The Oswestry Spinal Risk Index (OSRI): an external validation study.

PURPOSE: The Oswestry Spinal Risk Index (OSRI) was recently reported as an adjunct in the management of metastatic spinal disease. Based on the tumour type and a general condition score, survivorship is predicted. We aimed to externally validate this new score. METHODS: We assessed the survivorship of 121 patients identified from a prospectively collated database in the National Spinal Injuries Unit in the Republic of Ireland. Actual survivorship was calculated according to the tumour subtype and general conditioning, according to the Karnofsky Performance Score (OSRI = Primary Tumour Pathology + (2-General Conditioning Score)). Our results were then compared to those previously published. RESULTS: 45.5 % were female (n = 55). The mean age at presentation was 61.5 years (range 23-85). Breast and prostate cancers were the most frequent diseases encountered. The actual survival in our cohort closely mirrored the predicted survival, according to the equation used to calculate the OSRI with an overall strong correlation found (r = 0.798, p = 0.001). CONCLUSION: We found that the OSRI is a simple to use scoring system. We found a strong correlation in our results with the predicted survivorship based on the OSRI. The OSRI can be used as a useful adjunct in the management of patient with metastatic disease of the spine.

Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.

The Internet has become a major source of health information for the public. However, there are concerns regarding the quality, accuracy, and currency of medical information available online. We assessed the quality of information about anterior cruciate ligament (ACL) reconstruction on the first 60 websites returned by the 4 most popular search engines. Each site was categorized by type and assessed for quality and validity using the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria, and a novel ACL reconstruction-specific content score. The presence of the Health On the Net Code (HONcode), a purported quality assurance marker, was noted. The quality of information on ACL reconstruction available online is variable, with many websites omitting basic information regarding treatment options, risks, and prognosis. Commercial websites predominate. Academic and allied health professional websites attained the highest DISCERN and JAMA benchmark scores, whereas physician sites achieved the highest content scores. Sites that bore the HONcode seal obtained higher DISCERN and ACL reconstruction content scores than those without this certification. The HONcode seal is a reliable indicator of website quality, and we can confidently advise our patients to search for this marker.

Internet use by parents of children attending a dedicated scoliosis outpatient clinic.

PURPOSE: No information exists on the level of internet use among parents of pediatric patients with scoliosis. The internet may represent a medium through which to provide information to augment the outpatient consultation. The aim of this research was to establish the prevalence of internet use amongst a cohort of parents attending a pediatric scoliosis outpatient clinic. METHODS: A previously used questionnaire (Baker et al., Eur Spine J, 19:1776-1779, 2010) was distributed to parents attending a dedicated scoliosis outpatient clinic with their children. Demographic data and details about use of the internet were collected. RESULTS: Fifty-eight percent of respondents had used the internet to search for information on scoliosis, and 94 % were interested in a local internet provided information provision. A positive history of corrective surgery and possession of health insurance were independent positive predictors of internet use. CONCLUSIONS: As surgeons we need to be aware of our patients' use of the internet, and there is the opportunity to use this medium to provide additional education.

Can a periarticular levobupivacaine injection reduce postoperative opiate consumption during primary hip arthroplasty?

BACKGROUND: Several reports have confirmed the ability of intraoperative periarticular injections to control pain after THA. However, these studies used differing combinations of analgesic agents and the contribution of each, including the local anesthetic agent, is uncertain. Understanding the independent effects of the various agents could assist in improved pain management after surgery. QUESTIONS/PURPOSES: We therefore determined the ability of intraoperative periarticular infiltration of levobupivacaine to (1) reduce postoperative pain, (2) reduce postoperative morphine requirements, and (3) reduce the incidence of nausea and urinary retention. PATIENTS AND METHODS: A double-blinded, randomized, placebo-controlled trial of patients undergoing primary THAs was performed. Patients were randomized to receive a periarticular infiltration of 150 mg levobupivacaine in 60 mL 0.9% saline (n = 45) or a placebo consisting of 60 mL 0.9% saline (n = 46). We obtained a short-form McGill pain score, visual analog scale (VAS), and morphine requirements via patient-controlled analgesia (PCA) as primary measures. Postoperative antiemetic requirements and need for catheterization for urinary retention were determined as secondary measures. RESULTS: Subjectively reported pain scores and the overall intensity scores were similar for both groups in the postoperative period. At the same time the mean morphine consumption was less in the levobupivacaine group, most notable in the first 12 hours after surgery: treatment group 11.5 mg vs control group 21.2 mg. We observed no differences in the frequency of postoperative nausea and vomiting or urinary retention. CONCLUSIONS: Our observations suggest periarticular injection of levobupivacaine can supplement available postoperative analgesic techniques and reduce postoperative morphine requirements after THA. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography of the hip is dependent on specialist training of the radiologist.

OBJECTIVE: Significant differences between magnetic resonance imaging reports and intraoperative findings at the time of hip arthroscopy were documented in our practice. We sought to examine the accuracy of radiological reporting of hip pathology based on the training level of the reporting radiologist. MATERIALS AND METHODS: A retrospective review of hip arthroscopies carried out between July 2008 and June 2009 identified 61 cases where original MRI scans had been reported by general community radiologists. These scans were then reviewed by musculoskeletal specialist radiologists who were blinded to both the original report and the surgical findings. Accuracy of both subsets of radiologists was compared to arthroscopic findings with regard to labral, acetabular, femoral and impingement lesions. RESULTS: Musculoskeletal radiologists performed better than community radiologists in terms of overall accuracy. Accuracy rates for MSK radiologists were 85, 79, 59, and 82% for labral, acetabular chondrosis, and femoral chondrosis and impingement lesions, respectively. Whereas accuracy rates for community radiologists were 70, 28, 52, and 59% (p values = 0.08, <0.001, 0.59, <0.001). Accuracy was significantly improved for both groups of radiologists when MR arthrograms were reviewed rather than conventional MRIs. CONCLUSIONS: This study establishes the relationship between accuracy of reporting and the training level of the performing radiologists.

The 25 most cited articles in arthroscopic orthopaedic surgery.

PURPOSE: The purpose of this study was to use Web of Knowledge to determine which published arthroscopic surgery-related articles have been cited most frequently by other authors by ranking the 25 most cited articles. We furthermore wished to determine whether there is any difference between a categorical "journal-by-journal" analysis and an "all-database" analysis in arthroscopic surgery and whether such a search methodology would alter the results of previously published lists of "citation classics" in the field. We analyzed the characteristics of these articles to determine what qualities make an article important to this subspecialty of orthopaedic surgery. METHODS: Web of Knowledge was searched on March 7, 2011, using the term "arthroscopy" for citations to articles related to arthroscopy in 61 orthopaedic journals and using the all-database function. Each of the 61 orthopaedic journals was searched separately for arthroscopy-related articles to determine the 25 most cited articles. An all-database search for arthroscopy-related articles was carried out and compared with a journal-by-journal search. Each article was reviewed for basic information including the type of article, authorship, institution, country, publishing journal, and year published. RESULTS: The number of citations ranged from 189 to 567 in a journal-by-journal search and from 214 to 1,869 in an all-database search. The 25 most cited articles on arthroscopic surgery were published in 11 journals: 8 orthopaedic journals and 3 journals from other specialties. The most cited article in arthroscopic orthopaedic surgery was published in The New England Journal of Medicine, which was not previously identified by a journal-by-journal search. CONCLUSIONS: An all-database search in Web of Knowledge gives a more in-depth methodology of determining the true citation ranking of articles. Among the top 25 most cited articles, autologous chondrocyte implantation/transplantation is currently the most cited and most popular topic in arthroscopic orthopaedic surgery and research. CLINICAL RELEVANCE: Analysis of the 25 most cited articles allows us to identify the most popular field of research in arthroscopic orthopaedic surgery and gives us insight into the quality and characteristics that are required for an article to become highly cited.

Analgesic control and functional outcome after knee arthroscopy: results of a randomized double-blinded trial comparing a hyaluronic acid supplement with bupivacaine.

OBJECTIVE: Hyaluronic acid (HA) is a naturally occurring substance within normal synovial joints. Although its efficacy in treating osteoarthritis has been evaluated, it has not been established whether it is of benefit after routine arthroscopic procedures. We hypothesized that immediate supplementation with HA after completion of arthroscopy would result in improved short-term analgesic and functional outcomes after knee arthroscopy. DESIGN: Double-blinded randomized controlled trial. SETTING: Tertiary referral center. PATIENTS: One hundred ten patients presenting for routine arthroscopic procedures were invited to participate in the study. After exclusion criteria were applied, 98 patients were randomized to receive either 10 mL of 0.5% bupivacaine or 3 mL of HA into the joint immediately after completion of surgery. INTERVENTIONS: After completion of surgery, all patients were randomized to receive either 10 mL of 0.5% bupivacaine or 3 mL of HA into the knee joint. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) pain scores were obtained at baseline; 1, 2, and 24 hours; and 1, 2, and 6 weeks after surgery. Western Ontario and McMaster Universities (WOMAC) and Tegner-Lysholm scores were obtained at baseline and then at 1, 2, and 6 weeks after surgery. RESULTS: Forty-nine patients received intra-articular bupivacaine and 49 received HA. There was no statistical difference in any of the outcome measures (VAS pain scores, WOMAC, and Tegner-Lysholm) at any time point between the groups overall. CONCLUSIONS: There was no benefit of HA injection immediately at the end of knee arthroscopy in the first 6 weeks after surgery. CLINICAL RELEVANCE: Routine use of HA at the time of knee arthroscopy cannot be recommended.

Pravastatin suppresses matrix metalloproteinase expression and activity in human articular chondrocytes stimulated by interleukin-1ß.

BACKGROUND: Matrix metalloproteinases are catabolic enzymes that play a key role in the articular cartilage degeneration evident in degenerative and inflammatory conditions of articular cartilage. The aim of this study is to assess the ability of pravastatin to modify matrix metalloproteinase (MMP) messenger RNA (mRNA) expression and enzyme activity in a culture of normal human chondrocytes stimulated by interleukin-1ß. MATERIALS AND METHODS: Normal human chondrocytes were stimulated with interleukin (IL)-1ß for 6 h to induce MMP expression, simulating a catabolic state, and then treated with pravastatin (1, 5 and 10 µM) for a further 18 h before cell lysates and supernatants were harvested. Cells stimulated with IL-1ß but not treated with pravastatin served as controls. Real-time polymerase chain reaction (PCR) was used to assess expression of MMP-3 and MMP-9 mRNA. MMP enzyme activity was assessed using a fluorescent MMP-specific substrate. Statistical analysis was performed using analysis of variance (ANOVA). RESULTS: MMP-3 and MMP-9 mRNA expression was reduced at all concentrations tested with statistically significant trends in reduction (p = 0.002 and <0.001, respectively). Analysis of culture supernatants revealed that pravastatin treatment led to a reduction in total MMP activity but not to a statistically significant degree (p = 0.07). CONCLUSIONS: Treatment with pravastatin of stimulated human chondrocytes leads to significant down-regulation of selected MMP genes and a non-significant reduction in MMP enzyme activity. Our results provide further evidence that statins may have a role to play in future treatment of disease affecting articular chondrocytes.

Human chondrocyte viability after treatment with local anesthetic and/or magnesium: results from an in vitro study.

PURPOSE: We aimed to assess the effect on chondrocyte viability of adding magnesium to a variety of commonly available local anesthetic agents. METHODS: Human chondrocytes were grown under standard culture conditions. Cells were exposed to a local anesthetic agent with the addition of magnesium (10%, 20%, or 50%). Cells were also exposed to the varying concentrations of magnesium and 0.9% saline solution. Untreated cells served as controls. The CellTiter 96 AQueous One Solution Cell Proliferation Assay was used to assess for cell viability 24 hours after exposure. One-way analysis of variance was used to test for statistical significance. RESULTS: Magnesium sulfate alone was no more toxic than normal saline solution (P > .3) compared with untreated cells. The addition of magnesium to the local anesthetic agents resulted in greater cell viability than when cells were treated with a local anesthetic alone (lidocaine [P = .033], levobupivacaine [P = .007], bupivacaine [P < .001], and ropivacaine [P < .001]). CONCLUSIONS: Our findings support the use of magnesium either alone or in combination with a local anesthetic rather than a local anesthetic alone, and this represents a potential strategy for the reduction of chondrocyte toxicity associated with intra-articular local anesthetic administration after arthroscopy. CLINICAL RELEVANCE: The addition of magnesium to a local anesthetic results in a reduced toxic effect to the articular chondrocyte. This may represent a potential approach to intra-articular analgesia.

Post-operative opiate requirements after hip arthroscopy.

PURPOSE: Although hip arthroscopy continues to evolve in its use and its popularity grows, little attention has been paid to the anaesthetic and analgesic management of patients undergoing this procedure. We aimed to report on our initial experience of the anaesthetic and analgesic requirements of a consecutive series of patients undergoing hip arthroscopy. METHODS: We reviewed the surgical and anaesthetic records of the initial, consecutive 85 patients undergoing hip arthroscopy for any reason at our hospital. Basic demographics, intra-operative findings, operative procedures, analgesic requirements in the form of opiate requirement and post-operative pain scores were reviewed. RESULTS: The mean intra-operative morphine dose was 7.1 mg (S.D. 3.2 mg). Thirty-nine patients (46%) required I.V. morphine at in the recovery room post-arthroscopy (mean 1.8 mg; S.D. 2.6 mg). Regression analysis showed that lower intra-operative opiate dose resulted in higher maximum VAS pain scores (P = 0.03) and rescue intravenous opiate (P < 0.001) requirement post-surgery. CONCLUSIONS: Adequate intra-operative morphine use can minimize post-operative pain and subsequent need for rescue analgesia.

Simulation of tissue differentiation in a scaffold as a function of porosity, Young's modulus and dissolution rate: application of mechanobiological models in tissue engineering.

Numerous experimental studies have attempted to determine the optimal properties for a scaffold for use in bone tissue engineering but, as yet, no computational or theoretical approach has been developed that suggests how best to combine the various design parameters, e.g. scaffold porosity, Young's modulus, and dissolution rate. Previous research has shown that bone regeneration during fracture healing and osteochondral defect repair can be simulated using mechanoregulation algorithms based on computing strain and/or fluid flow in the regenerating tissue. In this paper a fully three-dimensional approach is used for computer simulation of tissue differentiation and bone regeneration in a regular scaffold as a function of porosity, Young's modulus, and dissolution rate--and this is done under both low and high loading conditions. The mechanoregulation algorithm employed determines tissue differentiation both in terms of the prevailing biophysical stimulus and number of precursor cells, where cell number is computed based on a three-dimensional random-walk approach. The simulations predict that all three design variables have a critical effect on the amount of bone regenerated, but not in an intuitive way: in a low load environment, a higher porosity and higher stiffness but a medium dissolution rate gives the greatest amount of bone whereas in a high load environment the dissolution rate should be lower otherwise the scaffold will collapse--at lower initial porosities however, higher dissolution rates can be sustained. Besides showing that scaffolds may be optimised to suit the site-specific loading requirements, the results open up a new approach for computational simulations in tissue engineering.

Predicting revision risk for aseptic loosening of femoral components in total hip arthroplasty in individual patients--a finite element study.

Advances in surgical procedure, prosthesis design, and biomaterials performance have considerably increased the longevity of total joint replacements. Preoperative planning is another step in joint replacement that may have the potential to improve clinical outcome for the individual patient, but has remained relatively consistent for a long time. One means of advancing this aspect of joint replacement surgery may be to include predictive computer simulation into the planning process. In this article, the potential of patient-specific finite element analysis in preoperative assessment is investigated. Seventeen patient-specific finite element models of cemented Charnley reconstructions were created, of which six were early (<10 years) revisions. Creep was simulated using a Maxwell model, and fatigue damage was simulated using an anisotropic continuum damage formulation. Account was taken of the relationship between annual loading cycles and age, and stair-climbing loads were included using a walking to stair-climbing cycle ratio of 9:1. Simulations for the equivalent of 10 years of loading were performed. Accumulated damage, inducible displacement, and migration were computed. Five of the six early revisions had the highest migration indicating that migration could have been used to identify early failures of these prostheses. Resultant migration showed the most significant difference between the early revised and unrevised groups (p = 0.0024). Furthermore, this trend was apparent from 1 year postimplantation (p = 0.0052). This ability to differentiate early revisions shows that computational simulation of aseptic loosening in cemented prostheses could prove clinically useful in helping surgeons optimize the preoperative plan for individual patients.

Scoliosis and the Social Media: Facebook as a Means of Information Exchange.

BACKGROUND CONTEXT: Over the last decade, the emergence of social networking websites such as Facebook have revolutionized information dissemination and broadened opportunities to engage in discussions. In particular, having been widely adopted in the younger generation, the use of this medium has become more prevalent in health disorders such as scoliosis in the adolescent population. However, the quality of information on Facebook is unregulated and variable, which may mislead patients in their decision making. PURPOSE: To document the various types of information available and assess the quality of information on Facebook discussion boards using recognized scoring systems. STUDY DESIGN: To evaluate the quality of information on the social network. PATIENT SAMPLE: A search for the keyword "scoliosis" on Facebook was performed and the first 100 pages generated were reviewed. OUTCOMES MEASURED: SCSS and DISCERN score. METHODS: Content analysis was performed on discussion boards and personal blogs. Two independent examiners evaluated each site according to scoliosis-specific content score (SCSS) and the DISCERN criteria, both previously used instruments to judge the quality of information on the Internet pertaining to scoliosis. The SCSS range from 0 to 32 (higher score better) and the DISCERN 16 to 80 (higher score better). RESULTS: Of the 100 sites reviewed, 33 were discussion boards and personal blogs. Of these, the overall average SCSS was 5.7 (SD 5.8, range 0-20) and the DISCERN was 22.5 (SD 7.6, range 16-45), indicating that using general scoring systems the quality of information provided was overall poor. CONCLUSION: Using recognized scoring systems to analyze Facebook pages used as discussion forums or blogs, we showed that the quality in general was poor. For modern practices to adapt to an era of information exchange via the social network, the orthopedic community should develop ways to incorporate the social media in future patient education.

Clinico-pathological analysis of renal cell carcinoma demonstrates decreasing tumour grade over a 17-year period.

INTRODUCTION: Renal cell carcinoma (RCC) represents about 3% of adult malignancies in Ireland. Worldwide there is a reported increasing incidence and recent studies report a stage migration towards smaller tumours. We assess the clinico-pathological features and survival of patients with RCC in a surgically treated cohort. METHODS: A retrospective analysis of all nephrectomies carried out between 1995 and 2012 was carried out in an Irish tertiary referral university hospital. Data recorded included patient demographics, size of tumour, tumour-node-metastasis (TNM) classification, operative details and final pathology. The data were divided into 3 equal consecutive time periods for comparison purposes: Group 1 (1995-2000), Group 2 (2001-2006) and Group 3 (2007-2012). Survival data were verified with the National Cancer Registry of Ireland. RESULTS: In total, 507 patients underwent nephrectomies in the study period. The median tumour size was 5.8 cm (range: 1.2-20 cm) and there was no statistical reduction in size observed over time (p = 0.477). A total of 142 (28%) RCCs were classified as pT1a, 111 (21.9%) were pT1b, 67 (13.2%) were pT2, 103 (20.3%) were pT3a, 75 (14.8%) were pT3b and 9 (1.8%) were pT4. There was no statistical T-stage migration observed (p = 0.213). There was a significant grade reduction over time (p = 0.017). There was significant differences noted in overall survival between the T-stages (p < 0.001), nuclear grades (p < 0.001) and histological subtypes (p = 0.022). CONCLUSION: There was a rising incidence in the number of nephrectomies over the study period. Despite previous reports, a stage migration was not evident; however, a grade reduction was apparent in this Irish surgical series. We can demonstrate that tumour stage, nuclear grade and histological subtype are significant prognosticators of relative survival in RCC.

Scoliosis-specific information on the internet: has the "information highway" led to better information provision?

STUDY DESIGN: A quality-control Internet-based study using recognized quality scoring systems. OBJECTIVE: To evaluate the quality of information available on the Internet. SUMMARY OF BACKGROUND DATA: The quality of information available is of poor quality and unreliable, and this study was to determine if it has improved in line with the exponential increase in Internet-based information since the last time it was reviewed in 2005. METHODS: To identify potential Web sites, the 5 most commonly accessed search engines were identified and a search for "scoliosis" was performed on each. The top 100 Web sites were reviewed. Each Web site was categorized according to its authorship and assessed using recognized scoring systems (Journal of American Medical Association [JAMA] and DISCERN criteria, scoliosis-specific content quality). The presence of the Health on the Net code, a reported quality-assurance marker, was noted. RESULTS: Forty-one unique Web sites were identified and analyzed. Five were academic, 11 were produced by physicians, 5 were commercial, 3 were nonphysician sites, 6 were attached to discussion groups or social media sites, 3 were media related, and 8 were not otherwise classifiable. There were significant differences noted between the authorship categories on the DISCERN score, JAMA benchmark criteria, and scoliosis-specific content quality score, (P = 0.001, <0.0001, and 0.009, respectively) with academic- and physician-related Web sites containing better-quality information. Internet sites with a Health on the Net code demonstrated higher-quality scoliosis-specific information than those without the code (P = 0.1368). CONCLUSION: The overall quality of information regarding scoliosis remains poor despite an exponential increase in the number of sites available. Patients need to be educated about appropriate Internet use-academic- and physician-provided sites have been shown to contain better-quality information. We have a potential role as clinicians to not only direct patients to appropriate sites but also to help in developing content on the Internet.

Simulation of fracture healing in the tibia: mechanoregulation of cell activity using a lattice modeling approach.

In this study, a three-dimensional (3D) computational simulation of bone regeneration was performed in a human tibia under realistic muscle loading. The simulation was achieved using a discrete lattice modeling approach combined with a mechanoregulation algorithm to describe the cellular processes involved in the healing process-namely proliferation, migration, apoptosis, and differentiation of cells. The main phases of fracture healing were predicted by the simulation, including the bone resorption phase, and there was a qualitative agreement between the temporal changes in interfragmentary strain and bending stiffness by comparison to experimental data and clinical results. Bone healing was simulated beyond the reparative phase by modeling the transition of woven bone into lamellar bone. Because the simulation has been shown to work with realistic anatomical 3D geometry and muscle loading, it demonstrates the potential of simulation tools for patient-specific pre-operative treatment planning.

Review article: Osteochondral reconstruction and grafting.

Osteochondral defects are a challenging problem. Osteochondral reconstruction and grafting techniques potentially benefit both young athletes and elderly osteoarthritis patients. Research on the treatment of osteochondral defects has been carried out, particularly on surgical options, but none shows lasting benefit. More objective evaluation of cartilage injuries and outcomes is needed. We present a review of surgical and non-surgical treatments for osteochondral defects, and their outcomes and costs.

Analgesic control after hip arthroscopy: a randomised, double-blinded trial comparing portal with intra-articular infiltration of bupivacaine.

The optimum anaesthetic and analgesic management following hip arthroscopy is yet to be determined. There is, in addition, some concern over the use of intraarticular local anaesthetic. We compared the analgesic efficacy of intra-articular infiltration compared with portal infiltration of bupivacaine following hip arthroscopy. Patients were randomised to receive either 10 ml of 0.25% bupivacaine either into the joint or around the portal sites following completion of surgery. 73 patients were recruited (40 intra-articular). The portal infiltration group required significantly more rescue analgesia immediately after surgery (2.33 mg vs.0.57 mg, p=0.036). Visual Analogue Scale pain scores were not significantly different at 1 and 2 hours following surgery, but at 6 hours the portal group had significantly lower VAS scores (p=0.0036). We believe that the initial pain following surgery results from capsular injury and this explains the need for more rescue analgesia in the portal infiltration group. Further work is needed to establish the ideal regimen. A combination of portal and intra-articular infiltration may be the most efficacious.