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.

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.

Dual modality of vertebral body tethering : anterior scoliosis correction versus growth modulation with mean follow-up of five years.

AIMS: Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. METHODS: We conducted a retrospective analysis of clinical and radiological data of 20 patients aged between 9 and 17 years old, (with a 19 female: 1 male ratio) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7). RESULTS: There were ten patients in each group with a total of 23 curves operated on. VBT-GM mean age was 12.5 years (9 to 14) with a mean Risser classification of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) with a mean Risser classification of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40° to 58°) with a Fulcrum unbend of 17.4 (1° to 41°), compared to VBT-ASC 56.5° (40° to 79°) with 30.6 (2° to 69°)unbend. Postoperative VBT-GM was 20.3° and VBT-ASC Cobb angle was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. The last Cobb angle on radiograph at mean five years' follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Patients with open triradiate cartilage (TRC) had three over-corrections. Overall, 5% of patients required fusion. This one patient alone had a over-correction, a second-stage tether release, and final conversion to fusion. CONCLUSION: We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for correction of scoliosis in the skeletally immature patient. This is the first report at five years that shows two methods of VBT can be employed depending on the skeletal maturity of the patient: GM and ASC. Cite this article: Bone Jt Open 2022;3(2):123-129.

Integrated Custom Composite Polyetheretherketone/Carbon fiber (PEEK/CF) Vertebral Body Replacement (VBR) in the Treatment of Bone Tumors of the Spine: A Preliminary Report From a Multicenter Study.

STUDY DESIGN: Retrospective, multicenter chart, and radiologic review. OBJECTIVE: To present the first case series of bone tumors of the spine surgically reconstructed with a new custom, fully radiolucent, polyetheretherketone/carbon fiber (PEEK/CF) vertebral body replacement (VBR) integrated system. SUMMARY OF BACKGROUND DATA: Surgical resections of spinal tumors result in large defects and local recurrence remains a concern. Current titanium-based implants adversely affects postoperative imaging, directly affects ability to identify tumor recurrence, and for delivery of radiotherapy treatments. PEEK/CF spinal implants allows for improved tumor surveillance, precise pre-radiation Computed Tomography planning, and reduces interference with post-reconstructive adjuvant radiotherapy. METHOD: Thirteen patients with spinal tumors underwent vertebral body resection and reconstruction with an integrated, fully radiolucent, custom PEEK/CF vertebral body replacement, and radiolucent posterior PEEK/CF screw-rod system and/or radiolucent anterior PEEK/CF plate system. Clinical and radiographic data were tabulated. Need for adjuvant radiotherapy determined based on final tissue histology and extent of surgical margins. Postoperative surveillance imaging were reviewed for local tumor recurrence. RESULTS: The ability to integrate the PEEK/CF VBR connected to either the posterior screw-rod system, or anterior plate system provided immediate stability. The VBR was placed directly on cancellous vertebral body surface in 46.2% of cases. Loosening of the distal, or proximal, aspect of posterior system was seen in 15.4% of cases. There was no clinical or radiographic evidence of VBR migration and subsidence at latest follow up. Local recurrence occurred in one (7.7%) patient. CONCLUSION: This is the first series to describe the use of a fully-radiolucent, integrated, PEEK/CF implant system for spinal tumor reconstruction. The use of a PEEK/CF VBR system integrated to either the anterior plate, or posterior screw-rod system is feasible and allows for superior postoperative surveillance imaging and effective delivery of postoperative adjuvant radiotherapy.Level of Evidence: 4.

Catching the second wave: clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients during the COVID-19 pandemic.

AIMS: The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. METHODS: A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). RESULTS: From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. CONCLUSION: During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661-670.

A Hybrid Virtual Fracture Clinic is Safe and Efficacious in the COVID-19 Era: Stay at Home and Save Lives.

Introduction The coronavirus disease 2019 (COVID-19) pandemic necessitated a change in the manner outpatient fracture clinics are conducted due to the need to reduce footfall in hospitals. While studies regarding virtual fracture clinics have shown these to be useful and effective, they focus exclusively on remote consultations. However, our service was bespoke to the patient - either a face-to-face, a telephone consultation or both, depending on patient need - a 'hybrid virtual fracture clinic' (HVFC). We report patient satisfaction and outcomes with this service from the first wave of the pandemic. Methods We retrospectively interviewed patients who availed of the HVFC service at our institution during the first two weeks of national lockdown in England from March 23 to April 5, 2020. The number and type of consultations, patient vulnerability to COVID-19, and type of management (surgical vs non-surgical) were among the factors taken into consideration. Patient experience was assessed using the Net Promoter Score (NPS), Customer Effort Score (CES), and Customer Satisfaction Score (CSS) on a scale of 0-10. Patient-reported outcomes were assessed using the EuroQol-5D-5L score (including EQ Visual Analogue Scale {EQ-VAS} scoring on a scale of 0-100). Results The mean overall NPS, CES, and CSS for the service were 7.32, 7.24, and 7.49, respectively. The mean self-reported EQ-VAS rating was 77.5. Of 442 consultations, 246 were conducted virtually; 10% were face-to-face, 29% virtual, and 61% were hybrid consultations. The HVFC resulted in a 55.65% reduction in footfall. Statistical analysis showed no significant difference across any outcome measure when compared between hybrid, virtual, and face-to-face consultations. Patients vulnerable to COVID-19 and those who did not require surgery tended to report better overall scores. Conclusion Our study indicates that the HVFC format can reduce patient footfall significantly (>50%) while providing effective and satisfactory outpatient care. There appears to be no difference in patient-reported outcomes between face-to-face consultations and hybrid or virtual consultations. Patients would recommend HVFC to family and friends, found it was easy to use, and reported good satisfaction with the service.

Corrigendum to: Tranexamic acid use in a patient with sickle cell disease undergoing posterior scoliosis correction surgery: safely mitigating bleeding and vaso-occlusive crises.

[This corrects the article DOI: 10.1093/jscr/rjaa559.].

Tranexamic acid use in a patient with sickle cell disease undergoing posterior scoliosis correction surgery: safely mitigating bleeding and vaso-occlusive crises.

A 15-year-old female with 2-year post-menarchal adolescent idiopathic scoliosis and sickle cell disease (SCD) underwent posterior scoliosis correction surgery. SCD is associated with higher rates of surgical complications, and these patients require careful management to prevent vaso-occlusive sickle cell crises (VOSCC); scoliosis correction surgery can be associated with high morbidity and mortality, including significant blood loss. Multiple techniques were employed to successfully prevent VOSCC in this patient including a preoperative transfusion, meticulous haemostasis at osteotomy sites, not performing a costoplasty despite presence of a rib hump, maintenance of intraoperative mean arterial pressure below 70 mmHg, aggressive postoperative hydration and the use of intraoperative tranexamic acid (TXA). This is the first reported case of the use of TXA in a patient with SCD and scoliosis correction surgery. A satisfactory correction was achieved with a longer than average inpatient stay due to non-sickle cell pain and protracted wound ooze.

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.

40 days and 40 nights: Clinical characteristics of major trauma and orthopaedic injury comparing the incubation and lockdown phases of COVID-19 infection.

AIMS: The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. METHODS: A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. RESULTS: A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). CONCLUSION: Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%.Cite this article: Bone Joint Open 2020;1-7:330-338.

Two-stage anterior and posterior fusion versus one-stage posterior fusion in patients with Scheuermann's kyphosis.

AIMS: Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann's kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion. METHODS: A retrospective review of patients treated surgically for Scheuermann's kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples t-tests, and z-tests of proportions analyses where applicable. RESULTS: There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches. CONCLUSION: A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: Bone Joint J 2020;102-B(10):1368-1374.

Spinal-Pelvic Dissociation in Pregnancy: Surgical Fixation of Culture-Negative Extrapulmonary Tuberculosis.

A 33-year-old gravid female from Pakistan presented to the Emergency Department with persistent, intractable low back pain and neuropathic left L5 leg pain, associated with a left foot drop. There was a notable history of weight loss for 1 year. Investigations revealed a large collection in the right posterior paraspinal muscles tracking from a large bony defect in the right half of her sacrum extending into the pelvis. The collection was suggestive of an abscess and underwent US-guided aspiration. Culture, PCR examination, and bone biopsy were culture-negative for tuberculosis (TB). Samples taken from the placenta showed two small granulomata in the chorionic villi only. A multidisciplinary approach commenced with initiation of empirical TB treatment and attempted normal vaginal delivery. An urgent caesarean section for the delivery of the baby was required for failure to proceed. Spinal-pelvic stabilization in two stages was performed for the unstable fracture pattern, followed by pharmacotherapy and physiotherapy rehabilitation. At 12-month follow-up, the patient showed resolving TB and eradication of the paraspinal abscess. There was bony union and stability of the spinal-pelvic reconstruction. Back pain and sciatica can be common in pregnancy. However, this case highlights a rare occurrence of culture-negative extrapulmonary TB leading to an unstable spinal-pelvic fracture requiring a multidisciplinary approach for careful obstetric and orthopaedic treatment with empirical treatment by the infectious disease team and microbiology.

Neurologic Injury in Complex Adult Spinal Deformity Surgery: Staged Multilevel Oblique Lumbar Interbody Fusion (MOLIF) Using Hyperlordotic Tantalum Cages and Posterior Fusion Versus Pedicle Subtraction Osteotomy (PSO).

STUDY DESIGN: A retrospective review of prospectively collected data. OBJECTIVE: The aim of this study was to determine the safety of MOLIF versus PSO. SUMMARY OF BACKGROUND DATA: Complex adult spinal deformity (CASD) represents a challenging cohort of patients. The Scoli-RISK-1 study has shown a 22.18% perioperative risk of neurological injury. Restoration of sagittal parameters is associated with good outcome in ASD. Pedicle subtraction osteotomies (PSO) is an important technique for sagittal balance in ASD but is associated with significant morbidity. The multilevel oblique lumbar interbody fusion (MOLIF) is an extensile approach from L1 to S1. METHODS: Single surgeon series from 2007 to 2015. Prospectively collected data. Scoli-RISK-1 criteria were refined to only include stiff or fused spines otherwise requiring a PSO. Roentograms were examined preoperatively and 2 year postoperatively. Primary outcome measure was the motor decline in American Spinal Injury Association (ASIA) at hospital discharge, 6 weeks, 6 months, and 2 years. Demographics, blood loss, operative time, spinopelvic parameters, and spinal cord monitoring (SCM) events. RESULTS: Sixty-eight consecutive patients were included in this study, with 34 patients in each Group. Group 1 (MOLIF) had a mean age 62.9 (45-81) and Group 2 (PSO) had a mean age of 66.76 years (47-79); 64.7% female versus PSO 76.5%; Body Mass Index (BMI) Group 1 (MOLIF) 28.05 and Group 2 (PSO) 27.17. Group 1 (MOLIF) perioperative neurological injury was 2.94% at discharge but resolved by 6 weeks. Group 2 (PSO) had five neurological deficits (14.7%) with no recovery by 2 years. There were four SCM events (SCM). In Group 1 (MOLIF), there was one event (2.94%) versus three events (8.88%) in Group 2 (PSO). CONCLUSION: Staged MOLIF avoids passing neurological structures or retraction of psoas and lumbar plexus. It is safer than PSO in CASD with stiff or fused spines with a lower perioperative neurological injury profile. MOLIF have less SCM events, blood loss, and number of levels fused. LEVEL OF EVIDENCE: 3.

Successful nonsurgical treatment for highly unstable fracture subluxation of the spine secondary to myeloma.

BACKGROUND CONTEXT: In multiple myeloma, patients may develop rapidly progressive, lytic, spinal lesions. These may result in spinal instability, but instrumented stabilization may fail because of poor bone quality. In addition, patients are immunocompromised and are therefore at increased risk of deep infection. PURPOSE: The aim was to describe a patient presenting with an unstable fracture subluxation of the thoracic spine secondary to myeloma, successfully treated with non-surgical management. STUDY DESIGN/SETTING: This is a case report of a patient seen in a specialist spinal myeloma service. METHODS: A 74-year-old Caucasian woman presented with destructive myelomatous lesions of T9 and T10. Greater than 50% of the T9 vertebral body was involved, and there was subluxation and translation of T9 on T10 (Spinal Instability Neoplastic Score of 14). There was a single episode of transient paresthesia of both lower limbs. The patient was in considerable pain, requiring large quantities of opioid analgesia. She was treated non-surgically in a thoracolumbar sacral orthosis for a period of 3 months (strict bed rest for the first 3 weeks). RESULTS: A computed tomography scan at 3 months demonstrated bony fusion and the brace was removed. The patient returned to her normal activities 5 months posttreatment. Her pain and patient-reported outcome scores were significantly improved. CONCLUSIONS: We present a successful non-surgical management of an unstable myelomatous vertebral fracture without neurologic deficit. However, surgical stabilization remains the treatment of choice in unstable vertebral fractures and spinal surgical opinion should be sought in all cases.

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.

Fibroma of the peroneus longus tendon sheath in a child: a case report.

Tendon sheath fibromas are rare, benign soft-tissue tumours and usually involve tendons of the upper extremities, particularly the fingers. The most common presentation is a painless, slow-growing swelling. Tendon sheath fibromas are composed of dense fibrocollagenous stromas with scattered, spindle-shaped fibroblasts and narrow, slit-like vascular spaces. Ultrasonography and magnetic resonance imaging are useful diagnostic tools. We report on an 11-year-old boy with a fibroma involving the right peroneus longus tendon sheath.

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.

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.

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.

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.