Treatment for hip displacement in children and youth with cerebral palsy (CP) is dependent upon when the problem is detected. Hip surveillance aims to identify hip displacement early through systematic screening and, together with timely orthopaedic intervention, can eliminate the need for salvage hip procedures. Here we report the impact on surgical practice of 1) hip surveillance program advocacy and knowledge translation efforts and 2) initial population-based program implementation. A retrospective review was completed of all children with CP undergoing surgery for hip displacement at a provincial tertiary pediatric hospital in the years 2004 to 2018. Date and type of surgery, age at surgery, Gross Motor Function Classification System (GMFCS) level, and pre-operative migration percentages (MP) were collected. Surgeries were categorized as soft-tissue release, reconstructive, and salvage procedures. Results were collected for three time periods: historical (September 2004- June 2010), hip surveillance advocacy and knowledge translation (July 2010- August 2015), and post provincial hip surveillance program implementation (September 2015 – December 2018). A total of 261 surgeries on 321 hips were reviewed. The rate of salvage procedures dropped from 29% (24) of surgeries performed in the historical period to 12% (14) during the period that included targeted hip surveillance knowledge translation and development of provincial guidelines. Since implementation of the surveillance program, salvage procedures have accounted for 7% (4) of interventions performed; all of these were in patients new to the province or existing patients. During the three study periods, reconstructive surgeries accounted for 64%, 81%, and 80% of the interventions performed. The mean initial MP at time of reconstructive surgery has decreased from 66% (SD 20%) in the historical time period to 57% (SD 25%) and 57% (SD 22%) in the subsequent time periods. There were a greater number of children at GMFCS levels III and IV in the two more recent time periods suggesting surveillance may assist in identifying children at these levels of impairment. The rate of soft-tissue surgeries was low during all time periods with the number trending higher since program implementation (7%, 7%, 10%). Knowledge translation and use of standardized surveillance guidelines can have a significant impact on the prevalence of salvage hip surgeries. Centers should utilize existing surveillance guidelines and educate key stakeholders about the importance of hip surveillance in the absence of a formal hip surveillance program

It is widely recognised that pelvic disruption in association with high-energy trauma is a life-threatening injury. The potential morbidity and mortality associated with acetabular injuries are less well understood. Due to chronic underfunding and the absence of a comprehensive and coordinated national approach to the management of acetabular trauma throughout the UK, patients can incur prolonged recumbency. Prompt and appropriate referral for specialist management, thromboprophylaxis and venous thrombosis surveillance are important issues for the referring centre. We performed a postal questionnaire to establish the current clinical practice in the specialist centres throughout the UK in pelvic and acetabular trauma, with respect to time to surgery, thromboprophylaxis, and surveillance. We identified twenty-one units and thirty-seven surgeons in the NHS who deal with pelvic and acetabular injuries. The mean time to surgery from injury in the UK is 8.5 days (range 2-19 days). The larger units that accept and treat patients from outside their region experience the greatest delay to surgery. Mechanical thromboprophylaxis was used in 67% (14) of the units. 24% (5) use arterio-venous boots, 19% (4) use calf pumps, and 52% (11) use TEDS stockings. No unit routinely use prophylactic IVC filters in acetabular trauma. Chemical thromboprophylaxis is routinely used in 100% (21) of the units. 95% (20) used prophylactic doses of unfractionated heparin or low molecular weight heparin. Clinical surveillance alone for thromboembolism is employed in 90% (19) of the units. Only 2 (10%) units routinely perform radiological surveillance with ultrasound Doppler on its acetabular fracture cases pre-operatively. Currently there is no published directory of dedicated pelvic and acetabular surgeons in the UK. There is no general consensus on the approach to thromboprophylaxis and surveillance in acetabular trauma in the UK. There is no consensus approach to thromboprophylaxis and surveillance in the literature

This study investigates the experience of one treatment centre with routine surveillance MRI following excision of sarcoma. Casenotes, MRI and histology reports for fifty-nine patients were reviewed. The primary outcome was the presence of local tumour recurrence and whether this was identified on surveillance or interval scanning. Forty-eight patients had a diagnosis of soft tissue sarcoma, the remaining 11 a primary bone tumour. Fifteen patients had local recurrence (25%). Eight were identified on surveillance scan, and the remaining 7 required interval scans. Surveillance scanning has a role in the early detection of local recurrence of bone and soft tissue sarcoma

Introduction. The need for the stringent surveillance of new devices was recognised by the NICE review of hip replacement surgery in 2000 and led to the Orthopaedic Data Evaluation Panel (ODEP) developing criteria for post-marketing surveillance (PMS) studies. This requirement has been reinforced by the recent recall of ASR devices. Methods. The South West London Elective Orthopaedic Centre's (EOC's) comprehensive outcomes programme has been adapted to manage and coordinate multi-centre, multi-surgeon, PMS studies. The system allows any schedule and combination of patient-reported outcome measures (PROMS), clinical and radiological assessments, and complications to be collected. Typically, PROMS are collected pre-operatively and yearly by post. Baseline clinical assessment is undertaken pre-operatively, with baseline radiological assessments pre- and post-operatively. Subsequent clinical and radiological assessments are usually obtained at the ODEP-mandated time points of 3, 5, 7 and 10 years post-operatively. Patients are telephoned twice yearly to document complications and any impending change of address. Results. EOC co-ordinated studies extend the ODEP criteria to provide high quality evidence on implant survivorship and patient outcome. In one study, over 500 subjects are under review. The operations were undertaken by twelve surgeons, at three centres. At 3 years participant withdrawal is 4%, mortality 4%, loss to follow-up 1% and revisions 0.5%. Average annual return of PROMS is 94%, and the percentage of invited patients returning for a 3 year review is 81%. Discussion. The EOC system provides a cost-effective method for the long-term follow-up of implants through multi-site, multi-surgeon national, and international, PMS studies. Participation by high-volume centres facilitates both rapid recruitment of study participants and the infrastructure required to maintain consistent data quality. The acquired information gives timely information to surgeons, manufacturers and healthcare purchasers. We advocate adoption of the EOC PMS model for all new implants that are introduced to the UK market

Introduction. There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery. Methods. The BOSS Study is a series of nationwide observational cohort studies of pre-specified orthopaedic disease. All relevant hospitals treating the disease are invited to contribute anonymised case details. Data will be collected digitally through REDCap, with an additional bespoke software solution used to regularly confirm case ascertainment, prompt follow-up reminders and identify potential missing cases from external sources of information (i.e. national administrative data). With their consent, patients will be invited to enrich the data collected by supplementing anonymised case data with patient reported outcomes. The study will primarily seek to calculate the incidence of the rare diseases under investigation, with 95% confidence intervals. Descriptive statistics will be used to describe the case mix, treatment variations and outcomes. Inferential statistical analysis may be used to analyze associations between presentation factors and outcomes. Types of analyses will be contingent on the disease under investigation. Discussion. This study builds upon other national rare disease supporting structures, particularly those in obstetrics and paediatric surgery. It is particularly focused on addressing the evidence base for quality and safety of surgery, and the design is influenced by the specifications of the IDEAL collaboration for the development of surgical research

Introduction. In addition to traditional posterior-stabilized (PS) designs with cam-post articulations, there are two new design concepts used in total knee replacement (TKR) to “substitute” for cruciate ligament function and restore anterior-posterior stability. These include i) guided-motion PS designs with a modified cam-post that is less restrictive to axial rotation; and ii) non-PS designs that incorporate progressive articular congruency to substitute the function of the resected anterior cruciate ligament (ACL-substituting). Early post-marketing surveillance of such new TKR designs is valuable because instability, loosening, and high complication rates within the initial 5 year follow-up interval have proven problematic for some design. This study reports the early clinical performance of sequential patients implanted with a new ACL-substituting TKR design at a German Center of Excellence for Arthroplasty (EPZ-Max) hospital. Methods. This is a single-site, multi-surgeon retrospective study with Institutional Review Board approval. The nine surgeons involved all used uniform surgical techniques, including a mid-vastus approach, PCL preservation with a bone block, tibial component alignment with the natural tibial slope, no patellar resurfacing, and cement fixation. All patients meeting the following inclusion criteria were contacted by phone: a) primary TKR from July 2008-June 2009; b) implanted with an ACL-substituting design (3D Knee™, DJO Surgical); c) no prior knee arthroplasty; and d) willing to consent to participate. Recorded outcomes at the 5 year follow-up interval included range of motion, Knee Society knee/function scores (KSS), and radiographic results (alignment, radiolucent lines, osteolysis). Additional surgery was classified as “revision” (metal components removed) or “reoperation” (metal components not removed). Results. Out of 166 sequential patients, a study cohort of 69 patients (84 TKR) consented to participate. Average follow-up was 6.2+0.6 (4.7–7.3) years. Maximum flexion averaged 115°+9° (85°–145°), including 39% at >120°. The TKR had stable function and average KSS scores of 94 (knee) and 94 (function). There were four patients (5 TKR, 6.3%) with function scores of <60 points who had considerable pre-operative extension lags (>10°) that lingered (5°–10°) at follow-up. No TKR had evidence of osteolysis or loosening. Non-progressive radiolucent lines were evident post-operatively in 10 TKR and in one additional TKR at last follow-up. Seven (8.3%) TKR required reoperation or revision. Five TKR in the 0–5 year interval required reoperation to treat acute infection, progressive patellar arthritis, and traumatic patellar fracture, and revision to treat pain of unknown etiology (2 TKR revised at another hospital). Two TKR in the 5–6 year interval required revision arthroplasty to treat pain associated with a loose tibial insert screw and unknown symptoms (1 TKR revised at another hospital). Conclusion. This new ACL-substituting design incorporates progressive congruency in the lateral compartment. These data, combined with previous studies (Table 1), provides evidence that this ACL-substituting TKR design restores stability while being robust to surgical and patient variations. These results for a fixed-bearing, non-PS TKR design are supported by international registry data from more than 370,000 TKR in six countries, which demonstrate that survivorship of fixed-bearing cruciate-retaining TKR designs is significantly higher than posterior-stabilized TKR designs, both with and without patella resurfacing

Awareness that minimising tip apex distance (TAD) when inserting a sliding hip screw reduces the risk of screw cut out is important for orthopaedic trainees. The advent of the Picture Archive and Communication System (PACS) has made the accurate measurement of TAD from x-rays and image intensifier films much easier. This study was to determine whether TAD would be reduced if a surgeon knew that his performance was being continually monitored. 31 consecutive cases of sliding hip screw insertion by a single group of surgeons were identified and the TAD measured. The mean TAD was 16.11mm (8.87mm-25.47mm). The same surgeons were then re-educated as to the importance of the TAD and informed that their results would be monitored and discussed. The next 34 consecutive cases were collected prospectively. The mean TAD in these cases was 13.83mm (6.72mm-21.51mm). There was a significant difference between the TAD for the two groups using the two-tailed t-test (p=0.034). There was one implant failure in the pre education group and none in the post education group. These results suggest that awareness of surveillance improves surgical performance even if the importance of the variable being assessed is already known

Background. In October 2008, CMS instituted a new “No payment for preventable complications“ programme and has released a list of conditions for which it intends to expand the programme in 2009. Although not reimbursing for preventable complications is justifiable, some of the proposed target conditions are lacking in both adequate diagnostic testing accuracy and preventability. Aims. This study examines the effects of imperfect sensitivity and specificity of diagnostic testing, the prevalence of condition, and the rate of surveillance on the ratio of numbers of DVT/PE diagnosed and those that actually occur. Methods. Given that proximal DVT following orthopaedic surgery are not preventable (incidence 4-10% despite prophylaxis), and that the accepted screening test (duplex ultrasonongraphy) has a sensitivity of 96.5% and specificity of 94%, up to 2.5 times as many DVT will be diagnosed as actually occur. Since the new CMS policy would withhold payment when a complication is identified, hospitals would be encouraged to decrease screening for DVT, which would save them lost reimbursement but would result in an increase in incidence of unrecognised – and therefore untreated – DVT after major orthopaedic surgical procedures. The study examines the likely CMS savings in the United States for implementation of this proposed policy (estimated $300M annually), as well as the potential increase in undiagnosed DVT likely to result from implementation of the policy. The overall goal of this study is to provide information to better enable the reader to draw their own conclusions on whether non-payment for DVT after an orthopaedic procedure is a fiscal policy that makes sense and improves the health and healthcare of Americans

A key challenge for healthcare delivery in OECD countries is the projected significant increases in populations over the age of 65 years. Australia for example will experience an increase of 16.4% by 2015 while Canada will experience an increase of 16%, UK an increase of 17.9% and US an increase of 14.3% during the same time period (Australian Bureau of Statistics, 2010). Increases of such magnitude will have significant and far reaching implications for healthcare delivery, labour force participation, housing and demand for skilled labour (Australian Bureau of Statistics, 2010). Given the impending economic impact of providing healthcare services to this projected increase of seniors, examination of technology solutions that serve to provide effective and efficient healthcare delivery during the peri and postoperative care process are highly desired and help those desiring to age in place.

Recent studies have demonstrated rapid growth in the number of seniors using computers in the US and other developed countries and is projected to increase further (Jimison et al., 2006). This technology adoption leads to further growth in the potential for health monitoring technologies (Clifford and Clifton, 2012) with the key aim being the maintenance of a seniors' autonomy through understanding how he or she can manage his or her individual health problem and what necessary actions should be taken and when (Ludwig et al., 2012).

Projections by the Congressional Budget Office for Social Security, Medicare, and Medicaid transfers as a percentage of GDP show the share of output spent on seniors' care programs in US rising from 7.6% in 2000 to 13.9% in 2030 to 21.1% in 2075 (Zhang et al., 2009, Falls, 2008). Despite the increased number of home monitoring technologies in age care contexts, there are several challenges that have to be met before integrating such services into the practice, as a real-life application (Ludwig et al., 2012). As the incidence of arthroplasty surgery is projected to increase over six fold between 2010 and 2030 in the US (Kurtz, Ong, Lau, Mowat, & Halpern, 2007), the post arthroplasty period represents a challenging environment for the adoption of new monitoring technologies to optimize the rehabilitative and recovery process.

This study develops a framework for post-arthroplasty monitoring through the application of the intelligence continuum (Wickramasinghe and Schaffer, 2006) to the post-arthroplasty care process including an analysis of the risks and complications. The benefits, barriers and critical elements of designing the theory based framework for home-monitoring technologies provides the structural framework for clinical application of the monitoring modalities. The entire arthroplasty process is included in order to provide appropriate management governance (figure 1) with the following metrics:

Improving post-operative quality by continuous monitoring of risk factors at home

This paper presents an ongoing review of the use of a wedge-shaped porous metal augments in the shoulder to address glenoid retroversion as part of anatomical total shoulder arthroplasty (aTSA). Seventy-five shoulders in 66 patients (23 women and 43 men, aged 42 to 85 years) with Walch grade B2 or C glenoids underwent porous metal glenoid augment (PMGA) insertion as part of aTSA. Patients received either a 15º or 30º PMGA wedge (secured by screws to the native glenoid) to correct excessive glenoid retroversion before a standard glenoid component was implanted using bone cement. Neither patient-specific guides nor navigation were used. Patients were prospectively assessed using shoulder functional assessments (Oxford Shoulder Score [OSS], American Shoulder and Elbow Standardized Shoulder Assessment Form [ASES], visual analogue scale [VAS] pain scores and forward elevation [FE]) preoperatively, at three, six, and 12 months, and yearly thereafter, with similar radiological surveillance. Forty-nine consecutive series shoulders had a follow-up of greater than 24 months, with a median follow-up of 48 months (range: 24–87 months). Median outcome scores improved for OSS (21 to 44), ASES (24 to 92), VAS (7 to 0), and FE (90º to 140º). Four patients died, but no others were lost to follow-up. Apart from one infection at 18 months postoperatively and one minor peg perforation, there were no complications, hardware failures, implant displacements, significant lucency or posterior re-subluxations. Radiographs showed good incorporation of the wedge augment with correction of glenoid retroversion from median 22º (13º to 46º) to 4º. All but four glenoids were corrected to within the target range (less than 10º retroversion). The porous metal wedge-shaped augments effectively addressed posterior glenoid deficiency as part of aTSA for rotator cuff intact osteoarthritis, producing satisfactory clinical outcomes with no signs of impending future failure

Aim. Two types of national registers surveil infections after primary total hip arthroplasty (THA) in Norway: The National surveillance system for surgical site infections (NOIS) that surveil all primary THAs 30 days postoperatively for surgical site infections (SSI), and the Norwegian Arthroplasty Register (NAR) that follow all THAs until any surgical reoperation/revision or the death of the patient. Since these registers report on the same THAs we assessed correspondence between and time trends for the two registers in period 2013 to 2022. All reported THAs were included. Method. The THAs were matched on a group level according to sex, age and ASA-class. In addition to descriptive statistics, adjusted Cox regression analyses were performed with adjustment for sex, age group (<45, 45-54, 55-64, 65-74, 75-84, >85 years) and ASA-class (1, 2, 3, 4 and missing). Changes in annual incidence and adjusted hazard rate (aHR) was calculated. Endpoints in the NOIS were 30-Days SSI and 30-Days reoperation for SSI. Endpoints in the NAR were 30-Days and 1-Year reoperation for periprosthetic joint infection (PJI). Results. The NOIS had registered 87,923 THAs with 1,393 (1.58%) SSIs and 765 (0.87%) reoperations for SSI within 30 postoperatively. The NAR had registered 91,194 THAs with 725 (0.80%) reoperations for infection after 30 days, and 1,019 (1.21%) reoperations for infections after one year. The distribution of sex, age and ASA-class was near identical in the two registers. There was a mean annual reduction in risk of both SSI (aHR 0.92 (95% CI 0.90-0.93)) and reoperation for SSI (0.95(0.92-0.97)) and PJI (30-Days: 0.96 (0.94-0.99), 1-Year: 0.95-0.99)) over the period 2013-2022. Conclusions. The NOIS and the NAR have excellent completeness and the registrations in both registers may be considered representative for the Norwegian population. Not all SSI are reoperated. The incidence and risk of SSI (NOIS) and reoperation for PJI (NAR) is declining and may reflect a true reduction in incidence of PJI after primary THA

Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients. A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted. Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively. In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics

Aim. Prosthetic joint infection (PJI) is a devastating complication of joint replacement, having an impact on morbimortality but also on national health systems and their budgets. The current situation of PJI-related hospitalizations in Spain and their changes over time are unknown. Therefore, we aimed to analyze the hospitalization burden of PJI, including costs and trends in recent decades. Methods. Retrospective observational study including data from the National Surveillance System for Hospital Data, which includes more than 98% of Spanish hospitals. During the period 2000–2015, hospitalizations due to PJI (ICD-9-CM 996.66) as main diagnosis were included. Epidemiological trends were evaluated during four periods: P1, 2000–2003; P2, 2004–2007; P3, 2008–2011; P4, 2012–2015. Annual hospitalization rates per 100,000 inhabitants and trends were also calculated. Results. Among 5,721,6725 hospitalizations, 49,835 were PJI related, which represented 8.71/10,000 admissions. We observed a significant increase in the number of PJI-related hospitalizations per 10,000 admissions during the study period: 6.43 P1, 8.53 P2, 9.60 P3, 10.05 P4 (p<0.001). The annual hospitalization rate was 6.9/100,000 inhabitants (95%CI 6.9–7), which also increased over time (p<0.001). The median age was 72 years (IQR 65–78) and 58.12% were women. Hospitalization rates were higher in women (7.95 vs 5.90; p<0.001) and also increased with patients’ age (p<0.001). Whereas the median length of stay was 7 days (IQR 7–8) in the global cohort, it was 18 days (IQR 10–31) in those with PJI-related hospitalization; however, the median length of stay in PJI-related hospitalizations decreased during the study period (P1 20 days, P4 16 days, p<0.001). The total cost for the healthcare system was 366 million euros and the median cost per patient was 6937 euros (IQR 3584–10505), which significantly increased from 4804 euros in P1 to 8534 in P4 (p<0.001). The majority of patients (90.32%) were discharged home and the case-fatality rate was 2.70%, without significant differences during the study (p=0.384). Conclusions. In Spain, PJI-related hospitalizations have increased in recent decades, with higher costs despite the decrease in length of stay. PJI is a first magnitude healthcare problem, which should be prioritized in health systems and budgets

Aims. The aim of this study was to present the first retrieval analysis findings of PRECICE STRYDE intermedullary nails removed from patients, providing useful information in the post-market surveillance of these recently introduced devices. Methods. We collected ten nails removed from six patients, together with patient clinical data and plain radiograph imaging. We performed macro- and microscopic analysis of all surfaces and graded the presence of corrosion using validated semiquantitative scoring methods. We determined the elemental composition of surface debris using energy dispersive x-ray spectroscopy (EDS) and used metrology analysis to characterize the surface adjacent to the extendable junctions. Results. All nails were removed at the end of treatment, having achieved their intended lengthening (20 mm to 65 mm) and after regenerate consolidation. All nails had evidence of corrosion localized to the screw holes and the extendable junctions; corrosion was graded as moderate at the junction of one nail and severe at the junctions of five nails. EDS analysis showed surface deposits to be chromium rich. Plain radiographs showed cortical thickening and osteolysis around the junction of six nails, corresponding to the same nails with moderate – severe junction corrosion. Conclusion. We found, in fully united bones, evidence of cortical thickening and osteolysis that appeared to be associated with corrosion at the extendable junction; when corrosion was present, cortical thickening was adjacent to this junction. Further work, with greater numbers of retrievals, is required to fully understand this association between corrosion and bony changes, and the influencing surgeon, implant, and patient factors involved. Cite this article: Bone Jt Open 2021;2(8):599–610

Non-invasive sampling of tumor-derived genetic material in circulation through liquid biopsy may be very beneficial for an accurate diagnosis and evaluation of response to treatment in patients with malignant and benign soft tissue tumors. We previously showed that tumor-derived genomic aberrations can be detected in plasma of patients with leiomyosarcoma (LMS) and leiomyoma (LM). In LMS patients, we also showed that the levels of circulating tumor DNA (ctDNA) correspond with response to treatment. We developed an approach tailored to genomic profile of LMS (characterized by intermediate levels of point mutations and copy number alterations, CNAs). Based on TCGA data, we designed a panel of 89 most frequently mutated genes in LMS, which we profiled in plasma DNA by deep sequencing. In parallel, plasma samples were analyzed by shallow whole genome sequencing for detection of CNAs. With this approach, we detected ctDNA in 71% (20/28) of samples from 6/7 patients with advanced disease with >98% specificity. The combination approach for orthogonal profiling of point mutations and CNAs proved to increase the sensitivity of ctDNA detection. Currently, we seek to further improve the sensitivity of ctDNA detection by refining our capture panel and tracking LMS-specific DNA methylation markers in circulation, in addition to point mutations and CNAs. The ultimate goals of our ctDNA studies are 1) to develop a highly sensitive assay for evaluation of response to therapy and long-term surveillance for patients with LMS, and 2) to develop a blood-based test for accurate pre-operative distinction between LMS and LM. To identify LMS-specific DNA methylation markers, we analyzed a test cohort of 76 LM, 35 uterine LMS and 31 extra-uterine LMS by Illumina Infinium EPIC arrays. We identified differentially methylated CpGs between LM and uterine LMS, and between LM and all LMS using a newly developed custom pipeline in R. The results of this analysis are currently being validated in a new dataset of 41 LM and 153 LMS generated by our group. Recently published (PMID: 34301934) genomic data from new 53 LMS samples are used to refine the panel of the most frequently mutated genes that we identified previously in the LMS TCGA data. Our preliminary analysis of test cohort revealed >270 differentially methylated CpGs between LM and uterine LMS, and >1000 differentially methylated CpGs between LM and all LMS. The preliminary analysis of genomic data shows that the initial panel of 89 frequently mutated genes could be substantially narrowed down to cover only selected tumor suppressor genes. Once validated, these results will be used to refine the ctDNA assay for LMS and LM. Our results point to multiple epigenetic markers that could be used for ctDNA profiling, in addition to point mutations or CNAs. Further validation will allow us to select the most reliable LMS- and LM-specific DNA methylation markers and the most frequently mutated regions across independent datasets, and these markers will be incorporated into our new ctDNA test for a concurrent detection of point mutations, CNAs and DNA methylation markers in circulation

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19

Aims. This study aims to enhance understanding of clinical and radiological consequences and involved mechanisms that led to corrosion of the Precice Stryde (Stryde) intramedullary lengthening nail in the post market surveillance era of the device. Between 2018 and 2021 more than 2,000 Stryde nails have been implanted worldwide. However, the outcome of treatment with the Stryde system is insufficiently reported. Methods. This is a retrospective single-centre study analyzing outcome of 57 consecutive lengthening procedures performed with the Stryde nail at the authors’ institution from February 2019 until November 2020. Macro- and microscopic metallographic analysis of four retrieved nails was conducted. To investigate observed corrosion at telescoping junction, scanning electron microscopy (SEM) and energy dispersive x-ray spectroscopy (EDX) were performed. Results. Adjacent to the nail’s telescoping junction, osteolytic changes were observed in bi-planar radiographs of 20/57 segments (35%) after a mean of 9.5 months (95% confidence interval 7.2 to 11.9) after surgery. A total of 8/20 patients with osseous alterations (40%) reported rest and ambulation pain of the lengthened segment during consolidation. So far, 24 Stryde nails were retrieved and in 20 (83%) macroscopic corrosion was observed at the nail’s telescoping junction. Before implant removal 11/20 radiographs (55%) of lengthened segments with these 20 nails revealed osteolysis. Implant retrieval analysis by means of SEM showed pitting and crevice corrosion. EDX detected chromium as the main metallic element of corrosion. Conclusion. Patients are exposed to the risk of implant-related osteolysis of unclear short- and long-term clinical consequences. The authors advocate in favour of an early implant removal after osseous consolidation. Cite this article: Bone Joint Res 2021;10(7):425–436

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection. If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading

Introduction. Leg length discrepancy (LLD) in patients with unilateral developmental dysplasia of the hip (DDH) can be problematic for both patients and surgeons. Patients can acquire gait asymmetry, back pain, and arthritis. Surgical considerations include timing of correction and arthroplasty planning. This study audits standing long leg films performed at skeletal maturity in our patients. The aim of this study is to identify if surgical procedure or AVN type could predict the odds of needing an LLD Intervention (LLDI) and influence our surveillance. Materials and Methods. Hospital database was searched for all patients diagnosed with DDH. Inclusion criteria were patients with appropriately performed long leg films at skeletal maturity. Exclusion criteria were patients with non DDH pathology, skeletally immature and inadequate radiographs. All data was tabulated in excel and SPSS was used for analysis. Traumacad was used for measurements and AVN and radiologic outcome grades were independently classified in duplicate. Results. 110 patients were identified. The mean age of follow-up was 15 years with final average LLD of 1mm(±5mm). The DDH leg tended to be longer and length primarily in the femur. 31(28.2%) patients required an LLDI. 19 Patients had a final LLD >1.5cm. There was no statistical significant difference in the odds of needing an LLDI by type of surgical procedure or AVN. AVN type 4 was associated with greatest odds of intervention. The DDH leg was more likely to require ipsilateral epiphysiodesis or contralateral lengthening in Type 1 and 2 AVN. Conclusions. The DDH leg tends to be longer, leg lengths should be monitored, and leg length interventions are frequently required irrespective of previous DDH surgical procedure or the presence of AVN

Introduction. Mechanically assisted crevice corrosion (MACC) in metal-on-polyethylene (MOP) total hip arthroplasty (THA) is of concern, but its prevalence, etiology and natural history are incompletely understood. Methods. From January 2003 to December 2012, 1356 consecutive THA surgeries using a titanium stem, cobalt chromium alloy femoral head, highly crosslinked polyethylene and a tantalum or titanium acetabular shell were performed. Patients were followed at 1 year, and 5 year intervals for surveillance, but also seen earlier if they had symptoms. Any patient with osteolysis or unexplained pain underwent exam, radiographs, CBC, ESR and CRP, as well as serum cobalt (Co) and chromium (Cr) level. MARS MRI was performed if the Co level was > 1 ppb. Results. Symptomatic MACC was present in 39/1356 patients (2.9%). Yearly MACC prevalence ranged from 0 % (0/139, 2005) to 9.9 % (16/162, 2009). 22/39 (56%) patients have undergone revision surgery, and 17/39 (44%) have opted for ongoing surveillance. Of the surveillance patients, serial serum metal ion levels appear to increase over time. Time of symptoms is correlated with tissue necrosis at time of revision. Conclusions. The prevalence of MACC in MOP hips is higher in this cross-sectional study than previously reported. The highest prevalence was found in 2009 with this vendor. Based on how common this finding is in symptomatic patients from 2009, we may consider asking asymptomatic patients to obtain baseline serum ion levels. The goal of our ongoing research is to understand how to avoid permanent soft tissue loss from adverse local tissue reactions caused by MACC