Association of Pre-Operative Hyponatraemia with Morbidity and Mortality in Patients Undergoing Non-Urgent Degenerative Spine Surgery, a Retrospective Study.

BACKGROUND AND OBJECTIVES: Hyponatraemia increases the morbidity and mortality risks of orthopaedic patients. When undergoing spine surgery, hyponatraemic patients have high risks of pneumonia and of staying in hospital for up to 1 day longer compared with non-hyponatraemic patients. This study aims to assess the occurrence of adverse events among patients with pre-operative hyponatraemia after undergoing lumbar surgery. MATERIALS AND METHODS: A retrospective cohort study was conducted. Patients who underwent spinal surgery in 2011 to 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate analysis was conducted to demonstrate the difference in post-operative complication rates between hyponatraemic patients and normonatraemic patients. Post-operative adverse events, need for blood transfusion and length of stay were considered as clinical outcome data. RESULTS: A total of 58,049 patients were included; pre-operatively, 55,012 (94.8%) were normonatraemic and 3037 (5.2%) were hyponatraemic. Multivariate analysis showed that hyponatraemic patients had higher rates of adverse events, blood transfusions and urinary tract infections. Specifically, 632 (20.8%) hyponatraemic patients developed adverse events, compared with 6821 (12.4%) normonatraemic patients; the hyponatraemic patients received transfusions, compared with 6821 (7.4%) normonatraemic patients; and 97 (3.2%) hyponatraemic patients developed urinary tract infections, compared with 715 (1.3%) normonatraemic patients. Finally, an extended length of stay beyond 6 days occurred in 604 (19.9%) hyponatraemic patients, compared with 4676 (8.5%) normonatraemic patients. CONCLUSIONS: Our study identified an association between pre-operative hyponatraemia and post-operative adverse events in spinal surgery patients. However, it is unclear whether hyponatraemia caused the higher adverse event rate.

Traffic Cameras-An Effective and Sustainable Method of Reducing Traffic and Airborne Particles During Arthroplasty Surgery.

BACKGROUND: Traffic in the operating room (OR) create turbulence and contaminates air by bacterial shedding. Therefore, we examined: (1) if the number and duration of door openings were associated with increased particles during arthroplasty surgery; (2) if traffic cameras installed in the operating room were an effective intervention to decrease traffic and particles during arthroplasty surgery; and (3) the effectiveness of traffic camera over time. METHODS: Fifty cases were included between November 3, 2021, and June 22, 2022, with 25 cases in each group. Two particle counters were used to count particles sized 0.5 to 10 µm. One counter was positioned within the sterile field, and another between the OR doors. Two door counters were mounted to count door openings. For the intervention, traffic cameras were mounted facing each door and took snapshots with door openings. RESULTS: The number of door openings/minute was 30% less in the Intervention group (P < .001). The Intervention group had significantly lower particles by 26 to 43% in the operative field (0.5 µm, P = .01; 0.7 µm, P = .008; 1 µm, P = .007; 2.5 µm, P = .006; 5 µm, P = .01; and 10 µm, P = .01). The particles between the OR doors were decreased by 2 to 42% in the Intervention group and the difference was significant for (0.5 µm, P = 0.03; 0.7 µm, P = .02; and 1 µm, P = .03). The decrease in door openings and particles were sustained over the study period. CONCLUSION: The use of traffic cameras was an effective and sustainable method to limit OR traffic and door openings, which resulted in a reduction in particles in the operating room.

Revision Distal Femoral Replacement Using Custom-made Stem and Cone to Augment Proximal Fixation.

Achieving bone fixation during megaprosthesis revision presents a formidable challenge in view of the substantial bone loss. We report treatment of a failed revision distal femoral replacement in an active 36-year-old male mechanic remotely treated for osteosarcoma. A custom stem and cone were manufactured to augment fixation and preserve bone stock within a short segment of the remaining proximal femur. The patient returned to regular function without the need for assistive devices. Follow-up imaging demonstrated stable implant fixation at 1-year follow-up. While cones and sleeves have vastly improved fixation in revision knee arthroplasty, a custom-made cone for the proximal femur was used to augment fixation of a revision megaprosthesis and obviate the use of a total femoral replacement.

Telemedicine-guided forearm emergency decompressive fasciotomy for compartment syndrome.

INTRODUCTION: We highlight the utility of telemedicine and telementoring for the management of orthopaedic emergencies using a case of forearm compartment syndrome following a penetrating trauma in a northern Inuit community in Nunavik, Quebec, Canada. METHODS & RESULTS: As in many cases of compartment syndrome in rural settings, the patient was at a high risk of developing irreversible complications. A prompt diagnosis followed by an emergency decompressive fasciotomy was warranted. Using telemedicine and telementoring guidance, the diagnosis of compartment syndrome was made, and the patient's volar compartment was successfully decompressed by a local emergency physician in a timely manner. Subsequently, the patient was able to be safely transferred to a level 1 trauma centre for further surgical management. This included a second-look operative exploration, irrigation and debridement, completion of volar fasciotomy and ulnar nerve decompression. No complications were seen. DISCUSSION: Our experience highlights two important clinical implications. First, telemedicine can be successfully implemented to facilitate clinical diagnosis of surgical emergencies in the rural setting. Second, telementoring can effectively allow surgeons to guide physicians remotely to perform emergency decompressive fasciotomy, which can help salvage the affected limb and significantly decrease the risk of debilitating complications.

Intramedullary Nailing Versus Plate Osteosynthesis for Humeral Shaft Metastatic Lesions.

In the event of surgical management of metastases to the humeral shaft, intramedullary nailing (IMN) is often preferred to plate osteosynthesis (PO) fixation despite a lack of consensus. In this study, we hypothesized that plate osteosynthesis will be associated with better functional and pain outcomes, thus better quality of life. Eighteen patients with the diagnosis of humeral shaft metastatic fracture or impending fracture were extracted from a prospective database of 140 metastatic patients collected across three hospitals over a five-year period. Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), Quality of Life (QOL) and Brief Pain Inventory (BPI) score were gathered during the year following the surgery. Statistical analysis was performed to compare the mean score differences between the two surgical options at baseline and five follow-up visits. Both treatment options were associated with an increase in functional outcomes based on both MSTS and TESS, and a decrease in pain level. However, no significant difference was found in quality of life and between the two treatment modalities. Thus, based on our results, a similar improvement in functional status and pain level can be achieved surgically by either intramedullary nailing or plating osteosynthesis.

Outcomes of Cemented Distal Femoral Replacement Using "Line to Line" Technique With All-Polyethylene Tibial Implant for Tumors.

BACKGROUND: Both cemented and cementless stemmed endoprosthetic implants have been used to reconstruct large skeletal defects after tumor resection with similar outcomes. In this study, we examined the oncologic, clinical, and functional outcomes in patients undergoing distal femur replacement using the French paradox technique. METHODS: A total of 125 patients who underwent distal femur replacement between 1990 and 2019 using the line-to-line cementation technique were reviewed. Implant failure was recorded as per Henderson's classification. Functional outcomes were analyzed using the Musculoskeletal Tumor Society and Toronto Extremity Salvage Score scoring systems. The mean follow-up was 84 (1-350) months. RESULTS: Aseptic loosening of the femoral stem was recorded in one patient at 21-years of follow-up. Twenty of 125 patients required bushing exchange for polyethylene wear, all after 10 years. Six tibial bearing component fractures were recorded in four patients while one femoral stem component Morse taper fractured. Two all-polyethylene cemented tibial implants were revised for polyethylene granuloma. Deep surgical site infection occurred in 13 patients, while six patients experienced local recurrence. Kaplan-Meier estimates for implant survival for all-cause revision were 85% at 1 year and 70% at 5 years. These estimates for femur or tibia loosening as an end point were 96% at 10 years and 90% at 15 years. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Score scores at the last follow-up were 76% and 74%, respectively. Thirty-five patients died of disease progression. CONCLUSION: The line-to-line cementation technique, used with all-polyethylene tibial implants, demonstrates low incidence of aseptic loosening at medium and long-term follow-ups. LEVEL OF EVIDENCE: III.

Two Cases of Polyethylene Granuloma After Distal Femoral Endoprosthesis With All-Polyethylene Tibia.

Limited literature exists on complications specific to the all-polyethylene tibial component in distal femoral replacement (DFR). Unlike in primary arthroplasty with polyethylene components, polyethylene granuloma has not been reported in DFR with an all-polyethylene tibia. Here, we report 2 cases of polyethylene granuloma in patients with primary bone sarcoma who underwent DFR with an all-polyethylene tibia. Radiologically, evidence of intraosseous granuloma formation and periprosthetic osteolysis was observed at the anterior tibial metaphysis. Both patients underwent an operative debridement of polyethylene granuloma and necrotic tissues, followed by a revision to a long-stem, cemented metal-backed tibia with impacted allograft to fill the defect. Polyethylene granuloma should be considered a differential diagnosis in the presence of a periprosthetic lytic lesion after DFR with an all-polyethylene tibial component.

An Extraosseous Aneurysmal Bone Cyst in a 59-Year-Old Man: A Case Report.

CASE: A 59-year-old man presented with a history of a painful, rapidly growing mass on the anteromedial aspect of his thigh. On examination, he had a mobile, hard, and nontender mass. Magnetic resonance imaging revealed a well-encapsulated, heterogeneous mass with high-intensity internal septations. Blood-filled spaces were observed within the mass with no involvement of the underlying normal bony structures. The mass was excised, and the diagnosis of an extraosseous aneurysmal bone cyst was confirmed histologically. CONCLUSIONS: Extraosseous aneurysmal bone cysts are rare benign lesions that can mimic malignant tumors. Careful clinical and pathological assessment should be performed in such cases.

Radiographic, Functional, and Oncologic Outcomes of Cemented Modular Proximal Femur Replacement Using the "French Paradox" Technique.

BACKGROUND: Endoprostheses are frequently used in the management of tumors involving the proximal femur. Aseptic loosening is a common complication that has been linked to the cementing technique. The "French paradox" is well-known cementing technique in the arthroplasty literature. No previous reports have assessed loosening in proximal femur replacements using this technique. We examined rates of femoral stem aseptic loosening in proximal femur replacements, functional outcomes, complications, and oncologic outcomes. METHODS: We conducted a retrospective review of 47 patients who underwent proximal femur replacement between 2000 and 2019. Two reviewers evaluated preoperative and postoperative radiographs using the International Society of Limb Salvage scoring system and Barrack criteria for stem loosening. The acetabulum was evaluated according to the criteria of Baker et al. Functional outcomes were assessed using Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score. The mean follow-up was 44 months. RESULTS: The mean International Society of Limb Salvage scores for the 2 reviewers were 86% ± 6% and 84% ± 6%. The first reviewer graded femoral stem loosening as "possibly loose" in 2 patients, one of whom was graded as possibly loose by the second reviewer. The 2 reviewers found no acetabular erosion in 16 (70%) and 15 (65.4%) patients, respectively. The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score at last follow-up were 61% and 72%, respectively. Twenty complications occurred in 13 patients, and 5 patients experienced local recurrence. CONCLUSION: Despite complications, we showed favorable femoral component survival rates. Cementing the proximal femur prosthesis with tight canal fit and thin cement mantle is a viable option for the short and medium term. LEVEL OF EVIDENCE: III.

Capsular closure outweighs head size in preventing dislocation following revision total hip arthroplasty.

INTRODUCTION: The high dislocation rate following revision total hip arthroplasty (THA) has been shown to be significantly reduced by closing the posterior capsule and by the use of large diameter femoral heads. The relative importance of each of these strategies on the rate of dislocation remains unknown. We undertook a study to determine if increasing femoral head diameter, in addition to posterior capsular closure would influence the dislocation rate following revision THA. METHODS: We retrospectively reviewed 144 patients who underwent a revision THA. We included all patients who underwent revision THA with closure of the posterior capsule and who had at least a 2-year minimum follow-up. 48 patients had a 28-mm femoral head, 47 had a 32-mm head and 49 patients had a 36-mm femoral head. RESULTS: At a minimum follow-up of 2 years, there were 3 dislocations. There were no dislocations in the 28-mm group (0%), 2 in the 32-mm group (4%) and 1 in the 36-mm group (2%). Head size alone was not found to significantly decrease the risk of dislocation (28-mm versus 32-mm p = 0.12; 28-mm versus 36-mm p = 0.27; 32-mm versus 36-mm p = 0.40). CONCLUSION: Both large diameter heads and careful attention to surgical technique with posterior capsular closure can decrease the historically high dislocation rate after revision THA when utilising the posterolateral approach. Capsular closure outweighs the effect of femoral head diameter in preventing dislocation following revision THA through a posterolateral approach.

Early Improvement in Pain and Functional Outcome but Not Quality of Life After Surgery for Metastatic Long Bone Disease.

BACKGROUND: Bone metastases represent the most frequent cause of cancer-related pain, affecting health-related quality of life and creating a substantial burden on the healthcare system. Although most bony metastatic lesions can be managed nonoperatively, surgical management can help patients reduce severe pain, avoid impending fracture, and stabilize pathologic fractures. Studies have demonstrated functional improvement postoperatively as early as 6 weeks, but little data exist on the temporal progress of these improvements or on the changes in quality of life over time as a result of surgical intervention. QUESTIONS/PURPOSES: (1) Do patients' functional outcomes, pain, and quality of life improve after surgery for long bone metastases? (2) What is the temporal progress of these changes to 1 year after surgery or death? (3) What is the overall and 30-day rate of complications after surgery for long bone metastases? (4) What are the oncologic outcomes including overall survival and local disease recurrence for this patient population? METHODS: A multicenter, prospective study from three orthopaedic oncology centers in Quebec, Canada, was conducted between 2008 and 2016 to examine the improvement in function and quality of life after surgery for patients with long bone metastases. During this time, 184 patients out of a total of 210 patients evaluated during this period were enrolled; of those, 141 (77%) had complete followup at a minimum of 2 weeks (mean, 23 weeks; range, 2-52 weeks) or until death, whereas another 35 (19%) were lost to followup but were not known to have died before the minimum followup interval was achieved. Pathologic fracture was present in 34% (48 of 141) of patients. The median Mirel's score for those who underwent prophylactic surgery was 10 (interquartile range, 10-11). Surgical procedures included intramedullary nailing (55), endoprosthetic replacement (49), plate osteosynthesis (31), extended intralesional curettage (four), and allograft reconstruction (two). Seventy-seven percent (108 of 141) of patients received radiotherapy. The Musculoskeletal Tumor Society (MSTS), Toronto Extremity Salvage Score (TESS), Brief Pain Inventory (BPI) form, and Quality Of Life During Serious Illness (QOLLTI-P) form were administered pre- and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. Analysis of variance followed by post hoc analysis was conducted to test for significance between pre- and postoperative scores. The Kaplan-Meier estimate was used to calculate overall survivorship and local recurrence-free survival. A p value of < 0.05 was considered statistically significant. RESULTS: MSTS and BPI pain scores improved at 2 weeks when compared with preoperative scores (MSTS: 39% ± 24% pre- versus 62% ± 19% postoperative, mean difference [MD] 23, 95% confidence interval [CI], 16-32, p < 0.001; BPI: 52% ± 21% pre- versus 30% ± 21% postoperative, MD 22, 95% CI, 16-32, p < 0.001). Continuous and incremental improvement in TESS, MSTS, and BPI scores was observed temporally at 6 weeks, 3 months, 6 months, and 1 year; for example, the TESS score improved from 44% ± 24% to 73% ± 21% (MD 29, p < 0.001, 95% CI, 19-38) at 6 months. We did not detect a difference in quality of life as measured by the QOLLTI-P score (6 ± 1 pre- versus 7 ± 4 postoperative, MD 1, 95% CI, -0.4 to 3, p = 0.2). The overall and 30-day rates of systemic complications were 35% (49 of 141) and 14% (20 of 141), respectively. The Kaplan-Meier estimates for overall survival were 70% (95% CI, 62.4-78) at 6 months and 41% (95% CI, 33-49) at 1 year. Local recurrence-free survival was 17 weeks (95% CI, 11-24). CONCLUSIONS: Surgical management of metastatic long bone disease substantially improves patients' functional outcome and pain as early as 2 weeks postoperatively and should be considered for impending or pathologic fracture in patients whose survival is expected to be longer than 2 weeks provided that there are no immediate contraindications. Quality of life in this patient population did not improve, which may be a function of patient selection, concomitant chemoradiotherapy regimens, disease progression, or terminal illness, and this merits further investigation. LEVEL OF EVIDENCE: Level II, therapeutic study.

Prevalence and Complications of Postoperative Transfusion for Cervical Fusion Procedures in Spine Surgery: An Analysis of 11,588 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database.

STUDY DESIGN: Retrospective cohort study. PURPOSE: The purpose of this study was to assess the rate of blood transfusion after cervical fusion surgery, and its effect on complication rates. OVERVIEW OF LITERATURE: Cervical spine fusions have gained interest in the literature since these procedures are now ever more frequently being performed in an outpatient setting with few complications. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent cervical fusion from 2010 to 2013. Multivariate regression analysis was used to determine postoperative complications associated with transfusion and cervical fusion. RESULTS: We identified 11,588 patients who had cervical fusion between 2010 and 2013. The rate of blood transfusion following cervical fusion found to be 1.47%. All transfused patients were found to have increased risk of venous thromboembolism (TBE) (odds ratio [OR], 3.19; 95% confidence interval [95% CI], 1.16-8.77), myocardial infarction (MI) (OR, 9.12; 95% CI, 2.53-32.8), increased length of stay (LOS) (OR, 28.03; 95% CI, 14.28-55.01) and mortality (OR, 4.14; 95% CI, 1.44-11.93). Single level fusion had increased risk of TBE (OR, 3.37; 95% CI, 1.01-11.33), MI (OR, 10.5; 95% CI, 1.88-59.89), and LOS (OR, 14.79; 95% CI, 8.2-26.67). Multilevel fusion had increased risk of TBE (OR, 5.64; 95% CI, 1.15-27.6), surgical site infection (OR, 16.29; 95% CI, 3.34-79.49), MI (OR, 10.84; 95% CI, 2.01-58.55), LOS (OR, 26.56; 95% CI, 11.8-59.78), and mortality (OR, 10.24; 95% CI, 2.45-42.71). Patients who had anterior cervical discectomy and fusion surgery and received a transfusion had an increased risk of TBE (OR, 4.87; 95% CI, 1.04-22.82), surgical site infection (OR, 9.73; 95% CI, 2.14-44.1), MI (OR, 9.88; 95% CI, 1.87-52.2), increased LOS of more than 2 days (OR, 28.34; 95% CI, 13.79-58.21) and increase in mortality (OR, 6.3; 95% CI, 1.76-22.48). While, transfused patients who had posterior fusion surgery had increased risk of MI (OR, 10.45; 95% CI, 1.42-77.12) and increased LOS of more than 6 days (OR, 4.42; 95% CI, 2.68-7.29). CONCLUSIONS: Our results demonstrate that although cervical fusions can be done as outpatient procedures special precautions and investigations should be done for patients who receive transfusion after cervical fusion. These patients are demonstrated to have higher rate of MI, TBE, wound infection and mortality when compared to those who do not receive transfusion.

Use of Computer Assistance in Lumbar Fusion Surgery: Analysis of 15 222 Patients in the ACS-NSQIP Database.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Several studies have shown that the accuracy of pedicle screw placement significantly improves with use of computer-assisted surgery (CAS). Yet few studies have compared the incidence of postoperative complications between CAS and conventional techniques. The objective of this study is to determine the difference in postoperative complication rates between CAS and conventional techniques in spine surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent posterior lumbar fusion from 2011 to 2013. Multivariate analysis was conducted to demonstrate the difference in postoperative complication rates between CAS and conventional techniques in spine surgery. RESULTS: Out of 15 222 patients, 14 382 (95.1%) were operated with conventional techniques and 740 (4.90%) were operated with CAS. Multivariate analysis showed that patients in the CAS group had fewer odds to experience adverse events postoperatively (odds ratio [OR] = 0.57, P < .001). Minor adverse events occurred in 2905 (20.2%) patients in the conventional group and in 98 (13.2%) patients in the CAS group (OR = 0.57, P < .001). Blood transfusion was present in 2488 (17.3%) of the patients in the conventional group compared to 81 (11.0%) of the patients in the CAS group (OR = 0.56, P < .001). The mean operative time in the conventional group was 205.2 ± 106.1 minutes, and it was 227.0 ± 111.9 minutes in the CAS group. This difference was statistically significant (r = 20.14, P < .001). CONCLUSION: This article examined the complications in lumbar spinal surgery with or without the use of CAS. These results suggest that CAS may provide a safer technique for implant placement in lumbar fusion surgeries.

Preoperative Computed Tomography Myelography Parameters as Predictors of Outcome in Patients With Degenerative Cervical Myelopathy: Results of a Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: To determine the preoperative computed tomography (CT) myelogram imaging parameters in patients diagnosed with degenerative cervical myelopathy (DCM) that correlate with severity of DCM and predict postoperative patients' functional outcome. METHODS: An electronic database search was performed using Ovid Medline and Embase. CT myelogram studies investigating the correlation between imaging characteristics and DCM severity or postoperative outcomes were included. Two independent reviewers performed citation screening, selection, qualitative assessment, and data extraction using an objective and blinded protocol. RESULTS: A total of 5 studies (402 patients) were included in this review and investigated the role of preoperative CT myelogram parameters in predicting the functional outcome after surgical treatment of DCM. All studies were retrospective cohort studies. CT myelogram characteristics included the transverse area of the spinal cord at maximum level of compression, spinal canal narrowing, number of blocks, spinal canal diameter, and flattening ratio. There is low evidence suggesting that patients with a preoperative transverse area of the spinal cord >30 mm2 at the level of maximum compression have better postoperative recovery and outcome. We found no studies investigating the correlation between preoperative CT myelogram parameters and DCM severity. CONCLUSIONS: Patients with greater transverse area of spinal cord at the level of maximum compression on the preoperative CT myelogram are more likely to have better neurological outcome after surgery. There is insufficient evidence to suggest that any of the other CT myelogram parameters investigated are predictors of postoperative outcomes in patients with DCM.

Differences between Manufacturers of Computed Tomography-Based Computer-Assisted Surgery Systems Do Exist: A Systematic Literature Review.

STUDY DESIGN: Literature review. OBJECTIVE: Several studies have shown that the accuracy of pedicle screw placement significantly improves with use of computed tomography (CT)-based navigation systems. Yet, there has been no systematic review directly comparing accuracy of pedicle screw placement between different CT-based navigation systems. The objective of this study is to review the results presented in the literature and compare CT-based navigation systems relative only to screw placement accuracy. METHODS: Data sources included CENTRAL, Medline, PubMed, and Embase databases. Studies included were randomized clinical trials, case series, and case-control trials reporting the accuracy of pedicle screws placement using CT-based navigation. Two independent reviewers extracted the data from the selected studies that met our inclusion criteria. Publications were grouped based on the CT-based navigation system used for pedicle screw placement. RESULTS: Of the 997 articles we screened, only 26 met all of our inclusion criteria and were included in the final analysis, which showed a significant statistical difference (p < 0.0001, 95% confidence interval 0.92 to 1.23) in accuracy of pedicle screw placement between three different CT-based navigation systems. The mean (weighted) accuracy of pedicle screws placement based on the CT-based navigation system was found to be 97.20 ± 2.1% in StealthStation (Medtronic, United States) and 96.1 ± 3.9% in VectorVision (BrainLab, Germany). CONCLUSION: This review summarizes results presented in the literature and compares screw placement accuracy using different CT-based navigation systems. Although certain factors such as the extent of the procedure and the experience and skills of the surgeon were not accounted for, the differences in accuracy demonstrated should be considered by spine surgeons and should be validated for effects on patients' outcome.

Intra-tumor delivery of zoledronate mitigates metastasis-induced osteolysis superior to systemic administration.

Bisphosphonates (BPs) have recently been shown to have direct anti-tumor properties. Systemic treatment with BPs can have multiple adverse effects such as osteonecrosis of the jaw and BP induced bone fracturing and spine instability. While benefits of systemic BP treatments may outweigh risks, local treatment with BPs has been explored as an alternate strategy to reduce unwarranted risk. In the present study, we examined whether local delivery of BPs inhibits tumor-induced osteolysis and tumor growth more effectively than systemic treatment in an animal model of tumor-induced bone disease. Following establishment of an intra-tibial model of bone metastases in athymic mice, the experimental group was treated by local administration of zoledronate into the tibial lesion. A comparison of the effect of local versus systemic delivery of zoledronate on the formation of tumor-induced osteolysis was also carried out. A significant increase in mean bone volume/tissue volume % (BV/TV) of the locally treated group (12.30±2.80%) compared to the control group (7.13±1.22%) (P<0.001). Additionally, there was a significant increase in the BV/TV (10.90±1.25%) in the locally treated group compared to the systemically treated group (7.53±0.75%) (P=0.005). These preliminary results suggest that local delivery of BPs outperforms both systemic and control treatments to inhibit tumor-induced osteolysis.

Incidence, Predictors, and Postoperative Complications of Blood Transfusion in Thoracic and Lumbar Fusion Surgery: An Analysis of 13,695 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database.

Study Design Retrospective cohort study. Objective To identify predictive factors for blood transfusion and associated complications in lumbar and thoracic fusion surgeries. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent lumbar or thoracic fusion from 2010 to 2013. Multivariate analysis was used to determine predictive factors and postoperative complications associated with transfusion. Results Out of 13,695 patients, 13,170 had lumbar fusion and 525 had thoracic fusion. The prevalence of transfusion was 31.8% for thoracic and 17.0% for lumbar fusion. The multivariate analysis showed that age between 50 and 60, age between 61 and 70, age > 70, dyspnea, American Society of Anesthesiologists class 3, bleeding disease, multilevel surgery, extended surgical time, return to operation room, and higher preoperative blood urea nitrogen (BUN) were predictors of blood transfusion for lumbar fusion. Multilevel surgery, preoperative BUN, and extended surgical time were predictors of transfusion for thoracic fusion. Patients receiving transfusions who underwent lumbar fusion were more likely to develop wound infection, venous thromboembolism, pulmonary embolism, and myocardial infarction and had longer hospital stay. Patients receiving transfusions who underwent thoracic fusion were more likely to have extended hospital stay. Conclusion This study characterizes incidence, predictors, and postoperative complications associated with blood transfusion in thoracic and lumbar fusion. Pre- and postoperative planning for patients deemed to be at high risk of requiring blood transfusion might reduce postoperative complications in this population.

Growing rod erosion through the lamina causing spinal cord compression in an 8-year-old girl with early-onset scoliosis.

BACKGROUND CONTEXT: Early-onset scoliosis often occurs by the age of 5 years and is attributed to many structural abnormalities. Syndromic early-onset scoliosis is considered one of the most aggressive types of early-onset scoliosis. Treatment starts with serial casting and bracing, but eventually most of these patients undergo growth-sparing procedures, such as a single growing rod, dual growing rods, or a vertical expandable titanium prosthetic rib. PURPOSE: This case report aimed to describe an unusual complication of erosion of a growing rod through the lamina that caused spinal cord compression in an 8-year-old girl with early-onset scoliosis. STUDY DESIGN: This is a case report. METHODS: A retrospective chart review was used to describe the clinical course and radiographic findings of this case after rod erosion into the spinal canal. RESULTS: The patient underwent successful revision surgery removing the rod without neurologic complications. CONCLUSIONS: Patients with syndromic early-onset scoliosis are more prone to progressive curves and severe rotational deformity. We believe that the severe kyphotic deformity in addition to the dysplastic nature of the deformity in this population may predispose them to this unusual complication.

Predictors of Discharge Destination After Lumbar Spine Fusion Surgery.

STUDY DESIGN: Retrospective cohort study of the prospective collected American College of Surgeons National Surgical Quality Improvement Program database. OBJECTIVE: The aim of the study was to identify predictive factors for the need of discharging patients to a facility other than home after lumbar spine fusion surgery. SUMMARY OF BACKGROUND DATA: Lumbar spine fusion surgery is a common surgical procedure used to treat a variety of lumbar spine conditions. A great number of patients fail to go home after surgery and require admission to a rehabilitation center. Predictive factors for discharging patients to a facility other than home after lumbar fusion surgery do not exist in the literature. METHODS: A total of 15,092 patients undergoing lumbar spine fusion were dichotomized based on discharge destination to patients who were discharged home (N = 12,339) and others who were discharged to a facility other than home (N = 2753). Outcomes included patient demographics, comorbidities, and clinical characteristics. A multivariate logistic regression was used to identify whether outcomes studied were predictive factors for discharging patients to a facility other than home after lumbar fusion surgery. RESULTS: Majority of patients were discharged home after lumbar fusion surgery (81.76%), with only some discharged to a facility other than home (18.24%). Multivariate analysis identified age, female sex, comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and obesity), minor and major complications, hospital length of stay, operative time at least 259 minutes, and multilevel surgery as significant predictive factors of discharging patients to a facility other than home after lumbar fusion surgery. CONCLUSION: The identified predictive factors can help the health system in developing an algorithm for early recognition of patients requiring postoperative admission to a facility other than home and possibly decreasing their hospital length of stay. This can significantly decrease the hospital costs for such patients. LEVEL OF EVIDENCE: 3.

Thirty-Day Complications of Conventional and Computer-Assisted Total Knee and Total Hip Arthroplasty: Analysis of 103,855 Patients in the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Computer-assisted surgery (CAS) has gained popularity in orthopedics for both total knee arthroplasty (TKA) and total hip arthroplasty (THA) in the past decades. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent a primary, unilateral THA and TKA from 2011 to 2013. Multivariate analysis was conducted to compare the postoperative complications in patients whose surgery involved the use of CAS with those by conventional techniques. RESULTS: We identified 103,855 patients who had THA and TKA in the database between 2011 and 2013. There were higher overall adverse events (odds ratio [OR], 1.40; CI, 1.22-1.59), minor events (OR, 1.38; CI, 1.21-1.58), and requirements for blood transfusion (OR, 1.44; CI, 1.25-1.67) in the conventional group when compared with CAS for TKA. However, rate of reoperation was higher in the CAS group for TKA (OR, 1.60; CI, 1.15-2.25). The results also showed higher overall adverse events (OR, 2.61; CI, 2.09-3.26), minor events (OR, 2.82; CI, 2.24-3.42), and requirements for blood transfusion (OR, 3.41; CI, 2.62-4.44) in the conventional group when compared to CAS for THA. Nevertheless, superficial wound infections (OR, 0.46; CI, 0.26-0.81) were shown to be higher in the CAS group undergoing THA. CONCLUSION: The use of CAS in THA and TKA reduced the number of minor adverse events in the first 30 days postoperatively. However, CAS was associated with an increased number of reoperations and superficial infections. The clinical benefits and disadvantages of CAS should be considered when determining the potential benefit-cost ratio of this technology.