Radiological and clinical assessment of the distraction achieved with remotely expandable growing rods in early onset scoliosis.

PURPOSES: Magnetically controlled growing rods (MCGR) allow controlled distraction of the immature spine for the treatment of early onset scoliosis. This study's primary aim was to determine the disparity between 'true' (TD) and 'intended' (ID) distraction. The secondary aim was to assess truncal growth and development during sequential lengthening. METHODS: Twenty-one patients with a maximum follow up of 37 months were included in the study. Patients in the study underwent three monthly distractions. The amount of TD was determined by measuring the expansion gap on dedicated fluoroscopic images of the actuator. The total TD to date was compared to the ID measurement reported on the external adjustment device (EAD). Weight, sitting and standing heights were recorded at each distraction. RESULTS: The average number of three monthly distractions was 8. The true to intended distraction ratio was calculated as 0.33. Patients who had undergone previous surgery gained less distraction with a ratio of 0.30 compared to patients undergoing MCGR as a primary procedure with a ratio of 0.35. Weight, sitting and standing heights increased in all patients by an average of 3.1 kg, 2.3 and 5.2 cm per year. The Cobb angle following surgical correction was maintained in 19 of 21 patients at the latest follow-up. CONCLUSIONS: The TI ratio of 0.33 suggests that for every unit of distraction registered on the EAD approximately 33 % of true distraction occurs in vivo. Increases in sitting and standing heights were observed in all patients in the study.

New method of Scoliosis Deformity Assessment: ISIS2 System.

Scoliosis deformity has been assessed using radiographic angle measurements. Surface topography systems are an alternative and complementary methodology. Working systems include the original ISIS1 system, Quantec and COMOT techniques. Over the last five years the new ISIS2 (Integrated Shape Imaging System) has been developed from basic principles to improve the speed, accuracy, reliability and ease of use of ISIS1. The aim of this study was to confirm that ISIS2 3D back shape measurements are valid for assessment and follow up of patients with scoliosis. Three-dimensional back measurements were performed in Oxford. ISIS2 includes a camera/projector stand, patient stand with a reference plane, and Mac computer. Pixel size is approximately 0.5 mm with fringe frequency of approximately 0.16 fringes/mm ( approximately 6.5 mm/fringe). Clinical reports in pdf format are of coloured images with numerical values. Reports include a height map, contour plot, transverse section plots, coronal plot, sagittal sections and bilateral asymmetry maps. A total of 520 ISIS2 scans on 242 patients were performed from February 2006 to December 2007. There were 58 male patients (median age 16 years, SD 3.71, min 7, max 25) and 184 female patients (median age 14.5 years, SD 3.23, min 5, max 45). Average number of scans per patient was 2.01 with the range of 1-10 scans. Right sided thoracic curves were the most frequent pattern. The median values and 95% CI are reported of back length; pelvic rotation; flexion/extension; imbalance; lateral asymmetry; skin angle; kyphosis angle; lordosis angle; volumetric asymmetry. ISIS2 scoliosis measurements are non-invasive, low-cost, three-dimensional topographic back measurements which can be confidently used in scoliosis assessment and monitoring of curve progression.

An NIHR-approved two-year observational study on magnetically controlled growth rods in the treatment of early onset scoliosis.

Aims: The primary aim of this study was to evaluate the performance and safety of magnetically controlled growth rods in the treatment of early onset scoliosis. Secondary aims were to evaluate the clinical outcome, the rate of further surgery, the rate of complications, and the durability of correction. Patients and Methods: We undertook an observational prospective cohort study of children with early onset scoliosis, who were recruited over a one-year period and followed up for a minimum of two years. Magnetically controlled rods were introduced in a standardized manner with distractions performed three-monthly thereafter. Adverse events which were both related and unrelated to the device were recorded. Ten children, for whom relevant key data points (such as demographic information, growth parameters, Cobb angles, and functional outcomes) were available, were recruited and followed up over the period of the study. There were five boys and five girls. Their mean age was 6.2 years (2.5 to 10). Results: The mean coronal Cobb angle improved from 57.6° (40° to 81°) preoperatively, 32.8° (28° to 46°) postoperatively, and 41° (19° to 57°) at two years. Five children had an adverse event, with four requiring return to theatre, but none were related to the device. There were no neurological complications or infections. No devices failed. One child developed a proximal junctional kyphosis. The mean gain in spinal column height from T1 to S1 was 45.4 mm (24 to 81) over the period of the study. Conclusion: Magnetically controlled growth rods provide an alternative solution to traditional growing rods in the surgical management of children with early onset scoliosis, supporting growth of the spine while controlling curve progression. Their use has clear psychosocial and economic benefits, with the reduction of the need for repeat surgery as required with traditional growing rods. Cite this article: Bone Joint J 2018;100-B:507-15.

Quantifying the 'law of diminishing returns' in magnetically controlled growing rods.

AIMS: Magnetically controlled growing rods (MCGRs) allow non-invasive correction of the spinal deformity in the treatment of early-onset scoliosis. Conventional growing rod systems (CGRS) need repeated surgical distractions: these are associated with the effect of the 'law of diminishing returns'. The primary aim of this study was to quantify this effect in MCGRs over sequential distractions. PATIENTS AND METHODS: A total of 35 patients with a maximum follow-up of 57 months were included in the study. There were 17 boys and 18 girls with a mean age of 7.4 years (2 to 14). True Distraction (TD) was determined by measuring the expansion gap on fluoroscopy. This was compared with Intended Distraction (ID) and expressed as the 'T/I' ratio. The T/I ratio and the Cobb angle were calculated at several time points during follow-up. RESULTS: The mean follow-up was 30 months (6 to 57). There was a significant decrease in the mean T/I ratio over time (convex rod at 3 months 0.81, sd 0.58 vs 51 months 0.17, sd 0.16, p = 0.0001; concave rod at 3 months 0.93, sd 0.67 vs 51 months 0.18, sd 0.15, p = 0.0001). A linear decline of the mean T/I ratios was noted for both convex rods (r2 = 0.90, p = 0.004) and concave rods (r2 = 0.81, p = 0.015) over 51 months. At the 24-month follow-up stage, there was a significant negative correlation between the mean T/I ratio of the concave rod with weight (r = -0.59, p = 0.01), age (r = -0.59, p = 0.01), and BMI of the child (r = -0.54, p = 0.01). CONCLUSIONS: The 'law of diminishing returns' is also seen after serial distraction using MCGR. Compared to previously published data for CGRS, there is a gradual linear decline rather than a rapid initial decline in lengthening. In older, heavier children a reduced distraction ratio in the concave rod of the MCGR device is noted over time. Cite this article: Bone Joint J 2017;99-B:1658-64.

The use of magnetically-controlled growing rods to treat children with early-onset scoliosis: early radiological results in 19 children.

AIMS: We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with early-onset scoliosis. PATIENTS AND METHODS: Between January 2011 and January 2015, 19 children were treated with magnetically-controlled growing rods (MCGRs) and underwent distraction at three-monthly intervals. The mean age of our cohort was 9.1 years (4 to 14) and the mean follow-up 22.4 months (5.1 to 35.2). Of the 19 children, eight underwent conversion from traditional growing rods. Whole spine radiographs were carried out pre- and post-operatively: image intensification was used during each lengthening in the outpatient department. The measurements evaluated were Cobb angle, thoracic kyphosis, proximal junctional kyphosis and spinal growth from T1 to S1. RESULTS: The mean pre-, post-operative and latest follow-up Cobb angles were 62° (37.4 to 95.8), 45.1° (16.6 to 96.2) and 43.2° (11.9 to 90.5), respectively (p < 0.05). The mean pre-, post-operative and latest follow-up T1-S1 lengths were 288.1 mm (223.2 to 351.7), 298.8 mm (251 to 355.7) and 331.1 mm (275 to 391.9), respectively (p < 0.05). In all, three patients developed proximal pull-out of their fixation and required revision surgery: there were no subsequent complications. There were no complications of outpatient distraction. CONCLUSIONS: Our study shows that MCGRs provide stable correction of the deformity in early-onset scoliosis in both primary and revision procedures. They have the potential to reduce the need for multiple operations and thereby minimise the potential complications associated with traditional growing rod systems. Cite this article: Bone Joint J 2016;98-B:1240-47.

Epidural steroid injection for nerve root compression. A randomised, controlled trial.

We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery. There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar.

Secondary neurological deterioration in traumatic spinal injury: data from medicolegal cases.

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

A complication of spinal decompression. A case report.

STUDY DESIGN: This case study is designed to report the previously unreported specific complication of acute cauda equina compression after decompression surgery for spinal stenosis. OBJECTIVES: To inform others of the possibility of such a complication; to suggest a possible mechanism for this situation, namely hourglass constriction of the cauda causing ischemia to distal nerve roots; and to suggest a management plan--immediate magnetic resonance imaging to identify the problem and return to the operating room for further decompression--which was successful in this case. SUMMARY OF BACKGROUND DATA: Previous reports of causes of paraparesis or paraplegia after surgery are listed, and previous theories on the etiology of acute cauda compression are discussed. METHODS: The clinical findings of spinal stenosis in a 32-year-old man are presented, and subsequent details of the surgery, complications after surgery, investigation, and future surgery, including magnetic resonance imaging scans before and after surgery, are provided. RESULTS: The result in this case was a patient free of symptoms. CONCLUSIONS: Incomplete decompression in surgery for spinal stenosis can result in acute cauda equina compression. In these circumstances, magnetic resonance imaging can reveal the cause, and in this case, immediate surgery was successful in relieving the symptoms and signs.

Cementless uncoated polyethylene acetabular components in total hip replacement. Review of five- to 10-year results.

We reviewed the results of 545 consecutive total hip replacements using a cementless non-coated high-density polyethylene acetabular component combined with a cemented Müller stem at five to 10 years. In all, 421 patients (445 hips) were available for review, 118 by questionnaire and 303 by examination and radiography. Of these, 86% had a good or excellent result. We found a high rate of radiological loosening of the cup after the sixth year, and a high rate of clinical loosening after the eighth year. Loosening was commoner in women, in younger patients and where a smaller size of acetabulum had been used. Calcar resorption was significantly related to loosening of the acetabulum. Loosening appeared to be mainly due to polyethylene debris produced by micro-movement of the acetabulum against the bone, which had resulted in a giant cell foreign body reaction and subsequent bone erosion. We have abandoned the use of this prosthesis and suggest that direct contact between bone and polyethylene should be prevented by a coating of metal or some other material.

The relationship between periosteal division and compression or distraction of the growth plate. An experimental study in the rabbit.

We subjected the proximal tibial growth plates of six-week-old rabbits to either compression or distraction of 1 kg on both legs. On one side the proximal tibial periosteum was divided circumferentially and stripped for 1 cm. After six weeks, growth was measured at both proximal and distal growth plates. Compression inhibited total tibial growth and distraction enhanced it. The compressed growth plate grew less and the distracted growth plate grew more, but there was a reciprocal change at the other end of the bone. Periosteal division enhanced growth at the adjacent growth plate but inhibited it distally; the effect of distraction was enhanced and that of compression reduced. We found reciprocal growth rates at the proximal and distal growth plates. Relatively small amounts of compression or distraction did affect total bone growth. Periosteal division appeared to induce overgrowth at least partly by a mechanical effect; it may be useful as an adjunct to other methods of leg lengthening, though not to epiphyseolysis.

Instability due to unrecognised fracture-subluxations after apparently isolated injuries of the cervical spine.

Instability may present at a different level after successful stabilisation of an unstable segment in apparently isolated injuries of the cervical spine. It can give rise to progressive deformity or symptoms which require further treatment. We performed one or more operations for unstable cervical spinal injuries on 121 patients over a period of 90 months. Of these, five were identified as having instability due to an initially unrecognised fracture-subluxation at a different level. We present the details of these five patients and discuss the problems associated with their diagnosis and treatment.

Bone growth and remodelling after fracture.

We used a rabbit model to investigate the mechanism by which the angulation of fractures is corrected in children. We produced a transverse proximal tibial fracture in one leg of 12 eight-week-old New Zealand white rabbits and measured bone alignment and length and the patterns of bone growth and remodelling. The angle between the joint surfaces changed rapidly to correct the alignment of the limb as a result of asymmetrical growth of epiphyseal plates. In an adult with closed plates, the angle between the joint surfaces cannot therefore improve. The angle at the fracture itself showed slow improvement because of bone drift and the asymmetrical growth of the epiphyseal plates. Remodelling corrected the shape of the bone in the region of the fracture. Periosteal division on the convex side increased the growth of the epiphyseal plate on that side, thus slowing the correction. The effect was relatively small, providing an indication that factors other than the periosteum are important in inducing correction. External torsional deformities developed because of helical growth at the plate. This was probably caused by abnormal posture which induced a torque at the growth plate. Helical growth is the mechanism by which rotational deformities can occur and correct.

Acute compression fracture of the scaphoid.

A previously unreported radiological sign of a sclerotic margin to an acute displaced scaphoid fracture due to bone compression is reported. This should to be recognized because of the implied bone loss and hence risks of both mal-union and non-union, and because of the implication that volar compression fractures of the scaphoid may occur.

Spot weld injuries of the hand.

Spot weld burns of the hand result in damage to structures deep to the skin by dissipation of heat locally causing extensive necrosis. This must be appreciated to optimize treatment.

Day case arthroscopy under local anaesthesia.

A prospective study of the effectiveness of local anaesthesia in arthroscopy of the knee was performed in 212 consecutive patients. Arthroscopic surgery was undertaken successfully in 121 cases (57%), including meniscectomy and drilling of osteochondral defects. Dynamic evaluation of the patellofemoral joint articulation was possible and demonstration of pathological abnormalities was felt to be beneficial by some patients. The method described is safe, reliable, confers good postoperative analgesia and enables physiotherapy to begin immediately. Conversion to general anaesthesia was necessary in one case due to pain localised to a stiff and osteoarthritic hip. Intra-articular haemorrhage was found to be a problem in one case with synovitis. Only ten patients complained of moderate pain, none had severe pain. Local anaesthesia is contraindicated in cases with ipsilateral osteoarthritis of the hip or with significant synovitis of the knee. This technique is particularly suited to day case surgery.

Diabetes is predictive of longer hospital stay and increased rate of complications in spinal surgery in the UK.

INTRODUCTION: Diabetes is a common co-morbidity of patients undergoing spinal surgery in the UK but there are no published studies from the UK, particularly with respect to length of hospital stay and complications. The aims of this study were to identify complications and length of hospital stay in patients with diabetes undergoing spinal surgery. METHODS: Data were collected retrospectively for 111 consecutive patients with diabetes (and 97 age and sex matched control patients, identified using computer records) who underwent spinal surgery between 2004 and 2010 in a single centre. The data collected included operative time, blood loss, details of surgery, Clavien complications and length of hospital stay. RESULTS: No significant differences were found by group in operative time, blood loss, instrumentation, use of graft or revision surgery. Overall complication rates were higher in the patients with diabetes than in the controls (28.8% vs 15.5%). The mean hospital stay was significantly longer for patients with diabetes than for control patients (4.6 vs 3.2 days, p<0.001). CONCLUSIONS: This study identified a significantly higher Clavien grade I complication rate and length of hospital stay in patients with diabetes undergoing spinal surgery than control patients (p=0.02). This has resulted in a predictive model being generated. Of note, no infections were seen in patients with diabetes, suggesting that infection rates in this particular group of patients undergoing spinal surgery might not be as high as considered previously.

Posterior occipitocervical instrumented fusion for dropped head syndrome after deep brain stimulation.

We describe dropped head syndrome in a patient with Parkinson's disease receiving subthalamic nucleus deep brain stimulation (DBS). Posterior occipitocervical instrumented fusion after transarticular screw fixation of an odontoid fracture is shown and its rationale explained. Pedunculopontine nucleus DBS as treatment for fall-predominant Parkinson's disease, and globus pallidus interna DBS for dystonia-predominant Parkinson's disease, are discussed.

Management and outcome of infective prepatellar bursitis.

Forty seven cases of prepatellar bursitis are reported. Twenty one patients had sustained a recent injury with a break in the skin which had caused the infection and seventeen patients were employed in jobs which involved kneeling. Oral antibiotics proved to be inadequate treatment in many cases. Splintage and intravenous antibiotics with or without aspiration of the bursa were usually successful in treating the condition, although nine patients required surgical drainage of the bursa. Twelve patients continued to have symptoms months or years after the infection, particularly those with preexisting chronic bursitis, or those who kneeled at work. There was little difference in the results between the different treatment groups.