Longitudinal survival trends of patients with cancer with surgically managed appendicular metastatic bone disease: systematic review.

BACKGROUND: Advances in systemic cancer therapies have improved survival for patients with metastatic carcinoma; however, it is unknown whether these advances have translated to improved survival for patients with appendicular metastatic bone disease (A-MBD) after orthopedic interventions. We conducted a study to evaluate the trend in overall survival for patients who underwent orthopedic surgery for A-MBD between 1968 and 2018. METHODS: A systematic search of Embase and Medline to identify studies published since 1968 evaluating patients treated with orthopedic surgery for A-MBD was conducted for a previously published scoping review. We used a meta-regression model to assess the longitudinal trends in 1-, 2- and 5-year overall survival between 1968 and 2018. The midpoint year of patient inclusion for each study was used for analysis. We categorized primary tumour types into a tumour severity score according to prognosis for a further meta-regression analysis. RESULTS: Of the 5747 studies identified, 103 were retained for analysis. Meta-regression analysis showed no significant effect of midpoint study year on survival across all time points. There was no effect of the weighted average of tumour severity scores for each study on 1-year survival over time. CONCLUSION: There was no significant improvement in overall survival between 1968 and 2018 for patients with A-MBD who underwent orthopedic surgery. Orthopedic intervention remains a poor prognostic variable for patients with MBD. This finding highlights the need for improved collection of prospective data in this population to identify patients with favourable survival outcomes who may benefit from personalized oncologic surgical interventions.

Waste and recycling among orthopedic subspecialties.

Background: It is estimated that one-quarter to half of all hospital waste is produced in the operating room. Recycling of surgical waste in the perioperative setting is uncommon, even though there are many recyclable materials. The objective of this study was to determine the amount of waste produced in the preoperative and operative periods for several orthopedic subspecialties and to assess how much of this waste was recycled. Methods: Surgical cases at 1 adult and 1 pediatric tertiary care hospital in Calgary, Alberta, were prospectively chosen from 6 orthopedic subspecialties over a 1-month period. Waste was collected, weighed and divided into recyclable and nonrecyclable categories in the preoperative period and into recyclable, nonrecyclable, linen and biological categories in the intraoperative period. Waste bags were weighed using a portable hand-held scale. The primary outcome was the amount of recyclable waste produced per case. Secondary outcomes included the amount of nonrecyclable, biological and total waste produced. An analysis of variance was performed to test for statistically significant differences among subspecialties. Results: This study included 55 procedures. A total of 341.0 kg of waste was collected, with a mean mass of 6.2 kg per case. Arthroplasty produced a greater amount of recyclable waste per case in the preoperative (2017.1 g) and intraoperative (938.6 g) periods as well as total recyclable waste per case, resulting in a greater ratio of waste recycling per case then nearly all other subspecialties in the preoperative (86%) and intraoperative (14%) periods. Arthroplasty similarly produced a greater amount of nonrecyclable waste per case (5823.6 g) than the other subspecialties, most of which was produced during the intraoperative period (5512.9 g). Overall an average of 27% of waste was recycled per case. Conclusion: Among orthopedic subspecialties, arthroplasty is one of the largest waste producers and it has the highest potential for recycling of materials. Effective recycling programs in the operating room can reduce our ecological footprint by diverting waste from landfills, as our study revealed that nearly three-quarters of this waste is recyclable.

Contexte: On estime qu'un quart à la moitié de tous les déchets produits en hôpital proviennent des salles d'opération. Le recyclage des déchets produits en contexte opératoire est assez rare, bien que de nombreux matériaux soient recyclables. Cette étude visait à déterminer la quantité de déchets produits pendant les périodes préopératoire et peropératoire pour plusieurs surspécialités orthopédiques, et à évaluer la quantité de déchets recyclés. Méthodes: Pour y arriver, on a étudié de façon prospective pendant 1 mois les chirurgies effectuées dans 2 hôpitaux de soins tertiaires de Calgary (Alberta), 1 hôpital pédiatrique et 1 hôpital pour adulte, pour 6 surspécialités orthopédiques. Nous avons recueilli les déchets, les avons pesés et les avons répartis dans les catégories « recyclable ¼ et « non recyclable ¼ pour la période préopératoire, et « recyclable ¼, « non recyclable ¼, « textile ¼ et « biologique ¼ pour la période peropératoire. Les sacs de déchets ont été pesés à l'aide d'une balance portative. L'issue principale était la quantité de déchets produits par cas, et l'issue secondaire, la quantité de déchets non recyclables et biologiques et la quantité totale de déchets. On a ensuite procédé à une analyse de la variance pour déterminer la présence de différences statistiquement significatives entre les surspécialités. Résultats: Au total, 55 opérations ont été étudiées, et 341,0 kg de déchets ont été recueillis, pour une moyenne de 6,2 kg par cas. Les arthroplasties produisaient une plus grande quantité de déchets recyclables par cas dans les périodes préopératoire (2017,1 g) et peropératoire (938,6 g) ainsi qu'une plus grande quantité totale de déchets recyclables par cas, ce qui leur donne un meilleur ratio de recyclage par cas que pratiquement toutes les autres surspécialités dans les périodes préopératoire (86 %) et peropératoire (14 %). De même, les arthroplasties produisaient une plus grande quantité de déchets non recyclables par cas (5823,6 g) que les autres surspécialités, et la plupart de ces déchets étaient produits pendant la période peropératoire (5512,9 g). En moyenne, 27 % de l'ensemble des déchets étaient recyclés. Conclusion: Parmi les surspécialités orthopédiques, l'arthroplastie est l'une de celles qui produisent le plus de déchets et qui ont le plus grand potentiel de recyclage. Notre étude a révélé que près des trois quarts des déchets sont recyclables; ainsi, des programmes de recyclage efficaces en salle d'opération peuvent réduire notre empreinte écologique en empêchant l'enfouissement de certains déchets.

No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis Is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study.

PURPOSE: To assess the functional outcomes of patients included in the Stability Study randomized controlled trial comparing anterior cruciate ligament reconstruction (ACLR) alone with ACLR with lateral extra-articular tenodesis (LET) at 6, 12, and 24 months postoperatively. METHODS: Six hundred eighteen patients undergoing ACLR, all under the age of 25 years either returning to contact pivoting sport or displaying signs of high-grade rotatory laxity or generalized ligamentous laxity, were randomly assigned to receive ACLR alone or ACLR plus LET. A total of 356 of these patients were randomized at centers participating in the functional assessments. Our primary outcome was Limb Symmetry Index, calculated using a series of 4-hop tests at 6, 12, and 24 months postoperatively. Secondary outcome measures included pain, patient-reported function, and isokinetic strength testing. RESULTS: We found no statistically significant difference in the proportion of patients either unwilling or unfit to complete the hop testing in the ACLR alone or ACLR with LET group at 6 months (40 vs 40 respectively; P = 1.00), 12 months (25 vs 27; P = .76), and 24 months (21 vs 23; P = .87). Of those who completed hop testing, there were no statistically significant differences between groups in Limb Symmetry Index at 6, 12, or 24 months. Self-reported function (Lower Extremity Functional Score) significantly favored the ACLR alone group at 3 (P = .01) and 6 months (P = .02) postoperative but was similar by 12 months postoperative. Pain scores (P4) also showed a statistically significant difference in favor of the ACL alone group, but this also resolved by 6 months. Quadriceps peak torque (P = .03) and average power (P = .01) were also significantly different in favor of the ACLR alone group at 6 months postoperative; however, these were similar between groups by 12 months postoperative (P = .11 and P = .32, respectively). CONCLUSIONS: The addition of a LET to ACLR results in slightly increased pain, a mild reduction in quadriceps strength, and reduced subjective functional recovery up to 6 months postoperatively. However, these differences do not have any impact on objective function as measured by hop test limb symmetry index. LEVEL OF EVIDENCE: I, Randomized Controlled Trial.

Lessons learned from a hospital-wide review of blood stream infections for paediatric central line-associated blood stream infection prevention.

AIM: Bacteraemia episodes were assessed to calculate a hospital-wide central line-associated blood stream infection (CLABSI) rate per 1000 catheter-days. Secondary objectives were to describe risk factors, microbiology and outcomes of children with CLABSI. METHODS: A retrospective study was conducted at an Australian tertiary paediatric hospital in children <18 years who had blood culture sampling during the 2-year period, 2014-2015. All blood culture results were extracted from the hospital's laboratory information system. National Healthcare Safety Network Centres for Disease Control and Prevention definitions for bacteraemia classification were used. Central venous access device (CVAD) insertion and removal dates were obtained from a surgical electronic database and anaesthetic records and then manually validated. RESULTS: Of 11 774 processed blood culture bottles, 207 episodes of blood stream infection were observed. Eighty-five (41%) episodes were community-acquired bacteraemia (CA-B) and 122 (59%) health care-associated bacteraemia (HA-B), of which 73 (35%) were CLABSI. The hospital-wide CLABSI rate was 0.62 per 1000 catheter-days (95% confidence interval: 0.49-0.77). Conditions associated with CLABSI were malignancy (n = 45, 62%) and gastrointestinal failure (n = 6, 8%). Thirty-three (45%) CLABSI episodes developed in an outpatient setting. CONCLUSIONS: HA-B has a significant impact on child health, exceeding the number of CA-B at our hospital. Children with CVADs are vulnerable in both the inpatient and outpatient settings. Collecting robust data for a hospital-wide CLABSI rate is important to understand the full spectrum of paediatric CLABSI. The value of validating data using both electronic and manual methods is demonstrated.

Peripheral fixation of meniscal allograft does not reduce coronal extrusion under physiological load.

PURPOSE: Meniscal graft extrusion is a concern following meniscal allograft transplantation (MAT). MAT surgical techniques continue to evolve in an effort to reduce extrusion; however, improvements remain difficult to measure in vivo. A novel MRI-compatible in vitro loading device capable of applying physiologically relevant loads has been developed, allowing for the measurement of extrusion under a variety of controllable conditions. The objective of this study was to compare maximal medial MAT extrusion (1) with and (2) without an additional peripheral third point of fixation on the tibial plateau. METHODS: Twelve human cadaveric knees underwent medial MAT, utilizing soft tissue anterior and posterior root fixation via transosseous suture, with a third transosseous suture tied over a button providing peripheral fixation on the tibial plateau. The joint was positioned at 5 degrees of flexion and loaded to 1 × body weight (647.7 ± 159.0 N) during MR image acquisition, with and without peripheral fixation. The joint was then positioned at 30 degrees of flexion and the process was repeated. Maximal coronal extrusion was measured. RESULTS: An increase in maximal coronal meniscal extrusion was noted between the unloaded and loaded states. At 30 degrees of flexion, with the addition of a peripheral fixation point, a statistically significant difference in absolute extrusion (p = 0.02) and relative percent extrusion (p = 0.04) between the unloaded and loaded state was found. The addition of a peripheral fixation suture resulted in an overall mean percent difference of - 2.49% (SD 14.1; 95% CI - 11.95, 6.97; n.s.) in extrusion at 5 degrees of flexion and a mean percent difference of - 0.95% (SD 7.3; 95% CI - 5.62, 3.71; n.s.) in extrusion at 30 degrees of flexion. These differences were not statistically significant. CONCLUSION: These results suggest that the addition of a peripheral anchor in medial MAT does not reduce the amount of maximal coronal extrusion and, therefore, may not confer any clinical benefit. Surgical techniques utilized to reduce MAT extrusion need further investigation to understand if the added technical difficulty and potential expense is warranted.

3D strain in native medial meniscus is comparable to medial meniscus allograft transplant.

PURPOSE: Injury or degeneration of the meniscus has been associated with the development of osteoarthritis of the knee joint. Meniscal allograft transplant (MAT) has been shown to reduce pain and restore function in patients who remain symptomatic following meniscectomy. The purpose of this study is to evaluate and compare the three-dimensional (3D) strain in native medial menisci compared to allograft-transplanted medial menisci in both the loaded and unloaded states. METHODS: Ten human cadaveric knees underwent medial MAT, utilizing soft-tissue anterior and posterior root fixation via transosseous sutures tied over an anterolateral proximal tibial cortical bone bridge. The joint was imaged first in the non-loaded state, then was positioned at 5° of flexion and loaded to 1× body weight (650 ± 160 N) during MR image acquisition. Anatomical landmarks were chosen from each image to create a tibial coordinate system, which were then input into a custom-written program (Matlab R2014a) to calculate the 3D strain from the unloaded and loaded marker positions. Six independent strains were obtained: three principal strains and three shearing strains. RESULTS: No statistically significant difference was found between the middle and posterior strains in the native knee compared to the meniscus allograft. This would suggest that soft-tissue fixation of meniscal allografts results in similar time zero principal and shear strains in comparison to the native meniscus. CONCLUSION: These results suggest that time zero MAT performs in a similar manner to the native meniscus. Optimizing MAT strain behavior may lead to potential improvements in its chondroprotective effect.

Optimal use of plasma and urine BK viral loads for screening and predicting BK nephropathy.

BACKGROUND: BK virus is a polyoma virus causing renal allograft nephropathy. Reduction of immunosuppression with the early recognition of significant BK viral loads in urine and plasma can effectively prevent BKV associated nephropathy (BKVN), however the optimal compartment and frequency of BK viral load measurement post renal transplantation are undetermined. Our purpose was to examine time to detection and viral loads in urine compared to plasma, and establish viral load cut-offs associated with histological BKVN. METHODS: We performed a retrospective analysis of the BKV screening frequency and compartment(s) of 277 adult renal transplant recipients (RTR). RESULTS: BKVN was histologically diagnosed in 17 (6.1 %) RTR. In cases where both urine and plasma were tested fortnightly for 6 months (n = 53), BKV was detected in the urine 29 days earlier than plasma. Fortnightly (n = 72) versus 3-monthly (n = 78) testing demonstrated that BKV was detected in the urine significantly earlier (median 63 versus 97 days, p = 0.001) and at a lower level (median 3.27 versus 6.71 log10 c/mL, p < 0.001) with more frequent testing, but this difference was not evident in plasma first detection (80 versus 95 days, p = 0.536) or first positive viral load (3.18 versus 3.30 log10 c/mL, p = 0.603). The optimum cut-off BK viral load for histological diagnosis of BKVN was 4.10 log10 c/mL for the first positive urine, 3.79 log10 c/mL for the first positive plasma, 9.24 log10 c/mL for the peak urine, and 4.53 log10 c/mL for the peak plasma. CONCLUSIONS: Frequent urinary BK viral load screening for the prevention of BKVN is suggested due to its high sensitivity and earlier detection.

Lateral Extra-articular Tenodesis Reduces Rotational Laxity When Combined With Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Literature.

PURPOSE: To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction would provide greater control of rotational laxity and improved clinical outcomes compared with ACL reconstruction alone. METHODS: Two independent reviewers searched 9 databases for randomized and nonrandomized clinical studies comparing ACL reconstruction plus LET versus ACL reconstruction alone in a human adult population. All years and 5 languages were included. Animal and cadaveric studies, revision or repair surgical techniques, and studies focused on biomechanical outcomes were excluded. Quality assessment of the included studies was performed with the Cochrane Collaboration tool. Outcomes of interest included the pivot-shift test, KT-1000/-2000 measurements (MEDmetric, San Diego, CA), and International Knee Documentation Committee scores. RESULTS: The literature search yielded 3,612 articles. After titles and abstracts were reviewed, 106 articles were selected for full-text review, of which 29 studies met the inclusion criteria (8 randomized and 21 nonrandomized studies). Of the 8 randomized studies, 3 concluded that the results were nonsignificant between treatment groups, 4 were in favor of the extra-articular tenodesis, and 1 was in favor of the ACL reconstruction alone. The Cochrane Collaboration tool showed an unclear to high risk of bias for most articles. A meta-analysis showed a statistically significant difference for the pivot-shift test (P = .002, I2 = 34%) in favor of ACL reconstruction with LET. No difference was found between the groups for International Knee Documentation Committee scores (P = .75, I2 = 19%) and KT-1000/-2000 measurements (P = .84, I2 = 34%). CONCLUSIONS: Meta-analysis showed a statistically significant reduction in pivot shift in favor of the combined procedure. Studies lacked sufficient internal validity, sample size, methodologic consistency, and standardization of protocols and outcomes. LEVEL OF EVIDENCE: Level III, systematic review of Level I, II, and III studies.

Stool culture.

Stool culture is a laboratory test used to determine the aetiology of infective, bacterial diarrhoea. It refers to the inoculation of selective agar plates with faeces and incubation for 1-2 days to detect the presence of pathogenic bacteria within the bowel flora.