Functional outcomes following knee replacement in community-dwelling older adults.

BACKGROUND: Knee replacements are increasingly performed in older adults but uncertainty remains regarding their benefits in the context of age-related decline in physical function and other comorbidities. This study aimed to examine (1) the effect of knee replacement on functional outcomes in the context of age-related decline in physical function and (2) the factors associated with minimal important improvement in physical function after knee replacement in community-dwelling older adults aged ≥ 70 years. METHODS: This cohort study was performed within the ASPREE trial, with 889 participants undergoing knee replacement during the trial and 858 age- and sex-matched controls without knee or hip replacement identified from 16,703 Australian participants aged ≥ 70 years. Health-related quality of life was assessed annually using the SF-12, including its physical and mental component summary (PCS and MCS). Gait speed was measured biennially. Multiple linear regression and analysis of covariance were used to adjust for potential confounders. RESULTS: Participants with knee replacement had significantly lower pre- and post-replacement PCS scores and gait speed compared with age- and sex-matched controls. Participants with knee replacement had significant improvement in PCS score following knee replacement (mean change 3.6, 95% CI 2.9-4.3) while PCS score remaining unchanged in age- and sex-matched controls (-0.02, 95% CI -0.6 to 0.6) during follow-up period. The greatest improvements were observed for bodily pain and physical function. Following knee replacement, 53% of participants experienced minimal important improvement in PCS score (increased by ≥ 2.7), while 24% experienced worsened PCS score (reduced by > 2.7). Participants experiencing improved PCS score postoperatively had significantly lower PCS and higher MCS scores pre-surgery. CONCLUSIONS: Although community-based older adults experienced a significant improvement in PCS scores after knee replacement, their postoperative physical functional status remained significantly lower than age- and sex-matched controls. The degree of preoperative physical function impairment was a strong predictor of functional improvement, suggesting that this could be an important consideration when identifying older people most likely to benefit from knee replacement surgery.

The relationship between publication of high-quality evidence and changes in the volume and trend of subacromial decompression surgery for patients with subacromial pain syndrome in hospitals across Australia, Europe and the United States: a controlled interrupted time series analysis.

AIMS: To evaluate the extent to which publication of high-quality randomised controlled trials(RCTs) in 2018 was associated with a change in volume or trend of subacromial decompression(SAD) surgery in patients with subacromial pain syndrome(SAPS) treated in hospitals across various countries. METHODS: Routinely collected administrative data of the Global Health Data@work collaborative were used to identify SAPS patients who underwent SAD surgery in six hospitals from five countries (Australia, Belgium, Netherlands, United Kingdom, United States) between 01/2016 and 02/2020. Following a controlled interrupted time series design, segmented Poisson regression was used to compare trends in monthly SAD surgeries before(01/2016-01/2018) and after(02/2018-02/2020) publication of the RCTs. The control group consisted of musculoskeletal patients undergoing other procedures. RESULTS: A total of 3.046 SAD surgeries were performed among SAPS patients treated in five hospitals; one hospital did not perform any SAD surgeries. Overall, publication of trial results was associated with a significant reduction in the trend to use SAD surgery of 2% per month (Incidence rate ratio (IRR) 0.984[0.971-0.998]; P = 0.021), but with large variation between hospitals. No changes in the control group were observed. However, publication of trial results was also associated with a 2% monthly increased trend (IRR 1.019[1.004-1.034]; P = 0.014) towards other procedures performed in SAPS patients. CONCLUSION: Publication of RCT results was associated with a significantly decreased trend in SAD surgery for SAPS patients, although large variation between participating hospitals existed and a possible shift in coding practices cannot be ruled out. This highlights the complexities of implementing recommendations to change routine clinical practice even if based on high-quality evidence.

A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.

BACKGROUND: The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. METHODS: In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. RESULTS: A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01). CONCLUSIONS: The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).

Variation in Prosthetic Joint Infection and treatment strategies during 4.5 years of follow-up after primary joint arthroplasty using administrative data of 41397 patients across Australian, European and United States hospitals.

BACKGROUND: To identify best practices and quality improvement initiatives, we aimed to assess whether the incidence of Periprosthetic Joint Infection (PJI) and treatment strategies differed across patients treated in Australian, European and United States (US) hospitals. METHODS: Routinely collected administrative data for 41397 patients undergoing a primary total hip or knee arthroplasty between July 2007-December 2010 across 22 hospitals were included. Patients were followed for 2 years looking for PJI occurrence, defined as early (within 4 weeks) and late PJI, and surgical treatment during 2.5 years after PJI diagnosis. Logistic and Poisson regression models were used to test for differences in PJI occurrence and treatment strategies across the three geographical regions, adjusted for age, sex, joint and Elixhauser comorbidity groups. RESULTS: PJI occurrence varied from 1.4% in European to 1.7% in Australian patients, which were significantly higher than US patients after adjustment for patient characteristics (OR 1.24 [1.01-1.52] and 1.40 [1.03-1.91] respectively). Early PJIs varied between 0.3% in European to 0.6% in Australian patients, but adjusted rates were similar. Revision following PJI was significantly lower in Australian than in US patients (OR 0.46 [0.25-0.86]) as were the total number of revisions (RR 0.51 [0.36-0.71]) and number of surgical procedures (RR 0.60 [0.44-0.81]) used to treat PJI. CONCLUSION: The overall PJI rate was significantly higher in Australian patients, but fewer procedures were needed to treat these PJIs. Future research should reveal whether this reflects PJIs caught earlier or less severe when diagnosed, and whether this is associated with the longer length of stay after primary arthroplasty in Australian hospitals.

HIP4Hips (High Intensity Physiotherapy for Hip fractures in the acute hospital setting): a randomised controlled trial.

OBJECTIVES: To investigate the effects of intensive acute hospital physiotherapy for patients with isolated hip fractures. DESIGN, SETTING: Single-institution, prospective, randomised trial at a level 1 trauma centre in Melbourne, March 2014 - January 2015. PARTICIPANTS: 92 patients aged 65 years or more with isolated hip fractures. Patients were excluded if the fracture was subtrochanteric or pathological, or if post-operative orders required the patient to be non-weight-bearing on the operated leg. INTERVENTIONS: Randomisation to usual care physiotherapy (daily; control group) or intensive physiotherapy (three times daily; intervention group). MAIN OUTCOME MEASURES: Outcomes were assessed at post-operative Day 5, at discharge, and at 6 months. The primary outcome was the modified Iowa Level of Assistance (mILOA) score, with other outcome measures including Timed Up and Go test performance and hospital length of stay (LOS). RESULTS: After controlling for sex, anaesthetic type and home setting, the between-group difference in Day 5 mILOA score favoured the intervention group (mean difference v control group, -2.7 points; P = 0.04). Hospital LOS was also shorter for the intervention group (median, 24.4 days v 35.0 days; P = 0.01). A Cox proportional hazard model that controlled for potential confounders indicated that the probability of discharge was greater for intervention group patients at all time points following surgery (P < 0.001). Re-admission and complication rates and 6-month outcomes for the two groups were not significantly different. CONCLUSIONS: Intensive acute hospital physiotherapy is safe and reduces hospital LOS after an isolated hip fracture. This has the potential to improve bed flow, given the large numbers of inpatient beds occupied by this patient population. TRIAL REGISTRATION: Clinical Trials Registry #NCT02088437.

Single- versus dual-rod anterior instrumentation of thoracolumbar curves in adolescent idiopathic scoliosis.

PURPOSE: Single or dual-rod instrumentation can be used for the anterior fixation of the spine in adolescent idiopathic scoliosis (AIS). We aim to compare the complications, radiographic and functional outcomes of patients with AIS who have undergone single and dual-rod instrumentation. METHODS: This is a multi-centre study involving the Royal Children's, Royal Melbourne and Epworth hospitals. Three primary surgeons were involved to ensure homogeneity of surgical technique and implants. Patients with AIS and thoracolumbar curves (Lenke 5 and 6) undergoing anterior instrumentation from 1st January 2000 to 30th June 2013 were included. Radiographic data were collected from X-rays. The functional outcome was measured through the Scoliosis Research Society questionnaire (SRS-30). RESULTS: The study included 58 patients (38 single-rod and 20 dual-rod patients). Thirty-nine patients were classified with Lenke 5 curves, while 19 patients had Lenke 6 curves. Structural interbody supports were used in 95 % of cases. In the preoperative to postoperative period, patients with single rods had an improvement of 75 and 51 % for primary and secondary curves, respectively, while patients with dual rods had an improvement of 70 and 38 % for primary and secondary curves, respectively. There were no cases of pseudoarthrosis or metalware failure in either group. Two patients (one single-rod and one dual-rod patient) required further unplanned posterior fusion. 91 % of patients were satisfied with the results of their back management. CONCLUSION: Pseudoarthrosis and metalware failure are rare complications of anterior instrumentation. Our study found no significant difference in functional or radiographic outcome between single and dual-rod instrumentation. LEVEL OF EVIDENCE: Level III.

What is the purpose of log roll examination in the unconscious adult trauma patient during trauma reception?

BACKGROUND: During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries. METHODS: A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) <9) and/or intubated major trauma (Injury Severity Scale (ISS) >12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed. RESULTS: There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8). CONCLUSIONS: Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine.

Could low grade bacterial infection contribute to low back pain? A systematic review.

BACKGROUND: Recently, there has been both immense interest and controversy regarding a randomised, controlled trial which showed antibiotics to be effective in the treatment of chronic low back pain (disc herniation with Modic Type 1 change). While this research has the potential to result in a paradigm shift in the treatment of low back pain, several questions remain unanswered. This systematic review aims to address these questions by examining the role of bacteria in low back pain and the relationship between bacteria and Modic change. METHODS: We conducted electronic searches of MEDLINE and EMBASE and included studies that examined the relationship between bacteria and back pain or Modic change. Studies were rated based on their methodological quality, a best-evidence synthesis was used to summarise the results, and Bradford Hill's criteria were used to assess the evidence for causation. RESULTS: Eleven studies were identified. The median (range) age and percentage of female participants was 44.7 (41-46.4) years and 41.5% (27-59%), respectively, and in 7 of the 11 studies participants were diagnosed with disc herniation. Nine studies examined the presence of bacteria in spinal disc material and all identified bacteria, with the pooled estimate of the proportion with positive samples being 34%. Propionibacterium acnes was the most prevalent bacteria, being present in 7 of the 9 studies, with median (minimum, maximum) 45.0% (0-86.0) of samples positive. The best evidence synthesis found moderate evidence for a relationship between the presence of bacteria and both low back pain with disc herniation and Modic Type 1 change with disc herniation. There was modest evidence for a cause-effect relationship. CONCLUSIONS: We found that bacteria were common in the spinal disc material of people undergoing spinal surgery. There was moderate evidence for a relationship between the presence of bacteria and both low back pain with disc herniation and Modic Type 1 change associated with disc herniation and modest evidence for causation. However, further work is needed to determine whether these organisms are a result of contamination or represent low grade infection of the spine which contributes to chronic low back pain.

An enhanced recovery after surgery program for hip and knee arthroplasty.

OBJECTIVE: To institute and evaluate the benefits of an enhanced recovery after surgery (ERAS) program across three hospitals in Victoria. DESIGN, SETTING AND PARTICIPANTS: We used a before-and-after quality improvement study design consisting of three phases: pre-ERAS program data collection from March to September 2012; ERAS training and implementation during September 2012; and change performance measurement following ERAS implementation from October 2012 to May 2013. MAIN OUTCOME MEASURES: The primary end point was duration of hospital stay after knee or hip arthroplasty. Secondary end points were adherence to the ERAS bundle, and process and patient recovery characteristics. RESULTS: We enrolled 412 patients to the pre-ERAS (existing-practice) phase and compared them with 297 patients in the ERAS phase. For ERAS patients, compared with existing-practice patients, hospital stay was reduced (geometric mean, 5.3 [SD, 1.6] v 4.9 [SD, 1.6] days; P < 0.001) and there was a significant improvement in the proportion of patients ready for discharge on Day 3 after surgery (41% v 59%; P < 0.001). The most common reason for delayed discharge was patients waiting for review or access to rehabilitation services. There were markedly improved indicators of processes and outcomes of care, including improved patient education, reduced fasting times, less blood loss, better analgesia, earlier ambulation and improved overall quality of recovery. CONCLUSION: We found that an ERAS program could be successfully implemented in elective joint arthroplasty, leading to a shorter duration of hospital stay. We recommend this orthopaedic ERAS pathway.

Weight change following knee and hip joint arthroplasty-a six-month prospective study of adults with osteoarthritis.

BACKGROUND: Inconsistent findings of weight change following total knee (TKA) and hip (THA) arthroplasty may largely be attributable to heterogeneous cohorts and varied definitions of weight loss. This study examined weight change following TKA and THA for osteoarthritis (OA). METHODS: 64 participants with hip or knee OA were recruited from orthopaedic joint arthroplasty waiting lists at a single major Australian public hospital between March and October 2011. The Short Form (SF) 12 survey was used to assess baseline physical and mental functioning. 49 participants completed 6 month follow-up (20 from the THA group and 29 from the TKA group). RESULTS: The majority of subjects lost weight (>0 kg) 6 months following THA (70 %) and TKA (58.6 %). When at least a 5 % reduction in total body weight was used to define clinically significant weight loss, the proportion of people with weight loss was 37.9 % for TKA and 25 % for THA. Greater weight loss occurred 6 months following TKA compared with THA (7.2 % versus 3.7 % of body weight; p = 0.04). Worse pre-operative physical functioning (SF-12) was associated with greater weight loss following TKA (ß = 0.22 kg, 95 % CI 0.02-0.42 kg; p = 0.04). CONCLUSION: Most people lost weight (>0 kg) 6 months following TKA and THA and a considerable proportion of people achieved ≥5 % loss of body weight. The magnitude of weight loss was greater following TKA than THA, with worse pre-operative function being a predictor of more weight loss. Further attention to weight management is required to assist a greater number of people to achieve a larger magnitude of weight loss following knee and hip joint arthroplasty.

Correlation between pedicle size and the rate of pedicle screw misplacement in the treatment of thoracic fractures: Can we predict how difficult the task will be?

STUDY DESIGN: A retrospective study. OBJECTIVE: To correlate the incidence of pedicle-screw (PS) misplacement with the dimensions of the pedicles in the treatment of thoracic spine fractures. SUMMARY OF BACKGROUND DATA: The technical challenge of internal fixation with PS in the thoracic spine has been well documented in the literature. However, there are no publications that document the correlation between the pedicle dimensions of the thoracic vertebrae in the preoperative computed tomography scans (CT) and the rate of PS misplacement. METHODS: All patients who had PSs inserted between the T1 and T12 vertebrae during a 24-month period were included in this study. PS position was assessed on high quality CT scans by two independent observers and classified in 2 categories: correct or misplaced. The transverse diameter, craniocaudal diameter and cross-sectional area of the pedicles from T1 to T12 were measured in the pre-operative CT. RESULTS: During the period of this study 36 patients underwent internal fixation with 218 PS. Of the 218 screws, 184 (84.5%) were correct and 34 (15.5%) were misplaced. Misplacement rate was 33% for pedicles with a transverse diameter less than 5 mm, 10.7% for those with a transverse diameter between 5 and 7 mm and 0% for those with a transverse diameter larger than 7 mm. There was a statistically significant difference in the rate of PS misplacement in pedicles with transverse diameter smaller than 5 mm compared with the others. Also, those with transverse diameter between 5.1 and 7 mm compared with those bigger than 7 mm in diameter. The rate of PS misplacement was higher between T3 and T9 (p < 0.05), which in turn correlated with pedicle transverse diameter. CONCLUSION: The rate of PS misplacement in the mid thoracic spine (T4-T9) is high and correlates with pedicle transverse diameter.

Sources and quality of literature addressing femoroacetabular impingement.

PURPOSE: In the last 5 years, there has been an increasing interest in the concepts, pathoanatomy, and management of femoroacetabular impingement (FAI). The aim of this study was to determine the trends in FAI literature with specific emphasis on the quality and source of publications in the literature. METHODS: A systematic review of two electronic databases (MEDLINE, EMBASE) was conducted to identify FAI-related publications from 2005 to 2010. Studies were included if they were published in peer-review journals and were written in English. Abstracted data included year of publication, study design, type of study, level of evidence, number of patients and hips, gender, weighted mean age of patients, and type of journal. RESULTS: There were 298 relevant studies. Between 2005 and 2010, there was an approximate fivefold increase in the number of FAI-related publications. Most of these studies came from the orthopaedic literature (197 articles or 66 %), while the remainder arose from other medical specialties. The majority of publications consisted of level 4 and 5 studies (248 articles). There were no level 1 studies identified. CONCLUSION: Between 2005 and 2010, there has been a dramatic increase in FAI-related publications, but high-quality studies are still lacking. LEVEL OF EVIDENCE: IV.

Can initial clinical assessment exclude thoracolumbar vertebral injury?

INTRODUCTION: The aim of this study was to test the hypothesis that all blunt trauma patients, presenting with a Glasgow coma scale (GCS) score of 15, without intoxication or neurological deficit, and no pain or tenderness on log-roll can have any thoracolumbar fracture excluded without imaging. MATERIALS AND METHODS: All patients diagnosed with a thoracolumbar fracture presenting to the emergency department of a major trauma centre and having an initial GCS score of 15 were included in the study. Variables collected included type of fracture, mechanism of injury, the presence of pain or tenderness on log-roll, ethanol levels and prehospital opioid analgesia. RESULTS: There were 536 patients with thoracolumbar fractures, of which 508 (94.8%) patients had either pain, tenderness or had received prehospital opioid analgesia. A small subgroup of 28 (5.2%) patients who received no prehospital opioid analgesia, did not complain of pain and had no tenderness to the thoracolumbar spine elicited on log-roll. This subgroup was significantly older (p=0.033) and a high proportion of patients (64.3%) had a concurrent fracture of the cervical spine. Within this subgroup, a clinically significant unstable thoracic fracture was present in three patients, with all three patients exhibiting symptoms and signs of neurological injury or having a concurrent cervical vertebral fracture. CONCLUSIONS: In this population of blunt trauma patients with a GCS score of 15, not under the influence of alcohol or prehospital morphine administration, the absence of pain or tenderness on log-roll can exclude a clinically significant lumbar vertebral fracture, but does not exclude a thoracic fracture.

Orthopaedic injuries due to electric scooter trauma presenting to a level 1 trauma centre before and after introduction of a scooter-sharing scheme.

Background: Epidemiological data from various jurisdictions has shown that electric scooters are associated with significant trauma. The Victorian state government introduced a trial scooter sharing scheme on February 1, 2022 in inner city Melbourne. This is a descriptive study from the largest trauma centre in Victoria, geographically at the heart of the government sharing scheme, investigating the "scope of the problem" before and after introduction of the ride sharing scheme. Methods: Retrospective case series. Insitutional orthopaedic department database was searched from 1 Jan 2021 to 30 June 2022 to identify all admissions, requiring orthopaedic management, associated with e-scooter trauma. Data collected included, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, injuries sustained, surgical procedures, discharge destination, and death. Results: In the 12 months prior to, and five months since introduction of the ride share scheme, 43 patients sustaining e-scooter related injuries were identified. Eighteen patients (42%) presented in the five months since ride sharing was introduced and 25 patients in the preceding 12 months. 58% of patients were found to be intoxicated. Fourteen percent required an ICU admission. Forty-four percent of patients were polytrauma admissions. The median length of stay was two days, longest individual hospital stay was 69 days. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. The mean Injury Severity Score was 17.28. Conclusion: Electric scooters are associated with a significant trauma burden. This data may be combined with other clinical services and could be used to inform policy makers.

Patient-Reported Outcomes following Total Knee Replacement in Patients Aged 65 Years and Over-A Systematic Review.

A previous systematic review showed positive patient-reported outcomes following total knee replacement (TKR) in patients aged < 65 years. However, the question remains as to whether these results are replicated for older individuals. This systematic review evaluated the patient-reported outcomes following TKR in individuals aged ≥ 65 years. A systematic search of Ovid MEDLINE, EMBASE, and Cochrane library were performed to identify studies examining disease-specific or health-related quality of life outcomes following TKR. Qualitative evidence synthesis was performed. Eighteen studies with low (n = 1), moderate (n = 6), or serious (n = 11) overall risk of bias were included, with evidence syntheses derived from 20,826 patients. Four studies reported on pain scales, showing improvement of pain from 6 months to 10 years postoperatively. Nine studies examined functional outcomes, showing significant improvements from 6 months to 10 years after TKR. Improvement in health-related quality of life was evident in six studies over 6 months to 2 years. All four studies examining satisfaction reported overall satisfaction with TKR results. TKR results in reduced pain, improved function, and increased quality of life for individuals aged ≥ 65 years. The improvement in patient-reported outcomes needs to be utilised in conjunction with physician expertise to determine what would comprise clinically significant differences.

Risk Stratification of Elderly Patients Undergoing Spinal Surgery Using the Modified Frailty Index.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To validate the 11-item modified Frailty Index (mFI) as a perioperative risk stratification tool in elderly patients undergoing spine surgery. METHODS: All consecutive cases of spine surgery in patients aged 65 years or older between July 2016 and June 2018 at a state-wide trauma center were retrospectively reviewed. The primary outcome was post-operative major complication rate (Clavien-Dindo Classification ≥ III). Secondary outcome measures included the rate of all complications, 6-month mortality and surgical site infection. RESULTS: A total of 348 cases were identified. The major complication rate was significantly lower in patients with an mFI of 0 compared to ≥ 0.45 (18.3% versus 42.5%, P = .049). As the mFI increased from 0 to ≥ 0.45 there was a stepwise increase in risk of major complications (P < .001). Additionally, 6-month mortality rate was considerably lower when the mFI was 0 rather than ≥ 0.27 (4.2% versus 20.4%, P = .007). Multivariate analysis demonstrated an mFI ≥ 0.27 was significantly associated with an increased incidence of major complication (OR 2.80, 95% CI 1.46-5.35, P = .002), all complication (OR 2.93, 95% CI 1.70-15.11, P < .001), 6-month mortality (OR 7.39, 95% CI 2.55-21.43, P < .001) and surgical site infection (OR 4.43, 95% CI 1.71-11.51, P = .002). The American Society of Anesthesiologists' (ASA) index did not share a stepwise relationship with any outcome. CONCLUSION: The mFI is significantly associated in a gradated fashion with increased morbidity and mortality. Patients with an mFI ≥ 0.27 are at greater risk of major complications, all-complications, 6-monthy mortality, and surgical site infection.

Outcomes after application of halothoracic orthosis for cervical spine trauma.

BACKGROUND: Cervical spine fractures can be managed operatively or nonoperatively, considering injury type and patient factors. Nonoperative management may include application of a halothoracic orthosis (HTO). The aim of our study was to describe our patients managed with HTO, review their 6-month and 12-month outcomes, and identify associated factors. METHODS: Patients fitted with an HTO at our institution in 2014 were included. Data collected included patient demographics, hospital-related data, and radiological union. Injury detail and 6-month and 12-month patient-reported outcomes (Glasgow Outcomes Scale Extended and return to work [RTW]) were accessed through Victorian Orthopedic Trauma Outcomes Registry. Factors related to these outcomes were included in a mixed-effect regression model for each outcome. RESULTS: Eighty-six patients (median age 46.5 years) of whom 52 (60%) were male individuals were included. Two-thirds (57 patients) were road trauma patients, and 58 patients (67%) experienced an isolated injury. Thirty-seven patients (43%) experienced a C2 fracture and 27 (31%) experienced a facet fracture. Twelve-month follow-up was completed for 78 patients (91%) with 27 (35%) reporting a good recovery, and 65% (31/48) patients returned to work. Factors associated with lower odds of RTW included compensation, a facet joint fracture, and experiencing comorbidities. No factors were significantly associated with functional outcome, although female individuals exhibited a slower recovery trajectory than male individuals. CONCLUSION: Many patients reported poor 12-month outcomes after HTO for traumatic injury. Factors associated with worse outcomes should be considered when deciding on management of patients with cervical spine fractures.

Implant Removal Versus Implant Retention Following Posterior Surgical Stabilization of Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: To compare biomechanical and functional outcomes between implant removal and implant retention following posterior surgical fixation of thoracolumbar burst fractures. METHODS: A search of the MEDLINE, EMBASE, Google Scholar and Cochrane Databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Of the 751 articles initially retrieved, 13 published articles pooling 673 patients were included. Meta-analysis revealed there was a statistically significant improvement in sagittal Cobb Angle by 16.48 degrees (9.13-23.83, p < 0.01) after surgical stabilization of thoracolumbar burst fractures. This correction decremented to 9.68 degrees (2.02-17.35, p < 0.01) but remained significant at the time of implant removal approximately 12 months later. At final follow-up, the implant removal group demonstrated a 10.13 degree loss (3.00-23.26, p = 0.13) of reduction, while the implant retention group experienced a 10.17 degree loss (1.79-22.12, p = 0.10). There was no statistically significant difference in correction loss between implant retention and removal cohorts (p = 0.97). Pooled VAS scores improved by a mean of 3.32 points (0.18 to 6.45, p = 0.04) in the combined removal group, but by only 2.50 points (-1.81 to 6.81, p = 0.26) in the retention group. Oswestry Disability Index scores also improved after implant removal by 7.80 points (2.95-12.64, p < 0.01) at 1 year and 11.10 points (5.24-16.96, p < 0.01) at final follow-up. CONCLUSIONS: In younger patients with thoracolumbar burst fractures who undergo posterior surgical stabilization, planned implant removal results in superior functional outcomes without significant difference in kyphotic angle correction loss compared to implant retention.

Posterior Instrumented Spinal Surgery Outcomes in the Elderly: A Comparison of the 5-Item and 11-Item Modified Frailty Indices.

STUDY DESIGN: Retrospective Cohort. OBJECTIVES: To validate the most concise risk stratification system to date, the 5-item modified frailty index (mFI-5), and compare its effectiveness with the established 11-item modified frailty index (mFI-11) in the elderly population undergoing posterior instrumented spine surgery. METHODS: A single centre retrospective review of posterior instrumented spine surgeries in patients aged 65 years and older was conducted. The primary outcome was rate of post-operative major complications (Clavien-Dindo Classification ≥ 4). Secondary outcome measures included rate of all complications, 6-month mortality and surgical site infection. Multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated and compared by DeLong's test. The indices were correlated with Spearman's rho. RESULTS: 272 cases were identified. The risk of major complications was independently associated with both the mFI-5 (OR 1.89, 95% CI 1.01-3.55, P = .047) and mFI-11 (OR 3.73, 95% CI 1.90-7.30, P = .000). Both the mFI-5 and mFI-11 were statistically significant predictors of risk of all complications (P = .007 and P = .003), surgical site infection (P = .011 and P = .003) and 6-month mortality (P = .031 and P = .000). Adjusted ROC curves determined statistically similar c-statistics for major complications (.68 vs .68, P = .64), all complications (.66 vs .64, P = .10), surgical site infection (.75 vs .75, P = .76) and 6-month mortality (.83 vs .81, P = .21). The 2 indices correlated very well with a Spearman's rho of .944. CONCLUSIONS: The mFI-5 and mFI-11 are equally effective predictors of postoperative morbidity and mortality in this population. The brevity of the mFI-5 is advantageous in facilitating its daily clinical use.