Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p. At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post- operatively, this was not the case for AAS scores

Background. There are no published studies investigating predictive values of psychological distress on effectiveness of epidural injection. Aims. To evaluate response to epidural injection (EI) in patients with chronic lower back pain (CLBP) with and without psychological distress. Methods. 96 patients with CLBP were recruited to this prospective cohort study. They had preoperative level of distress measured using Modified Zung Index (MZI) and Modified Somatic Perception Questionnaire (MSPQ); pain with Visual Analogue Score (VAS) and McGill Pain Questionnaire (MPQ); back related disability with Oswestry Disability Index (ODI). Fluoroscopic caudal EI comprising 80 mg methylprednisolone and 8 mg of lignocaine was performed. Scores were repeated at 6, 12, and 26 weeks. Successful outcome was Minimal Clinically Important Change (MCIC) in any given measure. Results. There were 62.5% not-distressed patients, 3.1% somatising, 15.6% depressed and 18.8% with mixed distress. Preoperative VAS was 82.4, MPQ 18.2 and ODI 51.6. Distress was associated with worse MPQ and ODI. Average VAS and MPQ improved significantly at 6 and 26 weeks. Mean change of ODI was significant but less than MCIC. Average magnitude of change of VAS and ODI did not differ between distressed and not-distressed. MPQ improved significantly more in the distressed. MZI was significant predictor of VAS-MCIC at 6 weeks while MZI and MSPQ at 6 months. None could predict this outcome independently. MSPQ was the only individual predictor of MPQ-MCIC at any time; MSPQ≥8 could predict MPQ-MCIC with 53%-sensitivity and 78%-specificity. MZI was significant predictor of ODI-MCIC but not individually.88% patients were satisfied with the treatment at 6 weeks and 63% at 6 months (significantly higher rate if somatising). Conclusions. Early psychological screen was correlated with outcome following epidural injection in CLBP and capable of predicting some response to treatment. Minimal, short-lived improvement of distress was not related to post-treatment CLBP measures

Worldwide, most spine imaging is either “inappropriate” or “probably inappropriate”. The Choosing Wisely recommendation is “Do not perform imaging for lower back pain unless red flags are present.” There is currently no detailed breakdown of lower back pain diagnostic imaging performed in New Brunswick (NB) to inform future directions. A registry of spine imaging performed in NB from 2011-2019 inclusive (n=410,000) was transferred to the secure platform of the NB Institute for Data, Training and Research (NB-IRDT). The pseudonymized data included linkable institute identifiers derived from an obfuscated Medicare number, as well as information on type of imaging, location of imaging, and date of imaging. The transferred data did not include the radiology report or the test requisition. We included all lumbar, thoracic, and complete spine images. We excluded imaging related to the cervical spine, surgical or other procedures, out-of-province patients and imaging of patients under 19 years. We verified categories of X-ray, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). Red flags were identified by ICD-10 code-related criteria set out by the Canadian Institute for Health Information. We derived annual age- and sex-standardized rates of spine imaging per 100,000 population and examined regional variations in these rates in NB's two Regional Health Authorities (RHA-A and RHA-B). Age- and sex-standardized rates were derived for individuals with/without red flag conditions and by type of imaging. Healthcare utilization trends were reflected in hospital admissions and physician visits 2 years pre- and post-imaging. Rurality and socioeconomic status were derived using patients’ residences and income quintiles, respectively. Overall spine imaging rates in NB decreased between 2012 and 2019 by about 20% to 7,885 images per 100,000 people per year. This value may be higher than the Canadian average. Females had 23% higher average imaging rate than males. RHA-A had a 45% higher imaging rate than RHA-B. Imaging for red flag conditions accounted for about 20% of all imaging. X-rays imaging accounted for 67% and 75% of all imaging for RHA-A and RHA-B respectively. The proportions were 20% and 8% for CT and 13% and 17% for MRI. Two-year hospitalization rates and rates of physician visits were higher post-imaging. Females had higher age-standardized hospitalization and physician-visit rates, but the magnitude of increase was higher for males. Individuals with red flag conditions were associated with increased physician visits, regardless of the actual reason for the visit. Imaging rates were higher for rural than urban patients by about 26%. Individuals in the lowest income quintiles had higher imaging rates than those in the highest income quintiles. Physicians in RHA-A consistently ordered more images than their counterparts at RHA-B. We linked spine imaging data with population demographic data to look for variations in lumbar spine imaging patterns. In NB, as in other jurisdictions, imaging tests of the spine are occurring in large numbers. We determined that patterns of imaging far exceed the numbers expected for ‘red flag’ situations. Our findings will inform a focused approach in groups of interest. Implementing high value care recommendations pre-imaging ought to replace low-value routine imaging

Degenerative disc disease (DDD) is a common cause of lower back pain. Calcification of the intervertebral disc (IVD) has been correlated with DDD, and is especially prevalent in scoliotic discs. The appearance of calcium deposits has been shown to increase with age, and its occurrence has been associated with several other disorders such as hyperparathyroidism, chondrocalcinosis, and arthritis. Trauma, vertebral fusion and infection have also been shown to increase the incidence of IVD calcification. Our data indicate that Ca. 2+. and expression of the extracellular calcium-sensing receptor (CaSR) are significantly increased in mild to severely degenerative human IVDs. In this study, we evaluated the effects of Ca. 2+. and CaSR on the degeneration and calcification of IVDs. Human donor lumbar spines of Thompson grade 2, 3 and 4 through organ donations within 24 hs after death. IVD cells, NP and AF, were isolated from tissue by sequential digestion with Pronase followed by Collagenase. Cells were expanded for 7 days under standard cell culture conditions. Immunohistochemistry was performed on IVD tissue to validate the grade and expression of CaSR. Free calcium levels were also measured and compared between grades. Immunocytochemistry, Western blotting and RT-qPCR were performed on cultured NP and AF cells to demonstrate expression of CaSR, matrix proteins aggrecan and collagen, catabolic enzymes and calcification markers. IVD cells were cultured in increasing concentrations of Ca. 2+. [1.0-5.0 mM], CaSR allosteric agonist (cincalcet, 1 uM), and IL-1b [5 ng/mL] for 7 days. Ex vivo IVD organ cultures were prepared using PrimeGrowth Disc Isolation System (Wisent Bioproducts, Montreal, Quebec). IVDs were cultured in 1.0, 2.5 mM Ca. 2+. or with cinacalcet for 21 days to determine effects on disc degeneration, calcification and biomechanics. Complex modulus and structural stiffness of disc tissues was determined using the MACH-1 mechanical testing system (Biomomentum, Laval, Quebec). Ca. 2+. dose-dependently decreased matrix protein synthesis of proteoglycan and Col II in NP and AF cells, similar to treatment with IL-1b. (n = 4). Contrarily to IL-1b, Ca. 2+. and cincalcet did not significantly increase the expression of catabolic enzymes save ADAMTS5. Similar effects were observed in whole organ cultures, as Ca. 2+. and cinacalcet decreased proteoglycan and collagen content. Although both Ca. 2+. and cinacalcet increased the expression of alkaline phosphatase (ALP), only in Ca. 2+. -treated IVDs was there evidence of calcium deposits in NP and AF tissues as determined by von Kossa staining. Biomechanical studies on Ca. 2+. and cinacalcet-treated IVDs demonstrated decreases in complex modulus (p<0.01 and p<0.001, respectively; n=5), however, only Ca. 2+. -treated IVDs was there significant increases stiffness in NP and AF tissues (p<0.001 and p<0.05, respectively; n=3). Our results suggest that changes in the local concentrations of calcium and activation of CaSR affects matrix protein synthesis, calcification and IVD biomechanics. Ca. 2+. may be a contributing factor in IVD degeneration and calcification

Introduction. Leg length discrepancy (LLD) is a common sequalae of limb reconstruction procedures. The subsequent biomechanical compensation can be directly linked to degenerative arthritis, lower back pain, scoliosis and functional impairment. It becomes particularly problematic when >2cm, established as a clinical standard. This two-arm experimental study assesses how reliable an iPhone application is in the measurement of LLD at different distances in control and LLD patients. Materials and Methods. 42 participants were included in the study, divided evenly into 21 control and 21 LLD patients. A standardised measurement technique was used to obtain TMM and iPhone application measurements, taken at a distance of 0.25m, 0.50m and 0.75m. Results. The mean discrepancy of iPhone-based measurements in the control group was 1.57cm, 1.59cm and 2.19cm at 0.25m, 0.50m and 0.75m respectively. This compares to measurements in the LLD cohort with a mean discrepancy of 1.71cm, 1.85cm and 2.19cm. The overall mean discrepancy of iPhone data was 1.78cm in the control cohort compared to 1.92cm in the LLD cohort. Conclusions. Results suggest that the iPhone application can be used to identify clinically significant leg length discrepancies. At 0.75 metres anomalous results become more prevalent and the accuracy of the application appears to decline. The results also suggest the application is slightly more accurate in the control group, nevertheless, in distances up to 0.50 metres the mean discrepancy sits within the 2cm standard of clinically significant LLD

Introduction. Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia. Methods. A cross-sectional study using an electronic survey was conducted in Riyadh. The questionnaire was distributed through email among orthopaedic surgeons in Riyadh hospitals. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms were used. Descriptive measures for categorical and numerical variables were presented. Student’s t-test and Pearson’s χ2 test were used. The level of statistical significance was set at p ≤ 0.05. Results. The response rate was 80.3%, with a total number of 179 of Saudi orthopaedic surgeons (173 males and six females). Of our sample, 67.0% of the respondents complained of having MSK pain. The most commonly reported MSK pain was lower back (74.0%), followed by neck (58.2%). Age and body mass index were implicated in the development of more than one type of MSK pain. Increased years of experience (≥ 6 years) was linked to shoulder/elbow, lower back, and hip/thigh pain. Smoking is widely associated with lower back pain development, whereas physicians who do not smoke and exercise regularly reported fewer pain incidences. Excessive bending and twisting during daily practice have been correlated with increased neck pain. Conclusion. MSK pain was found to be common among Saudi orthopaedic surgeons. Further extensive research should be conducted to understand and analyze the risk factors involved and search for possible improvements to avoid further complications. However, ergonomics education during surgical training could be effective at modifying behaviors and reducing MSK pain manifestations

Introduction. Dissatisfaction rates after TKA are reported to be between 15 – 25%, with unmet outcome expectations being a key contributor. Shared decision making tools (SDMT) are designed to align a patient's and surgeon's expectations. This study demonstrates clinical validation of a patient specific shared decision making tool. Methods. Patient reported outcome measures (PROMs) were collected in 150 patients in a pre-consultation environment of one surgeon. The data was processed into a probabilistic predictive model utilising prior data to generate a preoperative baseline and an expected outcome after TKA. The surgeon was blinded to the prediction algorithm for the first 75 patients and exposed for the following 75 patients. PROMs collected were the knee injury and osteoarthritis outcome score (KOOS) and questions on lower back pain, hip pain and falls. The patients booked and not booked before and after exposure to the prediction were collected. The clinical validation involved 27 patients who had their outcome predicted and had their PROMs captured at 12 months after TKA. The predicted change in severity of pain and the patients actual change from pre-op to 12 month post operative KOOS pain was analysed using a Spearman's Rho correlation. Further analysis was performed by dividing the group into those predicted by the model to have improved by more than 10 percentile points and those who were predicted to improve by less than 10 percentile points. Results. Prior to the clinical implementation of the application, the population of patients booked for TKR surgery had a preoperative KOOS pain score of 47.9 ± 17.1, while those not booked for TKR surgery had a mean KOOS pain score of 54.4 ± 21.0 points, with higher scores indicating a lower pain state. A difference of 6.5 points exists between the means. Following introduction of the application, the scores for the population of patients booked for TKR surgery were 40.0 ± 12.3, while those not booked were 55.2 ± 18.8, a significant difference of 15.2 (p<0.001). The clinical validation showed a strong correlation between the predicted and actual pain state change (Spearman's Rho = 0.63, p<0.0001). Patients who were predicted to have a change of less than 10 points pre- operatively had a lower KOOS total score at 12 months (72.16 vs 86.97, p = 0.02). Conclusions. We found a significant difference in the KOOS pain score of patients for whom a decision to operate was made following introduction of the application. A predictive algorithm based on PROMs may assist a surgeon to optimise their patient selection for TKR. The clinical validation showed a strong correlation between predicted and actual change in pain state before and after TKA, supporting the validity of the SDMT's prediction. Literature has shown that the change between pre TKA pain state and post TKA pain state influences patient satisfaction; those with a smaller change in reported pain being less satisfied. This concept has led to the development of a patient specific shared decision making tool that can be used by surgeons and patients in the pre TKA consultation

Revision surgery and surgery in previously operated areas are associated with an increased infection risk. In such situations, aggressive surgical debridement may be necessary to control and eradicate the infection. Full thickness defects resulting from such debridement present as a challenge. In most cases, an association of various methods, both surgical and non-surgical, is necessary. Our goal is to describe the use of vaccum dressings as an effective way to deal with extensive and infected dorsolumbar surgical defects, while avoiding the use of myocutaneous flaps. This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams. We present the case of a 57-years-old obese woman with prior history of double approach with posterior instrumentation and spine arthrodesis (D3 to L4) due to severe dorsolumbar adolescent idiopathic scoliosis. She presented to our consult 42 years after surgery, complaining of lower back pain. Clinical observation and imaging exams demonstrated degenerative disc disease in L5-S1 and L5 anterolisthesis. There was also distal instrumentation breakage (right L4 pedicular screw and contralateral rod) with pseudarthrosis suspicion. Distal instrumentation was removed and no pseudarthrosis was found. Therefore, posterior instrumentation and arthrodesis was performed, from L4 to S1. Surgery went without complications. One week after surgery, patient developed fever and inflammatory signs at the surgical incision, with purulent oozing. Escherichia coli and Proteus mirabilis were identified as the causative agents. Decision was made to remove both lumbar and distal dorsal instrumentation and perform aggressive debridement and lavage, with debridement surgery being repeated twice. Finally, a full thickness defect with approximately 20cm long and 6cm wide resulted from the debridement. A vacuum dressing was then applied, for 5 weeks, with progressive decrease in clinical and analytical inflammatory parameters and wound closure. Four months after the initial surgery, patient was discharged with complete defect closure and reepithelialization. This dressing technique provided a sound solution for defect resolution, as well as an important aid for infection control. It proved to be a viable option in an extensive defect, when surgical flap techniques and traditional dressing techniques could not provide a complete solution

We report the clinical features and treatment on a rare case of Candida albicans lumbar spondylodiscitis in a non-immunocompromised patient. Its indolent course leads to delayed suspicion and diagnosis. As soon as fungal infection is suspected investigations with MRI and biopsy should be performed followed by medical therapy. Retrospective data analysis. A 58-year-old male underwent surgery for adenocarcinoma of the ampula of Vater treatment. Subsequently, the patient had a prolonged intensive care unit stay due to major complications, during his stay he developed a septicemia with Candida albicans isolated in the blood work. He received antifungal therapy anidulofungin, later changed to fluconazole during 2 weeks. Repeated blood work were negative and no vegetations on echocardiogram were seen. He was discharged from the ICU to a surgery floor. During the surgical unit stay he presented with lower back pain radiating to the lower limbs. Findings on neurological examination were normal, radiographs of the lumbar spine revealed L5-S1 antero listhesis. He was treated with oral non-steroidal anti-inflammatory drugs and an lumbar MRI and orthopaedic consultation was agended. One month later, after minor trauma he developed myelopathic symptoms with weakness of both lower limbs and severe back pain. Plain radiograph showed anterolistesis worsening. Magnetic resonance imaging showed endplate erosion at L5/S1. There also was evidence of paraspinal collection with epidural compression of the dural sac. The patient was treated surgicaly with debridement and posterior instrumented fusion from L4 to S1. Disk and end-plate material collected confirmed Candidal infection. The patient recovered most of his neurological deficit immediately after surgery. He was subsequently treated during 2 weeks with liposomal amphotericin B, later changed to fluconazole 400mg per os per day. He maintained antifungal therapy during 15 months. He remains asymptomatic with no recurrence of infection clinically or radiologically after surgery. Fungal spondylodiscitis is rare. Sub-acute or chronic low back pain in either immunocompromised or non-immunocompromised patients cronically ill and malnourished (parental nutrition) there must be high index of suspicion for fungal infections. Therefore we recommend screening for Candida osteomyelistis in these cases. Without treatment, involvement of vertebral bodies can lead to compression fractures, deformity of the spine and neurological impairment

Introduction. Despite generally excellent patient outcomes for Total Knee Arthroplasty (TKA), there remains a contingent of patients, up to 20%, who are not satisfied with the outcome of their procedure. (Beswick, 2012) There has been a large amount of research into identifying the factors driving these poor patient outcomes, with increasing recognition of the role of non-surgical factors in predicting achieved outcomes. However, most of this research has been based on single database or registry sources and so has inherited the limitations of its source data. The aim of this work is to develop a predictive model that uses expert knowledge modelling in conjunction with data sources to build a predictive model of TKR patient outcomes. Method. The preliminary Bayesian Belief Network (BBN) developed and presented here uses data from the Osteoarthritis Initiative, a National Institute of Health funded observational study targeting improved diagnosis and monitoring of osteoarthritis. From this data set, a pared down subset of patient outcome relevant preoperative questionnaire sets has been extracted. The BBN structure provides a flexible platform that handles missing data and varying data collection preferences between surgeons, in addition to temporally updating its predictions as the patient progresses through pre and postoperative milestones in their recovery. In addition, data collected using wearable activity monitoring devices has been integrated. An expert knowledge modelling process relying on the experience of the practicing surgical authors has been used to handle missing cross-correlation observations between the two sources of data. Results. The model presented here has been internally cross validated and has some interesting facets, including the strongest single predictive question of bad outcome for the patient being the presence of lower back pain. Clinical implementation and long term predictive accuracy result collection is ongoing. Discussion. Unsatisfied patients represent a significant minority of TKR recipients, with multiple, multifaceted causal factors both in surgery and out implicated. Historically, focus has been on the role of management and improvement of the surgical factors, which is linked to the fact that surgical factors can often lead to far more disastrous consequences for the patient and the basic principle that “you only improve what you measure.” Growing collection of Patient Reported Outcome Measures by registries around the world has exposed the fact that management of patient factors has lagged behind. (Judge, 2012) Increasingly, the pivotal role of unmet expectations in determining patient satisfaction (Noble, 2006) and the “expectation gap” (Ghomrawi, 2012) between surgeons and patients has been exposed as an opportunity to improve patient outcomes. By developing a model that uses existing surgical expert knowledge to integrate research identified preoperative factors that can be accurately and practically gathered in a clinical setting, a workflow that manages patient expectations in order to optimize outcomes could reduce dissatisfaction rates in TKR recipients. Future work should focus on improving clinical integration and, in the absence of sufficiently wide, deep and complete patient response and predictor datasets, ways of harnessing existing expert knowledge into an evolving predictive tool of patient outcomes

Introduction:. Total knee replacement (TKR) and total hip replacement (THR) reliably relieve pain, restore function, and ensure mobility in patients with advanced joint arthritis; however these results are not uniform across all patient populations. Moreover, it is well established that knee replacement patients have outcomes inferior to those undergoing hip replacement procedures with lower rates of dissatisfaction with post-operative function and pain relief. We compared baseline demographic and symptom profiles in patients from a US national cohort undergoing primary TKR and THR to determine whether differences in demographic make-up, pre-operative symptoms, or pre-existing co-morbidities might contribute to these differences observed post-operatively. Methods:. A cohort of 2375 patients undergoing primary TKR and THR was identified from the FORCE national research consortium from all surgeries performed between July 1. st. 2011 and March 30. th. 2012. This set of patients was derived from 120 contributing surgeons in 23 US states. Gathered data included patient demographics, comorbidity (Charlson Comorbidity Index), operative joint pain severity (Western Ontario and McMaster Universities Arthritis Index (WOMAC)), physical function (SF-36; Physical Component Score (PCS)), emotional health (SF-36; Mental Component Score (MCS)), and musculoskeletal burden of illness (Hip and Knee Disability and Osteoarthritis Outcome Scores; Oswestry Disability Index). Using descriptive statistics, we compared the baseline demographic characteristics and symptom profiles of patients undergoing TKR (n = 1362) and those undergoing THR (n = 1013). Results:. In this large national sample, patients receiving knee replacements were found to be significantly older (66.5 vs. 64.3 years), more obese (BMI 31.7 vs. 29.3), and less educated (p < 0.005) than those undergoing THR. TKR patients had higher rates of medical comorbidities, specifically diabetes, gastrointestinal ulcers, and cerebrovascular disease (p ≤ 0.006). Conversely, THR patients had significantly worse physical function (PCS 31.6 vs. 33.3), lower back pain (35.6% vs. 30.5% moderate-severe), and operative joint pain, stiffness, and function (p < 0.005) when compared to those undergoing TKR. Conclusions:. US patients undergoing primary TKR are older with more comorbidities, however THR patient baseline functional and musculoskeletal limitations are significantly greater than primary TKR patients. These data may help explain the variability in physical function after primary TKR as compared to primary THR

Anterior lumbar inter-body fusion (ALIF) is a surgical procedure that is available to chronic lower back pain patients who fail to respond to conservative treatments. Failure to achieve fusion may result in persistence of pain. Fusion of the lumber vertebral segment is more accurately assessed using fine-cut helical Computed tomography (CT) scans (0.25 mm thickness slices). Unfortunately this technique exposes the body to high radiation dose with hazard of increase risk of late malignancy. An alternative imaging tool is radiostereometry (RSA) which developed as a means to determine the magnitude of relative motion between two rigid bodies. In this study we used RSA to detect movement at the fused lumbar segment (ALIF site) during flexion and extension and compare the results obtained with fine-cut helical CT scan using histopathology as final gold standard assessment tool. ALIF of three levels of lumbar spine (L1-L2, L3-L4, and L5-L6) was done in 9 sheep. The sheep divided into three groups (3sheep each). The first group had RSA assessment immediately, 3, and 6 months after surgery. The second group had RSA immediately, 3, 6, 9 months after surgery. The third group had an RSA immediately, 3, 6, 9, 12 months after surgery All the animals were humanly killed immediately after having the last scheduled RSA (group1, group2, and group 3 sheep were killed 6 month, 9month and 12 months after surgery respectively). This followed by in vitro fine cut CT and histopathology after the animals are scarified. Micro CT scan has been also used to identify the area where histopathology slide should be made to pick up fusion. Fine cut CT scan assessment for all sheep were done. The CT scan has been reported by two independent radiologists. Histopathology has been started and will finish in 2 weeks. RSA showed there was significant increasing stiffness of the spine though the fused segments as the time pass on compare to immediate postoperative assessment. CT scan were done and showed variable fusion though out the spinal segments. Histopathology of all sheep has been started and the results will be available in 2 weeks which will be followed by statistical assessment to decide how accurate RSA compare to CT scan in assessment of fusion

Introduction:. Leg length and offset discrepancy resulting from Total Hip Replacement (THR) is a major cause of concern for the orthopaedic community. The inability to substitute the proximal portion of the native femur with a device that suitably mimics the pre-operative offset and head height can lead to loss of abductor power, instability, lower back pain and the need for orthodoses (1). Contemporary devices are manufactured based on predicate studies (2–4) to cater for the variations within the patient demographic. Stem variants, modular necks and heads are often provided to meet this requirement. The number of components and instruments that manufacturers are prepared to supply however is limited by cost and an unwillingness to introduce unnecessary complexity. This can restrict their ability to achieve the pre-osteoarthritic head centre for all patient morphologies. Corin has developed bone conserving prosthesis (MiniHip™) to better replicate the physiological load distribution in the femur. This study assesses whether the MiniHip™ prosthesis can better match the pre-osteoarthritic head centre for patient demographics when compared to contemporary long stem devices. Method:. The Dorr classification is a well accepted clinical method for defining femoral endosteal morphology (5). This is often used by the surgeon to select the appropriate type and size of stem for the individual patient. It is accepted that a strong correlation exists between Flare Index (FI), characterising the thinning of cortical walls and development of ‘stove-pipe’ morphology, and age, in particular for females (Table 1) (3). A statistical model of the proximal femur was built from 30 full length femoral scans (Imorphics, UK). Minimum and maximum intramedullary measurements calculated from the statistical model were applied to relationships produced by combining Corins work with that of prior authors (Table 2) (2; 3; 6). This data was then used to generate 2D CAD models into which implants were inserted to compare the head centres achievable with a MiniHip™ device compared to those of a contemporary long stem. Results:. Results for the CAD overlay indicated the MiniHip prosthesis is better suited to restoring head centre for a range of morphological variations (Figure 1). In contrast, the long stem prosthesis requires a larger size range and increased inventory in terms of stem variants and modular components to achieve the same array of head centres. The disparity between the Corin FI and that of prior authors can be accounted for by the methods employed; the greyscale-based edge detection (Imorphics, UK) compared to a manual identification method. Discussion:. By overlaying the Corin MiniHip™ over the CAD representation of anticipated flare index, it is evident that the MiniHip™ stem is more suitable for the anticipated range of morphologies. The versatility of this design enables the restoration of head height and offset regardless of canal geometry, degree of offset and or CCD angle. This is not the case for contemporary long stem devices which rely on a more diaphyseal region for anchorage and stability and therefore depend on stem variants and modularity to cater for morphology changes

Aims

COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.