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...

In the United Kingdom, national guidelines have stated that patients undergoing elective hip surgery are at increased risk for venous thromboembolic events (VTE) following surgery and have recommended thromboprophylaxis for 28-35 days (1, 2). Studies of direct thrombin inhibitors have hitherto concentrated on major bleeding. We prospectively assessed wound discharge in patients who underwent hip arthroplasty and who received oral dabigatran postoperatively between March 2010 and April 2010 (n=56). We compared these results to a retrospective matched group of patients who underwent similar operations six months earlier, at which time all patients were given subcutaneous dalteparin routinely postoperatively until discharge, and then discharged home on 150 mg aspirin daily for 6 weeks (n=67). Wound discharge after 5 days was significantly higher in the patients taking dabigatran (32% dabigatran n=18, 10% dalteparin n=17, p=0.003) and our rate of delayed discharges due to wound discharge significantly increased from 7% in the dalteparin group (n=5) to 27% for dabigatran (n=15, p=0.004). Patients who received dabigatran were more than five times as likely to return to theatre with a wound complication compared with those who received dalteparin (7% dabigatran n=4, vs. 1% dalteparin n=1), but this was not statistically significant (p=0.18). We now administer dalteparin until the wound is dry and then start dabigatran. Our study demonstrates the need for further clinical studies regarding wound discharge and direct thrombin inhibitors.

In our series, results were disappointing where a large rim mesh or significant reconstruction was required. In light of these results, our technique has changed in that we now use predominantly larger chips of purely cancellous bone, 8-10 mm3 in size, to fill the cavity and larger diameter cups to better fill the aperture of the reconstructed acetabulum. In addition we now make greater use of i) implants made of a highly porous in-growth surface to constrain allograft chips and ii) bulk allografts combined with cages and morcellised chips in cases with very large segmental and cavitary defects.