected data was statistically analysed using StatWave software.

Results: Forty-three of the 45 living patients (47 hips) had no dislocations following surgery. Two patients suffered further dislocation, both of whom were previously recurrent dislocators. One suffered a single dislocation postoperatively which was reduced closed and to date has not re-dislocated. The second continues to dislocate. The mean postoperative Harris Hip Score in the whole group is 79 (range 49–100). Early results reveal no dislocations in the “at risk” primary group.

A.P. Oakley J.A. Matheson

Rapid bone turnover in Paget’s disease has been of concern to many surgeons performing hip arthroplasties. We present the case of a 71-year-old man with Paget’s disease affecting the proximal femur who fourteen years prior had undergone total hip arthroplasty. He sustained a fracture at the tip of the femoral component that was managed with revision total hip arthroplasty. His postoperative course was complicated by rapid and profound osteolysis of the femur distal to the fracture site, secondary to disease activity. This case highlights the need for awareness of Paget’s disease activity and this potential complication.

J.G. Horne D. Dalton P.A. Devane

The purpose of this study was to assess the incidence of pelvic osteolysis following the use of a one piece all polyethylene acetabular component a mean of 9.6 years following implantation. The radiographs of 86 hips followed for a mean of 9.6 years were reviewed. All had had primary total hip arthroplasty using a titanium plasma spray backed all polyethylene acetabular component. Radiographs were assessed for pelvic osteolysis in the three zones described by Charnley and Delee. There was no osteolysis seen in any cup in any of the three zones. There were no loose cups and no obvious cup migration. This acetabular component shows superior performance compared with all two pieced components in terms of the development of pelvic osteolysis. The use of two-piece cups should be reviewed.

M.J. Brick S. McCowan

Surgeons are becoming increasingly aware of the importance of matching a patient’s native offset during hip arthroplasty. During the course of a previous study investigating proximal femoral geometry in New Zea-landers it was noted that accurately measuring the femoral offset of a hip arthroplasty patient by traditional methods is difficult and inaccurate. The relationship of various surface parameters were studied to find a simple and reliable method for the surgeon.

Eighteen cadaver femora were skeletalised and the offset was measured using a standardised radiological technique. The femoral neck was then sectioned from a point 1–2 cm above the lesser trochanter to the base of the trochanteric fossa. The femoral head was sectioned in the coronal plane and the centre of the head located with concentric circles. The distance from the centre of the head to the most lateral spike of bone was measured. This measure was compared to the radiological offset.

Offset correlated closely with the measurement from the centre of rotation to the most lateral spike of bone provided the neck cut extends to the base of the tro-chanteric fossa. Eleven of eighteen measurements were within 2mm of true offset and fifteen were within 3mm. A simple intra-operative technique taking no longer than one or two minutes and requiring no special equipment has been devised to allow the surgeon to accurately estimate the patients femoral offset.

P.A. Devane J.G. Horne D. Hauser-Kara J. Martell H. Malchau W.H. Harris

The purpose of this study was to compare the 2D and 3D linear and volume wear readings of the three most commonly used methods for measuring polyethylene wear: the Livermore, Devane and Martell techniques. Inter-observer variation of measurements using the techniques of Devane and of Martell on conventional radiographs was also performed. The radiographs of 80 patients (mean age 60+/−10 yrs) who had a Harris-Galante I total hip arthroplasty were measured. Nine different reviewers for the Devane technique readings including Dr Devane and eight reviewers for the Martell technique readings including Dr Martell made blinded independent wear observations for each radiograph set. One reviewer measured the 20 annual linear wear rate for all radiograph sets using the 2D Livermore technique. Inter-observer variation as a function of patient, reviewer, and total variation was statistically assessed using variance component analysis. Mean wear measured using the Livermore technique was the same as with the Devane and Martell method, but with a greater variation. Comparison of the Devane and Martell method for patient STD, reviewer STD, error STD (multiple reviews of same radiographs), total STD (randomly picked reviewer), mostly show a mean 50% lower STD with the Devane technique. Correlation (correlation coefficient of two randomly selected reviewers) is significantly better with the Devane technique.

A.E. Hardy T. Lamberton

The purpose of this study was to determine whether a laminar flow operating system reduces deep infection rates in Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) and to examine the costs involved in implementing laminar flow technology. A retrospective analysis of deep infection rates in 759 patients who underwent THA and TKA was performed in one hospital prior to and after the introduction of a vertical laminar flow operating system together with the use of isolation body exhaust suits. A cost analysis was also performed on the cost of implementing laminar flow technology and the average inpatient hospital cost of managing a deep infection. A control group consisted of 387 THA and TKA performed in 2 years in a conventional operating theatre and follow up carried out to a mean of 29 months. There were 12 recorded deep infections, 3.1%. Case group consisted of 372 THA and TKA performed in 2 years after the introduction of a vertical laminar flow operating theatre together with the use of isolation body exhaust suits, with a mean follow up to 22 months. There were 4 recorded deep infections, 1.1%.

A comparison of deep infection rates yielded p value 0.06. There was a strong trend toward a reduction in deep infection rate in THA and TKA performed in the laminar flow theatre with the use of isolation body exhaust suits. The economic impact of deep infection in THA and TKA is vast and the cost of implementing laminar flow technology must be weighed against the deep infection rate as well as the number of operations performed at an institution.

G. Hooper S. Winchester

The purpose of this study was to establish whether retransfusion of blood collected in drains following total joint replacement was a safe and effective procedure. All patients undergoing a total joint arthroplasty, with no history of infection, between March and October 2001, were entered into the study. A single surgeon operated on all patients and no patient was excluded from the study. Informed consent was obtained and all blood drained into a recollection system within 6 hours of surgery was retransfused .A prospective protocol was filled out in all cases documenting the pre and postoperative haemoglobin, amount transfused and any extra transfusion requirements. A special note was made of any complications encountered during retransfusion. The results were then compared to previously known transfusion rates within the same hospitals.

There were 141 Total Joint Arthroplasties performed within the study period -12 were bilateral and 12 were revisions procedures. The average drainage was 655ml (60–3280ml) and the average amount of retransfused blood from the drains was 225ml (100–1822ml). There were a total of 9 (6.3%) subsequent blood transfusions. Four (3.8%) in primary and 5 (20.8%) in bilateral or revision procedures.

Transfusing patients with salvaged blood from the drains in total joint arthroplasty is a safe, reliable and cost effective practice, which significantly reduces the requirement for a subsequent blood transfusion. As a result of this study the Christchurch Orthopaedic Group has adopted a routine practise of retransfusing drained blood in all total joint arthroplasties.

A. Dalgleish J. Bartlett

The purpose of the study was to undertake a radiological and clinical comparison of uncemented tibial base-plate fixation with porous or hydroxyapatite coating. Knees were examined radiologically according to Knee Society Guidelines with image intensifier screening and spot films to highlight the bone prosthesis interface. Clinical assessment was performed using the Knee Society Clinical Rating.

Hydroxyapatite components were found to have significantly less radiolucent lines than porous coated. Seventy three percent of hydroxyapatite baseplates versus 28% of porous coated baseplates showed no radiolucent lines. All lucent lines in both groups appeared stable with a sclerotic margin and did not appear to be progressive or associated with component loosening. No knees showed any radiolucent lines around the stem in either group. Clinical assessment showed no significant difference between hydroxyapatite and porous coated components.

If cementless fixation is to be utilised on the tibial side in knee replacement advantage should be taken of hydroxyapatite augmentation of the component.

J.M. Fielden J.G. Horne S. Boyle P.A. Devane

Early discharge from hospital has the potential to reduce direct costs, but may result in patients being discharged without adequate preparation for a return to the community. This qualitative study aimed to investigate patient expectations of and satisfaction with in-hospital discharge planning after hip arthroplasty in early and late discharge patient groups. A prospective study of 33 consecutive patients requiring hip arthroplasty were recruited from two tertiary hospitals in the lower North Island. Participants were interviewed using in-depth, semi-structured interviews on the day of discharge from hospital and again four-eight weeks later. Comparative analysis of the interviews from patients in early and late discharge groups was made.

Findings reveal good levels of satisfaction with discharge planning for patients in both early and late discharge groups, facilitated by the opportunity to attend a pre-assessment clinic. Discharge planning was viewed as a partnership between patients and key members of the multi-disciplinary team. While written information provided was timely, restricted opportunity for dialogue with health professionals limited patient knowledge and understanding of recovery. Different needs of participants indicate that discharge planning needs to be tailored and more responsive to individuals. The role of health professionals as a mentor-coach is pivotal. Further interaction from health professionals, as a follow-up to written information provided may be a way to improve the discharge process and lead to more consistent outcomes.

P.C. Turner C.P. Williams

The purpose of the study was to determine the percentage of knowledge retained immediately following an outpatient consultation for total hip and knee joint arthroplasty, and whether any improvement in that knowledge occurred after reading an information leaflet about the operation. Patients who were placed on the waiting list for joint replacement surgery, were verbally given information during the consultation about basic operative details, post-operative programme, and potential complications. A questionnaire was completed asking them to recall these details. Information leaflets were then given to them to read. 6 weeks later they were again contacted and asked the same questions.

Immediately following a consultation, patients recall only a small percentage of information. In particular, retention of post-operative recovery time frames (51–63%), and possible operative complications (0–61 %). Despite an information booklet, their level of knowledge deteriorates from the initial consultation. Verbal and written information supplied to a patient, may be understood, but it is easily and quickly forgotten. In an increasingly medico-legal environment it is essential to gain an informed consent from a patient when performing interventions. The provision of an information booklet may provide nothing more than proof for the surgeon of information provision to the patient.

E.F. Newman

The purpose of the study was to review and present a series of early failures of the Miller Galante unicom-partmental knee replacement (UKR). Following several early failures all Miller Galante UKR’s inserted by the author (60 patients, 72 knees) were recalled for clinical and radiological review including assessment using the American Knee Society Score and the Oxford Knee Score. All knees with effusions were aspirated and specimens sent for histological analysis.

There were 22 females and 38 males with a mean age of 67 years. The mean follow up was 3.4 years. Six failures were noted with follow up from 10 months to 4 years. These 6 cases will be discussed in more detail including operative findings at revision and possible reasons for failure.

Early failure of this arthroplasty is unacceptable and caution should be exercised if contemplating using this implant unless more definite causative factors are identified.

J. Pennington R. Hill A. Bayan T. Doyle J-C. Theis

There are numerous papers from specialist arthroplasty centres outlining results of total knee replacement. This review was performed as there is little information on results in general orthopaedic centres. All patients received a Duracon/PCA replacement between 1992 and 1996. Patients were assessed clinically, fluoroscopically and completed SF12, WOMAC and IKSS questionnaires. At a mean of 6.7 (5–9) years follow up 93 (78%) were available for review. The average age was 70 years (52–88) with 58% being male. The primary diagnosis was osteoarthritis in 94.3%, with 41 %, 38% and 21 % being Charnley grades A, B and C respectively.

The average IKS knee score was 71.4 (23–96) and functional score 70 (0–100), with 72.7% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 38 (14–63) and mental score of 53 (25–67). There were 88.6% of patients satisfied with their knee and 92% would have the operation again if required. There were no deep infections or PE’s but there were 7 superficial infections and 2 DVT’s. A MUA was required in 8 patients. One patient retains a radiologically loose prosthesis at 8 years but had mild pain with stairs only, a WOMAC functional score of 85 and was happy. There was a best-case survival of 94.4% at 5 years. There were 5 knees revised in 5 patients and no revisions of the deceased patients, all surviving greater than 5 years from surgery. These results suggest that those in general orthopaedic centres are a little less reliable than those in specialist centres. However they are acceptable and patient satisfaction remains high.

J.G. Horne A.J. Worth M.R. Mucalo P.A. Devane

The purpose of the study was to assess the incorporation of defatted, and deproteinated bovine cancellous bone in a sheep bone graft model. Cylindrical defects were created in the femoral condyles of 12 sheep using custom-made trephines. The defect was filled with a cylinder of prepared bovine bone. The removed cylinder of bone was implanted into a defect created in the opposite femoral condlyle. Fluorochrome bone labels were administered over an 8-week period and the sheep sacrificed at 10 weeks. Undecalcified thin bone sections were viewed with a fluorescent microscope.

ln one sheep there was a technical problem leading to unsatisfactory histology. All other sheep showed similar histology. The autograft incorporated rapidly with the graft showing a rim of reactive bone and the graft itself showing rapid laying down of new bone on its surface. The xenograft showed a similar reactive rim of new bone with deposition of new bone throughout the graft and resorption of the graft material.

This study demonstrates that specially prepared bovine cancellous bone can act as a scaffold for the depostion of new bone in a sheep model. The role of this material in humans is to be evaluated.

E.C. Shors

Autologous growth factors or AGF is a technology that uses the patient’s own platelets as a source of growth factors. The platelets are super concentrated and then de-granulated to release mitogens, such as TGF-beta, PDGF, IGF, FGF and VEGF. AGF can be used alone as a source of signaling factors or it can be used with a variety of bone grafting materials, including autograft, allograft or porous ceramics. AGF is advantageous because it is completely autologous and obtained at the point of care in the operating room. AGF has been shown to be successfully collected by pheresing or separating the whole blood into its components to capture the buffy coat (i.e., platelets and white cells) using a conventional cell washer. To assure a predictable two to four fold increase in platelets and white cells over the peripheral blood concentration, the operator of the cell washer must follow a defined protocol. The buffy coat is then transferred to a processor containing an ultra concentrator. This achieves a further three fold concentration of platelets and white cells, as well as a three fold concentration of fibrinogen. This process can be effectively achieved using a single unit (approximately 450cc) of blood which produces approximately 60cc of autologous growth factors (AGF). The excess plasma and red cells can be returned to the patient.

We have developed as self-contained, electromechanically, software driven, turnkey device that separates and concentrates to produce AGF from as little as 100 cc of the patient’s whole blood. The device is the size and weight of a portable, tabletop clinical centrifuge. A single disposable, pre-sterilized cartridge is inserted into a centrifuge and automatic pumps. After the operator attaches the blood bag and provides minimal input, the machine automatically provides 10–15 ml of AGF. Total processing time is less than 15 minutes. Multiple, simultaneous cycling can process up to 450 ml of blood with operating times comparable to our contemporary system. Using human blood, the concentrations of platelets, white cells, and fibrinogen was comparable to the contemporary system. The AGF platelets were then de-granulated into a fibrin gel using either xenogenic or autologous thrombin. Consequently, the concentrations of TGF-beta, PDGF, IGF, FGF and VEGF were approximately 10 fold greater than blood levels and comparable to the separate component system.

We believe that we have developed a method and device that safely, simply, cost-effectively produces intra-operatively clinically relevant levels of autologous growth factors from 100 ml of autologous blood.

A. Edwards I. Dingwall

This paper suggests that bone-cement interlocking is superior when the cut surfaces of the bone have been prepared using pulsed lavage with saline prior to application of cement and the prostheses during total knee joint arthroplasty.

The aim is to put the case forward for the inclusion of the question whether or not pulsed lavage was used on the National Joint Register questionnaire. This will then in course give guidance as to whether there is an improved outcome when pulsed lavage was used or whether it is a waste of resources.

Review of the 6-month postoperative films of the total knee joint replacements of two senior surgeons was carried out in 1996. Both surgeons use the Genesis total knee system. Surgeon 1 uses pulsed lavage routinely, and surgeon 2 does not. This is the only difference in their techniques. There have been no early aseptic failures in either group at 5 years. A lucent line was consistently seen between the bone-cement interface when pulsed lavage was used. Furthermore, the depth of the cement mantle on the tibia was greater in the pulsed lavage group. We suggest that the use of pulsed lavage at the preparation of the cut bone surfaces before the application of the cement and prostheses improves the bone-cement interface. The significance of this finding is uncertain, but a case can be made for this question to be included in the National Joint Register questionnaire.

E.C. Shors

Tissue engineering is founded on the principle of pro-actively manipulating the triad of tissue regeneration. The triad consists of matrices, pluripotential cells and signaling factors. Our hypothesis is that advances in orthopedic surgery to successfully regenerate bone are accomplished by incorporating optimised matrices into the surgeon’s armamentarium.

Pro Osteon is a bioactive ceramic matrix with interconnected porosity. It has been evaluated in experimental animals and used clinically as a bone graft substitute for more than two decades. It is available in slowly resorbable form composed of hydroxyapatite and as a more rapidly resorbable composite of calcium carbonate and calcium phosphate. Experiments have been conducted in sheep, rats and dogs to demonstrate consistent and predictable bone regeneration when the implant is placed in direct apposition to host bone, the host bone is viable and the interfaces between the bone and implants are biomechanically stable. Most importantly, controlled, multi-center clinical trials showed consistent efficacy and safety in humans. Either as a block or granules, Pro Osteon is biocompatible and osteophilic and osteoconductive. Bone regeneration, as demonstrated radiographically and histologically, occurs directly within the porous ceramic in traumatic defects and tumors. Where surrounding viable bone or mechanical stability is inadequate, such as posterior spinal fusion, the ceramic must be co-mixed with autograft. For indications where autograft is limited or unavailable, bone regeneration within the porosity was enhanced and fusion achieved by supplementing Pro Osteon with bone marrow and/or with growth factors. This was demonstrated experimentally and clinically. Mitogenic and/or morphogenic growth factors were demonstrated to increase the rate or degree of bone formation. Methods and equipment for intra-operative collection of concentrated platelets were shown to be a cost-effective and safe source of autologous mitogens. Using a variety of ectopic and orthotopic animals models, we have shown that autologous, purified xenogenic and recombinant growth factors will bind to the surface of Pro Osteon and initiate or stimulate the bone induction process.

In conclusion, Pro Osteon is an effective matrix for bone formation. It can be used alone or it can be used in combination with pluripotential, osteogenic stem cells or with signaling proteins.

R.P. Pitto M. Schramm D. Hohmann

The purpose of this study was to evaluate the long-term clinical and radiological results of patients with hip dysplasia who underwent spherical acetabular osteotomy. The surgical technique used was that described by Wagner.

The first 26 unilateral spherical osteotomies performed by one surgeon at one institution were reviewed at a minimum clinical follow-up of 20 years (median 23.9, maximum 29 years). One patient had died 5 years after the index operation unrelated to the procedure. Three patients (3 hips, 11 %) could not be traced. Preoperative and follow-up radiographic measurements included lateral and anterior centre-edge angle, acetabular index angle, and acetabulum-head index of Heyman and Herndon. Antero-posterior radiographs of the pelvis were evaluated for the presence of joint congruency, joint space narrowing, increased sclerosis of the subchondral bone, and bone cysts.

Osteotomy improved the mean lateral centre-edge angle from −20 to +130, and the acetabular head index from 52% to 72%. The mean postoperative anterior centre-edge angle of Lequesne and de Seze was 23 (range: −10 to 62). Seven of 22 hips (32%) needed conversion to total hip replacement. The average Harris hip score at latest follow-up of the remaining 15 hips was rated 86 points (range: 50 to 100 points). Overall, 11 of the 15 hips were clinically rated good or excellent. On latest follow-up severity of osteoarthritis was unchanged in 13 of 15 hips. Only 3 of 9 hips requiring conversion to total hip replacement or showing progressive osteoarthritis were rated congruent after the index operation. On the other hand, 10 of 13 hips not requiring conversion to total hip replacement or progressive osteoarthritis were congruent. The 20-year-follow-up Kaplan-Meier survival estimates based on conversion to total hip replacement as an end point was 86.4%. (95% confidence interval: 63.4% to 95.4%). The 25-year-follow-up survivorship was 65.1 % (95% confidence interval: 35.6% to 83.7%).

The long-term results of the spherical osteotomy are satisfactory from the standpoint of both improvement in clinical condition and the radiological appearance of the joint. The Wagner spherical osteotomy had prevented progression of degenerative changes in 13 out of 22 hips (59%) after a median 23.9 year follow-up. Congruency of the joint seems to be a major factor predicting long-term outcome.

P. Blyth J.W. Fernandez S.F. Thrupp I.A. Anderson

A procedure is presented which allows the efficient production of a patient specific computer model of the femur, for surgical planning. Similar models require long processing times and/or high performance computing.

The method uses 24 key landmark points to customise a generic femur to patient data, using a desktop computer. By using non-linear elements a smooth, curved surface is obtained. A finite element mesh of a generic femur consisting of 384 elements was created using the analysis software CMISS (Bioengineering Institute, University of Auckland). A rectangular shaped host mesh was defined to enclose the generic femur. Datasets of 5 human femurs were obtained using a hand-held laser scanner on dry bones and the visible human dataset. Key landmark data points were selected on the generic femur along with corresponding target points on each data set. The host mesh was then deformed using a least squares algorithm, causing customisation of the generic femur to the patient specific model. Each customised model was compared with its entire dataset. The fitting process took less than 100 seconds on a 180 MHz 02 computer (SGI, CA, USA). The algorithm yielded an average root mean square (RMS) of 3.09mm with a standard deviation of 0.15mm. Operator time for positioning the projection points was less than 5 minutes.

This paper presents a novel means for customisation of human femoral geometry with generation of patient specific models on a PC from scan data in under 10 minutes. Current work is focusing on stress analysis, surgical simulation and planning.

H.A. Crawford J. Hicks

We have prospectively followed 18 patients having an opening wedge high tibial osteotomy for medial compartment osteoarthritis of the knee using the Puddu plate and autologous bone graft. The purpose was to assess the learning curve involved in the introduction of a new procedure and to follow its long-term success. Ethics committee approval was obtained.

Eighteen consecutive patients (4 female, 13 male, 1 bilateral, average age 47), operated on by 5 different surgeons were assessed pre-operatively using the American Knee Society knee and function scores and SF-36 health questionnaires. Radiographs were assessed using the Ahl-bach grading system for severity of degenerative change and the long-leg mechanical axis was measured as a percentage of total joint surfaces from the medial side.

Pre-operatively patients had an average Ahlbach score of 1.8 (range 1–3, mode 2). The long-leg mechanical axis average was 14.7% (range 3.75–27.5%), American Knee Society knee score average was 49.2 (range 28–64) and function score average 58.4 (range 40–70). By six weeks post-operatively all patients had at least 90 degrees of flexion and pain of less than 2 out of 10. There have been five complications: 1 deep infection requiring admission for intravenous antibiotics, 2 superficial infections requiring oral antibiotics only, and 2 intra-operative fractures, both internally fixed at the time of surgery. At follow-up of minimum 12 months the average mechanical axis was 50.6% (range 32–64%), Knee Society score 79 and function score 82.

These early results suggest that despite some complications this procedure is weII tolerated and gives good functional results.

J.A. Rietveld P. Armour

Surgical dislocation of the hip joint using the technique developed by Rheinhold Ganz, is a relatively new method for surgical exposure of the hip.

A review of 8 cases that underwent surgical dislocation of the hip joint was undertaken, to assess the short term outcome, complications associated with the procedure and to identify some of the indications for this technique. This is a retrospective analysis of surgical dislocation in two centers undertaken by the same surgeon with a maximum follow up period of one year.

Surgical dislocation of the hip allows access to the hip joint with some associated morbidity due to the surgical exposure but there were no cases of avascular necrosis in the short term follow up.

We were able to define specific pathological conditions affecting the hip where there is significant improvement following treatment using this method of exposure of the hip joint. Good exposure of the hip joint is obtained via surgical dislocation so allowing good access for surgical intervention.

There is an associated morbidity with the technique but this method of hip exposure allows an alternative to hip arthroscopy and allows easier access to the joint for the treatment of intra articular pathology.

D. Schluter P. Armour I. Penny J. Rietveld D. Walton

Since 1989 the Ganz periacetabular osteotomy has been performed in Christchurch for pain arising from hip dysplasia in selected patients. This review was performed to assess symptoms, function and radiographic appearances at a medium term follow up.

The results of 14 peri-acetabular osteotomies performed in 13 patients was evaluated. The mean age of the patients at the time of surgery was 23 years (range 17–44). The mean duration of follow up was 5 years (3 months to 13 years). The follow up examination included clinical evaluation, chart review and radiographic analysis. Of the 13 patients evaluated, improvement in pain was achieved in 12. One required a hip replacement and intermittent discomfort was noted in 3 resulting in restriction in activites. Complications included sciatic nerve palsy (1), leg length discrepancy (2), superficial wound infection (1), scar tenderness (2), numbness in lateral femoral cutaneous nerve distribution (5) and pain from prominent metalware (1). Improvement in femoral head coverage was seen in all patients on follow up x-ray with minimal progression of arthritic changes. Improvement in symptoms ranging from complete relief of pain and participation in high intensity sporting events to intermittent discomfort was achieved. One failure occurred requiring arthroplasty. Significant complications occurred but have largely resolved.

The osteotomy was successful in obtaining good relief of symptoms and has prevented the requirement for total hip replacement in this young active group.

M. Foster M. Hanlon S. Stott S. Walt

The purpose of the study was to evaluate the functional outcome of different limb salvage procedures for osteosarcoma about the knee.

A selection of patients who have undergone limb salvage procedures for osteosarcoma about the knee were invited to join the study. Medical and operation notes were reviewed along with recent radiographs of the involved limb. Patients completed the Musculoskeletal Tumour Society functional questionnaire and underwent a gait analysis assessing walking and running. Most patients had stage 2B osteosarcoma involving either the proximal tibia or distal femur. Limb salvage procedures included arthrodesis, allograft reconstruction, endoprosthesis and rotationplasty.

All patients scored highly (> 70 %) on the MSTS questionnaire except the arthrodesis that scored 57 %. The gait analysis revealed some subtle changes with a quadriceps-sparing gait in the endoprosthesis, mild foot drop in the proximal tibial allograft and a lateral lean of the trunk over the ipsilateral limb in the rotationplasty. The arthrodesis had an obvious straight leg gait with subtle pelvic hiking to assist foot clearance. While analysis of walking was close to normal most patients were unable to obtain a double float and run.

This study shows that limb salvage procedures tailored to each individual case can result in an excellent functional outcome with close to normal gait and high MSTS scores.

P.C. Turner G. Hooper

The purpose of the study was to assess the use of the Internet for medical information, both in the Orthopaedic Outpatient population, and in practicing Orthopaedic Surgeons in New Zealand.

To identify any potential sites that may be of use to the patient in gaining reliable information on their orthopaedic problem. 300 questionnaires were distributed to Orthopaedic Outpatient Clinics (Public Trauma, Public Elective, and Private) in Christchurch. Each clinic had 100 questionnaires. A second questionnaire was sent out to all Orthopaedic Surgeons currently practising in New Zealand. A literature search was also performed.

Overall 18% of patients use the Internet to look up medical problems. Internet use was highest amongst the younger population. 68% of patients had a computer at home. 52% of patients thought recommended Internet sites would be useful. 91 % of patients stated they used their Doctor as their most common source of healthcare information, with only 5% stating the Internet. 76% of Orthopaedic Surgeons used the Internet for work purposes. 54% thought that the Internet misinformed patients. Only 50% of surgeons had accessed the NZOA web site.

The Internet is becoming an increasingly common source of healthcare information for patients and doctors. The NZOA site has huge potential for both surgeons and the public with regard to useful links. At present this site is largely under-utilised.

R. Davidson P.A. Devane J.G. Horne

The aim of this study is to identify specific risk factors for developing haemophilia related orthopaedic complications and to provide a qualitative and quantitative analysis of the orthopaedic management of haemophilia complications.

A postal survey was sent to 48 patients on the Wellington region haemophilia database. The questionnaire covered both qualitative and quantitative questions covering the participants’ current condition and treatment, past and present orthopaedic and non-orthopaedic management, support, education, employment and leisure activities.

Twenty-five patients returned the questionnaire, a response rate of 52%, Most of the participants (68%; 17/25) felt that their education had been compromised as a result of haemophilia complications. Of those participants that were 16 years or older, 68.4% (13/19) felt that their working opportunities had been compromised as a result of haemophilia complications. Despite patients less than 18 years of age receiving prophylactic Factor VIII replacement (n=7) and all patients having Factor VIII available on demand, 18 patients had significant bleeds in the previous 6 months. Most bleeds were into joints, 13 knees, 13 ankles, 12 elbows, 6 shoulders and 3 hips, but a significant number of intra-muscular bleeds (n=22) also occurred. There were 62 painful joints reported by 19 patients, the ankle being most common (n=21), followed by hip (n=13), elbow (n=12), and knee (n=8). Twenty orthopaedic operations were described by 8 patients, mainly knee (n=6) and hip (n=3) replacements, and synovectomies (n=6). Discussion.

Despite good medical management, recurrent joint bleeds are a major problem in haemophilia. Many study patients commented that orthopaedic procedures were not performed readily enough, and that by the time they received their operation, their function had deteriorated significantly.

W.G. Atherton R.O. Nicol

The purpose was to review the results of latissimus dorsi and teres major transfer in a group of children with shoulder disability due to brachiaI plexus palsy. Whilst their incidence has steadily declined, obstetric brachial plexus palsies are a continuing problem in paediatric orthopaedic practice. Lesions of the upper plexus (C4, C5, C6) are characterised by a loss of abduction and external rotation at the shoulder. The L’Episcopo procedure and its variants aim to address this by transfer of the latissimus dorsi and teres major. There have been conflicting reports in the literature as to the functional benefit of such procedures.

A retrospective review of such procedures performed by one surgeon at a paediatric orthopaedic tertiary referral centre in New Zealand. Patients were assessed pre- and post-operatively in terms of range of movement and function. The Mallet scoring system was also used. Eight patients were examined by an independent observer up to 120 months following surgery (average 52 months). In most cases significant increases in range of movement, function and Mallet scores were noted. With regard to complications, where the paresis is severe to the extent that it is causing shoulder subluxation, tendon transfer surgery is contra-indicated.

The L’Episcopo procedure was largely successful in restoring improved function to the shoulder girdle in this group of patients.

D. Schluter G. Hooper

Despite a variety of reports to the contrary it was felt by the Christchurch Orthopaedic group that the “wait” on the orthopaedic waiting list has been escalating rapidly to the point that a routine operation is now in the order of approximately 3 years from the time of GP referral.

A review of the time taken for GP referrals to be assessed by an Orthopaedic Surgeon was undertaken. The waiting lists from October 98 to May 02 were analysed, in addition to the operation outputs from the Burwood Hospital elective theatre records over the same period. Time taken from referral to be seen, time taken from been placed on the waiting list to receive an operation and volume of elective procedures were evaluated. A breakdown was made of those removed from the list vs those operated on. A major reduction in the waiting list over the last three years was secondary to 1/3 of the people on the list (1177) been “culled”. This was initiated in January 1999 and completed by January 2001. Since January 1999, 2538 patients had received their operations. The waiting list had dropped from 3303 to a low of 1164. It has since climbed to 2036. That waiting longer than 12 months for surgery, initially 64%, had dropped to 29% and has climbed back up to 40%. The figures have climbed dramatically since the waiting list initiative for arthroplasty was discontinued. The culling of the list has been responsible for removal of 1/3 of people off the original list without having an operation and has given a false sense of success in reducing the waiting list to various political interests. The criteria set for culling people assessed as requiring an operation has been set arbitrarily There is twice the number of patients waiting to see an orthopaedic surgeon than 2 years ago of which a proportion are requiring reassessment to be deemed eligible for an operation that they have already been assessed as requiring.

The waiting list initiative was effective as an addition to the regular DHB lists in maintaining the lists at a manageable level. Even if all those culled represented a group that no longer required their operation the current list cannot be considered to have such a group as they have all been recently reviewed and are in genuine need. There is an apparent lack of concern and denial over the current escalation in the numbers on the waiting list, and no plan instituted to address it.

A.G.S. Vane D.P. Gwynne-Jones J.D. Dunbar J-C. Theis

The purpose of this study was to audit screening and treatment programmes for Developmental Dysplasia of the Hip (DDH) over a 12-year period from 1989 to 2000 with respect to late presentation and treatment rate and duration.

All babies born in Queen Mary Hospital are clinically screened for DDH by a consultant orthopaedic surgeon. Unstable hips are treated by Pavlik Harness and attend an ultrasound clinic run by an orthopaedic surgeon within 2 weeks. High-risk babies or those with suspected instability can also be referred for ultrasound. Serial ultrasound exams assisted with determining the duration of splintage. Radiographs are taken at 4 to 6 months. Late presenters were identified and analysed.

Over the 12-year period 13 cases of late presenting DDH were identified (0.6 per 1000). Half of these had not been screened. None had ultrasound screening. Our treatment rate was approximately 4 per 1000 live births.

Our screening programme can be improved by increased capture of patients for clinical screening. Ultrasound is a useful tool in managing neonatal hip instability allowing duration of splintage to be tailored to the individual and allows early detection of treatment failure.

J.S. McKie

CPT is a rare disorder often leading to multiple surgical procedures in an attempt to achieve union but frequently ending in amputation.

The author presents a personal series of four cases (ages 3 + 4, 3 + 4, 4 + 3, 7 + 9 years) three of which had had a total of ten previous procedures. All patients underwent removal of previous fixation, excision of the abnormal periosteal tissue, freshening of the bone ends and “ram rodding” together under compression with the application of an lIizarov frame. A separate proximal osteotomy was performed for lengthening. The non-union was grafted primarily at the time of fixator application. Following frame removal a custom made telescopic nail was inserted in the three most recent cases. Average frame time was 263 days (184–301). All four cases have healed primarily and remain healed (19, 28, 31 and 70 months) post frame removal. The case not treated with a nail underwent bending of the proximal regenerate bone and required a second osteotomy to correct the deformity. Other than pin infections managed by antibiotics and local cares, the only other complication was the backing out of a cross-locking wire from the IM nail which required reinsertion.

The use of the llizarov frame enables a radical excision of pathological tissue and rigid compression of the non-union with concurrent restoration of limb length. The telescoping rod that is locked in the epiphyses proximally and distally enables normal rehabilitation of the joints without the need for prolonged bracing. The ongoing success of this treatment has encouraged the author to recommend it as the primary management for established congenital pseudarthrosis of the tibia.

T. Bidwell N.S. Stott

Prophylactic pinning of the contralateral hip remains controversial in the management of unilateral SUFE. This paper reviews our experience, with particular reference to the fate of the non-operated hip.

We reviewed the charts and radiographs of 218 patients who were admitted to Starship Children’s Hospital between 1988 and 2000 with a diagnosis of SUFE. Of the 211 patients with data sufficient for analysis, 168 (80%) had unilateral hip pinning and 43 (20%) had bilateral pinning. 32.8% of patients with a unilateral slip were subsequently readmitted for pinning of the contralateral hip. The time between the two operations averaged 7.5 months and did not vary with race or gender. European females had an almost 50% readmission rate for pinning of the opposite hip while Maori females had the lowest readmission rate (15%). All European females less than 11.5 years with unilateral slips returned for pinning of the opposite hip. 28 of the initial unilateral hip pinnings were for an unstable SUFE. Only 8 of the 28 patients were readmitted for pinning of the opposite hip, all with stable slips. Only one patient with a stable first slip presented with an unstable second slip.

Despite a high incidence of bilateralism, this study shows that it is very uncommon for a patient to present with an unstable second slip. Prophylactic pinning can have complications. We therefore recommend follow-up rather than prophylactic pinning for patients presenting with unilateral SUFE. Caucasian females less than 11.5 years represent a group at high risk of a second slip.

H.A. Crawford R. Rowan

This prospective study was designed to audit the introduction of this new technique for the treatment of club-feet in New Zealand. Although well proven in Iowa, USA the Ponseti Technique has rarely been practiced outside of this state.

Fifty feet in 32 consecutive patients have prospectively been followed since September 1999. All the patients have been treated by one surgeon in an identical fashion to that described by Dr Ponseti. The only difference was that the percutaneous tenotomies were preferentially performed under a general anaesthetic. Twenty four feet have had a detailed radiographic analysis as well. There have been 2 patients lost to follow-up. Twenty three patients were of Maori or Polynesian ethnicity. The pre treatment Pirani score averaged 5.0. The first cast was usually applied within 2 weeks of birth and the average number of casts was 6.0. The Achilles tendon tenotomy was not preformed in 4 feet. The mean follow-up Pirani score was 0.5. Four feet in 2 patients have required posteromedial release at 11 months of age. One patient has required a tibialis tendon transfer at 2 1/2 years of age. There have been minor skin complications from the boot wearing. The compliance with boot wearing is low with more than 50% of the patients wearing them less that 50% of the prescribed time.

The Ponseti Technique demands attention to detail if it is to be successful. These excellent early clinical and radiographic results support this method of treatment for idiopathic talipes equinovarus. Our concern is the long-term outcome in the patients with poor boot wearing compliance.

N.S. Stott S.E. Walt G.L. Lobb R.O. Nicol N. Austin

The purpose of the study was to document the outcome in adulthood of treatment for idiopathic toe walking.

Twenty of 23 adults who had been previously treated for idiopathic toe walking from 1984 to 1990 were contacted. Three of the 20 subjects lived outside Auckland and four subjects declined to participate, giving a total of 13 subjects suitable for study. All but one of the subjects had had serial casts between the ages of 3.7 to 9.5 years. Six subjects had no further treatment while the other seven subjects went on to surgical lengthening of either TA or calf (average age 10.7 years). All participants underwent 3-D gait analysis and heel-rise test. Average follow-up was 10.8 years (range 5.4–15.6 years). Three patients still had signs of toe walking on visual observation of their gait. The maximum ankle dorsiflexion in stance averaged 90 on 3-D gait analysis (range 20 to 140). Eleven subjects showed maximum ankle dorsiflexion in stance greater than 2 standard deviations below normative values. Nine subjects had abnormal timing of maximal ankle dorsiflexion in stance with maximum ankle dorsiflexion prior to 50 percent of the gait cycle. Only two patients had ankle push off powers below normative values of 2 watts/kg.

This is the first study to report on adults treated for idiopathic toe- walking as children. Most subjects showed restricted range and altered timing of ankle dor-siflexion in gait, however this was detectable visually in only three subjects.

A. Dalgleish

The purpose of this report was to describe a new arthroscopic finding in anterior cruciate ligament rupture: the presence of osteochondral injury beneath the posterior horn of the lateral meniscus.

A single surgeon performed arthroscopic evaluation of 43 consecutive patients with ACL rupture within 12 months of injury. Nine patients (21 %) had a chondral lesion of the posterolateral tibia beneath the posterior horn of the lateral meniscus, not seen unless the meniscus was elevated with the arthroscopic probe. On four occasions a chondral loose body was identified and removed. Seven of the nine (78%) had an associated lateral meniscal tear and four (44 %) a chondral lesion of the lateral femoral condyle. MRI was not accurate in predicting the presence of a chondral lesion in those patients with a lesion that had an MRI preoperatively. We report a new arthroscopic finding in ACL rupture not previously mentioned in the literature. The clinical significance is that when chondral loose bodies are encountered of unknown origin, arthroscopic evaluation of the area beneath the posterior horn of the lateral meniscus should be involved in any systematic search for the lesion.

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B. Tietjens

To describe a simple effective technique of opening wedge tibial osteotomy for the treatment of recurvatum (hyperextension) instability of the knee. Recurvatum instability of the knee occurs in patients with pathological hyperextension. There are three patterns of recurvatum instability:-

Acquired bony deformity of the proximal tibia (growth plate arrest or fracture malunion)

Pathological laxity of the posterior capsule of the knee. This may occur without damage to the cruciate ligaments.

A combination of bony and soft tissue pathology

All three patterns are best treated by an opening wedge tibial osteotomy at the level of the tibial tubercle. A simple surgical technique is described that does not require detachment of the tibial tubercle. The necessary degree of correction is easily assessed clinically during surgery. The technique has been used with success in 8 patients. The Puddu tooth plate provides ideal fixation. Iliac crest cortico-cancellous wedge bone grafts have been used in all cases.

E. Hohmann P. Brucker A.B. Imhoff

Large osteochondral defects are difficult to treat, but several treatment options are available. The posterior condyle transfer salvage technique described by Wagner in 1964 and Imhoff in 1990 has been developed further and is now used for coverage of large osteochondral defects in the load-bearing zone. The new technique is called MEGA-OATS.

From July 1999, 25 patients of mean age 33.3 years (17 to 60) were treated with MEGA-OATS. Thirteen patients additionally underwent high tibial osteotomy and two bone grafting, using bone harvested from the proximal tibia. The mean follow up was 17.8 months. The technique calls for excision of the posterior femoral condyle which is placed in a specially designed work station. A MEGA-OATS cylinder of diameter 20 mm to 35 mm is prepared and, using the press-fit technique, grafted into the prepared defect zone. The Lysholm score increased postoperatively from 66.33 (49 to 71) to 87.8 (72 to 97). Three months postoperatively control MRI showed incorporation of all cylinders. Between six and 12 weeks postoperatively patients attained a full range of motion and became fully weight-bearing. To date one superficial infection resolving on oral antibiotics and two cases of arthrofibrosis four months postoperatively that required arthroscopic release were seen. No postoperative meniscal lesions of the posterior horn have been observed.

MEGA-OATS achieves a congruent reconstruction of the articular surface in the load-bearing zone of the femoral condyle. We consider it a good alternative in the treatment of large osteochondral defects of the femoral condyle in young patients.

E. Hohmann A.B. Imhoff

It is suggested that there is a link between arch type of the foot and overuse injuries. The use of individual selected running shoes can reduce running injuries substantially. To select the correct shoe the runner needs to have appropriate knowledge of his own foot anatomy and biomechanics. A questionnaire was used to investigate the knowledge of the runner about his arch height and biomechanics of running. Clinical examination was performed by 5 orthopaedic surgeons and experienced orthopaedic technicians. Weight-bearing podograms were used to further define the deformity.

We examined 92 volunteers with a mean age of 35.4 (12–63) years, a mean size of 176 cm (154–195) with a mean body weight of 70.38 kg (45–95). Eighteen out of 47 runners with a flatfoot deformity identified their deformity correctly. Twenty five out of 43 volunteers with a normal arch were correct in assessing their foot. Two runners with a cavus foot were correct in identifying their foot. Only 4 out of 38 runners that diagnosed themselves as being pronators have been found to be pronators. Four runners with a self-diagnosed non-pro-nating foot were classified as being pronators. Three runners that could not classify themselves were diagnosed as pronators.

This study demonstrates the poor knowledge of foot deformities in the running community.

S. Faraj H.A. Crawford M.J. Barnes

The purpose was to compare the results of two different surgical techniques in the treatment of severe cerebral palsy scoliosis.

This is a retrospective review of 12 consecutive cerebral palsy patients with scoliosis greater than 90 degrees undergoing simultaneous anterior and posterior spinal fusion. The clinical notes were reviewed along with sequential radiographs. Twelve patients were operated on between March 1997 and October 2001. There were 6 patients who had anterior release and fusion followed by posterior fusion from T2 to the sacrum using the Luque-Galveston technique. (Group 1). The other 6 patients had identical surgery but with the addition of anterior instrumentation as well. (Group 2). There was no loss of fixation or metalware failure. There was no pseudarthrosis. One patient died at the time of rod removal for infection 2 years following their index operation.

These results show that a good outcome is achieved in this group of severely affected cerebral palsy patients using either of the techniques described. The addition of anterior instrumentation may make the surgery easier and was not associated with significant increase in complications.

H.A. Crawford J. Ferguson M.J. Barnes

This is an outcome study of patients with spina bifida treated for scoliosis by anterior and posterior spinal surgery at the Starship Children’s Hospital.

The clinical notes and radiographs were reviewed of all spina bifida patients with scoliosis undergoing surgery between January 1991 and January 2001. In addition all patients were sent the Spina Bifida Health Related Quality of Life Questionnaire (HRQOL) and the Spina Bifida Spine Questionnaire (SBSQ). There were 19 consecutive patients with an average age at surgery of 13 years 5 months. Four patients had both anterior and posterior instrumentation. 14 patients had staged procedures.

There was an overall improvement in scoliosis of 61% and pelvic obliquity of 70% at latest follow-up that averaged 60 months. The major complications included 4 deep infections and 2 pseudarthroses. The patients scored an average of 68.8 on the SBSQ. The average score for 5–12 years old was178 and for 13–30 years old, 163, on the HRQOL questionnaire. There are good radiological results with combined anterior/posterior surgery in this group of spina bifida patients. Quality of Life does not seem to be greatly compromised in the operated spina bifida patient.

We recommend early single stage anterior and posterior fusion for these patients before the curve becomes too large and stiff.

J.M. Pennington K. Stewart Julie Hunt J-C. Theis

Magnetic Resonance Imaging is increasingly utilised for the assessment of knee pathology. The aim of this study was to review our entire knee MRI scans and to assess the accuracy of diagnosis when compared with operative diagnosis. Using data from the radiology department and medical records (public and private) all patients having knee MRI scans in a 6-year period were identified.

There were 956 scans performed on 930 patients. Scan diagnosis, operative diagnosis and diagnostic accuracy were assessed. Of the scanned patients 181 (19.5%) had normal scans and of these 168 (92.8%) were accurately diagnosed as normal. The remaining 749 (80.5%) had an abnormality noted on scan and of these 298 (39.8%) proceeded on to surgery. Of those patients having surgery, diagnosis at surgery was found to exactly match the results of the scan in 163 (57.0%) patients. Furthermore 51.5% of patients with a diagnosis of meniscal degeneration by scan actually had a meniscal tear at operation. However the sensitivity for diagnosis of ACL tears was 89.0% and that of medial meniscal tears was 90.6%.

MRI diagnosis is far from infallible and clinicians should be conscious of its limitations. However it is particularly reliable in confirming the lack of pathology within a knee with an accuracy of 93%. It also has high sensitivity for diagnosis of ACL and meniscal tears.

M.J. Sherwood P.A. Robertson A.T. Hadlow

Lumbosacral dislocation injuries are rare. Severe trauma disrupts the mechanically stable lumbosacral junction, rendering the injuries particularly unstable. Aggressive surgical management has been recommended. We present a review of our experience with these uncommon injuries defining injury patterns, surgical strategies and outcomes.

Six patients were treated at Auckland Hospital in the last decade. Thorough review and literature search were performed to revise recommendations for management. All injuries were associated with high-energy trauma. In two cases there was evidence of previous spondylolysis, with dramatic progression after injury. All cases were surgically treated with decompression, reduction as indicated, and fusion with instrumentation. The only instrumentation failure occurred when reduction reconstituted disc height without attention to reconstruction of the severely mechanically compromised intervertebral disc. Satisfactory recovery of nerve root injury occurred in all but one case. Major cauda equina damage did not occur. Correlations with previously described classification systems for this injury were poor, and often showed injuries to span grades. These highly unstable injuries require a high index of suspicion, and aggressive surgical management of these highly unstable injuries is warranted, yielding satisfactory outcomes.

Existing classification systems are of little value prognostically, or in planning treatment, and it is better to classify and treat these injuries specifically relating to the anatomical injury patterns. The severe disruption to the intervertebral disc warrants special consideration with attention to a stable reduction position or three-column reconstruction. Spondylolysis may represent a predisposing factor.

Full Access
A.T. Hadlow

In the first half of 2000, the Auckland District Health Board was not effectively meeting the Government’s Elective Waiting Times. The Auckland Hospital Orthopaedic Department was initially targeted as it had one of the worst high profile examples given by the Ministry of Health of non-actively managed waiting list and FSA (First Specialist Assessment) process. In September of that year at Auckland Hospital 224 patients were waiting longer than six months to be seen and a number of spinal referrals were waiting up to two years.

An Elective Service Project Team was established to place proactive resources to meet the governments’ objectives. A prospective study enlisting all referred patients seen at the spinal clinic was undertaken to determine those patients who subsequently became surgical candidates. The nature of the GP referral in terms of accuracy of urgency, status of the patient at clinic, diagnosis, need for surgery, need for investigation, and finally the patients decision about surgical options were recorded. Concurrently a working party composed of spinal surgeon, clinic staff, hospital GP liaison staff, GP’s, and management was co-ordinated, to develop guidelines for the local GP’s, with the intention of allowing GP’s to better identify those patients who would benefit from referral. Subsequently we liased with the pain clinic to develop a treatment program for those patients who would not be seen by an orthopaedic surgeon, so that their individual problems would be addressed to their satisfaction, and that of the referring GP. A Primary Care Management Guide was also produced for the GP’s.

The FSA time has been significantly reduced. Patients have responded positively. We are now able to safely screen patients from referral letters to a back pain management programme and review those at the orthopaedic spinal clinics who are most likely to require surgery so as to maximise the utilisation of resources and to provide better care.

A.T. Hadlow R.E. Willoughby

The purpose was to present a case of cauda equina entrapment in a lumbar burst fracture with associated lamina fracture and to review the literature and assess the appropriateness of current practices for cauda equina decompression. Reported incidence of cauda equina entrapment in the lamina fracture of lumbar burst fractures is 13–17%. Anterior surgery alone for decompressing the cauda equina in patients with lumbar burst fractures and associated lamina fractures will not always address the problem. We therefore suggest that posterior exploration may be the preferred approach if the aim of surgery is to decompress the neural elements.

J.A. Rietveld

The use of PMMA cement vertebroplasty for the treatment of severe disabling focal back pain as a result of osteoporotic compression fractures is well established. However clinical experience of this treatment is limited in New Zealand. This study reports a technique and indications for this treatment and early clinical results.

A prospective study of eight cases of severe disabling focal back pain due to osteoporotic compression fractures was undertaken. These were treated with percutaneous transpedicle vertebroplasty. The patient’s pain was assessed before and after the treatment using a visual analogue pain scale. All eight patients reported an improvement in pain immediately and at one month following the procedure. A sustained improvement in pain followed the vertebroplasty.

This is consistent with other case reports in the literature although in this study the response appears to be less dramatic than that reported in other series.

T. Geddes G.J. Coldham

To assess the outcome and safety of transarticular C1–C2 screw fixation. The clinical and radiological outcomes of 15 patients treated with posterior atlanto-axial transarticular screw fixation and posterior wiring was assessed at a minimum follow up of 6 months. Indications for fusion were rheumatoid arthritis in 8 (instability in 6 and secondary degenerative changes in 2), non-union odontoid fracture 4, symptomatic os-odontoideum one, C1–C2 arthrosis one and irreducible odontoid fracture one. Fusion was assessed with plain x-rays including flexion extension films.

Twenty nine screws were placed under fluoroscopic guidance. Bilateral screws were placed in 14 patients and a single screw in one patient. This patient had a single screw placed due to the erosion of the contralateral C2 pars by an anomalous vertebral artery. All patients had radiological union. Two screws (7%) were malpositioned; neither was associated with clinical sequelae. No neurological or vascular injuries were noted.

Transarticular C1–C2 fusion yielded a 100% fusion rate. The risk of neurological or vascular injury can be minimised by thorough assessment of pre operative CT scans to assess position of the vertebral artery and use of intra operative lateral and AP fluoroscopy.

H. Rawlinson G. Horne V. Stevanovic P. Devane

The purpose of this study was to assess the regional variation in the incidence of hip fractures in patients over 65 years. in New Zealand. Data from the National Minimum Data Set (NMDS) for hip fractures from 1 July 1998 to 31 June 2000 was obtained. The data was divided into 21 District Health Board (DHB) regions by mapping from domicile code to DHB. Population of interest as at 30 June 1999 was estimated on the basis of previous census in 1996. The incidence of hip fracture per 100,000 for each region was calculated and divided into age and sex cohorts.

There is a significant difference between DHBs in the sex and age adjusted incidence of hip fractures. The rates ranged from 556 per 100,000 to 838 per 100,00. As expected there was a higher fracture rate in women and the fracture rate increased with age. There was a weak correlation with sunshine hours (p=0.029) with increasing fracture incidence as sunshine hours decrease.

This study demonstrates a large variation in the incidence of hip fractures per DHB region. The cause for this is unclear, but the cost implications are significant. DHB’s with a high incidence of hip fractures in their region may wish to investigate strategies for reducing the incidence.

C. Hoffman P. Welsh C. Gregg

To determine if patients referred to a back clinic in NZ would respond to a structured program based on the Canadian Back Institute (CBI) system and match results obtained by the system in Canada.

All patients referred to the Wakefield Back Institute over one year were assessed using the CBI system. The program employs a structured history and physical exam to identify a pattern of pain. The identified syndrome then forms the basis for initial treatment and achieving the anticipated outcome confirms the original pattern. Patients undergo a 3-stage exercise program. A Spinal Status assessment and a satisfaction survey were completed on discharge. These were compared with the CBI National Outcomes (CBINO) data for 2001.

The clinic was referred 532 patients of whom 508 could be classified in to one of the recognised patterns of mechanical pain for the lumbar or cervical region. The distribution of pain patterns and patient’s demographics were similar to the CBINO data. Thus far, 162 patients have completed their program. Positive pain management (pain gone or markedly decreased) was reported in 85% of the lumbar group (93% in Canada) and 92% of the cervical group (same as Canada). Better pain control (lumbar 86%, cervical 93%) and longer pain-free episodes (lumbar 64%, cervical 75%) were reported. Patient Satisfaction was high (4.57 on a 1–5 scale).

The CBI program has been adapted and applied in a New Zealand environment and early results suggest outcomes similar to those reported in Canada can be obtained here.

A. Meighan B. Tietjens

The purpose of this study was to investigate the mechanism of injury causing anterior cruciate ligament ruptures in snowboarders and skateboarders.

Knee injuries in snowboarding and skateboarding are rare. We have seen 22 ACL ruptures with an identical injury mechanism that has not been previously described. Fifteen ACL ruptures occurred in snow-boarders and 7 in skateboarders. All were advanced or expert boarders. All injuries occurred on landing a high jump, which resulted in significant knee compression. All described a flat landing on a flexed knee with no twisting component.

We postulate that anterior cruciate ligament rupture in these patients is due to explosive eccentric quadriceps contraction when landing from a jump. The injury mechanism is not boot induced as has been described in downhill skiers landing from a jump.

A. Field J.G. Horne

The aim of the study was to assess the outcome of fractures of the fifth metacarpal neck and to develop an accurate method of assessing fracture angulation.

Forty-two patients who were available for review were assessed using a patient questionnaire, assessing range of movement, cosmesis, pain and strength. A trigonometric method of determining true fracture angulation from AP and oblique radiographs was developed. There were 36 males and 6 females with an average age of 23.4 years, with a minimum follow up of 12 months. Patients with fractures angulated more than 45 degrees in whom reduction was not performed had a significantly lower score for grip strength and function. 32 patients reported a mild cosmetic deformity. The method of reduction and the method and duration of immobilisation did not correlate with the final outcome. A phantom was constructed that confirmed the accuracy of the method of calculating true fracture angulation from the oblique radiographs.

Fractures of the fifth metacarpal neck if not reduced to a true angulation of less than 45 degrees produce an unsatisfactory outcome. A method of assessing true angulation has been developed.

A.J. Thurston

This study reviews the results of the treatment of non-union of fractures of the scaphoid by the use of micro-surgical, vascular pedicle grafts (VPG). The indications for VPG included long-standing non-union of a fracture of the scaphoid, avascular necrosis of the proximal pole and failed conventional grafting. The contraindications were periscaphoid degenerative changes (scaphoid non-union advanced collapse) and vascular damage from previous surgery. The technique in each involved harvesting a vascularised bone graft from the distal radius based on a vascular pedicle with retrograde flow from one of a number of described vessels that constitute the vascular plexus over the carpus. The scaphoid was prepared to receive an inlay graft and then the graft was positioned and its stability was determined. Some were secured with a single 0.7mm diameter Kirschner wire. The wrist was then immobilised in a plaster cast until either the fracture had healed or it was evident that the procedure had failed to result in union.

Fourteen patients have undergone VPG over 30 months. Of these eight have healed (four fractures of the waist and four of the proximal poles), four have failed (one waist and three proximal poles) and two are still in plaster casts. The mean time to healing was 20.6 weeks (range: 12.7–28.7 weeks). Of the eight that healed, seven were aged between 21 and 27 years. The four failures were aged between 34 and 44 years. The mean time since the fracture in the healed group was 2.9 years (range: 1.2 years to five years) and in the failed group it was 6.5 years (range: two years to 20 years). The first failure was related to deep infection and a subsequent Matte-Russe procedure has also failed. In the second failure the graft healed to the distal pole but the very small proximal pole collapsed resulting in a wrist arthrodesis. The graft in the third failure healed to the distal pole but failed to unite with the small proximal pole. No further treatment has been planned. The fourth failure was a non-union of the waist of 20 years standing. The graft became dislodged from the scaphoid but no further surgery has been carried out. One of the successful unions had a poor result because of degeneration in the scaphoid-trapezoid-trapezium (STT) joint secondary to damage done at the time of previous surgery (Herbert screw). A successful STT arthrodesis was done subsequently.

VPG is technically challenging. Careful patient selection is vital as is preoperative planning and vessel selection. VPG can be used successfully to salvage obstinate non-unions of fractures of the scaphoid.

N.K. Aggarwal

Faced with the challenge of managing war trauma in Afghanistan (1984–86), within limited resources and compromised conditions, we started managing open fractures with the pin and plaster method. With time a new External Fixation System evolved, which helped save hundreds of limbs and lives. Encouraged with the results, this system was used in the civilian practice, in India. There were further improvements in the design and refinements in technique. Subsequently biomechanical studies were conducted in Liverpool. The Fixator has been used at other centers in India and the UK with good results.

This paper describes evolution of the model, and its use in 116 patients by a single surgeon between February 1987 and July 1990. It has been used on every limb segment and indications included open fractures, infected non-unions, arthrodesis, osteotomy, etc. Analysis of results in 41 open tibial fractures showed 97.3% united at an average of 21.4 weeks. Delayed union occurred in 5.2 %. There was no malunion and pin tract infection was 6.3%. The system has proved to be simple yet versatile, cheap, easy to use, and an effective alternative to more costly and complex designs. It has been used as a modular system for varieties of conditions encountered in general orthopedic practice. Customized configurations can be produced and rigidity of fixation can also be altered in the same configuration, to meet biomechanical and biological demands in each patient.

With advent of newer techniques during last decade, the use of ExFix in our practice has been more selective and judicious.

A.J. Thurston

Laboratory evidence has shown that tears within the substance of the triangular fibro-cartilaginous complex (TFCC) of the wrist are caused by shear and/or compressive forces rather that by distraction. They are commonly associated with ulnocarpal abutment syndrome (UCAS). A number of different methods of treatment have been advocated for UCAS but no satisfactory comparison of these has been reported.

To compare the results of different forms of treatment for UCAS. The notes of 76 patients who had undergone wrist arthroscopy for UCAS were reviewed independently. The diagnoses made at the time of the arthroscopies and any surgical interventions (shaving the torn TFCC back to stable tissue, wafer resection of the ulnar head, repair of the TFCC) that were made at the same time were recorded. The results of these interventions were noted, as were any subsequent surgical procedures for persisting pain. These results were compared with those of a meta- analysis of the results for similar procedures published in the literature.

All 76 patients had TFCC tears, four were repaired arthroscopically and the remainder underwent debridement. Nineteen of these had, in addition, arthroscopic wafer procedures carried out. Of the 53 who had only debridement 63% were graded as good or excellent. The remainder underwent formal ulnar recessions and 93% of these improved and were graded as good or excellent. Of the 19 who had wafer procedures 53% were graded as good or excellent. Seven (36%) of this group underwent ulnar recessions with five (66%) improving to be graded as good or excellent. There were no major complications such as infection, nonunion or failure of the internal fixation. Of the four cases in which the TFCCs were repaired arthroscopically, three were graded as good or excellent. One remained the same and underwent and ulnar recession and improved to be graded as good.

From the meta-analysis 72% of patients who were treated by debridement alone were graded as good or excellent, while 66% were good or excellent after debridement combined with a wafer procedure. The patients who were treated by ulnar recession had a larger proportion of good or excellent results with 92% reaching this level of satisfaction. From these results it was concluded that arthroscopic debridement of tears of the TFCC was effective treatment in a majority of patients. The arthroscopic wafer procedure was effective as long as adequate bone was resected. Persisting symptoms of UCAS were very adequately treated by ulnar recession.

E. Dona M. Gillies W.R. Walsh M.P. Gianoutsos

The use of plates and screws for the treatment of certain metacarpal fractures is well established. Securing plates with bicortical screws has been considered an accepted practice. However, no study has questioned this.

This study biomechanically assessed the use of bicortical versus unicortical screws in metacarpal plating. Eighteen fresh frozen cadaveric metacarpals were subject to midshaft transverse osteotomies and randomly divided into two groups. Using dorsally applied Leibinger 2.3mm 4 hole plates, one group was secured using 6mm unicortical screws, while the second group had bicortical screws. Metacarpals were tested to failure using a four point bending protocol in an apex dorsal direction on a servo-hydraulic testing machine with a 1kN load cell. Load to failure, rigidity, and mechanism of failure were all assessed.

Each group had three samples that did not fail after a 900 N load was applied. Of those that failed, the mean load to failure was 596N and 541 N for the unicortical and bicortical groups respectively. These loads are well in excess of those experienced by the in-vivo metacarpal. The rigidity was 446N/mm and 458N/mm of the uni-cortical and bicortical groups respectively. Fracture at the screw/bone interface was the cause of failure in all that failed, with screw pullout not occurring in any.

This study suggests that there may be no biomechanical advantage in using bicortical screws when plating metacarpal fractures. Adopting a unicortical plating method simplifies the operation, and avoids potential complications associated with overdrilling and oversized screws.

E. Dona K. Latendresse P. Scougall M. Gillies W.R. Walsh

The behaviour of two different methods of reattachment of the flexor digitorum profundus tendon insertion was assessed. Cyclical testing simulating the first 5 days of a passive mobilisation protocol was used to compare the micro Mitek anchor to the modified-Bunnell pull-out suture. Twelve fresh-frozen cadaveric fingers were dissected to the insertion of the FDP tendon. The FDP insertion was then sharply dissected from the distal phalanx and repaired using one of two methods: group 1 -modified Bunnell pullout suture using 3/0 Prolene; group 2 micro Mitek anchor loaded with 3/0 Ethibond inserted into the distal phalanx. Each repaired finger was mounted on to a material testing machine using pneumatic clamps. We cyclically tested the repair between 2N and 15N using a load control of 5N/s for a total of 500 cycles. Gap formation at the tendon bone interface was measured every 100 cycles.

No specimens failed during cyclical testing. After 500 cycles, gap formation of the tendon-bone interface was 6.6mm (SD = 1.2mm), and 2.1 mm (SD = 0.3mm) for the pullout technique and the micro Mitek anchor repair respectively. Concerns related to suture anchors, such as anchor failure or protrusion, joint penetration, and anchor-suture junction failure, were not encountered in this study.

Cyclical loading results suggest that the repair achieved with both methods of fixation is sufficient to avoid failure. However, significant gap formation at the tendon-bone interface in the modified Bunnell group is of concern, suggesting it may not be the ideal fixation method.

J.G. Horne M. Chakraborty J.M. Fielden P.A. Devane

The aim of the study was to investigate functional outcomes and perceptions of quality of life in a series of elderly patients who have sustained tibial plateau fractures. A retrospective survey of all patients aged over 60 years who were admitted to Wellington and Hutt hospitals for treatment of a tibial plateau fracture between July 1996 and December 2000 was carried out. Patients were sent the Oxford 12 knee score and the Nottingham Health profile (NHP) by mail. Radiographs were reviewed to confirm fracture type and medical notes reviewed to ascertain treatment. Patients were divided into non-operative (plaster cast or brace; n=8) and operative treatment (open reduction and internal fixation (ORIF) or total knee replacement; n=15) groups.

Of 42 eligible patients, 23 returned completed questionnaires (rr=55%). The mean age of patients was 73.6 years with 16 (69.6%) females and 7 (30.4%) males. Mean time to follow up was 38.7 +/−14.5 months. The mean Oxford 12 knee score was 39.3. The mean NHP-part I scores were 17.6, 8.4, 3.3, 14.4, 2.9, 9.3 for energy level, pain, emotional reaction, sleep, social isolation and physical mobility respectively. 73% of the patients felt that their present state of health was not causing problems with any of the activities mentioned in the NHP-part II.

The perceptions of outcomes of tibial plateau fractures in the elderly after conservative treatment is comparable with operative treatment. The results show Oxford 12 Knee and NHP scores similar to other studies and indicate satisfactory knee function.

N.K. Aggarwal

Various modalities of treatment for intra/extra articular fractures of proximal tibia include, traction, open reduction and internal fixation by plates and screws, percutaneous screw fixation with or without external fixation, and recently introduced minimally invasive techniques. These methods have achieved varied success rates but the problems encountered have been prolonged recumbency with traction and dangers of extensive soft tissue stripping, infection and knee stiffness with internal fixation methods. Pin problems continue to haunt external fixators apart from poor acceptability of the frame by the patients. Encouraged with the excellent results achieved by us with intra- medullary inter-locking nail for complex fractures of distal femur, we have used the same device for selected cases of fractures of the proximal tibia during the last 5 years.

We used this method in 46 patients of which 43 were available for analysis. Twenty-one were open fractures and 34 had intra-articular extension. Six were floating knee injuries and 2 had an associated fracture of the patella. In all cases knee mobilization was started within 48 hours after the surgery. If associated injuries did not prevent, non-weight bearing crutch walking was started within a week and partial weight bearing within 3 weeks. Thirty-nine of the fractures have united at an average of 14 weeks and four are still being followed up. Thirty-seven have regained at least 90% of the original movement. There has been no infection except in two patients with Grade III open fracture, which settled after the implant was removed following fracture healing. There has been one delayed union, which is progressing to union after bone grafting.

Our early experiences with this implant are extremely encouraging as it provides adequate stabilization of the fracture without any soft tissue stripping and allows early mobilization of the joint and the patient.

A. Edwards A. Khaleel R. Simonis R. Pool

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an llizarov ring fixator.

Only patients with intra-articular fracture of the tibial plafond on plain radiographs that corresponded to type III pattern of Ruedi and Allgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the Ilizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided.

Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average of 6.3 months). Neither deep infection nor soft tissue complications occurred. Outcomes measured using the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire and our results compare well with other fixation techniques.

The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries.

V. Pai

This is an outcome study of the use of plate fixation for treatment of comminuted fractures of the distal third of tibia to determine prognostic factors such as age, sex, type of fractures, soft tissue injury and type of implant on healing.

Since 1999, a single surgeon (VP) has performed minimally invasive fixation in 18 patients for complex transitional fractures of the tibia. Follow up has been achieved by a combination of clinical and radiological assessment and notes review.

An overall excellent-good result was obtained in 17 of 18 patients. In one patient, the fixation was revised due to a 20 degree external rotation mal position. In two cases there was mild external rotation of 10 degrees. There were no infections.

The treatment of difficult juxta-articular fractures with a minimally invasive fixation is a useful management option. Peri-articular plates are easy to insert and give better results with respect to alignment correction.

P. Papadelis N. Christoforidis K. Antonis E. Mahaira C. Hanioti G.P. Lyritis

Achilles tendinitis can result, through inflammatory procedures, to tendon degeneration with microtears and nodules. Current conservative or surgical treatment of this lesion proved to be not effective enough. The reason for this is the absence of sufficient oxygenation in the area. In this study we report the results of a novel technique which tries to improve local vascularity.

We operated on 15 mature rabbits after they were anasthetized. Soleus fibers were trasplanted in the right achilles tendon. A lesion, 10mm long and 2mm wide was created in the inner band of the tendon simulating tendinitis. In the left achilles tendon the same procedure was done without transplantation. The rabbits were divided in three equal groups and were sacrificed in the first week, the 2nd and 3rd month after the operation. Histopathologic examination was done in both achilles tendons. The following parameters were assessed: transplanted muscle viability, inflammation and neoangiogenesis. We also evaluated the contact between muscle and tendon and the quality of tissue that was formed in the tendinitis simulating area.

Inflammatory process was noticed only in the 1st week after surgery. In the other groups viable muscle fibers and tendon tissue was observed. Muscle fibers were in contact with the tendon. The quality of tissue in the tendinitis simulating area was of better quality than in the control group.

We conclude that soleus transplanted muscle fibers in the rabbits achilles tendon seem to be oxygen carriers and improve the healing potential of the area. This fact results in tendon reinforcement.

A.J. Smyrnis J.N Germanis

The anatomic study of the connection between median and ulnar nerve in the forearm, were first described by the Swedish anatomist Martin, in 1763 and later by Gruber in 1840. This connection is now known as the Martin-Gruder anastomosis. Despite its long history, its nature remains unclear.

We performed anatomical dissection in 60 fresh cadaveric forearms. Thirty-four of them were on the right forearm and 26 on the left forearm. We supplement the anatomic study with a histologic examination of the bundles in the connections. We found 5 cases with a linking branch (8.5%).The distance between the proximal end of the anastomosis from the medial condyle were about 6.5 cm (5.0 to 8,0). The length of the anastomotic branches was between 3.5 – 6.5 cm. All the linking branches were located in the proximal third of the forearms. No connections between ulnar – median nerve were found.

In conclusion the Martin – Gruber anastomosis is clinically important. A lesion of the median nerve situated proximal of the anastomosis would affect the median thenar muscles, whereas a lesion distal of that level would not. The anastomosis has a clinical significance for understanding median nerve lesions and the carpal tunnel syndrome. A lesion of the ulnar nerve situated proximal of the anastomosis would affect the ulnar muscles of the hand, whereas a lesion distal of that level would not. By recognizing the existence of the linking branches mistakes in the diagnosis of the peripheral nerve lesions can be avoided.

T. Mollas G. Charitos C. Bikos V. Karamoulas I. Petkidis E. Papacostas T. Chouseinoglou T. Papaioannou

The purpose of this study was to present the long team functional results after conservative treatment of intraarticular calcaneal fractures. Nine patients with 11 fractures (mean age at accident 52 years old) were reevaluated. Mean follow-up was 8 years (6–15). 5 fractures were tongue type, 5 were compression fractures and 1 with comminution according to Essex Lopresti classification. These patients were clinically and functionally evaluated with the Ankle-Hind foot scale (Kitaoka, 1994). They were submitted to radiographic testing (foot AP, ankle lateral, axial and medial axial views). Osteoarthritic (OA) changes, calcaneal dimensions (height, width) and Bohler’s – Gissane’s angles were recorded.

According to Ankle Hind foot score (highest 100) our patients scored a mean 77 points (48–90). OA changes were recorded in 7 cases in the ankle joint and in all cases in taloscaphoid, calcanocuboid (severe in 8) and subtalar joints (severe in 5). We found width reduction in 6 patients and height reduction in 2, compared to the healthy side. Bohler’s angle was abnormal in 6 cases (−21°to 52°) while Gissane’s angle was abnormal in 9 (84° to 115°).

Treatment of intraarticular calcaneal fractures is still controversial. Recent studies show a tendency for surgical treatment. In the present study a distinction between clinical and radiographic findings was made. Patients had satisfactory functional results although severe osteoarthritic changes were recorded.

I. Ch. Koulouris I. Dontas I. Paspati L. Khaldi P. Raptou A. Galanos G.P. Lyritis

Purpose: The study was conducted to evaluate the effect of salmon calcitonin (sCT) on fracture healing in normal and hypogonadal male rats.

Material and Method: Fifty six male Wistar rats, aged 3 months, were undertaken hemiosteotomy of the distal femur shaft, of standard length and width. Half of the animals had been orchiectomised at the age of 2 months. The animals were divided in 8 groups, 7 rats each, as follow: A, a (normal, no sCT), B, b (normal+Sct), C,c(orchiectomised) and D,d (orchiectomised+Sct). Salmon calcitonin was administered immediately after the hemiosteotomy in a dose of 5IU/day subcutaneously. Groups A, a, C and c were given placebo. The animals of the groups a b, c, and d were killed at 2 weeks, while the animals of the groups A, B, C, and D were killed at 4 weeks. After the euthanasia, total bone density and cortical bone density of the callus was estimated by peripheral quantitative computed tomography (pQCT). Histological and histomorfometric parameters of the callus were estimated as well.

Results: The mean cortical bone density was 1221.93±13.82 (g/cm3±SE) for the group a, 1281.3±13.57 for b, 1221.41±18.24 for c, 1245±17.12 for d, 1173.45±34.14 for A, 1298.9±11 for B, 1280.78±13.68 for C, and 1279.4U19.2 for D. The mean total bone density was 843.95±13.69 (g/cm3±SE) for the group a, 859.84±26.46 for b, 892.27±25.3 fore, 861.37±10.88 for d, 818.97±32.5 for A, 926.39±19.6 for B, 888.31±24.19 for C, and 912.75±28.13 for D. Values of cortical bone density in group b and B were significantly greater than a and A, respectively (b> a, p=0.01 and B> A, p=0.002). Total bone density of the callus was statistically greater in group B than A (B> A, p=0.01). According to the histological and histomorphometric results, sCT increased the amount of cartilage (p=0.014) and the amount of woven bone (p=0.015) in group b compared to a, while osteoblasts number showed no difference between the two groups. Comparing groups c and d, sCT increased the amount of cartilage (p=0.036) and the amount of woven bone (p=0.0014) in group d compared to c, while decreased osteoblasts number in group d (p=0.03). In four weeks the amount of cartilage is significant greater in group D versus C (p=0.006), as well as the amount of woven bone (p=0.0004). The size of the callus is significant greater in group D compared to C as well (p=0.052).

Conclusion: It appears that salmon calcitonin administration improves significantly the parameters of callus bone density in normal rats and increases the amount of cartilaginous callus and woven bone both in normal and orchiectomised rats.

S. Dagkas N. Zacharakis P. Staulas A. Koinis D. Polyzois

The aim of this study was to evaluate and compare the results of acromioplasty in two groups of patients operated upon for impingement syndrome using two different techniques, In one group the insertion of the devoid was partially divided (deltoid off strategy) while in the other the insertion of the deltoid was preserved (deltoid on strategy).

Twenty-one patients, suffering from impingement syndrome of the shoulder, were operated during the period 1996–2001. Preoperatively all patients presented with positive impingement test and they were complaining of night pain as well as pain during activity. Two different techniques were used. In 2 group of 10 patients. the “deltoid off’”strategy was applied and the acromioplasty was performed with the use of an osteotome. In a second group of 11 patients the “deltoid on” strategy was applied and the acrormioplasty was performed by using a high speed burr.

Eight out of 10 patients of the first group were satisfied with the results of the operation, whereas all the 11 patients of the second group were satisfied. The return to full activity in patients with the “deltoid off” strategy was 10 weeks in average, while in the “deltoid on” group it was 8 weeks. Night pain subsided in ail patients in both groups. Two patients of the first group complained of mild pain with daily living activities, while 10 out of the 11 patients of the second group had no pain at all. Finally 2 patients of the first group and none of the second group presented residual painful arc.

We conclude that the “deltoid on” technique for treatment of the impingement syndrome of the shoulder appears more simple and reliable, has less morbidity and gives better clinical results, compared to the “deltoid off” technique.

I. Sarris D. Sotereanos

Massive rotator cuff tears associated with glenohumeral arthritis are currently an unsolvable clinical entity. This study strictly defines the use of bipolar hemiarthroptasty for the entity of RCTA.

Materials – Methods: We review our series of 14 patients with Rotator Cuff Tear Arthropathy (RCTA) who underwent a bipolar prosthesis of their shoulder. The average follow up was 27.8 months (range 24–48 months) and the average age was 71 years old (range 57–84 years old), of these 14 patients there were 9 male and 5 female. None of these patients had previous shoulder surgery and all patients underwent conservative treatment that failed to improve their symptoms or range of motion

Results: Preoperatively the average forward flexion was 300, external rotation 100 and the American Shoulder and Elbow Society (ASES) score was 25 points. Postoperativety the average forward flexion improved to 880, external rotation increased to 370 and the ASES score improved to 80 pts, 12 of the 14 patients stated that they had no pain with activities of daily living. Two patients persisted to have moderate pain in everyday activity.

Conclusion: We believe that bipolar hemiarthroplasty is currently a good option for treatment of Rotator Cuff Tear Arthropathy, The results of bipolar hemiarthroplasty provided more reliable pain relief than that for hemiarthroplasty.

G. Babalis C. Karliaftis E. Antonogianakis C.K. Yiannakopoulos C. Karabalis P. Mikalef A. Iliadis P. Efstathiou

Purpose: To present the technique and the results of simultaneous arthroscopic reconstruction of Bankart and SLAP lesions in patients with anterior shoulder instability.

Method: We performed shoulder arthroscopy in 95 patients aged 16–38 years (mean age:24,8) suffering anterior shoulder instability. Preoperative evaluation included clinical assessment, x-rays, MRI-arthrogram and examination under anaesthesia in comparison to the healthy shoulder. SLAP lesion was fixed using metallic suture anchors (FASTAK 2,4mm x 11,7 mm-Arthrex).The anchor was inserted in a 45° direction relative to the glenoid level. Bankart lesion was reconstructed using 2–3 bioabsorbable suture anchors (Panalok-Mitek J& J).The arthroscope was inserted through standard posterior, anterosuperior and anteroinferior portals while a posterolateral portal (portal of Whilrnington) was created for SLAP lesion repair. Patients’ average follow-up was 22 months (range, 18–30 months) and the results were evaluated using the ASES score.

Results: SLAP lesion was found in 13 patients: 6 pat.-type II (46%), 3 pat.-type I (23%), 2 pat.-type IV (15%), 1pat.-type III (7,6%) and 1 pat with a complex lesion. Of these patients 10 had also co-existed Bankart lesion. In 2 patients Hill-Sachs lesion was found while degenerative rotator cuff changes existed in 3 patients. While performing clinical evaluation anterior instability signs and symptoms were apparent with the patients complaining also for discomfort and crepitus during overhead activities. MRI preoperative sensitivity for SLAP lesion diagnosis was 59% while specificity and Positive predictive value were 90% and 76% respectively. Shoulder function and the overall ASES score improved from 44 pre-op. to 96 post-op.

Conclusion: Combined Bankart and SLAP lesions are uncommon in non-throwing patients with anterior instability. Arthroscopic suture anchors fixation ensures early and reliable rehabilitation. MRI arthrography study by a skeletal radiologist predicts to a high rate diagnosis.

K. Gouvalas S. Tsourvakas C Gimtsas N. Ameridis

Acromioclavicular joint dislocations (Grade 3) present challenging problems for the treating surgeon. We propose a retrospective radio clinical analysis of long-term outcome in a series of surgically treated patients to determine the long-term effects of the procedure on the acromioclavicular joint and possible implications for initial therapeutic decision.

Twenty patients were reviewed at a mean 45, 5 months after surgery (range 8 – 85 months). Mean age at surgery was 45, 8 years. All had an Allmon grade 3 acromioclavicular dislocation. All had early surgery for open reduction of acromioclavicular dislocation and temporary stabilization with two parallel transacromioclavicular pins and a wire (tension band).

Two patients had a postoperative complication: one wound dehiscence and one fracture of the wire. The subjective outcome was in 12 patients. In one patient we had redislocation and in two patients we had joint stiffnes. Radiographically there were 4 cases with acromioclavicular osteoarthritis and there were coracoclavicular ossification in all patients.

Surgical repair of grade 3 acromioclavicular dislocation by transacromioclavicular pinning without ligament suture, gave in this series satisfactory functional and subjective results that remained stable over time.

J. S. Maris A. Papanikolaou E. Karadimas J. A. Petroutsas C. Karabalis G. Deimedes K. Tsampazis

Introduction: The combined fractures of the clavicle (or A-C dislocation) and the scapular neck are complex injuries related to high energy trauma. Their management varies depending on the degree of instability and the presence of neurovascular complications. We evaluated the results of the treatment given to this rare injury.

Material and Method: During a five year period (1997–2001) we treated 12 patients with floating shoulder. The injury was in all cases the result of severe road traffic accident. Nine patients were males and three females with age ranging from 20 to 51 years. Seven patients had injured the right shoulder, the remaining five having injured the left one. Eight patients had additional injuries (chest in four, head in two, fracture of the T4 with complete paraplegia in one, chest and abdominal in one).

Three patients had neurovascular complications and were operated upon. Two of them with vascular injury were operated ungently and had arterial graft and stabilization of the clavicle or the A-C joint with tension band. The third patient with only neurological injury (axillary and suprascapular nerves) had similar stabilization of his clavicle. The remaining nine patients with minor displacement of the fractures and stable shoulder girdle were managed conservatively.

Results: We reexamined eleven patients. The mean follow-up period was 19 months (8–56 months). In nine patients-including the three operated-the fractures had healed in satisfactory position. In the remaining two the fracture of the scapular neck was malunited, resulting in loss of shoulder normal configuration and restriction of shoulder elevation. In two of the operated patients the coexistence of neurological injury resulted in poor functional outcome. The third one-with the axillary and suprascapular nerve injury-improved in relation to the axillary nerve within six months from the injury and had a fairly useful upper extremity. In the Constant-Murley scale the score ranged from 28–89 points (average 67 points).

Conclusion: In conclusion, fractures of the clavicle (or A-C dislocations) and the scapular neck are injuries of high energy and are usually encountered in multiplez injured patients. Severe displacement is usually related to instability of the shoulder girdle and neurovascular injuries; urgent operation is then necessary and the final result is often poor. In cases of severe displacement the stabilization of only the clavicle is not sufficient and open reduction and internal fixation of the scapular neck is recommended.

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C. Papachristou N. Efstathopoulos J. Lazarettos A. Kalliakmanis J. Sourlas V. Nikolaou E. Chronopoulos

Purpose: The aim of this paper is to present a new surgical method for the reconstruction of the recurrent sprain of the ankle.

Material – Methods: From 1980 until 1997, 17 patients 3 females and 14 males, average age 25.53 (19 – 44) underwent surgery suffering recurrent sprain of the ankle. In 11 patients the right ankle was involved and in 6 patients the left ankle. The cause of the injury was: athletic activities in 9 cases, weekend activities in 7 cases and daily activities in 1 case.

The patients were suffering from ankle instability 4–15 years prior the operation. All the patients underwent reconstructive surgery of the anterolateral elements (capsule and ligaments) according to senior author’s method. This included shortening of the anterolateral elements, capsule and ligaments, overlaping the anterolateral part over the anterolateral one in such a way, that the anterior drawer and varus tests were negative with the patient under anaesthesia.

Results: The follow up is 2–12 years. A patient underwent for a second time surgery, because of a new injury. In 2 patients early signs of ankle osteoarthritis. In the rest of them, restoration of the function of the ankle joint was excellent, obtaining full activities 3 months postperatively.

Conclusion: This surgical method for the reconstruction of the recurrent sprain of the ankle is considered satisfactory and when indicated allows young patients and athletes to participate in a rather short period of time, in their previous level of activities.

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F. Villanueva-Lopez V.N. Psychoyios J.C. Ramos-Salguero E. Zambiakis I. Esteo-Perez

Introduction: Pelvic ring injuries represent a complex injury pattern and sometimes have significant consequences. The aim of this retrospective study is to delineate the indications of surgical treatment with emphasis in the anatomic reconstruction.

Materials and Methods: 85 patients with pelvic ring fracture with or without acetabular fracture reviewed retrospectively. The average patient age was 34 years. Operative treatment was provided to 26 patients. Six isolated acetabular fractures were treated by ORIF. Twenty pelvic ring fractures were treated, by anterior Ex-Fix in five cases, Ex-Fix plus sacroiliac screws in three, anterior reconstruction plate plus sacroiliac screws in two, anterior plate plus sacral bars in three. The remaining seven patients with an additional acetabular fracture treated with anterior plate for the pelvis and plates for the acetabulum.

Results: All the acetabular fractures were anatomically reduced. All fractures consolidated and no patient has developed hip AVN or post-traumatic arthritis. Brooker’s grade III ossifications complicated two patients. Partial neurological deficit of sciatic nerve was seen in three cases of acetabular fractures that improved spontaneously. A case of vertical shearing sacral fracture through the foramina presented with lumbosacral plexus paresis that recovered near normal function in 6 months. Deep infection complicated a case that subsided at 2 weeks on antibiotics and serial surgical debridement.

Conclusions: The strict application on rational criteria and an exquisite surgical technique caring of the soft tissues produce satisfactory outcome of these injuries. The above-described surgical treatment shortens the hospital stay and allows early physiotherapy to restore function.

F. Villanueva-Lopez V.N. Psychoyios I. Esteo-Perez E. Zambiakis F. Villegas-Rodriguez

Introduction: Various surgical techniques existed for the treatment of three and four part proximal humeral fractures with variable outcomes. The aim of this study is to present a technique using small materials, to preserve all the biologic principles of fracture fixation, in the treatment of these challenging injuries.

Material: We perform a study taking as inclusion criteria: 3 and 4 parts proximal, closed, humeral fractures, treated surgically by open reduction and a modular biological internal fixation.

Surgical technique: Through a standard deltopectoral approach the fragments reduced, taking care to preserve the periosteum and manipulate meticulously the soft tissues. All the fractures were fixed with a combined system of Kirschner wires inserted to the proximal fragments, connected by “bone clips” forming a modular construction and fixed to the main distal fragment by AO screws.

Results: 24 patients complied with the inclusion criteria and were followed up a mean of 18 months. All patients achieved a satisfactory result except a fracture-dislocation that developed AVN and was revised into a shoulder arthroplasty and two demented elderly patients with metalware failure that were also revised.

Conclusion: In this first series of non-selected cases the outcome of fracture consolidation is promising. Although this technique is in its embryonary phase of development and the functional results are currently been assessed, the radiological outcomes suggest that the technique described is a valid alternative to the treatment of these fractures if we indicate an osteosynthesis method that combines biology and stability.

Th. Karachalios K. Bargiotas A.H. Zibis A. Damdounis Th. Moraitis KN. Malizos

Purpose: We present the results of subacromial decompression and repair of the rotator cuff through a minimal deltoid-on approach.

Material and Method: Eighty-seven patients with longstanding shoulder pain were evaluated in two years (1999–2000) in our department. In sixty -eight of them symptoms were due to impigment syndrome. Eight patients with follow up time less than six months were excluded from this study, twenty were treated conservatively and the remaining forty (22 female, 18 male, mean age 50.3) underwent surgery. Three x-ray views were obtained in all patients, i.e. standard AP, true AP, and subacromial space projection. MRI was also obtained in all patients. MRI revealed calcific tendinitis in fifteen patients, osteophytes of the acromioclavicular joint in thirteen, a hooked (type III) acromion in ten and partial tear of the supraspinatus tendon in nineteen. In five of them there was also a partial tear of the infraspinatus. Finally, seven patients were suffering of a full thickness tear of the supraspinatus tendon. All patients were operated through a minimal deltoid-on approach. Acromioplasty and coracoacromial ligament dissection was performed in all. In patients with osteoarthritis of the acromioclavicular joint, osteophytes were carefully removed. Calcific deposits were also removed in all patients. In eighteen patients tears of the rotator cuff were detected and repaired using bone anchors.

Results: All patients were examined six months postoperatively. Results were evaluated with CONSTANT SCORE and with a questionnaire for patient’s satisfaction. Thirty-seven patients were very satisfied with the result and three were satisfied. As for Constant score, pain improved at an average of 7.8 points, daily activities by 5.4, and range of movement by 4.2 points. Results were evaluated by the examiner as excellent in thirty-six patients (90%) and very good in four patients.

Conclusion: Deltoid-on approach, in patients with impingement syndrome of the shoulder provides adequate exposure for the surgical repair with minimal trauma and a very low rate of complications.

JC. Feroussis A. Zografidis P. Dallas C. Tsevdos A. Barbiltsioti A. Papaspiliopoulos

Airn: Treatment of acromioclavicular joint dislocations depends on the type of the dislocation and the patients symptoms. We present the results of surgical treatment with transfer of the acromical end of coracoacromial ligament in the distal end of the clavicle. (The Weaver Dunn procedure). Material – Method: 32 patients with acromioclavicular dislocation type III, IV and V according Rockwood, 20 acute and 12 chronic, were treated with open reduction and stabilization of the distal end of clavicle and transfer of the coracoacromial ligament. They were 26 men and 6 women, the average age was 28 years. The indications for the operation were: deformity, pain and numbness. On 28 patients resection of the distal end of the clavicle was performed but on 4 acute dislocations the stabilization was made without osteotomy.

Surgery was performed with the patients in the beach chair position and with a horizontal skin incision above the acromioclavicular joint. The length of the coracoacromial ligament was determinant to achieved reduction. The soft tissues were double breasted above the acromioclavicular joint. After surgery the limb was placed in a sling for 15 days and then complete mobilization exercises was began. Draft weight was avoided for 3 months.

Results: The average length of follow up was 4 years. All patients had almost no pain and full range of motion. Constant score was above 80 in all cases. Full range of motion was obtained until 2 months after operation. In 3 cases the primary reduction was not fully achieved. In 3 other cases loss of the primary reduction was observed due to suture rupture. In these cases the displacement was significantly minor than pre operatively. 15 patients had developed ectopic ossification bellow the acromioclavicular joint without consequence in the shoulder motion. The resection of the distal end of the clavicle did not alter the results.

Conclusion: The operation offers low percentage of complications and quick rehabilitation. It is recommended in acute as well in chronic injuries with very good results. The good results were not varied with time during follow up. Advantage of this operation represents the no use of metals. The pull angle of the ligament might create an anterior sublaxation during reduction of the dislocation, but this does not influence the results.

J.C. Feroussis A. Zografldis P. Dallas N. Konstantinou K. Tsevdos C. Pergaris

Aim: The common anatomic pathology responsible for the recurrent dislocation of the shoulder is in younger patients a trauma causes the Bankart lesion. Contrary to that, the common cause for recurrent instability in older patients, which is far more rare, is the massive tear of the rotator cuff tendons. During that the shoulder loose the of the posterior-upper stabilizing element (posterior mechanism according to Neer), and present a secondary anterior-inferior recurrent instability. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion.

Material – Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. The initial injury was associated with dislocation in 2 cases and without dislocation in 3. The other 2 had a prior infection of the glenohumeral joint, which was treated conservatively. The patients who suffered injury were initially treated with a sling for 2 to 4 weeks. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. The radiological findings consisted of subacromial space narrowing, sclerosis and spur formation of the inferior part of the acromion and diffuse osteoporosis. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure (osteotomy of the coracoid process, transfer of the conjoined tendon under the subscapularis tendon and repositioning of the coracoid process) with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases (in one the long head of the biceps was used), and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime.

Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Five cases out of seven showed a satisfactory response to daily life activities.

Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difficulty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difficult to achieve, while the treatment of the instability alone leads to dubious results as far as pain and range of motion is concerned. For the management of the above complex lesion the existing literature is rather poor, and the combination of the Boytchev procedure with an repair of the rotator cuff tear, yielded satisfactory results mainly in regard to pain control, and secondly in achieving a good postoperative range of motion.

H. Dinopoulos P.V. Ciannoudis

Introduction: Knee dislocations are uncommon injuries with most series reporting only few cases over a period of many years. The association of knee dislocations with femoral shaft fractures is exceedingly rare and further complicates the management of this injury. We describe four patients managed at our tertiary care trauma center and evaluate the outcome.

Patients and Methods: Out of 187 femoral fractures treated in our institution over a period of 6 years (1994–1999), 4 patients with 5 femoral fractures and ipsilateral knee dislocations were identified. All four patients (2 female) were in early twenties and involved in high energy road traffic accidents. One woman had bilateral knee dislocation with fractures of both femora and tibiae. None of these four patients had head, chest or major visceral injury. No patient had neurovascular damage or compartment syndrome. All were managed by immediate relocation of the knee, angiography, locked intramedullary nailing of femur and post-operative bracing of the knee for six weeks – either by external fixator or hinged brace. Following discharge from the hospital they were followed up regularly in the fracture clinic. Secondary reconstructive procedures were planned depending on the severity of injury and patient demands. The minimum follow up was two years.

Results: Four of five femoral fractures united within expected time scale. One with nonunion had exchange nailing twice and is presently under follow up. Out of the five knees, four underwent a secondary reconstructive procedure. One patient had an open dislocation of the knee with loss of quadriceps tendon, part of patella and patellar tendon, which was reconstructed with Leeds-Keio ligament strips and a free flap. One other patient required an ACL reconstruction two years after injury and finally had a stable painless knee. The lady with bilateral injury had reconstruction of both PCL 2 years after injury. At the final follow up seven years later, there was residual PCL laxity in one knee and she was mobile with one stick. At final follow up all the patients were assessed by the American knee score.

Conclusion: Femur fractures with knee dislocations are orthopaedic emergencies. These injuries should be treated by immediate relocation of the knee, stabilization of the femoral fracture and ensuring normal distal circulation. In our patients, we have braced the knee initially and symptomatic instability was later on managed by appropriate ligament reconstruction procedures. Cross instability may require application of bridging external fixator to facilitate knee ligament healing. Two patients in this series had a good outcome with stable painless knees. The treatment has to be individualized in each situation to achieve an optimum result.

P.V. Giannoudis H. Dinopoulos

Introduction: Injuries to the urinary tract are a well known complication in patients with pelvic trauma. A severe urological injury frequently results in adverse long term outcome and prolonged disability. We present a review of the results of management of urological injury and the impact on final outcome in patients with pelvic fractures.

Patients: Out of 554 patients admitted to our center with pelvic fracture, 39 with injury to the urinary tract were identified – 8 females and 31 males (study group). The mean age of the patients was 30.9 yrs (range 15 to 71 yrs) and the mean ISS was 12.9 (range 9 to 22). Two patients had a skin wound communicating with fracture hematoma. Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. The mechanism and type of injury, initial management, timing of urological intervention, orthopaedic procedure complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to age and sex matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow up period was 2.3 years.

Results: Upper urinary tract injuries: All were managed nonoperatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy. Three had acetabular fractures (one ant column and 2 both column fractures) and 4 had pelvic ring injuries (2 AP, 2 LC). Six were operated with av. time delay between injury and surgery being 7.1 days. We consider the urological injury related to the general trauma rather than the specific pelvic injury. Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extra-peritoneal tear was managed nonoperatively. Seven had LC injury, 6 had ARC and 2 had acetabular fractures (both column). One of the acetabulum fractures was managed by fixation and bladder repair on the day of arrival and the other had secondary congruence, which was not operated. Pelvic ring injuries were managed by internal and/or external fixation as appropriate. The average time delay between injury and surgery was 1.8 days. One patient with AP2 fracture died after 3 weeks due to severity of associated visceral injuries. Three patients reported failure of erection. All three patients with bladder neck injury had an APC fracture. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function. Thirteen males had urethral injury – average age 37 yrs (range 19 to 70 years). Five had APC and five LC pelvic ring injuries, three had acetabular fractures. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends and delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture. The only female patient with urethral injury had an open tilt fracture associated with urethral tear.

The control group had 7 acetabular fractures, 19 AP compression, 17 lateral compression injuries and 4 vertical shear injuries. Four were managed nonoperatively. None of these had an open fracture. The average time delay between injury and surgery was 2.2 days.

We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D.

Conclusions: Upper tract and bladder injuries in the context of pelvic trauma can be successfully managed as described, they do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function. Early management with primary alignment at the time of pelvic stabilisation and a delayed repair if required produced good results. A high index of suspicion and routine retrograde urethrograms would reduce risk of missed or iatrogenic injury. A team approach is required to achieve optimum results.

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V.N. Psychoyios H. Dinopoulos F. Villanueva-Lopez E. Zambiakis M Hamdeh

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment.

Material: There were 11 patients with an average age of 40 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but one fracture ware closed. The level of the tibia fracture included midshaft (two), middle-distal third (seven), distal third (two). Seven of the ankle fractures were classified as Weber B, three as Weber C and one Pilon. One fracture was treated by cast immobilization, eight with ORIF of both fractures and two with a combination of internal and external fixation. Of the patients treated operatively, five were treated initially in long leg casts, but each required surgical intervention to control fracture alignment.

Results: The average follow up was twenty- three months. The non-operatively treated fracture resulted in a mal-union and a severe loss of ankle mobility. Of the cases managed operatively, seven had complete structural and functional recovery, two patients regained 70% of ankle mobility and one developed ankle arthritis.

Discussion: The resulted experience from the treatment of these injuries shows their extremely unstable nature. It has been our experience that the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, a progressive slippage occurs over the time. We believe that stable fixation of both fractures should be the treatment of choice.

E.I. Karadimas J. Petroutsas K. Tsambazis C. Karabalis P. Papasteliatos G. Theodoratos

During the decade 1986–1996 were admitted in our hospital 2267 patients with hip fractures. From them 179 (7.98%) had already operated on for fracture to their other hip and the majority of them had a good way of life after the first operation. In 125 cases (69.83%) the second fracture was similar to the first.

The mean age was 78.5 years. From the 179 patients, 145 were women and 34 men (rate 4.3/1). The 94 (52.5 %) were intertrochanteric and the other 85 (47.5%) subcabital fractures. The mean time between fractures was 6.5 years in patients under 70 years and decreased in those over 80 years in 3.5 years.

On the bases of our follow up, mean time 18 months (12m–24m), from the 179 patients, 55 (30.7%) died during the first six months, (3 during hospitalization) and 13 (tot 37.98%) later but before our re-examination.

The evaluation of the remaining 111 patients, according pain and activities of the patients was: 16 (14.3%) very good, 52 (47%) good and 43 (38.7%) fair.

The patients with the better results were those under 75 years, who had similar hip fractures and had been operated on the first 3 days. In the other hand the majority of the 43 patients with the fair results were over 85 years.

We found out that the bilateral non simultaneous hip fractures had a high mortality incidence. We believe that, except the age, there were other risk factors for this high mortality, such as, cardiovascular diseases, chest and urinary infections, bed sores etc.

We noticed also that in all patients there was a decrease of the bone mass as a result of the extended immobilization and poor nutrition.

P.V. Ciannoudis H. Dinopoulos T. De Costa SJ. Matthews

Purpose: To document the incidence of neurological lesions and functional outcome following displaced acetabular fractures.

Patients and Methods: Prospective review of patients who underwent stabilisation of acetabular fractures in a University Hospital trauma centre. From December 1994 to November 2000 136 patients were identified with acetabular fractures. The open reduction and internal fixation of the acetabular fixation was performed by standard operative techniques. The time from the initial injury to the operation ranged from 24 hours to I4days. Patients with sciatic nerve injuries were prospectively followed up and long-term outcome recorded. Weakness or absence of dorsiflexion or plantar flexion was graded according to the standard Medical Research Council. Abnormalities of sensation, including absent or diminished sensation to light touch and pinprick as well as dysesthesia or hyperesthesia of the dorsal and plantar aspects of the foot were recorded. None of the patients had an injury of the spinal cord. Intra-operative monitoring was performed in most cases, and routine electromyography and nerve -conduction studies were done post-operatively and at least on one more occasion to record the level and severity of the lesion and to monitor progress of recovery. All the patients were followed up clinically in the trauma clinics and functional improvement was routinely assessed. The mean follow up of the patients was 3.4 years (range 1.5–6 years).

Results: Out of 136 patients who underwent stabilisation of acetabular fractures there were 27 (19.8 %) cases of neurological lesions. In 12 cases the femoral head was dislocated posteriorly. Twenty were men and eight were woman. The mean age was 33.8 (range 16–66). 15 patients had associated injuries. The mean ISS was 12.6 (range 9–34). At initial presentation there were 13 patients with a complete dropped foot lesion, 10 patients with foot weakness and 4 patients with burning pain and altered sensation over the dorsum of the foot. Intra-operative monitoring was performed in 16 cases. All the patients had EMG studies for neurophysiological assessment of the lesion. EMG studies revealed sciatic nerve lesions in all the cases but in nine patients with a dropped foot there was evidence of a proximal (sciatic) and distal (neck of fibula) lesion, “double crush syndrome”. Only in 3 of these cases there was documentation of an ipsilateral knee injury. In two patients there was deterioration of foot function after surgery due to iatrogenic damage. At final follow-up, clinical examination and associated EMG studies revealed full recovery in 5 cases with initial muscle weakness (mean time 4.2 years (2–5)) and complete resolution of sensory symptoms (burning pain and hyposthesia) in 4 cases (mean time 3 years (2–4)). There was improvement of functional capacity (motor and sensory) in two cases with initially complete drop foot and in 4 cases with muscle foot weakness (mean time 3.6 years (range 2–6). In 11 of the cases with dropped foot (all nine with “double crush”) at presentation, there was no improvement in function, (mean time 3.9 years (range 2–6).

Conclusion: Acetabulum fractures associated with sciatic nerve injuries continue to be a significant cause of long-term morbidity in trauma patients. In cases where there is evidence of “double crush lesions” the prospect of functional recovery is low as seen in this group of patients. Single lesions appear to be associated with a more favourable prognosis.

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H. Dinopoulos P.v. Giannoudis

Purpose: To determine any relation between scapular fracture, severity of chest injury and mortality in patients with multiple injuries.

Patients and Methods: We reviewed 621 consecutive patients admitted over a five year period (1995–1999) with multiple injuries. All had an associated chest injury. Such details were recorded and analyzed as – mechanism of injury, ISS, AIS for chest, GCS, ICU stay, total hospital stay, operations performed, presence or absence of scapular fracture, complications and mortality. Patients with chest injury but without scapula fracture formed the control group of the study.

Results: Out of 621 patients with multiple injuries (mean ISS 27.5), 79 (17 women) (12.72%) – group 1 were identified with scapular fractures. 542 (122 women) patients with chest injury but no scapular fracture formed the control group – group 2. The mean age of group 1 was 42 years versus 40 years of group 1 and the mean ISS was 27.12 (SD 15.13) and 28. 41 (SD 14.21) in group 1 and group 2 respectively (p value > 0.05). In group 1 the chest AIS was 3.46 (SD 1.10) and 3.18 (SD 1.06) in group 2 (p value < 0.05).The most common associated chest injury in group 1 was pneumothorax (28%) followed by pulmonary contusion (15.2%) whereas in group 2 it was likewise pneumothorax (20%) followed by pulmonary contusion (21%). There were 8 (10.1%) flail segments in the scapula group, versus 50 flail segments (9%) in the non scapula group. In group 1 there was an incidence of 3.8 % associated thoracic vertebral fractures compared to 8.3% in group 2. 2.6 % of patients in group 1 had major vessel injury or cardiac laceration as compared to 3 % in group 2. There were 4 brachial plexus injuries in group 1 (5.1%) versus nil in group 2. In group 1, 32 (40.5%) patients had sustained associated abdominal injuries mean AIS 3.1 versus 190 (34.6%) in group 2 with a mean AIS of 2.9. In the scapula group there were 31 clavicle fractures, 12 humerus fractures and 4 shoulder dislocations. In the non-scapula group there were 137 clavicle fractures, 93 fractures of the humerus and 2 shoulder dislocations. The mean hospital stay in both groups was 22 days (range 5–153). In group 1 the mortality rate was 11.4% (9 patients) mean ISS 48 (range 24–75) versus 25% (136 patients) mean ISS 41.3 (range 17–75) in group 2.

Conclusion: Patients with scapular fractures were found to have a higher chest and abdominal AIS. Overall, the scapular fracture was not associated with higher ISS or higher mortality and does not correlate with a poorer outcome.

C.I. Drosos P. Kouzoubasis N. Stavropoulos E.H. Kayias K. Tsioros E. Miliotis

Aim: The aim was to study the blood loss and the need for transfusion in patients with fracture of the upper end of the femur.

Patients – Methods: In a prospective study we included 50 patients with intertrochanteric fractures (Group 1) and patients with fractures of the femoral neck (Group 2). Patients with other concomitant injuries or fractures were excluded. The blood loss and the need for transfusion were studied using as lower limit for transfusion Hb 10 gr./dl.

Results: The average age of the patients was 80.2 years (s.d. 8.3). Patients of the Group 2 (mean 73, s.d. 10) were younger than patients in Group 1 (average 82, s.d. 5.6).

Two thirds of the patients were women, with higher proportion of women in Group 1 (women: 81.3%, men:18.7%) than in Group 2 (women: 66.7%, men:33.3%).

In Group 1 the average blood loss (3.4 units) as well as the average need for transfusion (1.9 units) was higher than in Croup 2 (average blood loss 2.8 units, average need for transfusion 1.6 units). The average Hb admission in Group 1 was 11.4 and in Group 2 was 11.8.

In patients that were operated on within the first 24 hours after the injury, the average blood loss was lower than in patients who were operated on later.

Conclusions: In patients with intertrochanteric fractures the blood loss as well as the need for transfusion was higher than in patients with femoral neck fractures. Early surgical treatment led to less blood loss.

I. Hatziantoniou E. Hatzianagnostou G. Diakos

Purpose: It is known that postoperative delirium and hypoxia are factors that make mobilisation of elderly patients more difficult. Our purpose was to estimate the rate of hypoxia and delirium postoperatively, and their possible correlation, in elderly people suffering from a hip fracture.

Material: One hundred-seventeen patients (35 male, 82 female) over 65 years old were studied. Sixty two of them, who had a fracture of the neck of the femur and 15 with an intertrochanteric fracture were treated with a hemiarthroplasty, and 40 who sustained an intertrochanteric fracture were treated with internal fixation with a gliding screw and a plate. Spinal anaesthesia was used in all patients. Their age was 65–97 (average 79, 7). Patients suffering from dementia or Alzheimer were excluded.

Method: We counted satO2 preoperatively and until the fourth postoperative day. Postoperative delirium was assessed with the Confusion Assessment Method (CAM). Postoperatively, O2 was given at patients with satO2< 90 or when saturation was 5% lower than the preoperative.

Results: Hypoxia occurred in 60 patients (51,28%), which was usually reduced until the 4th pop day. In two patients who suffered from chronic respiratory failure, hypoxia persisted until the 10th pop day.

Postoperative delirium occurred in 31 patients (26,5%). Seventeen of then had also hypoxia. Two patients didn’t recover until their discharge from the hospital. In one of them the delirium persists 3 months pop. Correlation between delirium and hypoxia was not noticed (p< 0,0024), neither the delirium was better after the administration of O2 in hypoxaemic patients, altought satO2 was made better.

Conclusion: Hypoxia, postoperatively, in elderly patients, sufering from hip fracture is usual, but it is made better after the 4th pop day. Postoperative delirium in these patients is also usual. In our study there was no correlation between delirium and hypoxia. Delirium wasn’t any better after administration of O2.

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G. Petsatodis A. Xatzisimeon E. Samoladas I. Pournaras

Aim: The scope of this study is to estimate the blood loss in major orthopaedics operations in the 24 and 48 hours, in order to evaluate the need of drainage for more than 24 hours.

Material-Methods: 100 consecutive in-patients included in this study and we formed 4 groups. Group A: THR (cemented-cementless), group B: TKR, group C: hemiarthroplasty, group D: DHS due to intertrochanteric fracture. We applied a drainage in all the patients for 48 hours and we measured the blood loss in 24 and 48 hours, the Hb for the next three days and the transfusion units.

Results: In group A the mean blood loss is 513, 75 ml in 24 hours and 147,08 ml in 48 hours. In group B the mean blood loss is 559, 62 ml in 24 hours and 91,31 ml in 48 hours. In group C the mean blood loss is 190 ml and 35, 6 ml in 48 hours. In group D the mean blood loss is 140, 48 ml and 16, 4 ml in 48 hours.

Conclusions: There is no need to keep the drainage more than 24 hours in the groups of hemiarthroplasty and DHS since the blood loss after 24 hours is minimum. We suggest to keep the drainage more than 24 hours in the groups of THR and TKR since there is significant blood loss after 24 hours.

E.L Fufulas D. Tsintzas B. Gabriilidis

The aim of this paper is to compare the effectiveness on the amelioration of symptoms of hip osteoarthritis (OA) between Nimesulide and intraarticular injection of Hyaluronic acid (HA).

In the Orthopaedic outpatient department of our Hospital we selected 22 patients suffering from hip osteoarthritis as it is defined by the American College of Rheumatology after clinical, radiological and blood examinations. The age range was 62 – 82 years and were all female. They were seperated into two groups.

Group A included 13 patients treated with Nimesulide (NSAID) for a period of 20 days and Group 2 included 10 patients treated with five intraarticular injections of HA in the hip joint, one every week, under ultrasound control. Before treatment initiation we performed clinical examination for active and passive flexion, internal and external rotation of the hip. Pain evaluation was with VAS and Lequense algofunctional index. We repeated the examination and evaluation a month, six months and a year after the end of the treatment.

Following the Helsinki proclamation we did not use placebo group.

The results in group A has shown that 8 patients had considerable amelioration of their symptoms, 3 has a mild amelioration and 2 patients none.

In group B considerable amelioration was observed in all 10 patients. We have noticed that although therapeutic result is usually expected at the end of the treatment, 6 of the patients had improvement after the first 2 intraarticular injections, especially for night pain, and the others just before the end of the treatment.

The duration of the improvement for group A was 15 days in one patient, 30 days in seven and 3 months in three patients.

In group B the duration of improvement was 20 days in one patient, 2 months in two, 6 months in five and 11 months in two patients.

In patients of group B symptoms’ recurrence was not so intense as in the first time. In group A symptoms’ recurrence was at the same level as before treatment initiation. No complication was observed from the intraarticular injections.

In conclusion we could say that treatment with HA is more effective concerning the duration of the symptoms amelioration. There is no risk from gastrointestinal complications.

D. Polyzois J. Kouvaras V. Polyzois P. Samelis K. Koukos

This study evaluates the results of our technique of proximal tibial osteotomy for treatment of osteoarthritis of the medial compartment of the knee.

One hundred and thirty eight knees were operated upon from 1981 to 1990. The degree of appropriate correction was measured in standing radiographs of the whole limb. Our technique consists of the creation of an osteotomy running obliquely just above the tibial tuberosity to the posterior tibial surface. No wedge is removed. Realignment is obtained by sliding the two osteotomy surfaces until the desirable correction is obtained. The osteotomy is fixed by a 90° blade-plate. By this technique precise correction can be achieved.

One hundred and seventeen knees were evaluated after a mean FU of 5, 5 years with 91% excellent or good result. In a second evaluation of 93 knees in a mean FU of 7.8 years, the good results dropped to 72%. In a third evaluation of 81 knees, after a mean FU of 11.8 years (range 9 to 16), only 54% of the knees maintained acceptable results.

The best results in the last evaluation were seen in 43 knees in which the postoperative alignment of femorotibial angle was 178° to 182°. Undercorrected or excessively overcorrected knees showed deterioration of the results in 4 to 9 years depending on the degree of mal-correction.

The results deteriorate with passage of time especially if precise correction is not achieved. Accurate preoperative radiographic measurements and precise operative technique is required to obtain exact correction of the axis in order to maintain the good results for a long period of time.

M. Drymoussis G.G. Karahalios G. Salagiannis E.J. Vlahos

Introduction: High tibial osteotomy is considered as alternative treatment for the unicompartmental arthritis of the varus knee. Low tibial osteotomy due to delayed union is avoided. Corticotomy and the use of external fixation system for stabilization and progressive correction of the axis offers all the osteotomie’s advantages, and, furthermore, reduces the bone healing time.

Material and Method: Fifty-seven patients, aged 49–76 y. (mean age 63.2 y.) with unicompartmental arthritis of the knee were treated, using the above technique. In all the cases arthroscopy was firstly performed to examine the knee joint. The mean time of external fixation presevation was six weeks. Folllow-up examination ranged from 6 months to ten years (mean time 6 y.). Since, the second postoperative day partial weight bearing was permitted. Patient’s hospitalization was 3 days. Postoperative correction of the axis was 1° per day, for 12–15 days.

Results: Regarding the pain and the range of motion the results are excellent in 49/57 patients. Loss of full knee extension was presented in one patient. Lateral knee instability and pain were presented in 3 patients. One patient was submitted in total knee arthroplasty two years after the osteotomy. Delayed-union of the osteotomy was presented in 4 patients that were fully healed, while non-union was presented in one patient. Two patients presented peroneal nerve neurapraxia, that were fully healed.

Conclusion: Conclusively, knee osteotomy with the use of external fixation system and progressive correction of the axis is a reliable method for the treatment of the unicompartmental arthritis of the knee. It permits the early weight bearing of the limb and offers very good results regarding pain and range of motion.

C. Papakostidis A. Grestas D. Vardakas E. Motsis D. Tsiampas I. Chrysovitsinos

Introduction: High tibial osteotomy is an established procedure for the mid-term treatment of unicompartmental osteoarthritis of the knee. Nevertheless, it produces anatomic alterations of the proximal part of tibia, which might affect the later performance of TKR. These anatomic changes are basically patella infera and medialization of the tibial medullary canal with respect to the tibial plateau (tibial condilar offset).

Material and Method: The purpose of the present retrospective study is the evaluation of the above mentioned anatomic changes, caused by high tibial valgus osteotomy (Mittelmeier’s technique). For this purpose we studied the X-rays of 44 kness (pre-op, p-op and 1 year p-op) that had under gone the above procedure.

Results: We didn’t find any statistically significant difference of the postoperative position of the patella with respect to the preoperative one, whereas there was definite medialization of the tibial anatomic axis with respect to the preoperative situation. The latter change was directly correlated with the degree of valgus correction. The mean change of the tibial anatomic axis (as estimated by the value of the tibial condylar offset ratio) was 15%.

Conclusions: Although Mittelmeier’s high tibial valgus osteotomy does not cause any significant alteration of the position of the patella, it does alter the relationship of the tibial medullary canal with respect to the tibial plateau in direct correlation with the degree of valgus correction. Thus, the performance of TKR after proximal tibial osteotomy necessitates a thorough preoperative plan and the selection of the appropriate implant.

C. Gimtsas K. Gouvalas S. Tsourvakas N. Ameridis

The efficacy and safety of hyaloyronic-acid in patients with osteoarthritis of the knee were investigated, in the present study.

A total of 125 patients were included in the study during the last five years (1996–2001). Treatment was one weekly, intraarticular administration of 20-mg/2ml hyalouronic acid for 5 consecutive weeks.

All the patients were clinically assessed before each injection and every three months after the end of the therapy. X-ray examinations were performed 6 months and one year after the end of therapy. All 125 patients complete the study.

Spontaneous pain decreased during the treatment course and continued to decrease-up to the end of the study in patients with 1st and 2nd stage osteoarthritis of the knee. In these patients observed a substantial improvement of morning stiffness and supra-patellar circumference. In all patients there weren’t any x-ray improvement at the end of the therapy. The pain and joint stiffness were reapproranced in all patients after a mean time of five months after the end of the therapy. We didn’t observed any local or systemic adverse during the therapy. The results of this study demonstrate that intraarticular administration of hyalouronic-acid is safe and effective and confirms that the product is a valid alternative in the treatment of osteoarthritis of the knee.

L. Badras l. Vossinakis V. Ceorgaklis H. Paleochorlidis E. Skretas D. Kafidas

The aim of this study is to evaluate the mid-term results of the Genesis I Total Knee prosthesis (asymmetric tibial component plateaus), retaining the posterior cruciate ligament and not resurfacing the patella in all patients.

Between 1992 and 1999, 90 patients (116 knees) were operated (81 women and 9 men) of an average age of 68 (52–82) years. The indication for the operation was osteoarthritis. 84 patients (109 knees) were evaluated clinically and roentgenographically (Knee Society Knee Score). The average follow-up time was 74.1 (29.6–113.7) months.

There were no cases of infections. Three of the patients required a second operation. Two of them had their patellae replaced (1,5 and 3 years postoperatively) due to persisting patellofemoral pain. In a third patient the knee was revised due to excessive wear of the polyethylene component five years postoperatively. Moreover, major polyethylene wear was also observed six years postopertively on another patient, asymptomatic and unwilling to undergo a revision. The clinical results were satisfactory with a mean Knee Score of 97 (74–100) and a Function Score of 80 (5–100). The mean range of motion was 113° (85°–135°). There was no evidence of loosening or any radiolucent line found radiographically.

We consider the results of the Genesis I Total Knee Arthroplasty satisfactory. The asymmetric shape of the tibial condyles ensures the fitting of the tibial component. Even in cases of severe patella damage, we believe that replacement of the patella is not required. Occurrence of patellofemoral problems can be usually attributed to mal-tracking of the patella or to component malposisioning.

S.A. Syggelos E. Ciannopoulou E. Panagiotopoulos J. Varakis A. J. Aletras

Aim: To examine the in vitro effects of several non-steroidal anti-inflammatory drugs (NSAIDs) on pro-inflammatory cytokines and PGE2 production by interface membrane from loose endoprosthesis of hip or knee arthroplasty. Since these factors are strongly implicated in the bone resorption process and aseptic prosthesis failure we hypothesize that the probable inhibition of their production by prophylactic administration of NSAIDs, will retard these processes.

Materials and Methods: Interface membranes were harvested from ten patients who were subjected to revision surgery for aseptic total hip or knee replacement loosening and cultured for 72h in the absence or presence of therapeutic dosages of each, of aceclofenac, piroxicam, tenoxicam and indomethacin. Paracetamol was used as neutral control. In conditioned media the levels of IL-6, IL-1 (3, TNF-a and PGE2 were determined by ELISA and the data were analyzed by the Student’s t-test (significance level p< 0.05).

Results: All the tested NSAIDs caused a statistically significant decrease on IL-6 and TNF-a levels, with aceclofenac and tenoxicam to be more effective (caused decrease in 7 out of 10 samples), while they had low or controversial effect on IL-1β production, except aceclofenac that seemed to augment the IL-1β levels (statistically significant increase in 5 out of 9 samples). Finally all the tested drugs, except paracetamol, caused a marked reduction (80–99%) of PGE2 levels.

Conclusions: The stimulatory effect of IL-6 and TNF-α in the osteoclastic bone resorption process is well established. Considering the above results, the tested IMSAIDs (especially aceclofenac and tenoxicam) reduce the in vitro production of these mediators by interface membranes. Hence, it is reasonable to propose that the prophylactic treatment with these drugs could delay the process of the aseptic loosening. However, in order to support this hypothesis, more experiments are required by which the effects of them on other factors implicated in the loosening process, such as metalloproteinases, will be examined.

K. Panousis B. Rana J. Reilly I. Butcher P. Crigoris

Introduction: Infection constitutes a serious complication of joint arthroplasty, with an incidence of 1–2% after primary arthroplasty and even higher after revision procedures. Detection of low-grade infection in a prosthetic joint can often be very difficult, with huge implications on the subsequent treatment, cost and patient morbidity. Revision of an unrecognised infected arthroplasty may lead to less satisfactory results in a high proportion of cases. We utilized Polymerase Chain Reaction, a molecular biology technique to detect bacterial DNA from the synovial fluid of patients undergoing revision surgery, in comparison with conventional infection detection techniques.

Methods: We prospectively assessed 81 patients undergoing revision arthroplasty (67 hips and 14 knees). Each patient was pre-operatively assessed clinically and radiologically. ESR and CRP results were noted. During revision, synovial fluid and tissue cultures were obtained and antibiotics were given only after the specimens were taken. Standard microbiology and histology study were done on tissue samples. In addition Polymerase Chain Reaction study was performed on the synovial fluid. In this method, DNA is extracted from the bacterial cell; it is polymerised and finally visualized by gel electrophoresis. Post-operatively patients were followed up at regular intervals. Diagnosis of infection included correlation between clinical, radiological and laboratory investigations along with intra-operative findings, tissue culture and histology results and a period of postoperative follow up of 12 to 36 months.

Results: Eleven (13.58%) of the 81 cases that had revision arthroplasty were clinically infected. Polymerase chain reaction was positive in 30 cases, tissue cultures were positive in 8 cases and histology was positive in 10 cases for infection. PCR showed sensitivity and specificity of 0.92 and 0.72 respectively. Tissue culture showed sensitivity and specificity of 0.72 and 0.81 respectively. Histology showed sensitivity and specificity of 0.9 and 1 respectively.

Discussion: Twenty out of 30 PCR positive cases did not show any clinical evidence of infection. It is unclear whether this represents contamination during surgery or in the PCR lab. Alternatively this may represent true positive PCR results in cases with low bacterial count or bacteria growing within a biofilm that can be detected only by ultrasonication of the implant and immunofluorescence methods. PCR could also be detecting non-culturable forms of bacteria or bacterial fragments.

Conclusion: PCR has high sensitivity and low specificity for detection of bacterial DNA. The combination of tissue cultures and histology can still provide a reliable diagnosis of infection.

K. Papaioannou V. Karamoulas Ch. Bikos Em. Papacostas I. Petkidis T. Papaioannou

Aim: There are more than 50 methods for the treatment of Reflex Sympathetic Dystrophy Our aim is to test how effective is the treatment of patients with Reflex Sympathetic Dystrophy with guanethidine

Method: 15 patients (F=12, M=3, Mean age 59.9) were seen in the chronic pain clinic with Reflex Sympathetic Dystrophy. 13 patients had sustained a Colles fracture and 11 of them had a closed reduction and application of POP and 2 had an external fixation. 1 had an operation for release of median nerve and 1 amputation of 3 fingers due to trauma. There were first seen in the Pain Clinic 12–16 weeks after the initial injury. Main symptoms were pain and stiffness. On examination all of them had oedema of the hand, stiffness and discoloration. Allodynia was present in 8. Patsy osteoporosis was evident on the x-rays. Palmar elytritis with atrophy in 6. The treatment was intravenous sympathetic block with 20 mg guanethidine plus 2ml 2% lignocaine and N/Saline up to 20 ml. The second block was repeated after 3 days and the following depending on the response to pain. Physiotherapy session followed each block.

Results: 2 patients needed 5 blocks, 7 patients 4 blocks, 5 patients 3 blocks and 1 patient 2 blocks. In the end there was complete regression of the pain, oedema and restoration of the movement.

Conclusion: The sympathetic block with I.V. administration of guanethidine in combination with physiotherapy seems to be a safe and simple treatment of choice, well tolerated and with good results.

A. Karageorgos A.X. Papadopoulos M. Marangos M. Tyllianakis

Aims: Evaluation of postoperative infections in T.H.R. and T.K.R., after randomized prophylactic use of Fusidic acid, Vancomycin and Cefuroxime and assessment of their side effects.

Methods: From December 2000 to April 2002, 128 patients were operated on T.H.R. and T.K.R. in Orthopaedic Department of University of Patras (64 for T.H.R. and 47 for T.K.R.). Mean age was 66.5 years (range 45–90yrs.). The patients were categorized into three groups. In the first group was administrated Fusidic acid 500mg and Cefuroxime 1.5gr preoperatively and 2 doses of Fusidic acid 500mg postoperatively. The second group received Vancomycin 1gr and Cefuroxime 1.5gr preoperatively and 2 doses of Vancomycin 1gr postoperatively. The third group received Cefuroxime 1.5gr preoperatively and 2 doses of Cefuroxime 750mg postoperatively. Blood tests were systematically performed preoperatively, and the first and fifth postoperative day. Mean follow up was 8 months. Results: No deep wound infection was observed. Superficial infections developed 2 pt. (1.58%) of the first group, 2 pt. (1.58%) of the second group and 3 pt. (2.3%) of the third group. Temperature over 38.3° C attributed to another infection site was observed in 4 pt. of the first group, 2 pt. of the second group and 7 pt. of the third group, while temperature over 38.3° C with unknown origin was noted in 7,2,6 patients respectively. No side effect was recorded.

Conclusions: The proper use of antibiotic prophylaxis according to pharmakokinetic and pharmakodvnamic properties combined with sterile surgical techniques, prevents early deep wound infections in T.H.R. and T.K.R. The use of specific antistaphylococcal agents is of no benefit in antimicrobial prophylaxis for the above operations.

J. Lazarettos N. Efstathopoulos C. Papachristou K. Kanellakopoulou E. Giamarellou A. Kapranou J. Elemenoglou A. Papalois

Aims: The effectiveness of the local treatment of experimental osteomyelitis by MRSA with a mixture of calcium phosphate bone cement and 3% teicoplanin into the femur of rabbits.

Methods: Thirty-six male rabbits with chronic (3 weeks) MRSA (Methicillin Resistant Staph. aureus) osteomyelitis of the right femur (Model of Norden CW) were treated with a new local Teicoplanin delivery system prepared by a mixture of calcium phosphate cement plus 3% teicoplanin. Osteomyelitis was introduced by inoculating 107 cfu/ml of the MRSA strain in a 2mm hole of the bone medula, placement of a needle serving as a foreign body and subsequent closure with a sterile bone wax. The follow-up of the infection was performed by clinical, microbiological, x-rays and histological findings. On the third week all animals were reoperated and the needle was removed followed by implantation of the above mixture. One control and five treated animals were sacrificed each week thereafter until the sixth week.

Results: Cultures of the treated animals were positive during the first week but turned negative after the second week, while throughout the same period cultures from the controls remain positive. Clinical and histologic studies were in accordance.

Conclusions: The above mixture could be approved as a supplementary method in the treatment of bone infections. It can be used by replacing the gentamycin polymethylmethacrylate beads whose use demands reoperation to be removed. Finally it offers the possibility to contribute to the filling of the bone gaps as it can be replaced by host bone.

Z. Kanonidou D. Atmatzidis E. Christou A. Tourtoglou M. Ventouri I. Terzidis A. Christodoulou

The purpose of this study was the investigation and treatment of all the complications that may occur from the epidural postoperative analgesia in patients who have undergone major orthopaedic surgery.

From October 1999 to April 2002, 200 patients ASA I- III, aged 45–90 (average 72) were studied. They all received postoperative epidural analgesia and were given a mixture of local anaesthetic and Opioid analgesic, more specifically Ropivacaine 2% 10 ml/h and Morphine 0, 1 ug/h via the epidural catheter by means of a stable infusion pump.

The analgesic effect covers the patients for the first 2–3 postoperative days and permits earlier and pain free mobilization and physiotherapy. The analgesic result of this method was completely satisfactory with a mean of VAS 96.

The most frequent side-effects were nausea and vomiting. Pruritus, mild hypotension, hypaesthesia and motor blockage were documented as well but in a very small percentage. No case of respiratory depression or medical toxicity was mentioned, neither epidural haematoma nor infection due to the placement of epidural catheter. The complications during the recovery phase were treated easily by discontinuation of the infusion or by symptomatic therapy.

Epidural analgesia with a steady infusion pump is a secure method of analgesia. However it is of great importance that the patient is informed about the epidural anaesthesia and postoperative analgesia, in a such a way as to attain his/ her consent, participation and collaboration for the best therapeutic result.

I. Sarris D Sotereanos

Proximal Row Carpectomy (PRO has been used as an alternative treatment for advanced radiocarpal arthrosis and carpal collapse. Its use has been recommended for Kienbock’s disease, chronic scaphoid nonunion and scapholunate advanced collapse (SLAC) deformity.

Materials – Methods: Twenty-three patients were divided into two groups: group 1, consisting of patients with Kienbock’s disease (10 patients), and group 2, consisting of patients with scapholunate advanced collapse (13 patients). The average age was 51 years (range 27–69) for group 1, and 45 years (range 29–57) for group 2. The average follow-up was 30 months for Kienbock’s disease (range, 23–49 months) and 31 months for SLAC deformity of the wrist (range, 24–51 months). Pre-operative staging was performed on all patients utilizing Lichtmann’s (Lichtmann and Degnan, 1993) classification for Kienbock’s disease and Watson’s (Watson and Ballet, 1984) classification for scapholunate advanced collapse.

The procedure was performed as described by Jorgansen (1969) utilizing a dorsal midline approach between the third and fourth dorsal compartments. Styloidectomy, preserving the radiocapitate ligament was performed in 7 out of the 23 patients (5 Kienbock’s and 2 SLAC wrist’s patients). Posterior Interosseous Nerve neurectomy was performed in 2 out of the 10 patients with Kienbock’s disease. Results: Statistically significant differences were noted between the Kienbock’s disease group and the SLAC wrist group (p=0.0023). Of the patients who underwent PRC for Kienbock’s disease 9 of 10 patients reported moderate to severe pain at the final follow-up visits. In the scapholunate advanced collapse group, 2 out of 13 patients demonstrated moderate or severe pain. It was noted that the patients in the SLAC wrist group lost less motion overall than those in the Kienbock’s dis ease group (p=0.00l 5). It was noted in the Kienbock’s disease group that at final follow-up the operated hand was weaker than preoperative (p=0.022). In the scapholunate advanced collapse group there was improvement of postoperative grip strength.

Conclusion: We currently recommend the use of wrist arthroscopy as an adjunct to determine the status of the lunate articular surface in Kienbock’s disease, before performing a proximal row carpectomy. Our results indicate that despite only minor chondromalacia of the capitate articular surface and lunate facet of the radius, the use of PRC in Kienbock’s has not been rewarding.

E. Apergis E. Karadimas C. Karabalis H. Mouravas S. Anastasopoulos M. Loukas

Introduction: Isolated compressive fractures of the scaphoid and lunate fossa of the distal radius are rare injuries and their closed reduction is almost impossible. Frequently the displacement becomes accepted and conservative treatment was applied which in the long-term could have catastrophic consequences concerning the fate of articular cartilage.

Material and Methods: Seven patients (6 males and 1 female) of mean age 30 years old (range 18–42) were studied with compressive fracture of scaphoid (4 patients) or lunate (3 patients) fossa. All patients (except one with compressive fracture of the lunate fossa who was treated early), were initially treated conservatively. Mean delay of surgical treatment was 36 days (3 patients) while two patients were operated 2 and 2, 5 years postinjury. One patient with fractured lunate fossa had concomitant fracture of the lunate. The vast majority of the patients underwent supplementary imaging techniques (CT scan, MRI, 3D-CT scan). The majority of patients were approached both intraarticularly and extraarticularly.

Results: Results were estimated after an average follow-up of 12 months (range, 6 months – 3 years) according to clinical and radiological criteria. Six patients revealed excellent or good result while one had a fair result.

Conclusion: In conclusion, operative treatment of these intraarticular fractures should be attempted independently of the time elapsed from injury on the premise that there are no arthritic changes and an adequate pre-operative planning has done.

E. Apergis K. Tsampazis J. Petroutsas P. Papasteliatos C. Caras P. Siakantaris

Introduction: Internal fixation of distal radius fractures with dorsal plates (when needed) comprise two potential problems: efficacy of stabilization and the high frequency of tendonitis which forced us to early removal of the hardware. Our purpose is to study the efficacy of the method of stabilization with 2 plates (2mm) the central and radial columns of distal radius according to the technique presented by Regazzoni (1993).

Material and Methods: Eight patients (5 males and 3 females), average 35 years old (range, 20–52 years) were treated with comminuted intraarticular fracture type C (6 patients) or malunion of distal radius (2 patients). A combined approach was used in 4 patients and only dorsal approach in the rest 4 patients. In all patients with recent comminuted fractures a supplementary fixation method with allograft were used. In patients with mal-united fractures the technique with two plates together with iliac graft were applied.

Results: Results estimated after mean follow-up of 14 months (range 9–18 months) according to clinical (pain, range of motion, and grip strength) and radiological (articular congruency, radial height, radial inclination and palmar tilt) criteria. Six patients revealed excellent or good result although two patients with loss of reduction needed a second operation.

Conclusion: We concluded, that when the technique with 2 plates was applied correctly the stability of fixation enhanced because the detrimental rotational forces were cancelled while the frequency of tendon irritation decreased.

I. Galanakis A. Aligizakis P. Katonis H. Vavouranakis K. Stergiopoulos A. Hadjipavlou

Aim: The purpose of this prospective study was an evaluation of results in primary treatment of flexor tendon laceration in zone II. Special emphasis has been given to the postoperative rehabilitation program.

Material and Methods: Nineteen patients, (23 fingers), with laceration of the flexor tendons in zone II were treated operatively. Twelve males and seven females were included in the study. Their mean age was 28 (range, 16 to 50) years. In twelve cases a concomitant laceration of the digital nerve was present, hi all cases primary repair of all injured tendons and nerves was performed and a dorsal splint was applied. On third to fifth postoperative day an exercise program commenced involving passive flexion-active extension of the injured fingers. Eighteen (22 fingers) of 19 patients completed the follow-up.

Results: The results were estimated according to Strickland’s original classification system. In fifteen cases the result was excellent, in five good, and in two fair. Conclusions: After primary repair of injured flexor tendons, close follow-up, early protected motion and unrestricted motion of the interphalangeal joints affers the best chance of restoring optimal function to the hand.

Z.H. Dailiana E. Petinaki F. Kontos A.N. Maniatis K.N. Malizos

Purpose: The purpose of this study was to evaluate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) isolates in the Orthopaedic Department of a new University Hospital, two years from its opening.

Material and Methods: Forty-three consecutive S. aureus isolates, collected from cultures (pus 90%) from consecutive orthopaedic inpatients were included in the study. Resistance to antimicrobial agents was assessed by the disk diffusion method. The mecA-gene was detected by PCR assay, whereas molecular typing of the isolates was performed by PFGE.

Results: Only 5 of the 43 strains (11.6%) expressed high level resistance to oxacillin (MIC ≥ 64mg/L). All these isolates possessed mecA-gene and exhibited resistance, except oxacillin, to more than four classes antimicrobial groups. The remaining 38 isolates (34 beta-lactamase positive) were susceptible to oxacillin (MIC ≤ 2mg/D, and expressed a less resistant type than that of MRSA. Molecular typing by PFGE showed apparent heterogeneity among isolates and the absence of predominant clones. Conclusions: The 11.6% prevalence of MRSA is well below the reported average in the literature. Apparently the isolates originated from different sources of contamination. All patients had previous hospitalizations, where they acquired the infections and subsequently transferred the MRSAs to our department.

Precautions and measures taken in the wards limited the spread and dissemination of the isolates as demonstrated by the heterogeneity and the absence of predominant clones. These findings further reiterate the value of the low-cost, standard preventive procedures to control nosocomial infections in a high-risk orthopaedic department.

N.A. Darlis V.Th. Chouliaras G.D. Afendras A.N. Mavrodondidis G.I. Mitsionis A.E. Beris P.N. Soucacos

The symptomatic non-union of the scaphoid, if left untreated, will eventually lead to established arthritis and by that time important alterations in carpal geometry will have occurred. The aim of this paper is to study the carpal geometry in patients with symptomatic scaphoid non-union without arthritis or with early arthritic changes.

The pre-operative x-rays of 58 patients were retrospectively reviewed and x-rays of 35 of those fulfilling strict criteria for true projections were included (32 posteroanterior and 31 lateral views). Patients’ mean age was 31.3 years and mean time from fracture 50.4 months. The x-rays were digitized and measured using CAD methodology. The measured variables concerned the carpal height, possible displacement of the carpal bones and carpal instability. The non-unions were classified according to the Herbert and Fisher classification and were further categorized in two subgroups concerning the absence (14) or presence (21) of early arthritic changes in the radio-carpal or in one of the mid-carpal articulations (patients with established or generalized arthritis were excluded).

In total (and varying according to the method of measurement) up to 28% of the patients were presented with an affected carpal height, up to 17% with ulnar translocation of the wrist and up to 48% with a DISI pattern of instability. 62.5% of the patients (including patients without radiologicaly obvious arthritis) had increased radial height and radial inclination. After statistical analysis (ANOVA and regression analysis) no significant differences have been found between the morphological groups or between the two subgroups concerning early arthritis. A tendency of the lunate to translocate both in the coronal and the sagital plain simultaneously was found and the measurement methods were correlated.

In conclusion the carpal geometry in scaphoid non-union although altered does not seem to change significantly with the appearance of early arthritis and from this point of view treating non-union with early arthritis with bone grafting and osteosynthesis or even with additional radial osteotomy seems justified.

Papanastasopulos E. Daskalogiannakis A. Andreadakis M. Kourtzeli S. Grylonakis D.P. Michaelides

Introduction : External fixation is a good alternative method for fractures of the distal end of radius that are not manageable for closed treatment. It is a simple technique, and has proved to be safe and effective in our experience.

Material and Methods: We present 25 patients with 26 fractures of the distal end of radius (age 32 to 85, avg 57 yrs) which were treated by external fixation during the last 4 years. Eight fractures were in polytrauma patients, 16 were unstable and one patient had bilateral fractures. According to Frykman classification 2 were in type II, 5 in type IV, 2 in type V, 5 in type VI, 4 in type VII and 8 in type VIII.

The time of surgical treatment since the date of fracture ranged from 9–15 days (avg 12 days) .We used Pennig’s fixator in 22 cases and Citieffe fixator in 4 cases.

Results: All patients were followed up for 8 to 42 months (mean 27, 7). Clinical union was established at an average of 6.5 weeks following the fracture. There was one infection of the distal pins, 2 cases with algodystrophy, but no malunion. For assessment of the anatomical result we used the Sarmiento and Latta modification of the Lidstrom classification: 16/26 (61.5%) were excellent, 8/26 (30.7%) good, 1/26 (3,87%) fair and 1/26 (3.87%) poor.

Conclusion: In comminuted, badly displaced fractures of the distal end of radius, the upper extremity following initial closed manipulation and application of plaster is characterized by a decrease in finger mobility, oedema, and large mass of bandaging. Instability of the fracture nad poor result is expected as soon as the oedema subsides. Alternatively, an external fixator is applied after remission of the edema and before two weeks from the fracture date, so to the fracture is easily reducible. With the delay in fixator application we avoid reduction difficulty and pin infection as the oedema has subsided, we have time to explain everything to the patient and organize the operation . This delay in the application of external fixation in distal fractures of the radius is favored in our department because of the low complication rate, excellent or good (92%) functional results, easy and safe approach.

D. Efstathopoulos P. Aretaiou N. Zagoraios D. Kontoulis N. Cekas N. Christou

In this report we present the results of the primary suture of the flexor tendons in zone II, in 198 patients who were operated in our department between 1998 and the first months of 2001. 142 were male from 16 to 65 years old and 56 were female between 14 to 60 years old. Children below 14 years old are not included in this report.

The majority of patients in this review reported an accident during dancing and late night activities. Patients with complex injuries such as fractures of phalanges, phalangeal dislocations and extensive soft tissue laceration were excluded. The majority of the patients operated immediately within the first 48 hours and only 28 patients (14, 5%) were operated with a delay ranging between 1 – 5 weeks. The suturing technique was variable in all cases. A Bruner (zig-zag) incision was utilized to facilitate. The tendon was sutured using a standard Kleinert technique and 4.0 nylon sutures as supportive sutures, 5.0 nylon sutures were used to suture the epitendon in a continuous fashion. A dorsal splint holding the wrist in 40° of flexion and the MP joints in 70° of flexion and PIPs and DIPs in extension was used postoperatively. Early mobilization was initiated (shortly after surgery, 3 – 4 days) and lasted 4 weeks. After this period the patient underwent a program of full active motion for an additional 4 weeks. They finally allowed to perform freely after a 12-week postoperative period.

We used the Kleinert score to evaluate the surgical results. According to this score results were found to be: Excellent in 80 patients (40%), good in 60 pts (30%), fair in 22 (12%) and poor in 16 pts (8%). Despite the satisfactory overall results we observed a high incidence of tendon ruptures (10%) in 20 patients and this may be related to poor follow up and rehabilitation conditions. No other complications (infection, hematoma formation, and skin slough) were observed in these patients.

Marios D. Vekris N.A. Darlis A.E. Beris G.I. Mitsionis P.N. Soucacos

Aim: Adequate length is an important prerequisite for a functional digit. Over the last 20 years small external fixators have been developed allowing the principles of distraction osteogenesis to be applied to the small bones of the hand. We present our experience in digital lengthening with the contemporary designs of external fixators.

Methods: From 1998 to 2001, 14 patients (15 rays) were treated with metacarpal or phalangeal lengthening through distraction osteogenesis using a monolateral frame with two half-pins on each site of the osteotomy. The mean age of the patients was 21 years (7–48) and the indications were traumatic amputation in 8 and congenital amputation (transverse deficiency, brachydactyly, constriction band syndrome) in 6. The mean distraction period was 3 weeks and the mean consolidation period 7 weeks. No protective splinting or additional bone grafting was necessary.

Results: The distraction callus consolidated in all patients. The mean total length gained was 17, 5 mm (68% of the original length). The mean treatment time was 2, 8 days for every mm of length gained. One patient suffered angulation at the distraction site due to hardware failure and the fixator had to be revised and in another bony prominence was noted necessitating trimming. No infection, fracture or half pin loosening were observed.

Conclusions: Callotasis using contemporary monolateral external fixators is a reliable technique for digital ray lengthening. Meticulous preoperative planning and surgical technique and close observation of the patient during the distraction phase are necessary in order to avoid complications. Over 2 cm of lengthening can be achieved without bone grafting.

V.N. Psychoyios D. Ring J.B. Jupiter

Introduction: The aim of the study was to assess the efficacy of the distal radius π-plate in the surgical treatment of acute, dorsally displaced, unstable distal radius fractures.

Material: 37 patients with an average age of 41 yrs included in the study. Upon dorsal exposure of the fracture and provisional reduction with the aid of a distractor and K-wires, a bending template was used to verify plate length and contour. The plate was then applied and the type, number and location of screws and buttress pins to be used were determined. Eight patients had supplementary fixation. Autologus bone graft was used to fill defects in 28 patients.

Results: The average follow up was 21 months. Radiographic evidence of union was documented at an average of 6 weeks postop. No loss of reduction occurred in any of the patients and no patient complained of residual deformity. The average ROM was 79% of the contralateral side, the average grip strength was 64% of the contralateral wrist and the average pinch strength was 76% of the contralateral hand. No infections, nonunions, wound problems or plate failures occurred. 5 patients developed irritation and 4 had their plates removed.

Concussion: The results of this study verify the safety and the efficacy of the π-plate for the treatment of complex fractures of the distal radius. Furthermore considering the technical advantages of the π,-plate it seems that complex distal radius fractures can effectively be addressed through a dorsal approach and stable internal fixation.

V.N. Psychoyios D. Ring J.B. Jupiter

Objective: Deformity post distal radius fracture can be associated with alterations in carpal kinematics. This study presents a review to detect the prevalence and clinical implications of such deformities and the variables that influence the outcome following osteotomy.

Material & Methods: 29 patients with distal radius mal-union, and an average age of 43 yrs, were treated by a single surgeon with a corrective osteotomy. Along with pain scales, wrist motion, and grip strength, pre and post osteotomy radiographs were evaluated. Preoperatively, 18 patients had dorsal deformity, 9 volar and 2 shortening and malrotation alone. 20 patients had carpal malalignment and 9 normal carpal alignment.

Results: The average follow up was 21 months. 24 out of 29 radial deformities were corrected to normal. Overall 17 patients had post-op normal carpal alignment. Three groups resulted; Group I: 11 patients with pre and post-op “fixed” deformities. Group II: 8 patients with normal pre and post-op carpal alignment; and Group III: 9 patients with “lax” pre-op malalignment converted to normal post-op. 1 patient was normal pre-op and converted to DISI at post-op. There was no statistically difference in outcome with regard to pain, forearm rotation, wrist extension, patient age or time to surgery between the three groups. There was statistically significant greater wrist flexion in Group II and III compared to Group I.

Conclusions: Carpal malalignement post radius osteotomy will have a negative effect on the functional outcome compared to those patients with preoperative carpal deformity, which corrects with radius osteotomy. Knowledge of this association will help advice patients of expected outcomes.

P. Areteou N Zervakis D. Kondoulis Z. Kokkalis N. Gekas D. Efstathopoulos

378 patients have been studied since 1988 when we started the investigation of scaphoid fractures and pseudarthrosis. 306 patients were scaphoid pseudarthrosis and 72 scaphoid fractures or control of fracture healing. This study consists of 3 groups:

Group l: 72 patients with acute injury of the carpus are examined radiographically and no scaphoid fracture was observed. A scaphoid cast is applied in these patients for 10 days. In follow up, the cast is removed and new comparative radiologic examination is performed. In 30 of these patients a scaphoid fracture was observed and the limb was inmmobilized in a scaphoid cast for 4 weeks. In the remaining 42 patients, in whom a fracture line could not be observed in a simple x-Ray, but continued to have clinical findings, a CT-scan was performed in 2 planes. In 26 patients with no fracture in the CT-scan were discharged, while in the remaining 16 patients with obvious fracture in the CT-scan a scaphoid cast was applied for 4 weeks.

Group 2: 30 patients with scaphoid fracture, from which the cast was removed and the fracture line was still visible in a simple X-Ray were examined with CT-scan in 2 different planes. In 18 we found intense healing of the fracture in all the width of the scaphoid and the patients were discharged . The remaining 12 displayed delayed non union with obvious fracture line in all the width of the scaphoid. These patients were treated operatively, by compressing the fracture line with a Herbert screw.

Group 3: This is the largest group of patients concerning the scaphoid pseudarthrosis and consists a topic of a different study. In conclusion the computer tomography scan in two different planes is the most reliable method for the investigation not only of scaphoid fractures but also of the efficiency of the callus. The contribution of the above method in the study of the scaphoid pdeudarhrosis is very important and valuable.

G. Papadokostakis P. Katonis I. Gaitanis A. Hadjipavlou

Aim: The aim of our study is to show if there is any relation between scoliosis in the lumbar spine and osteoporosis in postmenopausal women.

Materials and Methods: In 46 postmenopausal women who, according to WHO’s criteria (T-score < −2,5 ), had osteoporosis in lumbar spine and hip and in 40 post-menopausal women with established osteoporosis (T score < −2,5 and at least and vertebral fracture) was estimated clinical and radiological the presence or not scoliotic bow in the lumbar spine. The bone density was measured with DEXA method in the lumbar spine and in the hip and the scoliosis was measured radiologically with Cobb’s method. To all patients has been done full biochemical examination to exclude secondary osteoporosis cases. The radiological examination included face and lateral x-ray of the lumbar and thoracic spine and that was done to detect vertebral fractures and to exclude women with other degenerative lesions. Also were excluded from our study women with primary or metastatic tumors in the spine.

Results: Out of 46 women who had osteoporosis 32 (69%) had scoliotic lumbar bow and in 23 (50%) patients the bow was more than 10 degrees. Out of 40 women who had established osteoporosis 26 (65%) had scoliotic lumbar bow and in 22 patients (55%) the bow was more than 10 degrees. In contrast in the control group of 25 normal postmenopausal women 5 women (20%) had scoliotic lumbar bow and in 2 women (8%) the bow was more than 10 degrees. Also in the group with the 32 osteopenic women (34%) had scoliotic lumbar bow and in 8 women (25%) the bow was more than 10 degrees. Finally in the group of 32 postmenopausal women with degenerative lesions without osteoporosis 13 (31%) had scoliotic lumbar bow and only in 6 (18%) the bow was more than 10 degrees.

Conclusions: After the statistical analysis of the results is evident that postmenopausal women who have osteoporosis have also scoliosis in the lumbar spine.

A. Aligizakis P. Katonis A. Papoutsidakis I. Galanakis K Stergiopoulos A. Hadjipavlou

Aim: The purpose of this prospective study was to assess the functional outcome of conservative treatment with early ambulation of thoracolumbar burst spinal fractures, using the Load Shearing classification.

Material – Methods: From 1997 to 2001, 60 consecutive patients with single-level thoracolumbar spinal injury, with no neurological impairment, were classified according to the Load Shearing scoring and were managed non-operatively. A custom-made thoracolumbosacral orthosis was worn by all patients for six months, and early ambulation was recommended. Several radiological parameters were evaluated; the Denis Pain and Work Scale was used to assess the clinical outcome. The average follow-up period was 42 months (range, 24 to 55 months).

Results: During this period the spinal canal occupation was significantly reduced. Other radiological parameters, such as Cobb’s angle and anterior vertebral body compression, showed loss of fracture reduction, which was statistically insignificant. However, the functional outcome was satisfactory in 55 of 60 patients with no complications recorded on completion of treatment. Conclusions: Load Sharing scoring is a reliable and easy-to-use classification for the conservative treatment and prognosis of thoracolumbar spinal fractures. Because of the three characteristics of the fracture site this classification can also predict the structural results of the spinal injury, such as posttraumatic kyphosis, and thereby the functional outcome in conservatively treated patients.

P. Katonis I. Thalassinos A. Papoutsidakis P. Alpantaki I. Gaitanis A. Hadjipavlou

Aim: The evaluation of the results of the posterior application of the combination of the implants Varifix (transcervical screws)/Varigrip (new generation under compression hook with middle line pedicle fixation) to the imstable thoracic and lumbar vertebral fractures.

Patients and Methods: During the years 1999–2001, 30 patients have been operated on with the combination of the implants Varifix/Varigrip to the unstable thoracic (T3–T10: 4), thoracolumbar (T11–L2:21) and lumbar (L3–L5:5) vertebral fractures. Mean age was 33, 5 years and sex variation was 22 men and 8 women. Road traffic accidents were the most common cause and the thoracic and lower limp injuries were the most common (17%) accompanied injuries. For the fracture type and the treatment indications the combination of Gertzbein & Gaines classification was used.

Results: The evaluation of the results was with radiological and clinical examination. Mean surgical time was 170 min (120–240) and the mean blood loss was 500ml (350–800). According to special questionnaire, 25 of the 30 patients (83, 5%) were free of pain and able to return to their previous activities. There was no deterioration in the 24 patients who were in Frankel E neurological condition and the mean post surgical improvement according to Frankel classification was 1, 4 points. In the radiological evaluation (compression percentage, Gardner ankle, conquest of the spinal canal) there was statistical significant difference (p < 0, 05, p < 0, 01, p < 0, 05) between pro and post surgical values. Two patients with acute infection were dealt with surgical cleaning, washing and closing of the wound in second time surgery. One failure of the hook in one patient with osteoporosis was dealt with removal of it.

Conclusions: TheVarifix/Varigrip combination has nearly the same surgical results with traditional partial implants. The satisfactory reduction during the operation in the 30 patients was preserved during the follow up time. The posterior Varigrip system acts with cross link splinting and provides multidirectional spinal stability when it is used alone or supporting the system Varifix for avoiding the detachment or break of the transcervical screws. We suggest the use of these systems for all the unstable thoracic and lumbar injuries because of their safe fixation and easy application.

E. Papacostas C. Bikos S. Siganos T. Chouseinoglou V. Karamoulas T. Papaioannou

The purpose of this study was to present long-term results of elbow dislocation in children. Eleven patients (10 male) with elbow dislocation (mean age 10.4 years old) were re-evaluated with mean follow up 85 months (24 – 186). Active range of motion and instability were clinically evaluated. Osteoarthritic changes, position and shape of medial epicondyle were radiographically recorded. Functional evaluation was made with Hospital for Special Surgery Elbow Assessment protocol (up to 100).

All cases were treated with closed reduction under general anaesthesia. Three patients were treated surgically with KW for fractures of medial epicondyle. Lack of extension (5° – 15°) was detected in 3 patients two of which had fractures (1 osteochondral and 1 of medial epicondyle). 4 patients were presented with flexion deficit (5° – 10°) while 1 patient had reduction both for supination and pronation (fx of medial epicondyle). Decreased pronation was recorded in two more patients (5° — 10°). Radiologically we found a patient with medial and lateral epicondyle alteration, a patient with osteochondral fracture and another one with ossification of LCL. Functionally the overall result was excellent (subjectively) while mean HSS Elbow Assessment score was 99.1 (96–100).

K. Stafilas A. Korompilias K. Zaharis V. Chouliaras G. Mitsionis P.N. Soucacos

Aim: The primary purpose of this study was to establish data concerning normal hand grip strength in the population of N.W Greece.

Material and Methods: The Jamar dynamometer was used to measure grip strength. A sample of 115 males and 117 females, with no extremity disability or injury, aged 21 to 58 years, from the Ioannina area was tested. The dynamometer was tested in a standing position, with shoulder adducted and neutrally rotated, elbow flexed at 90 degrees and forearm and wrist in neutral position. Each participant was asked to grip first with the right and then with the left hand three consecutive times. The highest grip strength for each hand was used for analysis. All complementary factors such as age, sex, height, weight, hand dominance for writing and exercise and living habits were recorded.

Results: Grip strength diminishes curvilinearly with age, and men are consistently stronger than women. Mean maximum grip for women was 67 pounds and for men was 123 pounds. The hand dominance does not significantly affect hand strength scores. The mean grip strength of the left hand was about 90% that of the right hand. In left-handed participants, mean grip was the same for both hands. The results from this study showed that sex is the most important determinant of hand grip strength.

Conclusions: The random sample, the high participation rate of this study and the number of the factors that affect the hand strength give the highest validity in this study. These data suggest a basis to help hand surgeons as a guide regarding grip strength in the treatment of upper extremity pathologic conditions and postoperative evaluation.

A.X. Papadopoulos A. Panagopoulos M. Papas E. Tsota C. Kalogeropoulou P. Zouboulis E. Lambiris

Purpose: We present the midterm results of conservative treatment of upper (atlas and axis) cervical spine injuries and we propose a CT-based radiological follow-up study.

Material and Methods: In a 12 year period (1990–2001), 45 patients (33 male and 12 female) with a mean age 37.2 years (range 15–75) were presented with an acute injury of the upper cervical spine. There were 19 fractures of the atlas (8 Jefferson’s fractures, 6 isolated lateral mass fractures and 5 posterior arch fractures) and 26 axial fractures (12 odontoid fractures, types I–III according to Anderson’s classification and 14 traumatic spondylolisthesis, types I–II according to Effendi classification). Twenty (20) patients were immobilized using halo-vest and 25 Minerva orthosis. Two (2) patients presented with Brown-Sequard syndrome. All patients were retrospectively reviewed and had clinical and radiological follow-up study (plain films and CT spiral reconstruction films).

Mean follow-up was 6.2 years. Mean immobilization time was 3.8 months range.

Results: Patients with incomplete neurological lesion did not recover. One patient with an isolated atlas lateral mass fracture, developed a hemiparesis during his hospitalization, which was partially resolved. In the final follow-up study, all patients presented a stable upper cervical spine, on the dynamic flexion/extension plain films. In the final CT spiral reconstruction films, fracture line was evident in 12 patients (27%), while atlantoaxial joint incongruity was obvious in 5 patients. Seven (7) patients (16%) complained for residual neck pain and stiffness and presented reduced range of motion.

Conclusion: Conservative treatment of atlantoaxial injuries is effective and offers a stable upper cervical spine. Solid fracture union is not always present. CT spiral reconstruction is very helpful in detecting transverse ligament efficacy and atlantoaxial joint incongruity.

P. Katonis A. Muffoletto Ch. Papadopoulos I. Thalassinos S. Hohlidakis A. Hadjipavlou

Aim: Of Calveston (USA) and Crete (HELLAS). We studied immediate and long-term outcome of 50 patients who underwent subaxial lateral mass fixation of the cervical spine between January 1997 and March 2001.

Patients and Methods: Intraopeartive fluoroscopy and somatosensory evoked potential monitoring were employed in all patients. Immediate postoperative CT scans were performed to determine screw trajectory and placement. Follow up ranged from 1 to 5 years.

Results: Postoperative CT scans showed that 113 of 210 screws (54%) had unicorticate and 46% had bicorticate purchase. Forty-five screws (31 %) had suboptimal trajectory, but only 7 of these screws minimally penetrated the foramen transversarium without resultant vascular or neurological sequelae.

The overall fusion success rate in our series was 90%, while pseudoarthrosis occurred in 5 patients (10%), with screw breakage in 1 patient (2%). Two of these patients had bone graft supplementation and in other 2 patients was done anterior fusion.

Conclusions: Results of this study show that the recommended drilling technique and trajectory (15–25 degrees postal to the sagital plane, 20–30 degrees lateral I the axial plane), supplemented bone grafting and intraoperative SEP monitoring are all associated to good screw placement, fusion and neurological outcome and are recommended for all lateral mass fusion procedures.

P. Korovessis P. Iliopoulos A. Misiris G. Koureas

Previous investigations have postulated that the asymmetry of the breasts in female adolescents may be linked with the development of right convex thoracic scoliosis, although there is no correlation between breast asymmetry and curve type or scoliosis magnitude. This breast asymmetry is supposed to be linked with anatomic and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomic and haemodynamic parameters of internal mammary artery have been made to justify or to reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics.

Twenty female adolescents with right thoracic scoliosis and 16 comparable female individuals without spine deformity were included in this study. Standing roentgenograms of the whole spine were made in all scoliotics to measure scoliosis curve, vertebral rotation and concave and convex rib-vertebra-angle at three vertebrae (apical, one level above and one below the apical vertebra). The Color Doppler Ultrasonography was used to measure at the origin of internal mammary artery its lumen diameter, cross sectional area, time average mean flow and flow volume per minute in scoliotics and controls and were compared each other. The roentgenographic parameters were compared with the ultrasonographic parameters in the scoliotics to disclose any relationship.

The reliability of color Doppler ultrasonography was high and the intraobserver variability low (ANOVA, P=0.92–0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. In scoliotics the right mammary artery time average mean velocity increases with the convex and concave rib-vertebra-angle one level above the apical vertebrae (P< 0.01), convex rib-vertebra angle one level below the apical vertebra (P< 0.05), and concave apical rib-vertebra angle (P< 0.01). The left internal mammary artery time average increases with only the convex rib-vertebra angle one level above the apical vertebra (P< 0.05). The right and left internal mammary artery flow volume increases with the convex rib-vertebra-angle one level above the apical vertebra (P< 0.05), while the right internal mammary artery flow volume increases furthermore with the apical concave rib-vertebra-angle (P< 0.01) and concave rib-vertebra angle one level above the apical vertebra (P< 0.01). The concave apical rib-vertebra-angle (P< 0.01) and concave rib-vertebra-angle one level above the apical vertebra (P< 0.01) increases with left internal mammary artery cross sectional area.

We concluded that anatomic and haemodynamic flow parameters measured at the origin of internal mammary artery are significantly correlated with apical rib-vertebra-angle in female adolescents suffering from right convex idiopathic thoracic scoliosis. This study did not find any evidence for side-difference in vascularity of the anterior thorax wall thus could not justify previous theories for development of right thoracic scoliosis in female adolescents.

A. Karageorgos M. Chanos A. Kargados PE. Zouboulis E. Lambiris

We evaluate the patients with lumbar spinal stenosis in multiple levels that were treated with posterior decompression and posterolateral fusion, using transpedicular screw fixation system. Twenty-six patients, mean age 65.7 years (range 49 to 77years), with lumbar spinal stenosis, in more than three levels, were treated surgically between 1994 and 2002. Indications for surgical treatment included low back pain and neurogenic claudication for more than 6 months. The diagnostic approach consisted of x-rays, MRI, myelography and myelo-CT. Oswestry disability score and VAS (visual analog scale), were used for the clinical evaluation of the patients. Surgical procedure consisted of wide posterior decompression, regarding laminectomy, complete or incomplete facetectomy and foraminotomy, combined with posterolateral fusion, using transpedicular screw systems and bone graft. Fusion in three levels was performed at seven patients, in four levels at ten, in five levels at seven, in six and seven levels at one patient respectively.

Mean follow-up was 26.8 months (range 12 to 38 months). Oswestry score and VAS revealed improvement 40.75% and 5.4 levels respectively. The better results were concerned to pain (2.88 levels improvement) and the less good to lifting (1.58 levels improvement). Two cases with superficial infections were observed and treated with surgical debridement. Screw breakage was observed in 1 patient and treated conservatively. Loosening of two sacral screws, which were removed, was observed in one patient.

We conclude that myelography and myelo-CT revealed with satisfactory accuracy intra and outer foraminal lumbar spinal stenosis. Posterior decompression and instrumented fusion, offer satisfactory clinical results in patients with lumbar spinal stenosis in multiple levels when performed by experienced surgical team.

I. Gaitanis P. Katonis K. Kakavelakis K. Papadomihelakis A. Hadjipavlou

Aim: Presentation of the technique, the mistakes and the results of a new minimal invasive surgical procedure for reduction and augmentation of pathological fractures of the vertebrae in spine.

Patients and Methods: 12 patients (2 men / 10 women) with mean age 68 years (54–73) with pathological vertebral underwent kyphoplasty. The mean pain according to VAS was 7, 3 (6–10) and the mean follow up time is 8 months (5–14). 11/12 patients (20 vertebrae) had osteoporotic vertebral and 1/12 (1 vertebra) had metastatic lesion. 8/21 vertebrae were in thoracic spine and 13/21 in lumbar spine. In 20/21 the procedure was transcervical to the vertebra and in 1/21 was out of the cervix. 11/12 patients had kyphotic deformity in the plain x-ray and 18/21 vertebrae had decreased their height. To all patients was spilled PMMA.

Results: 10/12 patients referred degrease of their pain in the first 48 hours and 2/12 in the 5th postoperative day. Correction of the kyphotic deformity was observed in 11/12 and reduction of the reduction of the fracture was occurred in 16/21 vertebrae. Leakage of PMMA was occurred in 5/21 vertebrae; in 2/5 the leakage was in the canal, in 1/5 in the intervertebral space and in 2/5 out of the vertebrae. 1/12 patient 2 moths postperatively had another vertebral fracture in a lower vertebra that was deled again with kyphoplasty. None of the patients had neurological deficit postoperatively. According to Oswestry questionnaire all the patients referred return to all their before fracture daily activities.

Conclusions: Kyphoplasty in pathological vertebral fractures has as a result the immediate decrease of the pain and the return of the patient to his/her daily activities. Also there is correction of the kyphotic deformity decreases the possibility of a new vertebral fracture and the establishment of chronic back pain.

V.N. Psychoyios F. Villanueva-Lopez E. Zambiakis M. Hamdeh G. Koutsoudis N. Sekouris

Introduction: The aim of this study is to present a modification of the single tension band technique for the treatment of olecranon fractures, using a double tension band with smaller wires, preserving all the biological parameters for fracture fixation, in an effort to decrease related complications.

Material: Thirty-three patients with olecranon fractures treated with a double tension band fixation. Surgical Technique: Through a posterior approach the fracture is reduced keeping all principles for biologic fixation and stabilized with two parallel small K-wires inserted from the olecranon process and exit through the anterior cortex of the ulna. Then the extensor carpi ulnaris and flexor carpi ulnaris are partly elevated from the ulna and two 1.5-mm transverse drill holes are made through the ulna 3 and 4 cm distal to the fracture. Two 22-gauge wires are passed through the proximal and distal holes, bent into a figure of 8 over the dorsal ulna and simultaneously tightened. The proximal ends of the K-wires are bent and impacted into the olecranon process.

Eleven patients needed supplemental fixation with screws. All patients mobilized the first postop day.

Results: All the fractures consolidated. All patients but two regained full range of motion. No hardware failure was noted except one patient in whom one band was broken but without clinical relevance.

Conclusion: It seems that a double tension band fixation despite the smaller material utilized, provides a very stable construct, permitting early mobilization. Furthermore two bands tensioned independently provide greater compression forces at the fracture site and offer a back up in case that one band fails.

D.S. Korres I. Psicharis PJ. Boscainos A. Stamatoukou G. Themistocleous P. Nikiforidis

Diving injuries are the cause of devastating trauma, primarily affecting the cervical spine. The younger male population is more often involved in such injuries. This study describes our experience on diving injuries treatment and offers a long follow-up.

During a 31-year period (1970–2001) 20 patients, 19 male and one female have been admitted with cervical spine trauma following a diving injury. All admissions have been made between May and September. One patient was lost to follow-up. The mean age of the patients was 23 years (16–47). The lower cervical spine was involved in 13 patients; four patients had lesions in the middle and upper cervical spine, while one patient had combined lesions. The most commonly fractured vertebrae were C5 and C6. Fracture-dislocation was evident in 10 patients, while a teardrop fracture was diagnosed in six patients. Six patients were classified, as ASIA A upon admission and bladder control was absent in 12. Only four patients were treated surgically, two with iliac bone grafting alone, one with posterior plating and one with an anterior plate plus graft. The other patients with initial neurological deficit were treated conservatively, because of their rapid neurological improvement, their lesion being regarded as stable. Fourteen patients were treated conservatively with steroids and Crutchfield skull traction or halo vest, followed by the application of a Minerva or Philadelphia orthosis.

The mean follow-up was 11 years (6 mo to 23.8 years). Four patients in the ASIA A category died in the first month of their hospitalization (two of cardiac arrest, one from pulmonary embolism and one from respiratory infection) and two remained unchanged. Six patients with ASIA B and C improved neurologically and one remained unchanged. Nine patients had developed urinary tract infection and two had respiratory infections. Two out of the four operated on develo