Surgical repair of lumbar stress fractures in professional cricketers .

BACKGROUND: Professional cricket fast bowlers sustain high rates of lumbar stress fractures (spondylolysis). Limited research exists around the success of surgical repair when these injuries fail conservative treatment. We present an ambispective cohort study of spondylolysis surgical repair in a consecutive group of multi-national professional cricket fast bowler using a technique not previously reported in this unique sporting group. METHODS: Between 2004 and 2019, a consecutive series of male professional fast bowlers with lumbar spondylolysis who had repeatedly failed conservative treatment and subsequently received surgical repair using a cable-screw construct were reviewed. Analysis comprised of ambispective outcome and radiological data collection and a survey at final follow-up. RESULTS: The cohort included 13 elite (7 state and 6 international) cricket fast bowlers from 3 countries (New Zealand, Australian and India) with an average age of 26 years (range, 20.3-29.5 years). All returned to play professional cricket at a median time of 8 months (IQR, 7-11 months) post surgery. All ten players surveyed at final follow-up [median, 38 (IQR, 31-103) months, range, 15-197 months] rated their bowling performance as the 'same or better' compared with prior to surgery. At final follow-up, 10 players continue to play cricket professionally ranging from 15 to 107 months post-surgery [median 35 (IQR, 24-43) months]. CONCLUSIONS: Our cohort demonstrated favorable return to play rates and career longevity following surgical repair of spondylolysis. To our knowledge it is the largest published surgical series of spondylolysis repair in cricketers, and the first to document the success of a cable-screw surgical technique in this sporting group.

Rationing of hip and knee referrals in the public hospital: the true unmet need.

AIM: The aim of this paper is to outline the development of a triage system for elective hip and knee referrals to the Orthopaedic Department of the Canterbury District Health Board (CDHB), and to determine the unmet need within this population for accessing first specialist assessment (FSA). METHODS: Between 1 August 2015 and 31 March 2016 data was collected from all elective hip and knee referrals that underwent triage for a FSA. The number of outpatient appointments available according to the government four-month waiting time is set by the CDHB. Patients were triaged by two consultant surgeons on the basis of their referral letter and radiological imaging into one of five categories: accepted for FSA, insufficient information, no capacity, low priority or direct entry to waiting list (if already seen by a specialist). Those not accepted for an FSA were returned to general practitioner (GP) care. RESULTS: During the study period there were 1,733 referrals (838 hip related referrals and 895 knee related referrals) to the orthopaedic department with a request for FSA. All patients had failed conservative management. Of these referrals 43% of hip and 54% of knee related referrals could not be offered an FSA and were returned, following triage, to general practitioner care unseen. Only 8% and 9% respectively were declined for insufficient information in the referral letter or lack of need. CONCLUSION: This study details the implementation of a triage system for elective hip and knee referrals to the CDHB and with accurate data we have been able to determine the large number of patients unable to access a specialist opinion. These patients represent the unmet need within our community and highlights the degree of rationing taking place within the public hospital.

Access to orthopaedic spinal specialists in the Canterbury public health system: quantifying the unmet need.

AIM: The aim of this project was to determine the unmet need within the public health system for patients referred for elective Orthopaedic Specialist Spinal assessment and treatment in the Canterbury District Health Board (CDHB) region. METHODS: Between January 2014 and January 2015 data was collected from all elective referrals to the CDHB Orthopaedic Spinal Service. During this period, the number of available outpatient appointments was set by the CDHB. Within this clinical capacity, patients were triaged by the four consultant surgeons into those of most need based on the referral letter and available radiological imaging. Those unable to be provided with a clinical appointment were discharged back to their GP for ongoing conservative care. Of those patients that received specialist assessment and were considered in need of elective surgical intervention, a proportion were denied treatment if the surgery was unable to be performed within the government determined four-month waiting time threshold. RESULTS: During the study period, 707 patients were referred to the CDHB orthopaedic spinal team for elective specialist assessment. Of these, 522 (74%) were declined an outpatient appointment due to a lack of available clinical time. Of the 185 patients given a specialist assessment, 158 (85%) were recommended for elective surgery. Ninety-one (58%) were denied surgery and referred back for ongoing GP care due to unavailable operating capacity within the four-month waiting list threshold. Within this group of 91 patients, 16 patients were declined on multiple occasions (14 patients twice and two patients on three occasions). CONCLUSIONS: This study quantifies the unmet need for both Spinal Orthopaedic Specialist assessment and, if warranted, surgical management of elective spine conditions within the Canterbury public health system. It highlights the degree of rationing within the public health system and its failure to adequately provide for the Canterbury Public.

Cervical chordoma managed with multidisciplinary surgical approach.

BACKGROUND: This paper describes the interdisciplinary management of a 62-year-old man who presented with a cervical chordoma of C2/3. This is a rare neoplasm of the axial skeleton which is usually treated surgically. This is technically challenging due to the surrounding anatomy and requirement for wide exposure. A number of surgical approaches have been described to access the clivus and upper cervical spine. METHODS: This case involved both the Orthopaedic and Otolaryngology Head and Neck Surgery departments. Trotter's surgical technique was used to gain access for excision of the cervical chordoma and there was collaboration with an Orthopaedic Biotechnology Company in which a bio-model of the spine was created and a corpectomy cage specific to the patient developed. RESULTS: This approach allowed excellent visualisation of the tumour and the unique cage and plate achieved immediate stability and long term fusion. CONCLUSION: An interdisciplinary approach should be used in the management of upper cervical chordomas to facilitate tumour resection and reduce the potential for recurrence.

Comparison of usual surgical advice versus a nonaggravating six-month gym-based exercise rehabilitation program post-lumbar discectomy: results at one-year follow-up.

BACKGROUND CONTEXT: Discectomy is the surgery of choice for the lumbosacral radicular syndrome. Previous studies on the postsurgical management of these cases compare one exercise regime to another. This study compares an exercise-based group with a control group involving no formal exercise or rehabilitation. PURPOSE: The outcomes of a formal postsurgical exercise-based rehabilitation when compared with the usual rehabilitative surgical advice were evaluated. STUDY DESIGN: A randomized clinical trial comparing management regimes after lumbar discectomies. PATIENT SAMPLE: Ninety-three lumbar discectomy patients were randomized to two groups. OUTCOME MEASURES: The following postoperative outcomes were used: levels of pain; levels of function; psychological well-being; time off work; levels of medication; and number of doctor/therapist visits. METHODS: Ninety-three lumbar discectomy patients were randomized to two groups. The treatment group undertook a 6-month supervised nonaggravating exercise program. The control group followed the usual surgical advice to resume normal activities as soon as the pain allowed. Both groups were followed for 1 year by using validated outcome measures. RESULTS: The results are based on an intention-to-treat analysis. Patients in both groups improved during the 1-year follow-up (p=.001). There was no statistical significance between the groups at the clinical endpoint. The treatment group returned to work 7 days earlier and had fewer days off work in the 1-year follow-up period. CONCLUSION: There was no statistical advantage gained by the group that performed the 6-month supervised nonaggravating exercise program at 1-year follow-up. They did, however, have fewer days off work.