Background

Internet delivered interventions may provide a route to rapid support for behavioural self-management for low back pain (LBP) that could be widely applied within primary care. Although evidence is emerging that more complex technologies (mobile apps linked to digital wristbands) can have some impact on LBP-related disability, there is a need to determine the effectiveness of highly accessible, web-based support for self-management for LBP.

Aim:

An assessment of the relationship between pathological Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV).

Aim

Two different techniques to release subscapularis during total shoulder replacement (TSR) have been described (tenotomy and osteotomy) with no consensus as to which is superior. In this study we review the clinical outcomes of a sequential series of patients in whom a TSR for primary osteoarthritis had been performed using either technique at our institution. Subscapularis function was tested using a new graded belly press test, a modification of the traditional belly press test which is described for the first time here.

Subscapularis function following Total shoulder joint replacement has been a concern in recent literature. It has been postulated that lesser tuberosity osteotomy approach may have better Subscapularis function than transtendonous approach.

To assess whether lesser tuberosity osteotomy vs. subscapularis tenotomy is better for post-operative function of subscapularis in total shoulder replacements done by a single surgeon in a District general hospital.

117 shoulder replacements performed by the senior author (TH) at Waikato district general hospital between years January 2002 to January 2010 were reviewed retrospectively. Revision replacement, inverse shoulder replacement & acute traumatic hemiarthroplasty were excluded. Patients with previous rotator cuff problems, previous surgery to subscapularis, rheumatoid arthritis and post-trauma sequelae were also excluded from the study. Inclusion criteria were normal subscapularis function and intact subscapularis on MRI pre-operatively.

41 shoulders were eligible to participate in study of which 1 pt died (bilateral TSR), 1 pt unfit to participate due to cervical disc problems. Of remaining 38 shoulders 11 shoulders had transtendonous and 27 shoulders had lesser tuberosity osteotomy approach. 37 shoulders were reviewed clinically for range of motion of the shoulder and subscapularis strength. Range of motion and subscapularis strength was significantly higher in the osteotomy group. All osteotomies were united on axillary radiograph.

Lesser tuberosity osteotomy approach result in better subscapularis function than transtendonous approach.

Much has been written about ESP (Extended Scope Practitioners) lead clinical services, the vast majority of which have been developed in secondary care. Little evidence is available on the efficacy of ESP. clinics either for both the patient and weather they stream line back pain treatment. We present an interim audit of an assessment pathway for community management and MDT practice for lower back pain.

56 patients were reviewed with a revised ESP assessment tool and then presented to an MDT meeting. Each, assessment was 45 minutes long and outcome measures used included ODI and STaRT scores. Patients were telephoned at 12 weeks following their appointment and then at 18 weeks, to ascertain the progress they were making and to see if the 18-week target had been met.

56 patients were reviewed from September 2009. The average ODI, was 63%, and 56% at 12 weeks; most patients had a STaRT score of 6, and 3 on the psychological component it the beginning of the study. The EQ-5D scores were observed to show an improvement. MRI rates were 3.8% and the DNA rate was 7%. A total of 11 MRI requests; the results of 7 of these were available for analysis. The scans that were requested all showed a disc lesion that was amenable to surgical decompression or stabilization. Overall patients were very satisfied.

Our formatted methodology allowed clinical governance at source to measure the efficacy of patient treatment. Early results suggest an efficient in delivering an acceptable standard of care as long as they are properly supported.

Tissue reconstruction, based on stem cell activity has become an important part of orthopaedic practice. It is now possible to develop cell lines which are able to produce the fundamental cells which can be used in musculoskeletal regeneration, especially in fracture healing, cartilage regeneration, and muscle repair. However, for the newly implanted cells to be effective, it is vital to have an adequate and developing blood supply to that area. Human and animal studies have demonstrated the marked contribution of bone marrow derived precursor cells in the normal bone healing process. Studies of the application of bone marrow graft have shown that there is greater bone growth when more precursor cells are grafted and these cells are thought to be a mixed population of stems cells and their associated progeny. CD34+ cells have shown remarkable ability to differentiate into many cells types which include chondrocytes and osteocytes. They have also been shown to home on to sites of bone injury and mature into bone cells which take part in the repair process. Colleagues in our laboratories have described a plastic adherent sub-population of CD34+ cells which have been able to reconstitute and sustain hematopoeisis over 5 weeks, similar to long-term marrow culture. This sub-population of cells are called omnicytes. Using this sub-population, we have conducted in vitro and animal experiments using a fracture healing model to assess the role of stem cells in accelerating the fracture healing process.

However, it is clear that in order for these cells to be effective, the blood supply needs to be viable. In this paper, the importance of the blood supply and the role of blood flow will be discussed particularly in relation to fracture healing and intervertebral disc regeneration. In fracture healing, the increase of blood flow occurs within the first 6 weeks after the fracture has occurred and CD34+ cells applied to the fracture site via the nutrient artery could accelerate the process of fracture union. In the same way, intervertebral disc patients with chronic low back pain for more than 3 months could be treated with enhanced CD34+ cells in order to allow disc cartilaginous type cells to regenerate.

This will be a review of the role of the blood supply, the development of CD34+ cells (namely omnicytes), and the clinical application of these cells to patients with long bone fractures and low back pain.

Introduction: The purpose of the study was to evaluate the outcome of multiple spinal operations by an expert spinal surgeon HV Crock.

Materials and Methods: A retrospective review of 169 patients who had multiple spinal surgery including spinal Fusion and spinal decompression was undertaken. A special Questionnaire form was designed and sent to each patient to answer with an appointment for the patient to be seen and assessed in the spinal assessment clinic where data from the questionnaire, clinical notes and thorough clinical examinations were recorded in a spinal data base which covered the following sections:

Patients Symptoms

Results:

– 76 patients 66% of the patients who replied “were satisfied” with the surgery.

There were no significant post-operative neurogenic complications, such as cauada equina syndrome or severe leg weakness interfering with standing and walking retirement. There was always a temporary relief followed by deterioration of symptoms after a period ranging between 1–2 years.

Conclusions: Overall, patients with failed back syndrome need to be evaluated and treated in a multidisciplinary setting, where a group of Health Care Professionals from various fields, such as Physiotherapy, Pain Management and Clinical Psychologist work together, towards the common goal for the benefit of the patient

Background and objectives: Tenocytes change their structure, composition and mechanical properties to adapt to mechanical loading. Voltage gated and mecha-nosensitive ion channels may play a key role in human tenocytes to regulate some or all initial responses to mechanical stimulation. To date, there has been no direct investigation of ion channel expression by human tenocytes.

Methods: Human tenocytes were cultured from patellar tendon samples harvested from five patients undergoing routine total knee replacement surgery (mean age: 66 years; range 63-73 years). RT-PCR, Western Blotting and whole cell electrophysiological studies were performed to investigate the expression of different classes of ion channels within tenocytes.

Results: Human tenocytes express mRNA and protein encoding voltage operated calcium channel (VOCCs) sub-units (Ca alpha 1A, Ca alpha 1C, Ca alpha 1D, Ca alpha2 delta1) and the mechanosensitive tandem pore domain potassium channel (2PK+) TREK-1. They exhibit whole cell currents consistent with the functional expression of these channels. In addition, other ionic currents were detected within these tenocytes consistent with the expression of voltage gated potassium channels, voltage gated sodium channels, and other outwardly rectifying leak currents.

Discussion and conclusions: Human tendon cells show increased levels of intracellular calcium when stress is applied to them. One of the mechanisms by which this occurs is by the influx of extracellular calcium into the cell via ion channels. VOCCs and TREK channels have been implicated in mechanotransduction signalling pathways in numerous connective tissue cell types. This study suggests that these mechanisms may be present in human tenocytes. In addition, human tenocytes may express other channel currents. Ion channels may represent potential targets for the pharmacological management of chronic tendinopathies.

Leucocytes are white blood cells that help the body fight against bacteria, viruses and tumour cells. However, the activity of leucocytes has been implicated in other clinically important inflammatory conditions such as ischaemic heart disease, stroke, and during cardio-aortic and orthopaedic surgery.

The main objectives of this study was to optimise methods for the isolation of leucocyte subpopulations (neutrophils and monocytes), and to assess in vitro the effects of PMA and fMLP on markers of leucocyte adhesion (CD11b, CD62L) and activation (intracellular hydrogen peroxide) (n=10). Leucocyte subpopulations were labelled by incubation with fluorescein isothiocya-nate (FITC) conjugated anti-human CD11b and CD62L antibodies. The cell surface expression of these labelled adhesion molecules were measured by flow cytometry. Intracellular production of hydrogen peroxide by neutrophils and monocytes was measured by flow cytometry, using the fluorochrome dichloroflurorescin diacetate (DCFH-DA). These were visualised by Immunofluorescence microscopy.

During this study, methods of isolating leucocyte subpopulations from whole blood were optimised. This ensured that these cells were isolated with consistently high yields, purity and with no changes in cellular function. Following incubation with PMA and fMLP, neutrophils and monocytes displayed an increase in CD11b cell surface expression; a decrease in CD62L cell surface expression; and increased leucocyte activation. Leucocyte activation was represented by the intracellular production of hydrogen peroxide.

In conclusion this study confirms that both PMA and fMLP have an intrinsic effect on markers of leucocyte function. These findings are in agreement with previous studies performed.

Introduction: Preliminary studies suggest that prolonged retraction of the paraspinal muscle during spinal surgery may produce ischaemic damage. We describe the continuous measurement of intramuscular pressures (IMP) during decompressive lumbar laminectomy and the relationship to back pain and disability.

Methods: In this prospective interventional study, 28 patients undergoing surgery for lumbar canal stenosis were recruited. Back pain and function were assessed using the Visual Analogue Score (VAS), Oswestry Disability Index (ODI) and Short Form 36 (SF36) health survey. During surgery, IMP was continuously recorded from the multifidus muscle using a pressure transducer. The intramuscular perfusion pressure (IPP) was derived as the difference between the patient’s mean arterial pressure (MAP) and IMP (IPP = MAP − IMP). The data was analysed using repeated measures ANOVA (SPSS package).

Results: The mean age was 60.4 ± 3 years and the mean duration of symptoms of 31.0 ± 6 months. The predominant symptoms were neurogenic claudication (14) and/or sciatica (13). Patients underwent 1 (N=3), 2 (N=20) or 3 (N=5) level laminectomies. The muscle retractors used were Norfolk and Norwich (N=16) and McCullock (N=12). The mean duration of deep muscle retraction was 68.5 ± 9 mins (range 19–240). On application of deep muscle retraction, there was a rapid and sustained increase in IMP (F=26.8; p< 0.001; repeated measures ANOVA), and overall the calculated mean IPP approached 0 mmHg or less during this period (F=36.8; p< 0.001). On release of deep muscle retraction there was a rapid decrease in IMP to pre-operative levels. The IPP was greater with Norfolk and Norwich than McCullock retractors (F=12.2; p< 0.001). Compared to pre-operative values, there was a decrease in ODI (F=18.6; p< 0.001) and VAS for back pain (F=9.9; p< 0.001) at discharge, 4–6 weeks and 6 months, post-operatively. Compared to pre-operative values, there was a decrease in SF36 scores at 6 months (F=26.7; p< 0.001). Total duration of muscle retraction over 60 mins was associated with higher VAS scores for back pain at 4–6 weeks and 6 months postoperatively (F=3.7; p< 0.01). There was no relationship between IPP and post-operative ODI or VAS for back pain.

Conclusions: This study demonstrates a simple technique for the continuous monitoring of IMP during spinal surgery, from which the IPP can be derived. Comparison of two muscle retractors has shown that the McCullock retractor generates a higher IMP than Norfolk and Norwich retractor. Decompressive lumbar laminectomy improves the VAS for back pain and ODI and SF36 outcome scores in these patients. The results show that duration of muscle retraction, rather than extent of the pressure generated by the retractor, is related to postoperative back pain.

Introduction: Duplex ultrasound has recently been used to demonstrate inflammatory hyperaemia in arteries supplying inflamed joints in RA, bursitis, and tendonitis. The technique has yet to be applied to examine blood flow in lumbar arteries in LBP patients, though we have previously shown its feasibility in healthy subjects. Our aim was to determine if there are differences in the flow characteristics of lumbar arteries in patients with LBP that may be reflective of pathology.

Materials and Methods: Sixty four patients with LBP (21–82 years) and 30 volunteers with no history of LBP (19–82 years) were studied. Sacral and lumbar arteries at L5 to L1 were identified and hemodynamic data was obtained using Duplex ultrasound. Angle corrected measurements of blood flow peak systolic velocity (PSV) were obtained at all lumbar levels and the aorta.

Results: Mean lumbar artery PSV was normalized with mean aorta PSV for patient and control groups. Reference range (mean ± 1.96SD) for normal lumbar artery PSV was defined from the control data and the proportion of patients with abnormally high PSV determined.

Discussion: Blood flow velocity in lumbar arteries of LBP patients is significantly higher compared with asymptomatic controls (p< 0.01). Approximately 40% of the LBP group have abnormally high lumbar artery flow velocity and the proportion of abnormal values increases at lower levels. Abnormally high velocity flow suggests the presence of an inflammatory component in the lumbar spinal structures. This technique has important applications in improving diagnostic specificity and assessing outcome of treatment in patients with LBP.

Aims: To compare the results of resurfacing hip arthroplasty with conventional total hip replacement and to find out any differences in complication rates, discharge patterns and the resulting financial implications.

Trial Design: Retrospective analysis comparing resurfacing hip arthroplasties to conventional total hip replacements in patients who were 65 years old or younger at the time of operation. Criteria for comparison were blood loss, post operative complications (including the need for blood transfusion), revision of arthroplasty and the length of hospital stay.

Materials and Methods: All patients who had resurfacing arthroplasty in our hospital were included in the study (77 patients), and a similar group who had total hip replacements in the same time period were randomly selected for comparison. Case notes, computer records as well as X-rays were used to identify postoperative complications, especially DVT’s ,PE’s, neuro-vascular injuries, infection, fractured neck of femur and the need for revision of an arthroplasty. A detailed analysis of all revision arthroplasties including the causes, failure pattern of implant and the type of revision hip arthroplasty used and its cost implication was made. We also compared the pre and post-operative haemoglobin and units of blood transfused, if any. A comparison was also made of discharge pattern of these two groups of patients. A student t-test was performed to observe any difference in these two group.

Results:

Resurface hip arthroplasty Group: Average age 52.1 years; pre-operative Hb 14.22gm/dl; postoperative Hb.10.95gm/dl; average blood loss 3.28 gm/dl; Total hips revised 12; Average length of stay 8.53 days.

Conclusions: 1.There were no appreciable differences between these two group as far as the usual complications, blood loss and length of stay are concerned. 2. There was appreciable difference in revision rate, which has significant cost implication for health authority and patients

Antibiotics are frequently administered prophylactically in spinal procedures to reduce the risk of disc space infection. There is still controversy, however, over which antibiotics are able to penetrate the intervertebral disc effectively and whether the charges on the antibiotics are important in determining their ability to diffuse into the negatively charged intervertebral disc.

In a prospective randomised double blind clinical study, we examined the penetration of two commonly used antibiotics, cefuroxime (negatively charged) and gentamicin (positively charged), into the intervertebral discs. Twenty patients, randomised into two separate groups, received either 1.5g cefuroxime or 5 mg/kg gentamicin prophylactically two hours before their intervertebral discs removed. A blood specimen, from which serum antibiotic levels were determined, was obtained simultaneously with each discectomy.

Clinical therapeutic levels of antibiotic were detectable in the intervertebral discs of all the ten patients who received gentamicin. Only two of the ten patients (20%) who received cefuroxime had quantifiable level of antibiotic in their discs even though serum levels of cefuroxime were at therapeutic levels in all ten patients. Our results showed that cefuroxime does not diffuse into human intervertebral discs as readily as gentamicin and suggest that the charge due to ionisable groups on the antibiotics is important in determining the penetration of antibiotics. We therefore recommend the use of gentamicin in a single prophylactic dose for all spinal procedures to reduce the incidence of post-operative discitis.

Vascular Endothelial Growth Factor (VEGF) has been shown to stimulate angiogenesis in a number of tissues and, in addition, to possess direct vasoactive properties. Stimulation of blood flow and angiogenesis are important features of the fracture healing process, particular in the early phases of healing. Inadequate vascularity has been associated with delayed union after fracture. The periosteum, and in particular its osteogenic cambial layer, has been shown to be very reactive to fracture and to contribute substantially to fracture healing. Fracture haematoma contains a considerable concentration of VEGF and enhanced plasma levels are observed in patients with multiple trauma. VEGF has been suggested to play a role during new bone formation possibly providing an important link between hypertrophic cartilage, angiogenesis and consequent ossification. However, the expression of VEGF in normal periosteum and in periosteum close to a fracture has not been previously reported. We hypothesise that the expression of VEGF in long bone periosteum will show a distinct response to fracture.

We investigated the expression of VEGF in vivo in human periosteum, using immunocytochemistry to detect the expression of Factor VIII and VEGF protein respectively. Under prior approval from the local Ethics Committee, biopsies of periosteal tissues were collected from two distinct groups (1) control and (2) following long bone fracture. Patient age range was 16 – 45 years for both groups. Group 1 consisted of patients (n = 5) who underwent an elective orthopaedic procedure during which periosteum was disrupted. Group 2 patients (n = 8) had long bone fractures from which periosteal tissue was harvested close to the fracture site during internal fixation at various time points following fracture (24 hours to nine days).

In Group 1 the periosteum showed abundant but delicate blood vessels staining throughout for VEGF but there was no other visible staining of other structures or cells. In Group 2 the vasculature in the periosteum close to the fracture site demonstrated a characteristic, time-dependent course of expression of VEGF. At 24 and 48h following fracture the vasculature showed a heterogenous picture. The vessels in periosteum showed signs of activation: thickened endothelia and dilated lumina, but did not express VEGF. At 60h the vessels began to show signs of the presence of VEGF protein and by 4 days most periosteal vessels expressed VEGF. Also at this time, VEGF staining was visible in some of the stromal cells of the periosteum that was not seen in any of the earlier times. At 9 days VEGF was visible not only in the omnipresent vasculature, but now consistently in spindle shaped cells of fibroblastic appearance and chondrocytes throughout the early callus.

This study, though limited by the number of patients, shows for the first time the expression of VEGF in normal periosteum as well as in periosteum during fracture healing. Interestingly, activated vessels in the early healing phase show little expression of VEGF; however it is known that the fracture haematoma contains VEGF in abundance. It is possible that the vasoactive role of VEGF prevails in these early days. There may be a critical time point at around 48h post fracture following which angiogenesis begins and VEGF is expressed in the endothelium throughout the vessel wall. The study suggests an important role for VEGF in the regulation of fracture healing. VEGF is not only expressed in endothelial cells within the periosteum but also in fibroblast-like stem cells and chondrocytes throughout the early callus suggesting it may play an important role in both osteo- and angiogenesis

Aim of Study: The aim of the study was to investigate the effect of muscle retractors on intramuscular pressure in the posterior spinal muscles during posterior spinal surgery.

Methods: Twenty patients undergoing posterior spinal surgery were recruited into this study and recordings of intramuscular pressure during surgery were performed using a Stryker® compartment pressure monitoring system, prior to insertion of retractors, 5, 30 and 60 minutes into surgery and on removal of retractors. Prior to and following use of the retractors, muscle biopsies were taken from the erector spinae muscle for analysis.

Results: A significant increase in intramuscular pressure (p< 0.001) was observed during surgery, with pressure rising from 7.1±4.1 mmHg pre-operatively to 26.4±16.0 mmHg 30 minutes into the operation. On removal of retractors, this pressure returned to or near to the original value. Analysis of muscle biopsies using calcium-activated ATPase birefringence revealed a reduction in muscle function following prolonged use of self-retaining retractors.

Discussion: This study demonstrates a substantial rise in pressure in the erector spinae muscle during posterior spinal surgery. Following retraction, marked changes were noted in the function of the muscles. This could be an important factor in the generation of operative scar tissue and post-operative dysfunction of the spinal muscles, and therefore, may be a cause of persistent back pain frequently observed in post-operative patients. Currently, this work is being extended to investigate the relationship between loss of muscle function and duration of retraction, and to study the long term implications of loss of muscle function with respect to surgical outcome and chronic back pain.

Study Design: To examine the innervation of the lumbar spine from patients with lower back pain, and spinal nerve roots from patients with traumatic brachial plexus injuries.

Objectives: To demonstrate the presence of nerve fibres in lumbar spine structures and spinal nerve roots, and determine whether they express the sensory neuronespecific sodium channels SNS/PN3 and NaN/SNS2.

Summary of background data: The anatomical and molecular basis of low back pain and sciatica is poorly understood. Previous studies have demonstrated sensory nerves in facet joint capsule and prolapsed intervertebral disc, but not in ligamentum flavum. The voltagegated sodium channels SNS/PN3 and NaN/SNS2 are expressed by sensory neurones which mediate pain, but their presence in the lumbar spine is unknown.

Methods: Tissue samples (ligamentum flavum n=32; facet joint capsule n=20; intervertebral disc n=15; spinal roots n=8) were immunostained with specific antibodies to protein gene product (PGP) 9.5, a pan-neuronal marker, SNS/PN3 and NaN/SNS2.

Results: PGP 9.5-immunoreactive nerve fibres were detected in 72% of ligamentum flavum and 70% of facet joint capsule but only 20% of intervertebral disc specimens. SNS/PN3-and NaN/SNS2-positive fibres were detected in 28% and 3% of ligamentum flavum and 25% and 15% of facet joint capsule specimens respectively. Numerous SNS/PN3 and NaN/SNS2-positive fibres were found in the acutely injured spinal roots, and some were still present in dorsal roots in the chronic state.

Conclusions: SNS/PN3 and NaN/SNS2-immunoreactivity is present in a subset of nerve fibres in lumbar spine structures, including ligamentum flavum and injured spinal roots. This is the first time that sensory nerve fibres have been demonstrated in the ligamentum flavum, and this raises the possibility that, contrary to the conclusions of previous studies, this unique ligament may be capable of nociception. Selective SNS/PN3 and NaN/ SNS2 blocking agents may provide new effective therapy for back pain and sciatica, with fewer side effects. Other novel ion channels are being studied in these tissues.

There is a paucity of information regarding patient rated expectations of surgery and measures of satisfaction with surgery in terms of specific outcome measures such as pain. The aim of this study was to investigate patient expectations of surgery and short and long term satisfaction with the outcome of decompressive surgery in terms of pain, function, disability, general health.

Eighty-four patients undergoing spinal stenosis surgery were recruited into this study. On recruitment into the study patients were also asked to rate their expectations of improved in pain, general health, function etc. In addition at each review stage patients were asked to rate their satisfaction in improvement of these key outcome measures.

These demonstrated that patients had very high expectations of recovery particularly in terms of pain and function and that patients were confident of achieving this recovery (76.8%) confident of a good result. Levels of satisfaction however, varied considerably. 41% of subjects were 50% satisfied with the outcome, whilst 30% were dissatisfied. Most patients felt that they had made the right decision to have surgery although the surgery had only achieved 43.4% ± 37.8 of the outcome they had expected.

Examination of patient’s expectations of and satisfaction with surgery revealed that frequently patients had unrealistic expectations of their surgery and as a consequence tended to have lower levels of satisfaction.

The majority of studies investigating the outcome of lumbar decompression surgery have been retrospective in nature and have not used validated measures of outcome. The aim of this study was to prospectively investigate the short and long term outcome of lumbar decompression surgery in terms of function, disability, general health and psychological well being.

Eighty-four patients undergoing lumbar spinal stenosis surgery were recruited into this study. Patients were assessed using validated measures of outcome pre-operatively, and at 6 weeks, 6 months and one year post-operatively.

A significant reduction in pain (p< 0.001) was observed at the 6 week post-operative stage, this did not change at the subsequent assessment stages. Only some of the SF~36 categories were sensitive to change. The sub-categories that were sensitive to change were; physical function (p< 0.05); bodily pain (p< 0.001); and social function (p< 0.05). Improvements were observed in these categories at the 6 week and 6 month reviews. A gradual reduction in the Oswestry Disability Index (ODI) was observed with time, with changes principally being observed between the 6 week and 6 month review, and 6 week and one year review stages (p< 0.05). Minimal changes were observed in the psychological assessments with time. The outcome of surgery could not be predicted reliably from psychological, functional or pain measures.

Lumbar decompression surgery leads to a reduction in pain and some improvements in function.