Abstract: It is known that the treatment of intra or extraspinal paediatric tumours with surgery and radiotherapy or radiotherapy alone can lead to the onset of progressive spinal deformity the management of which can be extremely challenging. We review our series of patients who have developed a spinal deformity in these circumstances.

Methods: A review of all patients seen between 1996 and 2007 in the spinal department who have developed a significant spinal deformity following treatment for an intra or extra spinal tumour.

Results: 14 patients were identified. The age of presentation to the spinal service was between 2 years 6 months and 15 years 3 months. The underlying diagnoses were Wilms Tumour treated with surgery and radiotherapy in 3, 1 extraspinal sarcoma treated with surgical resection, radiotherapy and chemotherapy, 1 extraspinal neuro-blastoma treated with surgery, radiotherapy, chemotherapy and stem cell rescue and 9 intra spinal tumours (PNET, astrocytoma, ganglioneuroblastoma and der-moid) all managed with resection with or without radiotherapy. The spinal deformities that have developed were thoracic kyphoscoliosis, thoracolumbar kyphosis and lumber hyperlordosis. The spinal management of these deformities has been conservative in 12 with regular assessment to allow intervention if indicated. 2 patients have undergone surgery, a vascularised fibular strut graft and anterior instrumentation in 1 and a non vascularised rib graft in 1 for progressive deformity felt to lead to neurological dysfunction or lung hypoplasia. The cases managed operatively were complicated by poor posterior soft tissues following previous surgery and radiotherapy requiring an anterior approach. In all patients who were treated with radiotherapy platyspondyly was always seen in the vertebral bodies anteriorly and this corresponded to the apex of the deformity.

Conclusion: In all children who undergo spinal surgery and or radiotherapy for paediatric tumours there must be ongoing surveillance for the development of a spinal deformity. We feel that this is as much a result of anterior growth arrest secondary to radiotherapy as to posterior laminectomy for intra canal tumour excision. The surgical management of this problem is complex and may require innovative solutions.

Introduction: The natural history of scoliosis in the presence of a cord syrinx, either treated conservatively, or post surgically, is disputed. It is generally believed to be associated with a greater likelihood of rapid deformity progression pre-operatively and a much greater likelihood of intraoperative neural injury.

In this study we aimed to retrospectively assess the local experience by reviewing patients, treated over the last 10 years, in whom scoliosis has been established, by means of MR imaging, to be associated with a cord syrinx.

Methods: A retrospective cohort study was undertaken of paediatric patients attending the Leeds Spinal Unit between the years of 1997 and 2007. The entry criteria for this study were spinal deformity with MRI proven cord syrinx, in a patient without underlying tumour or other cord anomaly. Given the association with Chiari malformation this was a measured parameter rather than exclusion criteria. Other parameters assessed were mode of presentation, progression of scoliosis, details of the identified syrinx, chosen mode of treatment for the syrinx and the scoliosis (including conservative) and outcome measures (neurological function and sequelae, change in Cobb angle/deformity correction).

Results: A total of 46 patients were identified with scoliosis and an associated syrinx. The age range was from 3 to 18 years. Only 12 were male. The syrinx was associated with an Arnold Chiari malformation in 24% of patients, and located at the apex of, or local to, the maximum deformity in 73%.

The syrinx was treated surgically in 10 patients, with 80% of these achieving either deformity arrest, or no longer requiring surgical deformity correction. In the 2 patients from the same subset who did undergo deformity correction there was no neurological sequelae. Of the conservatively managed syrinxes, deformity correction with intraoperative cord monitoring was nevertheless undertaken in 31%, all without neurological sequelae. In just 4 patients (of 69%) who did not proceed to deformity correction, surgery was precluded by the inherent risks in the presence of an untreated syrinx.

Conclusion: This small series does not lend support to the literature and anecdotal evidence for significantly increased surgical risk in deformity correction without treatment for syrinx first. However, this may reflect the fact that all syrinxes likely to compromise the surgical procedure were assessed as such and treated first. In the cohort of patients whose syrinxes were treated conservatively, a significant proportion did not require subsequent deformity surgery. Identifying a syrinx by, the mandatory, MR imaging of a patient with a deformity before considering surgical correction, appears to identify a significant proportion of syrinxes which neither significantly accelerate the progression deformity, or which do not lead to poor outcome after deformity surgery.

Many studies in UK and other countries over the past 15 years have shown a high one year prevalence of back pain in teenagers rising from around 12% at the age of 12 to adult levels in excess of 30% by the age of 19.

Around 8% of all adolescents are significantly affected by chronic or recurrent back or neck pain sufficient to compromise school attendance and/or sport. Girls report around 10% more disability than boys.

Adolescent back pain, especially when accompanied by MRI changes at the age of 15, is associated with continuing symptoms in adult life.

Associated risk factors are physical, environmental, psychosocial and genetic. Some of these can be rectified, others clearly cannot, but once identified, they can usually be managed satisfactorily to minimise disability.

Known physical factors include too little or occasionally too much exercise, also many schools do not have adequate lockers which necessitates carrying heavy loads of books, sports equipment, etc. often in inadequate bags. A maximum load of 15% of body weight is recommended.

Environmental factors include poorly designed lowest cost school furniture causing postural strain, which cannot be adjusted to take account of the half metre variation in height of 15 year olds. One size does not fit all. Much school furniture would be illegal in an office, School is the workplace of the child.

This paper reviews the recent literature which indicates that attention to these factors results in better school performance and less back pain but further research is required.

Purpose of Study- To deliver high quality and high volume major joint replacement surgery through rigorous infection control and reduce both infective complications and late cancellations.

Deep infection complicating arthroplasty surgery carries a heavy fnancial and emotional burden on any orthopaedic service. The cost of hospital acquired infection is estimated at £1 billion per year 1 by the National Audit Office.

Healthcare associated infection is an area currently under great scrutiny. Each NHS trust will have an Inspector of Microbiology, who will ensure the co-ordination of information required to diagnose healthcare associated infection.

The Alexandra Hospital, Redditch has developed a dedicated elective orthopaedic ward free from multi resistant staphylococcus aureus (MRSA). that delivers high quality and high volume major joint replacement surgery through rigorous infection control.

Between October 2001 and December 2002, the Alexandra hospital had an infection rate of 0.21% for total knee replacements compared to the national rate of 2.1% p= 0.002 (CI 0.00005–0.01) The infection rate for total hip replacements was 1.31% compared to 3.8% nationwide. p = 0.01 (CI 0.004–0.03).

The total number of joint replacements performed per year increased from 256 in 2000 to 629 in 2002.

We have developed a safe, effective and efficient orthopaedic unit within the framework of an NHS trust for a relatively modest investment. We believe the practical changes that have been made within our department can be repeated in other units around the country with relative ease.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aim: To establish the surgical treatment of displaced intracapsular femoral neck fractures in hospitals across the United Kingdom.

Methods: The on-call registrars in all 223 hospitals receiving acute orthopaedic admissions in the UK, were interviewed by telephone. Their usual practices were recorded for two groups of patients, active and frail. The proportions of hospitals using the different surgical options were determined.

Results: Despite stereotyped clinical features, management varied between specialists within some hospitals: two or more different methods of treatment were in routine use for active patients in 22% of hospitals, and for frail patients in 27%. The management also varied between hospitals. Overall, for active patients, bipolar hemiarthroplasty was in use in 41%, internal fixation in 37%, unipolar hemiarthroplasty in 32% and total hip replacement in 16% of hospitals. For frail patients either Austin-Moore or Thompson prostheses or both were in use in 94% of hospitals. Where used, Austin-Moore prostheses were uncemented in 93% of hospitals, and Thompson prostheses cemented in 79%. Bipolar prostheses were in use in 8%, and the alternative of internal fixation undertaken for frail patients in 1% of hospitals.

Conclusions: The findings demonstrated a lack of consensus in several aspects of the treatment of displaced intracapsular fractures of the femoral neck, with implications for consideration of best practice, in the UK, and worldwide.

Following the discovery of a powerful venous pump in the foot that is activated by weight-bearing independently of muscular action, a pneumatic impulse device was developed to actuate this pump artificially. In a multicentre international trial the device was shown to reduce post-traumatic and postoperative swelling; pain also was alleviated. Evidence is also presented that dangerously high compartment pressures may be reduced to acceptable levels and fasciotomy avoided. We present an explanation of the clinical effects of activation of the venous footpump, based on recent improved understanding of the physiology of the microcirculation. The hyperaemic response that follows the liberation of endothelial-derived relaxing factor (EDRF) by sudden changes of pressure after weight-bearing or impulse compression is particularly important.