Further faculty included Jean-Noel Argenson (Marseille), Lars Carlsson (Gothenberg), Evan Williams (Capetown) Heinz Rottinger (Munich), Roy Crowninshield (Warsaw) and Claude Rieker (Winterthur). This ensured an overall delegate/faculty ratio of 4.6 to help facilitate this extensive course.

The main purpose of this meeting was to allow all those attending to explore current issues in the provision of high quality primary lower limb joint replacement. This year’s meeting was devoted to contemporary arthroplasty of the hip and knee, including resurfacing of the hip, MIS and unicondylar arthroplasty of the knee. The concept of minimal invasive surgery was widely debated, and consensus reached as to the appropriate application of these new techniques. Additional sessions covered advances in biomaterials, alternative treatment options for the younger patient, and the philosophical considerations of the need for progress, tempered with caution.

As always the meeting contained a high level of interactive debate and discussion utilising electronic voting systems and break out groups to ensure feedback from over 120 Orthopaedic surgeons in attendance. The feedback from delegates was very positive, with all of the sessions being rated good or excellent.

One delegate described the Knee meeting as: “Impressive national and international faculty giving authoritative opinion and instruction on common problems with knee arthroplasty”. Others noted how the interactive format was a refreshing change, while the course was was both professional and well organised.

Questions were posed to the audience about the surgical techniques and approaches they have preferences for, with the key results listed below.

Knee

• 72% of the audience expressed the fact that they had actively been trying to reduce the size of the incision used for total or unicondylar knee arthroplasty.
• 36% of the audience had adopted an MIS approach for unicondylar knee replacement; 28% felt that they were still learning the technique, and a further 32% had never tried the procedure.
• 59% had not tried MIS Mini total knee.
• The single biggest cause of failure, other than that due to infection, was felt to be polyethylene wear by 37%, and failure of the bone prosthesis interface by the remaining 63%.

• The audience identified their priority in THR as longevity of the implant (66%), ultimate functional level (29%), and lowest rate of failure (5%). Nobody felt that rapid recovery was the most important consideration.
• 59% preferred the lateral Hardinge approach to the posterior. 45% routinely perform hip replacement through a short incision, with only 9% utilising a special approach to facilitate minimally invasive surgery.
• An overwhelming majority, of 98%, preferred resurfacing to total joint replacement for the younger patient, with 51% regarding the blood supply to the resurfaced femoral head to be a critical issue.
• 78% of the audience would prefer to have their own hip resurfaced, rather than replaced.

Zimmer is committed to educational excellence and to the continued improvement in outcomes and patient safety afforded by high quality and innovative medical education with the Zimmer Institute™ offering a variety of courses, tailored to the interests and needs of the individual. These courses aim to promote excellence in surgery, by developing procedures and skills in the individual, and by promoting the principles of team working, multiprofessional care, and lifelong learning and reflective practice.

The aim of this study was specifically to assess any difference in outcome between post discectomy instability severe axial pain and primary severe axial back pain. Significant loss of disc height is a relative contraindication to disc replacement but not to anterior interbody fusion.

Anterior lumbar interbody fusion has been used for many years to achieve fusion in patients with degenerative disc disease. A variety of different techniques have been described in the literature^1-5, with varying success rates. The results of anterior lumbar spinal fusion vary considerably in the literature and there is a lack of reporting standardised outcome measures in the literature.

Although both anterior and posterior approaches for spinal fusion are well described, the choice of procedure is surgeon dependent. Reported results of cohort studies may be related to the enthusiasm of the reporter. A study comparing the approaches⁷ concluded that anterior interbody fusion with cages, for single level lumbar pathology, is associated with significantly less peri-operative morbidity than posterolateral fusion with pedicle screws. They did not find any significant differences in the clinical outcome between the two approaches.

A study by Greenough et al⁶ found that anterior fusion resulted in better clinical results based on the LBOS, with 40% of patients having an excellent or good result in the anterior fusion group and only 19% achieving a similar result in the posterolateral fusion group. They concluded that results of instrumented posterolateral fusion are poor. They believe that this is due in part, to damage to the spinal musculature during the posterior approach as well as anterior movement still occurring despite solid posterior fusion.

A trans-peritoneal approach may have a higher rate of retrograde ejaculation in males, while a retroperitoneal approach may have a higher venous vascular injury rate. Adequate exposure of the disc above, below and laterally must be achieved with suitable retraction. Operative level must be confirmed by X-Ray. After adequate exposure of the disc space, all disc material is excised and the endplates are removed to expose good cancellous bone.

The hard outer cortical rim should be preserved. The STALIF™ device is packed with bone graft or bone substitute and then inserted. All the patients in this reported study had cortico-cancellous bone harvested from the iliac crest.

The primary diagnosis was back pain due to degenerative disc disease, which was confirmed by pre-operative MRI scanning and all patients had provocative discography to confirm the disc as the source of pain. The patients were followed up for a minimum of 2 years and our primary outcome measures included Oswestry disability index (ODI), low back outcome score (LBOS) and visual analogue score (VAS).

The Mean pre-operative ODI score was 58 and at 2 years follow-up this had decreased to 31 [p=0.004]. Similarly the mean LBOS was 21 pre-operatively and increased to 41 [p=0.005] at 2 years follow-up. The Mean VAS score for back pain was 83mm pre-operatively and this had decreased to 49mm at 2 years follow-up [p=0.01]

When the data was analysed according to the pre-operative pathology we found that patients who had back pain post-discectomy showed a greater improvement in their ODI compared to patients who had back pain alone. The mean change in ODI for the back pain group was 17 points whereas the change in ODI for the back pain post-discectomy group was 29 points [p=0.33].

We found that although plain radiographs give some information about the position of the implant, it is very difficult to assess fusion on radiographs in all the patients, as the titanium device used prior to the introduction of PEEK-OPTIMA® does not allow accurate assessment on plain radiographs. We found no cases of loose screws or subsidence of the implant at 2 years follow-up.

The main complication in our group of patients was common iliac vein tear, which occurred in 2 patients. This was recognised and repaired intra-operatively with no untoward effects. One of our patients developed retrograde ejaculation post-operatively, which settled spontaneously after 24 months.

The STALIF™ device has been tried and tested for 12 years of clinical practice in the unit reporting these results. The senior author has no commercial interest in the device. He does believe it has an important clinical role as a safe and clinically effective implant that is also cost effective for the modern health service.

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2. Penta M, Fraser R.D: Anterior Lumbar Interbody Fusion: A Minimum 10-year Follow-up. Spine 15 Oct 1997, Vol 22(20); 2429- 2434.
3. Freebody D, Bendall R, Taylor R.D: Anterior transperitoneal lumbar fusion. J Bone Joint Surg Br 1971, 53:617-627.
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5. Sasso R.C, Kitchel S.H, Dawson E.G: A prospective, randomised controlled clinical trial of anterior lumbar interbody fusion using a titanium cylindrical threaded fusion device. Spine 15 Jan 2004, Vol 29(2); 113-22.
6. Greenough C.G, Peterson M.D, Hadlow S, Fraser R.D: Instrumented Posterolateral Lumbar Fusion: Results and Comparison with Anterior Interbody Fusion. Spine February 15 1998, Vol 23(4); 479-486.
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8. Ivar B.J, Sorenson R.F, Nygaard O, Indahl A et al: Randomised clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine Sep 1 2003, Vol 28(17); 1913-21.
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