Proximal humerus deformity, in a four-limb amputee following meningococcal septicaemia.

We present a challenging case of proximal humerus varus deformity in a four-limb amputee, caused by growth arrest from meningococcal septicaemia. The deformity resulted in a loss of function for our patient with inhibition of activities of daily living, requiring corrective osteotomy to help improve the range of motion of the shoulder. We describe in detail the management of our patient, highlight the importance of the orthopaedic manifestations of meningococcal septicaemia, and demonstrate the importance of monitoring potential deformities from growth arrest in these patients.

Outcome of partial repair of massive rotator cuff tears with and without human tissue allograft bridging repair.

BACKGROUND: The surgical management of massive rotator cuff tears remains a challenge. It is suggested that, even in a massive tear that appears irreparable, attempting to repair it as much as possible can be helpful in improving functional outcomes. However the results can be short term and variable. The purpose of our study was to determine if human tissue allograft bridged repair of massive irreparable rotator cuff tears to achieve a complete repair produces similar outcomes compared to partial repair alone. METHODS: We prospectively reviewed outcome scores in 13 patients who underwent partial repair alone for massive irreparable rotator cuff tears and compared them to 13 patients who had partial repairs bridged with allograft. Oxford and Constant scores were compared pre-operatively and at a minimum follow-up of 2 years (range 2 years to 5 years). RESULTS: The mean improvement in the Constant score at final follow-up compared to pre-operative scores was 27.7 points in the partial repair group and 42.8 points in the allograft group (p < 0.01). The Oxford Shoulder Score improved mean of 19.3 points in the partial repair group and 29 points in the allograft group (p < 0.02) at 2 years. CONCLUSIONS: Human tissue matrix allograft provides a better outcome for open bridging of irreparable rotator cuff tears than partial repair alone.

Do we need to follow up an early normal ultrasound with a later plain radiograph in children with a family history of developmental dysplasia of the hip?

BACKGROUND: We routinely perform a pelvic radiograph between 6 and 12 months of age for children with a family history of developmental dysplasia of hip (DDH). We conducted this study to determine whether children with a family history of DDH and a normal hip ultrasound after birth require any further radiological follow-up. METHODS: We identified all children referred to our hip-screening clinic in a 3-year period between August 2008 and August 2011 with a family history of DDH and a normal hip ultrasound after birth. A total of 119 patients with a normal hip ultrasound after birth had a pelvic radiograph at a median age of 6.6 months. RESULTS: Six patients had residual dysplasia (acetabular index >30°) on the initial radiograph; five of these had resolved spontaneously by age 12 months, and the remaining patient had a normal radiograph at 21 months of age and was discharged. CONCLUSION: We have found no cases of residual hip dysplasia requiring treatment in children with a family history of DDH and a normal hip ultrasound after birth. We have therefore changed our practice accordingly and no longer routinely followed up such cases. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Management of paediatric tibial fractures using two types of circular external fixator: Taylor spatial frame and Ilizarov circular fixator.

BACKGROUND: The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management. METHOD: A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months. RESULTS: Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group. CONCLUSION: In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter. LEVEL OF EVIDENCE: Level II-comparative study.

Proximal tibiofibular joint instability in a child: stabilization with Tightrope.

Proximal tibiofibular instability is a rarely reported clinical entity in children. In this case report, we describe such a case in an 8-year-old boy successfully stabilized using a minimally invasive technique with a Tightrope device. The child remained pain free and asymptomatic at 2 years of follow-up. The surgical technique is described as well as potential complications and a review of the literature.

Tumor necrosis alpha-blocking agent (etanercept): a triple blind randomized controlled trial of its use in treatment of sciatica.

STUDY DESIGN: Triple blind randomized controlled study. OBJECTIVE: To establish the treatment effect of etanercept in acute sciatica secondary to lumbar disc herniation. SUMMARY OF BACKGROUND DATA: Etanercept is a selective competitor of tumor necrosis factor-alpha which is a proinflammatory cytokine. It is currently used alone or in combination with other medication for the treatment of chronic inflammatory disease. METHODS: Inclusion criteria were acute unilateral radicular leg pain secondary to herniated nucleus pulposus confirmed on magnetic resonance imaging 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 posttreatment. Oswestry disability index and visual analog scores were among the assessment criteria. RESULTS: Fifteen patients were recruited in a 4 years period with a 3 months follow-up of 80%. The etanercept group had 8 patients whereas the placebo group had 7. The average Oswestry disability index for the etanercept group preintervention was higher than that in the placebo group (53.6 vs. 50.4) and this remained the same after 6 weeks (46.1 vs. 31.2) and 3 months of follow-up (37 vs. 35). Visual analog score was also higher in the etanercept group versus placebo; preinjection (8.6 vs. 7.4), 6 weeks (5.0 vs. 3.8), and 3 months (4.8 vs. 4.5). CONCLUSIONS: Small numbers of trial participants limited statistical analysis. The trend appears to show no benefit to the use of etanercept over placebo in the pharmacologic treatment of sciatica.

Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis.

The objective of this study is to evaluate the efficacy of corticosteroids in patients with radicular pain due to lumbar disc herniation or lumbar spinal stenosis through a prospective randomised, double blind controlled trial, and whether there was an effect on subsequent interventions such as additional root blocks or surgery. Peri-radicular infiltration of corticosteroids has previously been shown to offer no additional benefit in patients with sciatica compared to local anaesthetic alone. It is not known if the response to peri-radicular infiltration is less marked in certain subgroups of patients such as those with radicular pain due to lumbar spinal stenosis. Previous studies have suggested that peri-radicular infiltration of corticosteroids may obviate the need for subsequent interventions and we therefore further investigated this in the current study. We randomised 150 patients to receive a single injection with either bupivacaine alone or bupivacaine and methylprednisolone. Patients were assessed at 6 weeks and 3 months after the injection using standard outcome measures including Oswestry Disability Index (ODI), visual analogue score for leg pain and patient's subjective assessment of outcome. At 1-year follow-up, we looked at the outcome in terms of the need for subsequent interventions such as additional root blocks or surgery. At 3-month follow-up, there was no statistically significant difference in the standard outcome measures between the two injection groups. At a minimum 1-year post injection, there was no difference in the need for subsequent interventions in either group. Patients with lumbar spinal stenosis had a less marked reduction in the ODI at 3 months with a mean change of 3.3 points when compared with 15 points for patients with lumbar disc herniation. In conclusion, peri-radicular infiltration of corticosteroids for sciatica does not provide any additional benefit when compared to local anaesthetic injection alone. Corticosteroids do not obviate the need for subsequent interventions such as additional root blocks or surgery.

The effect of duration of symptoms on standard outcome measures in the surgical treatment of spinal stenosis.

The effect of the duration of symptoms on the outcome of lumbar decompression surgery is not known. The aim of our study was to determine the predictors of functional outcome of lumbar decompression surgery for degenerative spinal stenosis with particular emphasis on the duration of symptoms. In this prospective cohort study, we recruited 100 patients with a full data set available at 1-year and 85% at 2-year follow-ups: 49 females and 51 males with an average age of 62 (range 52-82). The pre- and post-operative outcome measures were Oswestry disability index (ODI), low back outcome score (LBOS), pain visual analogue score (VAS), modified somatic perception (MSP) and modified Zung depression (MZD) score. Dural tear occurred in 14%, and there was one post-operative extra-dural heamatoma. Overall, the ODI improved from a pre-operative of 56 (+/-13) to a 1-year ODI of 40 (+/-22) and at 2-year ODI of 40 (+/-21). The VAS improved from an average of 8 to 5.2 at 1 year and 4.9 at 2 years. There was a statistical significant association between symptom duration and the change in ODI (P=0.007 at 1-year follow-up, P=0.001 at 2-year follow-up), LBOS (P=0.001 at 1-year follow-up, P<0.001 at 2-year follow-up) and VAS (P=0.003 at 1-year follow-up, P=0.001 at 2-year follow-up). Subgroup analyses showed that patients with symptom duration of less than 33 months had a more favourable result. In addition, the patients who rated the operation as excellent had a statistically significantly shorter duration of symptoms. We have not found a predictive value for age at operation, MSP or MZD. The number of levels of decompression and the different types of decompression surgery did not influence the surgical results. Our study indicates that the symptom duration of more than 33 months has a less favourable functional outcome.

Randomised placebo-controlled trial on the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis.

This is a double blind randomised controlled trial to assess the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis. The trial compared the outcome of salmon calcitonin nasal spray to placebo nasal spray in patients with MRI confirmed lumbar spinal stenosis. Lumbar spinal stenosis is one of the commonest conditions encountered by spine surgeons. It more frequently affects elderly patients and lumbar decompression has been used to treat the condition with variable success. Non operative measures have been investigated, but their success ranges from 15% to 43% in patients followed up for 1-5 years (Simotas in Clin Orthop 1(384):153-161, 2001). Salmon calcitonin injections have been investigated in previous trials and may have a treatment effect. Nasal salmon calcitonin has become available and if effective would have advantages over injections. Forty patients with symptoms of neurogenic claudication and MRI proven lumbar spinal stenosis were randomly assigned either nasal salmon calcitonin or placebo nasal spray to use for 4 weeks. This was followed by a 'washout' period of 6 weeks, and subsequent treatment with 6 weeks of nasal salmon calcitonin. Standard spine outcome measures including Oswestry disability index (ODI), low back outcome score, visual analogue score and shuttle walking test were administered at baseline, 4, 10 and 16 weeks. Twenty patients received nasal salmon calcitonin and twenty patients received placebo nasal spray. At 4 weeks post treatment there was no statistically significant difference in the outcome measures between the two groups. The change in ODI was a mean 1.3 points for the calcitonin group and 0.6 points for the placebo group (P = 0.51), the mean change in visual analogue score for leg pain was 10 mm in the calcitonin group and 0 mm in the placebo group (P = 0.51). There was no significant difference in walking distance between the two groups, with a mean improvement in walking distance of 21 m in the calcitonin group and 8 m in the placebo group (P = 0.78). At the end of the trial the ODI had improved by a mean of 3.7 points in the calcitonin group and 3.8 points in the placebo group (P = 0.44). This randomised placebo controlled trial has not shown any treatment effect in patients with lumbar spinal stenosis treated with nasal salmon calcitonin.

Outcome scores in spinal surgery quantified: excellent, good, fair and poor in terms of patient-completed tools.

Outcome scores are very useful tools in the field of spinal surgery as they allow us to assess a patient's progress and the effect of various treatments. The clinical importance of a score change is not so clear. Although previous studies have looked at the minimum clinically important score change, the degree of score change varies considerably. Our study is a prospective cohort study of 193 patients undergoing discectomy, decompression and fusion procedures with minimum 2-year follow-up. We have used three standard outcome measures in common usage, the oswestry disability index (ODI), the low back outcome score (LBOS) and the visual analogue score (VAS). We have defined each of these scores according to a global measure of outcome graded by the patient as excellent, good, fair or poor. We have also graded patient perception and classified excellent and good as success and fair and poor as failure. Our results suggest that a median 24-point change in the ODI equates with a good outcome or is the minimum change needed for success. We have also found that different surgical disorders have very different minimal clinically important differences as perceived by patient perception. We found that for a discectomy a minimum 27-point change in the ODI would be classed as a success, for a decompression the change in ODI needed to class it as a success would be 16 points, whereas for a fusion the change in the ODI would be only 13 points. We believe that patient-rated global measures of outcome are of value and we have quantified them in terms of the standard outcome measures used in spinal surgery.

Incidental durotomy in lumbar spine surgery: incidence and management.

There is increasing awareness of the need to inform patients of common complications that occur during surgical procedures. During lumbar spine surgery, incidental tear of the dural sac and subsequent cerebrospinal fluid leak is possibly the most frequently occurring complication. There is no consensus in the literature about the rate of dural tears in spine surgery. We have undertaken this study to evaluate the incidence of dural tears among spine surgeons in the United Kingdom for commonly performed spinal procedures. Prospective data was gathered for 1,549 cases across 14 institutions in the United Kingdom. The results give us a baseline rate for the incidence of dural tears. The rate was 3.5% for primary discectomy, 8.5% for spinal stenosis surgery and 13.2% for revision discectomy. There was a wide variation in the actual and estimated rates of dural tears among the spine surgeons. The results confirm that prospective data collection by spine surgeons is the most efficient and accurate way to assess complication rates for spinal surgery.