Large symptomatic sacral Tarlov cyst in a paediatric patient: case report and technical note on a new variation of surgical technique to overcome one-way check-valve mechanism.

PURPOSE: Symptomatic Tarlov cysts in children with a possible underlying one-way check-valve mechanism are very rare. We aim to introduce a new variation of the surgical technique to overcome a check-valve mechanism. METHODS: A 15-years-old girl presented with double incontinence and anogenital numbness due to a large sacral Tarlov-cyst with possibly underlying one-way check valve mechanisms as suggested by preoperative computed tomography myelography. Intraoperatively, one-way check-valve was confirmed and could be eliminated by creating an artificial inner ostium between the Tarlov cyst and thecal sac with blunt perforation. RESULTS: Postoperatively, the patient had established normal sphincter control and sensation in the anogenital region. CONCLUSION: One-way check-valve mechanism might contribute to the symptomatology of large sacral Tarlov cysts in children. Our new variation of a surgical technique enables elimination of the check-valve mechanism without the necessity to open and close the typically very thin and fragile cyst surface and is therefore an efficacious and simple option in this situation.

The rising burden of penetrating knife injuries.

INTRODUCTION: Knife crime remains an area of public health concern. In order to tackle this problem and reduce its burden, the epidemiology of penetrating knife injuries needs to be understood. The aim of this study is to analyse the pattern of knife injuries at a major trauma centre (MTC) in London. METHODS: An analysis of cases from the prospectively collected Trauma Audit and Research Network database of patients attending the emergency department with violent intentional knife injuries from January 2014 to December 2018 was performed. Registry data were analysed for mechanism of injury, number of stabbings, month/date/time of admission, patient demographics, anatomical pattern of injury, hospital length of stay, intervention, ethnicity, repeat victims and fatality. RESULTS: 1373 penetrating knife injuries activated the major trauma call representing 11.7% of all major trauma alerts. 44% occurred in the 16-25 years age group and 85.6% were male. 67.2% required hospital admission. 14.1% required surgery. 50.3% required intervention from multiple specialities. 39.4% had thoracic injuries and 25.8% abdominal injuries. Fatality rate was 0.9% (n=12). 3.6% were repeat victims. 26.8% were multiple stabbings. 5.2% were deliberate self-harm. 23.2% were of white ethnic background. Injury incidence peaked on a Saturday. A significant peak in injuries occurred between 22:00 and 00:00. CONCLUSION: This study shows an increase in the incidence of knife crime per year. These cases contribute approximately 12% of major trauma calls. Female assaults increased from 8.4% to 14.3%. Approximately 2/3 injuries occur in the thorax and abdomen with high frequencies at weekends and evenings. These facts can help allocate resources more efficiently.

Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review.

Controversy surrounding the classification of thoracolumbar injuries has given rise to various classification systems over the years, including the most recent AOSpine Thoracolumbar Injury Classification System (ATLICS). This systematic review aims to provide an up-to-date evaluation of the literature, including assessment of a further three studies not analysed in previous reviews. In doing so, this is the first systematic review to include the reliability among non-spine subspecialty professionals and to document the wide variety between reliability across studies, particularly with regard to sub-type classification. Relevant studies were found via a systematic search of PubMed, EBESCO, Cochrane and Web of Science. Data extraction and quality assessment were conducted in line with Cochrane Collaboration guidelines. Twelve articles assessing the reliability of ATLICS were included in this review. The overall inter-observer reliability varied from fair to substantial, but the three additional studies in this review, compared to previous reviews, presented on average only fair reliability. The greatest variation of results was seen in A1 and B3 subtypes. Least reliably classified on average was A4 subtype. This systematic review concludes that ATLICS is reliable for the majority of injuries, but the variability within subtypes suggests the need for further research in assessing the needs of users in order to increase familiarity with ATLICS or perhaps the necessity to include more subtype-specific criteria into the system. Further research is also recommended on the reliability of modifiers, neurological classification and the application of ATLICS in a paediatric context.

Comparable clinical and radiological outcomes between skipped-level and all-level plating for open-door laminoplasty.

PURPOSE: To compare the clinical and radiological outcomes between skipped-level and all-level plating for cervical laminoplasty. METHODS: Patients with cervical spondylotic myelopathy (CSM) treated by open-door laminoplasty with minimum 2-year postoperative follow-up were included. All patients had opening from C3-6 or C3-7 and were divided into skipped-level or all-level plating groups. Japanese Orthopaedic Association (JOA) scores and canal measurements were obtained preoperatively, immediate (within 1 week) postoperatively, and at 2, 6 weeks, 3, 6 and 12 months postoperatively. Paired t test was used for comparative analysis. Receiver operating characteristic analysis was used to determine the canal expansion cutoff for spring-back closure. RESULTS: A total of 74 subjects were included with mean age of 66.1 ± 11.3 years at surgery. Of these, 32 underwent skipped-level plating and 42 underwent all-level plating. No significant differences were noted between the two groups at baseline and follow-up. Spring-back closure was observed in up to 50% of the non-plated levels within 3 months postoperatively. The cutoff for developing spring-back closure was 7 mm canal expansion for C3-6. No differences were observed in JOA scores and recovery rates between the two groups. None of the patients with spring-back required reoperation. CONCLUSIONS: There were no significant differences between skipped-level and all-level plating in terms of JOA or recovery rate, and canal diameter differences. This has tremendous impact on saving costs in CSM management as up to two plates per patient undergoing a standard C3-6 laminoplasty may be omitted instead of four plates to every level to achieve similar clinical and radiological outcomes. LEVEL OF EVIDENCE: III. These slides can be retrieved under Electronic Supplementary Material.

Eliminating the use of allogeneic blood products in adolescent idiopathic scoliosis surgery.

PURPOSE: The aim of this study was to compare transfusion requirements in patients before and after the introduction of tranexamic acid as standard in patients undergoing spinal surgery for idiopathic scoliosis in a national orthopaedic hospital. METHODS: A retrospective chart review of 56 idiopathic scoliosis patients who underwent posterior spinal instrumentation and fusion between 2009 and 2013 at our institution. Preoperative, intraoperative, and postoperative data were measured. RESULTS: Patients who received tranexamic acid as standard (n = 31) showed a trend towards a decrease in transfusion requirements compared with those who received no tranexamic acid (n = 25). These patients had a statistically significant decrease in operative time (223 vs 188 min, p = 0.005), and estimated intraoperative blood loss was reduced by nearly 50% in the tranexamic acid group. They also had an associated reduced decrease in haemoglobin between preoperative and postoperative levels (4 vs 5 g/dL, p = 0.01). CONCLUSIONS: Since February 2012, no patient has required intraoperative or postoperative allogeneic blood product transfusion in this hospital. The routine use of antifibrinolytic medications in patients undergoing surgery for adolescent idiopathic scoliosis has effectively eliminated the need for allogeneic blood products.

Fetal Scoliosis: Natural History and Outcomes.

INTRODUCTION: Scoliosis can be detected on prenatal ultrasonography and may be associated with structural and syndromic abnormalities. Associations and pregnancy outcomes related to the prenatal diagnosis of scoliosis are poorly understood. METHODS: A retrospective cohort study was undertaken at a tertiary referral center in London. Referred cases with spinal deformities between 1997 and 2021 were identified from the prenatal ultrasonography database. Outcomes were ascertained from the database and electronic notes. RESULTS: One hundred twenty-three cases of fetal spinal deformities (scoliosis, kyphosis, or kyphoscoliosis) were identified from a referral population of 660,000 pregnancies, giving an incidence of approximately 0.2 per 1000 fetuses. Fifty-eight live births (47.2%) and 65 cases (52.8%) of fetal or neonatal demise or termination were observed. Most live births were isolated spinal deformities with a good postnatal outcome (n = 35, 60.3%). The commonest syndromic diagnosis in this group was VACTERL association (n = 7, 12.1%). Most cases of fetal loss were associated with severe malformations, most commonly spina bifida, body stalk anomaly and amniotic band sequence, or chromosomal abnormalities, except in 2 cases (3.1%). CONCLUSIONS: This is the largest reported cases series to date of prenatally diagnosed fetal spinal deformity. This confirms that fetal scoliosis and associated vertebral abnormalities are underdiagnosed prenatally, with the reported incidence (0.2 per 1000) lower than the recognized incidence of congenital scoliosis (1 in 1,000). The concurrent finding of severe malformations was strongly associated with fetal loss. When an isolated finding, most fetal spinal deformities had a good postnatal outcome, while 1:8 live births were diagnosed with VACTERL association.

Evaluation of computed tomography artefacts of carbon-fiber and titanium implants in patients with spinal oligometastatic disease undergoing stereotactic ablative radiotherapy.

This study evaluated artefacts on computed tomography (CT) images using Hounsfield units (HU) in patients with spinal oligometastatic disease who received carbon-fiber (CF; n = 11) or titanium (n = 11) spine implants and underwent stereotactic ablative radiotherapy (SABR). Pre- and postoperative HU were measured at the vertebral body, pedicle, and spinal cord at three different levels: the lower instrumented vertebra, the level of metastatic spinal cord compression, and an uninvolved level. Areas measured at each level were delicately matched pre- and postoperatively. Significant differences in HU were observed at the vertebral body, the pedicle, and the spinal cord at the lowest instrumented vertebra level for both CF and titanium (average increase 1.54-fold and 5.11-fold respectively). At the metastatic spinal cord compression level, a trend towards a higher HU-increase was observed in titanium compared with CF treated patients (average increase 2.51-fold and 1.43-fold respectively). The relatively high postoperative HU-increase after insertion of titanium implants indicated CT artefacts, while the relatively low HU-increase of CF implants was not associated with artefacts. Less CT artefacts could facilitate an easier contouring phase in radiotherapy planning. In addition, we propose a CT artefact grading system based on postoperative HU-increase. This system could serve as a valuable tool in future research to assess if less CT artefacts lead to time savings during radiotherapy treatment planning and, potentially, to better tumoricidal effects and less adverse effects if particle therapy would be administered.

Antiviral Effects and Mechanisms of Green Tea Catechins on Influenza: A Perception on Combating Symptoms from COVID-19.

Over the centuries, influenza and its associated epidemics have been a serious public health problem. Although vaccination and medications (such as neuraminidase inhibitors) are the mainstay of pharmacological approaches to prevent and treat influenza, however, frequent mutations in the influenza genome often result in treatment failure and resistance to standard medications which limit their effectiveness. In recent years, green tea catechins have been evaluated as potential anti-influenza agents. Herein, in this review, we highlighted the effects and mechanisms underlying the inhibitory effects of epigallocatechin 3-gallate (EGCG), the most abundant ingredient in green tea, against different influenza viral infections, and their clinical benefits toward prevention and treatment. In addition, as the severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) causes the outbreak of COVID-19 pandemic, our review also delineates the current perspective on SARS-CoV-2 and future insights as to the potential application of EGCG on suppressing the flu-like symptoms caused by COVID-19.

Acute nontraumatic spinal intradural hematoma in a patient on warfarin.

BACKGROUND: Nontraumatic spinal intradural extramedullary hematomas are extremely rare. When they occur, they can rapidly lead to spinal cord or cauda equina compression and have devastating consequences. OBJECTIVE: The aim here was to report a case of this rare phenomenon and discuss the etiology, imaging, management, and outcome of intradural hematomas. CASE REPORT: We describe the case of a 76-year-old man on warfarin therapy who presented with severe lower back pain and flaccid paraparesis. Blood tests revealed an international normalized ratio of 6.0. A magnetic resonance imaging result suggested an intradural hematoma extending from L1 to L4 and compressing the spinal cord and cauda equina. Emergency surgical decompression revealed an extensive intradural extramedullary hematoma, which was evacuated. The patient showed only minor neurologic improvement 6 months postoperatively. CONCLUSIONS: Coagulopathy-induced spinal hemorrhage should be included in the differential diagnosis for patients presenting with signs of acute spinal cord compression.

Preoperative comorbidity and modes of failure in revision hip arthroplasty: a single-surgeon series in a tertiary referral centre.

Revision hip arthroplasty is associated with higher morbidity post-operatively than primary surgery. We reviewed data on 102 consecutive patients (124 procedures) undergoing revision hip arthroplasty by a single surgeon from January 2005 to June 2009 in 2 institutions. Indications of failure: 62% aseptic loosening, 15% infection, 11.5% fracture, 10.6% dislocation or instability and 0.9% implant failure. Preoperative comorbidities: 28.4% cardiac, 4% respiratory and 6.8% diabetic. Morbidity: 3.9% complication rate (5 of 124 procedures). 73.5 median age and 46% over 75 years old. Modes of failure in our population leading to revision hip arthroplasty are similar to other studies. We showed a low morbidity following revision hip arthroplasty despite significant preoperative comorbidities and a high proportion of elderly patients. In conclusion, gender, age (>75) and preoperative comorbidities should not deter from revision surgery.

A narrative exploration of identity in adults with de novo scoliosis.

Adult de novo scoliosis is a chronic health condition characterised by a curvature in the ageing spine. It can cause debilitating back pain and significant visible differences. Yet there has been very limited research on the psychological effects of this condition, particularly around identity. Therefore, we undertook semi-structured interviews to explore the ways in which individuals with scoliosis understood their identity. Findings from narrative analysis highlight the ways in which individuals negotiate their identity in relation to their social roles, their ability to control their condition and things around them, the extent to which their condition is visible and the extent to which they experienced physical pain from their condition. This article concludes by highlighting the relationship between identity and scoliosis and offers practical implications and suggestions for future research.

Anterior spinal separation surgery to allow for stereotactic body radiotherapy: a novel approach permitting radical oncological treatment of oligometastatic disease.

The treatment of spinal cancers has rapidly evolved in the past decade. Often the treatment for spinal metastases required highly morbid surgeries and with palliative outcomes. However, a paradigm shift in surgical oncology has allowed spinal metastases treatment to have curative results. In the state of oligometastatic disease (OMD), the accompaniment of Stereotactic Body Radiotherapy (SBRT) as a primary modality or adjuvant treatment to surgery has been shown to excellent survival outcomes, lower morbidities and better pain management. This case report illustrates a novel approach to the treatment of spinal OMD utilizing anterior spinal separation surgery with a custom carbon fibre vertebral body replacement cage followed by postoperative SBRT with excellent radio-oncological outcomes over 30-month follow-up.

An Examination of the Number of Adolescent Scoliotic Curves That Are Braceable at First Presentation to a Scoliosis Service.

Adolescent idiopathic scoliosis (AIS) affects between 0.5% and 5.2% of adolescents and is progressive in two-thirds of cases. Bracing is an effective non-operative treatment for AIS and has been shown to prevent up to 72% of curves from requiring surgery. This paper explores the presentation of AIS in the UK and identifies who would be suitable for bracing, as per guidelines published by the Scoliosis Research Society (SRS) and British Scoliosis Society (BSS), through curve severity and skeletal maturity at presentation. There were 526 patients with AIS eligible for inclusion across three tertiary referral centres in the UK. The study period was individualised to each centre, between January 2012 and December 2021. Only 10% were appropriate for bracing via either SRS or BSS criteria. The rest were either too old, skeletally mature or had a curve size too large to benefit. By the end of data collection, 38% had undergone surgery for their scoliosis. In the UK, bracing for AIS is only suitable for a small number at presentation. Future efforts to minimise delays in specialist review and intervention will increase the number of those with AIS suitable for bracing and reduce the number and burden of operative interventions for AIS in the UK.

Chemotherapy May Obviate Prophylactic Femoral Nail Surgery for Multiple Myeloma Patients With High Mirels' Score Lesions and Impending Pathological Hip Fracture.

Bone involvement presents in >80% of patients with multiple myeloma. This causes lytic lesions for which prophylactic surgery is indicated to prevent pathological fractures if the lesion is graded ≥9/12 on Mirels' score. Although successful, these surgeries have risks and extended recovery periods. We present a case indicating myeloma chemotherapy may obviate prophylactic femoral nailing for high Mirels' score lesions in the femoral head with impending pathological hip fracture. A 72-year-old woman presented in December 2017 with back pain. A plain X-ray indicated degenerative anterolisthesis in her lumbosacral spine. Serum analysis revealed abnormal protein, globulin, alkaline phosphatase, and albumin levels while protein electrophoresis and serum immunofixation revealed raised immunoglobulin A (IgA) kappa paraprotein and kappa serum free light chains, respectively. Whole-body CT scans showed widespread lytic bone lesions and bone marrow biopsy confirmed infiltration by plasma cells. She was diagnosed with International Staging System (ISS) stage 3 multiple myeloma, which was successfully treated with bortezomib, thalidomide and dexamethasone with regular bisphosphonates that year. She presented again to the hospital in June 2020 with acute back and pelvic pain; Her paraprotein and serum-free light chains had increased significantly from her previous clinic appointment, indicating serological progression. MRI showed a relapse of the myeloma deposits in her right femoral head and spine. The deposit in her femoral head was graded 10/12 on Mirels' score, which indicated prophylactic femoral nailing. Instead, the patient was treated with daratumumab, bortezomib, and dexamethasone with escalation to monthly zoledronic acid infusions, as it was thought surgery would provide limited cytoreductive effect, preventing chemotherapy for six weeks post-surgery, potentiating pathological hip fracture and disease progression at other sites. This resulted in a complete response, thus reducing the deposits such that the femoral lesion was graded <8 on Mirels' score, improved her pain, and restored her ability to traverse stairs. She remains in complete response with ongoing daratumumab and denosumab maintenance treatment as of December 2022. Chemotherapy and bisphosphonates substantially reduced the myeloma deposit in the femoral head such that indications of prophylactic surgery were eliminated according to Mirels' score recommendations. This reduced the risk of pathological hip fracture whilst eliminating surgical complications. Further research should be conducted into the safety and efficacy of this treatment regimen in patients with high Mirels' score lesions. With this knowledge, consideration can be taken as to whether prophylactic femoral nailing is necessary given strong indications.

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy.

Introduction: Tomita En-bloc spondylectomy of L5 is one of the most challenging techniques in radical oncological spine surgery. A 42-year-old female was referred with lower back pain and L5 radiculopathy with a background of right shoulder liposarcoma excision. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation hence wasn't suitable for Stereotactic Ablative Radiotherapy (SABR) alone. The seeding nature of sarcoma prevents the indication of separation surgery hence excisional surgery is considered for radical curative treatment. This case report demonstrates dual-staged modified TES including the utilisation of novel techniques to allow for maximum radical oncological control in the era of SABR and lesser invasive surgery. Methods: First-stage: Carbonfibre pedicle screws planned from L2 to S2AI-Pelvis, aligned, to her patient-specific rods. Radiofrequency ablation of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone-cutter assisted inferior L4 and superior S1 endplate osteotomies. Second-stage: Vascular-assisted retroperitoneal approach at L4-S1 was undertaken protecting the great vessels. Completion of osteotomies at L4 and S1 to En-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Results: Patient rehabilitated well and was discharged after 42 days. Cyberknife of 30Gy in 5 fractions was delivered two months post-op. Despite left foot drop, she's walking independently 9 months post-op. Conclusion: These are challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR to achieve maximum local control in spinal oligometastatic disease. This case promotes our modified TES technique in the era of SABR and separation surgery in carefully selected cases.

Six-Month Survivorship Prediction in Spinal Metastatic Patients by Oncologists Shows Reliable Prognostication.

STUDY DESIGN: A retrospective analysis of oncologist-provided prognoses vs actual survival outcomes of patients referred with Metastatic spinal cord compression (MSCC) to a supra-regional multidisciplinary team (MDT). OBJECTIVES: Prognostic scoring systems, such as the revised Tokuhashi, are commonly used to help guide the treatment of MSCC. However, scoring systems do not accommodate for the improved outcomes of contemporary cancer therapy. Oncologist-provided prognoses play an important role in real world rapid decision making. There is a paucity of evidence assessing the accuracy of the oncologist-provided prognosis. We conducted a retrospective study to evaluate this. METHODS: Data was captured between January 2015 and December 2018. Patients were split into 2 groups: Group 1 (prognosis estimated <6 months) and Group 2 (prognosis estimated >6 months). Median overall survival (mOS) and hazard ratio for death (HR) was assessed. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of the oncologist's prognosis. RESULTS: 829 patients were included. mOS in Group 1 was 5.8 months (95% CI 4.2-7.4 m), and in Group 2 mOS was not reached. Log rank test gave a Chi2 of 131 (P < .001). Cox regression analysis revealed a HR of .30 (P < .001). Area under the ROC curve was 78%. CONCLUSIONS: Oncologist-provided prognosis is accurate in this cohort of unselected, consecutive MSCC patients. It reduced reliance on scoring systems that can become outdated. Given the rapid progress in cancer treatment, the oncologist's prognostic prediction is integral in efficient and effective MSCC management to help rapidly determine surgical candidacy.

Bracing Adolescent Idiopathic Scoliosis (BASIS) study - night-time versus full-time bracing in adolescent idiopathic scoliosis: study protocol for a multicentre, randomized controlled trial.

Aims: Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of 'full-time bracing' versus 'night-time bracing' in adolescent idiopathic scoliosis (AIS). Methods: UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion: The primary outcome is 'treatment failure' (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or 'treatment success' (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry.

Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study.

BACKGROUND: Controversy exists with the use of the acromioclavicular hook plate for the treatment of lateral-third clavicle fractures (Neer type II). This is thought to stem from problems associated with the hook plate causing impingement symptoms, which can cause long-term limitation of movement and pain. Our aim was to evaluate the functional outcomes of patients with lateral-third clavicle fractures treated with the hook plate. METHODS: We prospectively reviewed all patients who underwent surgery from July 2005 to August 2009 using our prospectively recorded electronic patient information database. All patients were assessed in the clinic to determine both Oxford and Constant shoulder scores. RESULTS: We identified 36 patients who underwent surgery with the hook plate, 26 men and 10 women. The mean age was 36.2 years (range, 22-60 years). Of the patients, 46% were smokers. The median length of hospital stay was 2 days (interquartile range [IQR], 1-3). The median follow-up was 28 months (IQR, 23-37). The median time from date of injury to surgery was 7 days (IQR, 4-76). The mean time to union was 3 months (IQR, 2-4), and the union rate was 95%. In total, 92% of plates were removed. The median time to removal was 4.5 months (IQR, 3-8.75). There were no complications. Two patients presented months later after falls with fractures around the medial end of the hook plate. CONCLUSION: Hook plates are an effective form of treatment for lateral third clavicle fractures. The best outcomes occur with plate removal before 6 months postoperatively, provided that the fracture has healed.

Total joint arthroplasty in nonagenarians--a retrospective review of complications and resource use.

Increased age brings with it the potential for increased surgical risk. Assessment of specific age cohorts is necessary to plan future service provision and this is the case in hip and knee arthroplasty as the demand for these procedures is anticipated to increase. We retrospectively reviewed the outcomes, including complications, length of stay and blood transfusion rate, in a cohort of 35 nonagenarians undergoing primary or revision total hip and knee arthroplasty. All patients were pre-assessed by anaesthetists before being deemed suitable to undergo surgery in the unit. The mean length of hospital stay was 13.7 +/- 10 days (range 2-56). Thirty-one percent of patients required a blood transfusion. Patients who underwent primary total hip arthroplasty reported improved joint specific functional scores. In this appropriately selected group of nonagenarians, we found no evidence to suggest surgery be withheld on the basis of age alone. However, patients with multiple medical comorbidities warrant appropriate assessment and surgical intervention in an institution with appropriate support. Future planning needs to take into account the predicted increase in demand for arthroplasty surgery in this age group.

Hand dominance in orthopaedic surgeons.

Handedness is perhaps the most studied human asymmetry. Laterality is the preference shown for one side and it has been studied in many aspects of medicine. Studies have shown that some orthopaedic procedures had poorer outcomes and identified laterality as a contributing factor. We developed a questionnaire to assess laterality in orthopaedic surgery and compared this to an established scoring system. Sixty-two orthopaedic surgeons surveyed with the validated Waterloo Handedness Questionnaire (WHQ) were compared with the self developed Orthopaedic Handedness Questionnaire (OHQ). Fifty-eight were found to be right hand dominant (RHD) and 4 left hand dominant (LHD). In RHD surgeons, the average WHQ score was 44.9% and OHQ 15%. For LHD surgeons the WHQ score was 30.2% and OHQ 9.4%. This represents a significant amount of time using the non dominant hand but does not necessarily determine satisfactory or successful dexterity transferable to the operating room. Training may be required for the non dominant side.