Introduction. To develop an international guideline (AOGO) about use of osteobiologics in Anterior Cervical Discectomy and Fusion (ACDF) for treating degenerative spine conditions. Method. The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence were collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus. Result. Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about use of osteobiologic for single or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 in common clinical situations. Surgeons are recommended to choose one graft over another or one osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. Conclusion. This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore high quality clinical evidence is demanded to improve the guideline

AO Spine Guideline for Using Osteobiologics in Spine Degeneration project is an international collaborative initiative to identify and evaluate evidence on existing use of osteobiologics in spine degenerative diseases. It aims to formulate clinically relevant and internationally applicable guidelines ensuring evidence-based, safe and effective use of osteobiologics. The current focus is the use of osteobiologics in anterior cervical discectomy and fusion surgeries. The guideline development is planned in three phases. Phase 1- Evidence synthesis and Recommendation; Phase 2- Guideline with osteobiologics grading and Validation; Phase 3- Guideline dissemination and Development of a clinical decision support tool. The key questions formulating the guidelines for the use of osteobiologics will be addressed in a series of systematic reviews in Phase 1. The evidence synthesized by the systematic reviews will be assessed by Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology, including expert panel discussions to formulate a recommendation. In Phase 2, osteobiologics will be graded based on evidence and the grading will be integrated with the recommendation from Phase 1, and thus formulate a guideline. The guideline will be further validated by prospective clinical studies. In the third phase, dissemination of the proposed guideline and development of a decision support tool is planned. AO-GO aims to bridge an important gap between quality of evidence and use of osteobiologics in spine fusion surgeries. With a holistic approach the guideline aims to facilitate evidence-based, patient-oriented decision-making process in clinical practice, thus stimulating further evidence-based studies regarding osteobiologics usage in spine surgeries

Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice. In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment. Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

Abstract. Objective. Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017. Methods. Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018–01/02/2021. Results have been summarised and discussed. Results. Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus. Conclusion. The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed

The British Orthopedic Association recommends that patients referred to fracture clinic are reviewed within 72 hours. With the increase in referrals and limited clinic capacity it is becoming increasingly difficult to see every referral with in a 72 hour time frame. Some patients are waiting 2 weeks or more before they can be seen in a fracture clinic. With the aim of improving care by seeking to meet BOAST 7 target, waiting times for fracture clinic appointments at the Homerton University Hospital were audited prospectively against this national guideline, before virtual fracture clinic was implemented and 6 weeks after the implementation of virtual fracture clinic at our hospital. Virtual fracture clinic is where an Orthopedic consultant reviews a patients x-rays and A&E documentation and decides if that patients needs to be seen in a face to face fracture clinic to discuss operative vs. non-operative management of their injury or if a treatment plan can be delivered without the patient having to come back to hospital. The study was conducted as a prospective closed-loop audit in which the second cycle took place after the implementation of the new virtual fracture clinic service. The first cycle showed a non-compliant waiting time with only 18% of patients being seen within 72 hours. Following the implementation of virtual fracture clinic, 84% of all patients were reviewed within 72 hours. Virtual fracture clinic delivered a significant reduction in waiting times. Virtual fracture clinic has only just been implemented at the Homerton University Hospital and hopefully at the next audit we will be 100% compliant with the BOA BOAST 7 Guideline. We would recommend that virtual fracture clinics being rolled out in Orthopedic departments in all hospitals which have Orthopedic services

To unravel the relation between mechanical loading and biological response, cell-seeded hydrogel constructs can be used in bioreactors under multi-axial loading conditions that combines compressive with torsional loading. Typically, considerable biological variation is observed. This study explores the potential confounding role of mechanical factors in multi-directional loading experiments. Indeed, depending on the material properties of the constructs and characteristics of the mechanical loading, the mechanical environment within the constructs may vary. Consequently, the local biological response may vary from chondrogenesis in some parts to proteoglycan loss in others. This study uses the finite element method to investigate the effects of material properties of cell-seeded constructs and multiaxial loading characteristics on local mechanical environment (stresses and strains) and relate these to chondrogenesis (based on maximum compressive principal strain (MCPS) - Zahedmanesh et al., 2014) and proteoglycan loss (based on fluid velocity (FV) - Orozco et al., 2018). The construct was modelled as a homogenized poro-hyperelastic (using a Neohookean model and Darcys law) cylinder of 8mm diameter and equal height using Abaqus. The bottom surface was fully constrained and dynamic unconfined compression and torsion loading were applied to the top surface. Free fluid flow was allowed through the lateral surface. We studied the sensitivity of the maximum values of the target parameters at 9 key locations to the material parameters and loading characteristics. Six input parameters were varied in preselected ranges: elastic modulus (E=[20,80]kPa), Poissons ratio (nu=[0.1,0.4]), permeability (k=[1,4]e-12m4/Ns), compressive strain (Comp=[5,20]%), rotation (Rot=[5,20]°) and loading frequency (Freq=[1,4]Hz). A full-factorial design of experiment method was used and a first-order polynomial surface including the interactions fitted the responses. MCPS varies between 7.34% and 33.52% and is independent of the material properties (E, nu and k) and Freq but has a high dependency on Comp and a limited dependency on Rot. The maximum value occurs centrally in the construct, except for high values of Rot and low Comp where it occurs at the edges. FV vary between 0.0013mm/sec and 0.1807mm/sec and dominantly depends on E, k and Comp, while its dependency on Rot and Freq is limited. The maximum value usually occurs at the edges, although at high Freq it may move towards the center of the superficial and deep zones. This study can be used as a guideline for the optimized selection of mechanical parameters of hydrogel for cell-seeded constructs and loading conditions in multi-axial bioreactor studies. In future work, we will study the effect in intact and injured cartilage explants

Venous Thromboembolism (VTE) prophylaxis is an essential part of orthopaedic surgeries in preventing life-threatening thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopaedic surgery has the highest incidence rate of thromboembolic events as compared to any other surgical specialities, making it an essential component in managing any orthopaedic case. At Queen's Medical Centre (QMC), a major trauma centre in the United Kingdom (UK), sees up to 750 NOF fracture cases annually, making it one of the busiest trauma and orthopaedic centres in the UK. Our study aims to evaluate how VTE Prophylaxis is conducted in a UK Major Trauma Centre for NOF and pelvic fragility fractures and how human factors can improve its efficacy. The Nottingham University Hospitals (NUH) Trust has implemented new guidelines from August 2019 that patients with fragility fractures such as NOF and pelvic fractures are prescribed with 28 days VTE prophylaxis with Enoxaparin, or their own anti-coagulants if risk of thrombosis exceed the risk of bleeding. This is an adaptation from the trust to align their guidelines closer to the NICE 2018 guidelines. We will be evaluating the initial compliance of VTE Prophylaxis, identify and utilise human factors, then re-analyse the department after implementing interventions on the same batch of junior doctors working in the department. Data of 100 patients with fragility fractures were collected, 50 consecutive patients in the pre-intervention window during August 2019 and 50 in the post-intervention window during November 2019. The pre-intervention data had 43 NOF and 7 Pelvic fractures. Our study showed that 93% of NOF fracture and 100% of pelvic fracture received the correct course of VTE prophylaxis. The data was presented at the local department junior doctor academic session. Three simple human factor interventions were implemented over the course of September and October: Education to the trauma and orthopaedic department on the new guideline, extended VTE labels on drug charts for patients with fragility fractures, VTE reminder labels at doctors' stations. Another 50 consecutive patients' data were collected during November 2019. Data shows that 97.8% of NOF (p>0.05) and 60% of pelvic fracture (p>0.05) received the correct course of VTE prophylaxis. Our data has shown an increase in correct VTE prescription for NOF fracture patients, which is the main bulk of our fragility fracture patients whilst we see a drop in pelvic fracture patients. Due to the limited time frame of four months where junior doctors in the UK rotate between specialities, we are only able to collect data during the first month, implement interventions between datasets and collect data on the final month of the four-month rotation. A future bigger study might provide a more significant result on the department. We believe that the key to achieving 100% VTE prophylaxis in the T&O department is optimising human factors, educating junior doctors, who are not orthopaedic trained, with sufficient information of the guidelines, and evidence of the risk and benefits of providing prolonged VTE prophylaxis for orthopaedic patients. In conclusion, we found that QMC, a major trauma centre with high patient volume and turnover, has a high level of compliance with VTE prophylaxis for fragility fractures and it is imperative that utilising human factors will inch the department closer to its goal of 100% VTE compliance

Successful treatment of periprosthetic joint infection involves surgical intervention and identification of infecting organisms to enable targeted antibiotic therapy. Current guidelines recommend intra-operative culture sampling to include at least 4 tissue samples and for each sample to be taken with a separate instrument. We aimed to review current revision arthroplasty practice for Greater Glasgow, specifically comparing intra-operative sampling technique for infected revision cases with these guidelines. We reviewed the clinical notes of all patients undergoing lower limb revision arthroplasty procedures in Greater Glasgow Hospitals (WIG, GRI, SGH) from July 2013 to August 2014. Demographics of all cases were collected. For revision procedures performed for infection we recorded details of intraoperative samples taken (number, type and sampling technique) and time for samples to reach the laboratory. Results of microbiology cultures were reviewed. Two hundred and fifty five revision arthroplasty procedures (152 hips, 103 knees) were performed in the 12 month study period. Of these 57 (22%) were infected cases (28 hips, 29 knees). These cases were treated by 14 arthroplasty surgeons with a median number of 3 infected cases managed per surgeon (range 1–11). 58% of cases had the recommended number of tissue samples taken. The median number of microbiology samples collected was 4 (range 1–14). Most procedures (91%) had no documentation of whether separate instruments were used for sampling. Number of tissue samples taken (≥4, p=0.01), time to lab (<24 hours, p=0.03) were significantly associated with positive culture results. In Greater Glasgow, a large number of surgeons manage infected arthroplasty cases with variability in intra-operative sampling techniques. Sample collection adheres to guideline recommendations in 58% cases. Adhering to guideline standards increases the likelihood of positive tissue cultures. Implementation of a standardised approach to intra-operative sampling for infected cases may improve patient management

There is an inherent risk of iatrogenic new neurological deficit (NND) arising at the spinal cord, cauda equina and nerve root during spinal surgery. Intraoperative neurophysiological monitoring (IONM) can be employed to preserve spinal cord function during spinal surgery. IONM techniques include somatosensory and motor evoked potentials, amongst others. A Canadian survey of 95 spinal surgeons showed that 62.1% used IONM and a similar survey in France of 117 spinal surgeons showed that only 36% used IONM. Unavailability was a common reason for its disuse. Current literature by the British Society of Clinical Neurophysiology has outlined the importance of IONM in preventing NND and the need for the implementation of guidelines for IONM. The lack of an established guideline has resulted in a varied approach in the use of IONM in England. There has been no previous attempt to ascertain the current use of IONM in England. Our study is aimed at assessing the variability of the use of IONM in England as well as identifying the rationale amongst surgeons that dictate their use of IONM. We are in the process of investigating the indications of use of IONM for cervical and lumbar spine procedures in 252 spinal surgeons from 33 hospitals with spinal services. Our survey will illustrate the current use of IONM in spinal surgery in England. It will highlight some of the reasons for the variability of use of IONM and identify factors that can contribute to a more standardised use of IONM in spinal surgery

Introduction. Guidelines from the North American Spine Society (2009 and 2013) are the best evidence-based instructions on venous thromboembolism (VTE) and antibiotic prophylaxis in spinal surgery. NICE guidelines exist for VTE prophylaxis but do not specifically address spinal surgery. In addition, the ruling of the UK Supreme Court in 2015 resulted in new guidance on consent being published by the Royal College of Surgeons of England (RCSEng). This study assesses our compliance in antibiotic, VTE prophylaxis and consent in spinal surgery against both US and UK standards. Methods. Retrospective review of spinal operations performed between August and December 2016. Case notes, consent forms and operation notes were analysed for consent, peri-operative antibiotic prescribing and post-operative VTE instructions. Results. Four Spinal surgeons performed 45 operations during this period. 31 patients (69%) received a copy of the signed consent with this process being formally documented in 22 (71%) of those cases. All patients were consented by a competent surgeon. 82% of cases consented prior to the date of procedure were countersigned on the day of operation. There was a mean time of 25.3 days between initial consent and operation (Range: 0–170). 37 (82%) cases had clear instructions for VTE and antibiotic prophylaxis. All prescribed post-operative antibiotics were administered. Discussion. The North American Guidelines state that prophylactic antibiotic is appropriate in all spinal surgery with prolonged cases requiring intraoperative re-dosing and only complex cases needing a postoperative regimen. Eight patients underwent a complex procedure and 7 appropriately received postoperative antibiotics. Of the 29 patients that underwent a simple procedure, 12 did not receive post-operative regimen, in line with the guidelines. However, the remainder 17 were over treated. The US Guidelines recommend mechanical VTE prophylaxis only in elective spinal surgery except in high risk patients. All our patients received VTE mechanical prophylaxis. RCSEng guidelines require consent being taken prior to procedure by a competent surgeon and confirmed on day of procedure. All patients in our cohort were consented prior to the date of operation allowing time for considering options and independent research. 82% of patients had consent confirmed on day of operation. Conclusion. This study demonstrates that we met guideline advice for all patients with regards VTE prophylaxis. We have a tendency to over treat with post-operative antibiotics and not all patients had their consent confirmed on day of procedure but was consented well before day of operation. North America still lead the way with guidelines on spinal surgery to which we should adhere, with NICE guidelines providing limited instructions. New consenting guidelines from RCSEng may not be currently widely known and thus should be a source of education for all surgeons

Total hip replacement (THR) is an option in a subset of patients with a neck of femur (NOF) fracture. The Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Clinical Excellence (NICE) provide guidance on the use of THR in patients with a NOF fracture. We compare our experience and recommend changes at a local level to allow successful implementation of the guideline to improve patient care. From July 2008 to July 2011, 36 THRs preformed for trauma were identified retrospectively by cross-referencing several databases (Bluespier, Worcestershire, UK and surveillance of Surgical Site Infection (SSI), Scotland). 7 exclusions (3 failed internal fixation, 1 chronic NOF fracture, and 2 extra-capsular fractures) leaving 29 patients. All operations were carried out under the supervision of a hip surgeon. Outcome data (see results) was collected from electronic sources. Statistical analysis preformed using Fisher's exact test for categorical data. Median age 62 years (44–88), time to surgery 4 days (2–8), American association of anaesthesia grade 2 (2–4) and hospital stay was 12 days (6–18). The first operator was a consultant in 23 cases and registrar in 6. 9 hips were cemented, 5 uncemented and 15 hybrid. 13 (44.8%) patients had a complication including 8 major (27.6%) complications. A blood transfusion was required in 11 (37.9%) patients. There were 2 (6.9%) deaths. A delay to surgery of more than 2 days was associated with increased risk of major complication (p< 0.03). ASA, Age, Grade of surgeon or Cement not associated with major complications. Our results are inferior to those in the literature. We have identified potential causes; mainly a delay to surgery increasing risk of major complication. In keeping with the current guidelines we recommend that local pathways are instigated to ensure THRs for trauma may be preformed in a timely fashion

Troponin I is a widespread used blood test to confirm myocardial damage, usually attributable to myocardial infarction. Troponin tests require to be taken 12 hours after the initial event, and thus may be a potential cause for delay. SIGN and Hip Fracture Audit guidelines recommend 98% of patients obtaining surgery within 24hrs of admission. A population of 347 neck of femur patients presenting to Glasgow Royal Infirmary were assessed over a one year period. 44 (13%) Patients were identified as having a pre-operative Troponin I test. Retrospective case note review of this patient cohort who had pre operative troponin testing was undertaken to identify timing of TnI testing, admission, surgery and medical comorbidies. Time to theatre was compared with the 24hr guideline. From the cohort, 32 Patients had case notes which were located, of which 4 had no filed notes from the admission giving a 28 patient sample population. 18 (64%) had a Troponin of ‘negative’ value (<0.04 μg/l) of which the mean delay to theatre from admission was 46.4 hrs (median 44.5hrs). All 18 breached the 24hr target, 5 were delayed >48hrs. Of the 10 ‘postive’ patients, mean TnI was 0.4 and time to theatre was 85hrs (median 69hrs) with one excluded as treated conservatively. Only one patient was treated within the 24hr target (3.7% of sample group treated operatively) p=<0.001. Scottish Hip Fracture Audit shows GRI to have an overall 98.6% compliance with the 24hr target. The data presented shows significant (near complete) failure to meet the 24hr target in patients tested preoperatively for Troponin I. Almost three-quarters of these patients have normal TnI, but delay may be attributable to additional comorbidities

Great interest in unicompartmental knee arthroplasty (UKA) for medial osteoarthritis has rapidly increased following the introduction of minimally invasive UKA (MI-UKA). This approach preserves the normal anatomy of knee, causes less damage to extensor mechanism and results in a more rapid post-operative recovery. However, experience with this approach is limited in China. The aim of this report was to determine the short-term clinical and radiographic outcomes of MI-UKA in the Chinese, and to identify any features that are unique to this population. Fifty two knees, in forty-eight patients, with medial compartmental osteoarthritis treated by MI-UKA via C-arm intensifier guide (CAIG) from May 2005 to January 2009 were reviewed. Pain and range of motion (ROM) was assessed using the HSS scoring system before and after surgery. Pre- and postoperative alignment of the lower limbs was measured and compared. The mean follow up time was 24 months (12-42 months). In all cases the pain over medial compartment of the knees was relieved or subsided. The post-operative ROM was 0-136 degree (mean 122degree), and the mean alignment was 2degree varus (0- 7degree varus). The HSS score increased from 72(61-82) to 92(72-95). 93% of the postoperative scores were good or excellent. Interestingly, the distribution of femoral component sizes of these patients was XS 2%, Small 83%, Medium 15%, Large 0%, XL 0%; whereas tibial component size was AA 27%, A 55%, B 15%, C 3%, D 0%, E 0%, and F 0%. The optimal fitted match between tibial and femoral size was: tibia AA and A with XS and small femur, tibia B and C with medium femur. The estimated match was: tibia D and E with large femur, tibia F with XL femur. In contrast to the Oxford report, the sizes of these components are smaller and not in correlation with the height, weight and BMI of the patients. We conclude that MI-UKA is an effective method for treating medial compartmental osteoarthritis of the knee in the Chinese population. CAIG is a feasibly intraoperative measure to predict femoral component sizes. However, component sizes and combinations are different from the Oxford guideline

Background. The worldwide withdrawal of the DePuy Articular Surface Replacement (ASR) device in both its resurfacing and total hip replacement (THR) form on 26 August 2010, after 93,000 were implanted worldwide, has had major implications. The 2010 National Joint Registry for England and Wales quoted figures of 12-13% failure at five years; however these figures may be an underestimate. Patients and methods. In 2004 a single surgeon prospective study of the ASR bearing surface was undertaken. Presented are the Adverse Reaction to Metal Debris (ARMD) failure rates of the ASR resurfacing and ASR THR systems. The diagnosis of ARMD was made by the senior author and was based on clinical history, examination, ultrasound findings, metal ion analysis of blood and joint fluid, operative findings and histopathological analysis of tissues retrieved at revision. Acetabular cup position in vivo was determined using EBRA software. Mean follow up was 52 months (24-81) and 70 patients were beyond 6 years of the procedure at the time of writing. Kaplan Meier survival analysis was carried out firstly with joints designated ‘failure’ if the patient had undergone revision surgery or if the patient had been listed for revision. A second survival analysis was carried out with a failure defined as a serum cobalt concentration > 7microgrammes/L (MHRA guideline from MDA-2010-069). Full explant analysis was carried out for retrieved prostheses. Results. There were 505 ASR hips in total (418 resurfacings and 87 THRs). 657 metal ion samples were available at the time of writing including 152 repeats. Survival analysis using revision/listed for revision as end point (at 6 years): ASR resurfacing: 26.1% failure; ASR THR: 55.5% failure. Survival using ion analysis (at 5 years): ASR resurfacing: 50.1% failure; ASR THR: 66.5% failure. The median (range) volumetric wear rate of failed prostheses was 8.23mm3/year (0.51-95.5). Failure and high ion concentrations are linked to acetabular cup size, anteversion and inclination. Increased failure rates in THRs were due to wear at the taper junction of head and stem. Conclusion. Design flaws in the ASR have led to excessive wear and consequently catastrophic failure rates secondary to ARMD

Objectives

To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice.

Objectives

Osteoporosis has become an increasing concern for older people as it may potentially lead to osteoporotic fractures. This study is designed to assess the efficacy and safety of ten therapies for post-menopausal women using network meta-analysis.

We welcome letters to the Editor concerning articles that have recently been published. Such letters will be subject to the usual stages of selection and editing; where appropriate the authors of the original article will be offered the opportunity to reply.

Objectives

The evidence base to inform the management of Achilles tendon rupture is sparse. The objectives of this research were to establish what current practice is in the United Kingdom and explore clinicians’ views on proposed further research in this area. This study was registered with the ISRCTN (ISRCTN68273773) as part of a larger programme of research.