The current study aims to compare the clinico radiological outcomes between Non-Fusion Anterior Scoliosis (NFASC) Correction and Posterior Spinal Fusion (PSF) for Lenke 5 curves at 2 years follow up.

Methods:38 consecutive Lenke 5 AIS patients treated by a single surgeon with NFASC (group A) or PSF (group B) were matched by age, Cobb's angle, and skeletal maturity. Intraoperative blood loss, operative time, LOS, coronal Cobbs, and SRS22 scores at 2 years were compared. Flexibility was assessed by modified Schober's test. Continuous variables were compared using student t-tests and categorical variables were compared using chi-square.

The cohort included 19 patients each in group A and B . Group A had M:F distribution of 1:18 while group B had 2:17. The mean age in group A and group B were 14.8±2.9 and 15.3±3.1 years respectively. The mean follow-up of patients in groups A and B were 24.5±1.8 months and 27.4±2.1 months respectively. Mean pre-op thoracolumbar/lumbar (TL/L) cobbs for group A and group B were 55°±7° and 57.5°±8° respectively. At two years follow up, the cobbs for group A and B were 18.2°±3.6° and 17.6°±3.5° respectively (p=0.09). The average operating time for groups A and B were 169±14.2 mins and 219±20.5 mins respectively (p<0.05). The average blood loss of groups A and B were 105.3±15.4 and 325.3±120.4 respectively (p<0.05). The average number of instrumented vertebra between groups A and B were 6.2 and 8.5 respectively (p<0.05). The average LOS for NFASC and PSF was 3.3±0.9 days and 4.3±1.1 days respectively (p<0.05). No statistically significant difference in SRS 22 score was noted between the two groups. No complications were recorded.

Our study shows no significant difference in PSF and NFASC in terms of Cobbs correction and SRS scores, but the NFASC group had significantly reduced blood loss, operative time, and fewer instrumented levels. NFASC is an effective alternative technique to fusion to correct and stabilize Lenke 5 AIS curves with preservation of spinal motion.

The current study aims to find the role of Enhance Recovery Pathway (ERP) as a multidisciplinary approach aimed to expedite rapid recovery, reduce LOS, and minimize morbidity associated with Non Fusion Anterior Scoliosis Correction (NFASC) surgery.

A retrospective analysis of 35 AIS patients who underwent NFASC with Lenke 1 and Lenke 5 curves with a minimum of 1 year of follow-up was done. Patient demographics, surgical details, postoperative analgesia, mobilization, length of stay (LOS), patient satisfaction survey score with respect to information and care, and 90 days complications were collected.

The cohort included 34 females and 1 male with a mean age of 15.2 years at the time of surgery. There were 16 Lenke 1 and 19 Lenke 5 in the study. Mean preoperative major thoracic and thoracolumbar/lumbar Cobb's angle were 52˚±7.6˚ and 51˚±4.5˚ respectively. Average blood loss and surgical time were 102 ±6.4 ml and 168 ± 10.2 mins respectively. Average time to commencing solid food was 6.5±1.5 hrs. Average time to mobilization following surgery was 15.5± 4.3 hrs. The average duration to the stopping of the epidural was 42.5±3.5 hrs. The average dose of opioid consumption intraoperatively was 600.5±100.5 mcg of fentanyl i.v. and 12.5±4.5 mg morphine i.v. Postoperatively opioids were administered via an epidural catheter at a dose of 2 mg of morphine every 24 hours up to 2 days and an infusion of 2mcg/hr of fentanyl along with 0.12-0.15% ropivacaine. The average duration to transition to oral analgesia was 55.5±8.5 hrs .20 patients had urinary catheter and the average time to removal of the catheter was 17.5±1.4 hrs. 25 patients had a chest tube and the average time to remove of chest tube was 25.5±3.2 hrs. The average length of hospital stay was 3.1±0.5 days. No patient had postoperative ileus or requirement of blood transfusion or any other complications. No correlation was found between LOS and initial cobb angle.

The application of ERP in AIS patients undergoing NFASC results in reduced LOS and indirectly the cost, reduced post-operative opioid use, and overall improve patient satisfaction score.

Introduction

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty. Patients undergoing revision for PJI may experience considerable psychological distress and symptoms of depression, both of which are linked to poor post-operative outcomes. We therefore aim to identify the prevalence of depressive symptoms in patients prior to treatment for PJI.

Introduction

Cross table lateral (CTL) radiographs are commonly used to measure acetabular component anteversion after total hip arthroplasty (THA). CTL measurements may differ by >10 degrees from CT scan measurements, but the reasons for this discrepancy are poorly understood. We compare anteversion measurements made on CTL radiographs and CT scans to identify spinopelvic parameters predictive of inaccuracy.

Background: Median nerve motor branch compression in patients with Carpal Tunnel Syndrome is usually characterised by reduced finger grip and pinch strength, loss of thumb abduction and opposition strength and thenar atrophy. Surgical decompression is usually necessary in these patients but may result in poor outcomes due to irreversible intraneural changes.

Hypothesis: The aim of this study was to investigate patient-reported symptoms which may enable a clinical diagnosis of median nerve motor branch compression to be made irrespective of the presence of advanced signs.

Methods: One-hundred-and-twelve patients (166 hands) with a clinical diagnosis of Carpal Tunnel Syndrome were referred to the neurophysiology department and completed symptom severity questionnaires with subsequent neurophysiological testing.

Results: An increasing frequency of pain experienced by patients was significantly associated with an increased severity of median nerve motor branch compression with prolonged motor latencies measured in patients that described pain as a predominant symptom. An increasing frequency of paraesthesia and numbness and weakness associated with dropping objects was significantly associated with both motor and sensory involvement but not able to distinguish between them.

Conclusion: This study suggests that patients presenting with a clinical diagnosis of carpal tunnel syndrome with pain as a frequently experienced and predominant symptom require consideration for urgent investigation and surgical treatment to prevent chronic motor branch compression with permanent functional deficits.

Level of evidence: Prognostic study level 2

Introduction: Pseudoarthrosis in Ankylosing spondylitis is often misdiagnosed as infection. It is a slow progressing lesion resulting in a kyphosis and slow onset weakness of the lower limbs. We are presenting our strategy and experience in treating 9 patients with such a lesion.

Method: 9 patients age range from 40–55 years who presented with pseudoarthrosis of the ankylosed spine underwent back-front surgery during 2001–204. 6 patients had dorsal spine lesion, 2 had dorso-lumbar junctional lesion and 1 had cervico-dorsal junctional lesion. 8/9 patients had insidious onset with progressive weakness of both lower limb. 1 patient had an acute onset with deformity. 7/9 patients had neurodeficit (Frankel C) 1/9 had complete paraplegia. All patients underwent posterior kyphosis correction and decompression of the spinal cord. During posterior decompression 8/9 patients had an incidental dural tear due to adherence fractured lamina. The dura was repaired primarily or patch graft. 5/9 patients had single stage back and front surgery. The rest of the patients had staged surgery. The front surgery was excision of the tough fibrotic psuedoarthosis and reconstruction using strut graft/cage.

Results: Average duration of surgery was 4 ½ hours (3 ½ to 6 hours). Blood loss was 800 ml (600–1300 ml). All patients required blood transfusion. Primary dural repair was done in 7/8 cases, patch graft in 3/8 cases, ceiling with fusion glue and fat graft in 1 patient. 5 patients who had less that 1000 ml blood loss during posterior surgery had same stage anterior reconstruction. Rest of the patient had 2 staged surgery. 4/9 patients had previous THR B/L. All patients showed rapid improvement in the neurological status and at 3 months follow up all were Frankel E.

Conclusion: The surgical outcome of the ankylosing spondylitis patients with Andersson lesion with neurological deficit is encouraging. Excision of the pseudoarthroses anteriorly and posterior spinal stabilization resulted in full recovery of the deficit. However there were difficulties encountered during the posterior decompression due to adhesions of the posterior elements to the dura.

Summary: Twenty six consecutive patients with CSM were operated between Jan 2001–Dec 2004 with anterior corpectomy and reconstruction using strut graft/ lordotic cage and stabilization ACP. 10/26 were wheel chair bound/bought on stretcher. 16/26 had spastic lower limbs with myelopathic hands. Post operatively 20/26 had good gait improvement and are community ambulators. 3/26 house hold ambulators and 1 died. 18/26 had good improvement in hand function.

Introduction: Cervical spondylotic myelopathy is a degenerative disease of old age. Patients present with severe disabiling symptoms of spastic gait/inability to walk and varied involvement in the hand. The degenerative spondylosis being the commonest cause, CSM is also caused by OPLL and soft disc herniation.

Methods: 26 consecutive patients who had undergone anterior decompression and reconstruction were evaluated for recovery. The gait pattern, hand functions and return to activities were evaluated pre and postoperatively. No specific scoring system could be used in our studies due to practical reasons.

Results: 18/26 patients had CSM, 5/26 had OPLL and 3/26 soft disc herniations. Soft disc herniation were at 2 levels and all underwent discectomy, tricortical bone grafting and stabilization with ACP. Other patients had corpectomy 1 level – 4, 2 levels – 9, 3 levels – 4, 4 levels – 1. OPLL was removed in 4/5 patients. Xx/10 patients who were wheel chair bound preoperatively became ambulatory, 3/10 had decrease in spasm but still could not walk postoperatively. At 1 year follow up 9/10 patients had good gait pattern and 1 was still wheel chair bound. 18/26 had good hand function recovery with improvement in hand writing, 16/26 returned to previous activity, 1 patient expired.

Conclusion: Anterior decompression for CSN is an effective surgical option. It not only prevents further detoriation, but also improvement is seen in most of the patients.

Significance: Anterior decompression is indicated for all patients with CSM, OPLL and disc herniation as the pathology is anterior based.

Summary. Between January 2003 and October 2004,12 patients with non tuberculous spondylodiscitis were treated by radical debridment, reconstruction and stabilization. In our group 9 patients underwent posterior procedure and 3 underwent combined anterior and posterior procedures. 3 of these had fungal and 9 pyogenic infections. All the patients had appropriate antimicrobial therapy All patients had excellent to good functional results and no evidence of infection at 2 year follow-up.

Introduction. Surgical treatment of nontuberculous spon-dylodiscitis of lumbar spine is challenging due to extensive bone involvement and comorbid conditions. This study is to assess the role of radical debridment followed by reconstruction and stabilization of affected segments in reducing morbidity and mortality in these patients.

Methods. 12 consecutive patients were operated between January 2003 and October 2004. Patients presented with severe back pain, root compression or paraparesis.7 cases had prior spinal surgery. Blood and radiological investigations were diagnostic. All these patients underwent radical debridement, reconstruction and stabilization of affected segments done with titanium pedicular screws, titanium mesh cages, cancellous iliac crest graft. Only posterior procedure in 9 cases, combined anterior posterior in 3 cases followed by adequate and appropriate antimicrobials therapy. Follow-up ranged from 25 to 35 months.

Results: 3 cases were fungal and 9 were pyogenic infection. Oswestry low back questionnaire, kirkaldy-willis criteria showed dramatic improvement of function. All the blood parameters were normalized in 3 months.1 case had dural tear which was repaired immediately,3 cases had wound exploration and lavage. No major complications were encountered. All cases showed Radiological fusion at last follow-up.

Discussion: Radical debridement of necrotic material, decompression of neurological structures, create a good vascularised environment. Restoring stability compromised by either infection or prior surgery helps in healing process and reduces morbidity of patients

Significance: Reconstruction using pedicular system and interbody devices can safely be used in presence of non tuberculous infection provided debridement has been radical.

We present in this study our experience in wide decompression, gradual acute reduction and fusion performed in a single sitting, for high grade spondylolisthesis in 17 adolescent cases.

Between 1994 and 2005 we undertook surgical management of 17 adoloscents with high dysplastic Spondy-lolisthesis. All our patients were young females except for one with average age of 13.9 years. All of our cases involved the lumbosacral junction. 8/14 cases presented with frank spondyloptosis (Grade5). Of the remaining 9 cases, 5/14 cases were grade4 and 4/14 were grade3 dysplastic spondylolisthesis respectively. Our indication for surgery in all these patients was unremitting back pain, radicular pain, abnormal posture, gait abnormalities and progressive slip. All these patients underwent single stage wide decompression, posterior instrumentation and reduction of the slips and postero lateral fusion. Since 1999 in addition to the above we routinely performed inter body fusion with cages in lumbosacral segment (9/17 cases).

All patients’ spondylolistheses were reduced to < grade2.16/17 of our patients had a very satisfactory outcome. Our average follow-up of these patients is 4 years (range 1–9 years).4/17 of our patients developed some dorsiflexion weakness postoperatively and all recovered within 3 months of operation.1 patient developed deep postoperative infection necessitating the removal of the implant.

We conclude that acute correction of high grade spondylolisthesis is a demanding procedure. The newer instrumentation (improved sacral fixation) made reduction less difficult and the final outcome is highly satisfying for the patient and the surgeon.

Background The clinical standards board in Scotland has recognized hip fractures as the most common injury in older people. Hip fracture care is now emerging as a case study for clinical governance in Scotland. Aims/Methods The results of a prospective audit of 1177 hip fractures admitted to Wishaw General Hospital over a 36 month period are presented. All aspects of care from admission to discharge are analyzed, and patients followed up for 4 months after discharge. Results Pre Fracture The most common age group of patients was 80–90 Yrs (40.9%). 10 % of patients were over 90 Yrs.80.3% were female. There was no significant difference in side involved (L 53.3%: R 46.7%).60.1% patients were admitted from own home.71 patients (6%) originated from other wards within the hospital.39.6% patients were found to be living alone. Only 25.9% patients walked alone out of doors before fracture, while 39.1% walked alone indoors but not out of doors.43.8% could walk with out aids. Surgery 52.9% underwent osteosynthesis with screws and plate.34.2% had hemiarthroplasty.3.4% had total hip replacement. 4.1% was treated conservatively.48.3% had general anaesthetic and 47.4% regional anaesthetic.93 % received thromboembolic prophylaxis, and 96% antibiotic prophylaxis. The post operative wound infection rate was 3.2%. 4.9% required a second surgical procedure within 4 months. These included 14 patients who had dislocated prosthesis reduction, 14 conversions to total hip replacement, 9 conversions of osteosynthesis to hemiarthroplasty and 5 refixations. Post Fracture (4 Months) 41.9 % returned to their own home, while 14.7 went into nursing homes.11% were able to walk out of doors alone, and 28% could walk in doors alone. Only 7% could mobilize without and aids, 19.2% used one aid and 30.2% required a walking frame.41.6 % had no hip pain, 18.2 % complained of slight or intermittent discomfort.

Conclusions Older patients (80 Yrs +) are at significant risk of sustaining hip fractures. The risks are greater in patients living alone and in females. Patients with significant co morbidity may have to be treated conservatively. There is a considerable risk of requiring a second surgery. Only about 69 % of patients living in their own homes are able to do the same after fracture. Only about 50 % of previously independent patients were able to regain the same level of mobility.

Introduction and aims: Instrumentation in Spinal Tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem.

Method: We have operated on 147 patients with Spinal Tuberculosis between 1990 and 2001. Between 1990 and 1995 we treated 45 patients in the traditional manner with anterior decompression and strut grafting. During this period we encountered an unacceptably high rate of complications, such as graft collapse, progression of deformity and pseudoarthrosis.

Between 1995 and 2001 we adopted the practice of anterior radical surgery combined with instrumentation (mesh cages and modern multisegment hook/screw system), and employed this approach in 102 patients. Of these: 28 patients underwent surgery at dorsal vertebral level, 35 at dorsolumbar level, and 39 at lumbar level.

Our experience has enabled us to develop a protocol in the management of these patients depending on:

The level of vertebral involvement (cervico-dorsal/ dorsolumbar/lumbar),

In dorsal lesions involving less than two consecutive levels with no deformity, we performed anterior procedure only. In multilevel dorsal lesions with no deformity we did anterior followed by the posterior surgery. In dorsal lesions with deformity we performed Back-Front-Back procedure. In dorsolumbar lesions with single level disease we did anterior procedure only. In presence of multisegment involvement with or without deformity we did Back-Front-Back procedure. In lumbar lesions with anterior and middle column involvement without deformity we performed anterior surgery only. In lumbar lesions with all column involvement with deformity we performed anterior and posterior surgery.

Results: With the use of instrumentation we achieved satisfactory results in terms of correction of deformity. We were also able to carry out extensive debridement (with anticipation of gaining stability with instrumentation), thereby clearing infection locally and effecting neurological improvement in all our cases. There were a few minor complications in our second (instrumented) group. No major complications (death, deep secondary infection or deterioration of the neurology), occurred in this group.

Conclusion: We conclude that Instrumentation in Spinal Tuberculosis is safe. It allows the surgeon to debride the tissues safely and to stabilise the spine and thus prevent deformity. Instrumentation also allows early mobilisation. The radical debridement leads to a reduction in recurrence of infection at the operative site.

Introduction and Aims: Instrumentation in spinal tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem.

Method: We operated on 147 patients with spinal tuberculosis between 1990 and 2001. Between 1990 and 1995, we treated 45 patients in the traditional manner with anterior decompression and strut grafting. We encountered an unacceptably high rate of complications, such as graft collapse, progression of deformity and pseudoarthrosis. Between 1995 and 2001, we adopted the practice of anterior radical surgery combined with instrumentation (mesh cages and modem multi-segment hook/screw system), and employed this approach in 102 patients. Of these: 28 patients underwent surgery at dorsal vertebral level, 35 at dorsolumbar level, and 39 at lumbar level.

Results: Our experience has enabled us to develop a protocol in the management of these patients depending on a) the level of vertebral involvement (cervicodorsal/dorsolumbar/lumbar); b) the presence of single or multilevel disease; and c) location of disease in the spinal columns.

In dorsal lesions involving less than two consecutive levels with no deformity, we performed anterior procedure only. In multilevel dorsal lesions with no deformity we did anterior followed by posterior surgery. In dorsal lesions with deformity we performed Back-Front-Back procedure. In dorsolumbar lesions with single-level disease we did anterior procedure only. In the presence of multi-segment involvement with or without deformity we did Back-Front-Back procedure. In lumbar lesions with anterior and middle column involvement without deformity we performed anterior surgery only. In lumbar lesions with all column involvement with deformity we performed anterior and posterior surgery.

With the use of instrumentation we achieved satisfactory results in terms of correction of deformity. We were also able to carry out extensive debridement (with anticipation of gaining stability with instrumentation), thereby clearing infection locally and effecting neurological improvement in all our cases. There were a few minor complications in our second (instrumented) group. No major complications (death, deep secondary infection or deterioration of the neurology) occurred in this group.

Conclusion: We conclude that instrumentation in spinal tuberculosis is safe. It allows the surgeon to debride the tissues safely and to stabilise the spine and thus prevent deformity. Instrumentation also allows early mobilisation. The radical debridement leads to a reduction in recurrence of infection at the operative site.