Scientific work. Abstracts of Papers Published / Presented

Presentations include only those where abstracts are published)

Aquaflo pump vs FMS 4 pump for shoulder arthroscopic surgery. Ann R Coll Surg Engl. 1997 Sep;79(5):341-4. Ampat G, Bruguera J, Copeland SA. Royal Berkshire Hospital, Reading.

A prospective controlled trial was carried out to compare two different fluid delivery systems used for shoulder arthroscopy. One an advanced pump system that controls both pressure and flow of fluid delivered, the other an air-driven diaphragm pump that only controls fluid pressure. Blood loss, presence of bleeding vessels and visual clarity were parameters used to assess the pump systems. There was no difference between the pumps in straightforward shoulder procedures. However, complicated and prolonged procedures benefited from the use of the advanced pump system.


Trauma database and the need for computerised medical records G Ampat – Injury, Volume 29, Number 2, March 1998, pp. 149-149(1) Milton Keynes General Hospital, Milton Keynes, UK

There is a general need for proper computerised documentation of medical records. Medical records on paper are vast, unwieldy, cumbersome, sometimes illegible, often missing, difficult to process (data) and only locally accessible. Even with the explosion in medical knowledge and the vast armament of investigations available, decision making now, is more than ever before, under uncertainties. Natural histories of many diseases are unknown due to our over dependence on paper medical records. Computerised medical records on the contrary are compact, readable, globally accessible, aiding multiple and complex extractions and if properly formatted and programmed, can be used with ease.  In recording data, if computerised medical records relied on manual typing, then it would be equally or more cumbersome than paper records. Proper programming ensures that data can be recorded with ease.  Not as a panacea for all the deficiencies of paper medical records but rather as a small step towards a giant leap I present a Trauma Database. The trauma database though infantile has capabilities to collect information in an organised manner. The use of a graphical interface decreases the use of the keyboard. The AO-ASIF and ICD-10 classification systems are used in this database and any Trauma unit can easily use it.

HOSPRAC – AN ORTHOPAEDIC AND TRAUMA DATABASE. Journal of Bone & Joint Surgery – British Volume. 82-B Supplement III:264, 2000. Ampat, G. The Royal Hospital Haslar, Gosport, Hampshire, PO12 2AA [Combined Services Orthopaedic Society: Millennium Meeting, Scotch Corner, North YorkshireMay 19 2000]

The author developed HOSPRAC an Access©  based data base system 3 years ago for documentation of clinical activity in an Orthopaedic and Trauma department. The database was first installed at John Radcliffe Hospital, Oxford and has been functioning there with no major setbacks for the last 2 years. Service modifications were incorporated into the database and it is currently being used at Royal Hospital Haslar for the last 2 months. The database comes with a set up disc and is compatible with all 32 bit Windows[reg] operating systems. It is a run time version and the user does not need to have any other software. The user does not require even a separate copy of Access[reg] as it is a run time version. HOSPRAC comes with an in built help file and a demo for new users. The database codes all clinical activity appropriately. Diagnoses are coded in ICD9, Read and AO (AO classification for fractures only). The Operative procedures are coded in OPCS 4 and Read. The database produces Discharge Summaries for civilian patients, an FMed 14 for service patients, a daily record of inpatients with all clinical data, a cumulative data of clinical activity for the period specified, the ‘To Come In list’, the ‘Theatre List’ and the Log Book of individual surgeons. User friendly interface allows accurate and easy recording of data. Fractures are graphically depicted and the user records data by descending through the AO classification tree. Medical categories of all the three services are available and easily recorded. HOSPRAC has proven to be a robust and user friendly Orthopaedic and Trauma database in both service and civilian hospital with a good record of three hospital years. EUROSPINE 2001 3rd Annual Meeting of the Spine Society of Europe September 2–8, 2001 Gothenburg, Sweden

Successful Return to Fitness following Successful ACL Reconstruction in Service Patients. Journal of Bone & Joint Surgery – British Volume. 82-B Supplement III:264, 2000. Ampat, G.; Masilamani, N.; Spalding, T. The Royal Hospital Haslar, Gosport, Hampshire PO12 2AA [Combined Services Orthopaedic Society: Millennium Meeting, Scotch Corner, North YorkshireMay 19 2000]

The senior author (TS) has previously reported a “return to P2” (normal medical category) of over 70% following ACL reconstruction in service personnel. The true functional outcome in terms of activity level and quality of life is unknown and this study aims to quantify this.

All service personnel (n= 65) undergoing ACL reconstruction by the senior author have been prospectively assessed since 1995. Outcome data was collected at 3, 6, 9 12 and 24 months. The 65 patients comprised 14 from the Army, 5 from the RAF, 7 from Royal Marines and 39 from the Royal Navy. Average follow up was 35 months (Range 13 to 54). At the one year 17 (26.2%) were IKDC Grade A, 42 (64.5%) Grade B, 4 (6.2%) Grade C and 2 (3.1%) Grade D. 20 (30.8 %) patients were upgraded to P2 at six months, 12 (18.5 %) at 9-months, 14 (21.5 %) at one year and one (1.5%) at 24 months. The remaining 18 patients (27.7%) are either still downgraded or upgraded with restrictions. Four of these 18 have been medically discharged due to their knee and 4 are still within the 2 year limit of a downgraded medical category.

At one year 25 (38.5%) were at Level 1 IKDC activity level. 23 (35.4%) at level 2 and 17 (26.1%) at level 3 or 4. The mean Tegner activity level score pre injury was 8.1 with 95 % participating in sports scoring 7 or above. The mean Tegner score was 3.5 preoperatively and rose to 5.9 at one year and 6.6 at 2 years. The mean side to side manual maximum difference on KT 1000 arthrometric testing was 7.2mm preoperatively and decreased to 1.70 mm at one year and 1.39 mm at 2 years.

We conclude that ACL reconstruction is a reliable operation for service personnel achieving a 70.8% return to full occupational activities and medical upgrading by one year.


The Genzyme Procedure in the Knee – Does it prevent invaliding from the service? T Spalding, I Lasrado, G Ampat. JBJS Br 2000 82-B Supp III Page 266.[Combined Services Orthopaedic Society: Millennium Meeting, Scotch Corner, North YorkshireMay 19 2000Spalding, T.; Lasrado, ; Ampat, G Royal Hospital Haslar, Gosport, Hampshire, PO12 2AA

To determine whether autologous chondrocyte implantation (ACI) for the treatment of chondral and osteo-chondral lesions in the knee of service personnel facing medical discharge can result in sufficient improvement to avoid invaliding.

A prospective study of 10 active service personnel undergoing ACI with a mean follow-up of 18 months (range 6-30). The mean age at ACI was 32.4 (range 25 – 45) and the mean defect size was 4.19cm2 (range 2.3 – 6.3 cm2). Second look arthroscopy at 12 months was performed in 8 patients for scoring of repair tissue according to ICRS grading.

All 10 are improved as judged by subjective rating scale and by the Mohtadi Quality of life score which improved from 25.8 to 46.7 (p[lt]0.05). Six of the 10 have been retained in the armed forces and four medically discharged due to their knee. Worse outcome was associated with previous partial medial meniscectomy (p=0.02). Second look arthroscopy showed ICRS Grade I repair (normal) in six, partial graft separation in one and graft hypertrophy in another, both requiring debridement with a shaver.

ACI was successful in retaining 6 of 10 service patients who were facing medical discharge due to their knee symptoms and poor function. The technique is therefore a valuable tool in managing service patients with severely symptomatic chondral lesions in the knee. However the degree of improvement is variable and care should be exercised when offering this technique in the absence of a functional medial meniscus.

Outcome in Arthroscopic Subacromial Decompression. A Prospective study. G Delves, J Hayton, G Ampat, T Spalding JBJS Br 2000 82-B Supp III Page 265 [Combined Services Orthopaedic Society: Millennium Meeting, Scotch Corner, North YorkshireMay 19 2000Delves, G.; Hayton, J.; Ampat, G.; Spalding, T. Royal Hospital Haslar, Gosport, Hants, PO12 2AA

Objective: To establish if long term outcomes in arthroscopic subacromial decompression support its continued use over open surgery. Design: Prospective study of 25 patients Setting: Royal Hospital Haslar. Subjects: 25 Patients aged 44-83 with rotator cuff disease requiring surgical intervention. Intervention: Arthroscopic subacromial decompression performed by a consultant orthopaedic surgeon with an interest in shoulders. Outcome measures: American Shoulder and Elbow Surgeons Rating Scale, Constant Shoulder Function Score, UCLA Shoulder Rating Scale, Oxford Shoulder Questionnaire. Results: No difference was found between our arthroscopic outcomes compared to published open surgery outcomes.  Conclusion: Arthroscopic subacromial decompression has similar long term outcomes compared to open surgery, but with much shorter and less painful post operative recovery. This confirms findings in previous short-term outcome studies in this centre. EUROSPINE 2001 3rd Annual Meeting of the Spine Society of Europe September 2–8, 2001 Gothenburg, Sweden


THE NASCIS TRIALS Journal of Bone & Joint Surgery – British Volume. 84-B SUPPLEMENT II:169, 2002. Ampat, G.. Queens Medical Centre, University Hospital, Nottingham NG7 2UH Combined Services Orthopaedic Society: Wansford – May 2001]

To determine the current practice and to review the literature regarding administration of high dose Methylprednisolone for acute spinal cord injury (SCI). Administration of high dose Methylprednisolone for Acute Spinal Cord Injury has been widely practised following the publication of the three National Acute Spinal Cord Injury Studies (NASCIS). NASCIS recommends a bolus intravenous dose of 30mg/kg of Methylprednisolone in 15 minutes, followed by a 45 min pause and then followed by a maintenance dose of 5.4 mg /kg/hr for 23 hours. This regime has been recommended by the Advanced Trauma Life Support. The Cochrane reviews also extol the three NASCIS randomised controlled trials. The mechanism of neuroprotection by Methylprednisolone is based on its inhibition of lipid peroxidation. Three hundred questionnaires were sent to Consultants practising Spinal surgery. Neurosurgery and Accident & Emergency to determine the popular thought regarding the use of Methylprednisolone for Acute SCI. A thorough review of current medical literature was also performed. The literature search showed contradictory evidence regarding the use of high dose Methylprednisolone. The current popular thought, the diversity of responses between the three groups, the results of the 3 NASCIS trials and a recent review of literature is presented.

SpineBase – A SPINE DATABASE. Presented at the 8th International Meeting of Advanced Spine Techniques. Bahamas. July 12th to 14th 2001 G Ampat, Queens Medical Centre, Nottingham,

The author while a resident in Orthopaedics developed HOSPRAC an Access® based database for documentation of clinical activity in an Orthopaedic and Trauma department. Users in a survey scored 7.3/10  for Hosprac on a scale of 0 (Poor) to 10 (Excellent). A new database for Spinal Surgeons (SpineBase) has now been developed based on the experience from HOSPRAC. This database is a run time version of Access® and comes with a set up disc. It is compatible with all 32 bit Windows® operating systems. The database codes Diagnoses in ICD10 and Operative procedures in OPCS 4. Currently permission is being sought from the North American Spine Society to use their codes. The American Spinal Injuries Association assessment form the Oswestry Disability Index and the Neck Disability Index is also included in the database. The database produces a variety of pre programmed reports and allows data to be exported as an Excel®, .txt or .rtf file for further analysis. User friendly interface allows accurate and easy recording of data. Fractures are graphically depicted and the user records data by descending through the AO® classification tree. The database has an inbuilt standard Windows® help file, a users manual in Adobe® pdf format, an executable ScreenCam® demo and demonstration data that can be deleted prior to using the database. This database has undergone beta testing at one spinal centre and is being presented as an initial release. A database programmed by a clinician seems to have a better acceptance than currently available commercial programs.


 MY FIRST OPERATION DEPLOYMENT – RAF THUMRAIT. Journal of Bone & Joint Surgery – British Volume. 85-B SUPPLEMENT II:131, 2003. Ampat, G. [Orthopaedic Proceedings: Combined Services Orthopaedic Society: May, 2002]

INTRODUCTION: To audit the workload of an Orthopaedic Surgeon sent on deployment to the Middle East. The cases seen and treated are discussed. The audit was to determine the lessons for the future. DISCUSSION: 86 in patient admissions occurred between 12.01.2002 and 10.04.2002. A break up of speciality was a follows: Orthopaedic 38, Medical 27, General Surgical 16 and Psychiatric 5. A breakdown of the Orthopaedic cases were as follows: Ankle Injury 5, Arthralgia 3, Closed Fracture 4, Elbow Injury 1, Knee Injury 5, Low Back Pain 5, Multiple Soft Tissue Injury 3, Open Injury 3, Sciatica 1, Shoulder Injury 2, Soft Tissue Injury 3, and Stress Fracture 3. The 3 suspected stress fractures and the 2 gun shot wounds required special mention. 31 of 38 Orthopaedic patients were sent back to the UK through the Aeromedical chain. These patients were subclassified according to the requirement of evacuation through the Aeromedical chain. Seventeen patients, though not fit for theatre were able to undertake their own flight back. A trial of sending them back on unaccompanied flights failed. All patients were then evacuated through the Aeromedical chain. On average this meant one medical attendant per 2 patients. If civilian flights were taken this would have meant an extra expenditure of £4,800 (£600 × 8).Illness behaviour was noted in 10 of the 38 Orthopaedic patients. All these patients were evacuated to the UK. Malingering as tested by the Burns bench test, modified Schobers test, Hoover test and Inappropriate Waddells signs were positive in 4 of these patients whose initial complaint was of low back pain. CONCLUSION: It is proposed that the category of patients who are unfit for theatre but fit to fly unaccompanied should be recognised. It is also proposed that patients potentially deployable but showing illness behaviour should be discharged from the services earlier as it causes unnecessary expenditure and enforces extra work on other sincere and fit personnel.

IS LOW BACK PAIN A DISABILITY OR A VARIATION OF NORMALITY? Journal of Bone & Joint Surgery – British Volume. 85-B SUPPLEMENT II:177, 2003 Ampat, G Orthopaedic Proceedings: British Orthopaedic Association: Cardiff – 18-20 September, 2002]

This study was designed to determine the point prevalence of musculoskeletal pain among deployed personnel. 150 questionnaires were randomly distributed through the cashier and the mess at RAF Thumrait. 112 questionnaires were returned. The questionnaire, although a general musculoskeletal one, focused mainly on spine pain and also contained the Short Form 36. 107 males and 5 females responded. 85 (75.89%) personnel reported presence of some pain either in their spine and/or limbs. There was no difference in the report of pain between the various age groups mentioned (p=0.76). There were significant differences among the different occupational branches (p=0.0023). There was no correlation however between spinal pain and lifting (p=0.79), standing (p=0.28), sitting (p=0.98), or running/jumping/climbing (p=0.77). Though the 22 smokers reported higher pain than non-smokers this did not show statistical significance. There was negative correlation between the VAS report of pain and the Physical Component of Health (p=0.0001) and between stress at work and the Mental Component of Health (p=0.001) and between stress at work and the Mental component of health (p=0.001). 85 (75.9%) of the 112 personnel who had completed the questionnaire had some pain either in the spine or limbs. The lower back was the single anatomical region where pain was reported (n=68,60.7%) most frequently. It is interesting to note that all these personnel were on active duty in the armed forces and considered medically fit to deploy. It only shows to reinforce that low back pain in particular and musculoskeletal pain in general is common and normal and does not always imply disease and disability.

FUNCTIONAL OUTCOME FOLLOWING INTERNAL FIXATION OF INTRA ARTICULAR DISTAL HUMERUS FRACTURES (AO TYPE C) Aslam, G. Ampat, S. Nair and K. Willett , John Radcliffe Hospital, Headington, Oxford, UK European Federation of National Associations of Orthopaedics and Traumatology (EFORT): Helsinki – 4–10 June, 2003

Aims: To evaluate the functional outcome following internal fixation of distal humerus intra-articular fractures (AO type C) with a minimum follow up of two years. Methods: Design: Retrospective evaluation and clinical review. Setting: Regional trauma centre Patients and Participants: Twenty six consecutive patients with fractures of the distal humerus were treated over a thirty one month period (June 1993 to December 1995). The mean age was 55years (range,18–82). Clinical review of twenty patients at a mean follow up of more than two years (range 19–48 months). Six patients were lost to follow up. Results: Clinical evaluation of twenty patients was carried out. Fourteen patients (70 percent) had an excellent or good outcome, five patients (25 percent) a fair outcome and one patient (5 percent) had a poor result. Three patients (15 percent) underwent a second procedure for symptomatic metalwork. The mean arc of flexion-extension was 112 degrees (range, 85 to 122 degrees). Fifteen patients (75 percent) were able to return to their pre injury level of occupation and activity. Seventeen patients (85 percent) were satisfied with the final outcome. Conclusion: nternal fixation of intra-articular distal humerus fractures is an effective procedure with an excellent/good functional outcome in most patient age groups. Patients have a high level of satisfaction and return to previous level of activity.

COMPARATIVE OUTCOMES FOLLOWING PLATING OR TENSION BAND WIRING OF OLECRANON FRACTURES N. Aslam, S. Nair, G. Ampat and K. Willett, John Radcliffe Hospital, Headington, Oxford, United Kingdom, European Federation of National Associations of Orthopaedics and Traumatology (EFORT): Helsinki – 4–10 June, 2003

Aims: to evaluate the outcome following internal þxation of olecranon fractures using the techniques of tension band wiring and plating with a minimum follow up of two years. Methods:Design: retrospective evaluation and clinical review. Setting: regional trauma centre. Patients and participants: 48 consecutive patients with fractures of the olecranon were treated over a twenty month period (may 1993 to december 1994). 25 fractures were þxed using a tension band wiring technique and 23 underwent plating; the selection of method was based on agreed radiological fracture pattern criteria. Main outcome measurements: radiographic evaluation of the quality of reduction. Clinical outcome (broberg and morrey functional rating index). Results: clinical evaluation of 39 patients was carried out. In the tension band wiring group 17 (85 percent) patients had an excellent or good outcome and 11 (55 percent) patients underwent a second procedure for symptomatic metalwork. In the plating group 16 (84 percent) patients had an excellent or good outcome and 2 (11 percent) patients underwent a second procedure for symptomatic metalwork. The latter group had more complex and associated fractures and included the only poor result. Conclusion: internal þxation of fractures of the olecranon results in good functional outcome. Fixation with a plate is effective and produces good outcome even though selected for the more complex olecranon fractures. Patients who have tension band wiring more often require a second procedure for removal of symptomatic metalwork


Functional Outcomes Following Plating or Tension Band Wiring of Olecranon Fractures European Journal of Trauma Issue: Volume 29, Number 5 Date:  October 2003 (Page 273) Nadim Aslam, Sunil Nair, George Ampat, Keith Willett

Abstract: Purpose: To evaluate the outcome following internal fixation of olecranon fractures using the techniques of tension band wiring and plating. Design: retrospective evaluation. Setting: regional trauma center.

Patients and Methods: 48 consecutive patients with fractures of the olecranon were treated over a 20-month period (May 1993 to December 1994). Analyses of the results were based on the medical records, pre- and postoperative radiographs of all 48 patients and clinical review of 39 patients at a mean follow-up of  2 years (range 28–48 months). Intervention: 25 fractures were fixed using the AO tension band-wiring technique and 23 were fixed with a plate; the selection of method was based on agreed radiologic fracture-pattern criteria. Main outcome measurements: radiographic evaluation of the quality of reduction was carried out using a grading system. Clinical outcome was assessed using the Broberg & Morrey functional rating index.

Results: Clinical evaluation of 39 patients was carried out. In the tension band-wiring group, 17 (85%) patients had an excellent or good outcome and eleven (55%) patients underwent a second procedure for symptomatic metalwork. In the plating group, 16 (84%) patients had an excellent or good outcome and two (11%) patients underwent a second procedure for symptomatic metalwork. The latter group had more complex and associated fractures and included the only poor result.

Conclusion: Internal fixation of fractures of the olecranon results in good functional outcome. Patients who have tension band wiring more often require a second procedure for removal of symptomatic metalwork.


IS BACK PAIN FROM ROAD TRAFFIC ACCIDENTS AND OTHER TRAUMATIC INJURIES RELATED TO THE SACRO ILIAC JOINT ? M West , V Palial, P S V Prasad, G Ampat  Aim: This study was a sub group analysis of a larger study. The aim was to quantify pain relief and quality-of-life benefit from a single diagnostic SIJ (Sacro-Iliac joint) injection. Methods: Between August 2008 and February 2009, 56 consecutive patients were retrospectively recruited with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the SIJ, no obvious source of pain in the lumbar spine and no neurological deficit.  These were selected for a diagnostic SIJ injection. A structured questionnaire was completed both pre- and post-injection. Median patient age was 63. All patients were injected under fluoroscopic imaging with Triamcinolone 40mgs and 3mls of 0.5% Ropivacaine hydrochloride. Results: 6 patients were excluded from the study on the basis of incomplete answers. 38 patients (76%) had some form of previous non-operative treatment. No patients had previous injection or surgery. 8 patients (16%) were smokers. 17 patients (34%) had a desk based job, 22 patients (44%) had a manual job, 7 patients (14%) had heavy manual job. 18 patients (36%) had sustained previous back injury including rear ended road traffic accidents. A numerical rating score was carried out for low back pain and pain in the affected and unaffected leg; both pre- and post-injection. In 27 patients (54%) significant improvement was recorded, 16 patients (32%) reported no change in their symptoms, and only 7 (14%) reported worsening.  When considering the Oswestry Disability Index score, 58% improved, 18% reported no symptom change, and 24% worsened. The mean pre injection Numerical Rating Score of back pain in patients who had a previous injury to the back was 7.66 and that improved to 5.72 (P = 0.0287). Discussion Sacroiliac joint as a potential source of back pain has had less focus following the identification of the disc pathology by Mixter and Barr. The pain from the joint is real and needs to be addressed specifically with injection as a diagnostic measure. Blanket prescription of “low back – core stability exercises” without identification of other potential non red flag causes of back pain should be discouraged. The mechanism of sacroiliac joint syndrome following road traffic accidents occur due to one leg being on the brake pedal stabilizing one half of the pelvis, whilst the opposite hemipelvis twists forward following a rear end collision. Conclusion: History and physical examination can enter SIJ syndrome into the differential diagnosis, but cannot make a definitive diagnosis. Fluoroscopically guided diagnostic SIJ injection is the gold standard test for making the diagnosis whilst also conferring substantial pain relieve and quality-of-life benefit. This benefit is also seen in back pain following traumatic injuries including rear end motor vehicle collisions.


Can physiotherapists recognise Cauda equina syndrome (CES) better than doctors? D Hindmarsh, V Selvaratnam, G Ampat Southport and Ormskirk Hospital NHS Trust, England Abstract Aims Recent articles in the medical press highlight the potential dangers of Cauda Equina Syndrome (CES). CES has the highest rates of litigation due to its long-term neurological impairment, which can lead to devastating outcome on patients. The aim of this study was to assess health care professionals knowledge with regards to the urinary symptoms of CES and the timeframe in which treatment should be offered. Method A 4-part questionnaire was constructed establishing the type of medical professional and number of musculoskeletal cases seen per week. The participant was asked to rank 15 urinary symptoms from most to least alarming. 7 of the symptoms were not related to CES. The participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES Results A total of 44 questionnaires were analysed. Both doctors and physiotherapists ranked the CES symptoms on average significantly higher than then the non-CES symptoms. The physiotherapists rated the CES symptoms significantly higher than the doctors (P = 0.05) and on average rated the non-CES symptoms significantly lower than doctors (P < 0.05). 87.8% thought that complete CES should be treated < 24 hours and 9.76% thought that complete CES should be treated from 24-48 hours.  46.34% thought that CESI should be treated < 24 hours and 43.9% thought that CESI should be treated from 24-48 hours. Conclusion These results demonstrate that physiotherapists are better than Doctors at identifying the urinary symptoms in CES. The majority of health care professional who took part in this study stated that they would offer surgical intervention for both Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical professionals in the symptoms of CES and also the timing of treatment.


AN UNREPORTED PRESENTATION OF SARCOIDOSIS, BACK PAIN AND SPONDYLOLISTHESIS, S Morgan, G Ampat, Southport Hospital, Southport, UK. 8th Physiatric Summer School, Low Back Pain, Controversies in Clinical Practice and Research. 27/06/2007 to 29/06/2007. Orton Rehabilitation Centre, Finland.

Sarcoidosis is a multisystem syndrome characterized by the development of noncaseating granulomata. The lesion disrupts the architecture and function of the tissue in which they reside. Sarcoidosis in and around the spine is very rare affecting less than 1% of patients with the disease. It can affect various parts of the craniospinal axis: intramedullary, intradural, extramedullary, intraspinal epidural spaces and in vertebral bodies. In this report we present a rare case of sarcoidosis in the intervertebral disc causing diagnostic dilemma. To our knowledge this has never been reported before. Our patient has had aggressive systemic sracoidosis, however the first presentation of the disease was in his spine in the form of intractable low back and leg pain resistant to treatment. X-ray and MRI showed Listhesis at L4/5. Posterior Fusion was performed. Pain became worse and accordingly anterior fusion was attempted, which was aborted because of excessive bleeding. Patient then developed subcutaneous nodules. Biopsy from the nodules showed features of noncaseating granulomatous lesion. In view of the persistence of his symptoms biopsy from L4/5 disc was performed and showed similar histological features. CT chest and abdomen confirmed the diagnosis of sarcoidosis. The patient was commenced on steroids and Methotrexate. In this report we highlight the approach to diagnosis and management and present a review of the literature. Our main aim is to make the clinicians more aware of this rare condition and raise the index of suspicion, particularly if the first presentation of this multi-system granulomatous disorder is in the spine.


SACRO-ILIAC JOINT DYSFUNCTION, BACK PAIN AND RTA: HAVE WE MET BEFORE? S Morgan, L McGonagle, Ch Defty, J Kenyon, S Rodd, G Ampat. Southport Hospital, Southport, UK.8th Physiatric Summer School, Low Back Pain, Controversies in Clinical Practice and Research. 27/06/2007 to 29/06/2007. Orton Rehabilitation Centre, Finland.

Multiple treatments of Sacro-iliac joint(SIJ) dysfunction have been adopted by various disciplines that treat low back pain. The aim of this audit is to evaluate the effect of steroids and Local anaesthetic injection(LA) in the management of SIJ dysfunction and to determine the relation between road traffic accident and low back pain(LBP). We retrospectively reviewed 31 patients who were diagnosed as having SIJ dysfunction. All patients had steroids and LA injection under x-ray control. Based on previous history of road traffic accident patients were divided into RTA and non-RTA group. Through a postal questionnaire the severity of LBP and leg pain (pre and post injection) were assessed using visual analogue scale(VAS). Functional level was evaluated through the Oswestery disability Index(OD1). All patients showed improvements in LBP and leg pain post injection with mean improvement in VAS of 2.95 (SD 3.0, p-value <.0001) for LBP and mean improvement of 3.3 (SD 3.3, p-value c0.001) for leg pain. Similarly the OD1 showed mean improvement of 15.0 (SD 17.0, p-value <0.0001). Patients in the RTA group showed greater improvement than the non RTA group, however this did not reach statistical significance. We conclude that steroids and LA injection is an effective method in management of SIJ dysfunction. Also our study suggests that RTA can be a potential cause of back pain by causing SIJ dysfunction. We accept that our sample size is small and needed to be confirmed through a prospective randomised controlled trial which is currently taking place in our institution.


NICE GUIDELINES ON SECONDARY PREVENTION OF OSTEOPOROTIC FRACTURES: ARE THEY EFFECTIVE? ARE THEY BEING IMPLEMENTED? C.Hallam, D. Melling, G.Ampat Southport and Ormskirk District General Hospital, Southport, Merseyside, UK. Osteoporosis International (2007) 18 (Suppl 3) S277

In January 2005 The National Institute of Clinical Excellence provided guidelines for the treatment of secondary prevention of osteoporotic fragility fractures in postmenopausal women. With our study we wanted to determine whether there was compliance with these recommendations. Methods: The majority of the study was performed by a final year medical student who was attached to the Department of Orthopaedics on a Selective in Advanced Medical Practice (SAMP) for 7 weeks. All patients that were on the orthopaedic ward with a fracture neck of femur during the first 28 days of the attachment were included into the study. The study involved determination of the history of any previous fractures, DEXA scan or osteoporotic treatment. Hospital case notes, treatment charts and were reviewed. Results: 21 patients were identified during the 28 day study period. Their ages ranged from 67 to 95 There were 18 (86%) women and 3 (14%) men. 4 patients (19%) comprising of 3 women (aged 85, 86 and 89)and 1 (age 74) man had a previous osteoporotic fracture that involved the wrist, vertebra or hip. Despite the presence of these osteoporotic fractures, none of the patients had received DEXA scanning or any form of osteoporosis treatment. Conclusion: Despite being limited by size, we found a 100% non compliance of NICE guidelines for the secondary prevention of osteoporotic fragility fractures. We feel that the NICE guidelines are not forceful and do not apportion responsibility regarding who should commence investigation and treatment following an osteoporotic fracture. We also recommend that a named osteoporotic nurse / pharmacist should be created in all Trauma units dealing with fracture neck of femur.


A rare presentation of sarcoidosis, back pain and spondylolisthesis. Journal of Bone and Joint Surgery – British Volume, Vol 90-B, Issue 2, 240-242. S. S. Morgan, MBBCh, MRCS, Specialist Registrar in Orthopaedics; M. B. Aslam, MBBS, MRCPath, Consultant Pathologist; K. S. Mukkanna, MBBS, MD, DNB, Trust Registrar; and G. Ampat, FRCS(Trauma & Orth), Consultant Orthopaedic Surgeon

A 48-year old man presented with back pain that was resistant to treatment. An MR scan showed spondylolisthesis at L4-5 and narrowing of the exit foraminae. He had a posterior fusion which did not relieve his symptoms. He continued to have back pain and developed subcutaneous nodules in both forearms. Biopsy from the skin revealed cutaneous sarcoidosis, and one from the lumbar spine showed sarcoidosis granuloma between the bone trabeculae. A CT scan of the abdomen and chest revealed axillary lymphadenopathy, mediastinal enlarged nodes, apical nodular nodes and splenomegaly. The patient was started on large doses of methotrexate and steroids. His angiotensin-converting enzyme and calcium levels returned to normal and the back pain resolved.


Streptococcus Pneumoniae Infection Of The Sacro Iliac Joint – A Case Report And Literature Review J.Orthopaedics 2008;5(1)e9. Andrew O’Brien*, Mike Roberts**, George Ampat*, Judith Bowley**

Abstract: Streptococcus Pneumoniae is a relatively uncommon causative organism of septic arthritis, accounting for 3 – 10 % of cases of septic arthritis. The joints most commonly affected are knee, shoulder, elbow and polyarticular infections1. Streptococcus Pneumoniae infection of the SIJ in an adult is rarely reported2, with only 1 previously reported case in the UK3. We report a rare case of culture proven Streptococcus Pneumoniae sacroiliac joint (SIJ) infection.


Venous thromboembolism prevention post neck of femur fractures – does it make a difference? Thromb J. 2008; 6: 8. Published online 2008 June 26. doi: 10.1186/1477-9560-6-8. Radwane Faroug, Shireesha Konnuru, San S Min, Fazleenah Hussain, and George Ampat

Neck of femur fractures predispose patients to venous thromboembolism (VTE). NICE has issued guideline 46 to reduce this risk through the use of antithrombic agents. We audited our department’s VTE practise by reviewing the clinical notes of 123 consecutive patients with no exclusions. We found our compliance to be a low 6%. We also found that patients were likely to be given low molecular heparin (LMWH) only during their hospital stay. Reasons for the low adherence were probably secondary to confusion caused by the multiple thromboprophylaxis protocols used in our department. The correlation between duration of heparin administration and length of hospital stay was due to logistical difficulty in administering VTE prophylaxis out of hospital setting.


A SERIOUS pain in the… back! Recognition of Red Flags. Dr Emily Arnold (F1 Surgery), Dr Anil Jawalkar (FTSTA1 Orthopaedics), Dr Fahd Khan (F1 Surgery), Dr Chanaka Silva (ST1 Medical Microbiology), Dr. Anita Brown (Consultant, Radiology),  Cecilia Jukka (Consultant, Microbiology),  Dr. Judith Bowley(Consultant, Microbiology)  and Mr. George Ampat (Consultant, Orthopaedics). Clinical Case of the Month. Hospital Intranet Southport and Ormskirk Hospitals NHS Trust. July 2008.

We present an interesting case that demonstrates the need to recognise the presence of red flag signs1 in patients attending Accident and Emergency Departments (A&E) with low back pain. Low back pain is a common ailment and in the UK nearly 3.5 million patients develop back pain each year. Consequently the number of patients attending A&E with back pain is also high. Pal et al showed that nearly 30.6% of attendances for non-traumatic musculo-skeletal symptoms in A&E were for low back pain. Neck pain was not included in the above figure of 30.6%. It is possible that when such large numbers attend with back pain there may be an increased risk of missing significant pathology. In order to prevent this from occurring Red Flag Signs have been devised. Our case clearly illustrates the non recognition of red flag signs in a patient who attended our A&E on three different occasions. During the first consultation the patient was reviewed by an A&E doctor but for the following two consultations was seen by the Orthopaedic on call team. CONCLUSION It is reported that up to 90% of the general population will suffer back pain at some stage in their life.  We need to identify patients with serious pathology and refer for appropriate management.  This case highlights the importance of eliciting the presence of red flag signs (Listed at the end  of the article) in a patient presenting with back pain and ensuring that all results of investigations are appropriately acted upon.


Is arthroscopy beneficial to patients of age more than 50 years, presenting with knee pain? P837. Sarvpreet Ubee, Akshay Malhotra, George Ampat . Presented at EFFORT meeting 3rd to 5th June 2009 at Vienna, Austria.

Abstract: Aim: To objectively look in to the benefit of arthroscopy in patients with knee pain. Patients and Methods: We performed a retrospective case note study on 106 patients who underwent arthroscopy for knee pain between January 2005 and December 2005. These patients were asked to fill in questionnaires for Visual Analog Score (VAS) and Oxford Knee Score (OX) based on their pre-operative and post-operative conditions. The responses for the pre-operative and the postoperative scores were compared. The results were then correlated with their intra-operative diagnosis and grade of osteoarthritis (OA). Results: We achieved a response rate of 61.3% (65 patients) for the questionnaires. Male to female ratio was 1:1 and 66% of our patients were over the age of 50 years. OA was the main diagnosis after arthroscopy with 72% having grade III/IV (outerbridge classification). 40 patients (61.5%) had significant improvement in either their VAS / OX or both. 19 patients (30%) had little or no benefit form the procedure performed based on the VAS and OX. Out of these 67% (15 patients) were above the age of 50 years with 72% in this group had grade III / IV OA. Conclusion: Arthroscopy improved VAS and OX scores, but the procedure had questionable benefits in patients >50 years age, with grade III / IV osteoarthritis. Radiological imaging should be the non-invasive option for diagnosis in these patients.1, 2 For pain management other modalities should be tried prior to arthroscopy. 1, 2 Reference: 1. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. Moseley B, O’Malley K, Petersen NJ, et al. The NJEM,81-88, 347, 2, July, 2002 2. Arthroscopic treatment of osteoarthritis of the knee. Are there any evidence-based indications? Siparsky P, Ryzewicz M, Peterson B, Bartz R. Clinical Orthopaedics and Related Research. 107-112, 455, Feb, 2007

A potential addition to continuing professional development points. Hindmarsh D1, Manickavasagar T, Davenport J, Ampat G. Clin Teach. 2011 Mar;8(1):57-8.  The current system of using continuing professional development (CPD) points works on the principle that for 1 hour of an educational course you achieve one point.1 Every practising doctor should achieve 50 points throughout the year, with 25 being achieved away from hospital. Larger projects such as trials and audits can also be credited to varying levels. Using purely time as a factor for how many CPD points are accredited is, in the authors’ opinion, short sighted, and fails to take into account the quality of teaching, type of teaching, knowledge gained, knowledge retained, participant’s satisfaction, and change in both practice and patient outcomes. Advertisement of the course is also severely restricted to ‘word of mouth’, and the assurance of whoever distributed the original points.

Why have an operation if you can avoid one?


Malignering / Non Organic Tests – Are They Real? The impact upon the healthcare system of chronic disabling lower back pain with no discernable organic cause is vast, consuming not only the time of healthcare professionals but also ineffectual investigations and treatments. The key for the medical practitioner is to develop a repertoire of examination techniques allowing a distinction between patients who are at risk of developing disabling lower back pain and would instead benefit from psychological support. There are multitudes of specialist examination tests described in the literature which, if used carefully, will help in this process. This paper consolidates these tests describing their methodology so that a medical practitioner can complete them in the outpatient setting. Equally patients with low back pain most simply value a doctor prepared to listen to their views! Review Article
Volume 4 Issue 2 – December 2016 Orthopedics and Rheumatology Open Access Journal ISSN: 2471-6804


A Surgeon’s Perspective on Back Pain

A Surgeon’s Perspective on Back Pain

Can We Encourage Back Pain Sufferers Who Smoke and are on Benefits to Quit Smoking By Curtailing Social Benefits? MOJ Orthopedics & Rheumatology Volume 6 Issue 4 – 2016 Corresponding author: G Ampat, Consultant Orthopaedic Abstract One of the harmful effects of cigarette smoking is back pain. Cessation of smoking improves the pathological changes in the disc that are caused by smoking. Education has a greater effect among higher socio economic groups in encouraging to quit. Financial pressures are known to have a greater effect on lower socio economic groups. Back pain sufferers on social benefits and who smoke are more likely to be in the lower socio economic group. Given the benefits of quitting smoking would it not be beneficial to provide an intense campaign among this select group to give up smoking or to face curtailment of social benefits? Keywords: Back Pain; Smoking Cessation; Disability Evaluation; Public Assistance; Intervertebral Disk