Aims. The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines). Methods. The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up. Results. Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals. Conclusion. This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system. Cite this article: Bone Jt Open 2023;4(9):676–681

Australia is a foundation member of the Asia Pacific Orthopaedic Association—thus, recognising our geographical position in the most rapidly advancing region in the world. It is a serious mistake to think of Asia as ‘third world’. Research, education and surgical techniques are at the forefront of modern technology. Australia has to be a part of this ‘learn and teach’ movement. We have much to gain through exchange and travelling fellowships; paediatric, spinal, trauma and arthroplasty fellowships are available. The Orthopaedic Sports Medicine Travelling Fellowship is co-ordinated with corresponding organisations in Europe, North America and South America and previous travelling fellows become part of the influential Magellan Society. APOA has many sections (knee, hip, hand, spine, trauma, infection, sports medicine and paediatrics), with each having regular Congresses. Join APOA and attend the Triennial Congress in Taipei November 2010 and be impressed at the level of research

Aims. The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Methods. Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. Results. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Conclusion. Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research. Cite this article: Bone Joint J 2023;105-B(4):400–411

Study Design & Setting: Prospective multi-center longitudinal cohort study within the ‘European Multicenter Study of Human Spinal Cord Injury’ (EM-SCI) consortium. Introduction: Determination between complete and incomplete spinal cord injury (SCI) is commonly applied in prognosticating patients’ functional recovery. Complete and incomplete injury is defined by absence or presence of at least 1 of 4 ASIA sacral sparing (SS) criteria. To date, however, the ASIA SS criteria have not been validated with respect to chronic phase functional outcomes. Objectives: To validate the prognostic value of the acute phase sacral sparing (SS) measurements regarding to chronic phase ambulation in traumatic SCI patients. Methods: In 251 patients, acute phase (0–15 days) ASIA Impairment Scale (AIS) grades, ASIA SS measurements and chronic phase (6 or 12 months) Timed Up & Go (TUG) outcome measurements were analyzed. Calculation of sensitivity, specificity, positive and negative predictive values (PPV/NPV), univariate and multivariate logistic regressions were performed in all 4 SS criteria. The area under the receiver-operating characteristic curve (AUC) ratios of all regression equations were calculated. Results: In completing the 1-year follow-up TUG test, presence of voluntary anal contraction (VAC) showed the best PPV (94.3%, p< 0.001, 95% CI: 80.8–99.3). Best NPV was reported in the S4–5 light touch (LT) score (96.9%, p< 0.001, 95% CI: 92.9–98.9). Presence of anal sensation in the traumatic SCI patients resulted in a PPV of 41% (p=0.124). Use of the combination VAC and S4–5 LT score (AUC: 0.917, p< 0.001, 95% CI: 0.868–0.966) showed significantly better (p< 0.001, 95% CI: 0.042–0.102) discriminating results in 1-year TUG test prognosis than with use of currently used distinction between complete and incomplete SCI (AUC: 0.845, p< 0.001, 95% CI: 0.790–0.901). Conclusion: Out of the 4 sacral sparing criteria, VAC and S4–5 LT scores are the only acute phase measurements contributing significantly to the prognosis of ambulation. With the combination of acute phase VAC and S4–5 LT scores, significantly better chronic phase ambulation prognosis can be predicted than with use of currently used distinction between complete and incomplete SCI. This study stresses the importance of further research on functional predictive algorithms in the acute setting of traumatic SCI care

Concepts in glenoid tracking and treatment strategies of glenoid bone loss are well established. Initial observations in our practice in Singapore showed few patients with major bone loss requiring glenoid reconstructions. This led us to investigate the incidence of and the extent of bone loss in our patients with shoulder instability. Our study revealed bony Bankart lesions were seen in 46% of our patients but glenoid bone loss measured only 6–10% of the glenoid surface. In the same study we found that arthroscopic labral repair with capsular plication and Mason-Ellen suturing (Hybrid technique) was sufficient to stabilise patients with bipolar bone defects and minor glenoid bone loss. This led us to develop the concept of minor bone loss and a new algorithm.

Our algorithm and strategies to deal with major bone loss will also be discussed, and techniques & outcomes of Arthroscopic Bony Bankart repair, Arthroscopic Glenoid Reconstruction and Arthroscopic Remplissage procedures will be shown.

Purpose

The purpose of this study is to evaluate the clinical outcomes and and radiological findings of primary total hip arthroplasty(THA) performed by using cemented polished femoral stem.

Background

Recently the taper wedged stems (TWS) are used widely in Japan because of good bone fixation and ease of the procedure. However, it is unclear how TWS get initial fixation in Japanese, especially dysplasia hip or elderly patients who had stovepipe canal. The purpose of this study is to evaluate initial bone fixation of the TWS in Japanese using computed tomography and to estimate biological bone fixation of the TWS using the Tomosynthesis.

In Asia, traditional bands are placed around limbs of children to ward off evil spirits and ensure good health. This practice may lead to the Rubber Band Syndrome (RBS) a rare paediatric condition described mainly in Asia which results from a forgotten thread or elastic band applied to the limb of a child. Because pressure necrosis beneath the band is slow, rapid healing of tissues over the band can obscure its presence. This makes the condition difficult to diagnose and distinguish from other infective conditions. This study presents the first case of RBS reported in South Africa. Case: The patient aged 18 months presented with a swollen hand, circumferential scar and discharging sinus on the wrist. A radiograph was negative. In theatre the volar wound was explored. Debridement revealed a yellow rubber band deep to the wrist flexors and neurovascular bundles but superficial to the extensor retinaculum. Complete removal of the rubber band and antibiotics was followed by rehabilitation with Occupational Therapy. At a 3 month follow up, there was no evidence of infection, sensation was normal and motor function of the hand restored. In this case, the structures through which the band had already passed were intact and overlay the band. It would appear that as the band slowly eroded the underlying structures it was followed by healing along the tract until the band exited deep to these structures. The band may come to rest on bone causing osteomyelitis if allowed to progress. A high index of suspicion of RBS is needed in children presenting with a circumferential scar and a non-healing wound, especially on the wrist or ankle. Careful debridement and complete removal of the band are essential to resolve symptoms and restore function

Aims. This study aimed to gather insights from elbow experts using the Delphi method to evaluate the influence of patient characteristics and fracture morphology on the choice between operative and nonoperative treatment for coronoid fractures. Methods. A three-round electronic (e-)modified Delphi survey study was performed between March and December 2023. A total of 55 elbow surgeons from Asia, Australia, Europe, and North America participated, with 48 completing all questionnaires (87%). The panellists evaluated the factors identified as important in literature for treatment decision-making, using a Likert scale ranging from "strongly influences me to recommend nonoperative treatment" (1) to "strongly influences me to recommend operative treatment" (5). Factors achieving Likert scores ≤ 2.0 or ≥ 4.0 were deemed influential for treatment recommendation. Stable consensus is defined as an agreement of ≥ 80% in the second and third rounds. Results. Of 68 factors considered important in the literature for treatment choice for coronoid fractures, 18 achieved a stable consensus to be influential. Influential factors with stable consensus that advocate for operative treatment were being a professional athlete, playing overhead sports, a history of subjective dislocation or subluxation during trauma, open fracture, crepitation with range of movement, > 2 mm opening during varus stress on radiological imaging, and having an anteromedial facet or basal coronoid fracture (O’Driscoll type 2 or 3). An anterolateral coronoid tip fracture ≤ 2 mm was the only influential factor with a stable consensus that advocates for nonoperative treatment. Most disagreement existed regarding the treatment for the terrible triad injury with an anterolateral coronoid tip fracture fragment ≤ 2 mm (O’Driscoll type 1 subtype 1). Conclusion. This study gives insights into areas of consensus among surveyed elbow surgeons in choosing between operative and nonoperative management of coronoid fractures. These findings should be used in conjunction with previous patient cohort studies when discussing treatment options with patients. Cite this article: Bone Joint J 2024;106-B(10):1150–1157

Aims. Preprint servers allow authors to publish full-text manuscripts or interim findings prior to undergoing peer review. Several preprint servers have extended their services to biological sciences, clinical research, and medicine. The purpose of this study was to systematically identify and analyze all articles related to Trauma & Orthopaedic (T&O) surgery published in five medical preprint servers, and to investigate the factors that influence the subsequent rate of publication in a peer-reviewed journal. Methods. All preprints covering T&O surgery were systematically searched in five medical preprint servers (medRxiv, OSF Preprints, Preprints.org, PeerJ, and Research Square) and subsequently identified after a minimum of 12 months by searching for the title, keywords, and corresponding author in Google Scholar, PubMed, Scopus, Embase, Cochrane, and the Web of Science. Subsequent publication of a work was defined as publication in a peer-reviewed indexed journal. The rate of publication and time to peer-reviewed publication were assessed. Differences in definitive publication rates of preprints according to geographical origin and level of evidence were analyzed. Results. The number of preprints increased from 2014 to 2020 (p < 0.001). A total of 38.6% of the identified preprints (n = 331) were published in a peer-reviewed indexed journal after a mean time of 8.7 months (SD 5.4 (1 to 27)). The highest proportion of missing subsequent publications was in the preprints originating from Africa, Asia/Middle East, and South America, or in those that covered clinical research with a lower level of evidence (p < 0.001). Conclusion. Preprints are being published in increasing numbers in T&O surgery. Depending on the geographical origin and level of evidence, almost two-thirds of preprints are not subsequently published in a peer-reviewed indexed journal after one year. This raises major concerns regarding the dissemination and persistence of potentially wrong scientific work that bypasses peer review, and the orthopaedic community should discuss appropriate preventive measures. Cite this article: Bone Jt Open 2022;3(7):582–588

Aims. The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. Methods. A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. Results. The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher’s exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. Conclusion. For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103–111

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

Purpose: Multiple studies have described the general injuries associated with mountain biking. However, no detailed assessment of mountain biking associated spinal column fractures and spinal cord injuries (SCI) has previously been reported. The purpose of this study is to describe the patient demographics, injuries, mechanisms, treatments, outcomes and resource requirements associated with spine injuries sustained while mountain biking. Method: Patients who were injured while mountain biking, and presented to a provincial spine referral centre between 1995 and 2007 inclusive, with SCI and/ or spine fracture were included. A chart review was performed to obtain demographic data, and details of the injury, treatment, outcome and resource requirements. Results: 102 men and 5 women were identified for inclusion. The mean age at injury was 32.7 years 95%CI[30.6,35.0]. 79 patients (73.8%) sustained cervical injuries, while the remainder sustained thoracic or lumbar injuries. 43 patients (40.2%) sustained a SCI. Of those with cord injuries, 18(41.9%) were ASIA A, 5(11.6%) were ASIA B, 10(23.3%) ASIA C, and 10(23.3%) ASIA D. 67 patients (62.6%) required surgical treatment. The mean length of stay in an acute hospital bed was 16.9 days 95%CI[13.1,30.0]. 33 patients (30.8%) required ICU care, and 31 patients (29.0%) required inpatient rehabilitation. Of the 43 patients (39.6%) who presented with SCI, 14(32.5%) improved by one ASIA category, and 1 (2.0%) improved by two ASIA categories. Two patients remained ventilator-dependent at discharge. Conclusion: Spine fractures and SCI due to mountain biking accidents typically affect young, male, recreational riders. The medical, personal, and societal costs of these injuries are high. Injury prevention should remain a primary goal, and further research is necessary to explore the utility of educational programs, and the impact of helmets and other protective gear on spine injuries sustained while mountain biking

Our knowledge regarding neurological recovery following spinal cord injury is like a tip of an iceberg. Spinal cord does not regenerate once damaged but nerve roots do so if an optimum environment is provided. Although distal neurological recovery is unlikely in ASIA Impairment Scale A (complete lesions), root recovery at the site of injury can occur. ASIA has recognized Zone of partial preservation & Zonal segmental recovery below the neurological level. Such a recovery in motor functions (Motor segmental recovery-MSR) of lumbar roots in paraplegia may make all the difference in final outcome of ambulation & functional status of the patient. 100 Thoracolumbar injuries in ASIA A underwent surgery. In 60, Posterior instrumentation alone (Gp1) and in 40 posterior instrumentation with laminectomy (Gp2) was done. Results of these were compared with randomly picked up 100 similar cases treated conservatively (Gp3). Meritsofsurgery(Gp1& Gp2)overconservative(Gp3) were many in terms of reduction & stability, pain-function scores, total hospital stay, ambulation mode and time. At 1 year follow-up, functional distal neurological recovery (FDNR) was said to be significant when ASIA A improved up to ASIA D/E and MSR was said to be significant (MSR-Sig) when key muscle had a power > III. In Gp3, FDNR was (7/100) 7% and MSR-Sig was (40/100) 40%. In Gp1 FDNR was(7/60) 11.67% and MSR-Sig (41/60) 68.33%. When laminectomy was added with instrumentation (Gp2) FDNR was (5/40) 12.5% and MSR-Sig was found in (37/40) 92% cases. This was especially beneficial in thoracolumbar injuries where MSR-Sig of the L2 & L3 roots made all the difference between an ambulatory life (with braces) and an otherwise permanent wheel chair bound life. Motor segmental recovery becomes a blessing in disguise in complete cases of spinal cord injury where distal recovery of spinal cord is unlikely to occur

Purpose: To evaluate the demographics, presentation, treatment and outcomes of spinal infection in a population of Intravenous Drug Users. Method: Data on all patients with pyogenic spinal infection presenting to a quaternary referral center was obtained from a prospectively maintain database. Results: Over the five-year study period, there were 102 patients treated for Primary Pyogenic Infection of the Spine of which 51 were Intravenous Drug Users (IVDU). Of this IVDU group there were 34 males. Mean age was 43 years (range 25 – 57). Twenty-three had HIV, 43 Hepatitis C and 13 Hepatitis B. All were using cocaine, 26 were also using Heroin and 44 more than three recreational drugs. Thirty patients presented with axial pain with a mean duration of 51 days (range 3–120). Thirty-one were ASIA D or worse with eight ASIA A. Mean Motor Score of patients with deficit was 58.6. Most common ASIA Motor Levels were C4 and C5. Mean duration of neurological symptoms was seven days (range 1–60). Blood parameters on admission were in keeping with sepsis in immunocompromised patients. None had previous surgery for spinal infection. Twenty-sex were receiving IV antibiotics for known spinal infection. 44 patients were treated surgically. 32 had infection of the cervical spine, 9 Thoracic and 3 Lumbar. 22 had a posterior approach alone, 13 had anterior only while 9 required combined. Mean operative time was 263 mins (range 62 – 742). 13 required tracheostomy. 7 required early revision for hardware failure and 2 for surgical wound infection. Mean duration of antibiotic treatment was 49 days (range 28–116). 26 patients had single agent therapy. 17 had MSSA and 17 MRSA. At discharge 28 patients had neurological improvement (mean 20 ASIA points, range 1–55), 11 had deterioration (mean 13, range 1–50) and 5 were unchanged. There were no in-hospital deaths. At 2 years after index admission 13 patients were dead and none were attending the unit for follow-up. Conclusion: Primary pyogenic spinal infection in IVDU’s typically presents with sepsis and acute cervical quadriplegia. Surgical management must be prompt and aggressive with significant neurological improvement expected in the majority of patients

Purpose: To study the pattern of neurological lesions and the frequency they occur in patients with cervical injuries. The relationship of these lesions with certain types of injuries and the cause of omjury. Patients and methods: Between 1970–2001, 665 patients suffering a cervical injury were studied in our Department. There were 192 male and 73 female patients aged 42,3 years on average. Two hundred sixty-five of these cases (38,5%) were presented with neurological symptoms.The mean time of hospitalization was 43,45 days. The patients were classified according to the type and the level of injury. ASIA‘s functional classification was used (35,1% were ASIA A, 13,96% ASIA B, 10,57% ASIA C and 40,37% ASIA D). 194 were followed up for a mean period of 7 years. Conservative treatment was applied to 183 (69%) patients while 82 patients (31%) were treated operatively with anterior cervical fusion, posterior cervical fusion, or combined anterior and posterior fusion. Postoperatively, most of the patients with incomplete neurological lesion, were improved. Conclusions: An analysis of our cases showed the following: a) There is a relationship between the type of neurological signs and the type of osseous or ligamentous injuries. b) There is relationship between type of osseous or ligamentous injury and severity of neurological lesion.. c) Burst fractures are the most severe fractures, followed by bilateral dislocations and tear-drop fractures. d) There is a relationship between mechanism of injury and severity of neurological lesion