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Volume 88-B, Issue SUPP_II May 2006

EH Garling BL Kaptein ER Valstar R.G.H.H. Nelissen

Outcome measures must be valid, reliable and responsive to change criteria. The most common clinical outcome measures are Knee Society Scores, SF-36 quality of life scores, HAQ and DAS scores. However, performance based measures of functioning may not be dependent on patient report or observer judgment.

Examples of objective pre- and post-operative performance outcome measures are surface Electromyography (EMG) of muscles, kinematics and kinetics (gait analysis). For the evaluation of implant survival after joint arthroplasty, Roentgen Stereophotogrammetric Analysis (RSA) is the golden standard to assess micro-motion of the implants.

Surface EMG can be used to asses the stability of joints before and after intervention. Calibrating of raw EMG data is necessary to compare the data between subjects. It was shown that calibration of EMG data by means of isokinetic contractions on a dynamometer during flexion and extension was more reliable and repeatable than using a Maximum Voluntary Contraction in patients after total knee arthroplasty. After total knee arthroplasty RA patients have a lower net knee joint moment and a higher co-contraction than controls, indicating avoidance of net joint load and an active stabilization of the knee joint.

Fluoroscopy can be used to assess the kinematics of joints. In the pre-operative situation the use of CT models of the involved bones can be matched to the assessed fluoroscopic images. In the post-operative situation CAD models of the implants can be used for this purpose. In this way accurate 3D kinematics of joints can be assessed. During a step-up task of RA patients, the rotating platform of a mobile bearing knee showed no- or far less longitudinal rotation than the femur. Therefore, some of the theoretical advantages of this specific rotating platform knee prosthesis can be questioned. Fluoroscopy has also been used to assess soft tissue artifacts that occur in gait analysis i.e. displacements of skin-mounted markers relative to the underlying bone. The large soft tissue artefacts observed (displacements up to 17 mm and 12 degrees) question the usefulness of parameters found with external movement registration.

In order to assess the micromotion of implants after joint arthroplasty a measurement technique with a much higher accuracy than fluoroscopy is needed. RSA uses tantalum markers as landmarks bony structures and as landmarks on the implant. Recently a new RSA technique has been developed that does not rely on the attachment of artificial markers on the implant but uses CAD models of the implant instead. As an example of RSA as outcome measure, results showed that a calciumphosphate coating improves fixation of tibial components in RA patients, thus preventing mechanical loosening and subsequent long-term revision. In another clinical RSA study, it was found that mobile bearing knees are more predictable and forgiving with respect to micromotion compared to posterior stabilized tibial components in RA patients.

The results obtained by the above described performance outcome measures can be valued since the accuracy and precision of the used outcome measures are all published.

ER. Bogoch

Orthopedic surgeons treat numerous patients in whom osteoporosis (OP) is an important factor: inflammatory arthritides (rheumatoid arthritis); sports medicine (the anorexic, amenorrhoeic female athlete); in consultation to renal, transplant and cardiac units; patients on corticosteroids, as well as others. Orthopedic procedures in patients who have osteoporotic bone require special techniques and precautions. A common example is hip replacement, where, through endosteal resorption, the medullary canal is large, cortices are thin, and the risk of femoral fracture and a poor outcome is higher.

The commonest interface of orthopedic surgery with OP is in the management of fractures. In North America, most orthopedic surgeons manage fractures in hospital and in the fracture clinic, where typically 3%–8% of patient visits are for classic fragility fractures. Traumatic fractures also commonly occur in osteoporotic bone. The yield of screening for OP in orthopedic wards and clinics, targeting fragility fracture patients, is much higher than screening in a general population. Published guidelines based on Level I evidence indicate that fragility fracture patients are at highest risk of future hip fractures, which often occur within one year of index fragility fracture, and that preventive treatment is economical and safe.

Treatment prevents 30–50% of hip fractures in high risk groups. Unfortunately, less than 20% of fragility fracture patients generally receive appropriate OP care, in multiple studies in developed countries. There is a growing international focus on developing care delivery systems that will promote consistent OP investigation and treatment in the inpatient and outpatient orthopedic environment.

In Ontario, Canada, an Osteoporosis Exemplary Care Program was initiated in 2003 to identify, educate, evaluate, refer, and treat female (> 40 years) and male (> 50 years) fragility fracture patients for OP. In the first year of the program, over 95% of inpatients and outpatients were appropriately diagnosed, treated, or referred for OP care. Success resulted from the presence of a dedicated coordinator and cooperation by orthopedic surgeons and residents, technologists, allied health professionals and administrative staff.

Regional, national and international orthopedic associations have developed initiatives designed to improve processes of care for OP in the orthopedic environment.

A. Aeschlimann

A better understanding of the pathophysiology of rheumatoid arthritis has led to important and innovative approaches to its treatment In the case of confirmed diagnosis the recommended gold standard is to give methotrexat, possibly in combination with corticosteroids. If disease activity cannot be controlled, other basic therapies, possibly in combination with or as biologic DMARDs (Diseases modifying drugs) are prescribed. The main emphasis here is placed on TNF-Alpha blocker and drugs that inhibit Interleukin-1. New drugs such as anti-CTLA4-Ig and anti-CD20 (Rituximab) aim to influence the activation of T- and B-cells. Management is supplemented by educating the patient, physiotherapy and ergotherapy as well as specific surgical intervention, as required.

JK Stanley

Rheumatoid arthritis is a whole body, lifetime incurable disease. The problems engendered by the disease process itself are highly individual, given that each set of problems that a patient has, the assessment and planning of surgery is a crucial aspect of the appropriate management of patients with polyarthritis.

The presence of deformity does not necessarily indicate a problem of function, but one has to accept that certain deformities cause more problems than others and I draw your attention to swan neck deformity being relatively function-impairing and Boutonnière deformities less so. There is always a balance between the risk of surgery and the benefits to be obtained.

The assessment is functional, anatomical, radiological, psychological, medical, financial and, finally, surgical. The functional assessment is intended to identify the problems a patient has in the activities of daily living, the anatomical assessment identifies the structures damaged which need to be prepared or replaced, the x-rays define the bone loss and, therefore, determine the limits of bony surgery, the psychological aspect identifies the patient’s capacity and willingness to be involved in often quite complex therapy programmes over a significant period of time. The medical problems of vasculitis and active disease are less frequent now but are contra-indications to surgery in the acute phases.

The financial aspects are often under-rated. The costs of maintaining someone with significant disabilities is really quite great and, therefore, although surgery may only give some small improvement in function, it often has quite a significant impact on the degree of care and help an individual needs.

Finally, the surgical assessment is to identify which structures and in which order.

In terms of planning, the surgical priorities, described by Nalebuff, are:

1 Nerves 2 Flexor tendons 3 Wrist 4 Thumb 5 MCP joints 6 Extensors 7 PIP joints 8 Distal Interphalangeal joints

Prolonged nerve compressions do not recover well; ruptures of flexor tendons are very difficult to treat; if the wrist is painful and unstable it inhibits any function that the hand might have; the thumb is 50% of hand function; metacarpophalangeal joints need to be stable and to flex approximately to 60° in order to be functional; extensor tendons need to glide and to be able to lift fingers away from the palm; the interphalangeal joints contribute greatly to the closing of grasp.

The role of the therapist is pre-operatively to assess the patient appropriately for surgery, assessing all the aspects defined above and to ensure that the patient is compliant with the treatment post-operatively. The aphorism that 20% of the effort comes from the surgeon, 50% from the therapist and 20% from the patient is probably a fairly accurate representation of the importance of therapy post-operatively. Therapy must be planned, purposeful and progressive.

Dieter Grob

Introduction Rheumatoid arthritis also affects the spine and creates conditions that need surgical treatment. As in other parts of the body, the maintenance of function and reduction of pain are primary goals of surgical treatment, however the additional threat to the neurological structures create an additional dimension in the surgical treatment of the spine.

Destructive processes of osteoligamentous structures and severe osteoporosis may be blamed as the principle cause for pain, deformity and subsequent neurological deficit in the rheumatoid patient’s spine. Cervical spine Atlantoaxial instability is the most frequently encountered pathology in the cervical spine of the rheumatoid patient. In order to avoid late appearance of myelopathy, the timing of surgery in the presence of significant atlantoaxial instability (ADD < 5mm) has to be carefully evaluated. The tendency is towards early surgical stabilization since no spontaneous improvement is to be expected in cases with aggressive rheumatoid arthritis. Late surgery not only carries the risk of causing myelopathy by repeated micro-trauma of the myelon, but also the need for extensive surgery including the occiput and the lower cervical spine in case of advanced destructive processes.

The subaxial cervical spine has a tendency to disintegrate in the presence of aggressive course of rheumatoid arthritis. The extent of instability and site of compression has to be carefully analyzed, using MRI and neurophysiological examinations. Due to weak bone structures anterior and posterior interventions are often necessary. Lumbar spine The rheumatoid pathology in the lumbar spine is mainly influenced by the degree of osteoporosis. Typical osteoporotic fractures, often on several levels, represent the most frequent pathology, which needs surgical help. In case of persistent pain the relatively new technique of vertebroplasty offers an elegant way to reduce pain. If severe deformities occur, the osteoporotic structure of bone limits the surgical possibility of correction of the deformity.

Conclusion “Wait and see”-policy in rheumatoid patients with spinal pathology is often not appropriate (as in other joints of the body) if function and neurology should be preserved and maintained. Early surgery represents usually minor intervention and is better tolerated than extensive corrections. Osteoporosis is the main limitation for surgical treatment in the rheumatoid spine.

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F Angst J. Goldhahn

Background Critical reflection in clinical routine and research raises the question of how we measure outcome. The classical etiopathogenetic way of thinking has led to biophysical, investigator-based, ‘objective’ parameters. However, new concepts of holistic health assessment based on the WHO’s International Classification of Functioning, Disability, and Health (ICF) emphasize the patient’s (subjective) perception.

Methods We present different approaches to health and health-related quality of life assessment by applying assessment tools to specific examples and providing an overview of some of the existing instruments with an analysis of their properties.

Results Self-assessments reflect the patient’s needs more closely than biophysical parameters. Reliability and validity of the self-assessments are high and population surveys provide valid norms for comparisons. Generic instruments offer a comprehensive range of measurements, and condition-specific self-assessment tools differ in their pattern of health dimensions and their sensitivity to change (responsiveness) as expressed by specific scales. A specific set of instruments has to be compiled appropriate to the focus of interest.

Conclusions Self-assessments are an important complement to clinical signs as indicators of the patient’s condition and fulfill the requirements of the modern salutogenetic, holistic view of the patient as set out in the ICF concept. As a valid representation of the patient’s needs they help in the optimization of disease management and medical-economic planning.

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Yoshitaka Minamikawa

Development of newer finger implant in Japan started with hinged Ceramic implant in early 1980’ and was abandoned its use in early stage (Doi 1984 and Minami 1988). Although silicone finger implant has been most popular, breakage of the implant, particle induced inflammation and implant subsidence continued to be the problems of the silicone implant. In turning to new century, there was another enthusiasm of developing new finger implant in Japan. Surface replacement was chosen for the PIP joints, however, most of design for the MP joint had constrained mechanism, including ball and socket joint with stem allows piston motion and semi-hinged joint with much freedom. Currently available finger implants in Japan will be discussed briefly.

The author developed cement-less surface finger implants (Self Locking Finger Joint, SLFJ) for the MP (including thumb) and PIP. Characteristics of the implant include,(1) the joints anchor(stem) has tapered screw with two long legs which spread intramedullary allows fixation without cement and thus change the position during the operation for optimum collateral tension, (2) joint design that preserve collateral ligament and surface contour, (3) simultaneous replacements of both MP and PIP are possible. Over 500 joins in 200 patients have been operated during last seven years. Of 50 cases operated by author with minimum of 4 years follow up, 34 cases were available for evaluation. There were 98 joints: 72 MP, 12 PIP and 14 MP of the thumbs. Average follow up was 5 years and 5 months (4 years ~ 6 years and 6 months). Fixation of the joints anchor were stable, only three joints showed marked loosening. Breakage of the joint anchors was found in 7 MP and 2 PIP; 5 out of 9 breakage of the legs were occurred during the operation. In x-ray evaluation, about half of the joint anchors were found securely fixed to the bone within 2 years. Dislocations of the joints were found in 4 MP joints in 3 cases (3 were early dislocation and were found to be technical failure and one late dislocation) and 2 PIP joints (one early and one late dislocation). Five MP implants were removed because of progressive flexion contracture and 3 MP and 2 PIP were re-operated. Range of motion of ext/flex averaged −25/70 in MP and −20/65 in PIP.

M Huber P. Rippstein

For many decades ankle fusion has been the only option for treatment of symptomatic osteoarthritis of the ankle joint. From the late 60’s on the crusade of joint replacement for hip and knee led to successful functional restoration for severe destruction of these joints. Because of a lack of understanding the biomechanical principals of the ankle a similar approach in reconstructing the ankle arthritis was doomed to fail. On the other side very good functional outcome after fusion of the ankle seemed to make needless further development. Although first encouraging results with non-constrained designs and cementless fixation were obtained in mid-late 70’s a wider acceptance within the orthopaedic society was found only almost 20 years later whereas today many surgeons wouldn’t give up the ankle arthroplasty for several indications. Despite good and very good midterm results we still need to understand limits and further develop operative techniques especially soft-tissue balancing.

In our institution we have been using TAR since 1995 on a regular basis and by now overlook a total of almost 400 TAR’s. The experience with different designs (Agility, S.T.A.R. and Buechel-Pappas) led to the development of the Mobility-TAR in collaboration with two surgeons from England and the U.S. It is a 3-component TAR, non-constrained. As a unique feature the instrumentation allows an accurate centring of the implants both in the frontal and the saggital plane. In a prospective trial in Wrightington and Zurich we clinically and radiographically evaluate the outcome. The first 42 cases in Zurich with a follow-up of more than 1 year showed a significant pain reduction from av. 8.1 on a visual analogue scale to av. 1.4 after one year. The ROM assessed radiographically could be improved from 26° preoperatively to 33° after one year. We have seen 4 fractures/osteotomies of the medial malleolus and one neuropathy of the tibial nerve as intraoperative complications. Postoperative complications included two superficial wound healing problems, one deep infection and finally two stress fractures of the medial malleolus. One case had to be revised because of aseptic loosening after 6 months. All but one of the first 42 patients would undergo the same procedure again.

The first results are encouraging because of good overall results with significant pain reduction and good ROM combined with only few complications.

H.J.L van der Heide B Schutte J.W.K Louwerens H.A van Heereveld F.H.J van den Hoogen M.C. de Waal Malefijt

Introduction: Total ankle prostheses (TAP’s) are implanted for end stage cartilage damage especially in patients with rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) or post-traumatic arthritis. Little is known about the long term survival of these prostheses in patients with RA and JIA. In this study we examined the outcome of TAP in these patients.

Patients and methods: Between 1994 and 2004 85 TAP’s were implanted in 58 cases (10 males and 48 females) with RA (n=53) or juvenile chronic arthritis (n=5). The records of all patients were reviewed. Every patient was invited for a visit to our outpatient clinic for a history taking, a physical examination and a Kofoed ankle score (a clinical score for ankle function ranging from 0 to 100) was obtained.

Results: The record of every patient was available for review. Two patients had died (cause of death was unrelated to the surgery), and 56 patients could be reexamined. A perioperative fracture (8 medial 3 lateral and 2 tibial) occurred in 13 cases. The fractures were fixed in the same operation and healed without complications; none of these prostheses needed a reintervention. After a mean follow up of 2.7 years (range 1 to 9 years) two patients died with the prosthesis in situ, one patient underwent an above knee amputation for infected arthroplasties of ankle and knee and four prostheses were removed because of loosening or malfunctioning of the prosthesis and arthrodeses were performed. The other 51 cases were analysed and showed a mean Kofoed ankle score of 72.8 (SD=15.8). This score is similar to scores obtained from patients receiving ankle arthroplasties for non-rheumatic indications.

Conclusions: Placement of total ankle prostheses in patients with RA shows good medium term results. The intra-operative fracture rate is high, but does not affect the outcome; none of the failed arthroplasties was due to a preoperative fracture.

A Röser F.-W Hagena R.M. Christ

With the increasing number of implantation of total ankle arthroplasty a higher rate of pitfalls and failures has to be expected.

Intra- and postoperative complications in total ankle arthroplasty, their sources of failure and revision options are demonstrated.

In the time of 7/97 until 1/06 269 S.T.A.R. total ankle prostheses have been implanted at our hospital.

Intraoperative complications occurred in 7 cases (4 fractures of the malleolus medialis, 2 fractures of distal fibula, 1 fissure of talus).

We observed early complications in form of delayed wound healing (n=31) and 4 deep infections. A higher incidence of secondary wound healing is shown in rheumatoid arthritis patients in comparison to patients with OA.

Late complications included persisting intraarticular synovitis, especially in rheumatoid arthritis, an impingement (11 cases) and osteolysis (4 cases).

Revision surgery was performed in 45 cases (16.7%) 1.5 years after primary implantation (14 operations with problems in secondary wound healing, 9 lengthenings of the Achilles tendon with a dorsal capsulotomy (2 rheumatoid arthritis patients), 11 revisions of the PE gliding core with resection of periarticular hypertrophic bone formation, 4 revisions of singular components, 2 complete revisions of the prosthesis, 4 ankle fusions, 1 amputation. Only in 18 cases (6.7%) these complications and the following surgical procedures influenced the satisfaction of the patients.

Despite the demonstrated complications, total ankle arthroplasty is more than an alternative to open ankle arthrodesis in the progressive phases of arthritic joint destruction, also in RA at a LDE stage ≥ III.

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P Bijlsma H.J.L van der Heide F.H.J van den Hoogen J.W.K. Louwerens

Introduction: The standard procedure when operating the rheumatoid forefoot is resection arthroplasty of the metatarsophalangeal joints of the lesser rays. Correction of the hallux is mostly achieved by arthrodesis of the first metatarsophalangeal joint. Good clinical results (with a follow-up of over ten years) have been reported when a combination of these two techniques is used. Another technique is repositioning of the metatarsophalangeal subluxation or dislocation of the lesser rays, thereby preserving the metatarsophalangeal joints, thus leaving the function of the aponeurosis plantaris intact. As a result of this it can be expected that unrolling of the forefoot is unaffected and therefore a better function of the forefoot remains.

Aim: To assess the results of forefoot reconstruction using the repositioning technique performed in 54 feet (39 patients) by one surgeon using this technique.

Methods: Fifty-four feet (39 RA patients) were treated with the technique of repositioning the metatarsophalangeal subluxation or dislocation. All surgery was performed by one orthopaedic surgeon. In case of severe deformity of the metatarsophalangeal joint of the hallux, an arthrodesis was performed. All patients were reviewed after a mean follow up of 40 months (range 12–72 months) and an AOFAS [American Orthopaedic Foot and Ankle Society] foot score, and FFI [Foot Function Index] were obtained.

Results: At a mean of 40 months (SD=15.6 months) postoperatively, the mean AOFAS forefoot score was 69.80 (SD=11.8) if, in addition of repositioning the metatarsophalangeal joints, an arthrodesis of the hallux was performed. In patients with no operation on the hallux, the AOFAS score was 42.2 (SD=18.8) (P=0,001). The postoperative FFI-scores were 74.0 (SD=17.5) and 57.6 (SD=14.6) respectively (P=0,026)

Conclusions: Reconstruction of the rheumatoid forefoot by repositioning the metatarsophalangeal joints of the lesser rays, thereby preserving the joints, can be considered a procedure that provides improvement in the clinical outcome. Best results were seen in patients in whom, in addition of reconstruction of the lesser rays, an arthrodesis of the hallux was performed.

M.H. Makoto Hirao J.H. Jun Hashimoto H.T. Hideki Tsuboi K.S. Kazuomi Sugamoto A.M. Akira Myoui H.Y. Hideki Yoshikawa

Background: Heel valgus and flattening of arch are common in rheumatoid arthritis (RA). The progression of hindfoot valgus deformity results in pain and debilitating disability, and causes the excessive stress on the ankle joint. Subtalar arthrodesis is often indicated in these cases to reduce the pain and to correct the talocalcaneal alignment. However, accurate correction is not easy without bone grafting, because bone defect often appears after correction. Bone grafting is necessary for accurate correction in these cases, but we have avoided it because of following reasons; donor site problem like insufficiency fractures of pelvis, supply limitation of autograft for possible multiple operations during long term disease progression of RA and the lack of bone graft substitutes, which possesses enough osteoconductivity. Now we have developed the interconnected porous calcium hydroxyapatite (IP-CHA) which possesses good osteoconductivity and achieves major incorporation with host bone much more rapid than the other porous calcium hydroxyapatite. So, we evaluated the usefulness of the packing with the newly developed IP-CHA in bone defect after correction of pes planovalgus deformity of RA patients.

Methods: The best possible correction of talonavivular alignment and fixation is performed using one cubic hydroxyapatite block (1x1x1cm), staple and Kirschner wire. Then granular IP-CHA is implanted in bone defect existing mainly in talar body, gap of talonavicular joint and sinus tarsi. Six planovalgus feet were treated with subtalar arthrodesis in 4 female RA patients (3; triple arthrodesis, 3; subtalar and talonavicular arthrodesis). The average age was 56.8 years. Angle of internal arch (IA), tibiocalcaneal (TC) angle in modified Cobey’s method, talocalcaneal height (TCH) in standing position were assessed on the basis of the radiographies at just before operation and final follow-up (average 17.5 months, range 7 to 25 months).

Results: Mean IA angle was 138.9 degrees pre-operatively and 132.4 at the last follow-up. Mean TC angle was 14.9 degrees pre-operatively and 7.2 at the last follow-up. No collapse or deformity of hydroxyapatite implanted in the bone defect was observed.

Conclusion: Our original technique using IP-CHA was shown to prevent from initial sinking or loss of correction. This technique could make it quit easy to correct the malalignment of talocalcaneal joint with regaining of TCH in painful planovalgus deformity of RA patients.

H.C Doets E.R. Valstar

Introduction Mobile-bearing total ankle arthroplasty has gained more interest in recent years. Clinical results show favourable but varying results, with survival rates between 70% and 90% at 10-year follow-up. Design-specific differences in early migration patterns might explain differences in result and possible modes of failure.

Methods Prospective study of a cementless mobile-bearing total ankle arthroplasty by radiostereometric analysis (RSA). Fifteen total ankle arthroplasties were performed in patients with rheumatoid arthritis. The American Orthopaedic Foot and Ankle Society ankle score and radiostereometric radiographs were evaluated at regular intervals throughout the follow-up period: immediately postoperatively, 6 weeks postoperatively, 3 months, 6 months, and 12 months postoperatively and yearly thereafter.

Results The postoperative clinical results improved. We observed increased migration of the tibial component during the first 3 months, but this stabilized by the 6-months followup. The mean lateral-medial migration was 0.8 mm, distal-proximal migration was 0.9 mm, and posteroanterior migration was −0.5 mm. The latter implicated that the total resultant migration was in anterior and valgus tilting of this tibial component. This resulted in a main mode of migration proximal, anterior and valgus tilting of the tibial component.

Discussion This pilot study showed initial migration of this mobile-bearing ankle prosthesis into upward anterior and valgus tilting. However, migration stabilized at 6 months postoperatively. We think the surgical technique (anterior cortical window for placement) and the method of tibial fixation likely explain this migration.

K. Tillmann

The ankle joint offers adverse conditions to any prosthetic replacement: high loads on small surfaces, only vague landmarks for the insertion, complex and individually very different functional anatomy.

Despite these obstacles many excellent short- and some long-term results have been published, giving little way to a learning curve. This contrasts with our own experiences over at all 29 years now: 24 % failures of cemented two-component EP’s after 14,6 (6,1–21,2) years (n=67) and 8,7 % failures of uncemented tri-component EP’s after 3,7 (0,6–7,6) years (n=92).

We analyze and explain special problems and typical failures by a brief historical review of ankle joint replacement: as a logical sequence of various concepts, each of them basing on the knowledge of preceding insufficiencies. The general concern of the functionally useful, but limited mobility after the implantation will be discussed, also on the basis of own early and medium-term results: ROM ranging on average from 26° for TPR-(n=35) and 29° for New Jersey LCS-(n=30) up to 35° for S. T. A. R.-prostheses (n=12). Possible solutions of problems will be considered, respecting assumed causalities.

Basing on the literature and own earlier investigations, especially the long-term results will be compared critically.

The incertitude of an exact implantation has been partly compensated by the actual „meniscal“ concept of tricomponent prostheses. It should be favourable for their fixation to the bone and moreover reduce polyethylene-wear. But – as before – the discrepancy of high loads on a small area threatens the durability of ankle joint prostheses.

Prosthetic replacement has become indispensable in the treatment of painfully destructed ankle joints, but it demands a careful and critical indication.

U Müller L Staub C Röder O Tamcan

Introduction: Randomized Controlled Trials (RCT) are the golden standard in nowadays evidence based outcome assessment. Nevertheless, RCTs in surgery are associated with several concerns. The major concern focuses on ethical issues when randomization is done.

Method: We conducted an indebt analysis on advantages and disadvantages of three types of data acquisition (Case Control Study (CCS), RCT, and Registries) where scientific impact, ability to assess changes over time, cost efficiency, time consumption, ability to provide bench marks and other variables are compared.

Results: RCTs are best regarding the scientific impact. Registers are superior in detecting changes over time (post market surveillance, early warning system), cost efficiency, time consumption, ability to provide benchmarks, local/national/international comparability and ability to let private practitioners participate. CCSs are of minor value in respect to all the assessed variables.

Conclusion: In Surgery, registries are an excellent alternative to RCTs if a great majority of the treating physicians (in respect to a therapy) participate and if all the treated patients (per physician) are included. The register increases its scientific impact if alternative therapies are included (control). In this case, the scientific impact of a register is getting nearly equivalent to RCTs.

Take home message: If ethical aspects allow an RCT, than the RCT is the study set up of choice when a new technique/implant has to be introduced in the market. Once the implant has proved its evidence, the following post market surveillance should be accompanied by registries (introduction of an implant in each country). If an RCT is not indicated (ethical or other contra indications), than registries should be used to prove evidence for an indicated therapy. CCSs are not recommended.

C Kolling J Goldhahn B. Simmen

Since the successful introduction of National arthroplasty registers by the Scandinavian countries, requirements in arthroplasty research have changed from pure implant survival rates to functional results and quality of life aspects. More patient data are required to address these areas. The goal of our international arthroplasty register survey was to determine key factors for an effective database as source for these scientific analyses.

In the first step, we identified and analysed all available arthroplasty registers via extensive literature and web searches. The preliminary data were validated by sending out a standardized questionnaire with questions regarding goals, organization, funding, documentation, data handling and output of the register. The responses were checked and, if necessary, further information requested via phone.

So far we received detailed information from nine arthroplasty registers worldwide. Only two registers collect data from clinical scores or questionnaires in addition to data for the survival rate. The majority of registers are maintained by the national orthopaedic associations, others like Finland by governmental organizations. The legal boundary conditions vary considerably, e.g. in Finland participation is mandatory, while patient tracking via Social security numbers is not possible in all countries. The rate of participating hospitals ranges up to 100%: 510 surgeons in Canada (72%) – 43 hospitals in Denmark (100%). The preferred locations are hip and knee, the preferred documentation method is paper-based, several registers offer online access or other types of electronic data transfer. In return, surgeons receive a regular feedback from the registers, mostly in form of annual reports. Only a few registers allow the surgeons to have online access to their data in the database. Funding is still of major concern. Although the definition of annual total costs varies, they stay far below 500,000 dollars. Examples of funding sources are the government, National Orthopaedic Associations, grants, a levy placed on the sale of implants, and others.

For the completeness of the collected data, a high rate of participating hospitals as well as a high follow-up-rate is crucial. This can only be guaranteed with substantial funding, governmental support for setting up an adequate framework and the compliance of the participating hospitals. New ways of data collection and processing might help to increase patient and hospital compliance.

L.J Jung P.M Maldyk E.S Sommer B.W Wojciechowska J.C.W Chorostowska-Wynimko J.B Bany E.S.R Skopinska-Rozewska

Angiogenesis, the growth of new blood vessels from pre-existing vasculature has an obvious and essential role in soft and hard tissue repair. During the wound healing many potential angiogenic factors are released and may be found in circulating blood. The most important are basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF).

Experimental data confirm the important role of VEGF and bFGF in wounds and bone healing. It was proved that heparin and its low-molecular derivatives may interfere with various steps of angiogenesis process. Enoxaparine (En) is frequently used as anticoagulant for prophylaxis of thromboembolic complications. The aim of this study was to evaluate in vivo angiogenic potency and VEGF and bFGF content of sera collected from 7 patients after hip surgery, treated for 14 days with 40 mg of En (Clexane, Aventis) daily. Evaluation of angiogenic activity was performed twice before surgery (before and 1 day after one En dose) and 14 days after surgery. Sera were injected intra-dermally to anaesthetized Bal/c mice and 72 hours later the number of newly-formed blood vessels was counted in dissecting microscope (SIA test). Cytokines concentration was estimated by ELISA. Results: Sera obtained after one En dose presented increase of angiogenic activity (57,3+/− 2,4, n=112, p< 0.01)in comparison to the value before En (44.6 +/− 2.5, n=113 of newly-formed blood vessels. After 14 En doses, further increase was observed (72 +/− 4.9 blood vessels, n= 112).

BFGF levels increased after the first En dose, VEGF concentration was significantly higher after 14 injections as compare to the results obtained before or after one injection of En.

Conclusion: Beneficial effect of 14-days prophylaxis with enoxaparine on healing process might be expected in patients after hip surgery.

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U. Böhling

Summary: The tribological development in the metal-metal partners brought out a new surface texture for the femoral cup. A reduction of the coefficient of friction and a reduction of the metallic abrasion on almost half are secured in lab tests. First clinical applications took place in our hospital.

Question: Total hip surface replacement in metal-metal partners have, although in small quantity, metallic abrasion, which leads to clear increases of the serum concentration of the serological level. The long-term effect on the organism is not so far clarified. A reduction of the abrasion quantity is however worthwhile. Is a structural change of the surface of the femoral cup suitable to cause such a reduction of the metallic abrasion?

Methodology: Derived from bionic systems in nature the surface of total hip surface replacement was changed by dimple like surface, so that in presence of liquid an accumulation of liquid between both sliding partners takes place and takes place thus on this liquid film the articulation. Laboratory tests on a simulator were accomplished, in order to examine whether the desired reduction of the abrasion is obtained. This surface is called Biosurf-surface.

Results: Simulator wear tests of the standard total hip surface replacement in the metal-metal partner have been compared with the Biosurf-surface. The simulator attempts showed that after 5 million motion cycles the Biosurf –system the abrasion quantity in milligram reduces to more than a half. By this clear reduction of particles the concentration of the metal ions which can be expected in the serum is clearly smaller, so that thereby a contribution is made to reduce the possibly damaging influence of metallic ions in the organism.

S Egner-Höbarth W Goessler R Krassnig R Jeserschek R. Windhager

Introduction: Chronic infection after total joint arthroplasty is a complication of major concern to orthopaedic surgeons, especially if patients suffer from any type of immunodeficiency. But for extensive surgical and systemic treatment recurrence rates are high.

Silver is a long known local antimicrobial agent. The use of silver coated prostheses is a valuable option in some cases.

Yet there are patients for whom the permanent implantation of large amounts of silver does not seem to be the perfect solution.

Methods: From 02/2004 to 12/2005 nine patients with severe deep infections after multiple revisions following total joint replacement underwent two-stage revision and implantation of silver coated megaendoprostheses (MUTARS®).

From 04/2004 to 01/2006 seventeen patients of slightly less impaired disposition were treated by a comparable two-stage procedure using silver-augmented cemented spacer prostheses or cement fills.

Patients are closely observed regarding toxic side effects.

Concentration of silver in blood and puncture samples are measured using an argon plasma mass spectrometer.

Results: To date eight of nine patients with silver coated megaendoprostheses are free of infection. One patient with known cellular and humoral immunodeficiency recently developed a fistula, puncture showing superinfection by coag. neg. staphylococci.

In the second group one patient of seventeen actually shows a persisting infection, but cannot be matched properly as he primarily suffered from a long-term infected knee arthrodesis.

Silver concentrations ranged from a maximum of 1010 to 243 μg/kg (ppb) to a minimum of 84 to 304 μg/kg (ppb) with silver coating, and a maximum of 380 to 22,9 μg/kg (ppb) to a minimum of 76 to 5,02 μg/kg (ppb) with silver spacers.

There are large individual differences in both groups.

We found no signs of argyrosis or recently developed neurological deficits.

Discussion: The use of silver in the treatment of severely infected joint prostheses is a promising approach, but it is not without risks and throwbacks. Strict indication and surveillance are needed to keep possible side effects under control. It ought not to be used out of specialized centres.

J Goldhahn S Drerup F Angst B.R. Simmen

Introduction: Patient self-assessment plays a significant rule in the monitoring of patients within clinical studies as well as a separate quality indicator. The self-assessment of function, disease activity and quality of life is known to have a predictive value in the disease progression of rheumatoid arthritis (RA) and other orthopaedic diseases. However, all questionnaires challenge the clinical infrastructure. The questionnaire administration and their processing require still considerable manpower and is a potential source for errors. We analysed the in-house processes, identified the essential requirements and explored possible electronic solution with the aim to reduce necessary manpower and failure sources.

Materials and methods: In a first step we defined a set of questionnaires we want to administer on a regular base. We then evaluated candidate systems with respect to data handling and to further statistic processing. Two years later we re-evaluated the system and possible alternatives. We then paid special attention to scanning features and data export options. Finally we performed reliability and handling tests and a first clinical trial.

Results: The standardized set for shoulder patients comprises 144 items per patients. The set was designed as a four-color print for automatic processing with Qualicare. Four large studies with a total of more than 300 evaluations were performed using Qualicare. Our reevaluation of the system revealed major problems with the line scanner, the data processing in the system and the data export into statistics programs. After intensive search we installed a new scanning system based on an OMR reader that detects regions of interests on the questionnaire (Remark Office). This system allows simple form generation with the PC, the use of bar-code and faster processing. Reliability was more than 0.95 and handling revealed no major problems. Since first trials were successful the new system became the standard for all questionnaires in our department. Discussion: The high amount of variables in patient self-assessment requires automated processing to save manpower and to avoid failures during manual processing. During a three-year period we identified scanning and export options as the key factors for long-term success. The new system (Remark Office) accomplishes both requirements and might serve as the base for large studies or regular quality control.

K Kuriyama J Hashimoto M Fujii T Murase H Tsuboi A Myoui H. Yoshikawa

Background: Juxta-articular intraosseous cystic lesions (JAICL) are common lesion in patients with rheumatoid arthritis (RA) and could cause spontaneous pathological fractures and extensive joint destruction. Although surgical treatment is well indicated for benign bone tumour such as solitary bone cyst, RA induced JAICL have been rarely treated surgically because of following reasons. The first is the possible re-absorption of grafted bone due to disease progression. The second is donor site problem of iliac bone autografting. The third is limitation of autograft for possible operations in the future. The fourth is the lack of bone graft substitutes with good osteoconductivity. We have developed the interconnected porous calcium hydroxyapatite ceramic (IP-CHA) with excellent osteoconductivity. The IP-CHA achieved major incorporation with host bone much more rapid than the other porous calcium hydroxyapatite ceramics. We evaluated the feasibility and effectiveness of curettage and packing with the IP-CHA for the treatment of JAICL in RA patients.

Methods: Nine JAICL in 7 RA patients were treated by curettage and packing with IP-CHA. Eight lesions were impending pathological fractures. Two were male and five were female, the average age of operation was 57.8 years (range, forty-nine to seventy-two years). Follow-up assessment was based on final radiography at an average of 10.9 months after surgery (range, five to seventeen months). The expansion of the cystic lesions around the implanted IP-CHA and the re-absorption of the IP-CHA itself, which means erosion or increasing porosity of implanted IP-CHA, were assessed on the basis of the radiographies at just after operation and final follow up.

Results: The locations were as follows: distal radius, 6 lesions; distal ulna, 1; proximal tibia, 1; distal fibula, 1. No lesions showed the re-absorption of implanted IP-CHA itself. One of 9 lesions showed out-expansion of radiolucent area around the implanted IP-CHA without re-absoption of IP-CHA itself at the final follow-up. There were no postoperative fractures as complication.

Conclusions: These results suggested that surgical intervention with the IP-CHA could be useful for prevention of pathological fractures due to arthritis related JAICL. The efficacies of this technique might be augmented by amelioration of disease activity with concomitant drug therapy including biologics, since there was one case with out-expansion of cystic lesions in RA patients.

K.F. Kazuo Fujiwara K.A. Koji Asaumi H.E. Hirosuke Endo V.A. Nobuhiro Abe K.N. Keiichiro Nishida S.M. Shigeru Mitani T.O. Toshifumi Ozaki H.I. Hajime Inoue

Purpose: We use a minimally invasive surgical technique (MIS) when performing cementless total hip arthroplasty (THA). Because, it is difficult to put the implant correctly through the small incision, we have used a computed tomography (CT)-based navigation system navigation system since 2005. The current study is a preliminary report of the results.

Materials and Methods : We performed MIS-THA with an antero-lateral approach, in treating 10 osteoarthritis (OA) cases by navigated MIS-THA (Navi group) and compared them with the 10 OA cases treated without navigation (non-Navi group). Follow-up periods ranged from 6–9 months. All of the implants were AMS HA cup with a PerFix stem. The patient’s preoperative CT data in DICOM format was used in the work station for preoperative planning. Appropriate angle and the positions of cup and stem were decided preoperatively on the 3D model of pelvis and femur. The factors evaluated were operation time, blood loss, the inclination and the cup anteversion angle on post operative radiographs and CT images.

Results: The mean operation time and mean amount of blood loss were 110 minutes versus 80 minutes, and 417 ml versus 260 ml in the Navi and the non-Navi groups, respectively. The differences were significant. The differences between the planned and postoperative angles were lower in the Navi group than in the non-Navi group. However, the differences between the groups were not significant. There were no major complications, nerve palsy, or fracture in either group.

Conclusion: Our findings were similar to previous reports. The increase of operation time and the amount of blood loss were caused by lengthy registration and adjustments to the system. Although the navigation system increased implantation accuracy, improvements are necessary to reduce blood loss and operation time.

H. Osnes Ringen T Uhlig T.K Kvien

Background: The overall goal in the treatment of RA is to minimize the loss of function and preserve the quality of life. In addition to drug therapy orthopaedic surgery may offer an opportunity to improve functioning in varies parts of the skeletal system.

Objective: To examine the overall magnitude of change in quality of life over a ten years period, with special focus on the changes in physical functioning in different joint areas.

Methods: Data from the Oslo RA register with 1600 living patients were used as basis for the study. Self-reported questionnaires were sent to the patients in 1994, 1996, 2001 and 2004, including the SF36, the AIMS2, the MHAQ, and three 100 mm visual analogue scales (pain, fatigue and patient global). 310 patients (mean (SD) age 56.4 (13.0) years, and disease duration 12.0 (9.9) years, 85.5% women) who completed questionnaires at baseline and after 10 years were eligible for the current analyses. Changes in health status were adjusted for age, sex and duration of disease. Magnitude of change was analysed by standardized response mean (SRM), i.e. the change divided by the standard deviation. AIMS2 comprises physical scales for different parts of the body and was used to examine changes in physical functioning in different areas of the musculoskeletal system.

Results: The overall physical functioning was deteriorated with MHAQ SRM 0.25 and AIMS2 physical SRM 0.11. Larger average deterioration in physical functioning was seen in mobility and walking and bending, than for upper extremity function (arm and hand finger scales). These results were supported by adjusted SRMs for the individual items of MHAQ: Dressing 0.26, Get out of car 0.24, Walk outdoor 0.22, Bending 0.22, Get in and out of bed 0.16, Lift to mouth 0.13, Turning faucets −0.02.

Conclusion: Physical functioning and quality of life deteriorated over 10 years in patients with RA. The largest loss of functioning was seen in the lower limb physical activity (mobility, walking and bending). This finding may give a clue to priorities of resources to surgical procedures in patients with RA.

N Abe K Fujiwara T Yoshitaka Y Nasu H Date Y Sakoma T Ozaki H. Inoue

Purpose: Minimally invasive surgery (MIS) total knee arthroplasty (TKA) makes faster rehabilitation in many cases, but it was sometimes difficult to performed the precise osteotomy and place the implants correctly due to loss of view or orientation for its small exposure. The computer-assisted navigation TKA system (CAS) was reported to achieve the optimal alignment and placement. However, it had disadvantages of longer operation time and wider exposure to acquire the reference points than these of the conventional method. Now MIS technique needs the accuracy of implant placement, on the other hand, CAS needs less-invasive methods. Among CAS methods, CT-based navigation system would have the potential for MIS because it would be referred to preoperative CT images. This study examined the accuracy of the registration with CT-based navigation system and the possibility of its application for MIS.

Material and Methods: CT data were obtained from the femur and tibia of “Sawbone” (synthetic bone, Pacific Research Laboratories, Vashon, WA, USA) with a slice thickness of 1 mm. These data were transferred to Vector Vision Knee 1.5 (BrainLab Inc, Heimstettenm, Germany) and reconstructed to three-dimensional model. Two registrations were performed by a surface-matching algorithm. One is the conventional method as Vector Vision protocol; another is MIS approach which was allowed the limited area around the femoral notch and joint surface of tibia for registration. The accuracy of registration with these two methods was evaluated by Vector Vision Knee. And these registration points of these different methods were measured using a coordinate measuring machine, 3D surface scanner (Mitsutoyo, JAPAN) and were analyzed and calculated the distribution of points.

Results and Discussion: There was a high degree of reproducibility of the MIS approach compared with the conventional method in the femur. However, the reference points in the distal tibia were deviated 1.5 cm to medial and thus 2.39 degree in varus would be happened at the proximal tibia in both methods. Now this software should be improving to be more accurate.

U Rydholm Q. Li U. Kesteris

Different resurfacing implants offer different kinds of positioning instruments. As it is of outmost importance to position the components within rather narrow limits to diminish the risk of femoral notching or impingement we decided to measure the position achieved in 72 hips resurfaced with the Durom® resurfacing hip and instruments.

There were 38 males and 27 females with 72 hips (7 bilateral). The indication was OA in 51 cases, RA in 12 and ON in 2. We compared 2 groups, 26 hips operated with an antero-lateral approach (A) and 46 with a postero-lateral approach (B).

The acetabular cup anteversion angle was 22±11° in group A and 15±9° in group B. The abduction angle was 38±9 ° in group A and 44±7° in group B. The acetabular gap was 2±1 mm, resp. 2±2 mm. The stem-shaft angle was 140±5° resp. 141±6°. Retroverted cups averaged 7±4°.

The difference between pre- and postoperative acetabular size was 3 mm in group A (mostly RA patients) and 5 mm in group B (mostly OA patients).

Conclusions: We have obtained a fairly good implant position. The only significant differences between the two groups were decreased acetabular cup abduction angle compared to the preoperative angle in the antero-lateral group, but increased angle in the postero-lateral group, and that less acetabular bone was removed in the antero-lateral group (patients with RA included) compared to the postero-lateral group.

A Kitamura K Nishida Y Nasu T Ozaki H. Inoue

Introduction Rheumatoid arthritis (RA) commonly affects the forefoot, and pain caused by the deformity of forefoot impairs the walking ability. We have performed resection arthroplasty for all metatarsal heads using modified Lelièvre procedure in affected feet. The aim of the current retrospective study was to investigate the long term results and problems of this procedure.

Patients and methods We investigated 45 feet treated by modified Lelièvre procedure in 29 women from 1985 to 2003 at our institute. Their average age at operation was 54.8 years (range 39 – 76 years). They were followed-up more than two years (26 – 203 months). Resection of all five metatarsal heads was performed for the RA forefoot which had severe deformity and persistent pain, using medial approach for first metatarsophalangeal (MTP) joint and plantar approach for lesser MTP joint. The results were evaluated by the rating scale of the American Orthopaedic Foot and Ankle Society (AOFAS), Foot Function Index (FFI), physical examination, radiographic evaluation, as well as subjective assessment using questionnaire for mental and physical disability.

Results Pain and walking ability were improved in all but 2 feet; one of which underwent additional surgical treatment. Eight out of 45 feet had recurrence of MTP joint dislocation of thumb at the final follow-up. Re-formation of callosities was seen in 69% of the patients, 50% of which were developed within 3 years after operation, and 78% within 5 years. No superficial infection or delayed wound-healing was noted in any case. Satisfactory surgical outcome was maintained for at least 2 years after operation in all cases, and deteriorated later. At an average of 96 months postoperatively, the average AOFAS forefoot score was 67.9 points. Seven cases were judged to have excellent (25%), 13 cases good (46%), 7 cases (25%) fair, and 1 case poor (4%) results. The average radio graphic hallux valgus angle was 31.3 degrees. Eventually, 70% of patients underwent total hip or knee arthroplasty.

Conclusion Resection arthroplasty of all five metatarsal heads using modified Lelièvre procedure in RA patients with pain and deformity of forefoot seemed to be an effective procedure over a long postoperative period, providing reasonable relief of symptoms. Because RA affects multiple joints including hip and knee joints, the forefoot reconstruction alone cannot sustain the improved walking ability.

H. Thabe

The management of a bacterial periprosthetic infection by two-stage re-implantation should be presented using an implanted application spacer for antibiotics to maintain mobility and soft tissue balance and ensure simultaneous local delivery of antibiotics. Indication is an acute periprosthetic infection, acute and chronic course of the infection with unknown spectrum of organism, hardly to treat and with a probable loss of mobility due to protracted immobilization after implant removal. Acute infections with a known spectrum of organisms that can be controlled by synovectomy and antibiotic treatment or by one-stage re-implantation are contraindications for this treatment. Spacers are available for hip and knee replacements including surface replacements of the knee. First a complete synovectomy is performed; the implant bed is then prepared for implantation of the application spacer for antibiotics. Silicone catheters are advanced through two separate drill holes into the intramedullary canal and then inserted into the perforated implant stems. Daily parenteral doses of antibiotics in parenteral doses are delivered through the percutaneous silicone catheters directly into the intramedullary canal. The application spacer for antibiotics allows daily physiotherapy and even mobilization on a CPM device. Partial weight bearing may even be allowed, if there is sufficient stability. Once the CRP values have decreased to normal levels, the definitive implant is placed using antibiotic-impregnated cement according to current resistance studies. 36 patients have been treated with this method since 1993. Two-stage re-implantation of a total knee was performed in 20 cases, and re-implantation of a total hip in 16 cases. The longest postoperative follow-up period is now 10 years. Till now, no revision surgery has been required on a joint treated in this manner, and no periprosthetic re-infections have been observed. In the knee, a range of motion of 0/0 /106 degrees was achieved after an average follow-up period of 6.1 years. In the hip, values of 10/0/110 degrees were achieved after an average of 6.3 years. Revision surgery for infection included cases of fungal and tubercular infection. A postoperative Hospital for Special Surgery rating of 79.5 was achieved in the knee and a rating of 81.3 in the Harris hip score.

D Hirokazu A Nobuhiro Y Teruhito S Yoshimasa O Toshifumi I. Hajime

The precise implantation of the prosthesis is quite important to have the good long term outcomes. One of the important methods for the implantation is the preoperative templating to determine the selection of implant size, position and alignment. But the preoperative template system sometimes could not give us the reproducibility of the actual size of prostheses which were assessed intra-operatively. One reason for the inaccuracy of the radiograph based templating system is caused by the magnification of the view due to the fixed knee deformity and another is by the rotation view of the prostheses due to tilt shooting radiograph. We are now performing the preoperative CT based 3 dimensional templating system or intra-operative molding template system with virtual bone model, in the addition to the traditional preoperative radiographic templating system. Our aim is to assess the reliability of these templating systems which are traditional radiograph template (2D-template), CT-based template (3D-template) and intra-operative molding template (Free-template), for the selection of correct prosthetic size during operation. We randomly selected 51 patients with 19 osteoarthritis, 30 rheumatoid arthritis, 1 juvenile rheumatoid arthritis and 1 systemic lupus erythematosus, and performed PFC sigma total knee arthroplasty (DePuy). In all 51 knees, the sizes of implants were estimated on the traditional radiograph to get the 2D-template data. The 3D template data were obtained from 25 knees preoperatively by the CT-based navigation system (BrainLab) and Free-template data were collected intra-operatively from 27 knees with the CT-free navigation system (BrainLab). These template data were compared with the actual implanted size of the femur and tibia without any information. The statistical analyses were performed to evaluate the reliability of these templating systems. The precision of 3D-template was not significantly different from that of 2D-template. On the other hand, the reproducibility of Free-template data was significantly higher than the other templating system. In our conclusion, the precise selection of the prostheses could not be achieved with either 2D-template or 3D-template, due to the disappearance of joint space and severe osteophytes. CT-free system could be precisely acquire in-situ bone information of femur and tibia even in the severe deformity knees, and at the same time, CT-free system, which has the kinematics based navigation system, can determine the placement and alignment. Thus CT-free navigation system would be the best assistance during pre- and intra-operation to achieve the long-term good results.

K.S. Kaichiro Saigo J.R. Junnosuke Ryu S.S. Shu Saito T.I. Takao Ishii

Introduction: We reviewed clinical results of the performance of FNK-type total knee arthroplasties (TKAs) for treatment of rheumatoid arthritis (RA) knees.

Materials and Methods: Materials we had studied were 372 knee joints in 202 cases (21.1%) with RA (36 joints in 22 male patients, and 336 joints in 180 female) out of 1762 knee joints in 1032 cases who had undergone TKA using FNK type prostheses between May 1995 and December 2003. A mean age of patients at index procedures was 62.4 years (24 – 74 years), with a mean follow-up period of 6.7 years (1 – 9.4 years). With these cases, we discussed clinical evaluation on the basis of JOC rating scores, postoperative range of motion, complications, and others.

Results: 288 knee joints (77.4%) in 144 patients were involved in bilateral simultaneous TKA. The range of motion (ROM) had shown a significant improvement from a preoperative average of 15.2 – 110.2° to 2.3 – 125.0° at the last follow-up. There have been no cases of revision surgery at all, with excellent postoperative results.

J.M Wilkinson P Haslam J Williams D.J Moore C.J.M. Getty

We compared the long-term clinical outcome scores of the Stanmore total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA, n=26 subjects) versus osteoarthritis (OA, n=35 subjects) at a mean of 12 years after THA. Patients with RA were a mean of 11 years younger at review (66 years, P< 0.001) than those with OA. A greater proportion of RA patients had bilateral THA (19/26 versus 12/35, p=0.03), and were of Charnley grade C (23/26 versus 2/35, p< 0.001). The proportion of male versus female subjects and body mass index were similar between groups (p> 0.05 all comparisons). The overall SF-12 score and SF-12 physical component score were 8% and 15% poorer, respectively, in subjects with RA versus those with OA (P< 0.05). The hip-specific Oxford and Harris hip scores, however, were similar between groups (p> 0.05). Within the individual domains of the Harris hip score, patients with RA had poorer scores for walking distance, stair climbing, putting on of socks/shoes, and ability to enter public transport (p< 0.05 all comparisons). The other domains of pain, limp, use of walking aids, sitting, deformity and range of movement were similar between groups (p> 0.05). The observed differences in outcome scores between RA and OA groups were independent of age and whether the patient had bilateral THA (ANOVA, p> 0.05). Clinical outcome scores in the long term after THA are poorer in RA subjects versus OA. The principal differences occur in the ability to walk long distances, and the use of stairs and public transport.

A.M Thomas C McBryde P.B. Pynsent

Metal on metal hip resurfacing was introduced in 1992 by Derek McMinn initially using an all cementless device and then an all cemented device. A hybrid resurfacing with a cemented femoral component and a cementless acetabular component was introduced in 1994. The manufacturer of the hybrid hip resurfacing was changed in 1996. Since 1997 the Birmingham hip resurfacing has been in continuous use.

The device is approved by NICE (National Institute for Clinical Excellence) for use within the NHS in patients with Osteoarthritis of the hip. The device is not yet approved for use in patients with Rheumatoid Arthritis and other types of inflammatory arthritis. There are concerns regarding bone quality in rheumatoid patients, which may result in a high incidence of component loosening or femoral neck fracture. Conventional total hip replacement is a successful procedure in inflammatory arthritis however with modern treatments producing increased activity levels there are concerns about polyethylene wear.

The author has performed metal on metal hip resurfacing in patients with inflammatory arthritis over the past 12 years. A total of 170 patients have been operated on with 198 resurfacings. 33% of patients have a diagnosis of some type of inflammatory arthritis. The outcomes have been assessed using Oxford hip scores and long term clinical and radiological review. Our results indicate that there is a minimal risk of femoral neck fracture and a minimal risk of component loosening when the device is used with this approach in patients with inflammatory arthritis.

K Masuda T Mori T Juji R Marutani T. Hirose

Objective: The aim of this study was to evaluate the safety and efficacy of sequential bilateral total knee arthroplasty (TKA) for patients with rheumatoid arthritis (RA), in comparison with staged bilateral and unilateral TKA.

Patients and Methods: Between July 2000 and June 2005, 340 TKA were performed in our department. We investigated retrospectively the clinical data of each patient, including the peri-operative data such as the surgical time, the amount of haemorrhage and postoperative adverse events. We also examined the clinical outcome before and after bilateral TKA by using the Japanese Orthopaedic Association (JOA) evaluation chart of knee joint function (JOA score).

Results: We have done sequential bilateral TKA for 60 knees of 30 patients (group A), staged bilateral TKA for 26 knees of 13 patients (group B) and unilateral TKA for 254 knees (group C). Before TKA, the mean JOA score were 44.9, 40.1, 46.4 points, and the mean range of motion of affected knees were 14.6–113.6°, 27.9–89.6°, 14.1–116.9° in group A, B and C, respectively, indicating that group B included more severe cases. Whereas the mean surgical time were 136.4, 158.4, 154.3 minutes, the mean amount of peri-operative haemorrhage were 414.6, 273.4, 277.7 ml in group A, B and C, respectively. Although we experienced 1 case with symptomatic pulmonary embolism in group A, which was successfully treated, there was none of cases with death within 1 month of surgery or early-phase infection. The JOA score at final follow-up (the mean follow-up period was 1 year and 8 months) were 91.1 and 86.9 points in group A and B, respectively, showing good results in both groups.

Conclusion: In short-term data, sequential bilateral TKA was successfully performed and beneficial approach to patients with RA. The intensive pre- and post-operative management could be essential for good clinical outcome. Further improvement should be needed to perform this procedure more safely and prevent complications, especially serious cardiopulmonary events.

U Rydholm T Andersson L Linder P Maxander J Besjakov F Montgomery A. Carlsson

25 RA patients with their ankles fused with an intramedullary nail were compared to 35 RA patients with their ankles fused with compression screws.

24/25 nailed patients showed radiographic healing at follow-up after 3 (1–8) years, and 26/35 ankles in the compression screw group examined after 6 (1–14) years healed after the first attempt and another 5 after repeat surgery.

In the nailed group 23 patients were satisfied and 2 somewhat satisfied. In the compression screw group 20 were satisfied, 12 somewhat satisfied and 3 dissatisfied.

There were 4 deep infections (3 healed after nail extraction and antibiotics, one unhealed) in the nail group and 1 deep infection (healed after antibiotics) in the compression screw group.

Six patients in the nailed group also had a permanent plantar sensory loss.

Conclusion: Ankle fusion with retrograde intramedullary nailing seems to result in a high rate of healing and satisfied patients, but cares a substantial risk of deep infection compared to fusion with compression screws, which has a lower fusion rate fewer satisfied patients, but less complications.

RA patients with a normal subtalar joint are of course only managed by compression screws.

K.I. Kazuhiko Inoue

Purpose: Synovium proliferation of rheumatoid arthritis (RA) is a key role in development of destruction in articular joints. Arthroscopic synovectomy is quite useful for resection synovium less invasively for RA patients. However there are few papers about shoulder joint synovectomy of rheumatoid arthritis. Ho-YAG laser is also effective to decrease synovium proliferation. The advantage of using Ho-YAG laser is effective to pannus even in deep zone of bone erosion. In this paper, we treated 13 shoulders of 11 patients of RA by using Ho-YAG laser to assess whether Ho-YAGH laser is effective in shoulder arthroscopic synovectomy of RA

Materials and Methods: We treated 13 shoulders in 11 patients of RA, including 8 in stage II, 4 in stage III, 1 in stage IV. The duration of RA is an average of 4, 6 years. The follow-up period is an average of 14 months. We compared CRP, DAS28 and MRI findings before and after surgery. Those patients were taking DMARDs such as MTX in 8 patients, steroid in 3 patients infliximab in 1 patient and etanercept in 1 patient. We used 4.0 mm arthroscope, VAPR and shaver for synovectomy. Ho-YAG laser set to 10W to bone erosion area to reach deep zone of pannus and to resect synovium.

Results: We found villous synovium proliferation with vascularity in rotator interval and supraspinatus tendon in shoulder joint. In subacromial bursa, yellow fat tissue and white fibrous soft tissue was detected almost all shoulders. After synovectomy by using Ho-YAG laser, CRP was decreased from an average of 3.6 to 0.8 and DAS28 was also decreased an average of 5.4 to 3.7 at 14 month after surgery. MRI showed decreased pannus with synovium and joint destruction was not preceding after 14 month.

Discussion: Ho-YAG laser is effective for using shoulder arthroscopic synovectomy especially to treat pannus in bone erosion. The amount of energy of Ho-YAG laser for synovectomy is not clear so far. We used 10W for 5 second in each area that could be effective to decrease pannus formation. We would further investigate in the basic experimental levels to confirm Ho-YAG laser efficacy.

K Arai T Murai J Fujisawa N Kondo T. Hanyu

Our approach to reconstructing forefoot deformities in patients with rheumatoid arthritis was as follows. In the lateral toes with mild or moderate joint destruction, shortening oblique osteotomy of the metatarsals is performed. With severe joint destruction, metatarsal head is resected. Arthrodesis of the first MTP joint is performed as a rule with resection arthroplasty in the lateral toes. When shortening oblique osteotomy in the lateral toes is indicated, the great toe is managed as follows: in young patients with mild joint destruction in the great toe (Larsen grades I and II) and who are able to ambulate well, Mitchell’s osteotomy is done. In older patients, or in patients with moderate or severe joint destruction (Larsen grades III to V), flexible hinge toe prosthesis is implanted.

Between 1987 and 2000, Mitchell’s osteotomy was performed on 47 feet in 31 patients, whose mean age was 53 years, Larsen grade was 2.5 and hallux valgus angle (HVA) was 35.0 (SD11.9). Arthroplasty with flexible hinge toe prosthesis was performed on 31 feet in 23 patients, 58 years, Larsen grade was 3.7 and HVA was 45.3 (SD12.9). After 1995, grommets were used in 17 feet. In 2002, we studied clinical results of them. 40 feet of Mitchell’s osteotomy had no pain and 7 feet had some pain. 26 feet of arthroplasty with flexible hinge toe prosthesis had no pain and 5 feet had some pain. Radiologically, HVA was 17.2 (SD10.3) in Mitchell’s osteotomy and 12.1 (SD6.3) in arthroplasty with flexible hinge toe prosthesis. Maintenance of correction by arthroplasty with flexible hinge toe prosthesis was better than Mitchell’s osteotomy significantly, especially more than 30 degrees of HVA. Without grommets, grade 0 was 8 feet, grade I was 3, and grade II was 3 feet judged by Granberry’s grade. But no revision surgery was performed by silicone synovitis or fracture of implant. With grommets, there were no fractures.

We added degree of HVA to management of operation after 2002. More than 40 degrees of HVA was considered flexible hinge toe prosthesis. After 2002, Mitchell’s osteotomy was performed on 7 feet in 6 patients, 53.7 years, Larsen grade was 2.4 and HVA was 32.3 (SD6.8). Arthroplasty with flexible hinge toe prosthesis was performed on 14 feet in 10 patients, 60.7 years, Larsen grade was 3.9 and HVA was 42.5 (SD7.5). Radiological result in these patients at 2005, HVA was 14.6 (SD4.9) in Mitchell’s osteotomy and 14.9 (SD2.5) in arthroplasty with flexible hinge toe prosthesis.

A. Lluch

Introduction and aim: In the rheumatoid hand, a radial inclination of the wrist is commonly observed in the presence of an ulnar drift of the fingers. The question that remains is: Which came first? To find an answer to this question, we have studied the radiographs of 122 hand affected by rheumatoid arthritis.

Material and methods: In group I (44 hands), the disease was restricted to the wrist joint, which presented an average ulnar inclination of 15°, ranging from neutral to 43° of ulnar inclination.

In group II (13 hands), the disease was limited to the MP joints, with an average of 30° of ulnar inclination of the fingers, ranging from 10° to 70°. A compensatory radial inclination of 12° was observed at the wrist, ranging from 2° to 26°.

In group III (28 hands), both the wrist and MP joints were affected by the disease. The fingers presented an average ulnar inclination of 17°, ranging from 7° to 40°. The wrist presented an average radial inclination of 4°.

In group IV (34 hands) and V (3 hands), measurements were done before and after the finger deformity was corrected from an average of 45° to 7°, while the wrist corrected itself, without wrist balancing procedures, on an average from 30° to 2° of radial inclination.

Results: When only the wrist is involved, the metacarpals are always inclined towards the ulnar side. We have observed a radial inclination of the wrist only in the hands presenting an ulnar inclination of the fingers. When the ulnar drift of the fingers is surgically corrected, the radial inclination of the wrist will tend to correct itself.

Conclusion: It has been generally accepted that radial inclination of the metacarpals is one of the causes of the ulnar drift of the fingers, but from our studies the radial inclination of the metacarpals should not be considered the cause but rather a consequence of the ulnar drift of the fingers.

A. Hilker

Background The AscensionTM MCP-implant acc. to Beckenbaugh is an unconstrained endoprosthesis consisting of a graphite core with a pyrocarbon coating. Long term results published by the Mayo Clinic gave rise to the hope of good ingrowth properties and a long durability due to the optimum wear resistance of the material. Purpose of this study was the evaluation of the early results of this implant applied on the patients of a rheumatoid arthritis surgery department.

Methods In a prospective manner we evaluated the data of 18 patients with 19 involved hands in which we implanted a total of 29 Ascension endoprostheses between July, 2000 and Oktober, 2002. The mean follow up time was 39.7 months. We assessed hand function (SODA-score), mobility, radiographic appearance and the subjective parameters pain, functionality, power, cosmetic appearance and global satisfaction.

Results The SODA score increased from 82.8 preoperatively to 92.9 (maximum 108) at follow up. With 50.9 and 51.3 deg. respectively the range of motion remained almost unchanged. On a visual analogue scale from 0 – 10 the subjective results were: pain 2.1 (−5.2), functionality 6.5 (+3.0), power 5.3 (+2.3), cosmetic appearance 8.0 (+3.4), global satisfaction 8.1.

Radiographically we observed suspicious radiolucent lines around 17 of 58 implanted components (29%), three of them progressive. Around the tips of three stems an osteolytic area with minimal progression was found. Three stems showed a slight migration. The following intraoperative complications were observed: Two bone fissures and three lacerations of a collateral ligament, which all healed uneventfully. Five endoprostheses were converted into a flexible hinge silicone implant for persistent pain and loosening between 12 and 48 months p.o. One more implant had to be revised due to a late haematogenous infection 4 years p.o.

Conclusion With the AscensionTM MCP implant a good pain relief can be obtained in almost every case but only rarely an improvement in the range of motion can be seen. The subjective results were predominantly good. But the apparently inconstant bony ingrowth resulted in a rate of revisions for aseptic loosening as high as 17% at a mean follow up of 3 ½ years. A modification of the implant leading to a better bony fixation would be required before a wider clinical use of this implant can be recommended.

H Ishikawa A Murasawa K Nakazono I Toyohara A Abe S. Kashiwagi

Objective: The objective of this study was to clarify the clinical outcome of upper-extremity surgeries for the rheumatoid patients using the Japanese version of the DASH Disabilities of the Arm, Shoulder and Hand questionnaire and to investigate whether the outcome was affected by the activity of the disease.

Materials and methods: One hundred and twenty seven surgical procedures in 103 rheumatoid patients (male: 26, female: 77) were included in this study. Surgeries were performed in 4 shoulders (HHR: 4), 35 elbows (TEA: 28, synovectomy: 6 etc.), 60 wrists (Kapandji: 6, radiolunate arthrodesis: 28, total arthrodesis: 7, extensor tendon reconstruction: 19 etc), and 28 hands (MP Swanson: 13, PIP fusion: 7, thumb IP fusion: 4 etc.). The patients’ average age at the surgery was 61 years and an average duration of the disease was 11 years. The DASH (function/symptoms) score and DAS (Disease Activity Score) 28-CRP(4) were taken just before the surgery and an average of 1 year and 3 months after the surgery. According to the EULAR’s improvement criteria, disease activity and response to the medical treatment was determined.

Results: The preoperative DASH score decreased in 96 surgical procedures (76%) postoperatively and the average score decreased from 50 to 38 (n=127, p< 0.01). Change in the score was −17 in shoulder surgeries (n=4, p=0.17), −12 in elbow surgeries (n=35, p< 0.01), −12 in wrist surgeries (n=60, p< 0.01) and −10 in hand surgeries (n=28, p< 0.05). The DASH score in the patients with preoperative HDA (high disease activity: n=16, from 70 to 57, p< 0.01) remained high compared to those with preoperative LDA (low disease activity: n=23, from 45 to 32, p< 0.01) and MDA (moderate disease activity: n=88, from 47 to 36, p< 0.01). Decrease in the score was more prominent in the patients with good response to the medical treatment (n=34, −22, p< 0.01) than those with moderate response (n=38, −11, p< 0.01) or no response (n=55, −6, p< 0.05). There was no significant decrease in the postoperative score in the patients with increased DAS28-CRP (4) (n=26, −1, p=0.822).

Conclusions: The clinical outcome of upper-extremity surgeries for the rheumatoid patients was good. Control of the disease activity by the medical treatment proved to be one of the important factors to produce a favourable outcome of surgical treatment.

J.W Sperling R.H Cofield C.M Schleck W.S. Harmsen

Between January 1, 1976 and December 31, 1991, 195 total shoulder arthroplasties and 108 hemiarthroplasties were performed by the senior author in patients with rheumatoid arthritis. One hundred eighty-seven total shoulder arthroplasties and 95 hemiarthroplasties with complete preoperative evaluation, operative records, and minimum 2-year follow-up (mean 11.6 years) or follow-up until revision were included in the clinical analysis. Twenty patients died and one was lost to follow-up. All 303 shoulders were included in the survival analysis.

There was significant long term pain relief (P< .0001), improvement in active abduction (P< .0001), and external rotation (P< .0001) with both, hemiarthroplasty and total shoulder arthroplasty. There was not a significant difference in improvement in pain and motion comparing hemiarthroplasty and total shoulder arthroplasty for patients with a thin or torn rotator cuff. However, among patients with an intact rotator cuff, improvement in pain and abduction were significantly greater with total shoulder arthroplasty. Additionally, among patients with an intact rotator cuff, the risk for revision was significantly lower for total shoulder arthroplasty (p=0.04).

Radiographs were available for 152 total shoulder arthroplasties and 63 hemiarthroplasties with a minimum 2 year follow-up. Glenoid erosion was present in 62 of 63 hemiarthroplasties (98%). Glenoid periprosthetic lucency was present in 110 of 152 total shoulder arthroplasties (72%).

The data from this study indicate there is marked long term pain relief and improvement in motion with shoulder arthroplasty. Among patients with an intact rotator cuff, total shoulder arthroplasty appears to be the preferred procedure for pain relief, improvement in abduction, and lower risk of revision surgery.

J.R. Junnosuke Ryu T.I. Takao Ishii M.N. Masahiro Nagaoka

The recent advance of drug therapy for RA tends to replace preventive surgery, for example synovectomy. A rupture of a dorsal extensor tendon of the hand is an absolute indication for surgery, however. Such tendon ruptures are usually treated by tendon reconstruction and synovectomy of wrist joint. At our department, reconstructive surgery was administered with synovectomy for extensor tendon ruptures of the hand in 97 hands for 86 patients until June 2005. Recently, however, we occasionally encounter ruptures of extensor tendons not associated with severe synovitis. To treat such tendon ruptures, we usually administer tendon transfers in combination with tenosynovectomy through a small skin incision. Because this surgical procedure has achieved excellent results, we report our experience.

This study included 15 patients who received tenosynovectomy in combination with tendon transfers in 14 hands since February 2001. This surgical procedure is indicated for tendon ruptures associated with mild synovitis (swelling) without instability on the ulnar distal end. As a rule, a 2–3 cm transverse skin incision was made on the dorsum of the hand under maxillary nerve block. After exposure of the distal ruptured end of the tendon, tenosynovectomy was administered through the incision. Then, the distal end was transferred to the adjacent normal tendon and fixed to it with sutures. Postoperatively, the repair was immobilized with bandage. The patient was allowed actively to extend and bend the hand on the next day. As a rule, this operation is administered on an outpatient basis. The postoperative course was uneventful, without rupture of the repair. The preoperative ranges of motion of the MP and PIP joints were retained postoperatively without difficulty in ADL.

L.J. Jung

According to authors investigating problems with the hand in rheumatoid arthritis (RA), up to 95 % of patients suffer due to wrist involvement after 8–12 years from the onset of the disease. In a high activity and a progressive pattern of RA, wrist damage occurs earlier. The question is what to do when pain and instability are dominant factors and at the same time the x-rays show only a mild or moderate degree of destruction of the joint. Trying to find an alternative procedure to a more radical surgery, in 1995 I started surgical stabilization using a pedicled flap of the joint capsule and the extensor retinaculum.

Material and methods: 44 wrists in 36 patients were treated with this method. The patients were 34 women and 2 men at the ages from 24 to 73 (49 on average). The follow-up was from 2 to 9 years (average > 6). The operation was done through a dorsal approach. After synovectomy of the wrist, the capsular pedicled flap was prepared, in a case of subluxation, the carpal bones were repositioned and two mattress strong stitches were put on through the capsule flap and proximal and distal row of carpal bones. The joint was closed with single stitches. Depending on the pathology, hemi- or total- resection of the ulnar head was combined with the procedure. In some cases, a repair of the ruptured extensor tendons was necessary. Immobilisation in the palmar splint for 6 weeks was recommended, and then a rehabilitation program started.

Results: 25 wrists (63 %) at the latest follow-up were free from pain and stable, 8 (20 %) were stable but mildly and occasionally painful, 4 were moderately painful, and 3 needed arthrodesis because of the marked bone destruction and pain. The power of the combined grip was significantly improved in 31 wrists (77 %); moderate improvement was in 6 cases (15%).

Conclusion: Stabilisation of the painful and unstable wrist with the use of the method described above gives good results and seems to be a valuable procedure even in selected cases qualified as arthrodesis.

F. Hagena B. Mayer

Background: In 80% of patients with rheumatoid arthritis the metacarpophalangeal (MP) joints are involved with increasing destruction and loss of function. Silicone arhtroplasties of the MP joints produce a limited range of motion, increasing osteolysis and fractures of the implants. The cementless, unconstrained design of the ElogenicsTM prosthesis is a new concept for treating the MP joints of rheumatoid patients.

Methods: In a prospective study 72 ElogenicsTM prosthesis were implanted, 62 in patients with rheumatoid arthritis, osteoarthritis (n=4), polyarthritis (n=5) and 1 after revision of a silicone implant. The patients were reexamined after an average follow up of 21 months (12–51 months) clinically and radiologically.

Results: The average active range of motion for extension to flexion increased from 0/18/65° before surgery to 0/14/71° after surgery. The remaining ulnar drift was 12° (preoperative 18°!). Pain in the visual analogue scale improved from 2.3 to 1.7 postoperatively. Eight palmar luxations of the implants were recognized. They were revised and are stable during the follow-up. No infection occurred. Two prostheses were changed because of loosening. The X-rays showed osteointegration in the metacarpal components. Radiolucent zones were found in progress at the basis on the palangeal components.

Conclusion: The short- and midterm results after implantation of the cementless, unconstrained ElogenicsTM prosthesis show an improved hand function and pain relief. The design of the implant may solve the accepted postoperative problem of instability of the MP joints.

D.S Della Santa A.C. Chamay

Twenty five years ago, the 1 st paper concerning radiolunate arthrodesis was published by us (Med Hyg 38 1980). Ten years ago a 5 year follow-up radiological evolution of 26 operated rheumatoid wrists by radiolunate arthrodesis compaired with 20 non operated wrists was reported (JHS 20B 1995).

Six critera were retained for XR analysis :

- Evolutive stage classification (Alnot)

- Polyarthritis type classification (Simmen)

- Frontal desaxation (Thirupathi)

- Carpal collapse (Mc Murtry)

- Ulnar translation (Chamay)

- Carpal instability (Tubiana)

Our results showed that although radiolunate arthrodesis induced a lasting functional improvement, correction of the desaxation and collapse was only temporary.

Details of the radiological analysis will be presented and compaired with the litterature data.

E.H Garling D.B Herren R.G.H.H. Nelissen

Various radiological classification systems exist for rheumatoid wrist progression but few have been evaluated for reliability and clinical application. In order to research these three sets of wrist radiographs of 35 rheumatoid patients, with an average duration of disease of 11 years, were classified according to four different classification systems (Larsen, Simmen, Wrightington and Modified Wrightington). The inter- and intraobserver reliability of each was calculated. The reliability of the Larsen and both Wrightington systems were good but the Simmen system had poor interobserver and intraobserver reproducibility. None of the classification systems satisfactorily assessed the distal radioulnar joint (DRUJ) and the Modified Wrightington system could not classify DRUJ disease in 6 of the 35 wrists.

A Abe H Ishikawa A Murasawa K Nakazono I Toyohara S. Kashiwagi

Background: Total wrist arthrodesis is a reliable procedure for severely deteriorated and unstable rheumatoid wrist. In 1999, we developed a new wrist fusion rod (WFR), a cannulated titanium rod could be buried into the third metacarpal with proximal fins and a transverse pin to prevent the rod migration and rotation in the medullary canal. After bone preparation, the 4 mm diameter rod was inserted through a guide pin in ante-grade fashion from the carpus to the neck of the third metacarpal to prevent metacarpal fracture. Then the rod was inserted in retrograde fashion into the radius with an introducer, and countersunk until the distal end of the reached the metacarpal isthmus. After burying the rod, it was bent to the desired angle using a special bender.

Materials and Methods: Total wrist arthrodesis was performed using this rod on 39 wrists in 33 patients with rheumatoid arthritis (6 males and 27 females). Their radiographic change was Larsen grade IV or V with subluxation at the radiocarpal joint. The mean age at the operation was 60 yrs. old (28 to 75), and the mean duration of the disease was 12 yrs. (3 to 40). The mean follow-up period was 39 mos. (5 to 75). Supplemental fixation with staples was incorporated in this intramedullary fixation. Iliac bone was grafted on 8 mutilated wrists in 8 patients. Postoperative immobilization using a short arm cast or a wrist brace was continued for 8 weeks.

Results: Preoperative pain and swelling disappeared in all operated wrists, and grip strength increased in 31 wrists (79%). The mean preoperative grip strength increased from 97 mmHg to 124 mmHg postoperatively. Subluxated wrist was reduced and fused in slight extension and slight ulnar deviation. The rod did not migrate distally or proximally in the medullary canal. Bony fusion was obtained in 36 wrists (92%). Four rods (10%) were broken due to an overuse or a fall before completion of fusion; however, they did not cause any pain. There were no major complications.

Conclusion: Using this WFR, rigid fixation at the desired angle was obtained in the total wrist arthrodesis on rheumatoid wrist. It is technically simple, safe and fast to use.

H.J.L van der Heide M.J de Vos J.M Brinkman D Eygendaal F.H.J van den Hoogen M.C. de Waal Malefijt

Introduction: The Kudo total elbow prosthesis (TEP) is a well established implant, with good mid-term results. In the last decades this implant underwent several modifications. The last modification (type 5) has overcome the problems of stem breakage of the humeral component by modifications of the stem. The ulnar component can be placed with or without cement; the humeral component is always placed without cement.

Aims of this study: To examine the mid-term results of the Kudo type 5 TEP and to compare the results of the uncemented Kudo total elbow prosthesis (TEP), with the hybrid Kudo TEP (uncemented humeral component and cemented ulnar component).

Material and methods: Between 1994 and 2004 89 Kudo type 5 TEPs were placed for joint destruction due to rheumatoid arthritis (RA). The mean age of the patients was 55 years (range 21–84 years). Twenty-two prostheses were placed in males, 66 in females. Forty-nine TEPs (group 1) were fully uncemented and 40 TEPs (group 2) were hybrid (humeral component uncemented, ulnar component cemented). The groups were comparable as related to age, sex and indication for surgery. After implantation of the prosthesis a radiograph was made every two years or sooner when indicated.

Evaluation took place after an average of 5.3 years of follow up (range 1.7–10.6 years) and consisted of a questionnaire, elbow function assessment and anteroposterior and lateral radiographs in a standard way. Pre- and postoperative range of motion was analysed with the paired T-test. Pain scores and EFAS scores postoperatively were analysed using the independent sample T-test. The survival of the prosthesis was calculated from the time of implant to the time of revision or occurrence of radiolucencies.

Results: In group 1, seven ulnar components had to be revised due to aseptic loosening after a mean follow-up of 4 years (range 1.5–6.3 years). Three of these ulnar components were short-stemmed, four were long stemmed uncemented.

In group 2 five patients died of an unrelated course and no revisions have taken place, one TEP is loose on X-ray (after two years) with a suspicion of septic loosening The EFAS scores (87 in group 1 and 91 in group 2) and range of motion (84 degrees in group 1 and 90 degrees in group 2) were the same in both groups.

Conclusion: In this group of patients with RA the survival of the Kudo type 5 TEP with cemented ulnar component is better as compared to the uncemented ulnar component.

T Parkkila E Belt M Hakala H Kautiainen J. Leppilahti

Since the 1970s Swanson implant arthroplasty has become a treatment of choice in metacarpohalangeal (MCP) joint arthroplasty in destructed MCP joints of rheumatoid patients. Sutter (Avanta) implant is also composed of silicone but the centre of rotation is more anatomical, and volar to improve extension moment. Clinical results about these implants have been similar but fracture rates of Sutter implant have been reported to be high. Reason for osteolysis is inflammation reaction to silicone particles released from prostheses due to movement of prosthesis in bone or implant fractures. Reports about osteolysis around Swanson implants present variable result.

There is not grading of osteolysis in the literature before and we created a new radiographic grading for osteolysis around silicone MCP implants. Grading is based on involvement of cortical bone: Grade I: Osteolysis varying from a single clear line adjacent to the stem of the prosthesis to a larger, clear area which did not involve the bone cortex; Grade II: Osteolysis affecting the bone cortex to a maximum of one half of the thickness of the cortex; Grade III: Osteolysis affecting the cortex to more than one half of its thickness but not perforating the cortex; Grade IV: Osteolysis perforating the cortex.

In this study we compare the incidence of radiographic osteolysis following insertion of 89 Swanson and 126 Sutter MCP implants in rheumatoid arthritis patients. Before surgery hands were randomised one by one to Swanson and Sutter implant groups. The mean follow-up time in the two groups of patients was 57 (40–80) and 55 (36–79) months, respectively.

A total of 45 (60%) metacarpal and 40 (53%) proximal phalangeal bones showed no osteolytic changes in the Swanson group. In the Sutter group numbers were 20 (21%) and 26 (27%). In the Swanson group, there was less cortical osteolysis and there were 4 (5%) perforations of a metacarpal and no perforations of a proximal phalanx. In the Sutter group, there were 9 (9%) perforations in a metacarpal and 5 (5%) in a proximal phalanx. (p< 0.001). To create a single independent observation of osteolysis for a hand, the worst osteolysis of a metacarpal or proximal phalanx was recorded. There was only one (5%) perforation in the Swanson group, while there were 8 (30%) perforations in the Sutter group (p=0.011). In all grades of our classification, osteolysis was more frequent in the Sutter than in the Swanson group.

K.N. Keiichiro Nishida K.F. Kazuo Fujiwara K.H. Kenzo Hashizume Y.N. Yoshihisa Nasu A.K. Ai Kitamura H.I. Hajime Inoue

Objective: To investigate the long-term follow-up results of total elbow arthroplasty (TEA) with a non-constrained elbow prosthesis with a solid ceramic trochlea (Stemmed Kyocera type I, SKC-I) on patients who have rheumatoid arthritis (RA).

Materials and Methods: Between May 1988 and February 1999, 84 patients of RA underwent TEA with cement fixation (108 elbows). Fourteen patients (14 elbows) were lost due to change of address. One patient (1 elbow) required revision surgery due to aseptic loosening, and 2 elbow implants in 2 individuals were removed due to deep infection, and 18 patients (24 elbows) have died within 5 years after the surgery due to causes unrelated to TEA. Of the remaining 52 patients (70 elbows), 38 patients (53 elbows, 75.7%) were available for the over-5-year detailed clinical and radiographic review at a mean period of 9.2 years (range, 5–17 years). The clinical condition of each elbow before and after operation was assessed according to the Japanese Orthopaedic Association (JOA) elbow scoring system (up to 100 points).

Results: The average postoperative JOA score improved from 45.1 to 83.3 points with marked pain relief in all but 2 cases. The mean range of motion (ROM) of extension / flexion before the surgery was −35.6 / 117.1 and at last follow-up was −17.6 / 136.9 degrees. The mean ROM of pronation / supination improved from 49.6 / 55.8 to 80.0 / 82.1 degrees. Revision surgery was required in 2 patients (2 elbows) due to humeral fracture and ulnar component fracture, respectively. One elbow implant was removed due to deep infection. An ulnar component was removed from one patient with olecranon fracture. During the follow-up, 3 elbow joints had dislocated in 3 patients, and loosening was seen in 5 elbows in 5 patients. Of the 53 elbows, 45 elbows (84.9 %) were judged to have excellent (90–100) or good (75–89) results, and 2 elbows to have poor (< 60) results (0.04%). With loosening and revision or removal of the implant defined as the end point, the likelihood of survival of the prosthesis was 92.2 and 88.3%, respectively, for as long as 10 years by Kaplan-Meier analysis.

Conclusion: The results of the current study showed a high reliability over a long period of the SKC-I when implanted with cement. However, good results in the use of non-constrained devices are limited by the amount of bone and by the need for the ligamentous stability, which can be problematic in RA cases.

S.F Schindele A Steinbach D Herren B.R. Simmen

Introduction: Silicon-implant-arthroplasty in cases of severe destruction of the radiocarpal joint was a routinely used procedure in rheumatoid arthritis to restore mobility and function. However in many cases an implant failure with a fracture rate of up to 50% with massive synovitis and a severe carpal collaps must be documented. Main problem is the extensive bone loss which makes further procedures difficult. Revision-wrist-arthrodesis with bone grafting (iliac bone, allograft or free fibula-graft) is the commonly used procedure. Therefore non-union in these cases is documented in up to 40%.

Material and Methods: Between 1999 and 2003 we performed in 2 cases of severe seropositive rheumatoid arthritis and in one case of psoriatic wrist joint destruction with extensive bone loss only a revision arthroplasty with debridement and insertion of a new Swanson silicon implant. At the time of revision mean age was 61 years and primary silicon arthroplasty was done 11 years ago. In one case a decompression of the median nerve in the carpal canal was necessary. In one case a transposition of the ECU to ECRB was performed to neutralize the ulnar drift of the remaining carpus.

Results: In all patients a good mobility in the wrist with pain free function could be achieved. All patients were satisfied with this procedure. Clinical, subjective and radiological results are presented.

Conclusion: Revision after silicon-wrist arthroplasty with severe bone loss without or only minimal carpal bone stock and a thin trumpet-like distal radius is difficult. Revision arthrodesis often ends in a non-union despite substantial bone-grafts. Debridement and revision with a new silicon implant is easy to perform and respectable function and a pain free situation might be achieved.

W.A Souter L.S Lockerbie A.C Nicol R.J. Prescott

Aim of Prospective Study To assess the long-term survival of Souter-Strathclyde replacements and determine the causes of failure.

Materials and Methods: Between 1977–97, 445 Souter-Strathclyde replacements were undertaken by the presenting author in 321 patients, ranging in age from 25–81 years (mean 59). The Larsen X-ray grading at the time of surgery was Gd III-2%, Gd IV-43%, Gd V-55%. The standard humeral component was used in 76% and the long-stemmed model in 24% of cases, the standard ulna in 91%, and the long-stemmed in 9%.

Clinical and radiological assessments were carried out before surgery and at 6 months and one year after surgery and annually thereafter until the death of the patient or the revision of one or both components, the mean follow-up being 8.9 years (S.D. 5.6).

The survival statistics are based on Kaplan-Meier survival curves and Cox regression analysis applied to 3 Groups with differing end-points: 1) Revision of one or both components of the prosthesis 2) Ditto or the development of a complication, seriously threatening the survival of the arthroplasty and 3) As in (2) or definite evidence of progressive radiological loosening.

Results Very satisfactory pain relief was achieved in 90% of cases. Mean flexion improved from 129° to 144°, pronation from 42° to 59°, and supination from 43° to 62°. Once achieved, these results were well maintained. Mean extension was slightly reduced after surgery (47° to 52°)

For Group 1: the survivorship at 5, 10, 15 & 20 years was 95, 89, 82, & 81% respectively; for Group 2: 93, 87, 76 & 69%; and for Group 3: 91, 84, 72, & 68%. In Group 1, indications for revision or removal of one or both components were persistent dislocation (5), fracture (5), aseptic loosening complicated in some cases by fracture (20) and infection (14). In Group 2 the threatening complications included instability (2), un-united fracture of the ulna (4), infection (7), and clinical loosening (2)

Conclusions This method of elbow replacement offers very successful and durable pain relief and restoration of function in the adult rheumatoid patient. Survivorship in the first decade after surgery is very acceptable. Later, due to increasing disability and reliance on crutches, resulting from multi-joint involvement, more problems are likely to arise from aseptic loosening, fracture and infection.

A Hallett L Lockerbie W.A. Souter

Aim of study To determine the radiographic changes which can be regarded as indicative of probable eventual aseptic clinical loosening.

Methods 150 TERs performed in 121 adult rheumatoid patients (95 female) with a mean age of 59 years (34–81) were followed up for a mean of 8 years. All X-rays until the final review or revision of each TER were independently reviewed by the principal author. The cement/bone interface around each component was divided into Zones and any radiolucencies were graded within each Zone. This data was then analysed to determine in which zones and at which grading of severity, radiolucencies are of importance in predicting aseptic loosening.

Results Humeral Components Radiolucencies occurred quite frequently in Zones 1& 5. Where they became active and progressive, the usual pattern was for them to extend into Zones 2 and 4 and eventually into Zone 3. The incidence of lucencies of all grades of severity in Zones 1& 5 with standard humeral components was 55 and 53% respectively, in Zones 2& 4 29 and 33%, and Zone 3 18%. The significance of the radiolucencies also varied markedly in the different Zones. In Zones 1& 5, only 22% went on eventually to complete lines > Grade 3 severity in all Zones, 14% eventually requiring revision, while in Zones 2& 4, the corresponding figures were 36% with 22% requiring revision, and in Zone 3 60%, with 22% revision.

The results with the long-stemmed implants showed a very similar trend, the important Zones being 2B, 4B, and 3.

Ulnar Components Lucencies in Zones 1& 2 and in 3& 8 occurred in 90 & 73% of elbows respectively but are probably of little significance as only 15& 10% were later associated with the development of complete lines in other zones. The Zones of significance appear to be 5& 7, and especially Zone 6. Although lucencies were found in these Zones in only 35, 43 and 28% respectively, 49, 40 and 51% of these went on to form complete lucencies in all Zones, the eventual revision rate being 51, 21, and 32%.

Conclusions Many TERs demonstrate areas of lucency on follow-up radiographs but we would argue that it is only of importance in specific locations (humeral zone 3 for the standard implant and humeral Zones 2B, 4B and 3 for the long-stemmed implant and ulnar Zones 5& 7 and especially 6) and when it is of Grade 3 severity or more. Such cases require to be monitored very regularly and carefully so as to carry out revision at the optimal time should this eventually be required.

W Koithan P Magosch L. Staub

Introduction In view of the legal claim for quality assurance in Germany, complete documentation and a professional evaluation of shoulder arthroplasty procedures are indispensable.

Under the auspices of German AO International (DAOI), the German Society of Orthopeadics and Orthopeadic Surgery (DGOOC), the German Society of Trauma Surgery (DGU) and the German Society of Shoulder and Elbow Surgery (DVSE), and in collaboration with the MEM Institute for Evaluative Research in Orthopaedic Surgery, University of Bern, the nationwide online Shoulder Arthroplasty Register was implemented.

Register setup The German Shoulder Arthroplasty Register consists of three online questionnaires, covering surgery for primary shoulder arthroplasty, follow-up examination, and revision surgery. Registered surgeons can access the questionnaires via Internet. For easier administration in clinics, paper copies of the questionnaires are also available. Online validation procedures check all entered data for completeness and plausibility. After passing these checks, data are sent to the central database. The centralization of the data collection is crucial for data unification and validity.

Advantages Participating surgeons benefit from descriptive real-time statistics of their patients, and constant benchmarking of their performance in comparison with the whole register is possible. With the documentation of complications, implant failures and revision surgery, quality assurance reports can be easily produced. Furthermore, X-ray images of special cases can be uploaded.

Perspective The German Shoulder Arthroplasty Register was launched in January 2006 and documentation is ongoing. First scientific results will be available in 2007.

N Nakagawa Y Saegusa S. Abe H. Ishikawa

Purpose: Rheumatoid arthritis (RA) frequently affects the finger joints. Persistent synovitis is believed to cause not only bone destruction but also various deformities of the hands. For this reason, synovectomy of the finger joints is attempted when chronic swelling of the synovium of finger joints does not respond to any conservative treatment. The purpose of this study is to evaluate the effectiveness of surgical synovectomy of finger joints in RA patients.

Method: Forty-six finger joints (MP 24; Steinbrocker Stage II: 8, Stage III: 16) (PIP 22; Stage I: 5, Stage II: 9, Stage III: 8) of 20 patients with rheumatoid arthritis who had synovectomy were examined at an average of 20 months follow-up (range 14–43 months). The active motion exercises of the operated fingers started as early as 2 or 3 days after surgery. The results of synovectomy in these patients were evaluated by pain, range of motion, and radiograph.

Results: Pain was relieved (Visual analogue scale MP: 6.5→1.4, PIP: 6.2→0.7), swelling was diminished in all and only a little loss of motion was observed (arc of motion MP: 59.8→53.4, PIP: 75.5→69.6) after surgery. Radiological bone changes progressed in 4 (17%) MP and 3 (14%) PIP joints. Deformities (ulnar drift or subluxation) after surgery developed in 3 (12%) MP-joints.

Conclusion: Synovectomy performed on finger joints of RA patients were evaluated. From the results of this clinical study we recommend synovectomy of finger joints in RA patients before bone changes, when chronic synovitis of finger joints does not respond to any conservative treatment.

F.J Giesen R.G.H.H Nelissen P.M Rozing J.H Arendzen Z de Jong T.P.M. Vliet Vlieland

Objective: Complex hand function problems in patients with rheumatic diseases may require the expertise of physicians and health professionals from multiple disciplines. The aim of the present study was to describe the characteristics, management strategies and outcomes of patients with rheumatic diseases who were referred to a multidisciplinary hand clinic.

Methods: All consecutive patients with complex hand function problems who were referred to a multidisciplinary hand clinic including a rheumatologist, an orthopaedic surgeon, a rehabilitation specialist, an occupational therapist and a physical therapist were included. Of all patients, sociodemographic characteristics, general disease characteristics, the most troubling impairments and limitations regarding hand function and deformities were recorded at baseline. The following measures of hand function were assessed at baseline and 3 months after treatment: the Sequential Occupational Dexterity Assessment (SODA), the Michigan Hand Outcomes Questionnaire (MHQ), the hand/finger function subscale of the Arthritis Impact Measurement Scales (AIMS), grip strength (Jamar dynamometer) and pain (visual analogue scale, VAS, 0–10 cm).

Results: Over a period of 28 months 69 patients were included. Basic characteristics, characteristics of hand function, impairments and limitations that were most frequently mentioned as well as the advised management strategies were recorded. In 38/54 patients (70%) the advised treatment was executed and 33 of them completed the follow-up assessment.

Conclusion: The most frequently mentioned impairments and limitations of patients with rheumatic diseases and hand function problems pertain to grip ability and grip strength, pain and shaking hands. Management advices, including conservative and surgical treatment, are followed by two-thirds of the patients. On average, patients who are treated improve significantly with respect to grip strength and overall hand function as measured by a questionnaire.

F Angst J Goldhahn A Aeschlimann B.R. Simmen

Background The new concepts of health assessment based on the WHO’s International Classification of Functioning, Disability, and Health (ICF) require the increased use of patient self-rated outcome measurement. There is an extensive body of literature to support the concept that self-rating is far more valid than ‘objective’ parameters such as x-ray findings, range of motion etc. While the value of joint-specific assessment is obvious in rheumatoid arthritis (RA), the need for comprehensive outcome parameters may seem to be less important. We present an exemplary study which compares generic, comprehensive assessment with condition-specific assessment.

Methods In a cross-sectional catamnesis study, the outcomes of patients with RA and posttraumatic (PT) elbows were compared 11 years after total elbow arthroplasty using generic and specific self-rating instruments.

Results Compared to the scores recorded for the 20 PT patients, the 59 RA patients achieved mean scores of 105.6% on the Short Form 36 (SF-36) Mental Component Summary, 82.5% on the Patient Related Elbow Evaluation (PREE) function, 69.5% on the Disability of the Arm, Shoulder and Hand (DASH) function, and 60.2% on the SF-36 physical functioning (a higher score means better health).

Conclusions The elbow-specific PREE revealed little functional deficits for RA compared with PT, the arm-specific DASH showed moderate, and the generic, comprehensive SF-36 demonstrated large functional deficits, whereas psychosocial health was comparable for RA and PT. Post-interventional outcomes may be similar when focusing on a specific condition or joint. Functional deficits and holistic health can only be captured by comprehensive measurement when dealing with systemic polyarticular affection like RA.

J Goldhahn H.-.K Schwyzer S Drerup B.R. Simmen

Introduction: The restoration of the anatomical centre of rotation can be achieved in total shouder arthroplasty (TSA) using newly developed modular shoulder prosthesis (Promos), anchored with rectangled, non-cemented shaft. Especially patients with complex pathological destructions due to rheumatoid arthritis (RA) should benefit from this feature. So far it was not clear, whether the concept works in their poor bone stock too. The aim of this prospective study was to assess outcome and complication rate of patients with RA and Omarthrosis (OA) after TSA with Promos prosthesis.

Materials and Methods: All patients that received a TSA either due to OA or due to RA were prospectively recorded and evaluated 6 and 12 month after surgery. Functional outcome and quality of life was charged with a standardized scores set (DASH, Constant-Murley score, SPADI, ASES and SF-36, all normalized from 0=worst to 100=best) and compared with normative data as well as with data from a retrospective control, operated with an Aequalis prosthesis. Number and types of complications were recorded and the radiological findings evaluated from an independent observer.

Results: Although RA patients (n=8) did not reach the same functional results than OA patients (n=53) operated with Promos“ prostheses (DASH 78 in OA vs. 67.4 in RA, CS 74.3 in OA vs. 67.6 in RA) the difference between both indication groups was significantly smaller than for the Aequalis prosthesis (p< 0.001). Whereas RA patients after Promos“ prosthesis revealed functional deficits ranging from −6.7 in the Constant score, −10.6 in the DASH to −11.1 in the SPADI, this difference was larger in the Aequalis group with −16.4 in the Constant score, −25.2 in the DASH and −19.6 in the SPADI. Radiological findings and complication rate did not differ significantly.

Discussion: The newly developed modular design of the Promos prosthesis seems to offer better features to restore the complex anatomy, especially in RA patients. The required cementless shaft anchorage is not associated with a higher complication risk. Methodological issues limit the comparison of the two studies and the differences have to be proven in a prospective, comparative study therefore.

G. Meyer zu Reckendorf J.L Roux Y. Allieu

Reconstruction of deficient bone stock during total elbow arthroplasty in rheumatoid arthritis represents a challenge for the surgeon. Fracture and osteolysis of the olecranon process is a very rare condition in rheumatoid arthritis. The consequence of a deficient olecranon is an instable and painful elbow. We report a case of successful olecranon reconstruction with bone graft associated to total elbow arthroplasty with a 8 years follow up and discuss surgical aspects.

This case concerns a 44 years old woman with a very severe rheumatoid arthritis. She complains of pain and instability of her right elbow. X-rays show fracture and major osteolysis of the olecranon process with only some persistent bone at the insertion of the triceps tendon. The humeral condyles were subluxated posteriorly.

We performed a total elbow replacement with a GSB3 implant and reconstruction of the olecranon with two cancellous iliac bone strut fixed by 2.7 diameter screws to the proximal ulna. The triceps tendon with remnant olecranon bone chips was secured to the bone graft by tension band wiring. Postoperatively, the elbow was immobilized for 3 weeks.

With a follow up of more than 8 years the elbow is pain free with excellent function. The active range of motion of flexion – extension is 140° / −20°. The elbow is stable and triceps function is very satisfying authorizing the use of crutches. X-rays show good bony integration of the reconstructed olecranon process and no signs of loosening of the GSB3 implant.

The literature concerning olecranon reconstruction during total elbow arthroplasty in rheumatoid patients is very poor. Kamineni and Morrey reported on one case of olecranon reconstruction with strut allograft in revision total elbow arthroplasty with an unsatisfying result. Their fixation technique was different. We prefer an autograft whenever it is possible and we recommend our fixation technique using screws and tension band wiring.

M.A. Murtaza Adeeb N.R. Naeem Raza M.T. Michael Thomas

Background: To date there has been only one published series of elbow arthroplasty in patients with Juvenile Idiopathic arthritis. These patients pose particular problems because of the size and variable shape of the humerus and ulna together with the soft tissue contractures and bony erosion which can sometimes be severe. We have reviewed the results of elbow arthroplasty using the unlinked Kudo 5 and the linked Coonrad-Morrey implants which in our practice have different indications dependent upon bone stock and stability.

Methods: 19 total elbow replacements in 13 patients with juvenile idiopathic arthritis were performed by 1 specialist elbow surgeon, the senior author. 13 of these are Kudo 5 and 6 are Coonrad-Morrey implants. The mean age at operation was 39 years.

6 of the elbow replacements had undergone previous surgery, 4 had an interposition arthroplasty and 2 a synovectomy and radial head excision.

No patients were lost to follow up. All were evaluated at a mean follow up of 49 months [6–84 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films.

Results: Preoperatively 7 had moderate pain and 12 had severe pain. Postoperatively the pain was rated as none by 13 and mild by 6. The average Mayo Elbow Score improved from 26 preoperatively to 81 postoperatively. The mean arc of flexion/extension improved from 85 to 108 degrees.12 elbow replacements had intra and postoperative complications. 2 elbows have been revised, 1 for malalignment resulting in instability and 1 for aseptic loosening of the ulna component. 1 customised extra small implant has radiographic loosening of both components with minimal pain and a further aseptic loose implant awaits revision at 7 years.

Conclusions: The medium-term results of Total Elbow Replacements in patients with Juvenile Chronic Arthritis are acceptable and comparable to the only other published series which also records a high complication rate similar to that reported by ourselves.

M Adeeb I Mersich L Neumann M. Thomas

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals.

Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors.

16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films.

Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component.

Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant.

K.K. Katsuaki Kanbe

Purpose: In order to investigate if arthroscopic synovectomy is effective for non-responder by infliximab, anti-TNF-α antibody, for rheumatoid arthritis (RA), we assessed 7 patients including 10 arthroscopic synovectomy including in knee joint, in shoulder joint and in ankle joints respectively.

Materials and Methods: We performed arthroscopic synovectomy in 10 joints of 7 patients to compare CRP and DAS28 before and after surgery at 6 and 50 weeks. Those patients include 1 male and 6 female from 49 to 68 years old with average of 62 years old. 3 patients was underwent arthroscopic synovectomy after 4 times of infliximab, 2 patients were after 5 times and 2 patient was 6 times. All patients were initially responder to infliximab and MTX but gradually the effect decreased, the average of CRP was 3.45±0.4 (2.7–5.6) mg/dl at the surgery. The indication of operation was that after treatment infliximab CRP was more than 2.5 mg/dl and the numbers of arthritis joints were limited to within five joints of relatively large joints such as knee, shoulder including ankles and wrists. After arthroscopic synovectomy we continued infliximab treatment with MTX in routine manner.

Results: We detected synovium proliferation with vascular increase in patella femoral (PF) joint and around the meniscus and femoral and tibial side of the anterior cruciate ligament (ACL) in the knee joints. We also found synovial proliferation in rotator interval (RI) in the glenohumeral joint and fatty changing in subacromial bursa (SAB) in shoulder. In ankle joint we found synovial proliferation with white meniscoid between tibiofibular joint to develop impingement. Serum CRP was improved from 3.45±0.4 to 1.12±0.2 at 6 weeks, 1.22±0.4 at 50 weeks after arthroscopic synovectomy. There is no severe side effects by arthroscopic synovectomy during infliximab treatment, however 1 patient had slight rash that was improved. DAS28 was improved from 5.58±0.23, to 3.87±0.47 at 6 weeks, improved to 2.58±1.49 at 50 weeks after arthroscopic synovectomy.

Conclusion: It is possible that arthroscopic synovectomy can be one of the effective method to continue infliximab treatment when its efficacy decreased or in non-respond of infliximab for RA patients.

H.U.G. Hoffmeyer

Introduction Shoulder arthroplasty is a difficult procedure which, for success, is dependant on many factors as correct retroversion of the humeral implant.

An experimental set up was therefore devised, using a model to determine the actual accuracy of the retroversion obtained under ideal in vitro conditions in two different situations, one in which the proximal humerus was intact such as that encountered in osteoarthritis or P.A.R. and the other where most usual landmarks were missing such as that seen in the four-part fracture situation.

Materials and methods 106 prostheses were inserted into 106 arms (plastic bone). 54 bones were cut at the level of the surgical collar as in complex fractures and 54 were untouched as in omarthrosis. The first series was done without any guide (52 implants). Every operator has to put 3 prostheses with 30 degree retroversion according to his particular chosen method of mark, either the bicondylar line, or according to the position of the forearm. The second one was done with a jig (Neer 3) indicating 25 degrees of retroversion (54 implants).

The degree of retroversion of prostheses put is measured according to the angle between the axis passing by the previous face of the condyles of the ulna and the axis passing by the mark taken on the prosthesis (perpendicularly in the axis of the humerus).

The humeral axis, the condylar axis, the prosthesis plane and the cutting plane were determined. 3 barycentres of humeral sections determined the humeral axis. The condylar axis is determined from the 2 barycentres of the digitalized points on the anterior articular condylar surfaces. These 2 axes determine the frontal plane on which a reference mark R(x, y, z) is attached with Z lined up with the humeral shaft and X lined up on the condyles.

Discussion and results All these results show that with or without guide, the prosthesis is not inserted in the right way. Only one third of the P.T.E. ( 33 on 106) were put with a correct angle of retroversion, or between 20 and 40 °, with a maximum of 67,7 ° and a minimum of 4,4 ° (standard deviation 12, 8 !). Shoulder prosthesis, a difficult technique, may need computer help for the positioning especially for the retroversion angle.

M.J.H. McCarthy M.P. Grevit

Introduction: The NDI is a simple 10-item questionnaire used to assess patients with neck pain. The original validation was performed on 52 patients with neck pain and the test-retest on 17 whiplash patients with a 2-day interval. The SF36 measures functional ability, wellbeing and the overall health of patients. It is used in health economics to assess the health utility, gain and economic impact of medical interventions.

Objectives: (1) Independently validate the NDI in patients with neck pain. (2) Draw comparison of the NDI and SF36.

Subjects: 100 patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 30 patients after a period of 1–2 weeks.

Statistics: The internal consistency of the NDI and SF36 was calculated using Cronbach alpha. The test-retest reliability and the concurrent validity between the two questionnaire scores were assessed using Pearson correlation. Individual scores for each of the ten items of the NDI were correlated to the total disability score categories.

Results: Both questionnaires showed robust internal consistency – alpha for NDI = 0.85 (95% CI = 0.8–0.89) and SF36 = 0.84 (95% CI = 0.79–0.88). The NDI had significant correlation to all eight domains of the SF36 (p< 0.001). The individual scores for each of the ten items had significant correlation with the total disability score (p< 0.001). The test-retest reliability of the NDI was acceptable.

Conclusions: We have shown irrefutably that the NDI has good reliability and validity and that it stands up well to the SF36.

Dang Lei Douglas Wardlaw David W.L. Hukins

Introduction This abstract describes the development of an effective procedure for removing as much nucleus as possible from an intervertebral disc with minimal disruption to the annulus. The procedure was developed on cadaveric sheep discs which are well established as a model for human discs in studies of this kind. The purpose of the study was to develop a method for removing the nucleus as part of a laboratory study of nucleus replacement; however, it is also intended to guide the development of procedures for the removal of residual nucleus when indicated in surgical procedures that involve replacing the nucleus with synthetic materials.

Methods All procedures were performed via a 3 mm trocar. Four procedures were compared: (I) unilateral approach using rongeurs alone, (II) unilateral approach using rongeurs followed by chymopapain, (III) bilateral approach using rongeurs alone and (IV) bilateral approach using rongeurs followed by chymopapain. Chymopapain was administered as a solution (30 units in 0.1 cm3 de-ionised water) to a disc at 37°C. For each procedure (I–IV) 14 discs were used.

Results The percentages of nucleus removed were: (I) 34 ± 2%, (II) 41 ± 2%, (III) 52 ± 3% and (IV) 75 ± 8%; ANOVA showed a significant differences between the four sets of results (P < 0.05).

Conclusions Significantly more nucleus is removed using a bilateral than a unilateral approach; significantly more nucleus is removed if chymopapain is used in addition to rongeurs. A brush is useful in removing strands of nucleus loosened by chymopapain. For the purpose of these experiments a bottle brush with nylon bristles was trimmed to an overall diameter of about 10 mm, so that it could be inserted into the nuclear cavity via the trocar. Design of a surgical instrument for this purpose would be guided by a preliminary risk analysis.

Jitendra Mangwani Claire Giles Mark Mullins M.A Colin Natali

Study design: Prospective cohort study.

Objective: To investigate association between recovery from low back pain (LBP) and body mass index (BMI) in patients with LBP undergoing physiotherapy.

Introduction: The relationship between obesity and LBP has long been debated. There are no published studies examining the influence of BMI on recovery from LBP.

Methods: One hundred and forty patients with chronic LBP and no neurological deficit underwent a back-specific physiotherapy programme. BMI and recovery parameters such as pain intensity (visual analogue scale scores), and self-experienced impairment and disability scores were measured. The range of motion of the lumber spine was also recorded. These variables were compared pre and post treatment. Statistical analysis was performed using paired t tests, Spearman’s rank correlation coefficients and ANCOVA.

Results: Mean age was 38 years (range 18–67) with 62% males and 38% females. The treatment resulted in significant improvements in all the recovery parameters (P < 0.005, paired t test). No significant association was detected between the BMI of subjects and % changes in pain intensity, self-experienced impairment and disability, and range of motion of the lumbar spine. A comparative analysis of the after treatment recovery parameter scores in normal (BMI ≤24.9), overweight (BMI 25–29.9) and obese (BMI ≥ 30) revealed no significant differences in the mean pain intensity and mean self-experienced impairment and disability scores.

Conclusion: Although a BMI within normal range is desirable for prevention of many health conditions including LBP, it does not influence the overall recovery from low back pain in patients undergoing physiotherapy treatment.

R. Kamath P. Chandran S. Malek A.M.M.A Mohsen

Introduction and Aims Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. The aim of the study was to look at 1) Contributions from History and Examination. 2) Does Clinical Examination add any further information not identified from history?

Method A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually to reach the diagnosis and plan the management. 75 consecutive lower back pain and/or radiculopathy patients were included in the study. Two orthopaedic registrars saw all the patients. One took detailed history and the other registrar performed clinical examination. Both registrars based on their information arrived at a provisional diagnosis. A consultant also took history and examined these patients. MRI scan was done as per clinical indication.

Results The data was analysed using standard statistics software. In all patients history suggested the possible diagnosis. Clinical examination did not add any further information to alter the course of management, which was planned for the patient. Clinical examination did not show any further information that was not identified in the MRI scan.

Conclusion Clinical examination does not add to the body of information available from history. Clinical examination does not add any further information not available on the scan. Clinical examination should be performed for patients considered for surgery to document the findings; here both subjective and objective assessment should be performed. Examination is not a useful screening tool.

P Lakshmanan S Ahuja PR Davies J Howes

Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging.

Purpose The aim of this study is to find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who were diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level while it was in two patients in Group II (L4/5 or L5/S1). Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score(p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. There is no significant difference in the duration of the procedure as well between the two techniques. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.

T. Coltman P. Chapman-Sheath A. Riddell E. McNally J. Wilson-MacDonald

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation.

Objective: To investigate consistency between radiologists interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment.

Background: MRI has assumed a preeminent position in the diagnosis of lumbar disc prolapse.

Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy.

Results: Reliability tests show only fair agreement (k=0.36) between the radiologists and at best only moderate agreement (k=0.41) between the radiologists and surgical findings.

Conclusions: MRI is an excellent tool for diagnosis of a disc prolapse but does not appear to help in classifying discs suitable for percutaneous treatment.

M.J.H. McCarthy A.T. Brodie D. Annesley-Williams C.E.W. Aylott A. Jones M.P. Grevitt

Introduction: (1) Determine whether initial MRI findings correlate with clinical outcome.(2) Study the reproducibility of MRI measurements of large disc prolapses.(3) Estimate the ability to predict CES based on MRI alone.(4) Does CES only occur in degenerate discs?

Method: 31 patients with CES were identified and invited to attend clinic. 19 patients who underwent discectomy were identified. Digital photographs of all 50 MRIs were obtained. Observers: 1 Radiologist, 2 Spinal Surgeons and 1 Trainee did not know the number of patients in each group. Observers estimated the percentage spinal canal compromise on each view (0–100%), indicated whether they thought the scan findings could produce CES and commented on disc degeneration. Measurements were repeated after 2 weeks.

Results: 26 patients attended clinic – mean follow up 51 months (range 25–97). 12 of the 26 patients with CES had, on average, > 75% canal compromise. No significant correlations were found between MRI canal compromise and clinical outcome. Kappa values for intra-observer reproducibility of measurements ranged from 0.4–0.85 and inter-observer 0.63–5. Based on MRI, the correct identification of CES has sensitivity 68%, specificity 78%, positive predictive value 84% and negative predictive value 58%. Over 80% of the CES causing discs were degenerate.

Discussion: Canal compromise does not appear to predict clinical outcome. MRI measurement reproducibility has substantial agreement. CES is a clinical diagnosis supported by an MRI scan. In less clear cases the presence of a large disc on an MRI scan supports a diagnosis of CES (PPV 84%). CES occurs in degenerate discs.

J H H Chan G Heilpern G Marsh

Objective A prospective longitudinal study with a mean 22 month follow up (range 6–36 months) to assess the outcome of patients with chronic discogenic lumbar back pain who underwent intradiscal electrothermal therapy (IDET).

Method Patients with a discogenic origin of their back pain confirmed by diagnostic imaging and discography and who underwent IDET were included in the study. Discographic reproduction of symptoms with subsequent abolition with local anaesthetic led to inclusion in the study regardless of discogram volume. Outcome was assessed using VAS pain scores, Oswestry Disability Index (ODI) scores, employment status, subjective outcome and pain diagrams.

Results 68 patients were treated with IDET. 51 patients were successfully followed up for a minimum of one year, of whom 31 had at least 2 year follow up. These patients were divided into two groups. Group 1 consisted of 29 patients aged less than 40 with single level disease, no facet joint arthritis, a low volume positive discogram and an organic pain diagram. Their mean VAS scores decreased from 7.52 to 3.84 (p< 0.001). 70% reported a good or excellent outcome with only 30% fair or poor. Group 2 included the remaining 22 patients. Their mean VAS decreased from 7.41 to 6.13 and only 32% reported a good or excellent outcome with 68% fair or poor.

Conclusion We conclude that with very strict selection criteria, IDET can have a successful outcome.

J. Mangwani C. Natali C. Giles R. Sarvanan R. Francis

Study Design: Prospective study with a 2-year follow-up.

Background: Intradiscal electrothermal therapy (IDET) was developed as an intermediate stage between conservative measures (analgesia, physiotherapy and injections) and radical surgery (fusion and disc replacement) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this treatment.

Objective: To assess the long-term outcome of patients with discogenic low back pain (≥ 6 months duration) treated with IDET who had previously failed to improve with nonoperative treatment

Methods: Forty patients with IDD determined by pre-operative provocative discography and MRI were treated with IDET. VAS pain scores, SF-36 scores, analgesic usage and sitting tolerance (mins) were collected pre-treatment and at 12 and 24 months. Subsequent treatments were recorded. The differences in the outcome scores were tested by Wilcoxon signed rank tests.

Results: Average age was 46 years (range 25–62 years) with 44% males and 56% females. No significant improvement was seen in pain intensity as measured by VAS and bodily pain SF-36 scores pre treatment and at 12 and 24 months post IDET. There were no significant differences in the remaining SF-36 subscales. Only 11% used less pain medication. Sitting tolerance improved between pre and 1-year post IDET, the difference was not significant. Eight (20%) patients underwent further surgery; 5 disc replacement and 3 fusions at 1-year post treatment.

Conclusion: The patients with IDD did not show any improvement at 1-year or 2-year post IDET. A significant proportion of patients required further surgery. We believe that the efficacy of IDET is doubtful.

S Apsingi PL Sanderson

Introduction: Sciatica is the classical indication for decompression of the lumbar nerve roots. However there is a small group of patients who have atypical proximal pain i.e. pain in the groin, buttock and thigh pain without radiation below the knee, and have nerve root compression on the MRI scans. We investigated these patients with nerve root injection (NRI).

Methodology: We retrospectively studied 125-diagnostic NRIs, of these there were 12 patients (7 female & 5 male) with pain in the groin(5), thigh (4), buttock(6) & lower back(9) but no radiating pain below the knee. The MRI scans were reported independently as nerve root compression (11 L5 & 1 S1) by the radiologist. All these 12 patients were offered nerve root injection. The nerve root injection was carried out as described by Herron, under the guidance of image intensifier with bupivacaine and methylprednisolone.

Results: Of these 5 (42%) of them had temporary relief of the symptoms with nerve root injection; all of them underwent flavectomy & facetectomy of the affected nerve root. They were followed for an average duration of 39 months. Three patients were delighted with the result, 1 patient had a pain free period for 3 years then the symptoms recurred and the last patient did not benefit with the surgery.

Conclusion: We conclude that nerve root injection can be an important diagnostic tool in making a surgical decision regarding patients with such atypical symptoms.

Manal Siddiqui Malcolm Nicol Efthimios Karadimas Kay Mutch Frank Smith Malcolm Pope Douglas Wardlaw

Introduction Symptoms of neurogenic intermittent claudication in spinal stenosis are explained by the narrowing of the spinal canal in the extended (upright) position and widening in the sitting (flexed) position. The XStop inter-spinous process distraction device is a new product that is designed to hold the affected segments in a flexed posture. This prospective study looks at the changes in the lumbar spine in a variety of postures from pre- to post insertion.

Methods Using a positional magnetic resonance imaging (pMRI) scanner, patients were scanned before and six months after the insertion of the device. Images were taken in sitting flexed and extended, and standing positions. The change in the total range of movement of the lumbar spine and in the individual operated segments was measured along with changes in the surface areas of the exit foramen, the dural sac, and the disc height.

Results 12 patients with 17 levels distracted have been scanned and measured. The cross sectional area of the dural sac at the level of the stenosis has increased from a mean of 77.8 mm2 to 93.4 mm2 in the standing position (p=0.006) and from 84.56mm2 to 107.35mm2 on extension (p=0.008). There were no statistically significant changes in the range of movement of the whole lumbar spine, or at levels adjacent to the device.

Discussion This study demonstrates that the X Stop device increases the cross sectional surface area of the spinal canal at the stenosed level, without causing extensive changes in the posture of the lumbar spine.

E. Karadimas M Siddiqui M. Nicol W. Bashir T. Muthukumar M. Pope F. Smith D Wardlaw

Introduction The Dynesys device uses transpedicular screws linked by a cord and spacers. It is claimed that the advantage is that it allows some motion, in all directions, in the operative levels. In vitro laboratory biomechanical studies show that the movement permitted is similar to rigid fusions.

This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device.

Material-method In our study 20 patients with dominant low back pain, with or without leg pain, were treated with Dynesys system. Stress discography was made to evaluate the symptomatic level

All had a positional MRI preoperatively and nine months post-operatively in flexion-extension-lateral bending.

The patients were divided in to two groups:

Group(A) with 8 patients in which Dynesys was used with fusion (disc-height< 40 %)

Group(B) with 12 patients was the Dynesys-only group (disc-height=40–90%).

Results The operated levels were 42, 10 of those were fused levels. The results showed that there was a statistically significant difference in flexion-extension range of movement of the whole lumbar spine (mean= −13.45)(p< 0.005), but it wasn’t significant in the level above (mean=0.056)(p=0.972) and at a single instrumented segment was (mean=−4.06°)(p< 0.05)

The changes in the anterior disc height was (mean= −1.18)(p< 0.05) and to the posterior (mean=0.37)(p=0.134). In bending were (mean=−0.87°)(p=0.18) for left and (mean=−0.24°)(p=0.75) for the right

Discussion This study shows that in the Dynesys stabilizing system allows small range of movement at the instrumented levels, with no significant increased mobility in the adjacent levels. Also the device acted to compress the anterior annulus

JS Butler MJ Shelly M Timlin JM O’Byrne

Introduction: Haematogenous pyogenic spinal infection encompasses spondylodiskitis, septic discitis, vertebral osteomyelitis and epidural abscess. Management of pyogenic spinal infection can involve conservative methods and surgical intervention. We carried out a retrospective review of 48 cases of pyogenic vertebral osteomyelitis presenting over a twelve-year period to the National Spinal Injuries Unit of the Republic Of Ireland. Our objective was to analyze the presentation, aetiology, management and outcome of 48 cases of non-tuberculous pyogenic spinal infection.

Methods: Both the Hospital Inpatient Enquiry (HIPE) System and the National Spinal Injuries Unit Database were used to identify our study cohort. The medical records, blood results, radiologic imaging and bacteriology results of all patients identified were reviewed.

Results: The average age of presentation was 59 years with an almost even distribution between males and females. Most patients took between three and six weeks to present to hospital. Diagnosis was confirmed by serological testing of inflammatory markers and radiological imaging. The most frequently isolated pathogen was Staph. aureus (75% of cases). 94% of cases were managed by conservative measures alone, including antibiotic therapy and spinal bracing. However, in 6% of cases surgical intervention was required due to neurological compromise or mechanical instability.

Conclusions: With this large cohort of non-tuberculous, pyogenic spinal infections from the NSIU, we conclude that Staph. aureus is the predominent pathogen. In the vast majority, conservative management with antibiotic therapy and spinal bracing is very successful. However in 6% of cases surgical intervention is warranted and referral to a specialist centre is appropriate.

H* Sharma SA Mehdi E MacDuff M Jane A Reece R Reid

Between 1944 to 2003, eighty nine cases were registered with a diagnosis of Paget’s sarcoma in the Scottish Bone and Soft Tissue Tumour Registry. We found thirteen cases of sarcomatous degeneration of the spine (0.26% of the total bone tumour registry case) which were analysed in this study elaborating clinical, radiological and histopathological features. The mean age was 66.9 years (range 56 to 79 years). There were ten males and three females. There were seven cases involving sacral spine (63.6%), three cases involving lumbar vertebrae and two affecting dorsal spine. One case had diffuse dorso-lumbar involvement from D11 to L3 vertebrae. The mode of presentation was increasing low back pain (in all 13), unilateral sciatica (6, left sided-5, right sided-1), bilateral sciatica (2), lower limb weakness (8) and autonomic dysfunction (4, presented as chronic cauda equina syndrome). The majority of the cases (69.23%) were osteosarcomas. Out of these osteosarcomas, two showed giant cell rich matrix and one revealed predominant telengiectatic areas. Rest of the histological types was shared by chondrosarcoma, fibrosarcoma and malignant fibrous histiocytoma. Decompression laminectomy was performed in three cases. Eight patients had received radiotherapy. The mean survival was 3.93 months (range, 1 week to 7 months), nearly half to the whole Scottish Paget’s sarcoma series with a mean survival of 7.5 months. We found a constellation of symptomatology due to radiculo-medullary compression with a fatal evolution, predominantly lumbosacral involvement, predominantly osteosarcomatous histopathology with a poorest prognosis of all Paget’s sarcoma. Although, decompression laminectomy and adjuvant radiotherapy provided reasonable pain relief and palliation; however, there was no significant influence on the overall prognosis of the patients with Paget’s sarcoma of spine in the last six decades.

MJ Shelly M Timlin M Walsh A Poynton JM O’Byrne

Aims: Rugby is a popular sport in Ireland, with over 100,000 players registered with the Irish Rugby Football Union (IRFU) at all levels. We report a 10 year series of spinal injuries presenting to the National Spinal Injuries Unit (NSIU) at the Mater Misericordiae University Hospital.

Methods: A large series of spinal injuries in rugby players was isolated utilizing the NSIU database, HIPE and data from the IRFU. An extensive chart review and telephone interview was performed in all cases to determine age, mechanism of injury, possible aetiological factors, anatomic location of injury, American Spinal Injuries Association (ASIA) scores, current level of activity and response to rehabilitation.

Results: From 1994 to 2004, 22 rugby players with spinal injuries necessitated admission to the NSIU. Twelve patients (54%) presented with neurology. The average age at time of injury was 21.1 years (range 14 – 44 years) and all patients were male. The average length of hospital stay was 10.1 days (range 1 – 45 days). Twenty patients had cervical spine injuries. The most common mechanism of injury was hyperflexion of the cervical spine, with C5/C6 most commonly injured. Fifteen injuries occurred at adult level, the remainder at schoolboy level. Seventeen (77%) players were injured whilst playing First Team rugby. Eleven (50%) players were injured in the Backs, the remainder in the Forwards. 68% of injuries occurred in the tackle situation and 32% in the scrums, rucks and mauls. Winger, Full Back and Hooker were the playing positions at greatest risk.

Nine (41%) patients underwent surgery and 11 (50%) required rehabilitation in the National Rehabilitation Centre, Dun Laoghaire, with an average length of inpatient stay of 9.22 months (range 5 – 14 months). Eight (36%) patients felt that their injury was preventable. Of those patients without neurology, 60% have returned to playing rugby.

Conclusion: Rugby as a sporting pastime is not without risk. During the ten year period under review, 8 players suffered permanent disability as a direct result of participation in competitive rugby. Serious spinal injuries continue to occur and recent rule changes have had little effect in reducing their incidence.

P Lakshmanan A Jones K Lyons J Howes

Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearson’s Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (χ2 = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.

M.J.H. McCarthy C.E.W. Aylott M.P. Grevit M.C. Bishop

Introduction: To determine the factors which influence outcome after surgery for cauda equina syndrome.

Method: 56 patients with evidence of sphincteric disturbance who underwent urgent surgery between 1994 and 2002 were identified and invited to follow up. Outcomes consisted of history and examination, and several validated questionnaires.

Results: 42 patients attended with a mean follow up of 60 months (range 25–114). Mean age at onset was 41 years (range 24–67) with 23 males and 19 females. 26 patients were operated on within 48 hours of onset. Urinary disturbance at presentation did not affect the outcomes. Bowel disturbance at presentation was associated with sexual problems (< 0.005) and abnormal rectal tone (p< 0.05) at follow up. There was a weak association between delay to operation and bowel disturbance (p< 0.05) at follow up. Eight patients had faecal soiling and faecal incontinence at follow up and this was associated with sudden onset of symptoms, initial abnormal rectal tone and time to operation (p< 0.05). The 12 patients who failed their postoperative trial without catheter had worse outcomes. The SF36 scores at follow up were reduced compared to age matched norms in the population. The mean ODI was 29, LBOS 42 and VAS 4.5.

Discussion: In our series the duration of symptoms and speed of onset prior to surgery appears to influence bowel but not bladder outcome two years after surgery. Based on the SF36, LBOS and ODI scores, patients who have had CES do not return to a normal status.

R Kotnis A Jariwala N Henderson

Method: We reviewed the hospital notes of 45 patients who underwent a lumbar discectomy over a 30month period. The care pathway was divided into three components: Pre-Hospital Wait (time from GP referral to first outpatient appointment), Hospital Wait (first out-patient appointment to being listed for surgery) and the Waiting List period.

The patients were divided into three groups: those following a standard pathway (group I), patients referred with an MRI scan (group II) and emergency admissions to hospital (group III).

Results: The groups I, II and III comprised of 18, 12 and 7 patients respectively. The mean Pre-Hospital Wait in weeks was 16 (group I) and 14 (group II). The Hospital Wait was 12 (group I), 3 (group II) and 1 (group III). The Waiting List period was 26 (group I), 18 (group II) and 1 (group III). The difference in The Hospital Wait between groups I and II reached significance.

Discussion: The Waiting List Period is often blamed as the causa principale for a delay in treatment. This review shows that a considerable time is spent in the Hospital Wait period and draws attention to a recognised delay in the care pathway, which requires a multidisciplinary approach to reduce its effect.

J A Corner R Marshall

Bilateral decompression of spinal stenosis may induce instability which compromises outcome. In an attempt to overcome this problem, bilateral decompression can be carried out through a unilateral approach. The ipsilateral side is decompressed by hemi-laminectomy with undercutting partial facetectomy and the contra-lateral side is treated by careful excavation beneath the spinous processes and laminae with preservation of the laminae, posterior ligament complexes and paraspinal muscles. This is achieved with the aid of an operating microscope or loupe and headlight. Previous reports contain little information about outcome and complications.

We reviewed 30 patients with bilateral spinal stenosis, but without significant spondylolisthesis who were decompressed bilaterally from a unilateral approach by a single surgeon during a calendar year. They represented a third of our annual operations for spinal stenosis. Thirty patients had 45 levels decompressed. Female to male ratio was 2:1 and average age was 66 years. The average duration of preoperative symptoms was 1.6 years. The mean follow up period was 30 weeks (12 weeks to one year).

Assessment was carried out using the Oswestry Disability Index, pre- and post-operative visual analogue pain scores for leg pain and back pain, walking distance and MacNab criteria of patient outcome.

Results: improvement in Oswestry Disability Index, pain scores for sciatica and back pain and improved walking distance. All but one case had good or excellent outcome.

Complications: one dural tear and two cases with temporary dermatomal sensory change.

Whilst the technique is safe, and effective, a longer randomised controlled study is needed to demonstrate any real advantage over traditional approaches.

S Tafazal P Sell

Introduction: Lumbar spinal stenosis commonly affects elderly patients with multiple co-morbidities. They are at increased risk of complications following surgical interventions. Non-operative strategies for treating them are desirable and previous studies have shown some benefit of subcutaneous salmon calcitonin for the treatment of spinal stenosis.

Objectives: To assess the effectiveness of nasal salmon calcitonin for the treatment of lumbar spinal stenosis in a cohort of patients.

Study design: Prospective cohort study

Methods: 34 patients with MRI proven lumbar spinal stenosis were enrolled into the trial. They received salmon calcitonin in the form of a nasal spray for 6 weeks. All the patients had multiple co-morbidities making them high risk for any surgical intervention. They were followed up at 6 weeks and at 12 weeks. The main outcome measures were oswestry disability index (ODI), low back outcome score (LBOS) and visual analogue scale (VAS). The patient’s were also subjectively asked to rate the treatment excellent, good, fair or poor.

Results: The mean age was 73.5 years (range 51–92 years). The mean duration of symptoms was 32.6 months (range 3–120 months) The mean ODI pre-treatment was 50 and after 6 weeks of treatment decreased to 47 (p=0.14). The mean LBOS was 18 pre-treatment and increased to 21 (p=0.02) after 6 weeks of treatment. The mean VAS for leg pain was 76mm pre-treatment and decreased to 64mm (p=0.001) after treatment and the mean VAS for back pain only decreased from 64mm to 61mm (p=0.5). 11 patients (32%) had a minimum 20mm change in VAS scores after treatment and 7 patients (21%) improved their ODI score by a minimum of 10 points. All results remained stable at 12 weeks follow-up, suggesting a longer effect than the duration of treatment. With regards to patient’s subjective outcome 9 patients (27%) rated the treatment as fair, 3 rated it as good (9%) and 17 reported no change (50%).

Conclusion: Our results suggest the benefits of nasal salmon calcitonin treatment are marginal, with a minimal improvement in symptoms of patients with lumbar spinal stenosis.

Mr. A.S. Raman Mr. A. Rai Dr. T. Marshall Mr. R.J. Crawford

There are numerous surgical techniques described for cervical decompression for multilevel cervical stenosis. Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation. It is also described to have lesser incidence of post operative axial symptoms, range of motion and loss of cervical lordosis.

We are presenting our prospective case series of 23 patients who had this procedure in our institution between 2002 and 2004. Of these 16 patients are at least 6 months from their operation. We performed clinical outcome measurements using SF12 questionnaires, pre and postoperative clinical assessment performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression (Done by our musculoskeletal radiologist).

Our study showed a good clinical and radiological outcome with this relatively simple new procedure. This has become our standard operation for our patients with multilevel cervical stenosis with cervical myelopathy.

P J McKenna B J C Freeman R C Mulholland M P Grevitt J K Webb S H Mehdian

Introduction We report the two-year clinical outcome of a prospective randomised trial comparing Femoral Ring Allograft (FRA) to a Titanium Cage (TC) in circumferential lumbar spinal fusion.

Methods 83 patients recruited to the study fulfilled strict entry requirements (> 6 months chronic discogenic low back pain, failure of conservative treatment, one or two-level discographically proven discogenic pain source). 38 patients were randomised to receive FRA, 45 patients were randomised to receive TC. Posterior stabilisation was achieved with translaminar or pedicle screws. Patients completed questionnaires including Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) and the Short-Form 36 (SF-36) pre-operatively and 6, 12 and 24 months post-operatively.

Results Results were available for all 83 patients with a mean follow-up of 26.5 months (range 24–75 months). Baseline demographic data (age, sex, smoking history, number of operated levels, pre-operative outcome measures) showed no statistical difference between groups (p< 0.05). For patients receiving the FRA, mean VAS (back pain) improved 2.0 points (p=0.01), mean ODI improved 14 points (p=< 0.01), and mean SF-36 scores improved by > 11 points in all domains (p< 0.03) except general health and emotional role. For patients receiving the TC, mean VAS improved 1.2 points (p=0.002), mean ODI improved 5 points (p=0.02); SF-36 improved significantly in only one of eight domains (bodily pain).

Discussion Clinical outcome following circumferential lumbar fusion with FRA readily achieves the accepted mean clinically important differences (MCID). Fusion with TC does not achieve the MCID. The use of TC for circumferential lumbar fusion appears not to be justified.

Andrew Clarke Michael O’Malley James Hegarty Brian JC Freeman

Introduction Surgeons request cross-match based on habit not evidence. The spinal unit requested 686 units of blood during 2002–2003 and transfused only 42 for elective lumbar spine surgery. This wastes money, time and blood.

Aim Optimise the transfusion requests in elective lumbar spinal surgery by creating evidence based guidelines.

Methods The data on elective operations performed on the lumbar spine during the period June 2002 to June 2003 was collected from the spinal unit database and cross-referenced with the records of blood transfusion. Cross-match: Transfusion ratios (C:T Ratio) and Transfusion Index (TI) for common procedures were calculated. Based on these results, a Maximum Surgical Blood Ordering Schedule (MSBOS) was created and prospectively audited for six months.

Conclusion Eighty units were cross-matched during the prospective audit. Therefore, in one year one hundred and sixty units would be requested. This represents a reduction of over five hundred units.

A O’Brien C Southgate M Oliver A Tavakkolizadeh G Selmon J.A.N. Shepperd

We report a consecutive series of 352 patients with back pain treated by Dynesys flexible stabilisation between July 2000 and November 2004, to include perceived indications, surgical techniques and complications. A detailed analysis of the first 120 cases with minimum follow up of 2 years is included. Our unit has undertaken 352 operations to date, and this communication reports all cases. Follow up is to 48 months.

All patients were profiled prospectively using the Oswestry Disability Index, Euroquol, SF36, Pain analogue scale, Pain chart and modified Zung. The same measuring instruments were used at review for which follow up was 100%

The procedure involves paired bilateral pedicle screw instrumentation above and below the level of perceived pathology, with each screw pair connected by load relieving carbopolyurethane flexible spacers, in conjunction with a tension band polyethylene cord passed through the spacer. This construct is then held under tension with screws in the main pedicle screws.

All patients are profiled at entry to the hospital service using a proforma which includes the measures outlined above. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. All our cases have failed conservative treatment before enrolling for surgery.

There was significant improvement in symptoms for most of the patients in the series. However clear patterns emerged as to those cases in which Dynesys is contra-indicated.

This is the largest series of cases reviewed so far in the literature.

S Tafazal P Sell

Objectives: To assess the outcome of patients undergoing anterior lumbar interbody fusion with the Hartshill Horseshoe cage device.

Study Design: Prospective cohort of patients from a single centre in the UK

Methods: 20 patients underwent anterior lumbar inter-body fusion from September 1994 to November 2002. All patients underwent primary anterior fusion alone. The diagnosis was back pain alone in 10 patients, instability and back pain post discectomy in 9 patients and pseudoarthrosis in the remaining patient. The main outcome measures were oswestry disability index, low back outcome score, visual analogue scale for back and leg pain, modified somatic perception and modified zung depression score.

Results: Follow-up data was available for 17 patients at two years (85%). There were 11 females and 9 males and there average age at operation was 39 years (range 30–50 years). The mean ODI pre-op was 56 and this improved to 30 post-op (p=0.004). The mean LBOS pre-op was 21 and this improved to 41 post-op (p=0.005). The VAS pre-op was 83mm and improved to 48mm postop (p=0.01). Overall 13 of the patients (76%) improved their ODI by a minimum of 10 points. When comparing the groups according to diagnosis, the patients with back pain alone had a 17 point improvement in ODI whereas the patients with back pain post discectomy had a 29 point improvement in ODI (p=0.33). The main complication of surgery was common iliac vein tear occurring in two patients which was repaired intra-operatively.

Conclusion: Anterior lumbar interbody fusion using the Hartshill horseshoe cage device is a safe and effective method of achieving spine stabilisation in patients with back pain. It seems to be particularly effective for those patients who have instability and back pain post-discectomy.

M. Khatri H Norris ERS Ross

Introduction: Disc Replacement has been described as 21st Century revolution in spinal surgery that preserves mobility and prevents adjacent segment degeneration. Numerous short-term studies are available on clinical outcome but to date there are no published long term clinical, radiological and survival data on disc replacement.

Aim: To analyse clinical, radiological & survival results of Charite III Disc Replacement.

Study Design: Ethical committee approved retrospective study.

Methodology: 160 patients (Av. Age 46yrs; Std.Dev 8.06; 62 Males & 98 Females) underwent disc replacement surgery between Jan1990 and Dec2000. An independent observer reviewed case notes, radiographs and administered a questionnaire that included Oswestry Disability Index, and Pain Score.

Results: Clinical: At an average follow up of 79 (range 31 to 161) months, mean improvement in ODI and pain score were 18.01(p< 0.001) and 1.69(p< 0.001) respectively.

Radiological: average movement at replaced disc, defined as greater than 4 degrees on flexion-extension lateral view was 1.5 degrees for L3L4, 4.01 degrees for L4L5 and 4.8 degrees for L5S1 disc replacement.

Survival: A mean survival time of 147(95% C.I. 140 to 154) months was observed with cumulative survival of 55% with implant removal as an endpoint. A mean survival time of 124(95% C.I. 116 to 133) months with cumulative survival of 35% was observed with all radiological failures as an endpoint.

Complications: were post-operative incisional hernia seen in 17(10.6%), wound infection 9(5.6%) and retrograde ejaculation in 5(3.1%) patients.

Conclusion: Charite III Disc Replacement results in clinically significant (> 15, p< 0.001) improvement in ODI, but does not result in clinical significant (> 2 points) improvement in back pain. Motion is preserved at L4L5 and L5S1 level. It has low survival rate and does not seem to prevent onset of facet arthritis. This study does not support the use of this device for management of back pain.

J H H Chan G Heilpern I Packham G Marsh A Knibb

Objective To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion.

Method 60 patients undergoing lumbar spinal surgery were prospectively recruited. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of the operation at the end of the procedure. VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively independently. The total dose of morphine required was recorded.

Results The patients randomised to receive fentanyl showed a decrease in their mean VAS scores as well as a 40% reduction in the total morphine dose delivered. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment. All patients left recovery after 2 hours to be nursed on an open ward.

Conclusion Intrathecal fentanyl is effective at reducing mean pain VAS scores and morphine use via a PCA after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward.

S. Molloy P. Jayakumar R. Kaila F. Gow A. Saifuddin

Background: There is conflicting evidence of correlation between clinical outcome and severity of thoracolumbar spine fractures in neurologically intact patients1. Kalyan et al2 presented the results of their prospective study of thoracolumbar spinal fractures and concluded that the clinical outcome was consistently better predicted by the severity of disc injury than that of the bony fracture. They suggested that if severe disc injury was present, treatment of the disc injury may result in a better short term clinical outcome. The aim of this study was to detail the incidence and type of disc injury in patients with thoracolumbar spinal fractures with intact neurology.

Methods: Retrospective analysis of a prospectively collected spinal injury database at a regional spinal injuries unit. Only patients with a thoracolumbar spinal fracture and intact neurology were included. Retrospective analysis of magnetic resonance imaging (MRI) findings. One hundred and thirty nine neurologically intact patients (89M:50F, mean age 36 years, range 15 – 77yrs) with a thoracolumbar (T11 –L5) spinal fracture were admitted to our spinal unit over the last 11 years (1994 – 2004). Patient data was collected prospectively onto a spinal injuries database. All of these patients had an MRI scan on admission. All types of thoracolumbar fracture were included in this study and the presence or absence of an associated disc injury was recorded retrospectively from the MRI study. The type of disc injury was also recorded.

Results: The incidence of severe disc injury adjacent to a thoracolumbar spinal fracture in our cohort of patients was 43% (60 patients). Disc prolapse or extradural herniation was seen in 16 patients (11%). Intraosseous disc herniation into an adjacent vertebral body was seen in 20 patients (14%). Internal disc disruption was seen in 24 patients (17%). Disc injury was found at more than one level in 21 patients (15%).

Conclusion: The incidence of severe disc injury in our study of neurologically intact patients with a thoracolumbar fracture was considerable (43%). Kalyan et al2 suggested that treatment directed at addressing the disc injury in these patients may promote earlier pain relief and also earlier return to pre-morbid activities. If this is the case, then the decision making regarding operative versus non-operative management, in a patient with a thoracolumbar fracture and intact neurology, should be based on the severity of the disc injury as well as the bony injury.

S. Molloy R. Kaila R. Green A. Saifuddin

Background: It is very difficult to ascertain how much of the degeneration seen in a post-traumatic spine was due to pre-existing disease and how much was due to the trauma. The aim of the current study was to determine the prevalence of pre-existing disc degeneration on MRI in a region of the spine injured by spinal trauma.

Methods: Prospective whole spine MRI study in 118 patients with spinal trauma. One hundred and eighteen consecutive patients (79M:39F, mean age 36years, range 13 – 90 yrs) admitted to our spinal unit for treatment of their acute spinal trauma were investigated with whole spine magnetic resonance imaging (MRI). Whole spine MRI was already the standard protocol for all patients admitted with spinal trauma to rule out co-existing pathology and multiple spinal fractures1. Patient data, including age, sex, and mechanism of injury was recorded prospectively onto a spinal injury database. We divided the spine into cervical (C1–C7), thoracic (T1–T12), and lumbosacral (L1–S1) regions. For the purpose of this study we documented the presence or absence of pre-existing degenerative disc disease in all regions of the spine. Of particular interest was any pre-existing degenerative disc disease in the region affected by the spinal trauma. The number of spinal levels affected by pre-existing disc disease within each region was also detailed.

Results: The two most common mechanisms of injury were flexion-compression (68 patients) and flexion-distraction (24 patients). Seventy-one of the patients sustained burst fractures and the vast majority of these were in the thoracolumbar region. Thirty-seven patients (31%) had degenerative disc disease in the same region of the spine that was injured in the spinal trauma. Seven patients had pre-existing cervical degeneration in the presence of cervical spine trauma and thirty had pre-existing lumbosacral degeneration in patients that had lumbosacral trauma. Twenty four patients (20%) had more than one level of degenerative change within the same region as their spinal trauma. Eighteen patients (15%) had degeneration in a different region of the spine to the one that was injured.

Conclusion: Thirty one percent of the patients in our study had pre-existing degenerative disc disease in the same region as their spinal trauma despite the average age of our patients being only 36yrs. This has important medicolegal implications because it means that a large % of patients who sustain spinal trauma have pre-existing degenerative changes which are not the result of their injury.

J Bernard S Molloy S Somayaji A Saifuddin

Background: It has been reported that there is poor correlation between neurological injury and degree of bony retropulsion in thoracolumbar burst fractures1. Wilcox et al2 showed biomechanically that there was poor concordance between the extent of post impact spinal canal occlusion and the maximum amount of occlusion that occurred at the moment of impact. In the current study we examined the possibility that variation in the termination of the conus medullaris may offer protection from neurological injury in a proportion of these fractures.

Methods: A retrospective study was made of 39 patients (26M:13M, mean age 35.9 years, range 15 – 75 years) presenting with a single level thoracolumbar burst fracture (T12–L2) between 1998 and 2001. A whole spine MRI scan was performed on all patients and the level of the conus noted. Age, sex, injury severity score (ISS), neurological status (ASIA motor score) and the transverse spinal canal area (TSCA) of the vertebral levels either side of the fractured vertebra was measured. A predicted TSCA for the injured level was then calculated from the mean of the TSCA’s of the adjacent levels. The actual TSCA of the injured level was calculated and this enabled a percentage decrease of the TSCA to be worked out from the predicted value. Analysis was made of the presence or absence of neurological injury in relation to canal compromise and involvement of the conus.

Results: Eighteen patients with neurological compromise and 21 with intact neurology (the age and sex distribution in the two groups were similar). The mean ± SD ASIA motor score of the patients studied was 90.4 ± 23. Mean ISS was 20.2 in the neurologically injured and 10.5 in the intact (p=0.0005). Mean TSCA of the canal was 218mm2 in the intact and 150mm2 in the injured groups (p=0.006) and mean %TSCA was 70 and 49 respectively (p=0.007). The conus lay between T12 and L2 in all patients. When the conus lay cranial to the fracture (n=13), 38% were neurologically intact. When the conus lay at the level of the fracture (n=26), 62% were intact (NS). Neurological deficit did not occur in the absence of neurological compression on MRI.

Conclusion: Our study showed that the risk of neurological injury from a thoracolumbar burst fracture was not decreased when the conus lay outside the fracture zone. However, there was a statistically significant difference in percentage of canal compromise when the patients with neurological impairment were compared with those that were neurologically intact.

RR Verma JB Williamson D Patel

Background: To assess the safety and efficacy of intrathecal diamorphine for the postoperative pain relief in patients having lumbar decompressive surgery.

Methods: Retrospective study of case records of 39 consecutive patients who underwent lumbar decompression surgery, carried out by the same surgeon. There were 39 (24 males & 15 females, age range 19–75 years) healthy patients (23 ASA 1, 13 ASA 2 and 3 ASA 3). All patients having lumbar microdiscetomy or decompression for spinal stenosis were treated by a single intrathecal injection of diamrphine, performed by the surgeon prior to wound closure. All were prescribed regular paracetamol, and a NSAID if there were no contraindications. Oral opiates were prescribed for “rescue” analgesia. Retrospective analysis of the case notes of these patients was carried out and visual analogue pain scores, sedation scores and side effects/complications were evaluated.

Results: Five patients required rescue analgesia in the first six hours after surgery. None was required subsequenty. Nausea occurred in 2 patients, 1 patient had vomiting and one pruritus requiring piriton. Respiratory depression and sedation were not found in any of the patients. None of the patients had neurological complications.

Conclusion: Intrathecal diamorphine proved to be safe, effective and eliminated the need for opioid infusions following lumbar decompression surgery.

N. R. Boeree

Background: To asses the safety and efficacy of the Wallis Stabilization System in degenerative disorders of the lumbar spine.

Methods: A prospective international multicentre clinical and radiological outcome assessment study. The study is ongoing. The study group comprises 260 consecutive patients meeting inclusion and exclusion criteria with respect to diagnosis (and levels affected), age, medical conditions and prior surgery. 61% were male, 39% female and the mean age was 44 years. The principal diagnosis was massive disc herniation in 37%, degenerative disc disease (with Modic type I change) in 27%, canal stenosis in 13%, recurrent disc herniation in 9% and disc herniation above a transitional segment in 5%. L4/5 was the operated level in 88%. Clinical assessment has been performed using a p atient completed questionnaire incorporating SF-36, JOA (Japanese Orthopaedic Association score), VAS (lumbar pain Visual Analogue Score, 0–100), ODI (Oswestry Disability Index) and Odem’s Criteria. Any adverse or serious adverse events were documented. Pre-operative static and dynamic radiographs and MRI scans have been undertaken, and the radiographs are then repeated at 3 and 6 months post-operatively and yearly thereafter. Post-operative MRI scans are obtained on a yearly basis up to 5 years post-surgery.

Results: Mean operating time has been 74 minutes overall, with mean implantation time of 19 minutes. Blood loss averaged 180 mls. The pre-operative mean VAS of 71 improved to 21 at 3 months (p< 0.01) with further improvement at 6 months (VAS 18) and 1 year (VAS 11). SF-36 scores improved in every category from 3 months onwards, this improvement being statistically significant in all categories except general health. At 1 year SF-36 scores were not distinguishable from an age and sex matched general population. JOA scores improved significantly from 6.1 (15 point scale) pre-operatively to 12.5 at 3 months and 13.7 at 12 months (p< 0.01). Odem’s criteria provide additional evidence of efficacy, with 80% of subjects categorized as ‘good’ or ‘excellent’ at 3 months, this proportion improving to 89% at 1 year. Of those graded as ‘fair’ at 3 months, half had improved to ‘good’ or ‘excellent’ by 1 year.

From the series of 260 cases there were only 3 implant related complications (1.2%).

Conclusion: Previous biomechanical and finite element analysis studies have shown that the Wallis stabilization system off-loads the intervertebral disc and improves the biomechanical characteristics of the degenerative lumbar motion segment. The surgical procedure is simple, minimally invasive and non destructive, preserving surgical options for the future.

This study provides preliminary evidence with respect to the safety and efficacy of the Wallis Stabilization System.

A Jackowski I Pitman

Background: To assess the clinical and radiological results of motion-segment sparing anterior cervical partial discectomy and foraminotomy surgery in patients with at least 1 year of follow-up.

Methods: The study is a prospective, non-randomized, observational study. The patients all had symptoms of intrusive nerve root irritation with or without motor symptoms, refractory to conservative management for greater than 6 weeks duration. Patients were asked to complete questionnaires capturing) VAS (visual analogue) pain scores, NDI (neck disability index) and European myelopathy scores, patient satisfaction, and return to work details. Radiographic assessments were collected preoperatively, at 4 weeks, 3 months, 6 months, 1 and 2 years postoperatively.

Results: 58 patients have been assessed with at least 1year follow-up. The mean duration of symptoms prior to surgery was 24 weeks (6–20 weeks). 55 patients had single level surgeries (C5/C6-15, C6/C7-38, C7-T1-2), 3 patients had two level surgeries (C4/C5& C5/C6-1, C5/C6& C6/C7-2). In 34 patients sugery was for soft disc prolapse, in 12 patients surgery was for hard osteophytes and in 12 patients both pathologies contributed equally. Operation time ranged from 50–85 minutes. Average in patient stay was 2.6 days. There were no complications apart from 1 patient who had to return early to theatre for evacuation of haematoma and then made a full recovery. All patients reported pain intensity reductions. Pain decreased from 6.7 to 1.4 for arm pain on a 10-point scale. NDI scores improved from a preop mean of 42 to 16 on a 100 point score at 6 months post-surgery. All patients returned to their usual occupations with the exception of 2 patients who are involved in litigation against an employer or third party. No patient required repeat surgeries. Radiographic analysis at 1 year shows preservation of segmental motion in 75% patients, preservation of interbody height in 60% patients, spontaneous fusion in 12% patients.

Conclusion: A clinical success rate of 90% was achieved (clinical success being defined as a patient rating of very satisfied or satisfied on a 5-point patient self-scoring outcome scale). 56 out of 58 patients would undergo the same procedure again and recommend it to friend.

D.S. O’Donoghue M. de Matas K. Kopitzki Z. Abidin J. Hickey R. Pillay

Background: To assess the accuracy of pedicle instrumentation placement using an image guidance system ( Medi Vision) in a pig cadaveric model.

Methods: A 4mm diameter (10cm long) screw was inserted transversely into the spinous process of a pig cadaver percutaneously using fluoroscopic guidance. The dynamic reference base (DRB) of the image guidance system was then attached to the screw. Using the navigation system both pedicles at each level were identified and 3.2mm guide wires inserted percutaneously. This process was performed for each level from D7 to L4. Actual wire placement was recorded using standard anteroposterior and lateral fluoroscopic images. Virtual trajectories generated by the image guidance system were recorded on the guidance system database. Accuracy of wire placement was then evaluated in an automated way by linear correlation between corresponding images.

Results: 20 pedicles were instrumented at 10 levels from D7 to L4. Mean estimate of accuracy for dorsal levels AP and lateral (mm). Mean = 1.452mm, standard deviation 1.57mm. Mean for lumber levels= 1.047mm, standard deviation 1.187mm

Conclusion: Lumbar pedicle instrumentation showed more accuracy when compared to dorsal pedicle instrumentation. The error of navigation that was accommodated by the image guidance system was 2mm.

There was correlation between fluoroscopic copies and virtual trajectories.

This image guidance system may not only aid in the placement of pedicle instrumentation but also assist the senior surgeon in trainee supervision.

M. Emran M. A. El Masry A. Al-Shawi W. J. Farrington C.R. Weatherley

Background: To determine whether the operation of LSD destabilizes the lumbar spine and leads to an increase in any pre-existing scoliosis or spondylolisthesis. Lumbar spondylosis, which commonly includes a degenerative listhesis and a scoliosis, is the commonest cause for stenosis in the lumbar spine. The standard operation for spinal stenosis remains a laminectomy with fixation and fusion in the presence of possible instability. The laminectomy, however, destabilises the spine and the instrumented fusion makes it a much bigger operation in patients often not best placed to cope with it. The more limited operation of LSD, which has previously been reported to this society, avoids a simultaneous fusion or instrumentation and has been shown to give long term symptomatic relief (1) Its possible effect on the stability of the spine has not previously been reviewed.

Methods: A retrospective clinical and radiological review of consecutive patients operated on for degenerative spinal canal stenosis with either a pre-existing scoliosis or degenerative listhesis or both. Sixty-one patients (44 female and 17 male) with a mean age at operation of 72.8ys (range: 54–85). Pre-operatively 35patients (57%) had a degenerative listhesis, 14 patients (23%) a lumbar scoliosis and 12 (20%) had both. The mean postoperative follow-up was three years (range from one to fourteen years).

Results: None of the 47 patients with a preoperative degenerative spondylolisthesis had any change in grade of the listhesis. Also no patient developed a new spondylolisthesis.

Of the 26 patients with a preoperative scoliosis, 10 progressed by a mean of 4.9° (range 2°–15°)

Conclusion: The results show that the operation of LSD was not associated with the development of a spondylolisthesis or a further progression of a pre-existing listhesis, and no patient developed a scoliosis. In those who had a scoliosis pre-operatively, 38% progressed and this only to a degree which we believe falls within the natural progression to be expected in such a group of patients. We believe these results support the view that the operation of Limited Segmental Decompression for spinal stenosis does not significantly destabilize the spine, even in a group that would appear most vulnerable, and as such there is no indication in such cases to consider a simultaneous instrumentation and fusion.

D. Flynn A. van Wersch P. van Schaik K. Ryan V. Ferguson S. Papastefanou

Background: Despite people with idiopathic scoliosis (PwIS) experiencing pain (typically radicular that is often unrelated to clinical factors) of significantly greater frequency and severity to matched controls and the general population1, a paucity of attention has been devoted to elucidating psychosocial correlates of pain in this population. Therefore, the aim of this study was to investigate the predictive value of clinical and psychosocial factors for the pain experiences of PwIS in the UK.

Methods: A questionnaire-based design was used to examine associations between pain experiences, sociodemographic, medical, treatment and psychosocial factors (stressors, coping styles, coping functions, perceived body image [PBI], acceptance of scoliosis [AoS], health-related quality of life [HRQoL] and Health Locus of Control [HLoC]). A sample of 126 PwIS (88% female) with a mean age 39.0 years. Mean age at onset, Cobb angle before and treatment was 16.6 years, 57.9°, and 36.4° respectively. The number with thoracic, thoracolumbar, double major and lumbar curves was 26 (41.3%), 16 (25.4%), 16 (25.4%) and 5 (7.9%) respectively. Sixty one (48.4%) had undergone some form of surgery. Pain experiences (presence [yes, no], intensity, description and location/distribution of pain) were assessed with the McGill Pain Questionnaire (MPQ). Medication use and factors reported by PwIS to increase and reduce their pain were assessed with open-ended questions.

Results: The majority (85%) of PwIS reported pain and 56% reported using medication for pain due to scoliosis. Logistic regression revealed that medication use was associated with undergoing surgery, increased sleep disturbances and reporting that medication decreased their pain. Presence of pain was correlated with education stressors, coping functions (emotional regulation and avoidance), AoS and HRQoL. Predictors of MPQ measures were predominately psychosocial factors. Pain intensity was predicted by pre-treatment Cobb angle, PBI, HRQoL, absence of stress due to inadequate hospital services and reporting abdominal pain. Total pain on the MPQ was associated with absence of bereavement stressors, increased satisfaction with appearance before adolescence, HRQoL, not taking medication and reporting abdominal pain.

Conclusion: The findings indicate that psychosocial interventions have the potential to impact positively on the prevalence of pain, analgesic usage and satisfaction with healthcare in PwIS. The findings also highlight a need to develop clinical guidelines for the multidisciplinary management of scoliosis that adequately address the medical and psychological aspects of this condition.

D.R. Cohen P. Tran S. Duckett T. Hall C.E. Bruce J C Dorgan

Background: In times of blood shortage, the department of health plan to cancel elective surgery requiring more than 2 units of blood cross matching preoperatively. We assessed the use of blood products in scoliosis surgery and identified factors increasing the need for post operative blood transfusion.

Methods: Prospective data collection. Forty four patients underwent corrective spinal surgery between January 2003 and June 2004. Numbers of units of blood cross matched pre operatively and transfused post operatively were calculated. Subtype of scoliosis and surgical approach were also identified.

Results: All patients were cross matched 6 units of blood pre operatively, total of 264 units. Only 133 units were actually transfused, giving an overall 50.4 % product use rate. All syndromic patients were transfused blood irrespective of surgical approach. Idiopathic patients who had a one stage anterior approach did not require transfusion. Idiopathic patients were transfused a mean of 2.4 units and 2.9 units for one stage posterior and 2 stage approaches respectively. Syndromic patients were transfused a mean of 2.5 units, 5.8 units and 4.2 units for one stage anterior, one stage posterior and 2 stage procedures respectively.

Conclusion: The department of health published a paper on contingency planning for the shortage of blood products (1). In times of shortage, those surgeries requiring preoperative cross matching of more than 2 units will be cancelled first. Therefore, not only is it important to reduce the waste of blood products from a cost perspective, but also to cross match appropriately to avoid unnecessary cancellation if blood shortages occur. Surgical approach and underlying diagnosis need to be identified when cross matching patients for corrective scoliosis surgery. Idiopathic scoliosis patients only require 2 units of blood cross matching preoperatively. Patients with syndromes require 2–6 units depending on the surgical approach. A prospective validation trial has been implemented to validate our retrospective findings.

D. Flynn A. van Wersch P. van Schaik K. Ryan V. Ferguson S. Papastefanou

Background: Instruments for the psychological assessment of people with idiopathic scoliosis (PwIS) are required to design and plan interventions and services for this population. The few instruments available such as the Scoliosis Research Society Outcome Instrument1 rely on single item measures, omit important domains such as coping, and are not validated for use by the UK population. Therefore, the aim of this study was to assess the psychometric properties of a battery of existing instruments to measure the psychosocial functioning of PwIS in the UK.

Methods: A non-experimental design was used to examine the psychometric properties of the following scales: Functional Dimensions of Coping (FDC); Iowa Body Image (IBI); Acceptance of Scoliosis (AoS); Quality of Life Profile for Spine Deformities (QoLPSD); Multidimensional Health Locus of Control (MHLoC); and the McGill Pain Questionnaire (MPQ). A sample of 126 PwIS (88% female) with a mean age 39.0 years. The number with thoracic, thoraculumbar, double major and lumbar curves was 26 (41.3%), 16 (25.4%), 16 (25.4%) and 5 (7.9%) respectively. Sixty one (48.4%) had undergone some form of surgery. The instruments were assessed in terms of factor structure (factor analysis); internal reliability (Cronbach’s alpha); discriminant validity (examining significant correlations with > 5% overlap in variance, i.e. r > 0.022); construct validity (correlations between one construct such as HRQoL and another construct that is expected to covary such as pain); and sensitivity (correlations between scores on the instruments and patient factors such as Cobb angle).

Results: The instruments had clearly defined factor structures that confirmed previous research and the sub-scales were universally reliable (Cronbach’s alpha ≥ 0.7; range 0.7 – 0.95). Except for MHLoC the instruments possessed adequate discriminant validity. Construct validity was demonstrated by 70% overlap in variance between AoS and HRQoL – Psychosocial Functioning subscale and significant correlations between HRQoL – Sleep Disturbances and HRQoL – Back Pain with all the MPQ subscales. Subscales on all the instruments (except MHLoC) were sensitive to differences in patient variables (e.g. age and Cobb angle).

Conclusion: Given the excellent psychometric properties of the instruments used, we propose a new outcome measure ‘The Scoliosis Psychosocial and Pain Profile Inventory’ (SPPPI), that consists of the following instruments: FDC, IBI, AoS, QoLPSD, and MPQ. Further research is needed investigate the test re-test reliability and responsiveness of the SPPPI after the delivery of medical, surgical and psychosocial interventions.

A. Mirza E. Aldlyami C. Bhimarasetty J. Spilsbury D. Marks

Background: Anterior scoliosis surgery is associated with potentially significant intra-operative blood loss, requiring homologous transfusion either intra- or postoperatively. Blood loss in this type of surgery correlates with surgical & anaesthetic techniques. In our centre the development of specific anaesthetic techniques as well as the routine use of Cell Salvage has dramatically reduced the rates of homologous blood transfusion. Currently, specific indications for the use of the Cell Saver in Anterior Scoliosis Surgery have not been proven. Previous studies have commented on the beneficial aspects of autologous transfusion for Orthopaedic patients in general; However, others have shown a negligible advantage specifically in anterior thoracolumbar fusion surgery. The aim of our study was to assess and quantify the use of homologous blood, as well as the effects on haematological indices.

Methods: We carried out a retrospective study of 144 consecutive patients, all of whom underwent instrumented anterior scoliosis correction between April 2001 and October 2004. A cell saver was used in all the cases, and hospital data (including haematological indices and number of levels fused) was collected.

Results: The median age of the study cohort was 15.0 years (range 8 – 46), and there were 31 males and 113 females. The mean preoperative haemoglobin in patients was 13.5g/dl and the mean postoperative haemoglobin was 10.6g/dl. Haematocrit values followed a similar pattern, the mean pre-op value being 0.41, mean post-op value was 0.29. The range of volume of intra-operatively salvaged cells was 200 to 1100mls. 25 of 144 patients required transfusion. In these patients, the average number of units given was 2.3, although the total homologous transfusion rate was 0.4 units per patient. Results show that homologous transfusion was not required in 82.6% of patients. This is better than previously published rates of transfusion in this procedure. There was no correlation between the number of levels instrumented and the number of units transfused (Pearson Correlation Coefficient 0.19), and no correlation between the number of levels instrumented and postoperative haematocrit values (Pearson Correlation Coefficient 0.16). None of the patients required intra-operative homologous transfusion.

Conclusion: Our experience shows that along with meticulous surgical haemostasis, and hypotensive anaesthesia the use of Salvaged Autologous Blood Transfusion in anterior scoliosis surgery has an important role in reducing the incidence of postoperative anaemia and homologous transfusion requirements.

D. Flynn A. van Wersch P. van Schaik K. Ryan V. Ferguson S. Papastefanou

Background: Despite the benefits of quality information material, there is a dearth of research on the information needs of people with scoliosis (PwS). The aim of this study was to identify the information needs of PwS including preferences for the presentation of benefit/ risk information, in order to inform the design of written information for this population.

Methods: A questionnaire-based design was used to identify the importance attached to characteristics of information material, scoliosis-related knowledge, preferred treatment decision-making role, preferences for presentation of risk information and current information needs. A sample of 73 PwS (86% female, mean age 41.9 years). The majority (74%) had at least an A’ level standard of education and 60% had undergone some type of surgery. The importance of 13 characteristics of information material was assessed using criteria described by previous research1. PwS were asked to rate their level of knowledge on 20 scoliosis-related topics. The Control Preference Scale was used to assess treatment decision-making role. Preferences for the presentation of risk information was assessed in terms of (a) absolute versus relative risk, (b) loss versus gain information, and (c) perceived clarity of different methods for presenting benefit/risk information. An open-ended question requested PwS to state their current information needs.

Results: Characteristics of information material assigned the highest importance were: information on benefits/ risks of treatment; coverage of all relevant treatments; and clear information on probability of benefits/risks of treatments. Scoliosis-related knowledge was rated below average for 14 of the 20 topics. The majority (88%) expressed a preference for an active or collaborative role in treatment decisions. The majority also preferred to be presented with information on benefits/ risks in both absolute and relative terms, and informed of both loss and gain information. Bar graphs and pie charts were assigned the highest clarity ratings for the presentation of benefit/risk information. Content analysis revealed 27 mutually exclusive categories of current information needs and the rank order of the top 3 were: psychological services and psychosocial support; surgery; and aftercare and self-management.

Conclusion: PwS lack knowledge about their condition, desire both psychological and medical information and wish to be involved in treatment decisions. Based on the results, written information will be designed to address the salient information needs of PwS. It is anticipated, following further evaluation that these materials could be used to impact positively upon clinical outcomes such as psychosocial functioning, patient satisfaction and participation in shared decision-making.

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H V Dabke A Jones S Ahuja J Howes P R Davies

Background: Long waiting lists in the NHS are a cause for public concern especially with regards to progressive conditions like scoliosis. We reviewed records to 61 patients to ascertain whether waiting time had any detrimental influence on their surgical management.

Methods: Retrospective review. Assessment of clinical records and radiographs of 61 patients who had scoliosis surgery over past two years was done by two independent investigators. Patient demographics, waiting times between referral and outpatient review and waiting time for surgery were collected.

Results: There were 41 females and 20 males with mean age of 11.8 years (range, 1– 22 years). Thirty-four patients had thoracic curves (28- right sided), 21 had thoracolumbar curves (19- right sided) and 6 patients had right sided lumbar curves. Mean Cobb angle at presentation was 58° (range,17°–90°) which increased to 71°(range, 30°–120°) at surgery. Average waiting time to be seen in the clinic was 16 months. Average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients (20%), of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° (range, 45°– 80°), which increased to a mean of 59° at surgery (range, 50°–92°). At presentation their Risser grades were: 5 – grade 0, 3- grade 2, 2- grade 4. These 10 patients had waited averagely 7.8 months to be seen in the clinic and for 11 months to have the surgery.

Conclusion: Significant curve progression occurred in 20 % of patients waiting to have scoliosis surgery. Ten of those required much more extensive surgery than originally planned. Long waiting times therefore have a detrimental effect on the surgical management of scoliosis patients.

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E Palayiwa Z Jana-Mohyadin

Background: To review the results of spinal cord monitoring over a five year period and determine whether the generally accepted criterion used for warning the surgeon is appropriate and whether this criterion could be modified without compromising patient safety.

Methods: This was a retrospective study of patients monitored at the John Radcliffe hospital between October 1999 and June 2004. Monitoring is carried out by stimulating the peroneal nerve behind the knee and monitoring using an epidural electrode above the surgical site. Results are recorded throughout the surgery using a Synergy mobile system. Exponential averaging is used and the surgeon is warned of possible damage if the amplitude of the signal drops by more than 50% from the reference value which is set as soon as the surgical site has been exposed1. Two hundred and twenty two patients were studied all of whom had spinal surgery with instrumentation. The age range was from 4 to 80 years old. Patient notes were assessed to determine whether there was any neurological damage and if so what the nature and duration of this was. These results were compared with the results of monitoring, both the absolute value of amplitude change and also the time course of any variations in amplitude.

Results: Of the 223 cases studied 78 exhibited a 50% drop of amplitude of the signal on one or both sides at some stage during the surgery. In 30 of these the deficit remained on at least one side at the end of surgery, 6 having a deficit on both sides. There were no cases of neurological damage in the patients where the signal amplitude was greater then 50% at the end of surgery. In the 30 cases where the signal amplitude was less than 50% at the end of surgery only one had any lasting neurological damage and one showed a transient neurological deficit. The time course of the change of amplitude appeared to be different in the cases of neurological damage than in those without damage.

Conclusion: In this study all patients suffering neurological damage were identified by the spinal cord monitoring. However, there was a significant number of “false positives” which could possibly be reduced by developing new criteria for warning the surgeon. It is also possible that the exact methodology used in monitoring may affect the number of false positives. Both the stimulus method and recording method may contribute to this2. Development of evidence based criteria for warning the surgeon and optimizing methods of monitoring would need co-operation between many centres. We would propose that a multicentre study should be set up with this objective.

Marianne McMaster A J Lee R G Burwell

Background: To our knowledge, there are no publications that have evaluated physical activities in relation to the etiology of AIS other than sport scoliosis (1,2) so we undertook a study to assess the physical activities of patients with progressive AIS from their first year to early teens and compared these with those of a control group.

Methods: All 156 children in this study had to adhere to the following 6 criteria:- born full term, fed well as infants, achieved their milestones, no hospital visits except for sports injuries, no family history of a scoliosis and no back pain (prior to diagnosis in the patient group). We compared 79 consecutive patients (girls 66, boys 13) diagnosed as progressive AIS (62 of whom subsequently had a spinal fusion) with a control group of 77 subjects (girls 66, boys 11) of similar age, gender, race and socioeconomic status. A structured history was obtained from the mother and child of each group average time taken to obtain the history was 47 minutes. Each child was examined for toe touching and vertical symmetry of spinous processes whilst standing. The findings suggest a relation between physical activities or the lack of them and the development of progressive AIS.

Results: There is a significantly increased odds of AIS in those who were introduced to a swimming pool within the first year of life (p=0.001), did not attend gymnastics/ karate classes (p=0.005), did not attend dance classes (girls only, p=0.045), did not have horse riding classes (p=0.003), did not go skating (< 0.001), and who could touch their toes (p=0.011). No association is found with playing football/hockey or regular swimming at the age of 10 years.

Conclusion: Progressive AIS is positively associated with an early introduction to swimming and ability to toe touch. Spinal asymmetry was noted in the controls. AIS is negatively associated with participation in dance, skating, gymnastics/karate and horse riding classes. Is it possible that children who develop AIS have a longstanding proprioception defect which makes them less likely to participate in sporting activities? If so, by encouraging children to participate in sport might we increase their proprioception abilities and make those at risk less likely to develop spinal asymmetry which may progress to a scoliosis requiring surgical correction?

J. Andrews J. Clamp M. Grevitt

Background: It is often useful to gauge the flexibility of curves while assessing patients with scoliosis. Our aim was to discover if there were any reliable x-ray predictors of stiffness.

Methods: Previously the flexibility index has been shown to be an accurate measure of curve stiffness. A random selection of fifty x-ray sets was analyzed for parameters that might predict flexibility. These were then compared to the flexibility index generated from bending films. We recorded age; Cobb angle; bending film Cobb angle; Perdriolle rotation assessment; percentage wedging of the apical vertebrae and translation of the apex of the curve from a central sacral/cervical line. We then calculated the flexibility index. All measurements were taken from immediately pre operative standing AP x-rays and fulcrum bending films (1). The group was then assessed as a whole and subgroups were analyzed. Large curves (> 50 degrees) were compared to small (< 50 degrees) curves and thoracic curves were compared with thoracolumbar curves. Correlation between the flexibility index and the other parameters was then studied. We used Pearson correlation coefficient for parametric data and the Spearman rank correlation coefficient to study the non parametric data. P values were then assigned using a statistics software package.

Results: Age and apical translation were not related to curve stiffness. The Cobb angle was the only strong predictor of flexibility (p-0.002) looking at all curve types together. The Cobb angle was, however, more useful in larger curves and did not reach statistical significance in the small curve subgroup. In small curves Perdriolle rotational assessment was a more useful measurement (p-0.02). In the thoracic curve subgroup the percentage wedge of the apical vertebrae was a strong predictor (p-0.007).

Conclusion: Our sample had a strong bias toward an adolescent age group (5–61) mean age 17 and probably did not have enough of a spread to demonstrate the previous relationship between age and stiffness (2). The study re enforces the value of the Cobb angle in predicting curve stiffness but suggests caution using it in smaller curves. It also suggests a role for Perdriolle measurement in small curves and percentage apical wedge in thoracic curves.

J. R. Andrews C. V. J. Morgan-Hough B. J. C. Freeman M. P. Grevitt J. K. Webb

Background: Anterior scoliosis correctional surgery can result in screw pull out or pedicular fracture. This is more common in stiff curves where the instrumentation extends to the smaller, higher, thoracic levels. The fracture/intra-operative pull out usually occurs during the reduction maneuver. In all of our cases the curve was reduced in the standard cranial to caudal direction using a cantilever maneuver. We describe a salvage technique using circlage wires that can be used for this problem. We present seven cases and the final outcome.

Methods: The technique involves placing a longer screw into the damaged vertebrae so it protrudes 5mm proud. A 1.25mm circlage wire is then cut to length and passed around the tip of the screw. It is then looped in a figure of eight passed under the rod and tightened around the respective pedicle screw head. A case record and x- ray review of seven procedures performed was then carried out. The age of the patients was between 14 and 41 years (mean 20) at surgery. The pre-operative Cobb was between 72 and 43 (mean 58). One curve was flexible with a flexibility index of 70% but the remainder was stiffer (range 34%–40%). There was one thoracolumbar curve with a T11 fracture. All other curves were thoracic and the fracture levels were T5, T7, T7, T6+7, T6+7+8, and T6+7+8 respectively. Four out of seven were braced post operatively for three months. The Cobb angle over the instrumented levels immediately post surgery and at final follow up was measured. The technique was deemed to be successful if no significant loss of correction occurred.

Results: The technique held position in six out of seven of the subjects. The average loss of position in these patients was two degrees (range 0–4). In one subject the curve went from 28 degrees immediately post operatively to 38 degrees over 2 years. The four month post operative x ray showed no loss of position suggesting that this loss of position may not be due to the fracture. This patient remained pleased with his cosmetic result and went from 72 degrees pre operatively to 38 degrees at 2 year follow up.

Conclusion: Care should be taken in patients with stiff proximal curves. The use of larger 8mm screws may decrease pull out and consideration may be given to caudal to cranial reduction in some cases. Circlage wire rescue is a useful salvage procedure for inter-operative fracture or screw pull out during anterior scoliosis correction.

MJ Hutchinson IW Nelson

Background: To describe – Forced traction radiographs under GA for operative planning; The use of segmental orthogonal image-intensification for screw insertion in thoracic & lumbar pedicles; An audit of X-ray exposure during these procedures; The use of multiple Chevron osteotomies as an alternative to anterior release; The correction of scoliosis with convex cantilever, Cotrel-Debousset manoeuvre, segmental translation, segmental rotation,” lumbar-levelling”.

Methods: We present our operative technique in addressing deformity. This represents an eclectic evolution, which we feel is sufficiently dissimilar to current standards to merit presentation. Pedicle screws are inserted at multiple levels with no recourse to hook or wires. Five reduction techniques are used and repeated.

Results: The complications of 1500 thoracic pedicle screws; the predictive value of forced traction films under GA; the Fulcrum Bending Correction Index and operative parameters of our series are submitted separately.

Conclusion: We commend consideration of some or all of our techniques to the society.

OA Gabbar MJ Hutchinson IW Nelson

Background: To assess reliability of traction views under GA in predicting curve flexibility when performing posterior correction of scoliosis deformity with pedicular screws.

Methods: Compare reliability of preoperative fulcrum bending film with intraoperative traction films in predicting and influencing the correction of scoliosis deformity using posterior pedicular screws. Twenty patients undergoing corrective surgery for scoliosis deformity the average age was 19 years old. The Lenke classification was used to classify the curves using pre-operative fulcrum bending views, the student’s t test was used to assess the reliability of x-ray views in predicting the end results.

Results: The mean preoperative major structural Cobb angle was 80 degrees and mean minor structural Cobb angle was 27, the mean major structural Cobb angle on fulcrum bending views was 49 degrees, the mean major structural Cobb angle on the traction views was 33.6, the minor structural Cobb angle was 9 degrees thus changing the lenke classification of the curve reducing the numbers of levels for fixation by at least one level either end of the curve. Posterior pedicular screws were used in all the patients. The number of patient at risk of combined anterior release and posterior instrumentation was reduced from 13 to 2. The P value for the difference between fulcrum bending views and traction views was P< 0.0001, for traction and end result P=0.18

Conclusion: The traction views under GA were superior in predicting curve flexibility when performing only posterior scoliosis correction with interpedicular screws reducing the number of levels required to incorporate and the number of procedures required to achieve adequate correction.

OA Gabbar MJ Hutchinson IW Nelson

Background: To assess the correction of curves using the Fulcrum bending correction index FBCI with pedicular screws in posterior scoliosis surgery.

Methods: Compare preoperative upright and fulcrum bending views, intraoperative traction films with postoperative views to assess the correction of scoliosis deformity using posterior USS II interpedicular screws. Peri-operative complications are reviewed. Twenty patients undergoing corrective surgery for scoliosis deformity were reviewed the average age was 19 years old 4 males and 16 females, 17 were idiopathic adolescent scoliosis, 3 were neuromuscular scoliosis. The Lenke classification was used to classify the curves, the Fulcrum bending correction index (FBCI) as a percentage for assessing postoperative correction.

Results: The mean preoperative major structural Cobb angle was 80 degrees and mean minor structural Cobb angle was 27 degrees, the mean major structural Cobb angle on fulcrum bending views was 49 degrees, the mean major structural Cobb angle on the traction views was 37 degrees. Pedicular screws were used in all the patients for posterior correction; only two patients required combined anterior release. The average inter-operative blood loss was 2200 ml, the initial results suggest an of FBCI of 181% compared to Luk et al results 100.2% to 109.1% 4 different methods of posterior stabilisation.

Conclusion: Pedicular screws provided excellent segmental correction and stabilisation for posterior scoliosis correction.

A Rafee D Mittal RB. Smith

Background: To assess the cosmetic advantage of costotomy at the angle of the ribs on the convexity of a curve in the management of Adolescent Idiopathic scoliosis. Whilst modem segmental correction produces gratifying improvement in Cobb-angle and, to some extent rotation, rib asymmetry often remains as a concern for patients. Performing costotomy at the angle of the rib at the same time as corrective surgery can improve the cosmetic appearance significantly. It avoids any further scars or surgery, and is associated with minimal complications, the main one being pneumothorax and the requirement of a chest drain.

Methods: Retrospective review of 50 patients. This has been a standard practice and this presentation reports on 50 patients treated in Preston with a variety of corrective devices; we have assessed results radiologically, with cosmetic acceptability by the patient and surface topographical analysis.

Results: Significant improvement occurs at the time of costotomy as the ribs drop from their arched position after the coronal deformity has been improved

Conclusion: The addition of costotomy at the time of primary surgery for Adolescent Idiopathic Scoliosis leads to minimal complications. Significant improvement occurs at the time of costotomy as the ribs drop from their arched position after the coronal deformity has been improved. This is maintained in the post-operative period by moulding of the brace.

CVJ Morgan-Hough Andrews BJ Freeman MP Grevitt JK Webb

Background: To assess the treatment of Lenke Type 1 Curves with anterior USS Instrumentation.

Methods: A retrospective radiographic review of 29 cases. Twenty nine patients with Lenke type 1 curves were treated with anterior USS instrumentation. The average age was 14.8 years (range 12–25 years) with an average of 17.4 month follow up (range 6–61 months). 27 were right sided curves, with 2 left sided. Standard AP and Lateral Standing X-rays were taken preoperatively (together with bending films), post-operatively and at follow-up. Measurements recorded at each assessment were the mean Cobb angle, sagittal and coronal balance, kyphosis and lordisis. Complications we associated with the instrumentation were also recorded.

Results: 12 patients had double minithoracotomies, the rest (17), single thoracotomies, the average blood loss at operation was 1055mls, with no significant difference between the two groups. The mean number ofleve1s instrumented was 6 (range 4–8). The mean pre-operative Cobb angle of the major thoracic curve was 53° (range 37–74). This value corrected to 24° on fulcrum bending films. The compensatory lumbar curve averaged 36° bending down to 6.°. The mean correction of these two curves post-operatively and then at most recent follow-up was 21 and 26 degrees for the thoracic curve, and 21 and 20 degrees for the lumbar curve. The mean pre-operative kyphosis was 25 increasing to 34 post-operatively and 39 at follow-up. The mean lumbar lordosis readings were 46, 46 and 45 respectively. Sagittal balance, gradually improved from a mean of 12mm to 11 then 10 at follow -up. Coronal balance did not show the same trend and was 3mm pre-operatively then 7 and 7 at final follow up. Instrumentation complications in total occurred in 9 cases, which included 4 cases of vertebral body fracture requiring circlage wiring and 5 cases of partial screw pulling out of the vertebral body. Fractures requiring wiring occurred at T5, T7, one case of three levels T6,7,8 and one case of two levels T6,7, this complication always occurred at the highest level instrumented. Partial screw pull-out always occurred at T5, with two cases occurring at two levels i.e T5,6.

Conclusion: Good correction was obtained with an mean of 6 instrumented levels. There was however a significant instrumentation complication (31 %). Despite this the intra-operative fractures caused no significant complications and good correction was still achieved in these cases. There are some concerns over mild deterioration in the curves over long term follow up but this deterioration is not clinically significant.

CJ Goldberg DP Moore EE Fogarty FE Dowling

Background: In adolescents at or near skeletal maturity, correction of severe scoliosis may be facilitated by first mobilising the spine anteriorly before the definitive posterior fusion and instrumentation. There is no dispute that this is effective, but it is significantly more invasive, and carries greater risks. The benefits have been measured in greater reduction in the Cobb angle, but the patient’s real concern is with cosmesis. Surface topography can measure this aspect.

Methods: Retrospective comparison of topographic parameters (before surgery and at 7 days, 6 months, and 2 years after, and at latest review, if more than two years) after one-stage (Group 5, N=10) and two stage (Group 3, N=39) with normal adolescents (Group 1, N=63). Patients operated for adolescent idiopathic scoliosis by one surgeon (FED) were compared with girls referred and then judged normal from the screening programme. Topographic parameters (spinal angle, saggittal profile, asymmetry and trunk balance) and Cobb angles were compared by t-test.

Results: Prior to surgery, both treatment groups differed significantly from the index group on all parameters except saggittal profile; from each other, they differed only in mean Cobb (Group 3: 73.6°, Group 5: 59°) and spinal angles and Suzuki hump sum. After surgery, both groups showed significant mean reduction in most parameters and in final Cobb angle (Group 3: 32.7° (−40.9°), Group 5: 29° (−30°) postoperatively) excepting rib hump, and were not statistically distinguishable. Over two years, there was continued improvement in trunk balance and re-establishment of lumbar lordosis in both groups. Group 5 (single stage) showed a slight recurrence of some asymmetry parameters that was statistically (but perhaps not clinically) significant. All patients had a solid fusion post-operatively.

Conclusion: Ideally, this study would be done prospectively, on a controlled, double-blind, randomised basis, but the numbers required and time involved make this impractical. These two surgical groups were pre-selected on the basis of curve severity, and these results may show that the anterior procedure is necessary to bring Group 3 to the same end-point as Group 5. Alternatively, while the anterior procedure improves the reduction of the Cobb angle, it might be the posterior fusion that rearranges the shape of the back and hence brings about the cosmetic improvement. In conclusion reducing the Cobb angle has been the standard of surgical assessment, but the cosmetic result does not necessarily correlate with this. The possibility that less invasive surgery may give as good a cosmetic outcome is worth discussing, as the savings in time, money and risk would be enormous.

S. Molloy G. Edge J. Lehovsky

Background: The long term survival of patients with type II and III spinal muscular atrophy differs considerably from patients with Duchenne muscular dystrophy. Despite this, treatment of scoliosis in both groups is often reported together1. There are only sporadic reports, all with small numbers, of combined anterior and posterior (two stage) scoliosis surgery in patients with spinal muscular atrophy (SMA)1. The aim of the current study was to document the peri-operative morbidity, length of stay and correction of deformity in patients with SMA that had two stage surgery and compare them with the patients that had single stage surgery.

Methods: A retrospective analysis of data on our consecutive series of patients with SMA.

We analysed the data of 31 patients with SMA (16M:15F) who underwent scoliosis surgery between 1996 and 2004. The data collected included SMA type, age at surgery, percentage predicted forced vital capacity(%PFVC), blood loss, duration of surgery, complications, type of surgery undertaken, pre-operative mean Cobb angle ± SD(including bending film Cobb angle ± SD), post-operative Cobb angle ± SD and length of hospital stay. The decision to do single or two stage surgery was based on the history of recurrent chest infection, %PFVC and the stiffness of the curve. Percentage correction of Cobb angle in patients that had two stage surgery compared with those that had single stage posterior surgery. Comparison of post-operative respiratory complications, estimated blood loss, total hours in theatre and mean length of stay between the two groups.

Results: There were 27 SMA type II and 4 SMA type III’s with a mean age at surgery of12.5 years (range 7.8 – 17.4). The mean pre-operative Cobb angle of all 31 patients was 89.7° ± 19.7°, the mean bending preoperative Cobb angle was 54° ± 13.3° and the mean post-operative Cobb angle was 33.7° ± 17.3°. Eighteen patients had single stage surgery and 13 had two stage surgery. Twelve out of the thirteen two stage operations had either a thoracotomy or a thoracoabdominal approach. In the patients that had single stage posterior surgery, the mean bending preoperative Cobb angle was 54° ± 13.3° and the mean post-operative Cobb angle was 38.7° ± 19.2°. In the patients that had two stage surgery the mean pre-operative bending Cobb angle was 53.6° ± 11.6° and the post-operative Cobb angle was 25.5° ± 10.8°. The %PFVC in the patients that had single stage and two stage surgery was 39.2 ± 12.8 and 69.2 ± 12.2 respectively. There were 3 respiratory complications in the single stage group and 4 in the two stage group. The average total estimated blood loss (EBL) in the single stage and two stage groups (first and second stage EBL’s combined) were 2433ml and 1902ml respectively. The length of stay for the patients with single stage surgery and two stage surgery was 14.1 ± 4.1 and 18.5 ± 7.4 days respectively. The total surgical hours for the patients with single and two stage surgery were 2.9 ± .6 hrs and 4.8 ± 1.2 hrs respectively.

Conclusion: The results of our series would suggest that in a selected group of SMA patients (no history of recurrent chest infection and an acceptable %PFVC) a better immediate deformity correction can be attained with two stage surgery. This has to be weighed up with a greater total EBL and mean length of stay for the patients that had two stage surgery.

LM Breakwell DS Marks AG Thompson RR Betz L D’Andrea LG Lenke

Background: To present the experience of three centres in the surgical management of scoliosis in patients with Prader-Willi syndrome1, and to describe the associated complications. A retrospective case series reviewing treatment type, surgical outcomes and complications with a review of the literature

Methods: There were 15 patients treated surgically in the three centres over an eleven year period. The average age at initial surgery was 9.6 (5 to 16+8) yrs. Minimum follow-up from index procedure was 28 months. 5 underwent posterior spinal fusion, 2 had anterior fusion alone and 2 had combined anterior/ posterior fusions as their index procedure. 6 patients were initially managed with growing rod constructs. Outcome measures included fusion rate, curve progression and complication rate.

Results: 11 patients achieved a solid fusion. 2 patients were still undergoing the lengthening process and were thus unfused. 1 patient had broken instrumentation with pseudarthrosis, and one patient not fit for final fusion remained without implants. No curve progression was seen in the 11 fused spines. Progressive kyphosis and scoliosis were noted in the two ongoing lengthening patients. There were 17 revision procedures not including planned lengthenings, with a total of 59 surgical procedures. 5 rod breakages occurred in the growing-rod patients. There were 11 infections (4 deep) in 7 patients. There were 6 respiratory complications, 3 requiring ventilatory support. One patient had post-operative neurological deterioration requiring re-exploration and who had grade 3 paraparesis at final follow-up. In total there were 36 complications (240%)

Conclusion: The outcome of surgical management of scoliosis in Prader-Willi syndrome is adversely affected by the obesity and respiratory difficulties of the patients and complications abound2. The use of growing constructs, whilst enabling the management of the growing child, greatly increases the risk of implant failures. Their use in Prader-Willi requires careful consideration.

T Ember H Noordeen

Background: To stimulate a debate as to whether neurological compromise as a result of spinal instrumentation is the result of direct or indirect cord injury of more the result of cord ischaemia due to the highly abnormal vascular anatomy encountered in these patients.

Methods: Review of three cases of neuromuscular scoliosis who underwent angiograms under general anaesthetic. Graphical comparisons with normal patterns spinal vascular anatomy

Results: Vascular anatomy was found to be so abnormal in these patients that the series was discontinued due to the perceived risk of paraplegia as a result of the angiogram procedure itself.

Conclusion: We plan to perform CT angiograms in patients with neuromuscular scoliosis to further elucidate the vascular anatomy in these patients

CJ Goldberg EE Fogarty FE Dowling A. O’Meara

Background: A sharp, localised, thoracolumbar gibbus is pathognomonic of the mucopolysaccharidosis (MPS) group of disorders, the most common of which is Hurlers syndrome (MPS I). Untreated patients with this disease run an inevitable course of neurological and physical degeneration until death within the first decade. Haemopoietic stem cell transplantation (HSCT) has resulted in considerable improvement in survival with amelioration of many of the symptoms and signs which characterise this disease. Data, however, is disappointing in relation to the impact of HSCT on skeletal dysplasia. This study reviews the natural history of spinal deformity in Hurler’s syndrome after HSCT in infancy.

Methods: Twenty three patients (12 male and 11 female), transplanted at a mean age of 0.9 years ± 0.47, (range 0.27 – 1.8yrs) were investigated, of whom 19 were at least two years post-HSCT and were included. HLA identical donor sources included unaffected or heterozygote family members, unrelated adults or cord blood. Mean age at review was 9.4 years ± 4.57, (range 2.5 – 18.4yrs). Serial measurements of the thoracolumbar spines incorporated clinical records, radiographs and surface topography. The thoracolumbar gibbus was measured on lateral spinal radiograph using the standard adaptation of the Cobb method. Two segments of the spine were documented: the gibbus itself and the thoracic profile above it. Clinical assessment and surface topography were contrasted with this.

Results: At presentation, all showed the characteristic gibbus at the thoracolumbar junction, with a flat and stiff thoracic spine above. Three patients underwent surgery to correct or maintain the gibbus, which was unsuccessful in two; the third is stable, but still young. Two patients have developed scoliosis: one in the juvenile period and one in infancy. Three female patients are now post-menarchal and have shown no progression of their gibbus. One male patient, now aged 19 years, had significant progression of his gibbus at puberty, but is now stable, untreated and cosmetically acceptable. The remainder are still pre-pubertal but their deformities are not currently progressive.

Conclusion: The fate of the spinal deformity in untreated MPS-I has been poorly documented, as the condition was invariably fatal from cardiorespiratory failure during the first decade. These interim results suggest that, while the deformity persists and may become more pronounced during growth and adolescence, it does not significantly impact on quality of life. The considerations which usually dictate intervention in other spinal deformities of childhood may not necessarily apply and should be approached with caution. The more recent availability of recombinant human -L- iduronidase adds further interest to the management of these patients and warrants cautious expectation , in the context of experience gained in these groups of patients. In conclusion atients with MPS I have complex multisystem disorders, independent of their orthopaedic status. While monitoring their spinal deformity is indicated, over-intrusive investigation and treatment may be counterproductive.

M Assous C Lawson DL Douglas AA Cole

Background: To assess the potential for Quantec imaging to save radiographs in the follow-up of patients with early onset scoliosis. This is a group of patients who often have many radiographs due their age at diagnosis.

Methods: This is a prospective cohort study. Twenty-four children with early onset scoliosis are identified. They all have a minimum of three simultaneous radiographs and Quantec scans as part of routine follow up for their scoliosis curves. There are 15 males and 9 females (22 thoracic, 1 thoracolumbar, 1 lumbar). Mean age at diagnosis is 3 years (range 1–4.8 years). The Cobb angle of the major curve is measured from each radiograph and compared with the Q-angle using Bland-Altman plots and linear regression analysis.

Results: The mean Cobb angle was 30° and the mean Q-angle 19°. The correlation coefficient was 0.68 (p< 0.05). In curves with Cobb angle < 30°, The Bland-Altman plots show a close scatter with a mean difference of 3.4°. It was calculated that this could have safely saved 18 radiographs in 14 patients. In curves > 30°, there was a large scatter and a mean difference between Cobb angle and Q-angle of 20.1°.

Conclusion: In early onset scoliosis, curves with Cobb angle less than 30° can be safely followed clinically and with the Q-scan reducing the number of radiographs required. Curves with Cobb angle greater than 30° cannot be reliably observed with Quantec scans alone.

P.M. Whittingham-Jones S. Molloy G. Edge J. Lehovsky

Background: There are conflicting reports regarding the effect of scoliosis surgery on respiratory function in Duchenne Muscular Dystrophy (DMD)1,2. Galasko et al2 found that the Percentage Predicted Forced Vital Capacity (%PFVC), remained static for thirty six months following surgery, in patients with DMD that underwent spinal stabilisation for scoliosis. The aim of the current study was to support or refute the above finding in a large series of patients with DMD.

Methods: A retrospective analysis of data on 55 consecutive patients with DMD that underwent single stage posterior surgical correction for scoliosis. We analysed the data of 55 boys with DMD who underwent scoliosis surgery between 1990 and 2002. Age at surgery, pre-operative Cobb angles, pre-operative %PFVC, and post-operative %PFVC at 6 months, 12-18 months and 2–3 years were collected. We documented the pre-operative Cobb angle ± SD to assess the difficulty level of our surgical cases. Percentage PFVC was used as our outcome measure to assess respiratory function. The mean pre-operative %PFVC was compared to the post –operative mean %PFVC at three different time intervals; at 6 months, 12 to 18 months and at 2 to 3 years.

Results: The mean age was 14.6 years (range 11.2–18yrs). The mean pre-operative Cobb angle was 65.4 degrees ± 14.8. The mean %PFVC pre-operatively was 33.9 ± 10.4. The mean post-operative %PFVC’s were: 6 months (29.1 ± 10.4), 12 to 18 months (27.6 ± 12.1) and 2 to 3 years (25.4 ± 8.7). Therefore the mean % PFVC following surgery at 6 months, 12 to 18 months and 2 to 3 years decreased from the mean pre-operative % PFVC by 4.8%, 6.3% and 8.5% respectively.

Conclusion: The natural history of patients with DMD is a gradual decline in respiratory function. In the current study the mean post –operative %PFVC was less than the mean pre-operative %PFVC at 6 months, 12 to 18 months and at 2 to 3 years post surgery. Our series would suggest that respiratory function declines post-operatively, even in the short term, in patients with DMD that undergo spinal stabilisation. The decline in respiratory function in our study was progressive over the 3 year follow up period.

T Ember H Noordeen

Background: To assess whether modern instrumentation systems are biomechanically strong enough to allow instrumented fusion to pelvis on the concavity of the major curve only and if this confers a significant advantage with respect to complications rates and disadvantages with respect to correction achieved and fusion rates.

Methods: A retrospective review from the notes and radiographs of blood loss, operation time, complication rates, degree of correction and fusion rates. Comparisons drawn with neuromuscular curves of similar aetiology treated by same surgeon using more traditional two rod fusion techniques. Subjects were high risk children with progressive neuromuscular scoliosis of varying aetiology requiring stabilisation. (7 cases to date) We compared operation times, blood loss, complication rates, degree of correction and fusion rates with standard segmental fusion techniques in a similar cohort of children. Basic statistical analysis only required to compare the two groups (Analysis of Variance (ANOV A) and Chi squared tests)

Results: Mean operation times, blood loss and complication rates of this small cohort were lower than the control group. No implant failure to date with longest follow-up now approaching two years.

Conclusion: We hope to open a debate as to whether there is a place for this more limited fusion technique in an effort to minimise the complication rates in these highly challenging children

H V Dabke A Jones S Ahuja J Howes P R Davies

Background: Campbell et al from Texas have pioneered the use of Vertical Expandable Prosthetic Titanium Rib (VEPTR) in congenital scoliosis. Our centre is the first in the UK to use it and we report our experience of 5 cases done in the past 2 years. VEPTR works on the principle of expansion thoracoplasty and thoracic spinal growth of upto 0.8 cms/year has been reported by the developers of this device.

Methods: This case series includes one child who had the index surgery in America and is undergoing sequential expansion in Cardiff. All surgeries were done using a standard technique with monitoring of somatosensory evoked potentials. After appropriate soft tissue and bony releases, VEPTR was inserted and expanded by 0.5 cms to maintain tissue tension. Subsequent expansions were done as day case surgeries at 4–6 month intervals through a small incision over the VEPTR. We assessed clinical and radiographic assessment, which included – hemithorax height ratio, Cobb angle, interpedicular line ratio, space available for the lung.

Results: There were 3 males and 2 females with mean age of 6.3 years (range 0.9 to 9 years) at the time of index operation. Average follow up is 2 years (0.4 to 5 years). Average hospital stay for the index surgery was 5 days (4–7 days). All patients had mean of 3 expansions (range: 0–6). Mean improvement in the Cobb angle was seen from 48° to 36° at last followup. Space available for lung improved from a mean of 72 % to 86 %. Mean improvement in hemithorax height ratio was from 72.5% to 86%. One child had mild pain due to prominent metalwork; 2 children had transient brachial plexus neurapraxia, one of whom had progression of a secondary cervical curve and is awaiting further surgery for the same.

Conclusion: Our early results show good improvement of clinical and radiographic parameters. Transient nerve palsies have been well reported on the concave side and occur due to traction on the nerves as a result of increased height of the thoracic cage. This occurred in one initial case and has not been seen later. These results are encouraging but do indicate a learning curve.

T Ember H Noordeen S Tucker

Background: To assess the use of subcutaneous rodding with sequential lengthening procedures to control progressive early onset curves not responding to conservative treatment modalities.

Methods: A retrospective study reviewing the notes and plain radiographs of all children with early onset scoliosis treated by growth rod insertion over a seven year period (two paediatric spinal surgeons using similar techniques at two major centres). Subjects were children with early onset scoliosis unresponsive to conservative management. Outcome measures – curves at time of instrumentation, curve progression, number of lengthenings, curve magnitude and age at time of definitive fusion, spinal growth achieved and complications encountered.

Results: Majority of children treated uneventfully with satisfactory control of curvature until age at which definitive fusion acceptable. However our results do suggest a number of cases and circumstances where simple growth rod instrumentation is not sufficient and augmentation with anterior apical fusion is required (will discuss these on an individual basis).

Conclusion: The management of early onset progressive scoliosis by means of growth rod instrumentation and sequential lengthenings is safe and effective.

RG Burwell RK Aujla AA Cole PH Dangerfield BJC Freeman AS Kirby RK Pratt JK Webb A Moulton

Background: In preoperative thoracic (TC) and thoracolumbar (TLC) AIS curves to evaluate periapical rib-vertebra angle asymmetry [1] and rib-spinal angle asymmetry in relation to the spinal deformity and the 4th column support of the spine [2].

Methods: Consecutive preoperative AIS patients having spinal instrumentation and fusion were assessed using radiographs and ultrasonographs. Twenty-eight preoperative patients with AIS were studied (TC 19, apex T8-9 in 15, TLC 9, apex T12 in 2, L1 in 7, mean Cobb angle 51 degrees). In AP radiographs the following were measured by one observer (RGB): Cobb angle (CA), apical vertebral rotation (AVR) and apical vertebral translation (AVT) from the T1-S1 line; in TC at 6 levels about the apical vertebra (3 above, at and 2 below) for each of 1) rib-vertebral angles (RVAs) and difference (RVAD=concave minus convex RVA), 2) rib-spinal angles (RSAs) to the T1-S1 line and difference (RSAD), and 3) vertebral tilt; and in TLC the RVAs, RVADs, RSAs and RSADs of ribs 11 & 12. The ultrasound apical spine-rib rotation difference (SRRD) was obtained as a measure of transverse plane rib deformity. With the subject in a prone position and head supported, readings of laminal rotation (LR) and rib rotation (RR) were made on the back at 12 levels by one of two observers (RKA, ASK) using an Aloka SSD 500 portable ultrasound machine with a veterinary long (172mm) 3.5 MHz linear array transducer. The maximal difference between LR and RR about the curve apex was calculated as the apical spine-minus-rib rotation difference (SRRD).

Results: Thoracic curves. The RVADs (but not the RVAs, RSAs or RSADs) only at 2 & 3 levels above the apex correlate significantly with each of CA (p=0.054), AVR (p=0.047), AVT (p=0.014, after controlling for CA p=0.131) and vertebral tilt (p=0.032) but not SRRD (all two levels above apex). Thoracolumbar curves. The 11th RSAD (but not RVAD or RSAs) correlates significantly with each of AVR (r= −0.776, p=0.014, after controlling for CA p=0.022) and SRRD (r= −0.890, p=0.001, after controlling for CA p=0.003) that together correlate significantly (r=0.672, p=0.048).

Conclusion: In TC supra-apical rib asymmetry (RVAD) in sternally-stabilized [2] and longest levers of the sternal-rib complex is associated with spinal deformity; in TLC supra-apical rib asymmetry (11th RSAD) is associated with transverse plane deformity of each of the apical vertebra (mainly L1) and 12th ribs. These rib associations, probably secondary to the spinal deformity, may involve a primary rib component in the 4th spinal column. The prognostic value of supra-apical RVAD and RSAD for progressive AIS needs to be evaluated.

CJ Goldberg DP Moore EE Fogarty FE Dowling

Background: Scoliosis occurring during the growing years of childhood, while less common, has a greater potential for severe deformity than that with adolescent onset. Treatment is therefore more urgent, and the untreated natural history more difficult to determine. Orthotic treatment and the more recently improved surgical techniques may halt or even reverse the natural history, but the length of time needed for adequate follow-up makes this hard to verify. This report examines the outcome for a historical group of these patients, treated and not, to establish a bench-mark against which results can be measured.

Methods: Retrospective analysis of records derived from the scoliosis database. Subjects were patients presenting with non-congenital scoliosis before the age of ten years and who were at least ten years old when last reviewed. Outcome measures were treatment protocols, the age and incidence of surgery, and the radiological and cosmetic outcome.

Results: 243 children were included, being 38 infantile idiopathic scoliosis (IIS: 20 male, 18 female); 86 juvenile idiopathic scoliosis (JIS: 19 male, 67 female); 119 symdromic scoliosis (Syn:46 male, 71 female) Depending on age, perceived progression potential and individual factors, treatment was either jacket and brace, or observation unless surgery was deemed advisable. In all, 81 children were braced and 162 were not; 129 have had surgery (25 IIS, 48 JIS; 56 Syn.). The individual groups showed no statistical advantage to non-operative treatment in preventing surgery, but in the whole group it appears that a significantly greater proportion (Z=2.7269, p< 0.01) of those braced were subsequently operated. Mean age at surgery was 7.3 years for IIS, 12.97 for JIS and 8.3 for Syn. Recurrence of deformity post-operatively was always observed in those operated before puberty, regardless of the surgical technique.

Conclusion: Ten years of age was taken as the minimum for inclusion, although it is significantly earlier than skeletal maturity, because it has been practice to offer surgery well before this age, and some short term effects may already be apparent by the tenth birthday. This was not a trial of treatment between similar groups, so the appearance of increased surgery in the braced children suggests that, while the clinicians were well able to identify those with a worse prognosis, orthotic treatment was not effective in altering this prognosis. A recently published study1 demonstrated the failure of past surgical techniques to prevent progressive deformity and respiratory compromise in infantile-onset scoliosis. Here it was found that the older the patient at corrective surgery, the better the result, that methods supposed to prevent post-operative recurrence in skeletally immature children failed to do so, and, while non-operative treatment may be effective at least in postponing surgery, even preventing it in some cases, this was not demonstrated statistically. Treatment of spinal deformity in pre-adolescent children warrants debate as a separate subject, and is a more serious problem than that occurring in adolescence.

T Ember H Noordeen

Background: To quantify the distraction forces required to lengthen a standard subcutaneous domino linked two rod construct. This was a seminal piece of work as part of a project to design a magnetic coil driven micro electromechanical internal device that would mitigate the need for surgical lengthenings of these growth rod constructs.

Methods: A distraction tool with strain gauge was designed and built in the RNOH Department of Biomechanics and following calibration and testing was used to perform five distraction procedures. Subjects were five patients with early onset progressive scoliosis unresponsive to conservative treatment modalities who have previously had a subcutaneous rodding procedure and are hence having regular lengthenings. Forces were transduced and collected on a laptop computer in theatre running a piece of software specifically written for the experiment.

Results: Forces will be displayed in graphical format with correlation with pre- and post-lengthening radiographs.

Conclusion: The magnitude of force required to achieve distraction is compatible with that achievable via a magnetic coil driven internal micro electromechanical device that we are currently in the design phase of producing.

H Al-Hussainy N Chiverton DL Douglas AA Cole

Background: It is generally accepted that surgical correction in adolescent idiopathic scoliosis (AIS) is largely for cosmesis. Scoliometer measurements of back surface asymmetry and rasterstereographic methods are used to attempt to quantify the surface deformity, These methods are also used to determine the ‘success’ of surgery. This study objectively evaluates trunk cosmesis from pre-operative photographs.

Methods: This is a prospective cohort study. Twelve pre-operative girls with thoracic AIS had standard photographs taken in the standing and forward bending positions. The mean Cobb angle is 74°, mean age 13.7 years. Twenty observers were selected by their profession (3 Spinal Consultants, 4 Orthopaedic Specialist Registrars, 4 nurses, 4 medical illustrators and 5 lay-people). Each patient’s photographs were arranged on a single sheet and the observer was asked to arrange the patients in order of cosmesis and having done this to give a score between 0 (best) and 100 (worst) for overall cosmesis.

Results: There was no good agreement either in the ranking or the scoring for any of the groups of observers. Some observers agreed quite well whilst others ranked and scored much differently to the ‘mean’.

Conclusion: Cosmesis is a spectrum and is most definitely in the eye of the beholder with wide disagreement between individuals both for ranking and scoring cosmesis. We must identify the components of trunk cosmesis (for the majority of observers) so that we can quantify these and produce a score to reflect what we are trying to treat. Only then will we be able to assess the results of our treatments.

RG Burwell RK Aujla PH Dangerfield BJC Freeman AS Kirby JK Webb A Moulton

Background: In lumbar scoliosis curves of school screening referrals were evaluated (1) for the possible relation of pathomechanisms to standard and non-standard vertebral rotation (NSVR) [1], and (2) the relation between apical lumbar axial vertebral rotation and the frontal plane spinal offset angle (FPTA) [2].

Methods: Consecutive patients referred to hospital during routine school screening using the Scoliometer were examined in 1996–9. None had surgery for their scoliosis. There are 40 subjects with either pelvic tilt scoliosis (11), idiopathic lumbar scoliosis (19), or double curves (10)(girls 31, postmenarcheal 25, boys 9, mean age 15.3 years). One observer (RGB) measured: 1) in AP spinal radiographs Cobb angles (CAs), apical vertebral rotations (Perdriolle AVRs), and trigonometrically sacral alar tilt angle (SATA), and FPTA as the tilt of the T1–S1 line to the vertical; and 2) total leg lengths (tape).

Results: Excluding the double curves there are 16 left and 14 right lumbar curves mean CA 11 degrees (range 4–24 degrees), mean AVR 9 degrees (concordant to CA in 18/30, discordant in 7/30), SATA 2.8 degrees (range 0.2–7.7 degrees associated with CA side and severity, p=0.0003), and leg-length inequality 0.7 cm (significantly shorter on left, p< 0.0001 and associated with SATA (p=0.02) but not CA). Neither CA nor AVR in each of the laterality concordant and discordant lumbar or thoracic curves is significantly different. Twenty-six subjects have thoracic curves (16 right) 22 with AVR (mean CA 11 degrees, range 4–17 degrees, AVR 9 degrees, n=22) the CA being associated with each of lumbar CA and SATA (respectively p< 0.0001, p=0.003, n=26). Thoracic curve laterality of CA and AVR is concordant in 12/26 curves and discordant in 10/26 and for concordance/discordance neither is significantly different; thoracic AVR sides with laterality of lumbar curve AVR shown by thoracic AVR (but not CA) being greater in lumbar discordant than in lumbar concordant curves (14 & 7 degrees respectively, p=0.03, n=18 & 7). Both for lumbar curves alone and for lumbar with double curves, AVR by side is significantly associated with FPTA by side (r= −0.568, p=0.001, n=30; r=−0.560, p=0.0002, n=40).

Conclusion: (1) It is hypothesized that different pathomechanisms may separately affect the frontal (CA) and transverse (AVR) planes: in discordant curves these mechanisms may neutralize each other and limit curve progression; concordant curves require these biplanar mechanisms to summate and facilitate curve progression. (2) The association of frontal plane spinal tilt angle and lumbar AVR may result from balance mechanisms affecting trunk muscles – mechanisms that may underlie the complication of post-operative frontal plane spinal imbalance or decompensation [2].

AA Cole RG Burwell JK Webb

Background: The study evaluates the inter-relationships between Cobb angle (CA), apical vertebral rotation (AVR), apical vertebral translation (AVT) and maximal angle of trunk inclination (max ATI). The effects of sex, curve laterality, curve type and apical levels will be studied

Methods: This is a study of consecutive pre-operative AIS patients. There are 122 pre-operative AIS patients (106 thoracic, 16 thoracolumbar), with a mean age of 15.6 years. From the pre-operative AP radiograph, CA, AVR (Perdriolle) and AVT are measured. The max ATI is measured using the Scoliometer with the patient in a standing forward bending position. Ratios between the measurements are calculated to allow comparison between different curve types and curves at different apical levels.

Results: For a given Cobb angle, each of AVR, AVT and max ATI are largest in King type IV curves, less in King type III curves and smallest in King type II curves (p=0.001 to 0.015). For curves without a significant compensatory curve, for a given AVR, the max ATI reduces significantly as the curve apex passes caudally (p=0.002 to 0.019). Sex and curve laterality are not significant factors.

Conclusion: It is suggested that as a curve develops, the interaction between the measurements in different planes may be responsible for determining the curve type (presence or absence of a compensatory curve). The smaller surface hump as the curve apex passes caudally is probably due to the transition from fixed ribs to floating ribs to no ribs. These finding also have implications for surgery. In King type IV and III curves, the emphasis should be on correcting translation and derotation perhaps with a primary costoplasty whilst in King type II curves, the emphasis should be on the correct selection of fusion levels and achieving a balanced spine.

P H Dangerfield R.C. Davey N Chockalingam T Cochrane J C Dorgan

Background: To compare height-adjusted fat and fat-free mass components of body composition in girls with adolescent idiopathic scoliosis to young adolescents with eating disorders. Adolescent idiopathic scoliosis (AIS) has been linked with low bone densities. Animal and human studies have shown that bone densities are influenced by a wide variety of inter-related factors that includes body fat, oestrogen levels, nutritional status and energy balance. Anthropometric studies have reported girls with AIS as being taller and more slender than their age-matched peers and that they also exhibit complex patterns of body asymmetry, particularly in the upper limb. There are also some studies report eating disorders in this population.

Methods: Height-adjusted fat and fat-free mass components of body composition were examined. Fat mass index (FMI) and fat-free mass index (FFMI) were calculated and normalised for height and were superimposed onto UK 1990 growth reference data. The data for left and right limb length was also compared. A sample of 325 girls with AIS referred to the specialist spinal unit in Liverpool during the period 1970–1990.

Results: The fat mass index and fat-free mass index were reduced in this sample of AIS subjects compared with normal reference children, but were similar to those diagnosed with eating disorders (anorexia nervosa). The cohort also exhibited significant upper limb asymmetry.

Conclusion: The findings suggest that this population has significantly low fat mass compared to normal, healthy reference values. Since fat mass reflects energy balance, nutritional status (possibly eating disorders) and is closely linked to endocrine function, the implications of reduced fat mass on growth, bone mass accretion and the aetiology of AIS merit further investigation.

S.C. Daivajna C.I. Adams S.M.H. Mehdian

Background: To analyse the effects of surgery on sagittal alignment1 in patients with severe Scheuermann’s kyphosis. To assess the ability of two surgical techniques to prevent loss of correction in the thoracic kyphosis. To assess factors of patient’s Body Mass Index (BMI) and instrumentation level on the risk of adjacent level kyphosis or pullout.

Methods: A retrospective study of 13 consecutive cases of rigid Scheuermann’s kyphosis. Group A: 6 patients with anterior interbody cages. GroupB: 7 patients with interbody autogenous rib graft. All patients were instrumented posteriorly from T2 to L2. Radiographs from initial presentation, pre-operatively, post-operatively and at final follow –up were assessed. The thoracic kyphosis, lumbar lordosis, sagittal balance2 and sacral inclination were measured.

Results: There were 7 males and 6 females with a mean age of 22 years (range 15 to 38yrs). The mean follow-up was 26 months (range 7 to 53 mths). In Group A: the mean preoperative kyphosis was 87° (range 82° to 92° ) and postoperative kyphosis was 45° (range 38° to 60°). The mean loss of correction was 0.3° (range 0° to2°). In Group B: the mean preoperative kyphosis was 83° (range 70° to 100°) while the postoperative kyphosis was 43° (range 30° to 60°). The mean loss of correction was 1.1° (range 0°to 2°) at final follow-up. The mean lumbar lordosis pre-operatively for all patients was 66° (range 62° to 84°) reducing to 48° (range 34° to 82°) following surgery. The mean sacral inclination pre-operatively was 41° (range 18° to 80°) reducing to 32 °(range 14°to 40°) following surgery. The mean sagittal balance preoperatively was −1.1 cm (range +0.1 to −3.5). It reduced postoperatively to −2.2 cm (range +1.5 to −4 cm) and was −1.6cm (range +0.2 to – 3.5cm) at final follow- up. Three patients with BMI greater than 25 had an increased lumbar lordosis at final follow up, with one case of implant failure and 2 cases with lower junctional kyphosis. No patient had an upper thoracic junctional kyphosis. There was no evidence of neurological compromise.

Conclusion: Patients had a mean thoracic kyphosis correction of 41° (49%). This was maintained during follow-up with no significant difference between autograft and cages. Cranially, all patients had instrumentation to T2 and there was no junctional kyphosis. Caudally, three obese patients (BMI > 25) suffered screw pullout (1 patient) or junctional kyphosis (2 patients). Instrumentation to L3 may avoid this complication in this patient group. The lumbar lordosis and sacral inclination reduced immediately postoperatively, with further correction at final follow –up.

J. Bernard S. Molloy P. Hamilton A. Saifuddin

Background: The incidence of neurological symptoms due to spinal stenosis in patients with achondroplasia is reported to be as great as 38%1. These symptoms most commonly occur in the 4th decade and myelography and CT myelography are most commonly described in evaluation of the stenosis. Difficulty arises in localisation of stenosis in patients presenting with neurological deficit2. The value of MRI of the cervicomedullary junction has been reported in achondroplasia but it has not yet been evaluated in the investigation of spinal stenotic symptoms. The aim of this study was to review our experience of whole spine imaging in patients with achondroplasia that presented with symptoms and signs of neurological deficit.

Methods: We retrospectively reviewed the clinical notes and radiological imaging of 10 consecutive achondroplastic patients (3F:7M, mean age 31.7 years, range 13 to 60yrs) that presented to our unit with neurological compromise between 1998 and 2003. All patients had whole spine MRI at the time of presentation. Recorded from the notes were age and sex, and whether symptom pattern was radiculopathy, claudication or paresis. All radiological levels of stenosis on MRI were documented.

Results: Four patients presented with spinal paresis, four with neurogenic claudication, and two with radiculopathy. MRI confirmed that each patient had at least one region (cervical, thoracic or lumbar) of significant spinal stenosis. In six of the patients an additional region of significant stenosis was identified. All ten patients had lumbar stenosis but this was only the primary site in six of the ten. In the other four patients two had the dominant stenosis in the thoracic spine, one in the cervical spine and one at the foramen magnum – the clinical symptoms correlated with the dominant site in each of these four cases.

Conclusion: MRI was a useful tool for assessment of neurological compromise in the patients with achondroplasia in our study. All ten patients had classical lumbar stenosis on MRI but this was only the dominant site of stenosis in six of the ten cases. The MRI and clinical findings need to be evaluated together to ensure correct surgical treatment.

A.I. Tsirikos M.J. McMaster

Background: Congenital anomalies of the chest wall and Sprengel’s shoulder are often associated with congenital deformities of the spine. It has been suggested that extensive rib fusions on the concavity of a congenital scoliosis may adversely affect progression of the spine deformity, thoracic function and growth of the lungs, which can lead to a thoracic insufficiency syndrome.

Methods: This is a retrospective study of the medical records and spine radiographs of 620 consecutive patients with congenital spine deformities. The rib anomalies were classified into simple and complex and the presence of a Sprengel’s shoulder was recorded.

Subjects: There were 497 patients (80%) with scoliosis, 88 patients (14%) with kyphoscoliosis, and 35 patients with kyphosis (6%). The mean rate of scoliosis deterioration without treatment, age and curve size at surgery was compared for the different types of vertebral abnormalities in patients with and without rib anomalies.

Results: Rib anomalies occurred in 124 patients. The rib anomalies were simple in 97 patients (78%) and complex in 27 (22%). The most common simple rib anomaly (70 patients; 72%) was a fusion of two or three ribs. The most common complex rib anomaly (20 patients; 74%) was a fusion of multiple ribs associated with a large chest wall defect. Rib anomalies were most commonly associated with a congenital scoliosis (116 patients; 93.6%), and much less frequently with a congenital kyphoscoliosis or kyphosis (8 patients). In those patients with a scoliosis, the rib anomalies were simple in 91 patients (78.5%) and complex in 25 patients (21.5%). Eighty-eight of the 124 patients (76%) with rib abnormalities had a scoliosis due to a unilateral unsegmented bar with or without contra-lateral hemivertebrae at the same level, and 8 patients had mixed unclassifiable vertebral anomalies. In contrast, only 17 patients with a scoliosis and rib anomalies had hemivertebrae alone. The rib anomalies were most frequently associated with a thoracic or thoracolumbar scoliosis (107 patients; 92.2%) and occurred on the concavity in 81 patients (70%), convexity in 27 patients (23%), and were bilateral in 8 patients. Sprengel’s deformity occurred in 45 patients; 43 patients with congenital scoliosis (8.6%), and 2 with kyphoscoliosis or kyphosis. A Sprengel’s shoulder occurred most frequently in association with a thoracic scoliosis due to a unilateral failure of vertebral segmentation (28 patients). The elevated shoulder was on the concavity of scoliosis in 26 patients and on the convexity in 16 patients. We compared the mean rate of curve progression without treatment, the age and curve size at spine surgery for the different types of spine deformities in patients with and without rib anomalies either simple or complex and found no significant difference (p> 0.05); the only statistical difference was that the mean age at surgery was higher for patients with a unilateral unsegmented bar without rib anomalies (p=0.005).

Conclusion: Congenital rib anomalies and Sprengel’s shoulder occur most commonly on the concavity of a thoracic or thoracolumbar congenital scoliosis due to a unilateral failure of vertebral segmentation. However, these anomalies do not have an adverse effect on curve size or rate of progression.

A Ohlin

Background: Patients with adolescent idiopathic scoliosis (AIS) exceeding fifty degrees or more at maturity are at risk for continuous progression. For curves in the thoracolumbar or lumbar region vertebral olisthesis, with severe low back pain with or without radicular pain, may result. Conventional techniques with anterior, posterior or combined approaches often fail to achieve a good alignment. The technique described by Bradford employing a shortening osteotomy at the apical segments can be used in very stiff curves with translations.

Methods: Three women with AIS and successive curve deterioration were treated by means of shortening osteotomy at our institution. The mean age was 40 (48–35) years and the follow up was 26 (60–8) months. The resected vertebrae were L1 in two cases and L2 in one. The operations were staged, initially anterior discectomies were performed. A flap of the vertebral wall was then raised and a total resection of the vertebral body and the convex pedicle was undertaken. After protection of the dual sac with a Spongostan film, the harvested bone was impacted into the defect. One week later, the remnants of the vertebra were removed posteriorly following temporary stabilization. Correction was achieved by compression.

Results: Two osteotomies united and the patients are pain free, in good balance and back at work. The other case had a temporary partial drop foot on one side, however radiographically is progressing well and she remains in rehabilitation. There have been no implant related complications.

Conclusion: Shortening osteotomy appears to be a good technique when treating adult patients with late rigid, painful scoliotic deformities of the thoracolumbar region.

M Al-Maiyah J Mehta D Fender M J Gibson

Background: To evaluate bone mineral density in patients with scoliosis of different causes and compare it to the expected values for the age, gender and body mass.

Methods: A Prospective, observational case series. From October 2003 to December 2004, Bone Mineral Density (BMD) of patients with different types of Scoliosis was recorded. Patients listed for corrective spinal surgery in our institute were included in the study (Total of 68 patients). BMD on lumbar spine and whole body was measured by DXA scan and recorded in form of Z-scores. Z-scores = number of Standard Deviations (SD) above or below age matched norms; it is age and gender specific standard deviation scores. Data collected using the same DXA scan equipment and software.

There were 29 patients with Adolescent Idiopathic Scoliosis and 7 patients with congenital or infantile scoliosis. Z-scores from patients with neuromuscular scoliosis also included, 10 patients with cerebral palsy and 11 with muscular dystrophies (mainly Duchenne MD). There were also 3 patients with Neurofbromatosis and 8 patients with other conditions (miscellaneous). Outcome measures were bone mineral density in patients with different types of scoliosis in form of Z-scores.

Results: Bone mineral density was significantly lower than normal for the age, gender and body mass in all patients with neuromuscular scoliosis; whole body z-score in group with cerebral palsy was −1.00 and −1.30 in muscular dystrophies group. Lumbar spine BMD was even lower in lumbar spine, mean z-score, – 4.51 in cerebral palsy and −2.36 in muscular dystrophies (mainly Duchenne MD). In idiopathic Scoliosis group mean BMD was markedly lower than normal for the age, gender and body mass, mean z-score = – 1.87, however whole body BMD was within the normal range, mean z-score = +0.124. Similar results were found in congenital and infantile scoliosis group, mean lumber z-score= – 1.36 and whole body z-score, – 0.30. In patients with neurofibromatosis, there were low BMD on spine, mean z-score was −1.19 while whole body z-score was + 0.19. In group of patients with other miscellaneous causes of scoliosis or syndromic scoliosis lumbar mean z-score= −2.22 and whole body mean z-score was −1.67.

Conclusion: This study showed that BMD on spine was lower than normal for the age, gender and body mass in all patients with scoliosis and the condition was even worse in neuromuscular and sydromic scoliosis. There was no correlation between spine BMD and whole body BMD. Spine BMD was lower than normal in almost all patients even when whole body BMD was within normal range. Thus we believe that DXA scan is a useful adjunct in the preoperative assessment of scoliotic patients prior to spinal surgery.

D Chan

Background: We report on the surgical treatment of a case spinal neuroarthropathy, where surgical fusion of the pathological level was achieved by a shortening osteotomy and apposition of the adjacent vertebral bodies. Neuropathic (Charcot) arthropathy of the spine is relatively an uncommon problem. Spinal neuroarthropathy has been described to occur after traumatic paralysis as well as other causes of neuropathic arthropathy. Surgery has been recommended for the treatment of painful or unstable neuropathic joints of the spine. From the few cases that have been reported in the literature, surgical management included extensive debridement, bridging of the defect with autogenous graft as well as instrumentation to achieve an anterior and posterior fusion. To the knowledge of the authors, the technique of spine shortening and vertebral apposition was reported only once in the literature, however the patient had to be kept recumbent in a cast for six months. (1)

Methods: Literature review and a case of spinal neuroarthropathy successfully treated by a shortening osteotomy and instrumented arthrodesis is presented.

Results: Patient was allowed to mobilize in his wheelchair by the second week post operation with a support of a TLSO, which was used for five months. Roentgenograms and CT scan done at thirteen months showed good position of the spine and evidence of solid bone arthrodesis. This matched marked clinical improvement in the preoperative symptoms.

Conclusion: Treatment of a Charcot affection of the spine should be directed toward vertebral stabilization to eliminate the pathological effects and complications secondary to instability. Sound arthrodesis in our case could be achieved with resection of the affected level(s), shortening of the spine and good apposition of fresh bleeding bone surfaces. Careful attention to the demanding surgical technique is required. Yet, any fusion procedure poses additional stresses to the adjacent levels. So long term monitoring of the rehabilitation is mandatory to detect the possibility of developing secondary levels of Charcot joints below a previously successful fusion.

S.C. Daivajna A. Jones S.M.H. Mehdian

Background: A 9- year-old child with osteogenesis imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. There is no report of upper cervical kyphosis associated with wedged vertebrae in osteogenesis imperfecta in the literature. We discuss the methods and difficulties in the surgical management of this condition and to highlight the appropriate surgical approach.

Methods: Methods:A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years she underwent posterior cervical fusion (C1–C6) for instability and deformity. Radiological and laboratory investigations confirmed the diagnosis of osteogenesis imperfecta. Radiographs of the cervical spine revealed a kyphotic deformity of 120° Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scans showed anterior cord compression due to wedged vertebrae at C3 and C4. MRI-Angiography was performed pre-operatively to identify the anatomical position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed. Anterior C3 and C4 corpectomies with interbody fusion with cage and plate fixation was carried out.

Results: Postoperatively the patient made a full neurological recovery and significant correction of the deformity was achieved and correction was maintained at final follow-up.

Conclusion: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine with severe kyphosis is a challenging problem. Which surgical approach should be used is controversial? There are difficulties exposing wedged vertebrae by a standard anterior or chin split approach to perform vertebrectomy. Costo-transversectomy has been used successfully in patients with Gibbous deformity in the thoracic spine but due the presence of vertebral artery in the cervical spine posterolateral approach is impossible. We have used a modified anterolateral approach to overcome this problem. Spinal stabilisation in children with Osteogenesis Imperfecta and poor bone quality is another challenge. We have used a small diameter MOSS cage with maxillofacial plate and screws to achieve stabilisation and fusion. The purpose of this report is to highlight the importance of diagnosis of progressive cervical kyphotic deformity in children with osteogenesis imperfecta and also to describe the difficulties encountered with surgical management of this condition.

A Jackowski

Background: A novel, elastomeric total cervical disc replacement is currently undergoing clinical evaluation in an MHRA approved Multicentre European study. At the time of abstract submission seven patients have been implanted with the device. The device is a two component one consisting of an inner core of medical grade silastic enveloped in an outer jacket of embroidered polyester that replicates the annulus, posterior and anterior longitudinal ligaments.

Methods: The pre-clinical testing of the device included biomechanical, biocompatibility and mechanical fatigue testing have previously been reported at the 2002 Spine Arthroplasty Society meeting in Montpellier. At the time of abstract submission seven patients have been implanted with the device. The clinical trial is a prospective, non-randomized observational study. Patients are followed for a period of two years. VAS pain scores, SF36, NDI and European myelopathy scores, patient satisfaction and detailed radiographic assessments are collected preoperatively, at 4 weeks, 3 months, 6 months, 1 and 2 years postoperatively.

Results: Seven patients (2 female, 5 male) have been implanted at the time of abstract submission. All cases were single level surgeries (C3/C4-1, C5/C6-2, C6/C7-4). Operation time ranged from 55-104 minutes. Blood loss averaged less than 15mls. The NeoDisc implant is very straightforward to implant with no special instrumentation. The lack of any metal components has allowed postoperative MRI and CT scanning to be performed with virtually no artefact present and excellent visualisation of cord and root detail. All patients reported pain intensity reductions. Pain decreased from 4.6 to 1.4 for neck pain and from 6.5 to 0.9 for arm pain on a 10-point scale.

Conclusion: A clinical success rate of 83% was achieved (clinical success being defined as a patient rating of excellent or very good on a 6-point patient self-scoring outcome scale).

J Chitnis H V Dabke DAS Jones S Ahuja J Howes P R Davies

Background: Although either anterior or posterior corrective scoliosis surgery has been reported in Jehovah’s Witnesses, we did not find any reports of single stage combined anterior and posterior scoliosis surgery being done in these patients. We report our experience in one such case.

Methods: This is a case report of a 14 year old female Jehovah’s Witness who had cerebral palsy with total body involvement presented with right sided thoracolumbar scoliosis. She was wheel chair bound and was being treated in a spinal brace. She had a partially correctible thoracolumbar curve from T5 to L2 measuring 94°, which reduced to 74° in brace. Her parents were counselled regarding scoliosis surgery. They consented for the surgery and also signed a special consent form for Jehovah’s witnesses specifying that they would prefer their child not to have transfusion of blood or blood products under any circumstances. They were explained that in case of excessive bleeding, further surgery may need to be deferred.

Results: Although her pre-op Haemoglobin was 14.3 g/dl, she was given oral ferrous sulphate because of low serum ferritin level (34 mcg/L). After induction of anaesthesia, intra operative hemodilution was performed using 900 ml of crystalloid. During surgery aprotinin infusion was used with controlled hypotension and cell salvage. Anterior release was performed followed by posterior instrumentation. The operation lasted for 8 hours. Central venous pressure and arterial oxygen saturation remained stable throughout the operation. She recovered well following surgery, with post-operative haemoglobin of 9.8 g/dl and was discharged on the7th post-operative day. Oral iron supplementation has been continued after surgery.

Conclusion: Due to religious reasons, Jehovah’s Witnesses do not accept transfusion of blood and blood products, which makes major surgery like scoliosis correction difficult as it involves a significant amount of blood loss. Such patients benefit from pre-operative iron supplementation, pre-operative haemodilution, intraoperative hemodilution, cell salvage, use of Factor 7, aprotinin and erythropoietin. These modalities have made it possible to perform major operations like scoliosis surgery in this group of patients.

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D Williams L Lougher A Mukherji S Ahuja

Background: There has been an exponential rise in Internet use over recent years with over 11 million homes in the United Kingdom currently having access to the Internet. Previous studies have shown that up to 50% of orthopaedic outpatients have researched their condition on the Internet and that this percentage is dependent upon the condition from which they are suffering. The aim of our study was therefore to assess the prevalence of Internet usage among three groups of orthopaedic outpatients and to further determine how the patients felt their Internet research compared to the information received at consultation.

Methods: Data was collected from 150 patients / parents attending three outpatient clinics; 50 consecutive patients attending scoliosis clinic; 50 patients attending paediatric orthopaedic clinic; 50 patients attending back pain clinic.

Results: 58% of scoliosis, 22% of general paediatric and 30% of back pain patients had researched their condition on the Internet. 83% of scoliosis, 64% of paediatric and 80% of back pain patients found this information useful. Nearly all patients, however, would trust their doctor more than the Internet.

Conclusion: We believe therefore that clinicians need to keep up to date with information available on the Inter-net and provide recommended websites to patients wishing to consolidate their knowledge of their condition.

T. Williams D. Williams S. Ahuja A. Jones J. Howes P. Davies

Background: More patients are turning to the Internet for health-related information. Studies indicate that this information is being used to make decisions about their management. The aim of this study was to assess the information available specific to scoliosis on the Web using four common search engines.

Methods: Four search engines (Google, Yahoo, Hotmail and Ask Jeeves) were used in scanning the Web for the following key word- “Scoliosis”. Both U.K. only and World Wide sites were accessed. Four Spinal Surgery Consultants independently graded each site for layout, content, relevance to patients as opposed to medical professionals, ease of use and links to other sites. Each point was marked on a scale of 0–2 and a total of 10 points available. Web sites were assessed via U.K. search engines and forty via World Wide search engines. Good was awarded to a site with a score of 7–10; an average awarded for a score of 4–7 and poor was given to a site with a score of 0–4.

Results: For the U.K. search engines, twenty sites were evaluated and five common sites identified (spineuniverse.com, S.A.U.K.org, orthoteers.co.uk, B.O.A.ac. uk and scoilosis.info). From these sites only two were given a rating of good. For the World Wide Web search engines eighteen sites evaluated and seven common sites identified (SRS, spineuniverse.com, scoliosis.org, orthinfo.aaos.org, iscoliosis.com, scoliosisrx.com and scoliosis-world.com). From these sites four were given a rating of good. It was evident that the Scoliosis Association of United Kingdom did not appear in three of the search engines but only in Hotmail.

Conclusion: These results suggest that there are good sites available for patients to access information with regards to their condition and treatment options but there are also very poor sites available where incorrect information is available. Commonly, unfamiliar users of the Web will not search U.K. sites specifically and could easily miss the S.A.U.K. site, which is an excellent site and was one of the two sites via the U.K. search engine awarded a good score. Obviously, there were more good sites via the World Wide Web due to the American healthcare system. We recommend that leaflets should be available to parents and patients with scoliosis with information from the BSS of the condition and available Web sites with good ratings. Also we recommend that these sites be linked to the Royal College of General Practitioners Web site to provide reference on good practice.

S. Molloy J. Langdon R. Harrison B. A. Taylor

Background: Sacral tumours are commonly diagnosed late and therefore are often large and at an advanced stage before treatment is instituted. The late presentation means that curative surgical excision is technically demanding1. Total en-bloc sacrectomy is fraught with potential complications: deep infection, substantial blood loss, large bone and soft tissue defects, bladder, bowel and sexual dysfunction, spinal-pelvic non-union, and gait disturbance2. The aim of the current study was two-fold: firstly to detail the technique used by the senior author and chronicle how this has evolved; and secondly to present the complications and outcome of nine total en bloc sacrectomies.

Methods: We retrospectively analysed of total en-bloc sacrectomies between 1991 and 2004. Nine patients (2M, 7F, mean age at surgery 39 years, range 21 – 64yrs) with a diagnosis of primary sacral tumour underwent total en-bloc sacrectomy under the care of the senior author. The mean follow-up was 50.2 months (range: 3.5 – 161 mths). Patients’ functional outcome was evaluated using the Functional Independence Measure (FIM) instrument and the SF-36. Intra-operative and postoperative complications (including disease progression) were documented.

Results: Surgical technique has evolved from single stage surgery without and with colostomy to two stage surgery with colostomy. Currently, the first stage includes an anterior lumbar interbody fusion at L4/L5 retaining the L5 nerve roots. In the second stage an L4 to pelvic fusion is performed posteriorally. The dura is tied and divided just below the L5 roots. The mean total operating time was 13.3 hrs (range: 8 – 20.1hrs); the mean total blood loss 14.1 ltrs (range: 4.2 – 33 ltrs). There were two revision L4 to pelvic fusions for pseudoarthroses. The mean length of hospital stay was 8.9mths (range: 2 – 36mths). One patient had a recurrence and died 2 years after her surgery. Of the surviving 8 patients the results from the functional outcome scores were variable. Three patients are able to walk independently; the remaining 5 are all mobile but require differing degrees of assistance to walk.

Conclusion: Total en bloc sacrectomy is a major surgical undertaking but our series has shown that it is probably justified in view of the fact that 8 out of 9 patients have had no tumour recurrence and all are able to walk.

J Yu

Background: The intervertebral disc has a highly organised collagen network (1) which has an important role in regulating the mechanical properties of the tissue. A recent study of bovine discs has also revealed an abundant and organised elastic fibre network (2) indicating that elastic fibres could play an important mechanical role. The aim of this study was to describe changes in organisation of the collagen and elastin fibre networks in scoliotic relative to normal discs.

Methods: Intact wedges of intervertebral disc were obtained from patients undergoing routine spinal surgery where the disc was removed by an anterior approach. Frozen sections were cut and examined as described in detail elsewhere (2). Briefly, they were digested with hyaluronidase to remove glycosaminoglycans. Micrographs of the sections were examined by polarised light to visualise collagen organisation. The elastic fibre network was visualised by histochemical staining with orcein or immunohistochemically. We examined 9 discs from 6 scoliotic patients (12–22y), ranging in level from T1 0/11 to L4/L5; three had adolescent idiopathic scoliosis and three neuromuscular scoliosis. We also examined 4 discs from a 12 year old female patient with a spinal tumour not affecting the discs, and 2 discs from a 17 year female patient who had discs removed as the result of trauma.

Results: The ‘control’ discs showed a highly organised collagen network arranged in regular lamellae as described previously (1). A highly organised elastic fibre network, similar to that described in bovine discs (2) was also revealed in the ‘control’ human discs. Dense elastic fibres were located between adjacent lamellae of the annulus. Elastic fibres appeared to be long (> 100μm) and straight in outer annulus and were at angle of approximately 600 or 1200 to those in adjacent lamellae in the inner annulus. Elastic fibre bridges crossing the lamellae perpendicularly or obliquely were observed. In scoliotic discs however, the organisation of the collagen network was grossly disturbed with marked loss of lamellar structure. Elastic fibres were very sparse and the elastic fibre networks were highly disorganised in all regions. Cell clusters, typical of disc degeneration, were seen in scoliotic but not in age-matched ‘control’ discs.

Conclusion: Our results reveal an abundant and organised network of elastic fibres in the young (12–17yr) human intervertebral disc. The localisation of these fibres in the inter-lamellar space suggests that the elastic fibre network plays a significant biomechanical role. This network is sparse and disrupted in scoliotic discs; loss of network integrity could affect disc biomechanical function adversely and could be involved in the progression of the spinal deformity.

P Katrana JR Crawford S Vowler A Lilikakis RN Villar

Aims: Resurfacing arthroplasty of the hip is increasing in popularity. Recently concerns have been raised about resorbtion of the femoral neck after hip resurfacing, which may increase the risk of femoral neck fracture. We conducted a study to assess the degree of femoral neck resorbtion after using a cemented femoral component at hip resurfacing arthroplasty and to compare this with an uncemented femoral component.

Patients and Methods: We included 130 patients who had undergone a hip resurfacing arthroplasty in our study. Our uncemented group included 70 consecutive patients who had received an uncemented Cormet hip resurfacing arthroplasty (Corin, Cirencester, UK). Our cemented group included 60 patients who had received a cemented Birmingham hip resurfacing arthroplasty (Smith and Nephew, Cambridge, UK). All patients were regularly followed up for a minimum of two years. Clinical outcome was assessed using Harris hip scores. Femoral neck resorbtion was assessed by measuring the cup-neck ratio on post-operative radiographs by two independent observers.

Results: The mean age of the patients was 50.7 years for the cemented resurfacing group and 51.5 years for the uncemented resurfacing group. No difference was found in Harris hip scores between the two groups at any of the follow-up periods. The overall survival rate at two years was 100% for the cemented group and 98.6% for the uncemented group. There was however, a significant increase in femoral neck resorbtion for the cemented resurfacing group compared to the uncemented resurfacing group (median cup-neck ratio 1.11 vs. 1.04), p< 0.0001

Conclusion: We found a significant increase in femoral neck resorbtion with the use of a cemented femoral component at hip resurfacing arthroplasty compared with an uncemented femoral component. This may increase the risk of femoral neck fracture and could affect the long-term outcome if a cemented femoral component is used.

MHA Malik BM Wroblewski PR Kay

Introduction: We describe the association between postoperative femoral stem radiological appearances and aseptic failure of THA (total hip arthroplasty).

Methods: A retrospective review of records and radiographs of all patients attending for follow-up between August 2002 and August 2003 who had a cemented Charnley femoral stem and either a cemented polyethylene acetabular cup inserted. Femoral stem aseptic loosening was defined either by findings at revision surgery, the definite radiographic loosening criteria of Harris or progressive endosteal cavitation across zones as described by Gruen. Well-fixed control THA’s were defined as those that demonstrated none of the radiographic features of aseptic loosening or ‘at risk’ signs as described by Wroblewski. Parameters measured were: Alignment, Barrack grade of cementation, cement mantle width of the cement mantle and the presence and width of any radiolucent lines

Results: 63 hips were entered into the aseptic failure group and 138 into the control group. The alignment of the femoral stem was not associated with failure (p=0.283). Thickness of the cement mantle was statistically associated with failure in Gruen zones 6 (p=0.040) and Gruen zone 7 (p=0.003). A significant association for the presence of radiolucent lines was found for Gruen zones 3 (p=0.0001) and 5 (p=0.0001). The grade of cementation as measured by the Barrack grade was strongly associated with failure for grades C (p=0.001) and D (p=0.001).

Discussion and conclusion: This study has demonstrated that easily applied radiological criteria can be used to identify ‘at risk’ Charnley THA’s from the immediate post-operative AP radiograph.

Professor BM Wroblewski PD Siney PA Fleming

Triple-tapered cemented polished C-Stem has evolved from the study of long-term results of the Charnley low-frictional torque arthroplasty when the first fractured stem and then proximal strain shielding of the femur and stem loosening were identified as the continuation of the same process: lack or loss of proximal stem support.

The C-Stem, by the concept, design and the surgical technique, caters for a limited slip of the stem within the cement mantle transferring the load more proximally. With a follow-up past 10 years and 3299 primary procedures there have been no revisions for aseptic stem loosening and no stem is radiologically loose.

Four hundred and forty eight patients had 500 LFAs using the C-Stem with the longest follow-up: 256 women and 192 men; 52 patients had bilateral LFAs. The patients’ mean age at surgery was 55.5 years (range 17–89 years) and at a mean follow-up of 5.2 years.

There was an overall improvement in the clinical outcome graded according to d’Aubigne and Postel for pain, function and movement from 3.1, 2.9 and 2.8 to 5.9, 5.7 and 5.5 respectively.

A good quality proximal femur had been maintained in 56.8% and improved in 21.8%.

The results are encouraging and support the concept but place a demand on the understanding of the technique and its execution at surgery.

SM Hussain K Barnett DF Finlayson

Total hip replacement using components from different manufactures is common and has been known as cross-breed arthroplasty. The implant industry clearly advises against it for primary arthroplasty, even though this has been the accepted practice in revision hip surgery. The response of the Medicine and Healthcare products Regulatory Agency is to agree with the manufacturers. Thus this advice has been implemented in National Institute of Clinical Excellence guidelines without any supportive clinical data.

A consecutive series of 206 crossbreed total hip arthroplasties were performed in 192 patients by a single surgeon between 1990 and 1993. These were observed for an average 11.5 years (range, 10–13years). There were 126 women and 80 men with an average age of 69 (range, 41–89) at the time of surgery. There were 9 failures defined as reoperation. Of these, 5 were for aseptic loosening of cup, 2 for deep infection, 1 for recurrent dislocation and 1 for revision of stem for Periprosthetic fracture following a fall. There was no aseptic loosening of stem. With survivorship to date of 94% these data suggest that it is safe to continue using at least one of the common combinations in primary hip arthroplasty.

Professor BM Wroblewski PD Siney PA Fleming

We report the results of our continued review of 11 hip arthroplasties using 22.225mm alumina ceramic femoral heads (CCH) on a Charnley flanged stem articulating with a chemically cross-linked polyethylene (XLPE) cup. The initial bedding-in of up to 0.41mm, which was reached within about 2 years, has not progressed further with a follow up to 18.1 years. The mean total penetration of the XLPE cup for this group of patients is 0.31mm (0 – 0.41) and a penetration rate of 0.019 mm/year (mean 0 – 0.026). One patient with CCH/XLPE arthroplasty on the left side and a conventional metal on ultra high molecular weight polyethylene (UHMWPE) on the right side, has a ten fold difference in total penetration: 0.41mm compared with 4.1mm and a year shorter follow-up.

The mean age of the 9 patients (11 hips) attending was 47.2 years (26–58) at the operation and is now 64 years (42–73). Clinical results remain excellent with freedom from pain and normal activity level appropriate to their age and gender.

Radiographically none of the cups or stems show evidence of loosening or osteolysis and there have been no problems that could have been attributed to the materials or the design used.

Mr A Rafee Mr G J Mclauchlan Dr R Gilbert Mr D Herlekar

Background Elevated plasma levels of D-dimer have been found to be a useful screening tool in the diagnosis of deep venous thrombosis (DVT) in the general population. In the postoperative setting however their role is less clear.

In approximately 73% of NHS trusts D-dimer is a prerequisite test prior to radiological imaging to diagnose DVT.

This study evaluates the effectiveness of D-dimer as a screening tool for DVT in the postoperative period following total hip and knee arthroplasty.

Method Plasma D-dimer levels were measured pre operatively and on post-operative days 1, 3, 5, and 7 in 78 patients undergoing primary total hip or knee arthroplasty. On day 7 patients underwent bilateral duplex ultrasound scanning in order to confirm the absence of DVT.

All patients wore pneumatic foot pumps for DVT prophylaxis. Chemical thromboprophylaxis was not used. All patients were under the care of one surgeon with the same postoperative regimen.

Results D-dimer levels in the post-operative period were characterized by a double peak, on days 1 and 7. Mean day 1 value 3.63 (sd=2.72, range 0.60–14.34), mean day 7 value 2.83 (sd=1.58, range 1.10–10.30). Mean values on days 3 and 5 were 2.52 (sd=2.26, range 0.50–11.85) and 2.45 (sd=1.41, range 0.91–5.05)

Comparing D-dimer levels between hip and knee arthroplasty we found that both groups displayed the same trend in post-operative D-dimer levels (i.e. peaks at days 1 and 7); however levels were significantly higher following knee replacement (At day 7 p< 0.005)

We compared D-dimer levels of these patients with a second group of 43 patients who had a confirmed DVT following hip or knee arthroplasty. The mean D-dimer level in this group was 2.20 (sd=0.98 or range 0.80 – 4.46). This group was subdivided into two groups, those with D-dimer samples before (and including) day 7 and those after. We found a significant difference between the groups (p=0.01). Mean ≤ day 7 = 2.70. Mean > day 7 = 1.97.

The group of patients with Confirmed DVT on or before day 7 were compared with those free of clot. There was no significant difference found between the D-dimer levels of the two groups. (p=0.37)

Conclusion The D-dimer level is never normal (< 0.4mg/l), in the week following total hip or knee replacement and so cannot exclude a DVT. The level it rises to is indistinguishable form that seen in the population with a DVT and so cannot identify those patients in whom further investigation is warranted. Requesting a D-dimer test in this population wastes time and resources and is of no benefit.

Mr RJK Khan Mr D Fick Dr P Khoo Dr F Yao Prof B Nivbrant Prof D Wood

Introduction We believe minimally invasive surgery should be defined by the extent of soft tissue dissection rather than incision length. We describe a new technique that is truly soft-tissue sparing and report our early results.

The surgical approach The landmarks for the incision are identified and an incision is made over the posterior aspect of the greater trochanter. Piriformis is preserved. A capsular repair is performed through drill holes into bone. There are no restrictions to mobility. No specialised instruments are required.

Method The standard posterior approach (group 1) was compared with the PSMI approach (group 2) in a prospective cohort study of 200 consecutive patients over 60 years of age. Patients were scored pre-operatively and followed up prospectively, by a blinded observer.

Results Mean operation time was about 1 hour in both groups. Mean incision length was 21.5 cm in group 1 and 8.4cm in group 2. Mean blood loss in group 1 was significantly higher than group 2 (P< 0.0001). Mean inpatient stay was significantly higher in group 2 (P< 0.0001).

Minimum follow-up was 3 years in group 1 and 1.5 years in group 2. There were 3 dislocations in group 1, and none in group 2. There were 2 re-operations in both groups. The relative improvement in WOMAC scores was significantly greater in group 2 at 3 months and 1 year (P< 0.05).

Conclusion: This is the first study to suggest the benefits of minimally invasive surgery may be prolonged. Cosmesis is a by-product rather than primary objective.

NA Siddiqui P Mohandas SK Muirhead-Allwood

Here we present the results of functional outcome of 531 patients (aged from 27.6 to 88.7, mean 62.6) who have had the Trilogy (Zimmer; Warsaw IN, USA) acetabular shell implanted for 5 years or longer. All patients operated at our unit between 20/1/1992 and 31/3/2004 were included, looking at both Primary (431) and Revision (100) hip arthroplasties. All surgery was performed by the senior surgeon using the Trilogy shell and liners. The Trilogy acetabular shell was used with either an ultra-high molecular weight polyethylene liner or ceramic liner, along with a wide variety of femoral stems, mainly: Harris Pre-coat stem (183 patients, Zimmer), Versys cemented stem (102 pts, Zimmer), CADCAM (140 pts, Stanmore), and HAC Furlong (96 pts, JRI). There were a variety of other stems, including Exeter and Pro-femur. 48 patients had revision of socket only.

Functional outcome was assessed by three questionnaires: the Oxford Hip Questionnaire (12 best function-60 worst), the Harris Hip Score (100 best to 0 worst), and the WOMAC Hip Score (0 best-96 worst).

Patients filled in these questionnaires at every postoperative follow-up clinic. These were compared with the pre-operative scores obtained from questionnaires which the patients completed retrospectively. Mean follow up questionnaire times were 76.5 months postoperatively for primary arthroplasties, and 70.6 months for the revision arthroplasties.

For primary arthroplasty mean scores improved from 40.8 pre-operatively to 16.4 post-operatively (Oxford), 43.9 to 92.9 (Harris), and 51.8 to 9.4 (WOMAC) (all p< 0.05). For revision arthroplasty mean scores improved from 39.1, 41.7, and 49.3 pre-operatively to 19.6, 88.0, and 12.5 (all p< 0.05).

No patients required re-operation for loosening, one patient dislocated at day 5.

We can conclude that the Trilogy acetabular component is a versatile acetabular implant which can be used with a wide range of femoral components, both in primary and revision Total Hip Arthroplasty, with successful functional outcome scores greater than 5 years after implantation.

Piers Yates Nasir Qurashi Eric Swarts Alan Kop Don Howie Clare Marx

Relatively high rates of fracture of the femoral stem of total hip replacements were seen with early designs manufactured with stainless steel. Improvements in metallurgy, alloy chemistry, materials and stem design have led to a reduction in the incidence of this complication and the occurrence of fracture with modern femoral stems is a now a rare event. However, the implantation of modern stems into heavy patients and the use of higher offset stems leads to considerable testing of the mechanical capabilities of some stem designs.

We present ten cases of fracture of modern stainless steel polished tapered stems. The fractures occur either in the neck, or in the distal half of the stem. Our clinical data suggests that heavy patients with small stems and high offsets are at risk of breaking their implants. Varus positioning of the stem in a number of cases further increases the bending moment of the stems, and the sacrifice of cement mantle thickness for implant size within narrow medullary canals may lead to the loss of proximal support. Failure analysis of the retrieved high nitrogen stainless stems also suggests there may be metallurgical factors that contribute to their failure.

On the basis of our findings, careful consideration is required when using high offset stainless steel stems in large patients.

D A Hoad-Reddick I Stockley

Aims and Objectives Hybrid hip replacement became popular in some centres for younger patients with expected lower rates of acetabular loosening and subsequent revision. We have previously reported our 5 year results and now have further follow-up data on the same cohort of patients.

Materials and Methods 86 uncemented acetabular components of the same design were implanted into 68 patients between 1992 and 1997 who were prospectively followed with respect to clinical outcome, polyethylene wear and intention to revise as a definition of failure.

Results Data is available on 73 acetabular cups with a mean follow-up of 9.5 years. The failure rate is 22%. 9 patients have been revised and 7 further patients await revision for polyethylene wear and osteolysis which in some cases has been very aggressive. Further patients have advanced wear and early lysis which is under close observation.

Conclusion The prosthesis studied has a high failure rate. Patients often report few symptoms until advanced osteolysis has occurred. We recommend that all patients with this type of prosthesis be recalled for frequent radiological review and report on an implant which seems to be failing unacceptably early.

D. Campbell L. Cochrane D.I. Rowley

As part of a user group of a collarless polished tapered stem a database was established in 1993 recording all significant data pre-operatively, intra-operatively and at 1,3,5 and 7 years.

All were primary hip replacements and the study included 38 different surgeons who were free to use the head size, approach and cup of their choosing. All hips had a collarless polished tapered prosthesis (Zimmer inc.).

Data on 2,250 hips were available for analysis and stratification of risk factors for dislocation. Correlation of head size and surgical approach was performed and tested for significance. The patient demographics were standard for a typical arthroplasty study group. Of the surgical approaches used, 13.1% were anterolateral, 27.55% lateral, 23.88% posterior and 35.47% Hardinge. There were no trochanter osteotomies or anterior approaches.

94 (100%) of the hips had a first dislocation occurring in the first two years: 38 during acute stay (40.43%), 45 from acute stay to the first year (47.88%) and 11 during the second year (11.7%). The 22mm head was associated with the greatest risk of dislocation (5.93%, P < 0.001). The risks with the 28mm head (3.05%) and the 26mm head (2.5%) were not significantly different. The lowest risk of dislocation occurred with the lateral approach (2.11%) and the highest with the posterior approach (5.99%). Dislocation rates for the anterolateral and Hardinge approaches (4.1% and 3.28% respectively) were not significantly different. Unfortunately data pertaining to frequency of capsular repair combined with the posterior approach was not available.

The combination of lateral approach and 28mm head was associated with the lowest dislocation risk of 1.56%, while the risk with the posterior approach and 22mm head was the highest at 10.09%.

A Gordon E Kiss-Toth I Stockley A Hamer R Eastell JM Wilkinson

Cytokine mediated activation of osteoclasts can lead to peri-implant osteolysis and aseptic loosening. The aim of this study was to determine the IL-1β and TNFα mRNA cytokine expression profile of human macrophages when stimulated with polyethylene particles using relative quantitative real-time polymerase chain reaction (rqRT-PCR).

Human peripheral blood monocytes or human monocytes from the cell line THP-1 were used in this study. rqRT-PCR conditions were optimized by stimulating human macrophages with 200ng/ml lipopolysaccharide (LPS). The median CV% value for duplicate measures was 12.6 (range 4.5–54). Stimulation assays were performed using unfractionated endotoxin-free commercial polyethylene particles (median size 7μm); or fractionated particles (size range 0.1–1.2μm). Human macrophages were stimulated with high dose unfractionated polyethylene particles at 0, 3500 or 10500 mm3/cell or with fractionated polyethylene particles at 0 and 100mm3/cell at time points 0 and 3 hours. Low dose unfractionated polyethylene stimulation was performed on THP-1 cells at 0, 50, 100, 1000 and 10000 mm3/cell. In all experiments LPS stimulation was used as a positive control. RNA was extracted and rqRT-PCR was performed using standard techniques

High dose unfractionated polyethylene stimulation did not result in a significant difference in cytokine mRNA levels between groups. Using fractionated polyethylene, a small increase in IL-1β mRNA was identified (21% versus maximal stimulation using LPS). Low dose unfractionated polyethylene stimulation of THP-1 cells demonstrated dose dependent decreases in TNFα and IL-1β mRNA expression that was not due to inhibition of RNA extraction or a decrease of cell viability.

Endotoxin-free polyethylene particles do not appear to be a major stimulus for IL-1β and TNFα mRNA production as measured by rqRT-PCR. We did observe a small positive effect on IL-1β mRNA expression using a fractionated polyethylene stimulus. However it remains unclear whether this effect is due to fractionation of particles into the submicron range or is due to introduction of endotoxin during the filtration process.

J. Page A. Jennings T. Fawcett

The use of sub-lethal doses of cell wall active antibiotics to induce cell wall deficiency in S aureus has been described. Cell Wall Deficient S aureus show an increased in-vitro ability to form biofilm. Cephalosporins(cell wall active antibiotics.) are commonly used at time of arthroplasty surgery as antimicrobial prophylaxis. Adherence is fundamental step in biofilm formation.

The adherence of cell wall deficient S aureus versus ‘wild type’ S aureus to glass was investigated. Slides comparing the two types of organisms were analysed using fluoroscopy and J-image software. The ability to adhere to plastic was investigated using a micro-titre based absorption test. In a third investigation a centrifugal force was used to quantify the adherence ability of the cell wall deficient organisms to the glass slides.

The cell wall deficient organisms demonstrated an increased ability to adhere to glass compared to the ‘wild type’. After exposure, there was on average twenty times more cell wall deficient organisms per unit area compared to the ‘wild-type’. The micro-titre plates were similar. After incubation, the absorption of each well was measured. Compared to the ‘wild type’ there was a significantly increased absorption in wells containing the cell wall deficient organisms. Showing an increased ability to adhere to plastic. The third technique quantified the ability to adhere using a centrifugal force. The slides were exposed to ‘wild type’ and cell wall deficient organisms, however before staining they were placed in a centrifuge. On analysis there were five cell wall deficient S aureus per field of view, compared to 0.5 ‘wild-type’.

An increased ability of cell wall deficient S aureus to adhere to surfaces has been shown. Adherence is fundamental to biofilm formation. The significance to orthopaedics is that the inadequate use of Cephalosporins at time of operation may be facilitating chronic infections.

Mr. Y. Michla Dr. M. Holliday Dr. K. Gould Mr. D.J. Weir Prof. A.W. McCaskie

Introduction Infection is a disastrous complication of arthroplasty surgery, requiring multidisciplinary treatment and debilitating revision surgery. As between 80–90% of bacterial wound contaminants originate from colony forming units (CFU’s) present in operating room air tending to originate from bacteria shed by personnel present within the operating environment, any steps that can reduce this bacterial shedding should reduce the chances of wound contamination. These steps have included the use of unidirectional downward laminar airflow theatre systems, and the introduction of theatre attire modelled on this principle (e.g. total body exhaust suits). Our unit has introduced the use of the Stryker Sterishield Personal Protection System helmet in conjunction with laminar flow theatre systems. This study compares an enclosed helmet system used with standard gowns, with standard hood & mask attire.

Method 12 simulated hip arthroplasty operations were performed, six using disposable sterile impermeable gown, hood and mask, with a further 6 using a Sterishield helmet & hood. Each 20 minute operation consisted of a series of arm and head movements simulating movements performed during surgery. Air was sampled at wound level on a sterile draped operating table using a Casella slit sampler, sampling at 700l/minute. Samples were incubated on Blood agar for 48 hours at 37°c & the CFU’s grown were counted.

Results The mean number of CFU’s for the helmet was 9.33 with hood and mask attire having 49.16 CFU’s (S.Ds 6.34 & 26.17; p value 0.0126). In all cases, the organism isolated was a coagulase negative staphylococcus

Conclusion Although the sample size was small, we demonstrated a fivefold increase in the number of CFU’s shed when using hood and mask attire compared to personal helmet and sterile hood. We conclude that the helmet system is superior to non-sterile hood & mask at reducing bacterial shedding by theatre personnel.

1Alison L. Galvin 1Eileen Ingham 2Martin H. Stone 1John Fisher

Introduction Zero wear of highly crosslinked UHMWPE has been reported in hip simulators (1). In contrast clinical studies have reported finite wear rates (2). The aim of this study was to compare the wear rates produced by UHMWPE with different levels of crosslinking in a hip joint simulator and compare them to clinical wear rates.

Materials and Methods Studies were carried out using 28mm diameter cobalt chrome femoral heads. These were articulated against UHMWPE in the Leeds ProSim hip joint simulator. The acetabular cups were manufactured from UHMWPE GUR 1050. The PE was highly crosslinked with 10MRad or 7.5MRad of gamma irradiation in nitrogen followed by re-melting at a temperature above 150°C. Slightly crosslinked (gamma irradiated with 2.5MRad in air) and non-crosslinked PE were also tested. Wear measurements were taken every million cycles using a coordinate measuring machine. At each million cycles a 3D measurement was taken of the contact region of the acetabular cups.

Results and Discussion The wear rates decreased as crosslinking levels increased. The non-crosslinked material had an overall average wear rate (mm3/million cycles) of 45.6±1.35, the 2.5MRad material 46.9±9.4, the 7.5MRad 15.04±4.28 and the 10MRad 8.7±3.11. All four polyethylenes showed greater volume change in the first million cycles and this was associated with initial creep deformation. The results of the surface topography showed that the highly crosslinked materials became smoother than the other materials. This would benefit the crosslinked materials in aiding lubrication and could have contributed to the lower wear rate seen with these materials.

Conclusion Finite wear rates have been recorded for the first time in simulator studies with highly crosslinked polyethylene. The wear rates and wear surfaces compare with those found in clinical studies.

Constant A Busch Robert B Bourne Cecil H Rorabeck Steven J MacDonald Richard W McCalden Dr John M Martell Christopher M Haydon

Background: Reduced implant survivorship due to aseptic loosening has prompted research into alternative bearing materials. Simulator testing is useful, but clinical studies are the gold standard to evaluate the wear characteristics of new bearing materials. Net compression molded polyethylene has clinically reported improved wear characteristics over traditionally used RAM extruded UHMWPE 1,4,17,22. Machining of the compression molded acetabular component however may be detrimental to its wear properties 29. We report a 23–29% increase in 2D and 3D linear and volumetric wear in a cohort of patients in which machined compression molded acetabular components were used.

Methods: Ninety-two patients matched for gender, body mass index, primary pathology, Charnley grade, and length of follow up underwent uncemented total hip replacement using an identical acetabular and femoral implant. Group 1 (52 patients) had a RAM extruded polyethylene liner (GUR 4150 HP) and Group 2 (40 patients) had a machined compression molded polyethylene liner (Montell H 1900). UHMWPE sterilisation regimes were identical. Antero-posterior and lateral radiographs were analysed for acetabular wear using the Martell technique at a minimum follow up of five years and a maximum mean follow up of 87.4 months for group 1 (SD=8.7) and 84.9 months for group 2 (SD 7.7).

Results: Both 2D and 3D linear and volumetric wear rates in patients with a RAM extruded polyethylene acetabular component were 23–29% less compared to patients that received a machined compression molded acetabular liner. There was a statistical difference in age between to the two groups (P=0.007). Looking at acetabular wear in patients over 55 years, machined compression poly was still 16–31 % worse then RAM extruded polyethylene although statistical difference could not be reached for 3D linear and volumetric wear. The incidence of acetabular osteolysis on review of radiographs at maximum follow up was similar in both groups (group 1 =16.3% versus group 2 =15%).

Conclusions: Despite favourable reports of improved wear characteristics of net compression molded UHMWPE, this study shows a 23– 29% increase in 2D and 3D linear and volumetric wear in machined compression molded acetabular components. It appears that machining of compression molded polyethylene bar stock, to obtain the final component, is detrimental to the wear properties of the acetabular liner.

FCNK Kwong RA. Power

The longevity of cemented femoral components has been shown to be related to the cement used. The reason for this difference between the available commercial preparations is unclear. One mode of failure of the stem is thought to be cracking within the cement mantle. This may be secondary to residual stress resulting from shrinkage of the cement on curing. It was hypothesised that there was a difference in shrinkage on curing between the different polymethylmethacrylate cements used commonly in hip arthroplasty.

Under standardised conditions, a fixed volume of Palacos-R, Palacos-LV, Simplex, CMW1 Radio-opaque, CMW2 and CMW Endurance was mixed under vacuum and allowed to cure in a measuring cylinder of fixed volume. The cylinder was then split open 24 hours later and the block of cement removed. The final volume of cement was then determined by measuring the volume it occupied in a container filled with water using Archimedes principle.

Our results indicate that, under standardised conditions, the degree of shrinkage for each commercial preparation was Palacos-R 6.9%, CMW1 5.2%, CMW2 5.4%, CMW Endurance 5.3%, Simplex 5.8% and Palacos-LV 7.2%.

There is a difference in the amount of shrinkage on curing between the different types of bone cements in use commercially and this may account for their differences in long term outcome.

S Williams Z M Jin M H Stone E Ingham J Fisher

There is currently much interest in the wear of metal-on-metal THRs and potential concerns about elevated metal ion levels. Generally, wear of metal-on-metal THR’s has been low in simulator studies. Slightly higher and more variable wear has been found clinically. Variations in surgical approach, technique and fixation method may influence the level of force applied across the prosthesis during gait. It is hypothesised that increased joint tensioning may increase loading of THR’s during the swing-phase; leading to elevated wear and friction due to depleted fluid film lubrication. This study aimed to assess the effect of swing-phase load on the friction, lubrication and wear of metal-on-metal THR’s.

Cobalt-chrome 28mm metal-on-metal THR’s were tested in a physiological hip simulator, loading was modified to provide; (1) ISO swing-phase load (280N, as per ISO 14242-1) and (2) low swing-phase load (< 100N). Friction testing was conducted using a pendulum friction simulator, with 280N and 100N swing-phase loads. Theoretical lubrication modelling was carried out using elastohydrodynamic lubrication theory.

The overall mean volumetric wear rates was 10-times greater in THR’s tested with an ISO swing-phase load in comparison to THR’s tested with low swing-phase loads (0.58±0.49 compared to 0.06±0.039mm3/million cycles). The friction factors were 0.129 and 0.173 respectively under low and ISO swing-phase conditions. A decrease in the predicted lubricant film thickness when the swing-phase load was increased was observed; at the start of stance phase this was 0.12microns and 0.07microns under low and ISO swing-phase conditions respectively.

The results demonstrate that the performance of metal-on-metal THR’s is highly dependent on swing-phase load conditions. It is postulated that fixation method and surgical technique can affect the swing-phase load. This study has demonstrated that over-tensioning of the tissues may also accelerate wear. These observations may explain some of the variations reported clinically.

A P Sprowson A W McCaskie M A Birch

Background A biomaterial serves to support, organize and directly influence the behaviour of growing cells. Chitosan has the capability to be a very useful biomaterial in the speciality of orthopaedics, due to its excellent biocompatibility, and physical properties that allow topographical modification. Chitosan films have potential to be used to coat implant surfaces, regulating bone cells at the implant interface. Enhanced integration may therefore help towards solving problems such as aseptic loosening.

Method 85% deacylated chitosan (Sigma) was dissolved in 2% acetic overnight. The viscous chitosan was then sterilized by autoclaving for 10 minutes. PDMS patterned stamps produced from a silicon mould were added to the viscous chitosan and as the chitosan film forms the topographic impression is left on the surface. The gel was then dried for 36 hours in a sterile system. The pH is neutralized with NaOH1M for 24 hours. The gel was washed in sterile hanks balanced salt solution until the pH was 7.4. Osteoblasts were then grown on these surfaces in a cell culture system and analysed by light microscopy and image analysis.

Results We have successfully designed a protocol for the production of sterile topographically modified chitosan, with surface features that can be produced in the range of 1–100um. We have shown that cells on un-modified chitosan differentiate and form bone at a much slower rate than on chitosan with a modified surface. Findings supported by in-situ alkaline phosphatase levels. Control can be exerted on cell shape and inter-cellular interactions based upon shape and surface area between shapes; with a smaller surface area making adhesion more difficult.

Conclusion. Our data shows that osteoblasts can be controlled by altering chitosans surface topography. Being able to influence biology by changing biomaterial surface features will enhance interaction at the bone implant interface, allowing greater implant integration.

Mr C. N. Peck Miss A. Foster Mr G. J. Mclauchlan

It has been suggested that minimal incision surgery for hip arthroplasty allows earlier mobilisation and reduces hospital stay. Intensive post-op physiotherapy may also have the same effect. This study aimed to assess which was the more important factor.

The study compared 45 patients (26 NHS and 19 private) undergoing primary total hip arthroplasty using a standard posterior approach to 51 patients (29 NHS and 22 private) with a minimal incision of 10cm or less. Physiotherapy involved once daily weekday sessions with the NHS patients (five sessions per week) versus twice daily with the private patients (14 per week). We compared demographics, incision length, post-operative stay, complication rates and Oxford Hip Scores between the four groups.

Results showed no significant difference in age, sex and BMI between the groups. There was a significant difference (p = 0.0002) in mean scar length between the mini and standard incision groups (15.3 vs. 8.3 cm). There was no significant difference in post-op stay between the mini and standard incision NHS patients or the mini and standard incision private patients. There was a significant difference (p = 0.003) in stay between NHS and private patients (11.4 vs. 7.9 days) regardless of the incision used. There were four (4%) early dislocations, three in the mini incision group. Eleven patients received prophylactic antibiotics compared to five in the standard groups for prolonged wound ooze (> 5 days); only one patient had a proven superficial infection. There was no significant difference in the change in the Oxford Hip Scores between any of the groups.

This study suggests that intensive physiotherapy can significantly reduce in-patient stay but minimal incision surgery itself does not. The higher dislocation rate in the mini incision group demonstrates the learning curve for this technique.

Fares Haddad Rahul Patel Nada Al-Hadithy Michelle Odumenya Mike Grocott Monty Mythen

Aim: To identify the incidence of post-operative morbidity in elective total hip replacement patients as a cause for prolonged admission using the POMS. To assess the utility of POMS as a measure of short term orthopaedic outcome and a tool to influence decision making for appropriate discharge time.

Background: The currently available methods for assessing overall surgical outcome (as opposed to quality of life or joint specific outcome) are generally unreliable, unvalidated, unresponsive and almost always inconsistent. Mortality is usually infrequent and length of hospital of stay is likely to be affected by non-medical factors and monitoring of complications is subject to variations in both definition and intensity of surveillance.

The POMS is the only published method for prospectively describing complications associated with major surgery. It comprises a 9-point survey and provides a generic measure of short term post-operative outcome. Data is simple and quick to collect and easily learnt. No additional tests are required for data collection.

Method: Patients undergoing elective primary and revision hip arthroplasty were recruited. Research assistants collected POMS data prospectively on postoperative days 1, 3, 5, 8 and 15 (if the patients were still in hospital).

Results: 182 patients were recruited and followed-up. Median length of stay was 11 days (range 2–58). Of the patients remaining in hospital on post-operative days 1, 3, 5, 8 and 15, 0% (n=182), 34% (n=61), 30% (n=51), 29% (n=39) and 63% (n=22), respectively, had no evidence of medical morbidity as defined by the POMS.

Conclusions: The POMS is a generic post-operative screening survey, designed to monitor morbidity in all main organ systems. This study suggests that a significant proportion of orthopaedic patients remain in hospital despite having no evidence of medical morbidity as defined by the POMS. Length of hospital stay is influenced by a number of other factors, further investigation is warranted to identify the factors responsible for their post-operative length of stay. We also hypothesize that POMS may be very useful in areas were managed care / insurance companies dictate the length of hospital stays.

R Nagai I Ines AJ Fox V Edwards-Jones M Upton PR Kay

Purpose Coagulase negative staphylococci (CNS) have been one of the major pathogens responsible for prosthetic joint infections, and are showing increasing multiple-antibiotics resistance. Intact cell mass spectrometry (ICMS), based on the analysis of bacterial surface proteins, has been recognised as a new technique for identification of micro-organisms. The aim of this study was to evaluate the ability of ICMS for species level identification of clinical CNS isolates.

Method A total of 50 CNS strains from revision joint replacement operations were studied. ICMS and commercial identification kits were used for identification of those CNS. The commercial kits were used following the manufacturer’s recommendations. For ICMS, single colonies were smeared onto five spots on a sample slide. After drying, a 1 μl of aliquot of matrix solution was added to each spot. Analysis of strains was performed using a Kompact MALDI 2 linear, time of flight mass spectrometer and 3-ns pulse width nitrogen laser light. Combined spectra were constructed from 100 shots at each spot on the sample slide.

Results In this study, the commercial kit did not require any special equipment, but required overnight incubation and could not identify at least seven strains. On the other hand, the ICMS method was rapid, accurate and highly reproducible. The mass: charge spectra produced by ICMS contained potential biomarker peaks that could be used for species level identification.

Conclusions ICMS has the potential as a powerful tool for species level identification of clinical CNS isolates in terms of rapidity, accuracy and cost effectiveness. This study suggested that ICMS is a possible new method of identifying causative organism in infected joint replacements.

N.R Shetty A.J Hamer I. Stockley R. Eastell J.M. Wilkinson

Peri-prosthetic bone loss may contribute to aseptic loosening after THA. The aims of this randomised controlled trial extension study were to study the effect of pamidronate therapy on Peri-prosthetic bone mineral density (BMD) and Peri-prosthetic osteolysis over 5 years after primary THA.

50 patients were enrolled in the study in 1998. All received a hybrid THA (Ultima-TPS stem, Plasmacup) for osteoarthritis. Subjects were randomised to receive either 90mg of pamidronate or placebo by intravenous infusion on the 5th post-operative day. At 5 years 36 patients (41 Hips: placebo n=21, pamidronate n=20) returned for measurement of BMD and clinical and plain radiographic assessment. Five patients had died and nine had withdrawn from the study.

The effect of pamidronate in maintaining femoral bone mass in the region of the calcar previously reported at 2 years was maintained at 5 years (Gruen zone 6 pamidronate versus placebo ANOVA P=0.038; Gruen zone 7 ANOVA P=0.048). No differences in pelvic BMD were found between treatment groups at 5 years. Harris hip scores used to evaluate clinical outcome did not show any significant difference between the 2 groups over the 5-year period. (Mann Whitney p> 0.05). Isolated expansile osteolytic lesions were identified on AP radiographs of the hip at 5 years in 4 patients (2 placebo, 2 pamidronate; P> 0.05). One patient had a 5x9mm lytic lesion in the region of the femoral calcar, and 3 patients had pelvic lytic lesions in the region of the acetabular dome (largest measuring 20x10mm).

Single-dose peri-operative pamidronate therapy preserves femoral calcar bone mass over a 5 year period after THA. However, although the number of subjects with osteolysis is small, we have seen no difference in the rate of osteolytic lesions between treatment groups. Long term study of this patient group is required to examine the rate of aseptic loosening between the treatment groups.

P Gaston CR Howie R Burnett RW Nutton IH Annan D Salter AHRW Simpson

If an arthroplasty patient presents with wound breakdown, sinus formation or a hot, red joint the diagnosis of infection is straightforward. However, most total joint replacement (TJR) infections are difficult to distinguish from aseptic loosening. It is imperative to know if a painful TJR is infected to plan appropriate management.

In this prospective study of 204 patients we analysed the diagnostic accuracy of various tests for infection: Inflammatory Markers (CRP/ESR); Aspiration Microbiology; and the Polymerase Chain Reaction (PCR) – a novel technique in this situation. We used international criteria as the gold standard for infection, applied at the time of revision surgery. Any of – a sinus; frank pus in the wound; positive intra-operative microbiology; positive histology – classified the patient as infected. The sensitivity (Sens), specificity (Spec), positive predictive value (PPV) and negative predictive value (NPV) of each test were calculated.

52 patients with an original diagnosis of inflammatory arthritis were excluded, as histology may be inaccurate. The results for the remaining 152 patients are: CRP > 20mg/l: Sens 77%; Spec 76%; PPV 49%; NPV 92%. ESR > 30 mm/hr: Sens 61%; Spec 86%; PPV 57%; NPV 87%. Aspiration Microbiology: Sens 80%; Spec 83%; PPV 71%; NPV 88%. PCR: Sens 71%; Spec 78%; PPV 43%; NPV 89%.

Few patients with negative CRP/ESR were found to be infected; if positive, there was a 50/50 chance that the joint was infected. Positive aspiration microbiology was associated with underlying infection 3 times out of every 4, and negative results were correct 9 times out of 10. PCR was no more accurate than existing tests.

All patients with painful TJR’s should have inflammatory markers checked – if negative the clinician can be relatively reassured that the implant is not infected. If positive or suspicion remains, further investigation should be undertaken. Joint aspiration for microbiology is currently the best available second line investigation.

VE Hannah JV Smith M Riggio J Bagg DB Allan

Infection is one of the major reasons leading to early revision of total hip joint replacements. Traditionally, samples have been taken for microscopy, culture and sensitivity at the time of surgery. However, this doesn’t always reveal a causative organism. Molecular techniques have now been refined to improve sensitivity in bacterial detection.

In this study, samples were taken from acetabular and femoral components at the time of revision hip surgery for suspected infection. These underwent conventional culturing and also PCR and DNA sequencing. The white cell count, CRP and ESR were also recorded.

Results are available for 6 cases. All of these patients had an elevated CRP level (17–169). Microscopy at the time of surgery showed scanty white cells and no organisms on at least 1 sample from 2 cases. Subsequent culture was negative. When sonication techniques were used to remove bacterial DNA, followed by PCR and sequencing, one of these cases yielded Stenomophonas sp. A further 4 cases were positive for Stenophomonas using molecular techniques despite conventional culture being negative.

Stenophomonas sp is a gram negative bacillus. Its ability to adhere to plastic and to produce a bacteraemia are of significance in its proposed role in hip arthroplasty infection. It is also known to be resistant to most commonly used broad spectrum antibiotics.

This study demonstrated that we may be under-diagnosing infection in hip revision patients. These new techniques could prove invaluable in detecting low yet significant levels of bacteria which may lead to a change in current antibiotic policy for joint replacements and subsequently a reduction in the number of revisions required for loosening due to infection.

A Dramis DJ Dunlop RJ Grimer E Aldlyami N O’Connell TS Elliot

Background The exclusion of infection at the site of a painful or failed prosthetic joint replacement is important for pre-operative planning and counselling. A variety of investigations can be used to assist in the diagnosis or exclusion of infection.

An ESR and CRP are widely used as the initial screening investigation to differentiate between aseptic and septic loosening of prosthetic joint replacements1. Propionobacteria are organisms of low virulence, although they do cause deep peri-prosthetic infections2. We believe that Propionobacteria do not always cause a significant rise in ESR and CRP.

Methods Between May 2001 and May 2004, we identified 78 patients with prosthetic joint replacements colonised with Propionobacteria. There were 48 hip joint replacements, 27 knee joint replacements, 2 endoprosthetic replacements of the femur and 1 shoulder joint replacement. There were 48 males and 30 females. The preoperative values of ESR and CRP were recorded. For the purposes of this study, an ESR rate of 30mm/hr or higher and a CRP level of 10mg/lt or higher were considered to be suggestive of infection and were deemed a positive result.

Results All of the 78 patients had both ESR and CRP measured preoperatively. In only 17 patients (22%) both ESR and CRP were higher than 30mm/hr and 10mg/l respectively. In 33 patients (42%) with prosthetic joint replacements colonised with Propionobacteria, the preoperative values of both ESR and CRP were normal.

Conclusion In our study we have shown that 33 out of 78 patients (42%) with prosthetic joint replacements colonised with Propionobacteria had normal preoperative of both ESR and CRP values. This is to suggest that normal preoperative values of ESR and CRP in suspected failed prosthetic joint replacements might not exclude infection, if the causative organism is of low virulence such as Propionobacteria.

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Nikhil Shah Farokh Wadia Matthew Frayne Kate Pendry Martyn Porter

Aim We have prospectively investigated the effect of tranexamic acid in reducing blood loss and transfusion requirements in primary and revision total hip arthroplasty in a comparative study.

Patients and Methods In the study group, tranexamic acid was given half an hour before the skin incision. (10 mg/kg as an intravenous bolus, followed by 10 mg/kg as intravenous infusion over 6 hours). We recorded the haemoglobin level preoperatively and prior to discharge, and number of units of blood transfused. The total peri-operative blood loss and the fall in haemoglobin after surgery was calculated in consultation with our haematologist. There were 9 primary and 17 revision hip replacements in the study group. We compared the results with a control group of 10 primary and 20 revisions performed during a similar period, without tranexamic acid, recording identical parameters. Thrombo-embolic and wound complications were recorded.

Results Patients receiving tranexamic acid had a mean fall in haemoglobin level of 3.1 g/dl and mean blood loss of 4.1 litres. The control group operated without tranexamic acid had a mean fall in the level of haemoglobin of 3.7 g/dl, and the mean blood loss 5.4 litres. The average number of units of blood transfusion required was 0.77 per patient in the study group compared to 2.03 per patient in the control group. The differences were significant (p value of 0.05). There was no increase in the incidence of complications such as deep vein thrombosis, pulmonary embolism, or wound problems in the study group.

Conclusion Tranexamic acid given prior to surgery reduces blood loss and need for blood transfusion, not only in primary but also in revision hip arthroplasty, without any increase in the rate of thrombo-embolic complications.

R Jenabzadeh N Wardle F Haddad

Treatment Centres (TCs) specialise in common elective operations with long waiting lists. One of the concerns that has arisen with this enforced new healthcare model is the potential for suboptimal outcomes after joint arthroplasty. In order to decrease this risk we set in place a number of measures and have evaluated the outcome of the fist 100 total hip and total knee replacements undertaken at our TC and compared these to 100 consecutive controls undertaken concurrently by out hip and knee service. •Cases were only to be performed by consultant orthopaedic surgeons appointed to our trust – to the exclusion of visiting / sessional arrangements. •Same implants and care pathways as used within the rest of our department. •Weekly team arthroplasty rounds and planning sessions.

There was no significant difference in baseline demographics with both groups showing a slight female preponderance, and similar age ranges (35–88 av. 62; 42–86 av. 64). The treatment centres patients were heavier (78Kg range 48–111Kg; 72Kg range 43–101Kg). The TC group averaged 2.9 comorbidities per patient compared to 2.2. The average time to discharge was similar at 7.6 days . There was no significant difference in the improvement in Harris Hip or Knee Society Scores at a minimum 6 months follow-up. There were 2 infections in the TC group and one in the control group. There were 3 thromboembolic complications in each group and there was one unrelated death in each group. There was one dislocation and one fracture in the TC group and two fractures in the control group. Radiographic criteria including implant size, position, slope, offset, cementing and alignment were comparable in the two groups.

TC patients are not “fitter more predictable” patients and may have greater comorbidity. Our insistence on a local consultant led service and on identical standards to those of our non TC department have generated similar short term outcomes to those of non TC patients.

P McGraw S Hossain JP Hodgkinson

Background: With the foreseeable increase in demand for revision hip surgery, it is likely that orthopaedic surgeons working in district general orthopaedic units will undertake an increasing number of secondary procedures. This article set out to determine whether a single orthopaedic surgeon, working in a district general hospital, could achieve results comparable to those obtained by surgeons working in specialised tertiary referral centres.

Patients and methods: Complete records and serial radiographs of 72 patients (76 hips) having revision total hip arthroplasty by a single surgeon and follow-up of at least 1 year, were reviewed by an independent observer.

Results: The mean follow-up period was 4 years. Indications for revision were aseptic loosening (N=51), sepsis (N=16), fracture (N=3), dislocation (N=2), and other (N=4). Complete cement removal was achieved in 97% of acetabular components revised and 88% of femoral components revised. There were no documented complications in 68% of revised hip prostheses. The complications of the remaining cases comprised trochanteric bursitis (9%), dislocation (10%), thromboembolism (5%), periprosthetic fracture (1%) and infection of the revised prosthesis (1%). None of the cases studied died as a direct result of surgery. All radiographic parameters measured were improved by revision of the prostheses.

Conclusions: Orthopaedic surgeons working in district general hospitals performing 5 to 10 revision hip arthroplasties per year can achieve results comparable to those of surgeons working in specialised units.

RJK Khan D Fick M Lee R Alakeson AG Bowers DJ Wood B Nivbrant

Introduction Primary and revision total hip surgery in the face of poor neuromuscular function, cognitive impairment or recurrent dislocation are fraught with complications. A useful option for such cases is the constrained acetabular component, or “captive cup”. We present the largest series reported to date, and use radiostereometric analysis (RSA) to assess cup migration.

Method Between February 1999 and September 2003 133 patients (141 hips) were identified as high risk of dislocation and were treated with a constrained acetabular component. One hundred and twenty cases were revision arthroplasties and 21 were primary replacements. Patients were assessed pre-operatively (WOMAC, Harris Hip Scores and SF-36). Defects were reconstructed with allograft (massive, morsellised or strut) where required. Most components were inserted into uncemented metal cups. Radiostereometric beads were inserted. Post-operatively patients were followed up regularly and clinical scores repeated. Radiostereometric analysis (RSA) was performed at 6 months, and then annually to assess prosthesis migration.

Results Mean follow-up was 3.1 years (range 1 – 5.6 years). At last review 26 patients had died, and 7 were lost to follow-up. There were 8 revisions for cup loosening. There were 5 dislocations and 2 dissociations in 6 patients. There was a statistically significant improvement in WOMAC and Harris Hip scores. RSA confirmed cup migration was greater than for non-captive cups, but was nevertheless minimal. Interestingly there was no statistically significant difference at 6, 12 and 24 months suggesting most migration occurs early on.

Conclusion Our results suggest the “captive cup” is an effective and safe option for the treatment of primary and revision arthroplasty in those at high risk of dislocation.

Fares Haddad

The management of infected total hip replacements remains controversial. The standard of care is two stage revision with antibiotic load ed cement during the interval period and parental antibiotic therapy for six weeks. Single stage revision may have economic and functional advantages however.

Fifty consecutive patients with infected total hip replacements were treated according to a Standard Protocol. Patien