Abstract. In the pediatric population, scoliosis is classified into congenital, syndromic, idiopathic, and neuromuscular in aetiology. Syndromic scoliosis represents a wide range of systemic anomalies associated with scoliosis. The primary challenge for a clinician is to think beyond the scoliotic curve, as the underlying pathology is multisystemic. The aim of this review is to identify the systemic anomalies, associated with syndromic scoliosis. MEDLINE, EMBASE, and CINAHL databases were searched, dating from 1990–2020, relevant to the purpose of our study. Keywords used: “scoliosis”+ “syndrome” + “genetic”. Retrospective, prospective studies were included. Case reports that had fewer than 4 patients were not included. Delineating 60 articles, we found a total of 41 syndromes to be associated with scoliosis. Thoracic region was the most common level of scoliosis curve, being noted in 28 syndromes. Mental retardation, seizures, and ataxia were the commonly noticed CNS anomalies. VSD, ASD, and TGA were the anomalies associated with CVS; Hypotonia, rib and vertebral malformations were the most identified neuromuscular anomalies; pulmonary hypoplasia, renal agenesis, and strabismus were other associations. A multidisciplinary approach, involving spinal surgeons, paediatricians, geneticists, anesthesiologists, and allied health professionals, is vital for the best care of patients with syndromic scoliosis. The location of the scoliotic curve reflects the associated anomalies, as thoracic curvature is more closely linked with cardiac anomalies, while lumbosacral curvature is seen to be often linked with genitourinary anomalies. We hope that this article provides a clear overview of the systemic associations in syndromic scoliosis and thus, facilitates and streamlines the management protocol

Introduction. In vitro studies have shown that low clearance metal-on-metal hip joints have the potential of reducing wear during the running-in phase [1]. However, cementless acetabular cup relies on press fitting into the acetabulum, which can generate non-uniform compressive stresses and non-uniform in vivo cup deformation [2, 3]. This could then lead to equatorial contact, resulting in higher wear and friction for a MoM bearing with low clearance. To benefit from low wear generated by low clearance and at the same time to avoid the potential of head seizure and high frictional torque caused by cup deformation, a deflection compensation acetabular cup (DefCom) has been developed based on the Birmingham Hip Resurfacing (BHR) device. The articulating sphere of the DefCom cup provides a low clearance bearing area, whilst the non-articulating sphere maintains the standard BHR clearance. The aim of this study was to evaluate the wear performance of the novel DefCom hip joint using a hip wear simulator. Materials and Methods. Five pairs of 50 mm DefCom devices were tested in a ProSim hip wear Simulator for 5 million cycles (MC) at a frequency of 1 Hz. The lubricant was new born calf serum with 0.2% sodium azide diluted with de-ionised water to achieve protein concentration of 20 mg/ml. The flexion/extension was 30° and 15° and the internal/external rotation was 10°. The force was Paul-type stance phase loading with a maximum load of 3 kN and a standard ISO swing phase load of 0.3 kN. Five standard 50 mm BHR devices were tested under the same testing conditions for comparison. Statistical analyses were performed at a 95% confidence level (CL) using the statistics function in Excel (Microsoft(r) Excel 2003). Results. Fig. 1 shows the cumulative volume loss against number of wear cycles for the DefCom and the BHR devices. Similar to the BHR device, the DefCom joints experienced relatively higher amount of material loss during the running-in phase from 0 to 1.0 Mc. However, the running-in wear rate for the DefCom device (0.23 ± 0.06 mm. 3. /MC) was much lower than that for the BHR device (0.72 ± 0.15 mm. 3. /MC). Steady state wear was achieved for all the joints from 1.0 to 5.0 MC. The steady state wear rate was 0.11 ± 0.03 mm. 3. /MC for DefCom and 0.18 ± 0.01 mm. 3. /MC for the BHR joints. Discussion. This study has shown that the DefCom acetabular cup has the potential to reduce the initial running-in wear by reducing the clearance at the contact area between the head and cup. The device also has the potential to avoid deformation induced head seizure and high frictional torque by maintaining a larger clearance at the periphery of the cup

The classic Hill-Sachs lesion is a compression or impression fracture of the humeral head in occurrence with anterior glenohumeral instability. The true incidence is unknown but clearly increases with recurrent instability episodes. Recent peer-reviewed literature has highlighted the importance of addressing “significant” humeral and glenoid bone defects in the management of glenohumeral instability. Quantification of the “significance” of a Hill-Sachs lesion with regard to location, size, and depth in relation to the glenoid has helped guide indications for surgical management. Options for managing Hill-Sachs lesions include both humeral-sided techniques (soft tissue, bone, and/or prosthetic techniques) and also glenoid-sided techniques (bone transfers to increase glenoid width). The majority of significant acute or chronic Hill-Sachs lesions can be effectively managed without prosthetic replacement. Is a prosthetic surface replacement ever indicated for the management of Hill-Sachs lesions? The peer-reviewed literature is sparse with the outcomes of this treatment, and significant consideration must be given to both the age of the patient and the need for such management when other effective non-prosthetic options exist. In a patient with more than half of the humeral head involved after instability episodes (perhaps seizure or polytrauma patients), metallic surface replacement arthroplasty may be an option that could require less involved post-operative care while restoring range of motion and stability

Acute peri-operative blood loss warranting transfusion is a frequent consequence of major joint replacement (TJR) surgery. Significant peri-operative anemia can contribute to hypotension, dyspnea, coronary ischemia and other peri-operative medical events that can result in increased risk of peri-operative complications, readmissions and impair the patient's ability to mobilise after surgery resulting in a longer length of stay (LOS) and increase skilled nursing facility (SNF) utilization. The risks associated with allogeneic blood transfusions (ABT) administered to treat symptomatic peri-operative anemia are numerous and extend beyond the concerns of transmission of communicable disease (HIV, hepatitis, other). Patients receiving ABTs have been shown to have a longer hospital LOS, higher risk of infection, and higher mortality after TJR than those who do not require transfusion after surgery. As a result, many different pre-operative, peri-operative and post-operative strategies have been utilised to minimise peri-operative blood loss and transfusion need for patients undergoing TJR. Several studies have shown that the strongest predictor of the need for ABT in the TJR patient is the pre-operative hematocrit (Hct). As a result, all patients with unexplained pre-operative anemia should be evaluated for an underlying cause prior to elective TJR surgery. In recent years, focus has shifted towards peri-operative reduction of blood loss with the use of pharmacologic agents like tranexamic acid (TXA). These agents work by inhibiting fibrinolysis and activating plasminogen. Numerous studies have shown that TXA given IV, applied topically into the surgical wound or given orally have been shown to reduce peri-operative bleeding and ABT after both THA and TKR. Regardless of route of administration, all appear to be more efficacious and considerably more cost-effective in reducing the need for ABT than other methods discussed previously. Despite concerns about the potential increased thromboembolic risk in patients undergoing TJR, there does not appear to be any conclusive evidence suggesting an increased risk of venous thromboembolic disease (VTED) in TJR patients who receive peri-operative TXA. Although it may be unnecessary, many TJR surgeons still, however, avoid use of TXA in patients with a past history of VTED, stroke, coronary artery disease (including coronary stents), renal insufficiency, hypercoagulable state and seizure disorder. The use of topical TXA may be safer in some of these high risk patients since systemic absorption is minimal when administered via this route. Although the optimal method of administration (IV, topical, oral or combined) has not yet been determined based on safety, cost and reduction of need for ABT, incorporation of tranexamic acid into a blood conservation program is clearly the standard of care for all TJR programs that should nearly eliminate the need for ABT for patients undergoing TJR

A 35-year-old female (age 35Yrs) had primary MOM total hip arthroplasty (THA) in 2008. At 8 months this patient postoperatively developed headaches, memory loss, vertigo, and aura-like symptoms that progressed to seizures. At 18 months review, she complained of progressive hip pain, a popping sensation and crepitus with joint motion. This patient weighed 284lbs with BMI of 38.5. Radiographs revealed the cup had 55° inclination, 39° anteversion (Fig. 1). Metal ion concentrations were high (blood: Co=126 mcg/L, Cr= 64mcg/L). Revision was performed in November 2010 A dark, serous fluid was observed, along with synovitis. The implants were well fixed and the femoral head could not be removed; thus the stem was removed by femoral osteotomy. With the head fused on this femoral stem, for the 1. st. time it was possible to precisely determine the habitual patterns of MOM wear relative to her in-vivo function. We investigated (1) size and location of wear patterns and (2) signs of cup-stem impingement to help explain her symptoms developed over 32 months follow-up. The retrieved MOM was a Magnum™ with head diameter 50mm and 50×56mm cup (Biomet). This was mounted on a Taperloc™ lateralized porous-coated stem. Components were examined visually and wear damage mapped by stereo-microscopy, interferometry, CMM, SEM, and EDS. Main-wear zone (MWZ) areas were calculated using standard spherical equations. 1. and centroidal vectors determined. The head-cup mismatch was 427um with the cup revealing a form factor of 228um. The cup showed wear area of 1275mm² that extended up to the cup rim over 150°arc. The cup rim was worn thin over a 90° arc with loss of cup bevel. The head showed an elliptical wear area of 2200mm. 2. located centrally on the superior-medial surface (ellipsoidal ratio ×1.2). Compared to the hemispherical surface (50mm: hemi-area = 3927mm. 2. ), the worn area represented hemi-area ratio of 56%. The centroidal vectors measured 8° anterior and 24° superior to the head's polar axis (Fig. 2). Stripe wear damage revealed multiple impingement sites. SEM and EDS revealed stripes were contaminated by metal transfer from the stainless-steel instruments used at revision. The main impingement position was identified (Fig. 3) indicating the site of repetitive subluxations whereby the subluxing head thinned the cup, i.e. “edge wear”. Cup and head wear patterns corresponded well, reinforcing our definition of the MWZ locations in vivo. The femoral MWZ was centrally located superiorly and medially with respect to the polar axis of the femoral neck and head. The noted impingement position indicated this patient had experienced repetitive subclinical subluxations (RSS). 2. The taper inside the fused head may also have been a contributory factor that we cannot ignore. Nevertheless her excessive cup thinning was likely a result of a steep cup and considerable anteversion allowing the femoral head to sublux over the cup rim, thus thinning the cup and wearing the rim bevel, and producing MOM wear debris

Aims

Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.