Introduction: With the rising popularity of biological fixation, “Less invasive skeletal stabilisation system” (L.I.S.S.) has emerged as a valid option to treat complex fractures around the knee. Published reports have shown good results with shorter healing time and lesser re-operation rates. However as with any close procedure, restoring correct alignment of the limb could be difficult with this system and has not been reported previously. We report the results of CT alignment study in 20 cases of LISS fixation.

Methods: In a combined retrospective-prospective study, 20 patients, who were treated with LISS system for stabilizing either femoral or tibial fractures were enrolled. Patents with only unilateral fractures with a normal contra-lateral lower limb were included. All patients had CT scannograms and limited axial CT cuts of both lower limbs. Axial and rotational alignments were measured and assessed by one consultant radiologist.

Result: There were 9 cases of femoral and 11 cases of tibial LISS . The mean total malrotation was found to be 11.97 degrees (2.0–34.5). All femora were found to be malrotated externally with a mean of 11.71 degrees where as for the tibiae the mean internal and external malrotaions were found to be12.53 and 11.74 respectively. Mean coronal malalignment was found to be 3.76 degrees. If acceptable alignment was taken as 5 degrees in any plane, then the degree of malrotation in our study was found to be statistically significant.

Discussion and conclusion: Malalignment, mainly in the rotational plane has been reported in other closed techniques such as femoral and tibial nailing. As LISS is also minimally invasive and done through indirect reduction techniques, restoration of correct alignment could be difficult to achieve. This study is reassuring as we have found that generally, alignment of limb in our study was satisfactory and no corrective surgery was needed.

Introduction and Aims: Acute intramedullary stabilisation of femoral shaft fractures in multiply injured patients remains controversial. Intravasation of medullary fat during nailing has been suspected to trigger ARDS. This study investigates the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurisation in a canine experiment.

Method: Using an established model, 12 mongrel dogs were randomised into two groups. Under general anesthesia, cannulations were performed to measure left and right-sided pressures. Transoesophageal echocardiography was performed in all dogs. A special ‘TRAP ‘filter was inserted percutaneously into the left common iliac vein in six dogs, whereas the other six served as controls. In all dogs, the left femora and tibiae were then pressurised by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and echocardiography images were recorded continuously. After one hour, the animals were sacrificed and the lungs were harvested for histomorphommetric analysis.

Results: The mean pulmonary artery pressure at three minutes of pressurisation was 12mm of Hg in the filter group and 28mm of Hg in the control group. There was increase in the peak systolic pulmonary artery pressure and the right ventricular pressure after canal pressurisation in the control group, whereas no such changes were observed in the filter groups. The pulmonary vascular resistance as denoted by the difference between the mean pulmonary artery pressure and the end diastolic left ventricular pressure increased significantly (p< 0.05) at three, five, 10,15 and 30 minutes after pressurisation in the control group when compared to the baseline value. In the filter group, the pulmonary vascular resistance increased only slightly after pressurisation. Transesophageal echocardiography images were analysed by a blinded echocardiologist. There was evidence of moderate to severe embolisation in the control group with detection of large echogenic particles. In comparison, there was mild grade of embolisation in the filter group. Histological analysis showed statistically significant difference between the two groups, when comparison of the percentage of area of lung tissue occupied by fat, the percentage of pulmonary vasculature occupied by fat and the maximum size of the embolus were made (p< 0.05).

Conclusion: This study has conclusively demonstrated that mechanical blockade by venous filters prior to medullary canal pressurisation, significantly reduces the embolic load and its effect on the lungs. A retrievable filter with a system to remove the accumulated marrow content is being developed for use in high-risk patients.

Study Design: Prospective cohort study.

Objectives: To evaluate outcomes for back pain following primary single level spinal decompression for nerve root pain.

Subjects: All patients were managed in a single spinal unit with two spinal surgeons following the same management protocol. Any patient undergoing spinal fusion was excluded. Over a five-year period there were 217 patients, with a mean age of 39 years (15 to 78 years). The male to female ratio was 1:1. All had specific single level nerve root pain and definite nerve root compromise confirmed on MRI.

Outcome Measures: All patients were assessed preoperatively and followed at 3, 6, 12 and 24 months using a standard back pain questionnaire including visual analogue scores for leg and back pain, a pain diagram, Oswestry disability index (ODI), Zung depression index and somatisation scores.

Results: We report a statistically significant improvement in back pain post-operatively with 68.6% of patients improving their score (p < 0.001 sign test) with 19.5% reporting complete relief. This improvement was sustained over the follow-up period. Post-operative improvements in back pain correlated well with post surgical reduction in leg pain score, and ODI. Patients with increased back pain scores (> 5) at presentation, were more likely to report an improvement. In this group 80.5% reported a significant reduction in their back pain following surgery. No correlation could be identified between back pain scores and somatisation and Zung depression indices, age, gender or employment status.

Conclusions: These results are contrary to other reported series and suggest the prognosis for back pain following primary single level spinal decompression may be better than anticipated.

Study Design: A retrospective study of the clinical outcome of patients with lumbar discogenic pain with Modic changes on MRI prior to intradiscal steroid injection.

Objectives: To determine whether the clinical outcome of patients with discogenic back pain who underwent intradiscal steroid injection could be predicted from MRI Modic changes.

Methods: The pre-operative scans were studied by two senior spinal surgeons. The lumbar vertebral end-plate changes were then classified according to the method described by Modic. The intra- and inter-observer ratings were satisfactory.

Subjects: 40 patients with discogenic back pain were recruited in this study. The mean age was 43.6 years (23 to 72 years). The male to female ratio was 1 to 1.

Outcome Measures: The clinical outcomes at six months post-intradiscal steroid injection were correlated with the Modic changes. The clinical outcomes were assessed using visual analogue scores for back pain as well as Oswestry disability index (ODI). At least a 2-point improvement in visual analogue score and a 20-point improvement in ODI were required to indicate significant symptomatic relief.

Results: We found that in those patients without Modic changes there was improvement of the low back pain in 9% (1/11). In those with Modic I changes there were significant relief in 64% (9/14), moderate relief in 29% (4/14) and no relief in 7% (1/14). In those with Modic II changes there were significant relief in 27% (4/15), moderate relief in 27% (4/15) and no relief in 47% (7/15). There were no cases with Modic III changes.

Conclusions: Previous studies on intradiscal steroid injections have shown variable results. Two prospective double-blind clinical trials, using intradiscal steroids, identified no significant benefit or improvement in the clinical outcome. Our results however suggest that patients with Modic I changes on MRI are most likely to benefit from intradiscal steroid injection in the short term.

Study Design: A retrospective cross sectional cohort study of degeneration of the lumbar spine, using pre- and post-discography MRI scans of 28 patients, as compared to two consecutive MRI scans of an age and sex matched control group of 32 patients.

Objective: To determine whether injection of steroid into a lumbar intervertebral disc causes degeneration, as assessed by magnetic resonance imaging (MRI).

Methods: Twenty-eight patients with chronic discogenic low back pain were selected. Each had been investigated with an MRI, discography (with intradiscal injection of methylprednisolone), and a post-discography MRI scan. A randomly selected control group of thirty-two age and sex matched patients, having been examined on two occasions with MRI, was established. Two interpreters blinded to the patient groups assessed the degree of lumbar disc degeneration on the MRI scans on two separate occasions, using the Pfirrmann grading system.

Results: Kappa values proved interpretation consistency as compared with the published Pfirrmann paper. Variables of age and sex in the two groups showed no true variation in whether the discs improved, stayed the same or degenerated. The difference in the proportions for those with and without the injection gave a test statistic of 11.92 (p-value=0.002), indicating a discrepancy in the degeneration between those discs with and without an injection.

Conclusion: Previous studies on intradiscal steroid injections have shown variable results. Animal studies have shown that steroid administered intradiscally causes degeneration and primary calcification in discs. Two prospective double blind clinical trials using intradiscal steroids identified no significant benefit or improvement in the clinical outcome. This study indicates that intradiscal steroid injections cause MRI visible disc degeneration. In association with the results of the clinical trials, this study questions the indications for the use of intradiscal steroids in the management of discogenic low back pain.

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons’ score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016).

Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.