Accuracy of augmented reality-assisted pedicle screw placement: a systematic review.

OBJECTIVE: Conventional freehand methods of pedicle screw placement are associated with significant complications due to close proximity to neural and vascular structures. Recent advances in augmented reality surgical navigation (ARSN) have led to its adoption into spine surgery. However, little is known regarding its overall accuracy. The purpose of this study is to delineate the overall accuracy of ARSN pedicle screw placement across various models. METHODS: A systematic review was conducted of Medline/PubMed, Cochrane and Embase Library databases according to the PRISMA guidelines. Relevant data extracted included reports of pedicle screw placement accuracy and breaches, as defined by the Gertzbein-Robbins classification, in addition to deviation from pre-planned trajectory and entry point. Accuracy was defined as the summation of grade 0 and grade 1 events per the Gertzbein-Robbins classification. RESULTS: Twenty studies reported clinically accurate placed screws. The range of clinically accurate placed screws was 26.3-100%, with 2095 screws (93.1%) being deemed clinically accurate. Furthermore, 5.4% (112/2088) of screws were reported as grade two breaches, 1.6% (33/2088) grade 3 breaches, 3.1% (29/926) medial breaches and 2.3% (21/926) lateral breaches. Mean linear deviation ranged from 1.3 to 5.99 mm, while mean angular/trajectory deviation ranged 1.6°-5.88°. CONCLUSION: The results of this study highlight the overall accuracy of ARSN pedicle screw placement. However, further robust prospective studies are needed to accurately compare to conventional methods of pedicle screw placement.

Impact of closed-incision negative pressure wound dressings on surgical site infection following groin incisions in vascular surgery; a single-centre experience.

OBJECTIVES: Surgical site infection (SSI) is a common complication in vascular surgery, and is associated with increased patient morbidity, readmission and reintervention. The aim of this study was to assess the impact of closed-incision negative pressure wound therapy (CiNPWT) upon rate of SSI and length of hospital stay. METHODS: This study was reported in line with the STROBE guidelines. We assessed the baseline incidence of SSI from a 12-month retrospective cohort and, following a change in practice intervention with CiNPWT, compared to a 6-month prospective cohort. The primary endpoint was incidence of SSI (according to CDC-NHSN guidelines) while secondary endpoints included length of hospital stay, readmission, reintervention and Days Alive and Out of Hospital (DAOH) to 90-days. RESULTS: A total of 127 groin incisions were performed: 76 (65 patients) within the retrospective analysis and 51 (42 patients) within the prospective analysis (of whom 69% received CiNPWT). The primary endpoint of SSI was seen in 21.1% of the retrospective cohort and 9.8% of the prospective cohort (p = .099). Readmission was found to be significantly associated with the retrospective cohort (p = .016) while total admission (inclusive of re-admission) was significantly longer in those in the retrospective cohort (p = .013). DAOH-90 was 83 days (77-85) following introduction of the CiNPWT protocol as compared to the retrospective cohort (77 days (64-83), p = .04). CONCLUSION: Introduction of CiNPWT was associated with a reduced length of hospital stay and improved DAOH-90. Further trials on CINPWT should include patient-centred outcomes and healthcare cost analysis.

The efficacy of anchored stand-alone spacers in comparison to conventional cage and plate in anterior cervical discectomy and fusion surgery: A meta-analysis of randomised controlled trials for clinical and radiological outcomes.

Introduction: Anterior cervical discectomy and fusion (ACDF) is commonly performed with cage and plate constructs to stabilise diseased or injured cervical segments. Despite it being a commonly performed procedure, there are notable rates of associated morbidity reported in the literature. Stand-alone spacers represent a novel form of instrumentation to conventional cage and plate constructs. Research question: Do stand-alone spacers have improved operative characteristics and postoperative outcomes in ACDF cohorts when compared to cage and plate constructs? Methods: A systematic review and meta-analysis was conducted of PubMed/Medline, Embase and Google Scholar databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. Studies of interest included cage and plate instrumentation versus anchored stand-alone spacers for patients undergoing ACDF. Pre- and post-operative clinical and radiological outcomes were collated and compared for significance between cohorts. Results: 10 RCTs were identified and included with 779 patients total. Mean age of the entire cohort was 50.1 years. 62% (483/779) of the cohort were male. 384 patients underwent ACDF with stand-alone cage, while 395 had ACDF with conventional cage and plate. Stand-alone spacers significantly outperformed conventional instrumentation in terms of estimated blood loss (p < 0.01), total postoperative complications (p < 0.01), dysphagia rates (p = 0.04) and adjacent segment disease (p = 0.04). Non-inferiority was evident in both patient reported outcome measures and radiological outcomes. Conclusion: This meta-analysis highlights the efficacy of stand-alone spacers for the management of primarily cervical spondylitic disease for both single-level and multi-level pathology, and thus presents an attractive alternative to conventional instrumentation for patients undergoing ACDF surgery.

'Out of hours' orthopaedics in an Irish regional trauma unit and the impact of COVID-19.

INTRODUCTION: MRHT is the regional trauma service for the Midlands, providing 24/7 orthopaedic cover. 'Out of hours' surgery is reserved for those occasions where waiting for the next operating list during normal working hours would result in an unacceptable outcome for the patient. AIMS: To identify how many 'out-of-hours' surgeries were performed and what proportion of the total workload was made up by these cases. Secondly, to identify the impact of COVID-19 on our workload as an acute trauma service. METHODS: We performed a retrospective analysis of all operations performed in the emergency orthopaedic theatre between January 2017 and October 2020. Included were all emergency orthopaedic procedures performed after 6 p.m. and before 8 a.m. We compared this to the total number of trauma surgeries performed in the same time period to calculate the percentage of our total operations. RESULTS: There were a total of 7615 orthopaedic trauma operations performed in the 193 weeks. 164 of these were 'out-of-hours'. This represents 2.2% of the total operations performed and is equal to 0.84 cases per week. 55 of the 164 (33.5%) were performed in children under the age of 18. 62 were performed between 6 and 8 p.m., 61 between 8 and 10 p. m., 31 between 10 p.m. and midnight, and the remaining 10 were performed between midnight and 3 a.m. CONCLUSION: Surgery out of hours has been associated with increased complications, and so decisions to perform emergency surgery should not be made lightly. However, sometimes they are unfortunately necessary and are some of the most important operations we can perform as orthopaedic surgeons.

Frequency of complications in intramedullary nailing of open tibial shaft fractures: a systematic review.

Background: Open tibial shaft fractures comprise almost 45% of all open fractures and are frequently the result of high-energy trauma. Due to contamination, limited soft tissue coverage of the tibial shaft and poor tibial blood supply, open tibial shaft fractures are associated with high rates of complication including malunion, non-union and infection. Intramedullary nailing (IMN) is a mainstay of treatment. This study aims to determine the frequency of the various complications in this cohort. Methods: A systematic review of papers published on Embase, PubMed and Cochrane databases pertaining to the use of IMN to fix open tibial shaft fractures were included. The available evidence was collated in regard to the incidence of union, malunion, non-union and infection seen in this cohort. Results: A total of 2767 citations were reviewed, and 17 studies comprising 1850 patients were included in the analysis. There was a delayed union rate of 22.4%, malunion rate of 8.3%, non-union rate of 9.7% and infection rate of 8.1% (95% CI: 5.7%-10.8%) in this patient cohort. Subgroup analysis showed a 3-fold increase in non-union and a 2-fold increase in deep infection among Gustilo III injuries compared to Gustilo I and II. Conclusions: IMN for open tibial shaft fractures results in high rates of union and low rates of infection, comparable to figures seen in closed injuries and superior to those seen with alternative methods of fixation. There is a substantially increased risk of complication associated with Gustilo III injuries, reinforcing the significance of the soft tissue injury in these patients.

Pronator quadratus repair after volar plating for distal radius fractures: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: The purpose of the current study is to meta-analyze the randomized controlled trials in the literature comparing pronator quadratus repair versus no repair alongside volar plating of distal radius fractures. METHODS: A search of the PUBMED/MEDLINE, EMBASE, and The Cochrane Library databases was performed. Any randomized con- trolled trials comparing pronator quadratus repair versus no repair alongside volar plating of distal radius fractures were included. The relevant information was collected by 2 blinded reviewers using a predetermined data sheet. Clinical outcomes were compared, with all statistical analyses performed using Review Manager Version 5.3. RESULTS: Five randomized controlled trials with 273 patients were included. There was no significant difference in the range of motion in flexion-extension, ulnar-radial deviation, or pronation-supination. There was a significant difference in favor of the no repair group for Disabilities of the Arm, Shoulder and Hand (DASH) Score (MD [Mean Difference]: 2.63, P < .0001) and pronation strength (MD: 13, P < .0001). Furthermore, there was no significant difference in the visual analog scale score. There were 3 complications relating to pronator quadratus repair, in which patients developed carpal tunnel syndrome requiring a release. There was no significant difference in the re-operation rate. CONCLUSION: This study found that pronator quadratus repair when performing volar plating for distal radius fractures did not result in a significant improvement in functional outcome, range of motion, or strength. LEVEL OF EVIDENCE: I, Systematic Review of Level 1 Studies, Level I, Therapeutic Study.

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.

A Portable Hip Arthroscopy Simulator Demonstrates Good Face and Content Validity with Incomplete Construct Validity.

PURPOSE: We evaluate the face, content, and construct validity of a portable hip arthroscopy module in a regional orthopaedic unit. METHODS: Participants were recruited from a regional orthopaedic centre, and categorized into novice (0 arthroscopies), intermediate (1-29 arthroscopies), and expert (>50 arthroscopies) groups based on reported experience in arthroscopy. Face and content validity was evaluated by feedback from users immediately following completion of modules. Objective measurements, including time taken and subjective measurements consisting of simulation software metrics including, cam lesion locations attempts, scope strikes on bone, healthy bone burred, and cam lesion burred. Scores achieved by experts were recorded, and the median score was set at the level at which proficiency was demonstrated. Participant feedback on perceived educational use was collected following completion. RESULTS: In total, 20 participant results were included for analysis. Good face and content validity was expressed by participants with previous arthroscopic experience. Number of scope strikes within the simulator-derived metrics accurately discerned between levels of experience. Novices had a mean of 5 strikes per attempt (SD ± 5 ) ,  intermediates a mean of 5.8 strikes (SD ± 4.1). There was a significant difference between expert and novice groups (P = .01), and expert and intermediate groups (P = .002). No significant difference between overall performance scores achieved by participants in expert, intermediate, and novice groups (62% ± 19 vs 55% ± 22 vs 50% ± 23 , P = .15). This demonstrates incomplete construct validity of the simulator software-derived metrics. CONCLUSIONS: This hip arthroscopy simulator demonstrated acceptable face and content validity, with incomplete construct validity of simulator software metrics. Participants reported high levels of satisfaction with the module, highlighting that the addition of haptic feedback would be beneficial to improve procedural steps. Incorporation of tactile feedback to the modulator components would likely enable the software to accurately delineate between levels of experience. CLINICAL RELEVANCE: This study demonstrates good face and content validity. The addition of haptic feedback in a hip arthroscopy simulator may improve learning.

Achilles' tendon rupture dancing the 'Jerusalema' - A case series.

INTRODUCTION AND IMPORTANCE: The weekend warrior has long been prey to musculoskeletal injuries as a result of intermittent, high intensity activity. The Achilles tendon is known to be particularly vulnerable in this population cohort but during the COVID-19 lockdowns in Ireland and all over the world there has been a certain level of detraining and deconditioning among all age groups and populations. Throughout the worldwide restrictions, viral internet challenges and dances have encapsulated the spirit of a global community with the 'Jerusalema' dance being no exception. The rise of this particular viral sensation was at the detriment of the Achilles tendons of three middle aged gentlemen on who we base our case series. PRESENTATION OF CASES: Over the space of ten days three cases of Achilles tendon rupture repair presented to the emergency department in Midlands Regional Hospital Tullamore (MRHT) with the mechanism of tendon rupture being through the 'Jerusalema' dance. These patients were surgically managed in line with local institution practice and postoperative outcomes were good with no complications noted. Follow up is ongoing. CLINICAL DISCUSSION: This retrospective case series is based on the impact of the 'Jerusalema Dance' on presentations of Achilles tendon rupture to the Emergency Department in a single regional hospital from January to March 2021. We used these cases in conjunction with a review of current literature to highlight the benefit of an integrated Achilles Tendon rehabilitation programme in this at-risk patient cohort. CONCLUSION: This paper highlights the dangers inherent when well intentioned, but physically deconditioned individuals endeavour to perform a physical exercise which is deceptively demanding. Going forward, viral challenges such as the 'Jerusalema' may contribute to new and interesting mechanisms of injuries in our 'weekend warrior' cohort. In addition to this, given the global deconditioning seen due to the COVID 19 pandemic and subsequent lockdowns we may see a higher rate of Achilles tendon injuries in the near future across a multitude of patient cohorts. Level one evidence suggests that conservative treatment is just as effective as surgical treatments in the majority of patients with an Achilles tendon rupture, as long as a protocol of rehabilitation with early weightbearing is performed. Our accelerated rehabilitation programme in MRHT is in line with others however internal audit and new literature in the future may enable us to refine it further.

The Impact of Endograft Selection on Mid-Term Outcomes in Female Patients Following Endovascular Aortic Aneurysm Repair (EVAR) for Abdominal Aortic Aneurysm (AAA).

Background Abdominal aortic aneurysms (AAA) are far more common in male than female gender, although they appear to have a more aggressive pathophysiology in females. Given the lower incidence of AAA in females, it has been difficult to assess the impact of graft selection for endovascular aortic aneurysm repair (EVAR) in this cohort. Purpose To identify whether graft selection influences outcomes following AAA endoluminal repair in female patients. Methodology A retrospective analysis of published data for 711 female patients was conducted, collating data from three cohorts - Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE), Global Registry for Endovascular Aortic Treatment (GREAT) and U.S. Zenith multicenter trial in combination with the Zenith female registry. Patients were recruited into the ENGAGE registry between 2009 and 2011, the GREAT registry between August 2010 and October 2016, and into the Zenith registry between 2000 and 2003. Patients from ENGAGE received the Medtronic Endurant stent graft for infrarenal AAA repair, patients analysed in GREAT received the Gore Excluder stent graft and the Zenith group received the Cook Zenith stent graft. Analyses were performed to evaluate all-cause mortality, aorta-related mortality, endoleak occurrence and surgical reintervention rates between the three cohorts. Results Of the 711 females, 133 were from ENGAGE (mean age 76 years), 538 were from GREAT (mean age 75 years) and 40 were from Zenith (mean age 74 years). The rates of co-morbidities between the three groups were broadly similar except for atherosclerotic disease which was more commonly observed in those treated with the GORE Excluder. The rate of endoleaks was lower when the Excluder stent was utilised as compared to the other two stents (Excluder 6.7% vs. Zenith 12.5% vs. Endurant 35.3%) even considering the limited follow-up of the Zenith group to two years as compared to five years for both ENGAGE and GREAT. All-cause mortality was similar in all three groups across the period examined while aorta-related mortality was uncommon. Reintervention rate was 15% at two years following the utilisation of the Zenith aortic graft while the rate of intervention at five years was broadly similar between ENGAGE and GREAT. Conclusion The newer generation, lower profile aortic endografts appear to have provided a safe and successful tool in the management of AAA in female patients, despite more complex aortic anatomy with shorter infrarenal neck length and larger aortic neck angulation.

The Impact of Endograft Selection on Outcomes Following Treatment Outside of Instructions for Use (IFU) in Endovascular Abdominal Aortic Aneurysm Repair (EVAR).

Background Endovascular aneurysm repair (EVAR) has become the treatment modality of choice in patients with abdominal aortic aneurysms. This has resulted in endograft utilization within instructions for use (IFU) and in cases with proximal neck anatomy outside of IFU. Purpose To identify whether graft selection influences outcomes following EVAR outside of IFU. Methodology A retrospective analysis was conducted from previously published data for 636 patients, collated from the Endurant Stent Graft Natural Selection Global Post-Market Registry (ENGAGE) and the Global Registry for Endovascular Aortic Treatment (GREAT). Patients were recruited into the ENGAGE registry between 2009 and 2011 and into the GREAT registry between August 2010 and October 2016. In ENGAGE, they received the Medtronic Endurant stent graft (Medtronic Vascular Inc, Dublin, Ireland) for infrarenal AAA repair while patients analyzed in GREAT received the Gore Excluder stent-graft (W. L. Gore & Associates, Flagstaff, Arizona). Analyses were performed to evaluate all-cause mortality, aneurysm-related mortality, endoleak occurrence, and surgical reintervention rates between the two cohorts. Results Of the 636 patients, 225 were from ENGAGE (mean age 73 years) and 411 were from GREAT (mean age 75 years). 17.8% were treated outside of IFU in the ENGAGE registry, while 12.4% were treated outside IFU in the GREAT cohort. Five-year freedom from all-cause mortality was similar in both cohorts (65.6% vs. 63.8%). The rate of type IA endoleak development was lower in the Excluder cohort, although this may have been impacted by the fact that only endoleaks that underwent reintervention were recorded within GREAT analysis (Endurant 10.6% vs. Excluder 7.0%). The reintervention rate was 16% at five years following the Endurant aortic graft while it was 13.3% at five years with the Excluder. Conclusion Treatment outside of IFU, be it with a suprarenal or an infrarenal fixation device, is associated with worse outcomes. This analysis reinforces the importance of the consideration of either fenestrated or open repair in those aneurysms that fail to satisfy IFU while endovascular repair in such a setting should be reserved as a last resort strategy.