Are 2 Radiographic Views As Good as 3 Views to Diagnose Ankle Fractures in Children and Adolescents?

OBJECTIVES: Ankle radiographs are among the most commonly obtained trauma images in the pediatric population, with the standard 3 views (AP/mortise [M]/lateral [L]) routinely ordered in the emergency department. The purpose of this study was to compare the diagnostic accuracy, sensitivity, and specificity of sets of 2 views (AP/L or M/L) with the standard 3 views. METHODS: One hundred twenty sets of ankle radiographs of skeletally immature patients obtained in the emergency department of a level 1 pediatric trauma center were used. These included sets with and without fractures. Sets of 3 and 2 views were reviewed by pairs of pediatric-trained orthopedic surgeons, radiologists, and emergency physicians. Each completed 3 randomized viewing sessions where all possible combinations for each set of radiographs were reviewed. Diagnoses for the 3 sets of views were compared for accuracy, sensitivity, and specificity. RESULTS: Overall accuracy, sensitivity, and specificity for all reviewers were as follows: AP/M/L 74%, 94%, and 90%, AP/L 71%, 90%, and 94%, as well as M/L 69%, 90%, and 91%. P values for accuracy, sensitivity, and specificity of AP/L and M/L compared with 3 views were 0.34, 0.04, and 0.52, as well as 0.04, 0.004, and 1.00, respectively. CONCLUSIONS: In skeletally immature patients, statistically significant differences in accuracy were obtained when comparing the standard 3 AP/M/L views with more limited M/L views, suggesting that this set of 2 views is not as accurate. Differences in sensitivity of limited views were also statistically significant. Conversely, differences in accuracy between the standard 3 views and AP/Lateral views were not statistically significant. While more limited AP/L views may be comparable in accuracy and specificity and lead to dramatically decreased radiation and costs, this can be at the expense of less diagnostic sensitivity and increased risk of misdiagnosing or missing certain fractures. LEVEL OF EVIDENCE: Level III.

Open versus arthroscopic Latarjet procedures for the treatment of shoulder instability: a systematic review of comparative studies.

BACKGROUND: The arthroscopic and open Latarjet procedures are both known to successfully treat shoulder instability with high success rates. The objective of this study was to compare the clinical outcomes and positioning of the coracoid graft and screws between the arthroscopic and open Latarjet procedures. METHODS: The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies between database creation and 2018. Only studies directly comparing open and arthroscopic Latarjet procedures were included. RESULTS: There were 8 included studies, with a total of 580 patients treated arthroscopically and 362 patients treated with an open Latarjet procedure. Several papers found significantly better standardized outcome scores for either the open or arthroscopic procedure but these findings were not consistent across papers. Patients treated with arthroscopic Latarjet procedures had significantly lower initial post-operative pain, however pain scores became equivalent by one month post-operatively. Three of the five included studies found no significant difference in the coracoid graft positioning and two of three included studies found no significant difference in screw divergence angles between the two techniques. Arthroscopic procedures (112.2 min) appear to take, on average, longer than open procedures (93.3 min). However, operative times and complication rates decrease with surgeon experience with the arthroscopic procedure. Overall 3.8% of the patients treated arthroscopically and 6.4% of the patients treated with the open procedure went on to have post-operative complications. CONCLUSIONS: Both open and arthroscopic Latarjet procedures can be used to effectively treat shoulder instability with similarly low rates of complications, recurrent instability and need for revision surgery. Arthroscopic Latarjet procedures are associated with less early post-operative pain but require increased operative time. The evidence does not support there being any significant difference in graft or screw positioning between the two techniques. At this time neither procedure shows clear superiority over the other.

Diagnostic Accuracy of Neuromonitoring for Identification of New Neurologic Deficits in Pediatric Spinal Fusion Surgery.

BACKGROUND: Intraoperative neuromonitoring (IONM) modalities, transcranial motor-evoked potentials (TcMEPs), and somatosensory-evoked potentials (SSEPs) are accepted methods to identify impending spinal cord injury during spinal fusion surgery. Debate exists over sensitivity and specificity of these modalities. Our purpose was to measure the incidence of new neurologic deficits (NNDs) and estimate sensitivity and specificity of IONM modalities. METHODS: Institutional Ethics Board approval was obtained to review charts of patients younger than 22 years undergoing scoliosis surgery from 2007 to 2014 retrospectively. The definition of true-positive patients included two subgroups: (1) patients with an IONM alert, which did not resolve despite the interventions and had a NND postoperatively; or (2) patients with an IONM alert triggering interventions and the alert resolved with no NND postoperatively. Subgroup 2 of the definition is debatable; thus, we performed a multiple sensitivity analysis with three assumptions. Assumption 1: without interventions, all such patients would have experienced NNDs (assumption used in previous studies); Assumption 2: without intervention, half of these patients would have experienced NNDs; Assumption 3: without intervention, none of these of patients would have experienced NNDs. RESULTS: We included 296 patients. Patients with incomplete charts (n = 3), no IONM monitoring (n = 11), and inadequate baseline IONM (n = 7) were excluded. The incidence of NND was 3.7% (95% confidence interval, 2.1%-6.5%). Successful IONM in at least one modality was obtained in 275 patients (92.9%), of whom 268 (97.5%) and 259 (94.2%) had successful baseline TcMEP or SSEP signals, respectively. Fifty-one (17%) patients had IONM alerts, 41 were only TcMEP, 5 were only SSEP, and 5 were in both modalities. After interventions, 42 (82%) patients recovered, 41 had no NND (true-positive under Assumption (1), but one developed a NND (false-negative). Of the 9 patients with no alert recovery, 6 had a NND (true-positive) and 3 did not (false-positives). Of the remaining 224 patients with no alerts, 221 had no NND (true-negatives) and 3 did (false-negatives). Sensitivity was estimated to be 93.5%, 92.2%, and 46.7% for TcMEPs, combination (either TcMEPs or SSEPs), and SSEPs, respectively. Multiple sensitivity analysis demonstrated that sensitivity and specificity vary markedly with different assumptions. CONCLUSION: TcMEPs are more sensitive than SSEP at detecting an impending NND. IONM modalities are highly specific. Both sensitivity and specificity are impacted substantially by assumptions of the impact of interventions on alerts and NND. Properly designed, controlled, multicenter studies are required to establish diagnostic accuracy of IONM in scoliosis surgery.

Traumatic spinal injuries in children at a single level 1 pediatric trauma centre: report of a 23-year experience.

BACKGROUND: With a reported incidence of up to 10% compared to all spinal trauma, spinal injuries in children are less common than in adults. Children can have spine fractures with or without myelopathy, or spinal cord injuries without radiological abnormalities (SCIWORA). METHODS: We retrospectively reviewed the cases of children with spinal injuries treated at a level 1 pediatric trauma centre between 1990 and 2013. RESULTS: A total of 275 children were treated during the study period. The mean age at admission was 12 ± 4.5 years, and the male:female ratio was 1.4:1. Spinal injuries were more common in children of ages 12-16 years, with most injuries among ages 15-16 years. The top 3 mechanisms of spinal injury were motor vehicle-related trauma (53%), sports (28%) and falls (13%). Myelopathy occurred in 12% and SCIWORA occurred in 6%. The most common spine levels injured were L2-sacrum, followed by O-C2. Associated injuries, including head injuries (29%), and fractures/dislocations (27%) occurred in 55% of children. Overall mortality was 3%. Surgical intervention was required in 14%. CONCLUSION: The creation of a pediatric spinal injury database using this 23-year retrospective review helped identify important clinical concepts; we found that active adolescent boys had the highest risk of spine injury, that noncontiguous spine injuries occured at a rate higher than reported previously and that nonaccidental spine injuries in children are underreported. Our findings also emphasize the importance of maintaining a higher index of suspicion with trauma patients with multiple injuries and of conducting detailed clinical and radiographic examinations of the entire spine in children with a known spinal injury.

CONTEXTE: Les traumatismes médullaires sont moins fréquents chez l'enfant que chez l'adulte, avec une incidence d'au plus 10 % de tous les cas déclarés. Les enfants peuvent subir des fractures de la colonne vertébrale avec ou sans myélopathie, ou un traumatisme médullaire sans anomalie radiologique visible (SCIWORA). MÉTHODES: Nous avons effectué une analyse rétrospective des cas d'enfants atteints d'un traumatisme médullaire admis dans un centre de traumatologie spécialisé en pédiatrie de niveau 1 entre 1990 et 2013. RÉSULTATS: Au total, 275 enfants ont été traités durant la période de l'étude. L'âge moyen au moment de l'hospitalisation était de 12 ± 4,5 ans, et le ratio garçons:filles était de 1,4:1. Les adolescents de 12 à 16 ans formaient le groupe le plus représenté, et l'incidence de traumatisme la plus élevée a été observée chez les jeunes de 15 et 16 ans. Les 3 mécanismes lésionnels les plus fréquents étaient les accidents de la route (53 %), la pratique d'un sport (28 %) et les chutes (13 %). Le taux d'incidence de la myélopathie était de 12 %, et celui du SCIWORA, de 6 %. La section du rachis touchée le plus fréquemment s'étendait de L2 au sacrum, les vertèbres entre l'occiput et C2 arrivant au deuxième rang. Des lésions concomitantes, dont des blessures à la tête (29 %) et des fractures et luxations (27 %), ont été observées chez 55 % des enfants. Le taux global de mortalité était de 3 %. L'intervention chirurgicale a été nécessaire chez 14%. CONCLUSION: La création à partir de cette étude rétrospective d'une base de données sur les traumatismes médullaires chez l'enfant a mis en évidence quelques constatations cliniques dignes d'intérêt : les garçons adolescents actifs présentent le risque le plus élevé de traumatisme médullaire; les lésions médullaires non contiguës surviennent plus fréquemment que ce qui avait été rapporté précédemment; les traumatismes médullaires non accidentels chez l'enfant sont sous-déclarés. Nos conclusions viennent aussi souligner l'importance de maintenir un indice de suspicion élevé dans le cas de patients atteints de lésions multiples et d'effectuer un examen clinique et radiographique détaillé de la totalité de la colonne vertébrale des enfants ayant une lésion médullaire connue.

The Otto Aufranc Award. On the etiology of the cam deformity: a cross-sectional pediatric MRI study.

BACKGROUND: Femoroacetabular impingement (FAI) has been recognized as a common cause of hip pain as well as a cause of hip arthritis, yet despite this, little is known about the etiology of the cam morphology or possible risk factors associated with its development. QUESTIONS/PURPOSES: The purposes of our study were to determine when the cam morphology associated with FAI developed in a cross-sectional cohort study of pediatric patients pre- and postphyseal closure using MRI and whether increased activity level during the period of physeal closure is associated with an increased likelihood that the cam deformity will develop. METHODS: Alpha angles were measured at the 3 o'clock (anterior head-neck junction) and 1:30 (anterosuperior head-neck junction) positions in both hips with a cam deformity defined as an alpha angle ≥ 50.5° at the 3 o'clock position. Forty-four volunteers (88 hips) were studied: 23 with open physes (12 females, mean age 9.7 years; 11 males, age 11.7 years) and 21 with closed physes (five females, age 15.2 years; 16 males, age 16.2 years). Daily activity level using the validated Habitual Activity Estimation Scale was compared for patients in whom cam morphology did and did not develop. RESULTS: None of the 23 (0%) patients prephyseal closure had cam morphology, whereas three of 21 (14%, p = 0.02; all males) postclosure had at least one hip with cam morphology. Daily activity level was higher (p = 0.02) for patients with the cam morphology (7.1 hours versus 2.9 hours). Mean alpha angles at the 3 o'clock head-neck position were 38° (95% confidence interval [CI], 37.2°-39.1°) in the open physes group and 42° (95% CI, 40.16°-43.90°) in the closed physes group; at the 1:30 head-neck position, they were 45° (95% CI, 44.0°-46.4°) in the open physes group and 50° (47.9°-52.3°) in the closed physes group. CONCLUSIONS: The fact that cam morphology was present exclusively in the closed physeal group strongly supports its development during the period of physeal closure with increased activity level as a possible risk factor.

Time from injury to hip-fracture surgery in low-income and middle-income regions: a secondary analysis of data from the International Orthopaedic Multicentre Study in Fracture Care (INORMUS).

BACKGROUND: Globally, fall-related injuries are a substantial problem, and 80% of fatal falls occur in low-income and middle-income countries. We aimed to measure time from injury to hip-fracture surgery in people aged 50 years or older living in low-income and middle-income regions, as well as to measure the proportion of patients with surgical stabilisation of their hip fracture within 72 h of admission to hospital and to identify risk factors associated with surgical delay. METHODS: For this secondary analysis, we analysed data collected from Africa, Latin America, China, India, and Asia (excluding China and India) for the International Orthopaedic Multicentre Study in Fracture Care (INORMUS) between March 29, 2014, and June 15, 2022. Patients from INORMUS were included in this analysis if they were aged 50 years or older and had an isolated, primary hip fracture sustained from a ground-level fall. Staff at participating hospitals identified patients with musculoskeletal injury and referred them for assessment of eligibility. We report time from injury to surgery as three distinct time periods: time from injury to hospital admission, time from admission to surgery, and a total time from injury to surgery. Date and time of injury were self-reported by patients at the time of study recruitment. If time to hospital admission after injury exceeded 24 h, patients reported the primary reason for delayed admission. Reasons for surgery, no surgery, and surgical delay were reported by the treating team. For patients undergoing surgery, multivariable regression analyses were used to identify risk factors for surgical delay. FINDINGS: 4486 adults aged 50 years or older with an isolated, primary hip fracture were enrolled in INORMUS from 55 hospitals in 24 countries. Countries were grouped into five regions: Africa (418 [9·3%] of 4486), Latin America (558 [12·4%]), China (1680 [37·4%]), India (1059 [23·6%]) and Asia (excluding China and India; 771 [17·2%]). Of 4486 patients, 3805 (84·8%) received surgery. The rate of surgery was similar in all regions except in Africa, where only 193 (46·3%) of 418 patients had surgery. Overall, 2791 (62·2%) of 4486 patients were admitted to hospital within 24 h of injury. However, 1019 (22·7%) of 4486 patients had delayed hospital admission of 72 h or more from injury. The two most common reasons for delayed admission of more than 24 h were transfer from another hospital (522 [36·2%] of 1441) and delayed care-seeking because patients thought the injury would heal on its own (480 [33·3%]). Once admitted to hospital, 1451 (38·1%) of 3805 patients who received surgery did so within 72 h (median 4·0 days [IQR 1·7-6·0]). Regional variation was seen in the proportion of patients receiving surgery within 72 h of hospital admission (92 [17·9%] of 514 in Latin America, 53 [27·5%] of 193 in Africa, 454 [30·9%] of 1471 in China, 318 [44·4%] of 716 in Asia [excluding China and India], and 534 [58·6%] of 911 in India). Of all 3805 patients who received operative treatment, 2353 (61·8%) waited 72 h or more from hospital admission. From time of injury, the proportion of patients who were surgically stabilised within 72 h was 889 (23·4%) of 3805 (50 [9·7%] of 517 in Latin America, 31 [16·1%] of 193 in Africa, 277 [18·8%] of 1471 in China, 189 [26·4%] of 716 in Asia [excluding China and India], and 342 [37·5%] of 911 in India). INTERPRETATION: Access to surgery within 72 h of hospital admission was poor, with factors that affected time to surgery varying by region. Data are necessary to understand existing pathways of hip-fracture care to inform the local development of quality-improvement initiatives. FUNDING: The National Health and Medical Research Council of Australia, the Canadian Institutes of Health Research, McMaster Surgical Associates, Hamilton Health Sciences, and the US National Institutes of Health.

Design of Beta-2 Microglobulin Adsorbent Protein Nanoparticles.

Beta-2 microglobulin (B2M) is an immune system protein that is found on the surface of all nucleated human cells. B2M is naturally shed from cell surfaces into the plasma, followed by renal excretion. In patients with impaired renal function, B2M will accumulate in organs and tissues leading to significantly reduced life expectancy and quality of life. While current hemodialysis methods have been successful in managing electrolyte as well as small and large molecule disturbances arising in chronic renal failure, they have shown only modest success in managing plasma levels of B2M and similar sized proteins, while sparing important proteins such as albumin. We describe a systematic protein design effort aimed at adding the ability to selectively remove specific, undesired waste proteins such as B2M from the plasma of chronic renal failure patients. A novel nanoparticle built using a tetrahedral protein assembly as a scaffold that presents 12 copies of a B2M-binding nanobody is described. The designed nanoparticle binds specifically to B2M through protein-protein interactions with nanomolar binding affinity (~4.2 nM). Notably, binding to the nanoparticle increases the effective size of B2M by over 50-fold, offering a potential selective avenue for separation based on size. We present data to support the potential utility of such a nanoparticle for removing B2M from plasma by either size-based filtration or by polyvalent binding to a stationary matrix under blood flow conditions. Such applications could address current shortcomings in the management of problematic mid-sized proteins in chronic renal failure patients.

Surgical residency training and international volunteerism: a national survey of residents from 2 surgical specialties.

BACKGROUND: Many low- and middle-income countries (LMICs) lack basic surgical resources, resulting in avoidable disability and mortality. Recently, residents in surgical training programs have shown increasing interest in overseas elective experiences to assist surgical programs in LMICs. The purpose of this study was to survey Canadian surgical residents about their interest in international volunteerism. METHODS: We sent a web-based survey to all general and orthopedic surgery residents enrolled in surgical training programs in Canada. The survey assessed residents' interests, attitudes and motivations, and perceived barriers and aids with respect to international volunteerism. RESULTS: In all, 361 residents completed the survey for a response rate of 38.0%. Half of the respondents indicated that the availability of an international surgery elective would have positively influenced their selection of a residency program. Excluding the 18 residents who had volunteered during residency, 63.8% of the remaining residents confirmed an interest in international volunteering with "contributing to an important cause," "teaching" and "tourism/cultural enhancement" as the leading reasons for their interest. Perceived barriers included "lack of financial support" and "lack of available organized opportunities." All (100%) respondents who had done an international elective during residency confirmed that they would pursue such work in the future. CONCLUSION: Administrators of Canadian surgical programs should be aware of strong resident interest in global health care and accordingly develop opportunities by encouraging faculty mentorships and resources for global health teaching.

Western Australian Peritonectomy Service: a review of the first 6 years of operation of a low-volume peritonectomy centre.

BACKGROUND: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal early chemotherapy has gained acceptance as the standard of care for peritoneal surface malignancy over the past decade. This study reports the results of the first 6 years of activity of the Western Australian Peritonectomy Service to compare outcomes of a low-volume centre with world standards. METHODS: An audit of all patients who received CRS ± hyperthermic intraperitoneal early chemotherapy treatment at the Western Australian Peritonectomy Service in its first 6 years of operation was performed and results were compared to the recent world literature. RESULTS: A total of 130 patients were treated with 150 CRS procedures, including 50 pseudomyxoma peritonei (PMP), 53 colorectal cancers (CRCs), 27 appendix adenocarcinomas (AAs) and 20 other cancers. The median operating time was 12 h with median length of hospital stay of 15 days. Perioperative mortality was 0.67% and Clavien-Dindo III/IV morbidity was 20%. The mean packed red cell transfusion requirement was 0.34 units/case. Post-discharge readmission rate was 25% and the return to theatre rate was 13%. The 4-year overall survival rates for PMP, CRC and AA were 97%, 49% and 81%, respectively. The 3-year disease-free survival rates for PMP, CRC and AA were 74%, 26% and 36%, respectively. CONCLUSION: A CRS centre averaging 25 cases per year can achieve strong outcomes in line with high-volume world centres.

Is it feasible to implement a rapid recovery pathway for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion in a single-payer universal health care system?

PURPOSE: The purpose of this project was to determine if it is feasible to implement a rapid recovery pathway (RRP) for the surgical treatment of adolescent idiopathic scoliosis (AIS) within a single-payer universal healthcare system while simultaneously decreasing length of stay (LOS) without increasing post-operative complications. METHODS: A retrospective analysis was completed for all patients who underwent posterior spinal fusion for AIS at a tertiary children's hospital in Canada between March 2010 and February 2019, with date of implementation of the RRP being March 1st, 2015. Patient demographic information was collected along with a variety of outcome variables including: LOS, wound complication, infection, 30-day return to the OR, 30-day emergency department visit, and 30-day hospital readmission. An interrupted time series analysis was utilized to determine if any benefits were associated with the implementation of the RRP. RESULTS: A total of 244 patients were identified, with 113 patients in the conventional pathway and 131 in the RRP. No significant differences in demographic features or post-operative complications were found between the two cohorts (p > 0.05). Using a robust linear time series model, LOS was found to be significantly shorter in the RRP group, with the average LOS being 5.2 [95% IQR 4.3-6.1] days in the conventional group and 3.4 [95% IQR 3.3-3.5] days in the RRP group (p < 0.05). CONCLUSION: This study shows that it is possible to implement a RRP for the surgical treatment of AIS within a single-payer universal healthcare system. Use of the pathway can effectively reduce hospital LOS without increasing the risk of developing a post-operative complication. This has the upside potential to reduce healthcare and family costs. LEVEL OF EVIDENCE: Therapeutic III.

International Orthopaedic Multicenter Study in Fracture Care: Coordinating a Large-Scale Multicenter Global Prospective Cohort Study.

Traditionally, the orthopaedic trauma literature has been dominated by small studies that were largely single-center initiatives. More recently, there has been a paradigm shift toward larger, multicenter studies because the orthopaedic community embraced the concepts of evidence-based medicine and the need for high-quality research to guide clinical practice. The International Orthopaedic Multicenter Study in Fracture Care is a large multicenter international cohort study in musculoskeletal trauma in Africa, Asia, and Latin America. This is the first study of this magnitude within the global orthopaedic trauma community. The International Orthopaedic Multicenter Study in Fracture Care study has provided an opportunity to form new international collaborative relationships and to develop new research capacity and global collaborative relationships that will provide the foundation for future studies in injury prevention and management. LEVELS OF EVIDENCE: IV.

What Is the State of the Evidence in Anterolateral Ligament Research?

The anterolateral ligament (ALL) is a capsular structure of the knee that is the subject of increasing academic interest. This article reviewed recent ALL literature in terms of subject matter and quality. Although current literature focusing on the ALL is small and limited to level 4 and 5 evidence, it is rapidly expanding. Cadaveric studies describing ALL biomechanics are the most common study design, followed by radiographic studies. The methodologic quality of cadaveric studies focusing on the ALL is high. Clinically oriented research pertaining to the diagnosis, therapy, prevalence, or prognosis of injury to the ALL is presently lacking.

Homocysteine and abdominal aortic aneurysms.

There is evidence to suggest that increased levels of homocysteine play a significant role in vascular disease. It has been suggested that lowering homocysteine levels by dietary folate supplementation may reduce the risk of stroke and coronary heart disease. It is plausible that homocysteine may also play a role in the pathogenesis of abdominal aortic aneurysms (AAA) and that patients with this disease may benefit from folate supplementation. Our objective was to review the published work with regard to the role of homocysteine in the pathogenesis of AAA. Searches were carried out in published work in English with the keywords 'abdominal aortic aneurysm' and 'homocysteine'. There is evidence from in vitro and animal model studies that activation of metalloproteinases by homocysteine can influence aortic wall structure. Several case-control studies report an association between increased levels of homocysteine and the presence of an AAA. There are conflicting genotypic data concerning the association between methylenetetrahydrofolate reductase gene variants and AAA. Although there is evidence for an association between homocysteine and AAA, it is not strong enough to conclude that it plays a causal role in the pathogenesis of AAA. Further research is needed, given the potential benefit that simple vitamin supplementation may have for patients with AAA.

The 'trampoline ankle': severe medial malleolar physeal injuries in children and adolescents secondary to multioccupant use of trampolines.

The purpose of this study was to describe a series of patients presenting with medial malleolus Salter-Harris types III and IV fractures (MacFarland fractures) related to trampoline use. In total, 11 patients were reviewed retrospectively (mean age: 11.8 years; four boys and seven girls). Salter-Harris type III fractures were more commonly seen (n=7). Undisplaced fractures were more prevalent (n=6). Six children underwent surgical treatment. Average follow-up time was 17.8 months. A medial physeal bar with subsequent growth arrest and ankle deformity was observed in two patients. More than one user was present on the trampoline at the time of the injury in nine of the reported cases. Medial malleolus growth-plate injuries can be seen after trampoline injuries where multiple users were involved. Potential complications including growth arrest can occur.

Development of a Competence-Based Spine Surgery Fellowship Curriculum Set of Learning Objectives in Canada.

STUDY DESIGN: Modified-Delphi expert consensus method. OBJECTIVE: The aim of this study was to develop competence-based spine fellowship curricula as a set of learning goals through expert consensus methodology in order to provide an educational tool for surgical educators and trainees. Secondarily, we aimed to determine potential differences among specialties in their rating of learning objectives to defined curriculum documents. SUMMARY OF BACKGROUND DATA: There has been recent interest in competence-based education in the training of future surgeons. Current spine fellowships often work on a preceptor-based model, and recent studies have demonstrated that graduating spine fellows may not necessarily be exposed to key cognitive and procedural competencies throughout their training that are expected of a practicing spine surgeon. METHODS: A consensus group of 32 spine surgeons from across Canada was assembled. A modified-Delphi approach refined an initial fellowship-level curriculum set of learning objectives (108 cognitive and 84 procedural competencies obtained from open sources). A consensus threshold of 70% was chosen with up to 5 rounds of blinded voting performed. Members were asked to ratify objectives into either a general comprehensive or focused/advanced curriculum. RESULTS: Twenty-eight of 32 consultants (88%) responded and participated in voting rounds. Seventy-eight (72%) cognitive and 63 (75%) procedural competency objectives reached 70% consensus in the first round. This increased to 82 cognitive and 73 procedural objectives by round 4. The final curriculum document evolved to include a general comprehensive curriculum (91 cognitive and 53 procedural objectives), a focused/advanced curriculum (22 procedural objectives), and a pediatrics curriculum (22 cognitive and 9 procedural objectives). CONCLUSION: Through a consensus-building approach, the study authors have developed a competence-based curriculum set of learning objectives anticipated to be of educational value to spine surgery fellowship educators and trainees. To our knowledge, this is one of the first nationally based efforts of its kind that is also anticipated to be of interest by international colleagues.

Arterial embolization hyperthermia: hepatic iron particle distribution and its potential determination by magnetic resonance imaging.

Arterial embolization hyperthermia (AEH) consists of arterially embolizing liver tumours with ferromagnetic particles that generate hysteretic heating on exposure to an alternating magnetic field. A critical component of AEH is the concentration and distribution of ferromagnetic particles in the normal hepatic parenchyma (NHP), as well as in the tumour tissue. If the distribution of particles in NHP is heterogeneous, with areas of high concentration, then unwanted areas of necrosis may result during AEH. Using an in vivo rabbit liver tumour model, this study showed that hepatic arterial infusion of ferromagnetic particles does indeed result in a heterogeneous distribution of iron in NHP. The radiological technique of magnetic resonance imaging (MRI) was then evaluated as a potential tool for non-invasively and prospectively determining the concentration and distribution of particles within the hepatic tumour and NHP following hepatic arterial infusion. A preliminary in vitro experiment showed that although the concentration of iron within the tumour tissue (1.92-3.50 mg of iron per gram of tissue) was too great to measure, MRI was able to accurately determine the lower iron concentration (0.10-0.53 mg of iron per gram of tissue) in NHP. Further work is needed to evaluate MRI under in vivo conditions. If successful, MRI could become an important component of an emerging novel treatment for advanced hepatic malignancies.

Resecting large numbers of hepatic colorectal metastases.

BACKGROUND: Despite the widespread use of surgical resection as a treatment for hepatic colorectal metastases, the value of resecting more than three metastases remains controversial. It was the objective of this study to determine if resection of larger numbers of metastases affects patient survival. METHOD: The survival of 123 consecutive patients who underwent curative hepatic resection for colorectal metastases between 1989 and 1999 by a single surgeon was analysed retrospectively. Kaplan-Meier survival statistics and Cox regression were used to determine the factors that affected survival, and logistic regression was used to determine the factors that affected the risk of recurrence of hepatic disease. RESULTS: The median survival rate for the whole group of patients was 38 months, with 1, 3 and 5 year survival rates of 88%, 53% and 31% respectively. The survival rate of patients undergoing resection of four to seven metastases (n=22; 5 year survival=39%) was not significantly different to that of patients undergoing resection of one to three metastases (n=91; 5 year survival=30%), P=0.9. Age, sex, primary cancer site, hepatic disease distribution, resection margins and adjuvant hepatic arterial chemotherapy (HAC) did not affect survival. Local invasion of the hepatic metastases (relative risk (RR)=2.9; P=0.001) and hepatic disease recurrence (RR=2.1; P =0.007) were the only factors that independently affected survival. Local invasion of the hepatic metastasis was the only factor associated with an increased risk of hepatic recurrence (RR=2.8; P=0.03). Adjuvant HAC did not affect the risk of hepatic recurrence (RR=1.5, P=0.4). CONCLUSION: Although there are no randomized trials that quantify any survival benefit from resection of liver metastases, the comparison of our results with well documented historical evidence indicates that surgical resection of up to seven colorectal liver metastases can result in a significant survival benefit.

The World Health Organization's action plan on the road traffic injury pandemic: is there any action for orthopaedic trauma surgeons?

Road traffic crash-related death, injury, and chronic disability continue to be a major worldwide burden to drivers, pedestrians, and users of mass transit, especially in low- and middle-income countries (LMIC). Projections predict worsening of this burden, and while motorization of LMIC increases exponentially, a corresponding improvement in prehospital and acute in-hospital trauma care has not been seen. The WHO now has 2 programs that address different elements of this challenge, namely, the Violence and Injury Prevention department (prevention) and the Emergency and Essential Surgical Care project (treatment). Activities of Violence and Injury Prevention have included developing guidelines for prehospital and essential trauma care, whereas activities of the Emergency and Essential Surgical Care have included developing the Integrated Management of Emergency and Essential Surgical Care toolkit and a textbook, "Surgical Care at the District Hospital." Organized surgical institutions in high-income countries-trauma associations, university departments, surgical nongovernmental organizations, etc.-can benefit from the infrastructure and tools the WHO has developed to better address the deficits in surgical services to improve the equitable distribution of surgical care services and resources to LMIC.

Effect of pelvic osteotomy in the skeletally immature on acetabular coverage.

BACKGROUND: Although pelvic osteotomy in children has been effective in re-establishing containment of the hip joint, its impact on hip joint development with respect to acetabular coverage is ill defined. PURPOSE: The purpose of this study is to determine the prevalence of acetabular overcoverage in patients who had pelvic osteotomy during childhood and its impact on patient function. PATIENTS AND METHODS: Between 1980 and 2008, all patients who had a pelvic osteotomy done at our institution for non-neuropathic hip dysplasia (DDH) or secondary to Legg-Calvé-Perthes disease (LCP) prior to skeletal maturity were reviewed. A clinical assessment and the WOMAC, UCLA Activity Score, Marx activity score, and SF-36 quality-of-life questionnaires were completed. A standardized AP pelvic X-ray was performed to determine the acetabular coverage, signs of retroversion, and degenerative changes. RESULTS: Twenty-eight patients (32 hips) were identified, of which 14 (9 DDH, 5 LCP) agreed to participate. Impingement sign was positive in eight patients (six DDH, two LCP). Crossover and ischial spine signs were each present in ten hips. Tonnis grades were: 0 in 1 hip, 1 in 10 hips, 2 in 2 hips, and 3 in 1 hip. The mean Tonnis angle was 11.6 ± 8.6°. The mean CE angle was 24.0 ± 15.9° with six hips having a CE angle <20° and one hip with a CE angle >40°. There was no correlation between crossover sign or ischial sign and Tonnis grade (p = 0.739), hip pain (p = 0.520), or impingement sign (p = 1.00). CONCLUSIONS: Acetabular overcoverage is common in patients who underwent pelvic osteotomy during childhood. No correlation was identified between retroversion and hip pain in our patient cohort.