Abstract

Lumbar fusion surgery is an established procedure for the treatment of several spinal pathologies. Despite numerous techniques and existing devices, common surgical trends in lumbar fusion surgery are scarcely investigated. The purpose of this Canada-based study was to provide a descriptive portrait of current surgeons’ practice and implant preferences in lumbar fusion surgery while comparing findings to similar investigations performed in the United Kingdom.

Canadian Spine Society (CSS) members were sampled using an online questionnaire which was based on previous investigations performed in the United Kingdom. Fifteen questions addressed the various aspects of surgeons’ practice: fusion techniques, implant preferences, and bone grafting procedures. Responses were analyzed by means of descriptive statistics.

Of 139 eligible CSS members, 41 spinal surgeons completed the survey (29.5%). The most common fusion approach was via transforaminal lumber interbody fusion (TLIF) with 87.8% performing at least one procedure in the previous year. In keeping with this, 24 surgeons (58.5%) had performed 11 to 50 cases in that time frame. Eighty-six percent had performed no lumbar artificial disc replacements over their last year of practice. There was clear consistency on the relevance of a patient specific management (73.2%) on the preferred fusion approach. The most preferred method was pedicle screw fixation (78%). The use of stand-alone cages was not supported by any respondents. With regards to the cage material, titanium cages were the most used (41.5%). Published clinical outcome data was the most important variable in dictating implant choice (87.8%). Cage thickness was considered the most important aspect of cage geometry and hyperlordotic cages were preferred at the lower lumbar levels. Autograft bone graft was most commonly preferred (61.0%). Amongst the synthetic options, DBX/DBM graft (64.1%) in injectable paste form (47.5%) was preferred.

In conclusion, findings from this study are in partial agreement with previous work from the United Kingdom, but highlight the variance of practice within Canada and the need for large-scale clinical studies aimed to set specific guidelines for certain pathologies or patient categories.

Adverse events (AEs) are still a major problem in spinal surgery, despite advances in surgical techniques, innovative technologies available and the introduction of checklist and predictive score systems aimed at reducing surgical complications.

We previously analysed the results of the introduction of the WHO Safety Surgical Checklist (SSC) in our Institution, comparing the incidence of complications between two periods: from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist effectiveness.

The sample size was 917 patients with an average of 30 months of follow-up. Complications were observed in 107 patients (11.6%) among 917 spinal surgery procedures performed, with 159 (17.3%) complications in total. The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. We observed a reduction of the overall incidence of complications following the introduction of the WHO Surgical Checklist: in 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%) (p<0.0005).

Thus, the SSC appeared to be an effective tool to reduce complications in spinal surgery and we proposed to extend the use of checklist system also to the pre-operative and post-operative phases in order to further reduce the incidence of complications.

We also believe that a correct capture and classification of complications is fundamental to generate a clinical decision support system aimed at improving patients’ safety in spinal surgery.

In the period between January 2017 and January 2018 we prospectively recorded the adverse events and complications of patients undergoing spinal surgery in our department, without using any collection system. Then we retrospectively recorded the intraoperative and postoperative adverse events of surgically treated patients during the same one-year period, using the SAVES v2 system introduced by Rampersaud and collaborators (Rampersaud YR et al. J Neurosurg Spine 2016 Aug; 25 (2): 256-63) to classify them.

In the one-year period from January 2017 to January 2018 a total of 336 patients underwent spinal surgery: 223 for degenerative conditions and 113 for spinal tumors. Comorbidities were collected (Charlson Comorbidity Index [CCI]).

Overall, a higher number of adverse events (AEs) was recorded using SAVES compared to the prospective recording without the use of any capture system and the increased number was statistically significant for early postoperative AEs (138/336 vs 44/336, p<0.001).

210 adverse events were retrospectively recorded using the SAVES system (30 intraoperative adverse events, 138 early postoperative and 42 late postoperative adverse events). 99 patients (29.5%) on the cohort had at least one complication.

Furthermore, the correlation between some risk factors and the onset of complications or the prolonged length of stay was statistically analyzed. The risk factors taken into account were: age, presence of comorbidities (CCI), ASA score, previous surgery at the same level, type of intervention, location of the disease, duration of the surgery.

In particular, the duration of the surgery (more than 3 hours) and the presence of previous surgeries resulted to be risk factors for complications in multivariate analyses

Pain and disability following wrist trauma are highly prevalent, however the mechanisms underlying painare highly unknown. Recent studies in the knee have demonstrated that altered joint contact may induce changes to the subchondral bone density and associated pain following trauma, due to the vascularity of the subchondral bone. In order to examine these changes, a depth-specific imaging technique using quantitative computed tomography (QCT) has been used. We've demonstrated the utility of QCT in measuring vBMD according to static jointcontact and found differences invBMD between healthy and previously injured wrists. However, analyzing a static joint in a neutral position is not necessarily indicative of higher or lower vBMD. Therefore, the purposeof this study is to explore the relationship between subchondral vBMDand kinematic joint contact using the same imaging technique.

To demonstrate the relationship between kinematic joint contact and subchondral vBMDusing QCT, we analyzed the wrists of n = 10 participants (n = 5 healthy and n = 5 with previous wrist trauma). Participantsunderwent 4DCT scans while performing flexion to extension to estimate radiocarpal (specifically the radiolunate (RL) and radioscaphoid (RS)) joint contact area (JCa) between the articulating surfaces. The participantsalso underwent a static CT scan accompanied by a calibration phantom with known material densities that was used to estimate subchondral vBMDof the distal radius. Joint contact is measured by calculatinginter-bone distances (mm2) using a previously validated algorithm. Subchondral vBMD is presented using mean vBMD (mg/K2HPO4) at three normalized depths from the subchondral surface (0 to 2.5, 2.5 to 5 and 5 to 7.5 mm) of the distal radius.

The participants in the healthy cohort demonstrated a larger JCa in the RS joint during both extension and flexion, while the trauma cohort demonstrated a larger JCa in the RL during extension and flexion. With regards to vBMD, the healthy cohort demonstrated a higher vBMD for all three normalized depths from the subchondral surface when compared to the trauma cohort.

Results from our preliminary analysis demonstrate that in the RL joint specifically, a larger JCa throughout flexion and extension was associated with an overall lower vBMD across all three normalized layers. Potential reasoning behind this association could be that following wrist trauma, altered joint contact mechanics due to pathological changes (for example, musculoskeletal trauma), has led to overloading in the RL region. The overloading on this specific region may have led to a decrease in the underlying vBMD when compared to a healthy wrist. However, we are unable to conclude if this is a momentary decrease in vBMD that could be associated with the acute healing phase following trauma given that our analysis is cross-sectional. Therefore, future work should aim to analyze kinematic JCa and vBMD longitudinally to better understand how changes in kinematic JCa over time, and how the healing process following wrist trauma, impacts the underlying subchondral bone in the acute and longitudinal phases of recovery.

Revision surgeries for orthopaedic infections are done in two stages – one surgery to implant an antibiotic spacer to clear the infection and another to install a permanent implant. A permanent porous implant, that can be loaded with antibiotics and allow for single-stage revision surgery, will benefit patients and save healthcare resources. Gyroid structures can be constructed with high porosity, without stress concentrations that can develop in other period porous structures [1] [2]. The purpose of this research is to compare the resulting bone and prosthesis stress distributions when porous versus solid stems are implanted into three proximal humeri with varying bone densities, using finite element models (FEM).

Porous humeral stems were constructed in a gyroid structure at porosities of 60%, 70%, and 80% using computer-aided design (CAD) software. These CAD models were analyzed using FEM (Abaqus) to look at the stress distributions within the proximal humerus and the stem components with loads and boundary conditions representing the arm actively maintained at 120˚ of flexion. The stem was assumed to be made of titanium (Ti6Al4V). Three different bone densities were investigated, representing a healthy, an osteopenic, and an osteoporotic humerus, with an average bone shape created using a statistical shape and density model (SSDM) based on 75 cadaveric shoulders (57 males and 18 females, 73 12 years) [3]. The Young's moduli (E) of the cortical and trabecular bones were defined on an element-by-element basis, with a minimum allowable E of 15 MPa. The Von Mises stress distributions in the bone and the stems were compared between different stem scenarios for each bone density model.

A preliminary analysis shows an increase in stress values at the proximal-lateral region of the humerus when using the porous stems compared to the solid stem, which becomes more prominent as bone density decreases. With the exception of a few mesh dependent singularities, all three porous stems show stress distributions below the fatigue strength of Ti-6Al-4V (410 MPa) for this loading scenario when employed in the osteopenic and osteoporotic humeri [4]. The 80% porosity stem had a single strut exceeding the fatigue strength when employed in the healthy bone.

The results of this study indicate that the more compliant nature of the porous stem geometries may allow for better load transmission through the proximal humeral bone, better matching the stress distributions of the intact bone and possibly mitigating stress-shielding effects. Importantly, this study also indicates that these porous stems have adequate strength for long-term use, as none were predicted to have catastrophic failure under the physiologically-relevant loads. Although these results are limited to a single boney geometry, it is based on the average shape of 75 shoulders and different bone densities are considered. Future work could leverage the shape model for probabilistic models that could explore the effect of stem porosity across a broader population. The development of these models are instrumental in determining if these structures are a viable solution to combatting orthopaedic implant infections.

Aim

Studies have shown that retention of antibiotic cement spacer in selected elderly patients with low functional demand represents a viable option for periprosthetic joint infections (PJI) treatment^1,2.

The aim of this study is to compare the efficacy in infection treating among modular taylored preformed and hand-made antibiotic spacers. Our hypothesis is that modular tailored preformed spacer provides a better rate of infection resolution, better radiological and functional outcomes compared to hand-made spacers.

Arthroscopic hip procedures have increased dramatically over the last decade as equipment and techniques have improved. Patients who require hip arthroscopy for femoroacetabular impingement on occasion require surgery on the contralateral hip. Previous studies have found that younger age of presentation and lower Charlson comorbidity index have higher risk for requiring surgery on the contralateral hip but have not found correlation to anatomic variables. The purpose of this study is to evaluate the factors that predispose a patient to requiring subsequent hip arthroscopy on the contralateral hip.

This is an IRB-approved, single surgeon retrospective cohort study from an academic, tertiary referral centre. A chart review was conducted on 310 primary hip arthroscopy procedures from 2009-2020. We identified 62 cases that went on to have a hip arthroscopy on the contralateral side. The bilateral hip arthroscopy cohort was compared to unilateral cohort for sex, age, BMI, pre-op alpha angle and centre edge angle measured on AP pelvis XRay, femoral torsion, traction time, skin to skin time, Tonnis grade, intra-op labral or chondral defect. A p-value <0.05 was deemed significant.

Of the 62 patients that required contralateral hip arthroscopy, the average age was 32.7 compared with 37.8 in the unilateral cohort (p = 0.01) and BMI was lower in the bilateral cohort (26.2) compared to the unilateral cohort (27.6) (p=0.04). The average alpha angle was 76.3⁰ in the bilateral compared to 66⁰ in the unilateral cohort (p = 0.01). Skin to skin time was longer in cases in which a contralateral surgery was performed (106.3 mins vs 86.4 mins) (p=0.01). Interestingly, 50 male patients required contralateral hip arthroscopy compared to 12 female patients (p=0.01). No other variables were statistically significant.

In conclusion, this study does re-enforce existing literature by stating that younger patients are more likely to require contralateral hip arthroscopy. This may be due to the fact that these patients require increased range of motion from the hip joint to perform activities such as sports where as older patients may not need the same amount of range of motion to perform their activities. Significantly higher alpha angles were noted in patients requiring contralateral hip arthroscopy, which has not been shown in previous literature. This helps to explain that larger CAM deformities will likely require contralateral hip arthroscopy because these patients likely impinge more during simple activities of daily living. Contralateral hip arthroscopy is also more common in male patients who typically have a larger CAM deformity. In summary, this study will help to risk stratify patients who will likely require contralateral hip arthroscopy and should be a discussion point during pre-operative counseling. That offering early subsequent or simultaneous hip arthroscopy in young male patients with large CAMs should be offered when symptoms are mild.

Abstract

A concern of metal on metal hip resurfacing arthroplasty is long term exposure to Cobalt (Co) and Chromium (CR) wear debris from the bearing. This study compares whole blood metal ion levels from patients drawn at one-year following Birmingham Hip Resurfacing (BHR) to levels taken at a minimum 10-year follow-up.

A retrospective chart review was conducted to identify all patients who underwent a BHR for osteoarthritis with a minimum 10-year follow-up. Whole blood metal ion levels were drawn at final follow-up in June 2019. These results were compared to values from patients with one-year metal ion levels.

Of the 211 patients who received a BHR, 71 patients (54 males and 17 females) had long term metal ion levels assessed (mean follow-up 12.7 +/− 1.4 years). The mean Co and Cr levels for patients with unilateral BHRs (43 males and 13 females) were 3.12 ± 6.31 ug/L and 2.62 ± 2.69 ug/L, respectively, and 2.78 ± 1.02 ug/L and 1.83 ± 0.65 ug/L for patients with bilateral BHRs (11 males and 4 females). Thirty-five patients (27 male and 8 female) had metal-ion levels tested at one-year postoperatively. The mean changes in Co and Cr levels were 2.29 ug/l (p = 0.0919) and 0.57 (p = 0.1612), respectively, at one year compared to long-term. These changes were not statistically significant.

This study reveals that whole blood metal ion levels do not change significantly when comparing one-year and ten-year Co and Cr levels. These ion levels appear to reach a steady state at one year.

Our results also suggest that regular metal-ion testing as per current Medicines and Healthcare products Regulatory Agency (MHRA) guidelines may be impractical for asymptomatic patients. Metal-ion levels, in and of themselves, may in fact possess little utility in determining the risk of failure and should be paired with radiographic and clinical findings to determine the need for revision.

Aim

To evaluate the efficiency of pulse lavage combined with electrical fields to remove biofilm from a metallic surface.

Aim

Synovial fluid D-lactate may be useful for diagnosing septic arthritis (SA) as this biomarker is almost exclusively produced by bacteria. We evaluated the performance of synovial fluid D-lactate and determined its optimal cut-off value for diagnosing SA.

Background

Surgical site infection following spine surgery is associated with increased morbidity, mortality and increased cost for the health care system. The reported pooled incidence is 3%. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and often involve the lumbar spine. Accordingly, the objective was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column of the same lumbar vertebra using microdialysis in an experimental porcine model.

Immigrated Canadians make up approximately 20% of the total population in Canada, and 30% of the population in Ontario. Despite universal health coverage and an equal prevalence of severe arthritis in immigrants relative to non-immigrants, the former may be underrepresented amongst arthroplasty recipients secondary to challenges navigating the healthcare system. The primary aim of this study was to determine if utilization of arthroplasty differs between immigrant populations and persons born in Canada. The secondary aim was to determine differences in outcomes following total hip and knee arthroplasty (THA and TKA, respectively).

This is a retrospective population-based cohort study using health administrative databases. All patients aged ≥18 in Ontario who underwent their first primary elective THA or TKA between 2002 and 2016 were identified. Immigration status for each patient was identified via linkage to the ‘Immigration, Refugee and Citizenship Canada’ database. Outcomes included all-cause and septic revision surgery within 12-months, dislocation (for THA) and total post-operative case cost and were compared between groups. Cochrane-Armitage Test for Trend was utilized to determine if the uptake of arthroplasty by immigrants changed over time.

There was a total of 186,528 TKA recipients and 116,472 THA recipients identified over the study period. Of these, 10,193 (5.5%) and 3,165 (2.7%) were immigrants, respectively. The largest proportion of immigrants were from the Asia and Pacific region for those undergoing TKA (54.0%) and Europe for THA recipients (53.4%). There was no difference in the rate of all-cause revision or septic revision at 12 months between groups undergoing TKA (p=0.864, p=0.585) or THA (p=0.527, p=0.397), respectively. There was also no difference in the rate of dislocations between immigrants and people born in Canada (p=0.765, respectively).

Despite having similar complication rates and costs, immigrants represent a significantly smaller proportion of joint replacement recipients than they represent in the general population in Ontario. These results suggest significant underutilization of surgical management for arthritis among Canada's immigrant populations. Initiatives to improve access to total joint arthroplasty are warranted.

Over 500 supracondylar humerus fractures (SCHF) are treated at our institution each year. Our standard post-operative pathway includes a 3-week visit for splint removal, wire removal, and radiographs. Subsequent follow-up occurs at 12 weeks for a clinical examination. In an effort to minimize unnecessary follow-up visits, we investigated whether photographs and/or patient-reported outcome measure (PROM) scores could identify patients who do not need routine 3-month in-person follow-up.

At the 3-month visit, 248 SCHF patients (mean 6.2 yrs; 0.75-11yrs) had bilateral elbow motion (ROM) and carrying angles measured; and photographs documenting frontal and sagittal alignment of both injured and uninjured upper extremities, in both maximum elbow flexion and extension. Two independent assessors made the same measurements off the clinical photographs to compare these with the clinical measurements. Two PROMs: Self-Assessment Questionnaire (SAQ: 0 best to 14 worst) and QuickDASH (0 best to 100 worst) were completed at the 3-month visit.

Inter-rater reliability of the photograph measurements was excellent (Kappa: 0.88-0.93), but weakly concordant with clinical measurements (carrying angle Kappa=0.51;max flexion Kappa=0.68;max extension Kappa=0.64). SAQ moderately correlated with QuickDASH (Kappa=0.59) and performed better at identifying patients with abnormalities. SAQ score ≥ 4 identified patients meeting 3-month follow-up criteria, with sensitivity: 36.1%; specificity: 96.8% and negative-predictive-value (NPV): 87%.

We did not find that photographs were reliable. Although SAQ-score has high NPV, a more sensitive fracture-specific PROM is needed to identify patients who do not need a 3-month follow-up visit.

Aim

A novel anti-infective biopolymer implant coating was developed to prevent bacterial biofilm formation and allow on-demand burst release of anti-infective silver (Ag) into the surrounding of the implant at any time after surgery via focused high-energy extracorporeal shock waves (fhESW).

To date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for (1) clinical and (2) functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether (3) minimally invasive approaches are superior to conventional approaches for clinical outcomes.

All studies comparing MI approaches to conventional approaches were eligible for analysis. The PRISMA guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: ‘minimally invasive’, ‘muscle-sparing’, ‘THA’, ‘THR’, ‘hip arthroplasty’ and ‘hip replacement’. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the EU clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation).

Twenty studies were identified. There were 1,282 MI THAs and 1,351 conventional THAs performed.

Intermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim.

Abstract

Abstract

Abstract

Abstract

There is a need for non-radiographic, objective outcome measures for children with Adolescent Idiopathic Scoliosis (AIS). Standing balance and stability is altered in children with AIS. The Margin of Stability (MoS) has been used to compare gait stability in clinical populations. Our objective was to compare the MoS in anterior-posterior (MoS_AP) and mediolateral (MoS_ML) directions in girls with AIS to Controls.

Girls with AIS and healthy girls walked at three speeds on an instrumented treadmill wearing retroreflective markers, surrounded by motion capture cameras. The MoS_AP/ML was calculated at left and right heel strike. Data was processed in Visual 3D. A two-way ANOVA was used to compare MoS_AP/ML between group, speed and the interaction between group and speed. Pearson's correlation coefficient was used to compare the MoS to Cobb angle. Statistical significance was accepted when p > 0.05.

A priori power analysis suggested 12 participants per group. Three Cases and four Controls were recruited. Girls with AIS all had right-sided main thoracic curves (Lenke type 1a, 61.3° ± 10.0°). MoS_AP was significantly bigger for Cases compared to Controls on the left (p=0.038) and right foot (p=0.041). There was no significant difference between Cases and Controls for MoS_ML, but there was a visual trend for a smaller MoS_ML in Cases. There was no significant difference for speed or the interaction between group and speed for MoS_AP or MoS_ML. In Cases, MoS_AP increased with increasing Cobb angle on the left (r²=0.687, p=0.054) and right (r²=0.634, p=0.067) and MoS_ML decreased with increasing Cobb angle on the left (r²=-0.912, p=0.002). Further subjects are being recruited.

Girls with Lenke type 1a AIS are more stable in the AP direction and less stable in the ML direction than Controls during treadmill walking. AP stability increases and ML stability decreases with increasing Cobb angle. This research suggests that the MoS could be used as an outcome measure for children with AIS. Continued work is required to increase the power of this study. Further work could consider these changes during walking overground, measuring an MoS or MoS-like measure using a wearable device, and in different curve types.

Cartilage lesions vary in the spectrum from benign enchondromas to highly malignant dedifferentiated chondrosarcomas. From the treatment perspective, enchondromas are observed, Grade 1 chondrosarcomas are curetted like aggressive benign tumors, and rest are resected like other sarcomas. Although biopsy for tissue diagnosis is the gold standard for diagnosis and grade determination in chondrosarcoma, tumor heterogeneity limits the grading in patients following a biopsy. In the absence of definite pre-treatment grading, a surgeon is therefore often in a dilemma when deciding the best treatment option. Radiology has identified aggressive features and aggressiveness scores have been used to try and grade these tumors based on the imaging characteristics but there have been very few published reports with a uniform group and large number of cases to derive a consistent scoring and correlation.

The authors asked these study questions :(1) Does Radiology Aggressiveness and its Score correlate with the grade of chondrosarcoma? (2) Can a cut off Radiology Agressiveness Score value be used to guide the clinician and add value to needle biopsy information in offering histological grade dependent management?

A retrospective analysis of patients with long bone extremity intraosseous primary chondrosarcomas were correlated with the final histology grade for the operated patients and Radiological parameters with 9 parameters identified a priori and from published literature (radiology aggressiveness scores - RAS) were evaluated and tabulated. 137 patients were identified and 2 patients were eliminated for prior surgical intervention. All patients had tissue diagnosis available and pre-treatment local radiology investigations (radiographs and/or CT scans and MRI scans) to define the RAS parameters.

Spearman correlation has indicated that there was a significant positive association between RAS and final histology grading of long bone primary intraosseous chondrosarcomas. We expect higher RAS values will provide grading information in patients with inconclusive pre-surgery biopsy to tumor grades and aid in correct grade dependant surgical management of the lesion. Prediction of dedifferentiated chondrosarcoma from higher RAS will be attempted and a correlation to obtain a RAS cut off, although this may be challenging to achieve due to the overlap of features across the intermediate grade, high grade and dedifferentiated grades.

Radiology Aggressiveness correlates with the histologic grade in long bone extremity primary chondrosarcomas and the correlation of radiology and biopsy can aid in treatment planning by guiding us towards a low-grade neoplasm which may be dealt with intralesional extended curettage or high-grade lesion which need to be resected. Standalone RAS may not solve the grading dilemma of primary long bone intraosseous chondrosarcomas as the need for tissue diagnosis for confirming atypical cartilaginous neoplasm cannot be eliminated, however in the event of a needle biopsy grade or inconclusive open biopsy it may guide us towards a correlational diagnosis along with radiology and pathology for grade based management of the chondrosarcoma.

Abstract

Abstract

Abstract

Children undergoing posterior spinal fusion (PSF) for neuromuscular and syndromic scoliosis were admitted to the paediatric intensive care (PIC) until about 6 years ago, at which time we created a new unit, a hospital floor-based spinal high-dependency unit-plus (SHDU-plus), in response to frequent bed-shortage cancellations. This study compares postoperative management on PIC with HDU-plus for these non-hospital floor suitable children with syndromic and neuromuscular scoliosis undergoing PSF.

Retrospective review of 100 consecutive children with syndromic and neuromuscular scoliosis undergoing PSF between June 2016 and January 2022. Inclusion criteria were: 1) diagnosis of syndromic or neuromuscular scoliosis, 2) underwent PSF, 3) not suitable for immediate postoperative hospital floor-based care. Exclusion criteria were children with significant cardio-respiratory co-morbidity requiring PIC postoperatively.

55 patients were managed postoperatively on PIC and 45 on SHDU-plus. No significant difference between groups was found with respect to age, weight, ASA grade, preoperative Cobb angles, operative duration, number of levels fused and estimated blood loss. 4 patients in the PIC group and 1 in the SHDU-plus group were readmitted back to PIC or HDU following step-down to the hospital floor. Average length of stay was 2 days on PIC and 1 day on SHDU-plus. Average total length of hospital stay was 16.5 days in the PIC group and 10.5 days in the HDU-plus group. 19 (35%) patients developed complications in the PIC group, compared to 18 (40%) in SHDU-plus. Mean specialist unit charge per day was less on SHDU-plus compared with PIC. There were no bed-shortage cancellations in the SHDU-plus group, compared to 11 in the PIC group.

For children with neuromuscular or syndromic scoliosis undergoing PSF and deemed not suitable for post-operative care on the hospital floor, creation of a SHDU-plus was associated with fewer readmissions back to PIC or HDU, shorter hospital stays, an equivalent complication rate, significant cost-saving and fewer cancellations. Level of Evidence: Therapeutic Level III.

Introduction

Transfemoral osseointegration (TFOI) for amputees has substantial literature proving superior quality of life and mobility versus a socketed prosthesis. Some amputees have hip arthritis that would be relieved by a total hip replacement (THR). No other group has reported performing a THR in association with TFOI (THR+TFOI). We report the outcomes of eight patients who had THR+TFOI, followed for an average 5.2 years.

The early revision rate in elective Total Hip Arthroplasty (THA) three years after surgery in elderly patients over 80 years is significantly lower for cemented stems in the German Arthroplasty Register (EPRD): cemented 3,1% (3.0 – 3.2) vs. uncemented 4.2% (4.1 – 4.3; p < 0.001). However, the mortality rate in elderly patients is elevated for cemented fixation. This study presents a detailed analysis of the influence of stem type and fixation on revision and mortality rate in this patient cohort.

Elective primary THA cases for primary Coxarthrosis using uncemented cups from the EPRD data base were analysed (n₀= 37,183). Four stem type groups were compared: cementless, cementless with collar, cementless short, and cemented. Stems with at least 300 cases at risk three years after surgery were analysed individually. The reference stem was determined as the stem with the lowest revision rate and at least 1000 cases under surveillance 3 years after surgery (n₃ = 28,637).

The revision rate for cemented stems (2.5% [2.2–1.81] was lower than for uncemented (4.5% [4.2–4.9]; p<0.001) and uncemented short stems (4.2% [3.1–5.7]; p=0.002). The revision rate of uncemented collared stems (2.3% [1.5–3.6]) was similar to cemented stems (p=0.89) and lower than for uncemented stems (p=0.02). One year mortality showed no sig. differences between the groups (p>0.17): cemented 3.2% [2.9–3.6], uncemented 3.4% [3.1–3.7], uncemented short 3.5% [2.5–4.9], uncemented collar 2.0% [1.2–3.2].

“Cementless” and “cementless short” stems should not be used in patients over 80 years due to the higher revision risk. If cementing should be avoided, “cementless collared” stems seem to be a good alternative combined with a tendency for a lower one year mortality rate.

Abstract

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Abstract

Abstract

Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes.

This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test.

The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis.

The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable.

Abstract

Our understanding of pre-arthritic hip disease has evolved tremendously but challenges remain in categorizing diagnosis, which ultimately impacts choice of treatments and clinical outcomes. This study aims to report patient reported outcome measures (PROMs) comparing four different condition groups within hip preservation surgery by a group of fellowship-trained surgeons.

From 2018 to 2021, 380 patients underwent hip preservation surgery at our center and were classified into five condition groups: dysplasia: 82 (21.6%), femoro-acetabular impingement (FAI): 173 (45.4%), isolated labral tear: 103 (27.1%), failed hip preservation: 20 (5.3%) and history of childhood disease/other: 2 (0.5%). International hip outcomes Tool 12 (IHOT-12), numeric pain score and patient-reported outcomes measurement information system (PROMIS) were collected pre-operatively and at 3 months and 1 year post-operatively, with 94% and 82% follow-up rate respectively.

Arthroscopy (75.5%) was the most common procedure followed by peri-acetabular osteotomy (PAO) (22.4%) and surgical dislocation (2.1%). Re-operation rate were respectively 18.3% (15), 5.8% (10), 4.9% (5), 30% (6) and 0%. There were 36 re-operations in the cohort, 14 (39%) for unintended consequences of initial surgery, 10 (28%) for mal-correction leading to a repeat operation, 8 (22%) progression of arthritis, and 4 (11%) for incorrect initial diagnosis/intervention. Most common re-operations were hardware removal 31% (7 PAO, 3 surgical hip dislocation and 1 femoral de-rotational osteotomy), arthroscopy 31% (11) and arthroplasty 28% (10). All groups had significant improvements in their IHOT-12 as well as PROMIS physical and numerical pain scales, except those with failed hip preservation. Dysplasia group showed a slower recovery.

Overall, this study demonstrated a clear relation between the condition groups, their respective intervention and the significant improvements in PROMs with isolated labral pathology being a valid diagnosis. Establishing tertiary referral centers for hip preservation and longer follow-up is needed to monitor the overall survivorship of these various procedures.

Background and study purpose

Low back pain with no identified underlying cause is categorised as primary musculoskeletal pain by the International Association for the Study of Pain. In April 2021, the National Institute for Care and Excellence (NICE) published updated guidance for the management of primary chronic pain conditions in England. As part of the De-STRESS pain study, we explored the perspectives of GPs on the updated guideline and impact upon clinical practice.

Acetabular retroversion (ARV) is a cause of femoroacetabular impingement leading to hip pain and reduced range of motion. We aimed to describe the radiological criteria used for diagnosing ARV in the literature and report on the outcomes of periacetabular osteotomy (PAO) and hip arthroscopy (HA) in its management.

A systematic review using PRISMA guidelines was conducted on the MEDLINE, CINAHL, EMBASE, COCHRANE database in December 2022. English-language studies reporting outcomes of PAO, or open or arthroscopic interventions for ARV were included.

From an initial 4203 studies, 21 non-randomised studies met the inclusion criteria.

Eleven studies evaluated HA for ARV, with average follow-up ranging from 1 to 5 years, for a cumulative number of 996 patients. Only 3/11 studies identified ARV using AP standardized pelvic radiographs. The most frequent signs describing ARV identified were: Ischial Spine Sign (98% of patients), Posterior Wall Sign (PWS, 94%) and Crossover Sign (COS, 64%); with mean Acetabular Retroversion Index (ARI) ranging from 33% to 35%. 39% of HA patients had all three radiographic signs. Clinically significant outcomes were reached by 33–78% of patients.

Eight studies evaluated PAO for ARV, with a follow-up ranging from 2 to 10 years, for a cumulative number of 379 patients. Five of the eight studies identified ARV using standardized radiographs. ISS, COS and PWS were positive in 54%, 97% and 81% of patients, respectively with 52% of PAO patients having all three radiographic signs. Mean ARI ranged from 36–41%. Clinically significant results were reported in 71%–78% of patients.

The diagnostic criteria for ARV is poorly defined in the literature, and the quality of evidence is low. Studies on HA are more likely to have used lenient diagnostic criteria. It remains difficult to recommend which cases maybe more suitable for treatment by HA rather than PAO.

Aim

The number of periprosthetic joint infections (PJI) is increasing due to ageing population and increasing numbers of arthroplasty procedures and treatment is costly. Aim of the study was to analyze the direct healthcare costs of PJI in Europe for total hip arthroplasties (THA) and total knee arthroplasties (TKA).

Primary malignant bone tumours are a scarce entity with limited population-based data from developing countries. The aim of the study is to investigate the frequency and anatomical distribution of primary malignant bone tumours in a local South African population.

This will be an epidemiological retrospective study. Data will be used of patients that were diagnosed with primary malignant bone tumours over a period of nine years spanning from 1 January 2014 to 31 December 2022. This data will be received from private and government laboratories. Data to be considered are type of primary malignant bone tumours diagnosed, incidence of primary malignant bone tumours over a period of nine years and the most common anatomical sites of primary malignant bone tumours. The rationale behind our study is to assess the frequency of different primary malignant bone tumours in another geographic area of South Africa and to compare these findings to local and international literature. With a projected increase in diagnosis of primary malignant bone tumours in developing countries it is important to have more available data about primary malignant bone tumours from these areas to have a better understanding of these conditions and to understand the impact of the burden they impose on healthcare systems so that management of these conditions can also be improved. Preliminary results show that 23.83% of primary malignant bone tumours occurred in the age group 0–24 years of age, 49.22% in the 25–59 age group and 26.95% in the 60+ age group. The most common tumour that occurred was chondrosarcoma (49.21%) followed by osteosarcoma (41.80%) then Ewing's sarcoma (4,69%) and lastly chordoma (4.30%). From the 256 samples that met the inclusion criteria the five most common anatomical sites were distal femur (63), proximal tibia (41), proximal humerus (38), pelvis (34) and proximal femur (20).

Aim

By gaining insight into the Quality of Life (QoL) status and occurrence of complications, critical facets in the care for patients with Fracture-Related Infection (FRI) can be mitigated and measures can be taken to improve their outcome. Therefore, the aims of this study were to 1) determine the QoL in FRI patients in comparison to non-FRI patients and 2) describe the occurrence of complications in both FRI and non-FRI patients.

There is growing interest in the peri-operative management of patients with indications for hip and knee arthroplasty in the setting of modifiable risk factors such as morbid obesity, type 2 diabetes mellitus, and smoking. A recent survey of the American Association of Hip and Knee Surgeons (AAHKS) found that 95% of respondents address modifiable risk factors prior to surgery. The aim of this study was to poll Australian arthroplasty surgeons regarding their approach to patients with modifiable risk factors.

The survey tool used in the AAHKS study was adapted for use in the Australian context and distributed to the membership of the Arthroplasty Society of Australia via Survey Monkey.

Seventy-seven survey responses were received, representing a response rate of 64%. The majority of respondents were experienced, high volume arthroplasty surgeons. Overall, 91% of respondents restricted access to arthroplasty for patients with modifiable risk factors. Seventy-two percent of surgeons restricted access for excessive body mass index, 85% for poor diabetic control, and 46% for smoking. Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures.

Despite differences in healthcare systems, our findings were similar to those of the AAHKS survey, although their responses were more restrictive in all domains. Differences were noted in responses concerning financial considerations for potentially underprivileged populations. The survey is currently being administered by arthroplasty societies in six other countries, allowing comparison of orthopaedic practice across different healthcare systems around the world.

In conclusion, over 90% of Australian arthroplasty surgeons who responded to the survey address modifiable risk factors prior to surgery.

Acetabular component positioning is commonly referenced with the pelvis in the supine position in direct anterior approach THA. Changes in pelvic tilt (PT) from the pre-operative supine to the post-operative standing positions have not been well investigated and may have relevance to optimal acetabular component targeting for reduced risk of impingement and instability. The aims of this study were therefore to determine the change in PT that occurs from pre-operative supine to post-operative standing, and whether any factors are associated with significant changes in tilt ≥13° in posterior direction.

13° in a posterior direction was chosen as that amount of posterior rotation creates an increase in functional anteversion of the acetabular component of 10°.

1097 THA patients with pre-operative supine CT and standing lateral radiographic imaging and 1 year post-operative standing lateral radiographs (interquartile range 12–13 months) were reviewed. Pre-operative supine PT was measured from CT as the angle between the anterior pelvic plane (APP) and the horizontal plane of the CT device. Standing PT was measured on standing lateral x-rays as the angle between the APP and the vertical line. Patients with ≥13° change from supine pre-op to standing post-op (corresponding to a 10° change in cup anteversion) were grouped and compared to those with a <13° change using unpaired student's t-tests.

Mean pre-operative supine PT (3.8±6.0°) was significantly different from mean post-operative standing PT (−3.5±7.1°, p<0.001), ie mean change of −7.3±4.6°.

10.4% (114/1097) of patients had posterior PT changes ≥13° supine pre-op to standing post-op.

A significant number of patients, ie 1 in 10, undergo a clinically significant change in PT and functional anteversion from supine pre-op to standing post-op. Surgeons should be aware of these changes when planning component placement in THA.

Degenerative disc disease (DDD) is a common cause of lower back pain. Calcification of the intervertebral disc (IVD) has been correlated with DDD, and is especially prevalent in scoliotic discs. The appearance of calcium deposits has been shown to increase with age, and its occurrence has been associated with several other disorders such as hyperparathyroidism, chondrocalcinosis, and arthritis. Trauma, vertebral fusion and infection have also been shown to increase the incidence of IVD calcification. Our data indicate that Ca²⁺ and expression of the extracellular calcium-sensing receptor (CaSR) are significantly increased in mild to severely degenerative human IVDs. In this study, we evaluated the effects of Ca²⁺ and CaSR on the degeneration and calcification of IVDs.

Human donor lumbar spines of Thompson grade 2, 3 and 4 through organ donations within 24 hs after death. IVD cells, NP and AF, were isolated from tissue by sequential digestion with Pronase followed by Collagenase. Cells were expanded for 7 days under standard cell culture conditions. Immunohistochemistry was performed on IVD tissue to validate the grade and expression of CaSR. Free calcium levels were also measured and compared between grades. Immunocytochemistry, Western blotting and RT-qPCR were performed on cultured NP and AF cells to demonstrate expression of CaSR, matrix proteins aggrecan and collagen, catabolic enzymes and calcification markers. IVD cells were cultured in increasing concentrations of Ca²⁺ [1.0-5.0 mM], CaSR allosteric agonist (cincalcet, 1 uM), and IL-1b [5 ng/mL] for 7 days. Ex vivo IVD organ cultures were prepared using PrimeGrowth Disc Isolation System (Wisent Bioproducts, Montreal, Quebec). IVDs were cultured in 1.0, 2.5 mM Ca²⁺ or with cinacalcet for 21 days to determine effects on disc degeneration, calcification and biomechanics. Complex modulus and structural stiffness of disc tissues was determined using the MACH-1 mechanical testing system (Biomomentum, Laval, Quebec).

Ca²⁺ dose-dependently decreased matrix protein synthesis of proteoglycan and Col II in NP and AF cells, similar to treatment with IL-1b. (n = 4). Contrarily to IL-1b, Ca²⁺ and cincalcet did not significantly increase the expression of catabolic enzymes save ADAMTS5. Similar effects were observed in whole organ cultures, as Ca²⁺ and cinacalcet decreased proteoglycan and collagen content. Although both Ca²⁺ and cinacalcet increased the expression of alkaline phosphatase (ALP), only in Ca²⁺-treated IVDs was there evidence of calcium deposits in NP and AF tissues as determined by von Kossa staining. Biomechanical studies on Ca²⁺ and cinacalcet-treated IVDs demonstrated decreases in complex modulus (p<0.01 and p<0.001, respectively; n=5), however, only Ca²⁺-treated IVDs was there significant increases stiffness in NP and AF tissues (p<0.001 and p<0.05, respectively; n=3).

Our results suggest that changes in the local concentrations of calcium and activation of CaSR affects matrix protein synthesis, calcification and IVD biomechanics. Ca²⁺ may be a contributing factor in IVD degeneration and calcification.

Aim

Vancomycin is frequently used for bone and joint infections (BJI) because of the main role of Gram-positive bacteria as potential causal agents. It is crucial to achieve optimal vancomycin plasma concentrations since the first day to maximize treatment clinical and microbiological efficacy. The aim was to describe the patients’ profile that are more likely to achieve an optimal pharmacokinetic/pharmacodynamics (PK/PD) vancomycin target in the first therapeutic drug monitoring (TDM) sample.

Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement).

Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair.

A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group.

Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed.

Aim

The rise of multidrug-resistant bacteria and the decreasing efficacy of antibiotic therapy in successfully treating biofilm-associated infections are prompting the exploration of alternative treatment options. This study investigates the efficacy of different bioactive glass (BAG) formulations - alone or combined with vancomycin - to eradicate biofilm. Further, we study the influence of BAG on pH and osmotic pressure as important factors limiting bacterial growth.

Excessive resident duty hours (RDH) are a recognized issue with implications for physician well-being and patient safety. A major component of the RDH concern is on-call duty. While considerable work has been done to reduce resident call workload, there is a paucity of research in optimizing resident call scheduling. Call coverage is scheduled manually rather than demand-based, which generally leads to over-scheduling to prevent a service gap. Machine learning (ML) has been widely applied in other industries to prevent such issues of a supply-demand mismatch. However, the healthcare field has been slow to adopt these innovations. As such, the aim of this study was to use ML models to 1) predict demand on orthopaedic surgery residents at a level I trauma centre and 2) identify variables key to demand prediction.

Daily surgical handover emails over an eight year (2012-2019) period at a level I trauma centre were collected. The following data was used to calculate demand: spine call coverage, date, and number of operating rooms (ORs), traumas, admissions and consults completed. Various ML models (linear, tree-based and neural networks) were trained to predict the workload, with their results compared to the current scheduling approach. Quality of models was determined by using the area under the receiver operator curve (AUC) and accuracy of the predictions. The top ten most important variables were extracted from the most successful model.

During training, the model with the highest AUC and accuracy was the multivariate adaptive regression splines (MARS) model, with an AUC of 0.78±0.03 and accuracy of 71.7%±3.1%. During testing, the model with the highest AUC and accuracy was the neural network model, with an AUC of 0.81 and accuracy of 73.7%. All models were better than the current approach, which had an AUC of 0.50 and accuracy of 50.1%. Key variables used by the neural network model were (descending order): spine call duty, year, weekday/weekend, month, and day of the week.

This was the first study attempting to use ML to predict the service demand on orthopaedic surgery residents at a major level I trauma centre. Multiple ML models were shown to be more appropriate and accurate at predicting the demand on surgical residents as compared to the current scheduling approach. Future work should look to incorporate predictive models with optimization strategies to match scheduling with demand in order to improve resident well being and patient care.

Aim

Several local antibiotic-eluting drug delivery systems have been developed to treat bacterial bone infections. However, available systems have significant shortcomings, including suboptimal drug-release profiles with a burst followed by subtherapeutic release, which may lead to treatment failure and selection for drug resistance.

Here, we present a novel injectable, biocompatible, in situ-forming depot, termed CarboCells, which can be fine-tuned for the desired antibiotic-release profile. The CarboCell technology has flexible injection properties that allow surgeons to accurately place antibiotic-eluting depots within and surrounding infectious sites in soft tissue and bones. The CarboCell technology is furthermore compatible with clinical image-guided injection technologies.

These studies aimed to determine the therapeutic potential of CarboCell formulations for treatment of implant-associated osteomyelitis by mono- and dual antimicrobial therapy.

Background

BANDAIDE aka Back and Neck Discomfort relief with Altered behaviour, Intelligent Postures, Dynamic movement and Exercises (ISBN - 0995676933) is a concise self-help booklet containing strengthening exercises and illustrated information to enable patients self-manage their back and neck pain. The aim of this preliminary audit was to determine patient opinion on BANDAIDE. Institutional audit approval was obtained – No. 8429.

Aim

There are no definitive criteria for the definition of osteomyelitis in the hand and wrist and published case series are small. It remains a relatively uncommon, but difficult to treat problem. We present a series of 30 cases from 2016 to 2021 from a tertiary referral centre. We propose that the principles of thorough surgical debridement, dead space management, skeletal stabilisation and culture driven antibiotic therapy are the key to management of osteomyelitis in the hand and wrist. In addition, we show how these basic principles can be used for both functional and aesthetic impact for the wrist and digits with illustrated cases.