Purpose of the study

Release of tight lateral structures is an integral part of balancing the valgus knee during knee replacement surgery. The posterolateral capsule is released through an inside-out technique. The common peroneal nerve is in close proximity to the capsule during this step. This study was undertaken to determine the distance of the nerve and the safe level for the posterolateral release.

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study.

224 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006-2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently.

Among 224 patients 13 (5.8%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11-40). 84.6% (n=11) patients were female and 15.3% patients were male. There was varying severity of curve patterns. We have noted two lumbar/thoraco-lumbar curves (Lenke 5), King Type I-6, King Type II-2 and three King Type III curves. All scoliotic deformities were non-structural. Bilateral pars defect was noted in nine (69%) patients.

Previous studies (Fisk et al, 1978; Mau H 1981) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Sairyo et al.). Our study reveals the incidence of pars defect in AIS to be 5.8 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study.

Methods: 229 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006–2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently.

Results: Among 229 patients 18 (7.86%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11–40). Male -5 (27.7%), female- 13(72.2%). There was varying severity of curve patterns, major thoracic curve-10, major lumbar curve-4, mild thoracic curve-3 and mild lumbar curve in one. Bilateral pars defect was noted in 14 (77.8%) patients.

Discussion: Previous studies (Fisk et al, 1978; Mau H 1977) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Sairyo et al, 2009). Our study reveals the incidence of pars defect in AIS to be 7.86 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

Conflicts of Interest: none

Source of Funding: none

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study.

Methods: 229 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006–2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently.

Result

Among 229 patients 18 (7.86%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11–40). Male-5 (26.3%), female- 4(73.6%). Majority of the patients with were females (72.2%). There was varying severity of curve patterns, major thoracic curve-10, major lumbar curve-4, mild thoracic curve-3 and mild lumbar curve in one. Bilateral pars defect was noted in 14 (77.7%) patients.

Discussion

Previous studies (Fisk et al, 1978; Mau H 1977) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Jon R. Davids et al, 2004). Our study reveals the incidence of pars defect in AIS to be 7.86 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

Background A further two changes to the technique of primary Total Hip Arthroplasty (THA) have recently been advocated, computer assisted surgery and access by mini incision(s). These add to the potential different ways the surgeon can perform THA and are still in an early evolutionary stage. However, they add further fuel to the question, what is the best technique for THA ?

Method We considered the procedure of THA and broke it down into the main component stages. We then assessed the various possible different options for each different stage from the literature and a survey of 14 Orthopaedic Surgeons (6 consultants, 2 associate specialists and 6 trainees).

Results We calculate that THA can be performed by at least 1.08 x 10¹¹ different unique techniques. We were unable to find any consensus on the best technique for THA.

Conclusions This massive diversity causes problems with informed consent, research and training. NICE and NJR have issues regarding choice of implant but we believe the choice of surgical technique for THA can play an even more important role in outcome.

Few studies suggest that the use of a cemented stem reduces proximal stresses and may result in proximal bone resorption. Aim of our study: Does bone cement affect peri prosthetic bone density? The study was approved by the local ethics committee.

Patient and methods: 30 patients were included in each group based on power analysis. All 60 patients had the same type of knee replacement (Rotaglide rotating platform). Both groups, cemented and uncemented respectively were matched for the variables like mean age (67.2 & 67.33 years), gender (13: 17 males: females), body mass index (30.95, 29.90), average time following surgery (4 and 3.25 years), activity level (UCLA scoring: 6 & 4) and mean T score (osteoporosis index: −0.51 & −0.62). Periprosthetic bone density was measured in five regions of interest in the distal femur and five regions of interest in the proximal tibia. This was performed with Prodigy scanner (Lunar) using ‘orthopedic’ software to eliminate metal related artifacts. The same area was measured on the opposite unoperated knee. The values thus obtained were compared between the cemented and uncemented groups.

Results: There was no statistically significant difference in bone density around proximal tibia, patella and bone density proximal to femoral flange. However, there was some difference between the groups for bone density behind the flange of the femoral component measured in the lateral view, although not strictly significant at the 5% level. In this region of interest, the bone density in the cemented group appears to be less than in the uncemented group (p=0.059).

Conclusion: Use of bone cement do not seem to alter the peri prosthetic bone density contrary to suggestions in a few other studies. While reduction in periprosthetic bone density is noted in both groups, use of bone cement did not affect the results significantly.

Introduction: To measure the incidence of late presenting DDH following the introduction of selective ultrasound screening of neonatal hips with associated risk factors.

Method: Retrospective cohort study of children with late diagnosed DDH in a defined population of Greater Glasgow Region. A hip ultrasound program was introduced in the year 1997 for secondary screening of children with risk factors for DDH. The departmental and theatre database was used to identify children with late diagnosed DDH. (Defined as diagnosed 3 months after birth) Demographic details, age at presentation, presence of risk factors (Breech presentation, family history, clicks, caesarian section) and details of treatment were recorded. The number of live births for each year was obtained from the General Registrar Office for Scotland. The incidence of late presenting DDH was calculated taking in to account the year of child’s birth. The incidence of late DDH was then compared between the period 1992 –1996 and 1997– 2001.

Results: 78 children were identified, of which 49 babies were between 1992 – 96 and 29 between 1997 –01. The average age at diagnosis was 17 months (Median 15 months, range 5 –84 months). The average annual incidence from 1992 –6 was 0.84 per 1000 live births and from 1997 – 2001 was 0.57 per 1000 live births. This decrease in incidence of late DDH was not significant at 5% level (chi squared p = 0.088). 64 children (82%) with late diagnosed DDH had no factors that could be perceived as risk factors for the condition.

Discussion: Targeted ultrasound screening of babies with risk factors appears to have reduced the average incidence of late DDH from 0.84 to 0.57 per 1000 live births. However this reduction in incidence is not statistically significant. The vast majority of late presenters (82%) do not have risk factors. It remains unclear whether universal ultrasound screening program, practiced in some parts of United Kingdom is a cost effective alternative to eliminate the incidence of late presenting DDH.

Introduction and Aims: Numerous internal as well as external fixation techniques have been reported for achieving tibiotalocalcaneal fusion in rheumatoid arthritis with varying results. The purpose of this study was to assess the union rate and functional outcome following tibiotalocalcaneal fusion using the locked supracondylar nail.

Method: Twenty-four patients (27 ankles) were followed up. The mean age being 57 years (44–73 years) and mean follow-up was 37.4 months (10–74 months). Severe disabling ankle pain was the indication for operation in all cases. Standard operative technique and post-operative mobilisation protocol was followed. Seventeen cases had ankle debridement. The severity of rheumatoid arthritis was assessed using the Fries scoring system. Results were analysed using Rheumatoid ankle score (RAS), modified American Orthopaedic Foot & Ankle Society Score (AOFAS). All the patients were evaluated for clinical and radiological evidence of union.

Results: The mean Fries score of 2.3 suggest that most of the patients in the study group were affected by severe rheumatoid arthritis. The mean RAS score was 77 (35–95) and mean AOFAS score was 74.6 (40–95). Using the rheumatoid ankle scoring system, five ankles (20%) were rated excellent, ten ankles (40%) were rated good, six ankles (24%) were rated fair and four (16%) were rated poor. In general, patients who had ankle debridement at the time of nailing fared well in terms of clinical, radiological union and ankle scoring.

Conclusion: Tibiotalocalcaneal arthrodesis with supracondylar nail in rheumatoid arthritis provides pain-free stable joint and satisfactory functional outcome. Better functional results are achieved with bony union and this can be achieved only with joint debridement.

Introduction: Surgical treatment is indicated in Scheuermann’s disease with severe kyphotic deformity, and/or unremitting pain. Proximal or distal junctional kyphosis and loss of correction have been reported in the literature, due to short fusion level, overcorrection, or posterior only surgery with failure to release anterior tethering. We reviewed surgically treated Scheuermann’s kyphosis cases, to evaluate the factors affecting the sagittal balance.

Methods and results: 35 cases (22 male, 13 female) of Scheuermann’s kyphosis were treated surgically in this centre during 1993–1999. Mean age at operation was 21.5 years (14–53 years). The kyphosis was high thoracic (Gennari Type I) in two cases, mid thoracic (Type II) in 11 cases, low thoracic or thoraco-lumbar (Type III) in eight cases, and whole thoracic (Type IV) in 14 cases. Mean pre-operative kyphosis (Cobb angle) was 81° (range 70° to 110°). Ten cases (mean kyphosis 77°) had one stage posterior operation only with segmental instrumentation. Twenty-five cases had combined anterior and posterior (A-P) surgery. Fifteen cases (mean kyphosis 81°) had one stage thoracoscopic release and posterior instrumentation, and 10 cases (mean kyphosis 89°) had open anterior release, followed by second stage posterior instrumentation. Minimum follow-up was 14 months (mean 45 months, range 14–140 months). The mean post-operative kyphosis was 47.2°. Kyphosis correction achieved ranged from 39% after posterior surgery only, to 42% after thoracoscopic A-P surgery, and 48% after open A-P surgery. Mean loss of correction was 12° after posterior only surgery, 9.5° after thoracoscopic A-P surgery, and 6° after open A-P surgery. Four cases of open A-P surgery had additional anterior cages to stabilise the kyphosis before posterior instrumentation; a mean 55% kyphosis correction was achieved in this group, and there was no loss of correction. Younger cases, under 25 years (n=16) had significantly better kyphosis correction (p< 0.05). Two cases (6%) developed distal junctional kyphosis due to fusion short of the first lordotic segment, requiring extension of fusion. Four cases (12%) developed proximal junctional kyphosis requiring extension of fusion; all of them had primary posterior surgery only. Location of the curve (Gennari Type) had no significant influence on the initial curve, degree of immediate correction, or loss of correction. Complications included infection (4 cases), pneumothorax (1 case), haemothorax (1 case), instrumentation failure (3 cases); 3 cases had persistent back pain.

Conclusion: Combined anterior release and posterior surgery achieves and maintains better correction of Scheuermann’s kyphosis. Loss of correction, and proximal junctional kyphosis are more frequent after posterior surgery only, and short fusion. Use of cages anteriorly prevents loss of correction. Correction is better achieved in younger patients, but is not influenced by the location of the curve.