Adolescent idiopathic scoliosis is a three-dimensional deformity of the spine, affecting 1–3% of the population.

Most cases are treated conservatively. Curves exceeding 45° in the thoracic spine and 40° in the lumbar spine may require correction and fusion surgery, to limit the progression of the curve and prevent restrictive pulmonary insufficiency (curves above 70°). When fusion is required, it may be performed either by posterior or anterior approaches. Posterior is useful for thoracic (Lenke I) curves, notably to correct the thoracic hypokyphosis frequently observed in AIS. Anterior approaches by thoraco-lombotomies allow an effective correction of thoraco-lumbar and lumbar curves (Lenke V and VI), with fewer levels fused than with posterior approaches. However, the approach requires diaphragm splitting and one may be concerned about the long-term pulmonary consequences. The literature provides conflicting insight regarding the consequences of the approach in anterior scoliosis correction, the interpretation of the results being difficult knowing that the correction of the scoliosis itself may improve pulmonary function.

This is a retrospective observational study done at a Tertiary Institution. The HRQOL scores have been collected as a prospective cohort. Clinical and radiographic data was collected from patients charts and analysed by two senior surgeons

A cohort of 64 patients were operated in the given time period. 50 patients met the inclusion criteria. No major complications were reported. The Union rate was 100% and no post operative complications were noted. Pre and post SRS scores improved in all patients.

The Anterior approach for Lenke V AIS gives great surgical exposure and allows for excellent correction of Cobb angle with minimal risk to the patient.

Rates of prosthetic joint infection in megaprostheses are high. The application of silver ion coating to implants serves as a deterrent to infection and biofilm formation.

A retrospective review was performed of all silver-coated MUTARS endoprosthetic reconstructions (SC-EPR) by a single Orthopaedic Oncology Surgeon. We examined the rate of component revision due to infection and the rate of infection successfully treated with antibiotic therapy. We reviewed overall revision rates, sub-categorised into the Henderson groupings for endoprosthesis modes of failure (Type 1 soft tissue failure, Type 2 aseptic loosening, Type 3 Structural failure, Type 4 Infection, Type 5 tumour progression).

283 silver-coated MUTARS endoprosthetic reconstructions were performed for 229 patients from October 2012 to July 2022. The average age at time of surgery was 58.9 years and 53% of our cohort were males. 154 (71.3%) patients underwent SC-EPR for oncological reconstruction and 32 (14.8%) for reconstruction for bone loss following prosthetic joint infection(s). Proximal femur SC-EPR (82) and distal femur (90) were the most common procedures. This cohort had an overall revision rate of 21.2% (60/283 cases). Component revisions were most commonly due to Type 4 infection (19 cases), Type 2 aseptic loosening/culture negative disease (15 cases), and Type 1 dislocation/soft tissue (12 cases).

Component revision rate for infection was 6.7% (19 cases). 15 underwent exchange of implants and 4 underwent transfemoral amputation due to recalcitrant infection and failure of soft tissue coverage. This equates to a limb salvage rate of 98.3%. The most common causative organisms remain staphylococcus species (47%) and polymicrobial infections (40%).

We expand on the existing literature advocating for the use of silver-coated endoprosthetic reconstructions. We provide insights from the vast experience of a single surgeon when addressing patients with oncological and bone loss-related complex reconstruction problems.

INTRODUCTION

The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient THA/TKA program are uncertain. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and patients' satisfaction.

Purpose and Background

Both overall spine shape and the size and shape of individual vertebrae undergo rapid growth and development during early childhood. Motor development milestones such as age of walking influence spine development, with delayed ambulation linked with spinal conditions including spondylolysis. However, it is unclear whether associations between motor development and spine morphology persist into older age. Therefore, these associations were examined using data from the MRC National Survey of Health and Development, a large nationally-representative British cohort, followed up since birth in 1946.

The World Health Organisation (WHO) Surgical Safety checklist is an evidence-based tool shown to reduce surgery-related morbidity and mortality. Despite audits showing 96% checklist compliance, our hospital had 3 surgical never events in 10 months, 2 of which were in orthopaedics. By March 2018, the authors aimed to achieve 100% compliance with all 5 sections of the WHO Five Steps to Safer Surgery bundle for all surgical patients. Additionally, the authors aimed to assess the impact of the quality of bundle delivery on preventable errors related to human factors. Quantitative assessment involved direct observations of compliance in theatres. Qualitative data in the form of rich, descriptive observations of events and discussions held during checklist delivery was analysed thematically. Interventions included trust-wide policy changes, awareness sessions, introduction of briefing and debrief proformas and documented prosthesis checks. For elective surgeries, checklist compliance increased to 100% in 4 of 5 sections of the bundle. The incidence of reported preventable critical incidents decreased from 6.7% to 2.4%. A chi-squared test of independence demonstrated a significant relationship between the implementation of changes and completion of the checklist, X2 (1, N = 1019) = 25.69, p < 0.0001. Thematic analysis identified leadership, accountability, engagement, empowerment, communication, and teamwork as factors promoting effective checklist use. Our findings highlight the benefits of a qualitative approach to auditing checklists. Exploring the role of human factors and promoting staff awareness and engagement improves checklist compliance and enhances its effectiveness in reducing surgery-related adverse outcomes.

Aims

Little is known about the effect of haemorrhagic shock and resuscitation on fracture healing. This study used a rabbit model with a femoral osteotomy and fixation to examine this relationship.

Purpose

To investigate associations between sagittal thoracolumbar spine shape with sex and measures of adiposity throughout adulthood.

Aim

Our hospital is a referral center for Bone and Joint Infection (BJI) with a 15-bed orthopedic unit. Patients benefit from a multidisciplinary team management (surgeons, anesthetists, infectious disease physicians, microbiologists, dietician etc.). Computerized drug prescriptions are performed by anesthetists, surgical residents, surgeons and infectious disease physicians. Since 2015, a pharmacist has been included in ward rounds and in weekly multidisciplinary consultative meetings, where antibiotic treatment strategies are decided for hospitalized patients. This work aimed to assess the impact of a pharmacist in this unit to limit prescription errors.

Adipose tissue is an attractive source of mesenchymal stem cells (MSCs) as it is largely dispensable and readily accessible through minimally invasive procedures such as lipoaspiration. Until recently MSCs could only be isolated in a process involving ex-vivo culture. Pericytes (CD45−, CD146+, and CD34−) and adventitial cells (CD45−, CD146−, CD34+) represent two populations of MSCs (collectively termed perivascular stem cells or PSCs) that can be prospectively purified using fluorescence activated cell sorting (FACS). We performed FACS on lipoaspirate samples from n=129 donors to determine the frequency and yield of PSCs and to establish patient and processing factors that influence yield.

The mean number of stromal vascular fraction (SVF) cells from 100ml of lipoaspirate was 37.8×106. Within the SVF, mean cell viability was 82%, with 31.6% of cells being heamatopoietic (CD45+). Adventitial cells and pericytes represented 31.6% and 7.9% of SVF cells respectively. As such, 200ml of lipoaspirate would theoretically yield 24.5 million MSCs –a sufficient number to enable point-of-care delivery for use in several orthopaedic applications. The yield and prevalence of PSCs were minimally affected by donor age, sex and BMI. Storing lipoaspirate samples for up to 72 hours prior to processing had no significant deleterious effects on MSC yield or viability.

Our study confirms that pure populations of MSC-precursors (PSCs) can be prospectively isolated from adipose tissue, in sufficient quantities to negate the necessity for culture expansion while widening possible applications to include trauma, where a time delay between extraction and implantation excludes their use.

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Cite this article: Bone Joint J 2014;96-B:1178–84.

Objectives

The goals of this study were: 1) to determine if high-fat diet (HFD) feeding in female mice would negatively impact biomechanical and histologic consequences on the Achilles tendon and quadriceps muscle; and 2) to investigate whether exercise and branched-chain amino acid (BCAA) supplementation would affect these parameters or attenuate any negative consequences resulting from HFD consumption.

International and national predictions from the late 1990s warned of alarming increases in hip fracture incidence due to an ageing population globally. Our study aimed to describe contemporary, population-based longitudinal trends in outcomes and epidemiology of hip fracture patients in a tertiary referral trauma centre.

A retrospective review was performed of all patients aged 65 years and over with a diagnosis of fractured neck of femur (AO classification 31 group A and B) admitted to the John Hunter Hospital, Newcastle, New South Wales between 1st January 2002 and 30th December 2009. Datawas collated and cross referenced from several databases (Prospective Long Bone Fracture Database, Operating Theatre Database and the Hospital Coding Unit). Mortality data was obtained via linkage with the Cardiac and Stroke Outcomes Unit, Planning and Performance, Division of Population Health. Main outcome measures were 30-day mortality, in-hospital mortality, length of stay.

The JHH admitted (427 ± 20/year, range: 391–455) patients with hip fractures over the 9 year study period. The number of admissions per year increased over the study period (p = 0.002), with no change in the age-standardised incidence (p = 0.1). The average age (83.5 ± 0.2) and average percentage female (73.7%) did not change. There was an overall trend to decreased 30-day mortality from 12.4% in 2002 to 7% in 2009 (p = 0.05). The factors that were associated with increased mortality were age (p < 0.0001), male gender (p = 0.0004), time to operating theatre (p = 0.0428) and length of stay (p < 0.0001).

In accordance with national and international projections on increased incidence of geriatric hip fractures, the incidence of fractured neck of femur in our institution increased from 2002–2009, reflecting our ageing population. 30-day mortality improved and longer length of stay corresponded with increased 30-day mortality.

Geriatric hip fracture patients have a 14-fold higher 30-day mortality than their age matched peers. Up to 50% of these patients receive blood transfusion perioperatively. Both restrictive and liberal transfusion policies are controversial in this population. Aim: The longitudinal description of transfusion practice in geriatric hip fracture patients in a major trauma centre.

An 8-year (2002–2009) retrospective study was performed on patients over the age of 65 undergoing hip fracture fixation. Yearly transfusion rate; the influence of transfusion on 30-day, 90-day and 1-year mortality and length of stay (LOS) was investigated. On admission haemoglobin (Hb), pre-transfusion Hb and post-transfusion Hb and their effect on transfusion requirement and mortality was also reviewed. The yearly changes in on-admission and pre-transfusion Hb were also examined. The influence of comorbidities, timing, procedure performed and operation duration on transfusion requirement and mortality was also studied. From the 3412 patients, 35% (1195) received transfusion during their hospital stay. There was no change in age, gender and co-morbidities during the study. Thirty-day mortality improved from 12.4% in 2002 to 7% in 2009. The transfusion rate showed a gradual decrease from the highest of 48.3% (2003) to 22.9% (2009) (Pearson correlation - R2 = −0.707, p=0.05). There was no change during the study period in on-admission and pre-transfusion Hb. The mortality for non-transfused and transfused patients was [9.6% vs. 10.3 % (30-day)], [17.2% vs. 18.4%(90-day)] and [27% vs. 30.5%(1-year), p=0.031]. LOS was 11±9 for non-transfused patients and 13±10 (p<0.001) for transfused patients. Patients with more comorbidities experienced a higher transfusion rate, (0 – 31%, 1 – 38%, 2 – 46%, 3 – 57%), (Pearson Chi-squared, p<0.001). The need for transfusion by different procedures in decreasing order was 47.6% intramedullary device, 44.0% DHS, 25.2% cemented hemiarthroplasty, 23.6% Austin-Moore, and 5.5% cannulated screws. The length of the operation increases the chance of transfusion (<1hrs, – 33%, 1–2hrs – 35%, 2–3hrs – 41%, >3 hours – 65%), (Pearson Chi-squared, p=0.010). Preoperative waiting time had no influence on transfusion frequency (<24hrs – 36%, 24–48hrs – 34%, 48–96hrs – 36%, >96hrs – 33%), (Pearson Chi-squared, p=0.823).

The percentage of transfused geriatric hip fracture patients halved during the eight-year period without changes in demographics and co-morbidities. Perioperative transfusion of hip fracture patients is associated with higher 1-year mortality and increased LOS. A more restrictive transfusion practice has been safe and may be a factor in the improved 30-day mortality.

PURPOSE

We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy.

Background

One of the prime concerns when managing patients in plaster casts is loss of reduction. There have been studies showing that proper moulding of the plaster cast is critical in maintaining reduction. Recent studies have negated concerns that fibreglass (FG) casts do not allow swelling, when compared to plaster of Paris (POP) casts. However, their potential in maintenance of reduction has not been investigated.

Purpose of the study: Different metatarsal osteotomies performed via a percutaneous approach can be used to correct hallux valgus. The purpose of this work was to analyse the clinical and radiographic results of percutaneous treatment of hallux valgus using a distal wedge osteotomy of the metatarsal.

Material and methods: This was a consecutive prospective series of 125 cases of hallux valgus treated by the same surgical technique, distal wedge osteotomy of the metatarsal without fixation. Percutaneous lateral arthrolysis and percutaneous varus correction of the first phalanx were associated. The AOFAS function score for the forefoot was determined preoperatively and at last follow-up. Time to normal shoe wearing and to resumption of occupational activities were also noted. Angle correction was determined on the anteroposterior weight-bearing image. All patients were reviewed at mean 20 months (range 12–40).

Results: The AOFAS forefoot function score was 46/100 preoperatively and 87/100 at last follow-up. Mean motion of the metatarsophalangeal joint was 95 preoperatively and 80 postoperatively. Mean metatarsophalangeal valgus was 30 preoperatively and 12 at last follow-up. The mean intermetatarsal angle improved from 13 to 8 and the orientation of the joint surface of the first metatarsal (DMAA) improved from 11 to 7. The metatarsophalangeal joint of the first ray was congruent in 45% of the feet preoperatively and in 88% postoperatively. Mean time to wearing normal shoes was seven weeks for the treatment of hallux valgus alone and three months for surgery of the first ray and lateral rays.

Discussion: Percutaneous treatment of mild to moderate hallux valgus by distal wedge osteotomy of the metatarsal enables good clinical and radiographic improvement. The surgical technique requires experience with percutaneous surgery of the forefoot to avoid the main complications: secondary displacement in elevates and excessive shortening of the first metatarsal. This technique restores metatarsophalangeal congruence of the first ray compared with Isham-Reverdin osteotomy.

Statement of Purpose: Hard-on-hard bearing surfaces are finding increasing application in total hip replacements for wear reduction. Polycrystalline Diamond Compacts (PDCs) offer several potential advantages, including ultimate hardness, reduced metal ion release compared to metal-on-metal (MoM) articulations and increased strength/ toughness compared to ceramic-on-ceramic (CoC). This study investigates in-vitro wear and friction for a 28mm diamond-on-diamond (DoD) system under normal walking gait and also with distraction.

Methods: Six sets of 28mm PDC femoral heads and 28/41mm PDC acetabular liners (Dimicron, Utah) were tested on a hip simulator (AMTI, Boston). Radial clearances were 18–42 microns. Specimens were mounted anatomically with the cups superior and mounted at 45 degrees. All stations were lubricated with 37oC bovine serum diluted to 17g/l protein concentration. Components were subjected to a 3kN walking cycle (ISO14242-1) for 5 million cycles (MC). This was followed by 2MC of distraction testing with a reduced swing-phase load of 120N, an applied side force of 129N and with the abduction motion disabled. This produced approximately 0.5–0.7mm of horizontal displacement of the center of the head. The lubricant was changed and the components cleaned, dried and weighed at 0.5MC intervals.

Results: All heads and liners gained weight during each portion of the test. Potential mechanisms (still under investigation) include protein adsorption and hydration of metallic phases within the diamond compact. The weight gains were found to be somewhat reversible after drying in vacuum for extended periods (60–90 hours). However, the standard 1 hour drying cycle used for weight measurements during the test was found to be inadequate. Therefore, only the “dry weights” measured after 64–92 hours of vacuum drying at the beginning and end of each test portion were used to compute wear rates.

Overall wear rates for heads and liners for the 5MC of normal gait and the 2MC of distraction testing and for the whole 7MC. 95% confidence intervals are plotted for each set of six heads and liners. Weight changes were converted to volumetric wear using a density of 3,800kgm-3. Even after extended drying, the liners all showed small weight gains. The heads apparently wore slightly during the normal walking cycle but gained weight during the distraction cycle. Overall, the heads showed a small wear rate of 0.17±0.09mm3/MC and the liners showed a small ‘negative’ wear rate of −0.11±0.07mm3/MC. Due to the uncertainties involved in the drying procedure, it is concluded that DoD wear rates were unmeasurably low for this test. Distraction is known to increase wear rates for CoC systems [1] and might reasonably be expected to have a similar effect for DoD, due to the high elastic modulus of diamond.

However, the 2MC of distraction testing produced only small weight gains. The heads showed no evidence of ‘stripe wear’ as reported for CoC systems.

Conclusions: DoD wear rates were found to be unmeasurably low for an anatomical hip simulator test with and without distraction. Friction factors for DoD were slightly lower than for metal-on-UHMWPE.

A prospective study of displaced femoral neck fractures was conducted, using the Corail® stem, a non cemented HA-coated device, provided with a bipolar head. 293 consecutive patients were included. Our reasons to shift to an uncemented implant were:

the existence of intraoperative deaths during cementation;

Follow-up was extended up to 5 years, unless the patient died before. 7 patients were lost from FU. Function was assessed every year using various clinical scores (Parker’s mobility score, Qureshi’s mental status, Jensen’s autonomy index,). An X-Ray was obtained at each visit when possible, with a special insistence at completion of the follow up (136 out of the 144 still alive patients).

Intraoperatively, 11 isolated calcar cracks and 1 fracture of the major trochanter were seen. In three cases, it was impossible to obtain a stable implantation. In two of these, a cemented implant was used. In the third patient, instability was not seen, leading to an 8 mm subsidence, along with thigh pain and distal hypertrophy of the femur. The 278 other patients had no intra-operative complications.

Late complications were:

1) 14 patients had a secondary subsidence of their device (1–4 mm), with a subsequent good stability and unaltered fixation to the skeletal tissue;

Introduction: Lateral meniscectomies lead to degenerative arthritis and therefore meniscus transplantation has been considered. In literature, this procedure appears to have good clinical results. The aim of this study was to evaluate our clinical results at mid-term follow-up and to correlate these results to the morphology and position of the transplanted meniscus.

Material and methods: Twenty-eight patients operated in 4 surgical centers, were retrospectively reviewed following lateral meniscal allograft transplantation. The mean age of the patients was 34 years (range, 18 to 50 years). Before surgery, all these patients suffered of permanent lateral femorotibial pain without radiological knee arthritis. The knees were all stable or stabilized, without axial malalignment of the lower limbs or corrected by a concomitant high tibial osteotomy. Arthroscopic procedure was performed for 9 patients and arthrotomy for 19 patients. Different techniques of fixation of the transplant were used, with or without bone plugs. The associated procedures were 2 ACL reconstruction, 3 high tibial varus osteotomies, and 1 mosaicplasty. The IKDC score were used for the analysis of the functional results. An arthroTDM or an arthro MRI was used to analyse the morphology and position of the transplanted meniscus.

Results: The mean follow-up was 35 months (range, 12 months to 6 years). The mean post-operative subjective IKDC score was 65.5 points (range, 19.5 to 89 points). There were 2 failures associated with a fast arthritic evolution and 2 functional bad results. The others 24 patients (85%) were satisfied or very satisfied, with a real improvement of the pain and the function. Seventeen patients (60%) have started again a sportive activity superior than the one pre-operating. At the last follow-up, all transplanted meniscus have healed, but the morphology and position of the transplanted meniscus was not always normal with absence of the middle segment in 3 cases; its extrusion in 9 cases, a posterior segment shortened or partially hurt in 5 cases and its absence in 3 cases. Better results were associated with good meniscus positioning and morphology.

Discussion: Our works confirm that lateral meniscal allograft is a therapeutic option with favourable results in terms of pain reduction and functional improvement in the medium term for symptomatic patients after lateral meniscectomy. Our results are comparable with those of the literature. The allograft is technically reliable, reproducible notably for the methods of fixation. A long term follow-up is necessary to evaluate the benefit of these grafts on the protection of the cartilage.

Acetabular components of total hip joint replacement (THJR) in previously irradiated pelvis show high rates of failure. We present a literature review and a retrospective series evaluating the survival of acetabular cages in this difficult situation. Our hypothesis was that cage reinforcement of the acetabulum after previous pelvic irradiation would lead to early failure.

A cohort of 11 patients (12 hips) was identified, who had undergone THJR utilising an acetabular cage, after previous pelvic irradiation for malignant tumours. All operations were performed by a single surgeon in Waikato over the period of 1997–2007. Six patients (six hips) died within one year of their operation, the further five patients (six hips) were analysed for survival and radiograpical loosening of the acetabular component. Complications attributed to previous irradiation are also reported.

There is a paucity of literature of THJR survivorship after pelvic irradiation. The first series from the 1970’s showed 50% acetabular loosening at 5 years in cemented cups. Two conflicting series are published with 44% vs. 0% failure of uncemented cups. Only one previous series (22 hips) reports the use of acetabular reinforcement rings, and showed a 20% loosening and 10% deep infection rate at 4 years. In our cohort of 12 hips in 11 patients, only five patients survived greater than one year after joint replacement. The average follow up of the remaining six hips is five years (two to ten years). Two out of six of the acetabular cages have catastrophically failed. Of the remaining four cages, one is probably, and three are possibly radiologically loose. Two out of six have raised concerns in regards to deep infection that were not proven microbiologically. Overall of the patients who survived greater than one year after their THJR for pelvic irradiation, only four out of six of the acetabular cages remained insitu, and all had concerns raised in regards to radiographical loosening.

We report a high rate of clinical and radiographic failure of cage reconstruction of the acetabulum after previous pelvic irradiation. A superior method of acetabular reconstruction in this difficult situation is yet to emerge. Alternative methods of reconstruction continue to develop, with trabecular metal options a possible consideration.