IntroductionMechanical instability in the lumbar spine is a term often used to describe an altered pattern of segmental movement causing pain. This is usually due to degenerative disease. Historically, symptoms of mechanical instability have been treated surgically with spinal fusion.In an attempt to modify the movement pattern of an abnormal motion segment, the Graf ligament system was introduced. It consists of modified titanium pedicle screws inter-connected with bands of braided polypropylene. This arrangement attempts to recreate the lumbar lordosis and allows limited movement to occur, hence the concept of 'flexible intervertebral stabilisation'. The operation is quicker, less destructive and requires less rehabilitation than a definitive spinal fusion.Previous authors [3,4,7] have reviewed early results of the system, which have been encouraging. We reviewed over 50 patients who underwent this procedure with an average follow-up time of over 5 years. Patients and methodsWe retrospectively reviewed 69 patients who underwent Graf ligament stabilisation between 1993 and 1997. Of these, 51 patients were available for follow-up. There were 23 women and 28 men. The mean age was 41 years (range, 22-67 years). All patients had chronic low back pain. Eight patients had had previous spinal surgery in the form of discectomy. Conservative management of back pain had failed in all the patients. This included physiotherapy, epidurals and facet joint injection. All patients were assessed preoperatively with an Oswestry Disability Index for low back pain. Our indication for stabilisation with the Graf ligament was intractable low back pain for which conservative measures of treatment had failed. All patients had magnetic resonance imaging (MRI) or computed tomography (CT) scans. Abnormal degenerative discs, end-plate changes or marked facet degeneration were targeted for stabilisation. Patients with equivocal scans were further investigated using discography. The surgery was performed by the two senior authors (M.A.F. and A.J.B.F.) exclusively. Fifteen patients had significant leg pain with clinical and radiological signs of nerve root entrapment and consequently underwent nerve root decompression at the same time as the spinal stabilisation. The majority of patients (n=31) had single-level stabilisation, while 17 had two-level and 3 had three-level stabilisation.Patient notes were examined. Previous history and details of surgery were recorded. Post-operative complications and length of Abstract Previous studies have looked at early follow-up of the Graf ligament stabilisation system. We present mid-to long-term results of this procedure. A retrospective review of Graf ligaments inserted since 1993 was undertaken. A total of 51 patients were reviewed. Pre-operative Oswestry Disability Index scores were compared to post-operative scores recorded via a postal questionnaire. There were 28 men and 23 women. The average age was 41 years (range, 22-67 years). The mean pre-operative score was 46 (range, 22-78), the mean follow...

National Hunt jockeys suffer a disproportionate number of clavicular fractures and their return to riding may be considerably delayed by refracture and symptomatic nonunion, with obvious implications. We report six such cases in which excision of the clavicular fragment distal to the fracture was associated with an early return to work and no recurrent injury to the shoulder.

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A recent Supreme Court ruling in the United Kingdom has significantly altered the emphasis of informed consent, moving from a historically 'doctor-focused' to a more 'patient-focused' approach, in line with the situation in other international jurisdictions. The reasons for the change are discussed with some recommendations about how our attitudes need to change in the future. Cite this article: Bone Joint J 2015;97-B:1159-61.

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Many hospitals do not have a structured process of consent, the attainment of which can often be rather 'last-minute' and somewhat chaotic. This is a surprising state of affairs as spinal surgery is a high-risk surgical specialty with potential for expensive litigation claims. More recently, the Montgomery ruling by the United Kingdom Supreme Court has placed the subject of informed consent into the spotlight. There is a paucity of practical guidance on how a consent process can be achieved in a busy clinical setting. The British Association of Spinal Surgeons (BASS) has convened a working party to address this need. To our knowledge this is the first example of a national professional body, representing a single surgical specialty, taking such a fundamental initiative. In a hard-pressed clinical environment, the ability to achieve admission reliably on the day of surgery, in patients at ease with their situation and with little likelihood of late cancellation, will be of great benefit. It will reduce litigation and improve the patient experience. Cite this article: Bone Joint J 2016;98-B:1427-30.

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