Background. There is a 20% dissatisfaction rate with knee replacements. Calls for tools that can pre-operatively identify patients at risk of being dissatisfied postoperatively have been widespread. However, it is unclear what sort of information patients would want from such a tool, how it would affect their
Spinal infections are rare diseases, whose management highlights the importance of a multidisciplinary approach. Although treatment is based on antibiotics, always selected on coltural and antibiogram tests, surgery is required in case of development of spinal instability or deformity, progressive neurological deficits, drainage of abscesses, or failure of medical treatment. The first step of the algorithm is diagnosis, that is established on MRI with contrast, PET/CT scan, blood tests (CRP and ESR) and CT-guided needle biopsy. Evaluation of response to the specific antibiotic therapy is based on variations in Maximum Standardized Uptake Value (SUVmax) after 2 to 4 weeks of treatment. In selected cases, early minimally invasive surgery was proposed to provide immediate stability and avoid bed-rest. From 1997 to 2014, 182 patients affected by spinal infections have been treated at the same Institution (Istituto Ortopedico Rizzoli – Bologna, Italy) according to the proposed algorithm. Mean age was 56 years (range 1 – 88). Male to female ratio was 1.46. Minimum follow-up was 1 year. Infections were mostly located in the lumbar spine (57%) followed by thoracic (37%) and cervical spine (6%). Conservative treatment based on antibiotics needed surgery (open and/or percuteneous minimally invasive) as an adjuvant in 83 patients out of 182 (46%). Management of spinal infections still remains a challenge in spinal surgery and a multisciplinary approach is mandatory. This algorithm represents the shared decision- making process from diagnosis to the most appropriate treatment and it led to successful outcomes with a low-complication rate. We present this algorithm developed to organize the various professionals involved (orthopaedic surgeons, nuclear medicine and infective disease specialists, interventional radiologists and anaestesiologists) and set a shared pathway of
Total Hip Replacement (THR) is one of the most successful operations in all of medicine, however surgeons just rely on their experience and expertise when choosing between cemented or cementless stem, without having any quantitative guidelines. The aim of this project is to provide clinicians with some tools to support in their
Around 1% of total hip replacements are follow by prosthetic joint infection (PJI). There is uncertainty about best treatment method for PJI, and the most recent high quality systematic reviews in unselected patients indicates that re-infection rates following one-stage and two-stage revision arthroplasty are relatively similar. In the absence of evidence randomised controlled trials will help to identify the most clinically and cost-effective treatment for PJI. Before such trials are conducted, there is a need to establish reasons for current practice and to identify whether trials are feasible. This study aimed to deliver research that would inform trial design. Specifically, we aimed to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or two-stage exchange arthroplasty for patients with PJI after hip replacement and to identify whether a randomised trial comparing one-stage with two-stage revision would be possible. Semi-structured interviews were conducted with 12 consultant surgeons from 5 high-volume National Health Service (NHS) orthopaedic departments in the UK. Surgeons were sampled on the basis that they perform revision surgery for PJI after hip arthroplasty and final sample size was justified on the basis of thematic saturation. Surgeons were interviewed face-to-face (n=2) or via telephone (n=10). The interview study took place before design of a multicentre prospective randomised controlled trial comparing patient and clinical outcomes after one-stage or two-stage revision arthroplasty. Data were audio-recorded, transcribed, anonymised and analysed using a thematic approach, with 25% of transcripts independently double-coded. Results: There is no standard surgical response to the treatment of PJI and surgeons manage a complex balance of factors when choosing a surgical strategy. These include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether evidence supports the emergence of two-stage revision as a method. They described the use of loosely cemented articulating spacers as a way of managing uncertainty about best treatment method. All surgeons were supportive of a randomised trial to compare one-stage and two-stage revision surgery for PJI after hip replacement. Surgeons reported that they would put patients forward for randomisation when there was uncertainty about best treatment. Surgeons highlighted the need for evidence to support their choice of revision. Some surgeons now use revision methods that can better address both clinical outcomes and patients' quality of life, such as loosely cemented articulating spacers. Surgeons thought that a randomised controlled trial comparing one-stage and two-stage exchange joint replacement is needed and that randomisation would be feasible. The next stage of the work was to design a multi-centre randomised controlled trial, this has been achieved and the trial is now ongoing in the UK.
The computational modelling and 3D technology are finding more and more applications in the medical field. Orthopedic surgery is one of the specialties that can benefit the most from this solution. Three case reports drawn from the experience of the authors’ Orthopedic Clinic are illustraded to highlight the benefits of applying this technology. Drawing on the extensive experience gained within the authors’ Operating Unit, three cases regarding different body segments have been selected to prove the importance of 3D technology in preoperative planning and during the surgery. A sternal transplant by allograft from a cryopreserved cadaver, the realization of a custom made implant of the glenoid component in a two-stage revision of a reverse shoulder arthroplasty, and a case of revision on a hip prosthesis with acetabular bone loss (Paprosky 3B) treated with custom system. In all cases the surgery was planned using 3D processing software and models of the affected bone segments, printed by 3D printer, and based on CT scans of the patients. The surgical implant was managed with dedicated instruments. The use of 3D technology can improve the results of orthopedic surgery in many ways: by optimizing the outcomes of the operation as it allows a preliminary study of the bone loss and an evalutation of feasibility of the surgery, it improves the precision of the positioning of the implant, especially in the context of severe deformity and bone loss, and it reduces the operating time; by improving surgeon training; by increasing patient involvement in
In severe cases of total knee & hip arthroplasty, where off-the-shelf implants are not suitable (i.e., in cases with extended bone defects or periprosthetic fractures), 3D-printed custom-made knee & hip revision implants out of titanium or cobalt-chromium alloy represent one of the few remaining clinical treatment options. Design verification and validation of such custom-made implants is very challenging. Therefore, a methodology was developed to support surgeons and engineers in their decision on whether a developed design is suitable for the specific case. A novel method for the pre-clinical testing of 3D-printed custom-made knee implants has been established, which relies on the biomechanical test and finite element analysis (FEA) of a comparable clinically established reference implant. The method comprises different steps, such as identification of the main potential failure mechanism, reproduction of the biomechanical test of the reference implant via FEA, identification of the maximum value of the corresponding FEA quantity of interest at the required load level, definition of this value as the acceptance criterion for the FEA of the custom-made implant, reproduction of the biomechanical test with the custom-made implant via FEA,
Prosthetic joint infection (PJI) is an important cause of arthroplasty failure. There is no method to disclose the presence or map the distribution of the in vivo biofilm on infected arthroplasty despite the recognition that such a tool would aid intraoperative
In absence of available quantitative measures, the assessment of fracture healing based on clinical examination and X-rays remains a subjective matter. Lacking reliable information on the state of healing, rehabilitation is hardly individualized and mostly follows non evidence-based protocols building on common guidelines and personal experience. Measurement of fracture stiffness has been demonstrated as a valid outcome measure for the maturity of the repair tissue but so far has not found its way to clinical application outside the research space. However, with the recent technological advancements and trends towards digital health care, this seems about to change with new generations of instrumented implants – often unfortunately termed “smart implants” – being developed as medical devices. The AO Fracture Monitor is a novel, active, implantable sensor system designed to provide an objective measure for the assessment of fracture healing progression (1). It consists of an implantable sensor that is attached to conventional locking plates and continuously measures implant load during physiological weight bearing. Data is recorded and processed in real-time on the implant, from where it is wirelessly transmitted to a cloud application via the patient's smartphone. Thus, the system allows for timely, remote and X-ray free provision of feedback upon the mechanical competence of the repair tissue to support therapeutic
Chronic low back pain (CLBP) is the most common cause of disability worldwide, and lumbar spine fusion (LSF) is often chosen to treat pain caused by advanced degenerative disease when clinical treatment failed certain cases, the post-surgical outcomes are not what was expected. Several studies highlight how important are. In psychological variables during the postoperative spine surgery period. The aim of this study is to assess the role of preoperative depression on postoperative clinical outcomes. We included patients who underwent LSF since December 2021. Preoperative depression was assessed administering Beck Depression Inventory questionnaire (BDI). And pain and disability were evaluated at 1, 3, and 6 months, administering respectively Visual Analogic Scale (VAS) and Oswestry Disability Index (ODI). As statistical analysis Mann-Whitney test was performed. We included 46 patients, 20 female (43,5%) and 26 male (56,5%) with an average age of 64,2. The population was divided in two groups, fixing the BDI cut-off point at 10. Patients with BDI < 10 points (N=28) had normal mental health status, instead patients with BDI > 10 points (N=16) had depressive disorders. At 3 months patients with healthy mental status reported statistically significant reduction of pain (U = 372,5, p = .006) and improvement of disability but without statistical significancy (U = 318, p = 0,137). At 6 months patients without psychological disease reported statistically significant reduction of pain (U = 342, p = 0,039) and disability (U = 372,5, p = 0,006). This study demonstrates the correlation between pre-existing depressive state and poorer clinical outcomes after spine surgery. These results are consistent with the literature. Therefore, during the surgical
Abstract. Purpose The aim of this study was investigate the relationship between version and torsional abnormalities of the acetabulum, femur and tibia in patients with symptomatic FAI. Methods A systematic review was performed according to PRISMA guidelines using the EMBASE, MEDLINE, PubMed and Cochrane databases. Original research articles evaluating the described version and torsional parameters in FAI were included. The MINORS criteria was used to appraise study quality and risk of bias. Mean version and torsion values were displayed using forest plot and the estimated proportion of hips displaying abnormalities in version/torsion were calculated. Results. A total of 1206 articles were identified from the initial search, with 43 articles, involving 8,861 hips, meeting the inclusion criteria. All studies evaluating femoral or acetabular version in FAI reported ‘normal’ mean version values (10. 0. to 25. 0. ). However, distribution analysis revealed that an estimated 31% and 51% of patients with FAI displayed abnormal central acetabular and femoral version respectively. Conclusion. Up to 51% of patients presenting with symptomatic FAI show an abnormal femoral version, whilst up to 31% demonstrate abnormal acetabular version. This high percentage of version abnormalities highlights the importance of evaluating these parameters routinely during assessment of patients with FAI, in order to guide clinical
Abstract. Objectives. Principal Component Analysis (PCA) is a useful method for analysing human motion data. The objective of this study was to use PCA to quantify the biggest variance in knee kinematics waveforms between a Non-Pathological (NP) group and individuals awaiting High Tibial Osteotomy (HTO) surgery. Methods. Thirty knees (29 participants) who were scheduled for HTO surgery were included in this study. Twenty-eight NP volunteers were recruited into the study. Human motion analysis was performed during level gait using a modified Cleveland marker set. Subjects walked at their self-selected speed for a minimum of 6 successful trials. Knee kinematics were calculated within Visual3D (C-Motion). The first three Principal Components (PCs) of each input variable were selected. Single-component reconstruction was performed alongside representative extremes of each PC to aid interpretation of the biomechanical feature reconstructed by each component. Results. Pre-operatively patient demographics included (age: 50.70 (8.71) years; height: 1.75 (.11) m; body mass: 90.57 (20.17) kg; mTFA: 7.75 (3.72) degrees varus; gait speed: 1.06 (0.23) m/s). The HTO cohort was significantly older and had a higher mass than the NP control participants. For knee kinematics the first three PCs explained 88%, 95% and 89% of the sagittal, frontal, and transverse planes, respectively. The main variances can be explained by sagittal plane magnitude differences, peak swing is associated with toe-off, a reduced knee flexion angle is associated with a longer time spent in stance, pre-HTO remain adducted during stance and pre-HTO patients remain more externally rotated during stance and latter part of swing. Conclusions. This study has introduced PCA in trying to better understand the biomechanical differences between a control group and a cohort with medial knee osteoarthritis varus deformity awaiting HTO. Further analysis will be undertaken using PCA comparing pre- and post-surgery which will be of importance in clinical
Many surgical decisions taken in the operating theatre are based on the experience and the expertise of the surgeon. Using biomechanical and computational data can provide additional information for the surgeon. By carrying out biomechanical trials pre-operatively as well as a full three dimensional analysis of the skeletal structure of the patient, it is possible to provide the surgeon with clinical data that can support the
Spondylolisthesis is common recognized spine pathology. A lot of studies targeted spondylolisthesis in the recent years, few of which have made a major influential impact on the clinical practice. To the extent our knowledge this is the first study to highlight and analyze the top 100 cited articles on spondylolisthesis through a systematic search strategy used previously in published studies in different medical specialty. The aim of this study is to identify the most cited studies on spondylolisthesis and report their impact in spine field. Thomson Reuters Web of Science-Science Citation Index Expanded was searched using title-specific search “spondylolisthesis”. All studies published in English language between 1900 and 2019 were included with no restrictions. The top 100 cited articles were identified using “Times cited” arranging articles from high to low according to citation count. Further analysis was made to obtain the following items: Article title, author's name and specialty, country of origin, institution, journal of publication, year of publication, citations number, study design. The citation count of the top 100 articles ranged from 69 to 584. All published between 1950 – 2016. Among 20 journals, Spine had the highest number of articles 47, with citation number of 5964 out of 13644. Second ranked was Journal of Bone and Joint Surgery with 16 articles and a total citation of 3187. In respect to the primary author's specialty, Orthopedic surgeons contributed to the majority of top 100 list with 82 articles, Neurosurgery was the second specialty with 10 articles. United states had produced more than half of the list by 59 articles. England was the second country with 7 articles. Surgical management of lumbar spondylolisthesis was the most common discussed topic. This article identifies the top 100 influential papers on spondylolisthesis and recognizes an important aspect of knowledge evolution served by leading researchers as they guide today's clinical
Successful reconstruction of bone defects requires an adequate filling material that supports regeneration and formation of new bone within the treated defect in an optimal fashion. Currently available synthetic bone graft substitutes cannot fulfill all requirements of the highly complex biological processes involved in physiological bone healing. Due their unphysiologically asynchronous biodegradation properties, their specific foreign material-mediated side effects and complications and their relatively modest overall osteogenic potential, their overall clinical performance typically lags behind conventional bone grafts of human origin. However, defect- and pathology specific combination of synthetic bone graft substitutes exhibiting appropriate carrier properties with therapeutic agents and/or conventional bone graft materials allows creation of biologically enhanced composite constructs that can surpass the biological and therapeutic limits even of autologous bone grafts. This presentation introduces a bone defect reconstruction concept based on biological enhancement of optimal therapeutic agent-carrier composites and provides a rationale for an individual, requirement-specific adaptation of a truly patient-specific reconstruction of bone defects. It represents the pinnacle of the bone defect reconstruction pyramid, founded on the basic principles and prerequisites of complete elimination of the underlying pathology, preservation, augmentation or restoration of mechanical stability of the treated bone segment and creation of a biodegradable scaffold with adequate mechanical integrity. It summarises the current body of relevant experimental and clinical research, presents clinical case examples illustrating the various aspects of the proposed concept as well as early clinical results. The author hopes that the theoretical and conceptual framework provided, will help guide future research as well as clinical
3D imaging is commonly employed in the surgical planning and management of bony deformity. The advent of desktop 3D printing now allows rapid in-house production of specific anatomical models to facilitate surgical planning. The aim of this pilot study was to evaluate the feasibility of creating 3D printed models in a university hospital setting. For requested cases of interest, CT DICOM images on the local NHS Picture Archive System were anonymised and transferred. Images were then segmented into 3D models of the bones, cleaned to remove artefacts, and orientated for printing with preservation of the regions of interest. The models were printed in polylactic acid (PLA), a biodegradable thermoplastic, on the CubeX Duo 3D printer. PLA models were produced for 4 clinical cases; a complex forearm deformity as a result of malunited childhood fracture, a pelvic discontinuity with severe acetabular deficiency following explantation of an infected total hip replacement, a chronically dislocated radial head causing complex elbow deformity as a result of a severe skeletal dysplasia, and a preoperative model of a deficient proximal tibia as a result of a severe tibia fracture. The models materially influenced clinical
We noted, in the immature ankle, a discrepancy between the alignment of the distal tibial physis, the distal tibial articular surface and the talar dome in the coronal plane. This led to variability in the orientation of wires and half pins used for limb reconstruction depending on which landmark was used. We aimed to investigate the variability in normal ankle joints to determine which is the most reliable landmark to use for correct wire or pin insertion. Radiographs of the ankle of 98 children were analysed. A variety of angular measurements were made with respect to the axis of the tibia and classified according to methods described by Shapiro & Mulhotra. We investigated the inter- and intra-observer variation in these measurements and classifications. Using the Bland-Altman method we found that the talar plafond angle (TPA) showed less variation than the lateral distal tibial angle (LDTA) with narrower limits of agreement and coefficients of repeatability. This was the same across the age and gender groups studied. The Shapiro classification of distal tibial epiphyseal shape did not appear to correlate with age or gender, but showed more inter- and intra-rater variation using weighted Kappa analysis. This study suggests that when measuring the orientation of the ankle joint from plain radiographs that the TPA is a more reliable measurement than the LDTA and this should be taken into consideration during
Most lumps found in the extremity are benign. Some, however, are not. An approach to tertiary referral is required to accommodate the need for specialist evaluation of all concerning lumps, while maintaining an acceptable time to diagnosis and definitive management. We describe a new approach to tertiary sarcoma service, utilising modern communication technology and the “virtual clinic” approach. Methods. Data from 1053 consecutive patients referred to the MSK oncology service at Glasgow Royal Infirmary between January 2010 and August 2012 was prospectively collected. Results. All suspected musculoskeletal sarcoma cases were discussed referred to our tertiary sarcoma virtual clinic were discussed. Mean time from referral to clinic for the 625 patents referred from January 2011 was 5.1 days. 41% of referrals came from out-with our health trust. 28.3% of patients were discharged from the virtual clinic without need for physical appointment. 45.8% were sent for further investigation prior to first clinic appointment, with the remaining 25.5% given an urgent clinic appointment. Final diagnoses of soft tissue tumours, bone tumours and “tumour like conditions” were present in almost equal parts. 358 patients (34%) of patients went on to have surgery, with 59 malignant soft tissue and 53 malignant bone tumours over this time period. Conclusions. Through an early, virtual clinic approach to tertiary sarcoma care, a third of referrals have been managed quickly without the need for an unnecessary appointment for the patient. For a further 45% of patients the first appointment will be after all necessary investigations have been performed to facilitate rapid
Purpose of study. To explore the clinical reasoning strategies used by extended scope physiotherapists (ESPs) when assessing patients with low back pain. Background. Extended scope physiotherapists commonly work in back pain services and their training emphasises the acquisition of clinical skills and possible diagnostic tests (including MRI) to aid clinical reasoning and diagnosis. Whilst there has been some exploration of reasoning strategies of other professional groups (notably medically qualified) to date, the clinical reasoning strategies of ESP clinicians have not been reported. Methods. A qualitative study, with three focus groups, explored clinical reasoning by ESPs and non-ESPs, to compare how these clinicians assess patients' with back pain. This informed a second study, using a ‘think-aloud’ technique with 10 participants from four NHS sites, examining their reasoning strategies, immediately after completing initial consultations. Analysis was informed by a grounded theory approach. Results. Themes identified relating to clinical reasoning were prior thinking, patient interaction, gut-feeling, and formal testing. The differences in practice between ESP and non-ESP appeared to be driven by differences in accountability, safety and external influences. A key difference between the accounts of clinical reasoning provided by ESPs and non-ESPs centred on the role and appropriateness of ‘gut feeling’ in diagnostic
Aims. 1. To develop a decision aid - Decision Support Package (DSP) - that will provide low back pain (LBP) patients, and their treating physiotherapists with information on the treatment options available to the patients. 2. To develop a training package for physiotherapists on how to use the DSP. 3. To encourage and evaluate the informed shared
Evidence suggests that anterior cruciate ligament (ACL) injured individuals do not use the same movement strategies as healthy individuals. It is unknown how this may affect them in more challenging activities of daily living and sport. The aim of this study is to evaluate how ACL injured patients perform a single leg squat (SLS) compared to healthy controls. SLS was evaluated as it is more challenging than gait and therefore more relevant to clinical