Introduction

Heterotopic Ossification(HO) is a recognized complication following Total Hip Arthroplasty(THA) that can compromise patient outcomes. Our objectives were to report its incidence and risk factors in a modern arthroplasty unit(MAU).

Healthcare interventions are under increasing scrutiny regarding cost-effectiveness and outcome measures have revolutionised clinical research.

To identify all available outcome questionnaires designed for lowback, lumbar spine pathologies and to perform qualitative analysis of these questionnaires for their clinimetric properties.

A comprehensive e-search on PUBMED & EMBASE for all available outcome measures and published review articles for lowback and lumbar spine pathologies was undertaken over a two month period (Nov-Dec 2009). Twenty-eight questionnaires were identified in total. These outcomes questionnaires were evaluated for clinimetric properties viz:-

Validity (content, construct & criterion validity)

Reliability (internal consistency & reproducibility)

Responsiveness and scored on a scale of 0-6 points.

Eight outcomes questionnaires had satisfied all clinimetric domains in methodological evaluation (score 6/6).

Oswestry disability index (ODI)

Roland-Morris disability questionnaire (RMDQ)

Aberdeen lowback pain scale

Extended Aberdeen spine pain scale

Functional rating index

Core lowback pain outcome measure

Backpain functional scale

Maine-Seattle back questionnaire.

Sixteen of these questionnaires scored =5 when evaluated for clinimetric domains. RMDQ had the highest number of published and validated translations followed by ODI. Criterion validity was not tested for NASS-AAOS lumbar spine questionnaire.

32%(9/28) of the outcome instruments have undergone methodological evaluation for =3 clinimetric properties. Clinicians should be cautious when choosing appropriate validated outcome measures when evaluating therapeutic/surgical intervention. We suggest use of few validated outcome measures with high clinimetric scores (=5/6) to be made mandatory when reporting clinical results.

8 patients with cervical myelopathy treated by French-door laminoplasty and internal fixation. A novel technique of fixation is employed to provide immediate stability, pain relief and rapid mobilisation.

To report the clinical and radiological outcomes of this new fixation device for French–door laminoplasty with minimum follow-up of 30 months.

Hardware assisted laminoplasty has the potential advantage of instant stability and prevention of recurring stenosis. The use of titanium mini-plates has been described in open-door laminoplasty and now we describe this technique in French–door laminoplasty.

8 patients with cervical myelopathy secondary to congenital stenosis (2) and multi-level spondylotic myelopathy (6) underwent 2-4 level French–door laminoplasty and mini-plate fixation. The average follow-up was 46.5 months. Autogenous iliac crest bone graft was interposed between the sagittally split spinous processes and 16-18 holed titanium mini-plates were contoured into a trapezoidal shape and secured to the posterior elements with screws. Patients then mobilised without external support.

The mean follow-up was 46.5 months. The mean improvement in NDI at final follow-up was 35% and mean improvement in VAS was 4 points. JOA score improved from a mean of 10 to a mean of 14.8 post-operatively. All patients had achieved a significant neurological improvement and pain relief. There were no post-operative hardware related complications, pseudarthrosis or neurological deterioration.

French-door laminoplasty is an excellent alternative to laminectomy for treatment of young patients with cervical myelopathy. The use of titanium mini-plates not only provides instant stability and pain relief but also seems to minimize the risk of C5 nerve root palsy. Internal fixation appears to provide instant stability, early mobilisation and therefore reduces hospital stay and associated costs.

Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centres for their management are initially admitted to DGHs. The referral is made by mailing radiographs with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, financial and medico-legal implications. We discuss these issues between index DGH (Poole General Hospital) and its tertiary referral centres.

To review the existing management of spinal injury admissions at our hospital, analyse critical/adverse incidents and to identify areas for improving patient care.

A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centres over 6 months was undertaken. Twenty eight of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of booking and performing scans, time of referral & response from tertiary centre and time of transfer from hospital notes and delays at each level were critically analysed.

Seven of the 28 referrals had either neurodeficit or spinal instability. Common issues were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on results (av 1.8 days), delays due to missing/lost in transit’ scans (av 1.5 day), delay in obtaining opinion (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were approximately £73,000 & loss of 246 patient-days.

Training on induction day, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre to streamline referrals and enhance efficiency. This website has now grown into a national secure referral portal incorporating other referral centres.

Purpose: To determine presentation to publication conversion rate(PPCR) in peer-reviewed indexed journals of abstracts presented at SRS annual meetings and to evaluate for consistency between abstracts and subsequently published full-text articles(FTA).

Methods: We reviewed all presentations (podium & posters) of past SRS annual meeting proceedings(2000–04) and undertook a comprehensive PubMed search to determine if the abstract was followed by a publication subsequent to its presentation as FTA up to Dec 2008. The published FTA was compared with original abstract(OAb) and evaluated for consistency with respect to study cohort/design, conclusion and authorship against a structured proforma.

Results: 1063 abstracts(452 podium;611 posters) were identified. 560 (295 podium;265 posters) were published as FTA in 51 journals. The overall PPCR was 52.68%(65.26 for podium;43.37% for posters). Two-thirds of them were published in Spine (361 FTA). 87.32% of them were published within 3 years of presentation(489/560). Interestingly 16 presentations were already published as FTA before their sub-mission(2.85%). The PPCR was 1.5 times higher for free-papers as compared to posters and was statistically significant (p< 0.0001) and OR 2.45(1.90–3.15).

Conclusion: The PPCR of SRS presentations is better than AAOS(34.2%;Bhandari et al, JBJS(Am)2002:84(4),615–21) and stands high in comparison to other medical specialties (32–72%). Though the studies were of high quality/content, changes to the cohort, authors or/& conclusion was common (seen in two-thirds of FTA). The acceptance of an abstract for podium presentation at SRS annual meeting is a benchmark of quality. However they (esp. posters) should be interpreted with caution until their subsequent publication as a FTA.

Ethics approval: Not applicable

Interest Statement: None (No grants obtained from any agency).

Introduction: Capasso’s method(CM) has been described in orthopaedic textbooks to be the most sensitive tool for measuring Cobb angle in scoliosis. This method based on “bi-univocal principle” views the scoliosis curve to be an arc of circumference, to be a true reflection of angular values and hence geometrically more valid. However there is no comparative study between the established measurement tools i.e. Oxford cobbometer(OC) & Traditional protractor(TP) vs. CM. Our objectives were to to evaluate the sensitivity of CM against OC & TP in scoliosis and to determine intra & inter-observer reliability of the three methods.

Methods: Three independent blinded observers measured 24 digital AP radiographs of scoliosis on three separate occasions one week apart by CM, OC & TP. The three sets of readings obtained were statistically analysed for intra-observer (Cronbach’s alpha) & inter-observer [Inter-class correlation coefficient(ICC)] reliability.

Results: The mean Cobb angle measured by OC was 42.4(r13-91), by TP was 45.1(r16-89) and by CM was 70.4(r 20-148). The cronbach’s was 0.94 for OC, 0.91 for TP & 0.88 for CM. The ICC was 0.96 for OC, 0.90 for TP & 0.71 for CM. The measurements obtained by CM were higher than the other two methods for all magnitudes of the curves.

Conclusion: CM based on sound geometric principles is perceived to be superior to Cobb angle and has reasonable correlation(Pearson’s®=0.74) with it. However CM overestimates the magnitude of scoliosis as compared to other standard measurement tools. Management decisions based on CM would be inappropriate by current guidelines.

Ethics approval: Not applicable Interest Statement: None

Purpose: To eliminate iatrogenic Ulnar Nerve injury.

Methods: We prospectively reviewed 25 consecutive paediatric gartland’s type 3 supracondylar fractures with a minimum follow-up of 1 yr operated by our novel technique. Good reduction was achieved with closed reduction in 20 and 5 cases warranted an open reduction. Our technique involved passage of two percutaneous 1.6 mm smooth K-wires supero-medially from lateral condyle across the fracture site to obtain a purchase in upper medial cortex of proximal fragment. A third K-wire was passed percutaneously from lateral supracondylar pillar proximal to the fracture site in infero-medial direction to gain purchase in distal fragment’s subchondral bone of medial condyle thus creating a cross construct. Care was taken not to breach the subchondral bone so as to avoid ulnar nerve injury. All patients were operated in supine position under general anaesthesia and lateral collateral approach was used with same K-wire construct in cases that needed open reduction. Stability was checked post-operatively by rotation under real time imaging. The mean age of patients was 6.8 yrs. The mean time from sustaining the fracture to operative pinning was 24 hrs. An above elbow immobilisation backslab was applied for 3 weeks. The K-wires were removed at 3 and 4 weeks in cases that had closed and open reduction respectively and active assisted movements were initiated. All patients were followed up at 1/52, 3/52, 6/52, 3/12, 6/12 and 1 year post-operatively.

Results: Flynn’s criterion was used for post-op functional evaluation. 20 cases had excellent and 5 had good outcome at end of 1 year. There was no case of nerve palsy (superficial radian or ulnar N), pin-tract infection, loss of reduction or late cubitus varus/valgus or hyper-extension deformities.

Conclusion: Our innovative technique is an excellent alternative option without compromising on fracture stability in the treatment of these fractures.

Purpose: There is no data concerning morphological dimensions of distal femur(DF), proximal tibia(PT) and thickness of patella(TP) in Indian population and our objective was to analyse the anthropometric data in Indian knees and to correlate them with existing knee arthroplasty systems.

Methods: MRI scans of 25 patients(15M;10F) who underwent bilateral knee scans for ligamental injuries were collected. Patients with arthritis, bone loss, varus/ valgus deformity of > 150 and those with immature skeleton were excluded. The mean age was 32 years (range 18–53y). Three surgeons independently measured medio-lateral(ML), antero-posterior(AP) lengths & aspect ratio(AR) of DF, PT and TP on three occasions one week apart to account for intra & inter-observer variability. The resultant data of 50 knees was analysed using SPSS v16.0 and compared with five different knee arthroplasty systems (PFC sigma/NexGen/Scorpio/IB-II/ Gender specific knee).

Results: The mean ML & AP for proximal tibia was 73.3±5.3 & 47.8±4.3 mm. The mean ML & AP (lateral condyle) for distal femur was 74.3±5.9 & 65.4±5.0 mm. The mean unresected thickness of patella was 24.7 & 21.8 mm in males & females respectively. The ML & AP showed a statistically significant positive correlation with person’s height (ML®=0.55;AP®=0.50 & p=0.01). A decrease in AR for increasing AP dimension was noted for both distal femur and proximal tibia (Tibia®=0.153;p=0.29 & Femur:®=−0.91;p=0.001).

Discussion: None of the prosthesis designs mimicked this decrease in AR and NexGen infact showed increase in AR.

Only Gender specific knee closely mimicked normal variation in AR and is available only for females (in India). Most of the available TKR prosthesis designs differ from true knee morphometry of Indian population. These data provides the basis for designing optimal prosthesis for people of Indian/Asian origin in UK/overseas.

Purpose: To review the existing practice of coding in spinal surgery and ascertain its accuracy for surgical procedures, co-morbidities and complications.

Methods: A retrospective review of 70 cervical and 100 lumbar consecutive spinal surgeries performed since April 2006 was conducted. The clinical coding data and hospital notes were reviewed.

Results: Coding data of 5 cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). This reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. Medical co-morbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. The commonly missed co-morbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries.

Conclusion: Coding is a universal language of communication and its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. Following this study, a clinical coding facilitation form has been introduced to improve data quality.

Ethics approval: None

Interest statement: None

Purpose: There is no consensus regarding indications for anterior release and causative factors of junction kyphosis(JK) in Scheuermann’s Kyphosis(SK).

Methods: A retrospective review of 35 patients(19♂; 16♀) who underwent surgery for SK with a minimum follow-up of 5 years was undertaken. The mean age & follow-up were 20.5(13.25–45.75y) and 9 years(5–22y) respectively. Patient demographics, clinicoradiological parameters & functional outcomes (ODI/SRS-22) were assessed. The incidence of JK was correlated with radiographic parameters & instrumentation levels. Outcomes of posterior instrumentation(GroupI-13) were compared with anterior release & posterior instrumentation(GroupII-22).

Results: Cobb Λle of ≥600 hyperextension radiographs and presence of anterior bony bridge required anterior release. JK(≥100) was seen in 12 cases (7 proximal & 5 distal). PJK was seen in cases where T3-4 was the upper instrumented vertebra(UIV). DJK was seen in patients with body mass index(BMI) of ≥30 and when LIV did not include 1st lordotic disc. There was significant difference in mean thoracic kyphosis(TK) correction between the 2 groups (35.70vs44.50;p=0.003). The mean loss of correction at 9 yrs was 5.90 and 3.40 respectively. 33/35 were subjectively satisfied with cosmesis and 28/35 patients returned to their previous occupation. Three were off work due to chronic back pain and four patients had job modifications.

Conclusion: Stiff curves require anterior release. PJK could be overcome by including T2 as UIV.

DJK could be prevented by including 1st lordotic disc in LIV. Extending lower Instrumentation to L3 would reduce the risk of implant failure in obese patients. There was no advantage of cages over rib grafts.

Ethics approval: Not applicable

Interest Statement: None (No grants obtained from any agency)

Introduction: The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur in patients with Diabetes mellitus.

Methods: of study: 62 patients aged 50 years or more (17 males & 45 females) who underwent AO screws for fracture neck of femur over 7 yrs (1999–2005) and followed-up for a minimum of 2 yrs formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic & GP letters was made. Age, residential placement, Garden’s classification of fracture, mode of injury, associated other co morbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. An in depth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. Reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions were critically analysed. Post-op physiotherapy, proportion of patients sustaining contra-lateral fracture NOF & its management and mortality statistics were reviewed.

Results: The mean age of patients was 67 yrs (range 52–96 yrs). 11 patients died in 2 years time. 41 patients were less than 75 years of age and 21 patients were more than 75 years of age. All the patients more than 75 years of age had undisplaced intracapsular fractures. 13 patients were type 1 and 49 patients were type 2 diabetic. Non-union & avascular necrosis occurred in 9 (17%) & 13 (26%) patients respectively. Revision surgery in the form of total hip replacement or hemiarthroplasty were performed in 21 (41%) cases. The incidence of avascular necrosis following osteosynthesis at 1 yr was 14%. Age, control of diabetes, post-operative complications, pre-fracture mobilization status and degree of impaction on AP & version on lateral radiographs were of statistical significance in predicting fracture healing and its associated complications. Complications like wound infection etc were more principally in patients who had poorly controlled diabetes.

Conclusion: Patients with diabetes mellitus have metabolic bone disease due to vasculitis. This increases the risk of complications associated with fracture fixation such as non-union, cut-through and avascular necrosis (AVN). The complications and revision surgery rate was high in patients with displaced fractures and with poorly controlled diabetes. Comorbidities like diabetes & patient’s age were also strong predictors of healing in addition to fracture configuration. Looking at very high complication and reoperation rate, our recommendation in patients with diabetes is primary hemiarthroplasty irrespective of femoral head displacement, if there is age more than 75 years.

Introduction: Intra-operative localisation of small nidus in osteoid osteoma & osteoblastoma is difficult resulting in failed excision. Wide resection is fraught with prolonged operative time, increased bleeding and instability.

Methods: 8 patients (6M & 2F) with a diagnosis of osteoid osteoma(7) and osteoblastom(1) were operated at our centre between 1995–2005. The mean age at presentation was 20.9 years (9–31 yrs). The tumour was localised to cervical(2), thoracic(4) and lumbar(2) posterior elements respectively. All had back/neck pain of varying duration (mean 20 mo; range 6–48 mo). 2 patients presented with thoraco-lumbar scoliosis and 3 had failed treatments. All patients were worked-up with x-rays, CT/MRI and 99m technetium scan to localise lesion. 600 MBq Tech HMDP(hydroxy-methylene-di-phosphate) was administered intra-venously 3 hrs prior to surgery and fluoroscopy was used to confirm anatomical level. A 5 mm cadmium telluride (Cd Te) probe & rate meter were used to scan the area containing lesion and counts per second (cps) recorded. Background count from adjacent area was obtained for comparison purposes. The tumour nidus was then excised & cps from tumour bed and excised specimen recorded.

Results: The mean follow-up was 5.85 years (2–12.33). The mean cps for osteoid osteoma pre-excision was 203.8 (60–515) which fell to 72.5 (10–220) post-excision. The cps reduced from 373 to 40.5 postoperatively for osteoblastoma. Complete excision was recorded every time and all patients reported characteristic disappearance of pre-operative pain. All had discontinued analgesic medication, returned back to normal activities by 3 months and were followed-up at regular intervals for 2 yrs when they filled NDI, ODI & SF-36 questionnaire.

Discussion: Gamma probe guided surgical excision facilitates accurate localisation of lesion, is less invasive warranting minimal bone resection & resultant instability and perhaps most importantly confirmation of complete excision of the tumour nidus consistently every time (esp. failed surgeries).

Introduction: Accurate & ethical coding is challenging and directly impacts on Payment by Results (PbR). The objectives were to review the existing pattern of coding for lumbar spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical comorbidities and post-op complications.

Methods: A retrospective review of 100 consecutive lumbar spine surgeries operated from Apr2006–Jan2007 was conducted. The coding excel sheet, hospital notes and laboratory reports were reviewed.

Results: The primary procedural accuracy was 96%, however this reduced to 79% for the entire description of performed surgery. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Spinal fusion codes were omitted and revision cases were coded as primary surgeries in 2 instances each. Surgical levels were coded incorrectly in 12 and harvest of iliac crest bone graft omitted in 4 cases respectively. Medical comorbidities were coded appropriately in 70%. The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 62.5% of the cases(5/8).

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but also for data quality, audit and research. The financial implications regarding PbR governed by Healthcare Resource Group (HRG) codes (dictated by Official population and census surveys [OPCS4.4] & International classification of diseases [ICD–10] codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders & clinicians.

Purpose: To determine the level of promotion of minimally invasive surgery (MIS) & computer assisted orthopaedic surgery (CAOS) in total knee replacement (TKR) through internet sites by BASK members.

Methods: We obtained an updated list of active members of BASK in March 2007 and permission from the executive committee to undertake this study. Standard search engines commonly used in our daily lives (viz. Google, Yahoo and Ask.com) were used to search for websites related to each surgeon during Sep–Nov 2007 period. The surgeon’s name, initials and job title thereof were used as keywords in conducting the search. Thus for each surgeon, all websites found were browsed and evaluated for MIS/CAOS and TKR/UKR information. Both direct (surgeon’s personal website/private practice) and indirect (group practice/hospital/university affiliation) information from these websites were reviewed and a standard pre-formed questionnaire proforma was filled in against that particular surgeon.

Results: A total of 178 websites were found for 405 members (392 inland + 13 overseas). 2.8% and 4.5% made direct and indirect reference to MIS TKR respectively. The most commonly listed benefits of MIS were quicker recovery, smaller incision and hence lesser pain. Very few specific risks of MIS were outlined by these websites. None of the websites quoted any peer-reviewed publication to support their claims. CAOS was discussed in 1.7% and 2.8% of these sites respectively.

Conclusion: Our study suggests that many active members do not have personal websites and these procedures are not commonly promoted by them via the internet. Many of these are often associated indirectly with group practice/institutional affiliation websites which may not necessarily be endorsed the surgeon. Our plan in near future is to monitor the changes in internet dissemination of information and close the audit loop by next year.

Introduction: Cervical kyphosis is failure of posterior osteo-ligamento-muscular restraint secondary to a deficient anterior column. Prospective studies of stand-alone anterior construct in correction and maintainence of cervical column that would otherwise require combined ant & post surgeries is sparse.

Objectives: To evaluate the role of stand-alone anterior surgery for cervical kyphosis, determine its efficacy and analyse complications.

Methods: 42 consecutive patients aged 6 – 70 yrs (Av 31.4 yrs) who had a Kyphosis angle of more than 100 with its apex between lower end-plate of C2 and C7 on a lateral x-ray and underwent anterior only surgery for cervical kyphosis over 6 yrs (2000–06) formed the population for this prospective study. The average follow-up was 2.2 yrs (1 – 5 yrs). The mean pre-op kyphosis was 20.820 (100 – 780). Etiology was tuberculosis in 25, dysplasia in 7, trauma in 6 and tumors in 4 cases respectively. 39 of the 42 patients had myelopathic signs. Mean pre-op mJOA score was 7.4 (0–11). A left anterior cervical approach was used in all cases. Modified manubriotomy was required in 5 cases to instrument the caudal vertebra. Tricortical iliac crest strut graft was used in 40 and cylindrical mesh cage in 2 cases. Correction of kyphosis was achieved by intra-op adjustment of the head assembly & controlled distraction. Post-operatively all wore cervical orthosis for 3 mo.

Results: 41 patients were available for analysis (1 lost for f/u). The average number of corpectomies required were 2.5 (1–4) and the mean anterior column defect reconstructed was 27.3mm (22–42mm). The average graft subsidence was 3mm (0–10mm). 2 patients required revision surgery within 6 weeks for implant failure/graft resorption. Fusion occurred in rest of 39 patients. No further graft subsidence was noticed at 4 years in 17 patients. Spontaneous fusion at 3 mo was seen in normal adjacent segment due to plate overlapping in 2 cases. The average correction achieved was 15.220 (−40–730). The mortality rate was 2.12% (1 case). Visceral complications occurred in 3 cases (esophageal perforation in 1 and recurrent laryngeal nerve palsy in 2). The mean post-operative mJOA score was 14 (9 – 17). There was 1 deep and 1 superficial infection.

Conclusion: Ant decompression & reconstruction with instrumentation facilitates neurological recovery restoring alignment. Intra-op maneuvering allows the graft to be placed in an optimal position that allows fusion under compression.

Purpose: To review the existing coding for knee surgery and ascertain its appropriateness & accuracy for surgical procedures, associated co-morbidities and complications.

Methods: A retrospective review of 100 consecutive knee surgeries (50 arthroplasties and 50 arthroscopies) performed between July-August 2007 was undertaken. The coding data excel sheet and comprehensive hospital records were analysed.

Results: The accuracy of primary procedural codes was 100% & 88% respectively for arthroplasty & arthroscopy. However this respectively fell down to 56 & 60% when the accuracy for entire description of surgical procedure was taken into consideration. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility esp. for arthroscopies. In arthroplasties, patients had similar codes irrespective of whether they had patellar resurfacing or not. Co-morbidities were coded appropriately in 24% of arthroplasty & 36% of arthroscopy patients. The common co-morbidities missed were drug allergies, hypercholesterolemia, heart conditions (IHD, MI, AF, valvular pathologies) and h/o malignancy & deep vein thrombosis. Post-op adverse events were coded in only 2/5 arthroplasties (40%) and 0/3 arthroscopies (0%) respectively.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for reimbursement but also for data quality and audit. Coding database also serves as a powerful research tool. The financial implications with respect to generation of appropriate reimbursement i.e. healthcare resource group (HRG) codes (which are dictated by official population and census survey procedural [OPCS4.4] & international classification of diseases [ICD–10] co-morbidity codes) are discussed. The limitations of the existing coding system are highlighted and discussed. Literature emphasizes on the qualification of coders, legible & comprehensive documentation of surgeries & co-morbidities by treating physicians and regular interaction between coders and clinicians. Reimbursement for arthroscopy is less in the NHS unlike in BUPA where it is on par with open surgeries.

Introduction: Ronald McRae’s textbook clinical orthopaedic examination mentions “Capasso’s method1 of evaluation of coronal plane deformity to be the most sensitive tool of measuring cobb angle. However there is no study to date evaluating/comparing this method against popular & widely used tools viz. cobbometer and traditional protractor.

Objectives: To evaluate Capasso’s method against commonly used measurement aids w.r.t measurement of cobb angle in scoliosis.

Summary of background data: Studies of Cobb method of measurement have multiple sources of error and intra & inter-observer variability. The Capasso’s method which is based on “bi-uni-vocal principle” views the scoliosis curve to be an arc of circumference and to be a true reflection of angular values and hence geometrically more valid.

Methods: 24 scoliosis curves were measured by three different examiners on three separate occasions one week apart by 1) Capasso’s method 2) Cobbometer and 3) Traditional protractor on same set of hard copies of digital x-rays. The three set of Cobb angle readings obtained were statistically analysed for intra & inter-observer reliability and assessed for agreement between the three methods of clinical measurement.

Results: The mean intra observer variability for protractor, cobbometer & Capasso’s methods were 8.50, 5.50 10.00 respectively. The cobb angle readings obtained by Capas-so’s method was higher than the other two methods for all magnitudes of the curves (< 300, 300–600 & > 600) and was more than two times the conventional readings for curves < 300. The disagreement between Capasso’s method with either of the other two methods (cobbometer & protractor) was statistically significant (p< 0.01).

Discussion: This study demonstrates that Capasso’s method significantly overestimates the magnitude of scoliotic deformity esp. for curves < 300 as compared to other existing popular measurement tools. Surgical decision making if were to be based on it would invite criticism and wrath. The present existing methods have their own limitations and the need of the day is a simple three dimensional measuring system to accurately define the magnitude of the deformity.

Introduction: Accurate and ethical coding is challenging and directly impacts on Payment by Results (PbR). The aims & objectives of this study were to review the existing pattern of coding for spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical co-morbidities and post-op complications.

Methods: A retrospective review of 70 consecutive cervical and 100 consecutive lumbar spine patients who were operated from April 2006 onwards was conducted. The excel sheet provided by coding department, hospital notes – clinic letters, physicians’ entries, theatre notes and laboratory reports (biochemistry/microbiology/histology) – were reviewed. Of the 170 cases, 165 were available for analysis.

Results: Coding data of 5 patients who underwent cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). However this reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. Harvest of iliac crest bone graft was not coded in 5 cases. Medical comorbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Following this study, a clinical coding facilitation form has been introduced to improve data quality. Our plan is to close the audit loop and re-evaluate. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders and clinicians.

Introduction: The literature regarding the functional outcome following C1–C2 surgeries for non-rheumatoid C1–C2 pathologies following selective arthrodesis is sparse.

Aim: To determine the long term correlation between functional outcome and radiological determinants following C1–C2 fusion for conditions other than RA.

Methods: All C1–C2 surgeris performed between 1988–2002 for non-RA etiologies were reviewed retrospectively. Selective C1–C2 fusion performed in 32 pts with a min f/u of 5 yrs formed the study group. The mean age at surgery was 57.2 yrs (r 22–84yrs). The etiologies were trauma (15), non-union (6), congenital AAD (2), C1–C2 deg. arthropathy (2), os odontoideum (2), tumours (4) and instability due to TB (1). Neurodeficit were present in 7 pts. Transarticular (TA) screws supplemented with posterior wiring was performed in 27 & posterior wiring alone in 5 pts respectively. A monocortical H-shaped autograft from iliac crest was used in all cases. There were two deaths & two pts were lost for F/U. The mean F/U was 7.8 yrs (r 5–13 yrs). Disability & pain using NDI & VAS and subjective satisfaction were recorded in all pts. We measured 1) C1/2 fixation angle, 2) Inclination of C1, 3) Anterior shift of C2 and 4) C2–7 lordosis on pre and final F/U lateral x-rays.

Results: Optimal TA screw placement was seen in 78.5% of pts. The mean improvement in NDI & VAS were from 55.4% to 19.6% and 8.4 to 1.6 respectively and was better in younger pts. Fusion was seen radiologically in 82.1% of pts at 12 mo post surgery. Segmental stability and resolution of symptoms was seen in all patients despite implant failure in 4 and incomplete fusion 5 cases respectively. Two wound dehiscences needed debridement of which one elderly pt died of MRSA sepsis 2 mo post-op. The C1–C2 segmental lordosis was significantly increased by surgery (−4.2 0 vs. −11.80; P=0.016). The subaxial cervical spine became less lordotic in initial few months post-op but eventually regained more lordosis as time progressed. The C1 inclination came into more extended position w.r.t horizontal line post-op with minimal loss of inclination subsequently. C1–C2 fixation angle and anterior shift of C2 did not have significant correlation with long term functional outcome i.e. NDI and VAS (r=0.35, p=0.17).

Conclusion: The functional outcome following C1–C2 arthrodesis is usually good despite metalwork issues and incomplete fusion in these selective group of non-rheumatoid arthritis pathologies.

Introduction: Formulation of surgical protocol in CSM is marred by the diversity in clinico-radiological presentation. Prospective data that assigns a specific surgery with identifiable similarities in clinico-radiological attributes is sparse.

Objectives:

To identify radiological patterns of compression (POC) of the spinal cord

Methods: 135 consecutive patients aged 32–75 yrs (mean 48.1yr) operated for CSM from 1999–2005 formed the study group for this prospective series. The objectives were to identify radiological patterns of compression (POC), develop a surgical algorithm based on POC and evaluate outcome. Four POC were identified on MRI.

Pattern I – predominant one/two level compression in normal/narrow canal

Mean follow-up was 3 yrs (2–8). ACDF was performed for patterns I, II & III and posterior decompression for pattern IV and III(A). For pattern IV(A), a two stage primary posterior decompression followed by targeted ACDF at the site of maximal compression was performed. The clinical outcome was measured by modified JOA (mJOA) score, Hirayabashi Recovery Rate (HRR) and functional outcome by modified Neck Disability Index (NDI).

Results: The mean pre & post-op mJOA score was 10.40±3.33 & 15.76±1.45 respectively with average HRR of 80.10 ± 26.38. The difference in the mJOA scores was statistically significant (unpaired t test) for each POC. In multilevel CSM, anterior surgery in POC type III had statistically better post op mJOA as compared to those who underwent posterior surgery viz POC types IV and III & IV variants although the difference in their HRR and NDI were not statistically significant.

Conclusion: Anterior surgery has better neurological outcome in judiciously selected patients with multilevel CSM. Surgical decision-making guided by patterns of compression (POC) is pivotal for optimal functional outcome.