Tibio-Talar-Calcaneal Nail Fixation for Ankle Fractures: A Systematic Review and Meta-Analysis.

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multidatabase literature search was performed on December 14, 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36-104 weeks). Surgical site infection occurred in 11.2% (95% confidence interval [CI] 6.3%-19%) of patients, implant failure occurred in 8.1% (95% CI 5%-12.8%) of patients, and unplanned return to operating room occurred in 10.1% (95% CI 6.1%-16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7%-34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (95% CI: 67.4%-90.4%) of patients were able to return to similar preoperative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for nonoperative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. About 81.5% (95% CI 67.4%-90.4%) of patients were able to return to a similar preinjury mobility status after tibio-talar-calcaneal nailing.

Role of vertebroplasty and balloon kyphoplasty in pathological fracture in myeloma: a narrative review.

BACKGROUND: Up to 70% of multiple myeloma (MM) patients develop vertebral metastasis and subsequent pathological vertebral fractures (PVF). With contemporary systemic therapies, life expectancy of MM patients has improved drastically, and the need to manage pain and associated disability from PVF is increasingly a high priority. The aim of this review is to provide an updated comprehensive synthesis of evidence in the use of vertebral augmentation, including percutaneous vertebroplasty (PV) and balloon kyphoplasty (BKP), to treat MM-related PVF. METHODS: A comprehensive multi-database search in accordance with PRISMA guidelines was performed up to 10 February 2021. Relevant English language articles were selected and critically reviewed. FINDINGS: A total of 23 clinical studies have been included in the review. PV and BKP showed significant pain and functional improvements in terms of analgesia requirements, Cervical Spine Function Score, Eastern Cooperative Oncology Group scale, EQ-5D score, Karnofsky score, Neck Pain Disability Index, Oswestry Disability Index, Short form-36 (SF-36) questionnaire and VAS pain scale. Both procedures also reported promising radiographic outcomes in terms of vertebral height improvement, maintenance and restoration, as well as kyphotic deformity correction. Asymptomatic cement leakage was commonly reported. There was no significant difference between the two procedures. CONCLUSION: PV and BKP are safe and effective procedure that offers pain relief, reduction in pain associated disability and reduction of fracture incidence. Its minimally invasive approach is associated with minimal morbidity risk, making it a viable option in frail patients. LEVEL OF EVIDENCE IV: Narrative review.

Comparable dislocation and revision rates for patients undergoing total hip arthroplasty with subsequent or prior lumbar spinal fusion: a meta-analysis and systematic review.

BACKGROUND: There is a known correlation between the procedures of lumbar spinal fusion (LSF), total hip arthroplasty (THA) and the complication of hip dislocation and revision occurring in patients. However there is no consensus as to whether the risk of this complication is higher if THA is performed before or after LSF. This meta-analysis aims to determine the influence of surgical sequence of lumbar spinal fusion and total hip arthroplasty on the rates of hip dislocation and revisions. METHODS: A meta-analysis was conducted with a multi-database search (PubMed, OVID, EMBASE, Medline) according to PRISMA guidelines on 27th May 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model. FINDINGS: A total of 25,558 subsequent LSF and 43,880 prior LSF THA patients were included in this study. There was no statistically significant difference in all-cause revisions (OR = 0.86, 95%CI: 0.48-1.54, p = 0.61), dislocation (OR = 0.82, 95%CI: 0.25-2.72, p = 0.75) or aseptic loosening (OR = 1.14, 95%CI: 0.94-1.38, p = 0.17) when comparing patients receiving LSF subsequent versus prior to THA. CONCLUSION: Lumbar spinal fusion remains a risk factor for dislocation and revision of total hip arthroplasties regardless of whether it is performed prior to or after THA. Further preoperative assessment and altered surgical technique may be required in patients having THA who have previously undergone or are likely to undergo LSF in the future. EVIDENCE LEVEL: Level II, Meta-analysis of homogeneous studies.

No Difference in Functional, Radiographic, and Survivorship Outcomes Between Direct Anterior or Posterior Approach THA: 5-Year Results of a Randomized Trial.

BACKGROUND: Both the direct anterior approach (DAA) and posterior approach (PA) to THA have known advantages and disadvantages. The comparison between DAA and PA THA has been widely explored during the early postoperative period. However, few randomized trials have compared these approaches at a minimum follow-up of 5 years; doing so would be important to establish any differences in mid-term outcomes or complications. QUESTIONS/PURPOSES: We performed a randomized trial comparing DAA and PA in THA in terms of (1) patient-reported outcome scores, (2) quality of life and functional outcomes assessed by the EQ-5D and 10-meter walk test results, (3) radiographic analysis, and (4) survivorship and surgical complications at a minimum of 5 years follow-up. METHODS: Two hip specialist surgeons performed both DAA and PA THA using the same THA components at two hospital sites. One hundred twelve patients on the elective THA surgical waitlist were invited to participate in the study. Thirty-four patients did not meet the study's inclusion criteria and were excluded, and three patients declined to participate in the study. The remaining 75 patients who were eligible were randomized into DAA and PA groups. Thirty-seven patients were initially randomized to receive DAA THA, but two did not and were excluded, resulting in 48% (35 of 73) of patients who received DAA THA; 52% (38 of 73) of patients were randomized into and received PA THA. Over a minimum 5 years of follow-up, 3% (1 of 35) of DAA patients were lost to follow-up, and none of the patients undergoing PA THA were lost. A per-protocol analysis was adopted, resulting in further patients being excluded from analysis. Of the 73 study patients, 99% (72; DAA: 35, PA: 37) were analyzed at 1 year, 95% (69; DAA: 34, PA: 35) were analyzed at 2 years, and 72% (52; DAA: 23, PA: 29) were analyzed at 5 years. The primary outcome was the Oxford Hip Score (OHS) and WOMAC score. Secondary outcomes included the EQ-5D and EQ-5D VAS scores, 10-meter walk test results, radiographic evidence of loosening (femoral: lucency > 2 mm at the implant-bone interface, subsidence > 2 mm; acetabular: migration or change in inclination), 5-year survivorship analysis from all-cause revisions, and surgical complications. The study was powered to detect a 10-point difference in the WOMAC score, which is equivalent to the minimum clinically important difference (MCID). RESULTS: There were no differences in primary outcomes (OHS and WOMAC scores) or secondary outcomes (EQ-5D scores, EQ-5D VAS scores, and 10-meter walk test result) between the DAA and PA groups at the 5-year follow-up interval. The median (range) OHS at 5 years was 46 (16 to 48) for DAA and 47 (18 to 48) for PA groups (p = 0.93), and the median WOMAC score was 6 (0 to 81) for DAA and 7 (0 to 59) for PA groups (p = 0.96). The median EQ-5D score was 1 (0.1 to 1) for DAA and 1 (0.5 to 1) for PA groups (p = 0.45), and the median EQ-5D VAS score was 85 (60 to 100) for DAA and 95 (70 to 100) for PA groups (p = 0.29). There were no cases of component loosening on radiographs. There was no difference in component survival between the two approaches at 5 years (DAA: 97% [95% CI 85% to 100%] versus PA: 97% [95% CI 87% to 100%]). Eight of 23 patients in the DAA group reported decreased sensation in the lateral femoral cutaneous nerve distribution. CONCLUSION: DAA and PA are both effective approaches in performing primary THA. Each approach has its associated risks and complications. The choice of THA should be based on individual patient factors, surgeon experience, and shared decision-making. Early registry data indicate DAA and PA THA are comparable, but longer-term data with larger numbers of patients will be required before one can safely conclude equal survivorship between both approaches. LEVEL OF EVIDENCE: Level I, therapeutic study.

Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review.

BACKGROUND: Proximal humeral fractures are difficult injuries to treat and obtain satisfactory outcomes. For those treated with arthroplasty, humeral fracture stems have been popular due to better ability for reduction and fixation of tuberosities. This study aims to investigate the outcomes of fracture stems in shoulder arthroplasty for proximal humeral fracture and the comparison of outcomes between fracture vs. nonfracture stems. METHODS: A meta-analysis was conducted with a multidatabase search (PubMed, OVID, EMBASE, Medline) according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines on May 19, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed. FINDINGS: Eleven studies were included for analysis, including 383 hemiarthroplasties (HA) (294 fracture stems, 89 nonfracture stems) and 358 reverse total shoulder arthroplasties (RTSA) (309 fracture stems, 49 nonfracture stems). At the final follow-up, meta-analysis shows favorable overall ASES score in all fracture stem prosthesis (mean = 74.0, 95% confidence interval [CI]: 69.3-78.7), Constant-Murley score (mean = 67.2, 95% CI: 61.6-72.8), external rotation (mean difference [MD] = 7°, 95% CI: 3°-10°, P < .001), and forward flexion (MD = 17°, 95% CI: 10°-25°, P < .001). Pooled proportion (PP) of greater tuberosity healing (PP = 0.786, 95% CI: 0.686-0.886) was high, whereas all-cause revisions (PP = 0.034, 95% CI: 0.018-0.061) remained low. With the exception of RTSA scapular notching (PP = 0.109, 95% CI: 0.020-0.343), other complication metrics had PP of ≤0.023. In the 4 studies comparing fracture (138 HA, 54 RTSA) vs. nonfracture stems (89 HA, 49 RTSA), fracture stems had statistically significant better American Shoulder and Elbow Surgeons scores (MD = 14.29, 95% CI: 8.18-20.41, P < .001), external rotation (MD = 6°, 95% CI: 2°-9°, P = .003), forward flexion (MD = 16°, 95% CI: 7°-24°, P < .001), and greater tuberosity healing (odds ratio = 2.20, 95% CI: 1.28-3.77, P = .004). There was no statistically significant difference in complications. CONCLUSION: Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. The use of fracture stems is also associated with greater chance of tuberosity healing compared with nonfracture stems. There is increasing evidence to suggest the superiority of fracture stems over nonfracture stems in clinical outcomes, while maintaining similar complication rates.

Clinical outcomes and complication profile of total hip arthroplasty after lumbar spine fusion: a meta-analysis and systematic review.

BACKGROUND: Hip and spine pathology can alter the biomechanics of spino-pelvic mobility. Lumbar spine fusions can reduce the mobility of the lumbar spine and therefore result in compensatory femoral motion, contributing towards dislocations of THA. PURPOSE: This meta-analysis aims to determine the effect of pre-existing spine fusions on THA outcomes, and complication profile including hip dislocations, all-cause revisions and all complications. METHODS: A multi-database search was performed according to PRISMA guidelines. All studies that compared patients who underwent THA with and without prior SF were included in the analysis. RESULTS: Ten studies were included in this review, consisting of 28,396 SF THA patients and 1,550,291 non-SF THA patients. There were statistically significant higher rates of hip dislocation (OR 2.20, 95% CI 1.71-2.85, p < 0.001), all-cause revision (OR 3.43, 95% CI 1.96-6.00, p < 0.001) and all complications (OR 2.83, 95% CI 1.28-6.24, p = 0.01) in SF than in non-SF THA patients. When registry data were excluded, these rates were approximately doubled. Subgroup analysis of revisions for dislocations was not statistically significant (OR 5.28, 95% CI 0.76-36.87, p = 0.09). While no meta-analysis was performed on clinical outcomes due to heterogeneous parameter reporting, individual studies reported significantly poorer outcomes in SF patients than in non-SF patients. CONCLUSION: THA patients with SF are at higher risks of hip dislocations, all-cause revisions and all complications, which may adversely affect patient-reported outcomes. Surgeons should be aware of these risks and appropriately plan to account for altered spino-pelvic biomechanics, in order to reduce the risks of hip dislocations and other complications. LEVEL OF EVIDENCE: II (Meta-analysis of non-homogeneous studies). These slides can be retrieved under Electronic Supplementary Material.

Outcome after total ankle arthroplasty with a minimum of five years follow-up: A systematic review and meta-analysis.

BACKGROUND: Total ankle arthroplasty (TAA) is increasingly gaining recognition as an alternative to ankle arthrodesis in the treatment of end-stage ankle arthritis. Despite high rates of adverse events during early inception, newer generations of uncemented prosthesis and design modifications have improved outcomes. Questions remain regarding the long-term outcomes and implant survivorship of TAA. AIM: This analysis aims to establish an updated review of intermediate and long-term clinical outcome and complication profile of TAA. PATIENTS AND METHODS: A multi database search was performed on 14th October 2018 according to PRISMA guidelines. All articles that involved patients undergoing uncemented TAA with 5 years minimum follow-up, reported clinical outcome or complication profile of TAA were included. Seventeen observational studies were included in the review, with 1127 and 262 ankles in the 5 and 10 years minimum follow-up groups respectively. RESULTS: Mean difference between pre- and post-operative AOFAS score was 43.60 (95%CI: 37.51-49.69, p<0.001) at 5 years minimum follow-up. At 5 years minimum follow-up, pooled proportion (PP) of prostheses revision for any reason other than polyethylene exchange was 0.122 (95%CI: 0.084-0.173), all cause revision was 0.185 (95%CI: 0.131-0.256), unplanned reoperation was 0.288 (95%CI: 0.204-0.390) and all infection was 0.033 (95%CI: 0.021-0.051). At 10 years minimum follow-up, PP of prostheses revision for any reason other than polyethylene exchange was 0.202 (95%CI: 0.118-0.325), all cause revision was 0.305 (95%CI: 0.191-0.448), unplanned reoperation was 0.422 (95%CI: 0.260-0.603) and all infection was 0.029 (95%CI: 0.013-0.066). CONCLUSION: Despite good intermediate and long-term functional outcome measures, TAA has relatively higher revision surgery prevalence with longer follow-up periods. Further research should be directed towards identifying patient populations that would best benefit from TAA and those at greatest risk of requiring revision surgery.

Suture button versus syndesmosis screw constructs for acute ankle diastasis injuries: A meta-analysis and systematic review of randomised controlled trials.

BACKGROUND: Ankle syndesmotic injuries can be surgically managed with syndesmosis screws (SS) or suture button (SB) fixation. We performed a meta-analysis of randomized controlled trials (RCTs) aiming to compare the clinical and complication profiles of both modalities. METHODS: A multi-database search up to 4th of March 2018 was performed according to PRISMA guidelines. All RCTs comparing both techniques and published in English were included. RESULTS: Five RCTs with a total of 280 patients (140 SB, 140 SS) were included for analysis. SB had a statistically significant higher AOFAS score at 1 year (mean difference=5.46, 95% CI=0.40-10.51, p=0.03) and lower implant failure rate (OR=0.03, 95% CI=0.01-0.15, p<0.001). Infection and wound issues were marginally higher with SB (OR=1.4, 95% CI=0.4-4.85, p=0.60). No other parameters showed statistically significant difference. CONCLUSIONS: Both constructs yielded similar clinical outcomes. The 1 year AOFAS score was higher in SB but clinical significance is unlikely. SB had significantly fewer implant failures. LEVEL OF EVIDENCE: Level I.

Intermediate-term results of isolated minimally invasive arthroscopic cheilectomy in the treatment of hallux rigidus.

AIM: The aim of this study was to determine the intermediate-term results of minimally invasive cheilectomy of the first MTPJ using a high-torque low-speed burr and arthroscopic debridement. METHODS: A consecutive series of patients who underwent isolated unilateral minimally invasive cheilectomy of the first MTPJ were contacted by telephone. A questionnaire was used to assess patient satisfaction and complications. Patients with less than 2 years of follow-up were excluded. RESULTS: Thirty-six patients completed the study. Mean patient age at time of surgery was 50.0 years (range 24.5-67.0). Mean follow-up was 4.69 years (range 2.0-7.3). Thirty patients (83%) reported they would recommend the procedure. Mean postoperative improvement in pain was 69% (range 0-100). Twenty-seven (84%) of patients reported either no pain (28%) or mild pain (56%). For patients who reported any pain, the mean pain experienced was rated as 3.4 out of 10 (range 1-9). Twenty-nine (81%) patients reported they could wear a 'fashionable' shoe postoperatively. One patient experienced a delayed rupture of the extensor hallucis longus at 6 months postsurgery. One patient underwent further arthroscopic cheilectomy. No patient required conversion to fusion of the first MTPJ. CONCLUSION: Minimally invasive cheilectomy of the first MTPJ using high-torque low-speed burr and arthroscopic debridement results in high patient satisfaction with a low rate of complications at intermediate follow-up.

Antifibrinolytic agents for paediatric scoliosis surgery: a systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis of randomised controlled trials. OBJECTIVE: The purpose of this study is to perform a systematic review and meta-analysis of antifibrinolytic agents for paediatric spine surgery. BACKGROUND: Bleeding is an important consideration in paediatric scoliosis surgery; blood loss leads directly to higher morbidity and mortality. Antifibrinolytics are an attractive non-invasive method of reducing bleeding as evidenced in arthroplasty, cardiac surgery and adult scoliosis surgery. METHODS: A thorough database search of Medline, PubMed, EMBASE and Cochrane was performed according to PRISMA guidelines, and a systematic review was performed. RESULTS: Five randomised controlled trials were identified in this meta-analysis, consisting of a total of 285 spine surgery patients with subgroups of tranexamic acid (n = 101), epsilon aminocaproic acid (n = 61) and control (n = 123). This meta-analysis found that antifibrinolytics lead to statistically significant reductions in peri-operative blood loss (MD - 379.16, 95% CI [- 579.76, - 178.57], p < 0.001), intra-operative blood loss (MD - 516.42, 95% CI [- 1055.58, 22.74], p < 0.001), reduced fresh frozen plasma requirements (MD - 307.77, 95% CI [- 369.66, - 245.88], p < 0.001) and reduced post-operative blood loss (MD - 185.95, 95% CI [- 336.04, - 35.87], p = 0.02). CONCLUSION: This meta-analysis concludes that antifibrinolytics lead to statistically significant reductions in peri-operative blood loss, intra-operative blood loss, reduced fresh frozen plasma requirements and reduced post-operative blood loss with TXA. These slides can be retrieved under Electronic Supplementary Material.

Fixed- Versus Adjustable-Loop Devices for Femoral Fixation in Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To compare biomechanical and clinical outcomes between adjustable-loop devices (ALDs) and fixed-loop devices (FLDs) in the femoral fixation component of anterior cruciate ligament reconstruction (ACLR) using a hamstring autograft or allograft. METHODS: A multi-database search was performed on July 18, 2018, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. All articles directly comparing ALDs and FLDs in ACLR using hamstring grafts were included. Non-English-language articles were excluded. RESULTS: We included 13 biomechanical, 2 prospective, and 6 retrospective studies in this review. Retensioning of ALDs was performed in 4 of 13 biomechanical studies and in all clinical studies. Biomechanically, 11 studies showed a statistically significantly larger maximum irreversible displacement of the graft in the ALD group. Two studies showed no statistically significant difference with retensioning of the TightRope ALD, whereas all 3 studies that examined knotting of ALDs showed no statistically significant difference between the FLD and ALD groups. Five studies reported statistically significantly higher graft stiffness for FLDs than ALDs. Retensioning or knotting did not produce any significant change in construct stiffness. Nine studies reported a statistically significantly higher ultimate load to failure for FLDs. With knotting of ALDs, this difference was no longer statistically significant in only 1 study. Clinical studies showed no statistically significant differences in clinical, functional, radiologic, and complication outcomes between both groups. CONCLUSIONS: Despite the superior biomechanical properties of FLDs, ALDs and FLDs yielded similar clinical outcome scores and graft rerupture rates. Biomechanical outcomes were improved with retensioning of ALDs after tibial fixation, as per manufacturer recommendations. LEVEL OF EVIDENCE: Level III, systematic review of Level III and IV studies.

Relationship between sagittal balance and adjacent segment disease in surgical treatment of degenerative lumbar spine disease: meta-analysis and implications for choice of fusion technique.

STUDY DESIGN: Meta-analysis. OBJECTIVE: To conduct a meta-analysis investigating the relationship between spinopelvic alignment parameters and development of adjacent level disease (ALD) following lumbar fusion for degenerative disease. ALD is a degenerative pathology that develops at mobile segments above or below fused spinal segments. Patient outcomes are worse, and the likelihood of requiring revision surgery is higher in ALD compared to patients without ALD. Spinopelvic sagittal alignment has been found to have a significant effect on outcomes post-fusion; however, studies investigating the relationship between spinopelvic sagittal alignment parameters and ALD in degenerative lumbar disease are limited. METHODS: Six e-databases were searched. Predefined endpoints were extracted and meta-analyzed from the identified studies. RESULTS: There was a significantly larger pre-operative PT in the ALD cohort versus control (WMD 3.99, CI 1.97-6.00, p = 0.0001), a smaller pre-operative SS (WMD - 2.74; CI - 5.14 to 0.34, p = 0.03), and a smaller pre-operative LL (WMD - 4.76; CI - 7.66 to 1.86, p = 0.001). There was a significantly larger pre-operative PI-LL in the ALD cohort (WMD 8.74; CI 3.12-14.37, p = 0.002). There was a significantly larger postoperative PI in the ALD cohort (WMD 2.08; CI 0.26-3.90, p = 0.03) and a larger postoperative PT (WMD 5.23; CI 3.18-7.27, p < 0.00001). CONCLUSION: The sagittal parameters: PT, SS, PI-LL, and LL may predict development of ALD in patients' post-lumbar fusion for degenerative disease. Decision-making aimed at correcting these parameters may decrease risk of developing ALD in this cohort. These slides can be retrieved under Electronic Supplementary Material.

Locking stand-alone cages versus anterior plate constructs in single-level fusion for degenerative cervical disease: a systematic review and meta-analysis.

PURPOSE: To conduct a meta-analysis to compare the clinical and radiological outcomes in single-level anterior cervical discectomy and fusion (ACDF) surgery for degenerative cervical disease performed by either single-level locking stand-alone cage (LSC) or anterior plate construct (APC). METHODS: We performed a comprehensive database search of Medline, PubMed, EMBASE and Cochrane Database of Systematic Reviews according to PRISMA guidelines and identified six articles that satisfied our inclusion criteria. We excluded all non-English language articles and articles which did not directly compare LSC and APC. Only papers which focussed on single-level ACDF were included in the study. RESULTS: There were no significant differences in blood loss, clinical outcomes (JOA, VAS, NDI scores) or radiological outcomes (cervical lordosis, segmental Cobb angle, subsidence and fusion) between the two groups. Operative time was significantly shorter in the LSC group (MD 7.2 min, 95% CI 0.3-14.1, p = 0.04). APC was associated with a statistically significant increase in dysphagia in the follow-up period (OR 6.2, 95% CI 1.0-36.6, p = 0.05). CONCLUSION: LSC and APC have similar clinical and radiological outcomes. Further blinded randomised trials are required to establish conclusive evidence in favour of LSC with regards to minimising post-operative dysphagia. We also encourage future studies to make use of formalised dysphagia outcome measures in reporting complications.

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.

Hydrogen peroxide in orthopaedic surgery - is it worth the risk?

Hydrogen peroxide (H2O2) is commonly used in orthopaedic surgery during cemented arthroplasty and wound washouts. Its purported roles include antisepsis, haemostasis, mechanical debridement, and optimising the cement-bone interface during cementing. However, despite its apparent harmless mechanism of action, H2O2 has been implicated in fatal and near fatal complications caused through oxygen emboli. We present a case of oxygen embolism and review the existing literature to highlight its potential risks and its lack of therapeutic value. We believe there is little role for its use in orthopaedic surgery.

Bilateral thalamic high-grade astrocytomas in an early-adolescent child: A case report.

An early-adolescent girl presented with incoordination, headache, vomiting and dysphonia. MRI brain demonstrated diffuse increased T2 and FLAIR signal in bilateral thalami, consistent with anaplastic astrocytomas. A stereotactic burr-hole biopsy provided frozen tissues sections demonstrating an IDH-1 wildtype astrocytoma (anaplastic grade III according to prior WHO classification 2016-21). Chemoradiotherapy was commenced. Bilateral thalamic high-grade astrocytomas are very rare in the paediatric population and require timely diagnosis and interdisciplinary management. CT and MR imaging help point towards this diagnosis in the correct clinical context.

Triangular fibrocartilage complex injury: outcomes of operative and non-operative management.

OBJECTIVE: The prevalence TFCC injuries has increased over time. However, there remains a lack of understanding of its natural history. Along with the paucity of evidence on treatment options, there is lack of consensus on how best to manage them. This is a retrospective study with subgroup cohort analysis, examining variables and management options associated with patient-reported disability and pain. METHODS: Patients from a metropolitan health network who have been referred for Magnetic Resonance Imaging (MRI) of the wrist between 2010 and 2019 and identified to have TFCC injury, were followed up to determine patient-reported outcomes. Disability of arm shoulder and hand scores (DASH) and visual assessment pain scale (VAS) were used to measure disability and pain respectively. An 'excellent' DASH and VAS scores were defined as ≤10 and ≤2, respectively. RESULTS: One hundred and twenty-four patients met the inclusion criteria and consented to participate in this study. There were 53 patients with excellent DASH score, 95 excellent VAS score and 51 excellent outcomes at mean follow-up of 75.5 months (Range: 5-402.8 months). Concomitant pathology and surgical management were less likely to have excellent DASH and VAS scores, while traumatic aetiology and smoking were less likely to have excellent VAS score. Age was not predictive of excellent DASH or VAS score. CONCLUSIONS: Surgical management of TFCC injuries were associated with worse outcomes than if they were left alone. Smoking cessation is a patient-modifiable risk factor that may help improve outcomes.

Comparing outcomes of total hip arthroplasty versus hemiarthroplasty in neck of femur fracture patients: an Australian registry study.

PURPOSE: To determine discharge outcomes of displaced subcapital NOF patients who were from home, with intact pre-operative cognition, ASA 1 or 2 and independent walkers treated with either THA or hemiarthroplasty. METHODS: A retrospective registry study was performed using data from the Australia and New Zealand Hip Fracture Registry (ANZHFR). Institutional ethics approval was obtained prior to commencement. Hip fracture registry records between 1st January 2016 and 31st January 2020 were reviewed. RESULTS: A total of 930 patients with complete records were identified and included. There were 602 THA and 328 hemiarthroplasty patients. Using multivariate analysis, pre-operative factors associated with THA include younger age (OR = 0.90 for every year older, p < 0.001), females (p = 0.043), private admissions (OR = 1.62, p = 0.028) and receiving pre-operative geriatric assessment (OR = 1.89, p = 0.002). Delay to theatre due to not being fit for surgery was associated with not receiving THA (OR = 0.21, p < 0.001). THA resulted in a shorter total hospital length of stay (MD = 7.24, p < 0.001), higher likelihood of being discharged home (OR = 1.88, p < 0.001) and lower likelihood of being discharged to a residential aged care facility (OR = 0.32, p = 0.019). CONCLUSION: Displaced subcapital NOF patients who were admitted from home, had intact pre-operative cognition, ASA 1 or 2, independent walkers and had THAs, had shorter total hospital length of stay, were more likely to be discharged home directly and less likely to end up in residential aged care facilities compared to those undergoing hemiarthroplasty.