Aim

This study aimed to assess whether the severity of symptoms (assessed with the Oxford Hip Score (OHS)) can relate to the levels of mRNA expression of markers for muscle inflammation (tumour necrosis factor alpha (TNFα), interleukin 6 (IL-6)) in the proximal vastus lateralis (VL) of patients with severe OA undergoing THR.

Aim

To assess whether the Oxford Hip Score (OHS), is reflective of objectively assessed functional performance (timed up and go (TUG), 30 sec sit to stand (ST), 6 minute walk test (6MWT), stair climb performance (SCP), and gait speed (GS)) in patients undergoing total hip arthroplasty (THA).

Aim

To assess the relationship between mRNA expression of genetic markers of inflammation (tumour necrosis factor-alpha (TNFα)) and interleukin-6 (IL-6) in the vastus lateralis (VL) of the operated leg, and the strength of the operated leg quadriceps, in patients following THR.

Introduction

Late (commenced 6 months to 4 years post-op) home-based progressive resistance training programs are proven to improve muscle strength and function after total hip replacement (THR). This study assessed whether early (commenced < 1 week post-op) HBPRT post-THR improves muscle mass, strength and function relative to routine physiotherapy rehabilitation (RPR) at up to 12 months follow up.

Purpose of study: Self reported walking distance is a clinically relevant measure of function. Our aim was to report patient accuracy and understand factors that might influence perceived walking distance.

Method: A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and Modified Zung Depression index (MZD).

Results: There are over-estimators and under-estimators. Overall the accuracy to within 10 yards was only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 121.4 yds; mean response 268yds (95% CI 192.8–344.15), Functional test 1 actual distance 32 yards; mean response 78.4 yds (95% CI 58.6–97.3), Functional test 2 actual distance 21.4yds; mean response 51.9yds (95% CI 38.3–65.5). Surprisingly patients over 60 years of age (n=43) are twice as accurate with each test performed compared to those under 60 (n=60) (average 70% overestimation compared to 140%; p=0.06). Patients in social class I (n=18) were more accurate than those in classes II–V (n= 85) (59% vs 131% p=0.13). There was a positive correlation between poor accuracy and increasing MZD (Pearson’s correlation coefficient 0.250; p=0.012). ODI, LBOS and other parameters measured showed no correlation.

Conclusions: Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate.

Introduction: Metastases in multiple myeloma are typically lytic and when non-union occurs it is usually atrophic

Methods: We report a lady of 67 years who was diagnosed with myeloma 9 years previously. She presented with a sudden onset of pain in her right forearm. Plain radiographs demonstrated a lytic lesion typical of multiple myeloma with an undisplaced pathological fracture in her right ulna. The fracture was treated in a short arm cast for 6 weeks and then by mobilisation. The underlying bone deposit was treated subsequently by external beam irradiation.

Results: Nine months later she was re-referred to the orthopaedic oncology service with marked forearm pain particularly on rotation. Radiographs demonstrated a hypertrophic non-union of the pathological fracture with a typical elephant’s hoof appearance. The fracture was stabilised using a Foresight ulnar nail (Smith and Nephew, Warwick, UK).

Discussion: Whilst non-unions in metastatic malignancy are typically atrophic, just occasionally hypertrophic non-unions can occur. Management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate.

Purpose: Self reported walking distance is a clinically relevant measure of function, our aim was to report patient accuracy and understand factors that might influence perceived walking distance.

Method: A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and other measures.

Results: There are over-estimators and under-estimators. Overall the accuracy to within 10 yards was only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 121.4 yds; mean response 268yds (95% CI 192.8–344.15), Functional test 1 actual distance 32 yards; mean response 78.4 yds (95% CI 58.6–97.3) Functional test 2 actual distance 21.4yds; mean response 51.9yds (95% CI 38.3–65.5). Surprisingly patients over 60 years of age (n=43) are twice as accurate with each test performed compared to those under 60 (n=60) (average 70% overestimation compared to 140%; p=0.06). Patients in social class I (n=18) were more accurate than those in classes II–V (n= 85): There was a positive correlation between poor accuracy and increasing MZD (Pearson’s correlation coefficient 0.250; p=0.012). ODI, LBOS and other parameters measured showed no correlation.

Conclusions: Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate.

Ethics approval: not required

Interest Statement: none

Introduction: Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance. C. difficile is thought to cause about a quarter of cases of antibiotic-associated diarrhoea overall, but accounts for a greater proportion of more severe disease. The type ‘027’ strains are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in elective orthopaedic surgery patients (hip/knee arthroplasties)

Material and Methods: All the patients who were diagnosed with C. Difficile after a primary elective joint arthroplasties, performed at the District general hospital during the three year study period from April2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intra-venous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality.

Results: A total of 1430 patients underwent primary hip or knee arthroplasties during the three years of study period. A total of 32 patients suffered from C. Difficile diarrhoea (2.2%) after the arthroplasty procedure, and within this cohort, 5 patients died during the same admission to the hospital (0.35%). The average length of stay for an elective lower limb joint arthroplasty was increased from 10 days to 43 days due to the affection with C. Difficile diarrhoea.

Discussion: C. difficile infection not only adds to the morbidity, but also causes significant increase in the mortality rate after elective joint replacement. The broad spectrum peri-operative antibiotics used to prevent infection after a joint replacement generally render the patient vulnerable to this highly lethal hospital bug. Introduction of simple hygiene measure such as hand-washing and change of peri-operative antibiotic protocol lead to a statistically significant reduction in the incidence of C. Dificcile infections after elective joint replacement surgery without compromising arthroplasty results.

Introduction: Etanercept is a selective competitor of TNF alpha which is a pro-inflammatory cytokine. It is currently used alone or in combination with other medication for the treatment of chronic inflammatory disease.

Aim: To establish the treatment effect of etanercept in acute sciatica secondary to lumbar disc herniation.

Method: Triple blind randomised controlled study. Inclusion criteria were acute unilateral radicular leg pain secondary to herniated nucleus pulposus confirmed on MRI scan. Exclusions were previous back surgery, spinal stenosis and any contraindications to the use of etanercept such as immunosuppression. The patient, the injector and assessor were blinded to the agent being used. Follow up was at 6 weeks and 3 months post treatment. Oswestry Disability Index (ODI) and Visual analogue scores (VAS) were among the assessment criteria.

Results: 15 patients were recruited in a 4 year period with a 3 month follow up of 80%. The Etanercept group had 8 patients whilst the placebo group had 7. The average ODI for the Etanercept group pre-intervention was higher than that in the placebo group (56.1 vs. 50.4) and this remained the same after 6 weeks (50.5 vs 31) and 3 months of follow up (39.2 vs. 27.3). VAS was also higher in the Etanercept group vs. placebo; pre-injection (8.5 vs. 7.4), 6 weeks (5.6 vs. 3.8), and 3 months (7.0 vs. 4.5).

Conclusion: Small numbers of trial participants limited statistical analysis. The trend appears to show no benefit to the use of Etanercept over placebo in the pharmacological treatment of sciatica.

Aim: To assess surgical outcomes between discectomy at the L4/5 level and L5/S1.

Introduction: There is sound biomechanical reasoning to suspect a difference might exist between spinal levels. The L4/5 disc is more susceptible to axial torsion and is the most common site of lumbar instability. The L5/S1 motion segment is protected from torsional strain by extensive iliolumbar ligaments but more exposed to axial compressive forces.1 There appears to be a difference between the L4/L5 motion segment and the L5/S1 in outcomes of disc replacement surgery. The available literature implies a difference but does not include studies with accepted standard outcome measures.

Method: 130 patients from a single centre undergoing a single level discectomy at L4/L5 or L5/S1 for radicular pain with prospectively gathered data. Oswestry disability index (ODI), subjective walking distance, Modified Somatic Perception (MSP), Modified Zung Depression Index (MZD), Low Back Outcome Score (LBOS) and visual analogue score (VAS) were collected over an average of 56 months of follow up. Comparisons between L4/5 vs. L5/S1 levels were made with these outcome measures using student’s t-testing.

Results: There were 78 L5/S1 and 52 L4/5 discectomies identified. Pre-operative walking distance for L5/S1 patients was higher at L4/5 (455m vs. 278m; p=0.027). At 6 months a small clinical difference exists with the back function scores that achieves statistical difference (47.11 (L4/5) vs. 39.47 (L5/S1); p=0.0229). Across all other parameters, no significant difference was found to exist between both groups. There was no difference in the recurrence rate or re-operation rate. There was no difference in early and late outcomes.

Conclusions: No statistically significant difference exists between surgery at the L4/5 level and the L5/S1 level in terms of post-operative outcome. There is no clinically significant difference in outcome. Planned surgical treatment strategies should not be altered by perceptions of difference in outcome when none exists.

Aims: To determine outcomes in somatised patients and identify factors of clinical utility that help predict favourable and unfavourable results.

Introduction: Somatisation is a tendency to experience and express somatic distress and symptoms unaccounted for by pathological findings and to attribute them to physical illness, often with excess seeking of medical help for them. Somatised patients undergoing spinal surgery have less favourable outcomes than the normal surgical population. However a range of outcomes occur.

Methods: Prospective data from a single centre was obtained. Pre-operative modified somatic perception (MSP) and modified Zung depression (MZD) scores were available on 993 patients. The 46 patients with high somatic scores were identified as a discrete sub-group. Some patients did extremely well some patients had poor outcomes. Quantification of the number of consultants seen, outpatient clinic (OPD) reviews and duration of symptoms were compared to indicators of poor outcome (unchanged or increased visual analogue score (VAS), increased or < 10 point decrease in Oswestry disability index (ODI)) at 6 and 12 months of follow up.

Results: In the 46 patients the mean pre surgical scores were ODI 64.9 (SD 12.75) MSP 16 (SD 7.74); MZD 38 (SD 10.4); Prior to surgery they had a mean of 9.6 OPD attendances, the average number of consultants seen was 3.28 (SD 2.83). Overall the post-operative mean ODI was 36.81 (SD 24.58) a clinically satisfactory improvement. At 6 months patients who have a good outcome (ODI) had had an increased number of orthopaedic consultations (60% vs. 39.7%) but this was not statistically significant; p=0.16. At 12 months patients with a good outcome (ODI) had waited a lower number of months before surgery (5.5 vs. 11; p=0.026). Across all other parameters, including gender, age, surgical procedure undertaken, no other significant correlation exists between OPD, consultants seen and the changes in VAS, ODI at 6 and 12 months of follow up.

Conclusions: Dramatic differences exist between somatised patients who have good and poor outcome following spinal surgery. The number of months from decision to operate to surgery appears to predict good outcome at 12 months. No other identifiable pre-op factors were found.

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months.

Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.