Early CRP Trends in Childhood Osteomyelitis Predict Complicated Disease.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) remains a cause of severe illness among children. Contemporary research aims to identify predictors of acute and chronic complications. Trends in C-reactive protein (CRP) after treatment initiation may predict disease course. We have sought to identify factors associated with acute and chronic complications in the New Zealand population. METHODS: A retrospective review of all patients younger than16 years with presumed AHO presenting to a tertiary referral centre between 2008 and 2018 was performed. Multivariate was analysis used to identify factors associated with an acute or chronic complication. An "acute" complication was defined as the need for 2 or more surgical procedures, a hospital stays longer than 14 days, or recurrence despite intravenous antibiotics. A "chronic" complication was defined as growth or limb length discrepancy, avascular necrosis, chronic osteomyelitis, pathologic fracture, frozen joint, or dislocation. RESULTS: One hundred fifty-one cases met the inclusion criteria. The median age was 8 years (69.5% male). Within this cohort, 53 (34%) experienced an acute complication and 18 (12%) a chronic complication. Regression analysis showed that contiguous disease, delayed presentation, and failure to reduce CRP by 50% at day 4/5 predicted an acutely complicated disease course. Chronic complication was predicted by the need for surgical management and failed CRP reduction by 50% at day 4/5. CONCLUSIONS: CRP trends over 96 hours after the commencement of treatment differentiate patients with AHO likely to experience severe disease. LEVEL OF EVIDENCE: Level II, retrospective study.

Ten-year Review of Acute Pediatric Hematogenous Osteomyelitis at a New Zealand Tertiary Referral Center.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Recent research has highlighted an unusually high burden of disease in the New Zealand population compared with other Western regions. We have sought to identify trends in presentation, diagnosis, and management of AHO, with added focus on ethnicity and access to health care. METHODS: A 10-year retrospective review of all patients <16 years with presumed AHO presenting to a tertiary referral center between 2008 and 2018 was performed. RESULTS: One hundred fifty-one cases met inclusion criteria. The median age was 8 years with a male predominance (69.5%). Staphylococcus aureus was the most common pathogen using traditional laboratory culture method (84%). The number of cases per year decreased from 2008 to 2018. Assessment using New Zealand deprivation scores showed Maori children were most likely to experience socioeconomic hardship ( P ≤0.01). Median distance traveled by families to first hospital consult was 26 km (range 1 to 178 km). Delayed presentation was associated with need for prolonged antibiotic therapy. Incidence of disease varied by ethnicity with 1:9000 cases per year for New Zealand European, 1:6500 for Pacific, and 1:4000 for Maori. Overall recurrence rate was 11%. CONCLUSIONS: The incidence of AHO in New Zealand is concerningly high within Maori and Pacific populations. Future health interventions should consider environmental, socioeconomic, and microbiological trends in the burden of disease. LEVEL OF EVIDENCE: Retrospective study, Level III.

Septic arthritis of the native hip joint: a multi-pattern, multi-outcome disease.

PURPOSE: Septic arthritis of the native hip joint (SANH) is an uncommon surgical and medical emergency with few reports. The aim of this study was to determine predictors of return to theatre (RTT), complications and mortality. METHODS: Patients with SANH were identified from January 2009 to June 2022; 50 patients and three subgroups were identified: Pyogenic (surgical washout without systemic inflammatory disease), Systemic (surgical washout with SIDs) and patients managed non-surgically. Patterns of these groups were assessed with a principal component analysis. The cumulative incidences for death, any complication and RTT for repeat washout were calculated. The predictive variables associated with outcomes were selected with univariable models and then incorporated in multivariable CoxPH regressions. RESULTS: The 1-year cumulative incidence was 14% for mortality and 48.5% for any complication. Amongst patients managed surgically, 1-year risk of RTT was 46% in Pyogenic subgroup and 21% in Systemic subgroup. Systemic subgroup had lower complications and RTT and higher rate of sterile aspirate, compared to Pyogenic. Charlson comorbidity index (CCI) (HR = 1.41, P value = 0.03), preoperative albumin (HR = 0.81, P value = 0.009) and preoperative haemoglobin (HR = 0.95, P value = 0.02) were significantly associated with 1-year mortality. Time between symptom onset and admission > 7 days (HR = 3.15, P value = 0.042), preoperative Hb (HR = 1.05, P value = 0.016), socioeconomic deprivation (HR = 1.18, P value = 0.04) and Systemic subgroup (HR = 0.25, P value = 0.04) were significantly associated with RTT. CONCLUSION: Mortality was well predicted by the usual parameters including CCI, albumin, but also low haemoglobin. Patients presenting in a delayed fashion were more likely to have multiple lavages.

Global epidemiology of childhood bone and joint infection: a systematic review.

PURPOSE: Childhood bone and joint infection (BJI) is a potentially severe disease that may have permanent sequelae, including growth impairment and limb deformity. It has been characterised in the literature with a focus on Western epidemiology; there are currently no reports detailing global epidemiology and bacteriology. This omits key data from determining temporal trends, appropriate antibiotic therapy, and resource allocation. This review aims to identify studies that characterise the incidence of childhood bone and joint infection or provide detailed bacteriology within their region. METHODS: A systematic review of the literature was performed from 01/01/1980 to 31/12/2020. Data has been analysed to give incidence of disease per 100,000 children, primary pathogen by country where available, and risk ratio (RR) for disease by ethnicity. This is applicable for areas that experience race-related inequitable burden of disease. RESULTS: Forty-four articles met the inclusion area; of these, seven were population-wide studies, primarily from Europe or the United States, and the remainder were cohort studies. Incidence could be derived from 26 studies compromising over 34, 000 children. Information on bacteriology was available from 39 publications (10, 957 cases). Methicillin-sensitive Staphylococcus aureus is the most common pathogen in the West. Recently, disease secondary to Kingella kingae and methicillin-resistant S. aureus has increased. Salmonella remains a dominant pathogen in African regions. Increased risk of disease is observed in Aboriginal, New Zealand Maori, Pacific, Indigenous Fijian, and Bedouin children. CONCLUSION: The current state of the literature detailing incidence of childhood BJI focuses on disease patterns from the West. There is a paucity of high-quality publications in the developing world. Despite these limitations, global trends in burden of disease show race-related inequitable risk of BJI. Temporal and regional variation in bacteriology can be demonstrated. LEVEL OF EVIDENCE: III.

Comparison of L5 pedicle morphology in patients with and without L5 spondylolysis.

Only a small number of studies have reported on L5 pedicle morphology in the presence of spondylolisthesis let alone isolated spondylolysis and findings are therefore variable. The aim of this radiographic study was to analyze L5 pedicle morphology in the presence and absence of L5 spondylolysis. The was a retrospective cross-sectional analysis of computed tomographic (CT) imaging. Assessment of the L5 pedicle morphology (height, width, length, transverse angle and screw length) were measured in patients with and without L5 spondylolysis. Pelvic measures including pelvic incidence, sacral anatomic orientation and sacral table angle were recorded. Patients were matched for age and gender. Twenty-three patients with spondylolysis were matched to 46 patients without. The presence of spondylolysis alone did not have a significant influence on either pelvic or pedicle morphologic parameters. Only with the presence of associated spondylolisthesis was there a difference noted with an increase in pedicle length observed. Correlation analysis suggested further morphologic changes may result with increased remodeling. Isolated spondylolysis at L5 appears to have little influence on pedicle morphology in this CT-based analysis. Morphologic changes appear likely to become significant only with associated spondylolisthesis and associated remodeling.

Assessment of the acetabular version in relation to sagittal sacropelvic parameters.

The relationship between acetabular orientation and the sacropelvic parameters is of interest to both hip and spine surgeons as it is increasingly clear disease in one area can affect the other, including the outcome of surgical procedures. The aim of this study was to further clarify the relationship between measures of acetabular orientation and sacropelvic parameters. This study utilized a trauma CT database. A total of 100 scans on adult patients without overt hip or spinal disease were included. Measures of acetabular orientation included the acetabular sagittal angle (ASA) which uses the anterior pelvic plane as a reference and sacroacetabular angle which uses the sacral endplate as a reference (SA); spinopelvic parameters include the pelvic incidence (PI), sacral anatomic orientation (SAO) and pelvic thickness (PTH). Mean age 48.2 years (SD 18.0), 62% male. Mean values were: PI 50.5, SAO 50.7, PTH 106.4 mm, ASA-right 62.1, ASA-left 64.0, SA-right 67.2, and SA-left 65.4. There was substantial correlation between PI and SA (r = 0.628-0.630) and also between SAO and SA (-0.657 to -0.692). Liner regression determined SA was best predicted by the model: SA = 81 × SAO + 0.36 × PI. When using the anterior pelvic plane as a reference to define acetabular orientation, there does not appear to be any significant relationship between the sagittal orientation of the acetabulum and sacropelvic parameters. Using the sacrum as a common point of reference allows some further understanding of the interplay between pelvic parameters and the orientation of the acetabulum.

Ten-Year Single Center Retrospective Analysis of Adult Native Ankle Joint Septic Arthritis.

Septic arthritis (SA) of the native ankle joint can result in serious morbidity and mortality but is a poorly quantified issue with little literature available on its clinical features, treatment and outcomes. This was a 10-y review (N ≥ 30) of adults with SA of the native ankle joint presenting to a single center from December 2009 to January 2019. Patients with prior ankle surgery, prosthetic infection, inoculation from trauma, not initially treated at our institution or lost to follow-up were excluded. Thirty-six patients met inclusion criteria. This is the largest cohort of adult native ankle joint SA in the literature. Mean age was 63.5 y (range 28-93 y). Patients most often presented with pain (91.7%), swelling (61.1%), and fever (22%). Staphylococcus aureus was the most common causative pathogen (63.9%). Readmission rate was 60%. The 1-y mortality rate was 14.3% with Charlson Comorbidity Index and age identified as independent predictors of mortality. No statistically significant predictors were found for returns to theatre. When assessing ankle pain in elderly patients, and those with poor physiology, high clinical index of suspicion should be maintained for this potentially life-threatening condition. We recommend development of evidence-based clinical guidelines for adult native ankle joint SA and establishment of a prospective multi-center database to enable further research in this field.

Computed tomography study of the relationship between pelvic incidence and bony contribution to lumbar lordosis in children.

There is little data regarding the relationship in children and how it may change with aging. The aim of this radiographic study was to define the relationship between pelvic incidence (PI) and segmental vertebral body lordosis through childhood. In 150 children, CT scans of the lumbar spine and pelvis were analyzed measuring PI, sacral table angle (STA), sacral kyphosis (SK), and segmental lordosis (SL) individually L1-L5. Children were grouped by age: (1) 0-60 months; (2) 61-120 months; (3) 121-185 months. Mean PI for the entire cohort was 40.4, mean SL for L1-0.6, L2 0.0, L3 1.8, L4, 4.7, and L5 11.4. There were 40 children in Group 1, 63 in Group 2 and 37 in Group 3. SL differed between age groups at all levels except at L2. L1 and L2 became more kyphotic with increasing age; L3, L4, and L5 became more lordotic with increasing age. The correlation between PI and SL at each level became stronger with increasing age. Similarly, the correlation between PI and STA and between PI and SK also became stronger with increasing age. As children mature, the relationship between PI and segmental lordosis at each level of the lumbar spine becomes stronger-the relationship between PI and lordosis trends toward that seen in the adult. Future work should aim to define when the adult PI-LL relationship is realized.

Relationship of aortic bifurcation with sacropelvic anatomy: Application to anterior lumbar interbody fusion.

INTRODUCTION: Various sacropelvic parameters such as the pelvic Incidence (PI) are used to predict ideal lumbar lordosis and aid surgical planning. The objective of this study was to establish the relationship between the location of the aortic bifurcation from the sacral promontory and sacropelvic measures including the PI. MATERIALS AND METHODS: One hundred sixty five computed tomography (CT) scans obtained for major trauma including the entire spine were identified. Sacropelvic parameters including PI, sacral anatomic orientation, pelvic thickness (PTH), and sacral table angle were measured. Aortic bifurcation was identified on sagittal and coronal imaging and the distance from the sacral promontory (bifurcation-promontory distance [BPD]) measured (mm). RESULTS: Mean age of the cohort was 44.3 years (SD 18.5; range 16-88 years); 61.8% male. The mean PI was 49.2° (SD 10.2°; range 30°-80°). The mean BPD was 66.4 mm (SD 13.1 mm; range 38.3-100 mm). In the majority, the bifurcation was at the level of the L4 vertebral body (72.7%). Only age (r = -.389; p < .0001) and PTH (r = .172; p = .027) correlated with the BPD to a significant degree. PI did not correlate with BPD (r = .061; p = .435). Linear regression analysis provided the following predictive equation: BPD = 34.3 mm + 0.30 × PTH. CONCLUSION: This study demonstrates a lack of any meaningful correlation between sagittal pelvic parameters and the distance of the aortic bifurcation from the sacral promontory. Surgical planning for fusion surgery in the lumbar spine should include assessment of spinopelvic parameters and if anterior access to the lumbar disc(s) necessary, vascular anatomy should be carefully assessed independent of these measures.

Ten-year retrospective review of paediatric septic arthritis in a New Zealand centre.

BACKGROUND: Paediatric septic arthritis, although a rare diagnosis in the developed world, remains a significant challenge in the New Zealand population. In recent years, there has been effort to characterize the nature of paediatric bone and joint infection for New Zealand due to rising incidence of osteomyelitis and staphylococcal sepsis [1, 2]. We have sought to identify trends in presentation, diagnosis and management of paediatric septic arthritis, with added focus on ethnicity and access to healthcare. METHODS: A ten year retrospective review of all cases < 16 years with presumed septic arthritis presenting to a tertiary referral centre between 2008 and 2018 was performed. RESULTS: A total of 103 cases met inclusion criteria. Mean age was 5.9 years (SD +/- 4.17) with a male predominance (64%). Traditional laboratory culture method isolated an organism in 66% of cases: Staphylococcus aureus was the most common pathogen identified (61%). Incidence varied greatly by ethnicity 1:16,000 for NZ European children; 1:8760 for Pacifica and 1:4300 for Maori. Mean distance travelled by patients to reach the nearest emergency department was 38.3 km, ranging from 2 to 188 km. Assessment using NZ deprivation scores showed the Maori paediatric population were likely to reside in areas of worse socioeconomic deprivation (p = 0.0005). The majority (66%) of cases were treated surgically with a low recurrence rate (2.9%). Delayed presentation was associated with worse outcomes and more likely in patients residing > 20 km away from the nearest emergency department. CONCLUSION: The incidence of paediatric septic arthritis in New Zealand is concerningly high within Maori and Pacific populations. Future health interventions should consider environmental, socioeconomic, and microbiological trends in the burden of disease.

External Validation of an Algorithm to Predict Adjacent Musculoskeletal Infection in Pediatric Patients With Septic Arthritis.

BACKGROUND: Septic arthritis (SA) remains a potentially morbid disease in the pediatric population. Magnetic resonance imaging (MRI) is the most sensitive tool for recognizing associated osteomyelitis and intramuscular abscess, but is a limited resource. The aim of this study is to externally validate a previously developed algorithm (Rosenfeld and colleagues) to predict adjacent infection in pediatric patients diagnosed with SA. METHODS: We identified 120 children under 16 with presumed SA presenting to a tertiary referral center between 2008 and 2018. Patients without confirmed SA, those with insufficient data, and patients who did not receive perioperative MRI were excluded, leaving 53 patients. The previous algorithm suggests that patient age (above 4 y), C-reactive protein (>8.9 mg/L), platelet count (<310×10cells/µL), duration of symptoms (>3 d), and absolute neutrophil count (>7.2×10cells/µL) are risk factors for adjacent infection, with 3 or more variables signifying a "positive" result. Comparing against the gold standard of MRI, the accuracy of the algorithm was validated in terms of sensitivity, specificity, likelihood ratio (LR), and positive and negative predictive value. Discrimination and calibration of this algorithm have been assessed using receiver operating curve analysis and calibration plots. RESULTS: The sensitivity and specificity of criteria from Rosenfeld algorithm were 73% and 44%, respectively. Receiver operating curve showed poor discrimination [area under the curve=0.54, confidence interval (CI): 0.26-0.83]. The positive predictive value was 55.9% and the negative predictive value was 63.1% with LR +1.23 (CI: 0.87-1.98) and LR -0.61 (CI 0.28-1.30). Only 53% of patients with 4 or more criteria had an adjacent infection on MRI. Examining our cohort, children with a positive MRI finding had higher mean C-reactive protein (77 vs. 122 mg/L, P=0.04) and were more likely to have waited >72 hours days between symptom onset and hospital presentation (P=0.03). CONCLUSION: Although treatment algorithms are an attractive tool to guide clinicians and resource allocation, they need to take into account the local population characteristics before routine implementation. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Computed tomography analysis of sacropelvic parameters in relation to anterior access to the lumbosacral disc.

Purpose: Anecdotally a higher pelvic incidence (PI) confers a 'deeper' pelvis with the potential for challenging access, yet this is ill-defined in the existing literature. The aim of this study was to assess the relationship of sacropelvic sagittal parameters and their relationship with the projection angle (PA), an indicator of access to and orientation of the lumbosacral disc with respect to the pelvis and identify a threshold PI value beyond which more difficult surgical access may be anticipated.Materials and methods: Computed tomography (CT) scans taken for trauma were studied. Measures including the PI, sacral kyphosis (SK), sacral table angle (STA), PA and anterior pelvic angle (APA) were taken. The PA is the angle subtended by a line from the apex of the pubic symphysis to the sacral promontory and a line running along the sacral endplate. A positive value is obtained when the line from the endplate runs superior to the symphysis.Results: 168 scans were reviewed, mean age 44.2 years (s.d. 18.4). The mean PI was 50.0 (s.d. 10.2), SK 24.4 (s.d. 12.3), and STA 102.0 (s.d. 6.1). The mean PA was 20.1 (range -14 to 46; s.d. 10.3). PA correlated with PI (R = -0.892; p < .001) and also SK (R = -0.760; p < .001). With PI values above 73 the PA is likely to be negative with the lumbosacral disc orientation falling behind the pubic symphysis. One-way analysis of variance showed differences in PA according the six subclasses of PI.Conclusion: The PA, as an indicator of the orientation of the lumbosacral disc with respect to the pelvis, correlated strongly with the PI. Patients with high PI are more likely to have a lumbosacral disc with trajectory falling behind the pubic symphysis and surgeons should closely analyse pelvic anatomy, particularly in patients with high PI.

Pelvic Incidence: Computed Tomography Study Evaluating Correlation with Sagittal Sacropelvic Parameters.

Normal values for spinal alignment are often based on the pelvic incidence (PI), defined as the angle subtended by a line from the bicoxofemoral axis to the midpoint of the sacral endplate and a line perpendicular to the midpoint. Despite widespread use, determinants of its values remain obscure. The aim of this study was to determine correlation of sacropelvic parameters with the PI on computed tomography (CT). CT scans performed for trauma were identified over a 1-year period. Patients aged over 16 were included. PI, sacral anatomic orientation, sacral table angle (STA), sacral kyphosis (SK), pelvic thickness (PTH), femorosacral pelvic angle, pelvisacral angle, and sacropelvic angle were measured. Additional novel measures including crest-to-pubis distance, crest-to-sacrum distance (CSD), inlet distance, outlet distance, and inlet-outlet angle were taken. One hundred and seventy-seven scans were analyzed. Mean age 44.3 years; 62% male. The mean PI was 50.1 (SD 10.8; range 29-87). SK (r = 0.769), inlet-outlet angle (r = -0.533), PTH (r = -0.370), CSD (r = 0.290), and STA (r = -0.276) significantly correlated with PI. Multivariate analysis developed a predictive equation of: PI = 101.45 - (0.52 × STA) + (0.67 × SK) - (0.34 × inlet-outlet angle), with an adjusted R2 0.734 (P < 0.001). Measures that represent the sacral morphology, particularly SK, and the position of the sacrum in space correlated strongly with the PI and contributed strongly to a predictive equation. These findings may direct further efforts to explore how the PI is determined and therefore how it may be modified. Clin. Anat. 33:237-244, 2020. © 2019 Wiley Periodicals, Inc.

Incidence of Congenital Spinal Abnormalities Among Pediatric Patients and Their Association With Scoliosis and Systemic Anomalies.

BACKGROUND: Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies. METHODS: A retrospective cohort analysis on Health care Cost and Utilization Project's Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. OUTCOME MEASURES: Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies. Frequencies of congenital spine anomalies were estimated using KID hospital-and-year-adjusted weights. Poisson distribution in contingency tables tabulated concurrence of other congenital anomalies, grouped by body system. RESULTS: Of 12,039,432 patients, rates per 100,000 cases were: 9.1 hemivertebra, 4.3 Klippel-Fiel, 56.3 Chiari malformation, 52.6 tethered cord, 83.4 spina bifida, 1.2 absence of vertebra, and 6.2 diastematomyelia. Diastematomyelia had the highest concurrence of other anomalies: 70.1% of diastematomyelia patients had at least one other congenital anomaly. Next, 63.2% of hemivertebra, and 35.2% of Klippel-Fiel patients had concurrent anomalies. Of the other systems deformities cooccuring, cardiac system had the highest concurrent incidence (6.5% overall). In light of VACTERL's definition of a patient being diagnosed with at least 3 VACTERL anomalies, hemivertebra patients had the highest cooccurrence of ≥3 anomalies (31.3%). With detailed analysis of hemivertebra patients, secundum ASD (14.49%), atresia of large intestine (10.2%), renal agenesis (7.43%) frequently cooccured. CONCLUSIONS: Congenital abnormalities of the spine are associated with serious systemic anomalies that may have delayed presentations. These patients continue to be at a very high, and maybe higher than previously thought, risk for comorbidities that can cause devastating perioperative complications if not detected preoperatively, and full MRI workups should be considered in all patients with spinal abnormalities. LEVEL OF EVIDENCE: Level III.

Guided Growth: A Novel Treatment for Anterolateral Bowing of the Tibia.

BACKGROUND: Tibial pseudoarthrosis is a source of considerable morbidity in children with neurofibromatosis. Preventing the progression of anterolateral bowing of the tibia (ALBT) to tibial pseudoarthrosis is difficult. The aim of this paper is to report the successful use of guided growth to prevent tibial pseudoarthrosis in a child with neurofibromatosis. METHODS: With local ethical approval, we reviewed the case notes and radiographs of a child with pronounced ALBT who was treated with guided growth to correct the deformity and prevent fracture. RESULTS: At 4-year follow-up guided growth has successfully corrected the deformity and prevented tibial pseudoarthrosis. CONCLUSIONS: This is the first report of the use of guided growth to prevent the progression of ALBT to pseudoarthrosis of the tibia in a child with neurofibromatosis. LEVEL OF EVIDENCE: Level IV.

Open Ankle Dislocation Without Fractures With Tibialis Posterior Tendon Interposition Through the Interosseous Space.

Open ankle dislocations without fracture are rare injuries. Dislocation or interposition of adjacent tendons are a rare associated feature of ankle fracture-dislocation. We report an extremely unusual case of open ankle dislocation without fracture with concurrent tibialis posterior tendon interposition through the interosseous space that was detected incidentally on computed tomography. We highlight the clinical, radiologic, and intraoperative features to avoid missing similar diagnoses.

Degenerative spondylolisthesis: contemporary review of the role of interbody fusion.

Degenerative spondylolisthesis is a common presentation, yet the best surgical treatment continues to be a matter of debate. Interbody fusion is one of a number of options, but its exact role remains ill defined. The aim of this study was to provide a contemporary review of the literature to help determine the role, if any, of interbody fusion in the surgical treatment of degenerative spondylolisthesis. A systematic review of the literature since 2005 was performed. Details on study size, patient age, surgical treatments, levels of slip, patient reported outcome measures, radiographic outcomes, complications and selected utility measures were recorded. Studies that compared a cohort treated with interbody fusion and at least one other surgical intervention for comparison were included for review. Only studies examining the effect in degenerative spondylolisthesis were included. Two authors independently reviewed the manuscripts and extracted key data. Thirteen studies were included in the final analysis. A total of 565 underwent interbody fusion and 761 underwent other procedures including decompression alone, interspinous stabilisation and posterolateral fusion with or without instrumentation. Most studies were graded Level III evidence. Heterogeneous reporting of outcomes prevented formal statistical analysis. However, in general, studies reviewed concluded no significant clinical or radiographic difference in outcome between interbody fusion and other treatments. Two small studies suggested interbody fusion is a better option in cases of definite instability. Interbody fusion only provided outcomes as good as instrumented posterolateral fusion. However, most studies were Level III, and hence, we remain limited in defining the exact role of interbody fusion-cases with clear instability appear to be most appropriate. Future work should use agreed-upon common outcome measures and definitions.

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

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

Cervical disc replacement - emerging equivalency to anterior cervical discectomy and fusion.

PURPOSE: Cervical disc replacement has become an acceptable alternative to anterior cervical fusion for the surgical treatment of cervical spine spondylosis resulting in radiculopathy or myelopathy following anterior discectomy and decompression. This concise overview considers the current state of knowledge regarding the continued debate of the role of cervical disc replacement with an update in light of the latest clinical trial results. METHODS: A literature review was performed identifying clinical trials pertaining to the use of cervical disc replacement compared to cervical discectomy and fusion. Single level disease and two level disease were considered. Outcome data from the major clinical trials was reviewed and salient points identified. RESULTS: With lengthier follow-up data becoming available, the equivalence of CDR in appropriately selected cases is becoming clear. This is chiefly manifested by reduced re-operation rates and reduced incidence of adjacent level disease in those treated with arthroplasty. CONCLUSION: Cervical disc replacement shows emerging equivalence in outcomes compared to the gold standard anterior cervical discectomy and fusion. Further longer term results are anticipated to confirm this trend.

An assessment of the readability and quality of elective orthopaedic information on the Internet.

This study assessed the readability and quality of websites related to; total hip replacement, total knee replacement and anterior cruciate ligament reconstruction using validated instruments. 225 websites were analyzed from Google, Yahoo and Bing. Readability was assessed using the Flesch Reading Ease Score and Flesch-Kincaid grade level. Quality was assessed using the LIDA tool, HON-code status and an original assessment tool. Only 13.7% were set at or below the recommended 6th grade readability level. 27.35% were HON-code certified. There was a wide variation in quality scores between websites and the information relating to the three procedures was inconsistent and generally of poor quality. Given the deficit in information it is important Orthopaedic surgeons provide patients with high quality, readable information or direct them to an appropriate source.