Spinal metastasis: The rise of minimally invasive surgery.

INTRODUCTION: Bone is the third most common site of metastatic cancer, of which the spine is the most frequently involved. As metastatic cancer prevalence rises and surgical techniques advance, operative intervention for spinal metastases is expected to rise. In the first operative cohort of spinal metastasis in Ireland, we describe the move towards less invasive surgery, the causative primary types and post-operative survival. METHODS: This is a retrospective cohort study of all operative interventions for spinal metastasis in a tertiary referral centre over eight years. Primary spinal tumours and local invasion to the spine were excluded. Median follow up was 1895 days. RESULTS: 225 operative procedures in 196 patients with spinal metastasis were performed over eight years. Average cases per year increased form 20 per year to 29 per year. Percutaneous procedures became more common, accounting for the majority (53%) in the final two years. The most common primary types were breast, myeloma, lung, prostate and renal. Overall survival at 1 year was 51%. Primary type was a major determinant of survival, with breast and the haematological cancers demonstrating good survival, while lung had the worst prognosis. CONCLUSION: This is the first descriptive cohort of operative interventions for spinal metastasis in an Irish context. Surgery for spinal metastasis is performed at an increasing rate, especially through minimally-invasive means. The majority of patients survive for at least one year post-operatively. Prudent resource planning is necessary to prepare for this growing need.

Does country of origin influence research outcomes in operative interventions for lumbar spinal stenosis?

INTRODUCTION: Bias undermines evidence-based decision making. To counter this, surgeons must be aware of biases that may influence studies' reported outcomes. Lumbar spinal stenosis often requires operative intervention, with multiple available surgical strategies. Our aim was to assess the role that country of origin plays in published surgical outcomes for lumbar spinal stenosis. METHODS: We performed a search strategy of MEDLINE and EMBASE for all English language primary research papers evaluating operative interventions for lumbar spinal stenosis during the years 2010-2019 inclusive. Small case series and meta-analyses were excluded. Papers were assessed for outcome positivity and country of origin. Data analysis was conducted using GraphPad Prism statistical software. RESULTS: A total of 487 papers met the inclusion criteria. Of these, 419 (86%) reported positive outcomes. Asian studies were the most likely to report positive outcomes, at 93% (220 of 236), followed by US studies at 89% (98 of 110). European studies had the lowest positive publication rate at 69% (84 of 121). Region of origin was an independent predictor of positive study outcome on multivariable analysis when controlling for different study designs and healthcare systems. CONCLUSION: There is an association between country of origin and positive reported outcome in studies evaluating interventions for lumbar spinal stenosis. Clinicians should consider this when making management decisions based on published evidence. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

The Use of Dorsal Bridge Plate Fixation in the Operative Management of Lisfranc Injuries - A Retrospective Cohort Study at Medium Term Follow-Up.

INTRODUCTION: Traditionally, early surgical management of Lisfranc injuries with transarticular screws (TAS) was deemed to be the optimal treatment. However, concerns of potential iatrogenic articular cartilage disruption has led to discrepancies in opinion amongst surgeons, with many surgeons now utilizing dorsal bridge plates (DBP) for ORIF of Lisfranc injuries. OBJECTIVES: This study sought to investigate the clinical outcomes at medium-term follow-up of consecutive patients in our institution who underwent ORIF with DBP for Lisfranc injuries. METHODS: All consecutive patients who underwent ORIF with DBPs for Lisfranc injuries were identified. Outcomes of interest included; visual analogue scale (VAS), functional foot index (FFI), American Orthopaedic Foot & Ankle Surgeons (AOFAS) hindfoot scores, and complications. RESULTS: Overall, 37 consecutive patients (24 males) with a mean age of 34.8 ± 13.0 years underwent ORIF with DBPs for lisfranc injuries. After a mean 48.3 ± 28.7 months, the mean reported AOFAS and FFI scores were 77.4 ± 23.8 and 31.9 ± 32.7 respectively, with satisfactory reported pain scores as measured by VAS post-operatively at rest and whilst walking (2.2 ± 2.5 and 3.1 ± 2.6 respectively). The reported satisfaction rate was 86.5% (32/37). Overall, 25 patients (67.6%) had subsequent removal of metal or were listed for same, 88% (22/25) of whom did so electively in the absence of broken screws or infection. CONCLUSION: This study found that the use of Dorsal Bridge Plates for Open Reduction and Internal Fixation of Lisfranc Injuries resulted in satisfactory functional outcomes, high rates of patient-reported satisfaction and a low complication rate at medium-term follow-up. LEVEL OF EVIDENCE: Level IV; Retrospective Series of Consecutive Patients.

A novel scoring system incorporating sarcopenia to predict postoperative survival in spinal metastasis.

BACKGROUND CONTEXT: As the prevalence of spinal metastasis rises, methods to predict survival will become increasingly important for clinical decision-making. Sarcopenia may be used to predict survival in these patients. PURPOSE: The purpose of this study to develop a prediction model incorporating sarcopenia for postoperative survival in patients with spinal metastasis. DESIGN: Retrospective cohort study. PATIENT SAMPLE: This study included 200 patients who underwent operative intervention for spinal metastasis in our institution, a tertiary, academic spine center. OUTCOME MEASURES: The primary outcome measure was 1-year postoperative survival. The secondary outcome measures were 3-month and 6-month postoperative survival. METHODS: Clinicopathological and survivorship data was collated. Sarcopenia was defined using the L3 Psoas/Vertebral Body Ratio on cross-sectional CT. Independent predictors of postoperative survival were assessed by multiple logistic regression. RESULTS: Overall 1-year postoperative survival was 50%. L3/Psoas ratio ≥1.5 (OR 6.2), albumin ≥35g/l (OR 3.0) and primary tumor type were found to be independent predictors of 3 month, 6 month and 1 year postoperative survival on multivariable analysis. Age at surgery, ambulatory status and mode of presentation were not independent predictors of survival. Variables were used to generate a new scoring system, ProgMets, to predict postoperative survival. The ProgMets system had greater correlation and higher area under the curve (AUC, 0.80) for 1-year survival than other scoring systems. CONCLUSIONS: This is the first model to incorporate sarcopenia to predict survival in spinal metastasis patients and has good prediction of survival compared to previous models. This tool may be increasingly useful for informed decision making for patients and surgeons.

Modified trauma assessment clinic: A rapid, scalable model.

INTRODUCTION: Trauma Assessment Clinic (TAC) has become a very useful tool in managing busy trauma clinics and reducing attendances. There is good evidence of safety and efficacy. Extension of pre-existing TAC during the COVID pandemic has proven successful. Rapid start-up models for establishing TACs are not well described in the literature. This study aimed to prove that a modified TAC has similar efficacy and can be initiated in rapid start-up manner with minimal cost. METHODS: A new electronic pathway of referral with a template was created between the Emergency Department (ED) and the Orthopaedic department. RESULTS: Following introduction of our modified TAC 32% of patients referred to the TAC did not require in-person review thereby avoiding any additional hospital visit. Average time to first in-person review appointment was 15 days. Combining these, the projected reduction in all fracture clinic attendance was 48%. CONCLUSION: This paper describes the process of how a major teaching and tertiary referral orthopaedic unit developed an accelerated establishment process for a Trauma Assessment Clinic as an alternative to the traditional "Glasgow model". This can be instituted quickly, safely, and is scalable for use in a large hospital. The template provided can be used as a guide or "blueprint" should other orthopaedic departments require a rapid start-up of a Trauma Assessment Clinic.

Whole-body radiation exposure in Trauma and Orthopaedic surgery.

AIMS: The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery. METHODS: Radiation exposure to surgeons during common orthopaedic trauma operations was prospectively assessed using EPDs and thermoluminescent dosimeters (TLDs). Normative data for each operation type were calculated and compared to recommended guidelines. RESULTS: Current PPE appears to mitigate more than 90% of ionizing radiation in orthopaedic fluoroscopic procedures. There is a higher exposure to the inner thigh during seated procedures. EPDs provided results for individual procedures. CONCLUSION: PPE currently used by surgeons in orthopaedic trauma theatre adequately reduces radiation exposure to below recommended levels. Normative data per trauma case show specific anatomical areas of higher exposure, which may benefit from enhanced radiation protection. EPDs can be used to assess real-time radiation exposure in orthopaedic surgery. There may be a role in future medical wearables for orthopaedic surgeons.Cite this article: Bone Jt Open 2022;3(11):907-912.

Virtual fracture clinic reduces patient X-ray volume for common wrist and ankle fractures.

BACKGROUND: Virtual fracture clinics (VFC) have been widely adopted worldwide as part of the changes in healthcare delivery during the COVID-19 pandemic. They have been shown to be a safe and effective method of delivering trauma care for injuries which do not require immediate intervention or specialist management, whilst maintaining high levels of patient satisfaction. AIMS: Our aim was to evaluate whether VFCs reduce the volume of X-rays performed for common fractures of the wrist and ankle. METHODS: A retrospective cohort review was performed. The pre-VFC group consisted of 168 wrist and 108 ankle referrals from March to September 2019. The VFC group included 75 wrist and 68 ankle referrals, during the period March to September 2020. The total number of X-ray images, carried out within a 3-month period for each fracture was summated, with statistical analysis performed following fracture pattern classification. FINDINGS: A statistically significant decrease in mean X-rays was observed for isolated stable fracture patterns, such as non-displaced distal radius, - 0.976 (p = 0.00025), and Weber A ankle fractures, - 0.907 (p = 0.000013). A reduction was also observed for more complex fracture patterns such as dorsally displaced distal radius, - 0.701 (p = 0.129) and Weber B ankle fractures, - 0.786 (p = 0.235), though not achieving statistical significance. CONCLUSIONS: Virtual fracture clinics can reduce X-ray frequency for common stable wrist and ankle fractures, with resultant benefits for both patients and healthcare systems. These benefits may be sustained in patient care beyond the current COVID-19 pandemic.

A Rare Paraspinal Desmoid Tumour following Instrumented Scoliosis Correction in an Adolescent.

Desmoid tumours are benign neoplasms of myofibroblasts, often occurring after soft-tissue trauma. Rarely, desmoid tumours can occur following operative intervention, including spine surgery. In this case report, we describe the first reported case of desmoid tumour following scoliosis corrective surgery in an adolescent.

Acetabular Lip Augmentation Devices for the Unstable Total Hip Replacement-A Systematic Review.

BACKGROUND: The optimal management strategy for instability afte total hip arthroplasty remains unclear. Acetabular lip augmentation devices may offer an operative solution for recurrent instability. This systematic review reports the clinical outcomes of acetabular lip augmentation devices in comparison to other treatment options. METHODS: A literature search strategy was performed of Medline, EMBASE, and CENTRAL on September 19, 2020, for all studies reporting outcomes of acetabular lip augmentation devices for recurrent dislocation after total hip arthroplasty. Non-English language articles were excluded. Clinical and survivorship data were collated and analyzed. RESULTS: Thirteen studies describing acetabular augmentation were included for analysis. A total of 644 hips in 636 patients were augmented with a mean age of 75 years (39 to 103). Five different augmentation devices were used. The posterior lip augmentation device (PLAD, DePuy) was the most used (406 hips). Overall, acetabular lip augmentation devices had a 10% postoperative dislocation rate at a mean follow-up of 49 months (0.2 to 132). The PLAD had a 3.9% subsequent dislocation rate with a mean follow-up of 51 months (0.2 to 132). Only one study compared the PLAD to a dual-mobility cup, which demonstrated shorter operative times with the PLAD but higher rates of dislocation and revision surgery. CONCLUSION: The quality of literature on lip acetabular augmentation devices is poor. In these studies, the postoperative dislocation rate after lip acetabular augmentation was relatively high. The PLAD (DePuy) has the most evidence and may offer a therapeutic option for recurrent instability, in very specific clinical situations.

The rise of metastatic bone disease in Ireland.

To describe the expected rise of metastatic bone disease in Ireland, the relative primary types, and the locations of spread within the skeleton. This was a population-based epidemiological study using cancer registry data. We included patients with known metastatic cancer to bone, within 1 year of the primary diagnosis, during the years 1994 to 2012 inclusive. Our main outcome measures were age-specific, gender-specific and age-standardised incidence rates of bone metastasis, primary types and metastatic location within the skeleton. There were 14,495 recognised cases of bone metastasis in Ireland, 1994-2012 inclusive. Cases consistently rose over the time period, with 108% case increase and 51% age-standardised incidence rise. Annual percentage change increased across both genders and over all age groups. Most of this rise was not due to demographic population change. Breast, prostate and lung accounted for the majority of primary types. GI cancers were the fourth most common primary type. There were proportional increases in breast and lung, with proportional decreases in prostate. The spine was the major metastatic site. Bone metastasis is a significant and rising healthcare concern in Ireland. This rise is disproportionate to demographic changes. Breast, prostate and lung cancers account for the majority. GI cancers are implicated in an unexpectedly high number of cases. Spine is the most common location of bony metastasis, especially at presentation. Prudent healthcare planning is necessitated to prepare for the growing consequences of bone metastasis in cancer patients.

An Unusual Presentation of Right-Sided Sciatica with Foot Drop.

Rarely, sciatica is of extraspinal aetiology. By compressing the sciatic nerve, swelling of the short external rotators of the hip can cause sciatica. Uncommon anatomical relationships between the sciatic nerve and local muscles may potentiate this compressive effect. In this report, we describe the presentation of right sciatica and foot drop resulting from both extreme local constriction and unusual anatomical variation of the right sciatic nerve.