Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. To be a valid predictor of disease and management, radiographic evaluation should include frontal and lateral views of the spine and a complete view of the pelvis, leading to accurate Cobb angle measurements and Risser staging. The study objectives were to determine 1) the adequacy of index images to inform treatment decisions at initial consultation by generating a score and 2) the utility of index radiology reports for appropriate triage decisions, by comparing reports to corresponding images.

We conducted a retrospective chart and radiographic review including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1-April 30, 2021. A score was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity (view of full spine, coronal=two, lateral=one, pelvis=one, ribcage=one). Index images were considered inadequate if repeat imaging was necessary. Comparisons were made between index radiology report, associated imaging, and new imaging if obtained at initial consultation. Major discrepancies were defined by inter-reader difference >15°, discordant Risser staging, or inaccuracies that led to inappropriate triage decisions. Location of index imaging, hospital versus community-based private clinic, was evaluated as a risk factor for inadequate or discrepant imaging.

There were 94 patients reviewed with 79% (n=74) requiring repeat imaging at initial consultation, of which 74% (n=55) were due to insufficient quality and/or visualization of the sagittal profile, pelvis or ribcage. Of index images available for review at initial consult (n=80), 41.2% scored five out of five and 32.5% scored two or below. New imaging showed that 50.0% of those patients had not been triaged appropriately, compared to 18.2% of patients with a full score. Comparing index radiology reports to initial visit evaluation with <60 days between imaging (n=49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients, with 18.4% (95% CI 10.0, 31.4) categorized as major discrepancies. Risser stage was reported in only 14% of index radiology reports. In 13.8% (n=13) of the total cohort, surgical or brace treatment was recommended when not predicted based on index radiology report. Repeat radiograph (p=0.001, OR=8.38) and discrepancies (p=0.02, OR=7.96) were increased when index imaging was obtained at community-based private clinic compared to at a hospital. Re-evaluation of available index imaging demonstrated that 24.6% (95% CI 15.2, 37.1) of Cobb angles were mis-reported by six to 21 degrees.

Most pre-referral paediatric spine radiographs are inadequate for idiopathic scoliosis evaluation. Standardization of spine imaging and reporting should improve measurement accuracy, facilitate triage and decrease unnecessary radiation exposure.

This study aimed to identify factors associated with increased rates of blood transfusion in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF).

A retrospective case-control study was performed for AIS patients treated at a large children's hospital between August 2018 and December 2020. All patients with a diagnosis of AIS were evaluated. Data on patient demographics, AIS, and transfusion parameters were collected. Univariate regression and multivariate logistic modeling were utilized to assess risk factors associated with requiring transfusion. Odds ratios (OR) and 95% confidence interval (CI) were calculated. Surgeries were done by three surgeons and thirty anesthesiologists. To quantify the influence of anesthesia practice preferences a categorical variable was defined as “higher-transfusion practice preference”, for the provider with the highest rate of transfusion.

A total of 157 AIS patients were included, of whom 56 were transfused RBC units (cases), and 101 did not receive any RBC transfusion (controls). On univariate analysis, the following variables were significantly correlated with receiving RBC transfusion: “higher-transfusion practice preference,” “administration of crystalloids,” “receiving fresh frozen plasma (FFP),” “receiving platelets,” “pre-operative hemoglobin,” “cell saver volume,” and “surgical time.” On multiple regression modeling, “pre-operative hemoglobin less than 120 g/L” (OR 14.05, 95% CI: 1.951 to 135.7) and “higher-transfusion practice preference” (OR 11.84, 95% CI: 2.505 to 63.65) were found to be meaningfully and significantly predictive of RBC transfusion.

In this cohort, we identified pre-operative hemoglobin of 120 g/L as a critical threshold for requiring transfusion. In addition, we identified significant contribution from anesthesia transfusion practice preferences. Our multivariate model indicated that these two factors are the major significant contributors to allogenic blood transfusion. Although further studies are required to better understand factors contributing to transfusion in AIS patients, we suggest standardized, peri-operative evidence-based strategies to potentially help reduce variations due to individual provider preferences.

Neuromuscular scoliosis patients face rates of major complications of up to 49%. Along with pre-operative risk reduction strategies (including nutritional and bone health optimization), intra-operative strategies to decrease blood loss and decrease surgical time may help mitigate these risks. A major contributor to blood loss and surgical time is the insertion of instrumentation which is challenging in neuromuscular patient given their abnormal vertebral and pelvic anatomy. Standard pre-operative radiographs provide minimal information regarding pedicle diameter, length, blocks to pedicle entry (e.g. iliac crest overhang), or iliac crest orientation. To minimize blood loss and surgical time, we developed an “ultra-low dose” CT protocol without sedation for neuromuscular patients.

Our prospective quality improvement study aimed to determine: if ultra-low dose CT without sedation was feasible given the movement disorders in this population; what the radiation exposure was compared to standard pre-operative imaging; whether the images allowed accurate assessment of the anatomy and intra-operative navigation given the ultra-low dose and potential movement during the scan.

Fifteen non-ambulatory surgical patients with neuromuscular scoliosis received the standard spine XR and an ultra-low dose CT scan. Charts were reviewed for etiology of neuromuscular scoliosis and medical co-morbidities. The CT protocol was a high-speed, high-pitch, tube-current modulated acquisition at a fixed tube voltage. Adaptive statistical iterative reconstruction was applied to soft-tissue and bone kernels to mitigate noise. Radiation dose was quantified using reported dose indices (computed tomography dose index (CTDIvol) and dose-length product (DLP)) and effective dose (E), calculated through Monte-Carlo simulation. Statistical analysis was completed using a paired student's T-test (α = 0.05). CT image quality was assessed for its use in preoperative planning and intraoperative navigation using 7D Surgical System Spine Module (7D Surgical, Toronto, Canada).

Eight males and seven females were included in the study. Their average age (14±2 years old), preoperative Cobb angle (95±21 degrees), and kyphosis (60±18 degrees) were recorded. One patient was unable to undergo the ultra-low dose CT protocol without sedation due to a co-diagnosis of severe autism. The average XR radiation dose was 0.5±0.3 mSv. Variability in radiographic dose was due to a wide range in patient size, positioning (supine, sitting), number of views, imaging technique and body habitus. Associated CT radiation metrics were CTDIvol = 0.46±0.14 mGy, DLP = 26.2±8.1 mGy.cm and E = 0.6±0.2 mSv. CT radiation variability was due to body habitus and arm orientation. The radiation dose differences between radiographic and CT imaging were not statistically significant. All CT scans had adequate quality for preoperative assessment of pedicle diameter and orientation, obstacles impeding pedicle entry, S2-Alar screw orientation, and intra-operative navigation.

“Ultra-low dose” CT scans without sedation were feasible in paediatric patients with neuromuscular scoliosis. The effective dose was similar between the standard preoperative spinal XR and “ultra-low dose” CT scans. The “ultra-low dose” CT scan allowed accurate assessment of the anatomy, aided in pre-operative planning, and allowed intra-operative navigation despite the movement disorders in this patient population.

Neuromuscular scoliosis patients face rates of major complications of up to 49%. Along with pre-operative risk reduction strategies (including nutritional and bone health optimization), intra-operative strategies to decrease blood loss and decrease surgical time may help mitigate these risks. A major contributor to blood loss and surgical time is the insertion of instrumentation which is challenging in neuromuscular patient given their abnormal vertebral and pelvic anatomy. Standard pre-operative radiographs provide minimal information regarding pedicle diameter, length, blocks to pedicle entry (e.g. iliac crest overhang), or iliac crest orientation. To minimize blood loss and surgical time, we developed an “ultra-low dose” CT protocol without sedation for neuromuscular patients.

Our prospective quality improvement study aimed to determine:

Fifteen non-ambulatory surgical patients with neuromuscular scoliosis received the standard spine XR and an ultra-low dose CT scan. Charts were reviewed for etiology of neuromuscular scoliosis and medical co-morbidities. The CT protocol was a high-speed, high-pitch, tube-current modulated acquisition at a fixed tube voltage. Adaptive statistical iterative reconstruction was applied to soft-tissue and bone kernels to mitigate noise. Radiation dose was quantified using reported dose indices (computed tomography dose index (CTDIvol) and dose-length product (DLP)) and effective dose (E), calculated through Monte-Carlo simulation. Statistical analysis was completed using a paired student's T-test (α= 0.05). CT image quality was assessed for its use in preoperative planning and intraoperative navigation using 7D Surgical System Spine Module (7D Surgical, Toronto, Canada).

Eight males and seven females were included in the study. Their average age (14±2 years old), preoperative Cobb angle (95±21 degrees), and kyphosis (60±18 degrees) were recorded. One patient was unable to undergo the ultra-low dose CT protocol without sedation due to a co-diagnosis of severe autism. The average XR radiation dose was 0.5±0.3 mSv. Variability in radiographic dose was due to a wide range in patient size, positioning (supine, sitting), number of views, imaging technique and body habitus. Associated CT radiation metrics were CTDIvol = 0.46±0.14 mGy, DLP = 26.2±8.1 mGy.cm and E = 0.6±0.2 mSv. CT radiation variability was due to body habitus and arm orientation. The radiation dose differences between radiographic and CT imaging were not statistically significant. All CT scans had adequate quality for preoperative assessment of pedicle diameter and orientation, obstacles impeding pedicle entry, S2-Alar screw orientation, and intra-operative navigation.

“Ultra-low dose” CT scans without sedation were feasible in paediatric patients with neuromuscular scoliosis. The effective dose was similar between the standard preoperative spinal XR and “ultra-low dose” CT scans. The “ultra-low dose” CT scan allowed accurate assessment of the anatomy, aided in pre-operative planning, and allowed intra-operative navigation despite the movement disorders in this patient population.

Elderly patients undergoing surgery for a hip fracture are at risk of thromboembolic events (TEV). The risk of TEV is now rare due to thromboprophylaxis. However, hip fracture treatment has evolved over the last decade. The risk of TEV may have been modified. The objective of this study was to determine the risk of symptomatic TEV following surgery for a hip fracture, in an elderly population.

Retrospective cohort study of all patients > 65 years old undergoing surgery for a femoral neck or intertrochanteric hip fracture in two academic centers, between January 1st 2008 and January 1st 2019. The follow-up was fixed at 3 months. The cumulated risk of thromboembolic events was calculated using the Kaplan-Meier estimator and a predictive logistic regression model was used to determine risk factors.

3265 patients were eligible for analysis. The mean age was 83.3 ±8.1 years old and 75.6% of patients were female. The mortality was 7.55% (N=112) at 3 months. 98.53% of this cohort received thromboprophylaxis. The cumulated risk for a thromboembolic event was 3.55% at 1 month and 6.41% at 3 months (N=99). There were 9 fatal pulmonary embolisms. 89.19% thromboembolic events occurred within 20 days following surgery. Chronic obstructive pulmonary disease (odds ratio 1.909 [1.179–3.089]), renal failure (odds ratio 1.896 [1.172–3.066]) and the use of a bridge between different types of anticoagulant (odds ratio 2.793 [1.057–7.384]) were associated with TEV. The risk of bleeding was 5.67% at 1 month and 9.38% at 3 months (N=142). 77% of bleeding events were hematomas.

The risk of thromboembolic events is higher than expected in a population treated for this condition. Most thromboembolic events occur shortly following surgery. The risk of bleeding is high and most of them are hematomas. Future research could focus on the management of thromboprophylaxis in elderly patients undergoing surgery for a hip fracture.

Labral tears can lead to disabling hip pain however underlying structural (femoroacetabular impingement) and developmental abnormalities predisposing to labral pathology may be left untreated if the peripheral compartment is ignored during hip arthroscopy. Femoroace-tabular impingement (FAI) can be secondary to abnormal morphologic features involving either the proximal femur and/or the acetabulum. Both acetabular labral tears and FAI lead to premature osteoarthritis of the hip. Early diagnosis and treatment of these hip pathologic abnormalities is important, not only to provide pain relief but also to prevent the development of osteoarthritis.

Purpose: To describe the technique for arthroscopy of the peripheral compartment of the hip joint without traction.

Methods: We performed 9 hip arthroscopies without traction from a lateral and and anterolateral portals in the supine position.

After a traditional central arthroscopy with traction, 60 degrees of flexion at the hip joint without traction allowed relaxation of the anterior capsule and increased the intra-articular volume of the peripheral compartment.

Results: Inspection of the peripheral compartment was obtained from the anterolateral portal. The anterior neck area, medial neck area, medial head area, anterior head area, lateral head area and lateral neck area were viewed. In 3 patients, loose bodies were removed. In 1 patient with PVNS synovial biopsy was taken and synovectomy was performed. Osteochondroplasty was performed in 5 patients for femoroacetabular impingement. No complications were observed.

Conclusions: Hip arthroscopy without traction is mandatory to complete assessment and adequate treatment of the painful hip.

Purpose: To report our experience in diagnosis and treatment of Osteoid Osteoma in the foot and ankle.

Material and Methods: Six patients, 4 males and 2 females, mean age 24 (range 17–40), were diagnosed, suffering of osteoid osteoma of the foot and ankle in our outpatients clinic. All the patients had typical spontaneous pain and night pain improved by NSAIDs. In all patients, the diagnosis was delayed for one – two years. Treatment by Computed Tomography guided percutaneous radiofrequency ablation was performed in 4 patients, one patient underwent CT guided curettage and one underwent open excision and local bone graft of the lesion. In patients treated by RF, the lesions were heated three times to 90° for 2 minutes. All the procedures were done under ankle block and local anesthesia. Patients were evaluated in our outpatients foot and ankle clinic 1–2 years following the procedure.

Results: The Osteoid Osteoma was found in the talus of two patients and one in the cuboid, one in the base of third metatarsus, one in the calcaneus and one in the ankle. In all patients most of the pain was resolved within 3 days of the procedure. In 3 patients after a year there was still mild pain at tremendous physical efforts attributed to minimal damage to adjacent joint. Three patients completely recovered including pain free physical efforts. CT at follow-up in 2 patients revealed no pathology of the involved bones.

Conclusions: OO is an uncommon affection in the foot and ankle. The diagnosis is difficult and usually there is delayed. CT guided percutaneous radiofrequency of the foot is a safe and effective. The procedure can be performed under ankle block and local anesthesia.

Purpose of the Study: The outcome after revision knee arthroplasty with structural distal femoral allograft augmentation for major bone loss has been rarely reported in the literature. The aim of this study was to assess the outcome for patients managed with such a procedure in our hospital.

Materials and Methods: Since 2001, ten revision knee arthroplasties requiring structural distal femoral allograft for major bone loss were performed in nine patients who underwent surgery at mean age of 68.1±9.8 years and prospectively followed. All patients were operated by the same surgical team. The first assessment was completed for the patients during August 2005 for radiographic and clinical evaluation. The mean follow up time was 22.2±15.1 months.

Results: On radiographic analysis none of the allografts had resorbtion. Implant position

Was preserved in all patients. Two patients had postoperative complications: one had superficial wound infection without need of surgical revision, another patient needed angioplasty because of pseudoaneurisma of popliteal artery and temporary using of knee brace for mild medial instability. Clinical evaluation revealed that mean “Hospital for Special Surgery Score” had improved from 39.8 to 84.1 points and mean range of motions improved from 75.0±42.0 to 103.5±12.5 (p=0.05, paired t-test). Before the surgery all patients used a walker or a crutch, while only one of them used a cane and the remaining patients walked without any support after the operation.

Conclusions: Our preliminary results demonstrate that structural femoral allografts used in revision knee replacement improve clinical and functional outcomes. Further follow-up is planned.

Background: Displaced proximal humeral fractures (PHF) remain a challenge to the orthopedic surgeon. Conservative treatment yield poor results in the majority of these fractures. Surgical treatment, although preferable, lacks the proper exposure and fixation technique.

The locking compression plate (LCP), which is inserted in a minimal invasive technique, utilizing an anterolateral approach to the proximal humerus, allows adequate reduction and fixation, while minimizing the risk for complications derived from extensive exposure and poor fixation.

Methods: All patients admitted to our department with a complicated PHF between Jan 2004 and May 2005 were included. After obtaining informed consent, open reduction and internal fixation was performed through an anterolateral minimal invasive approach. After exposure and reduction with or without acromioplasty and rotator cuff repair, the fracture was fixated with a LCP 3.5mm. Patients were encouraged to perform pendular movements on the first post-operative day.

The patients were followed closely beginning 2 weeks post-operatively and afterwards on a bi-monthly basis. Immediate complications, radiographic and functional outcome were noted.

Results: 22 patients have been treated according to the treatment protocol during the study period. Minimal follow up of three months is available. A single complication was noted (deep wound infection which necessitated hardware removal). No nerve injury or hardware failures were noted.

Functional outcome was good, patients regained 120°±25 of flexion, 112°±27 of abduction and 17°±8 of external rotation.

Conclusions: The anterolateral approach to the shoulder and fixation with a LCP plate is a safe technique in our hospital. Rigid stabilization allows for early shoulder activation which results in a good range of motion and functional outcome on short-term follow up. Further study and long-term follow up are needed to validate this technique in treating complex proximal humerus fractures.