Odontoid Fracture with Locked Posterolateral Atlantoaxial Dislocation: A Case Report and Review of Literature.

CASE: Odontoid fractures with atlantoaxial dislocations are rare injuries. We report a case of a 41-year-old man with a Type 2 odontoid fracture with locket facet and posterolateral dislocation. He underwent single-stage C1-C4 posterior fixation and fusion, and at 2-year follow-up, he is symptom-free without any residual pain. Follow-up radiograph and CT scan show healed odontoid fracture with posterior fusion. CONCLUSION: This case highlights successful management of a complex odontoid fracture by a single-stage posterior surgery. Closed reduction is usually unsuccessful, and open reduction using posterior approach is preferable.

Historical Perspectives on the Evolution of Spino-Pelvic Fixation and its Implications on Clinical Care A Narrative Review.

STUDY DESIGN: Broad narrative review. OBJECTIVES: To review and summarize the evolution of spinopelvic fixation (SPF) and its implications on clinical care. METHODS: A thorough review of peer-reviewed literature was performed on the historical evolution of sacropelvic fixation techniques and their respective advantages and disadvantages. RESULTS: The sacropelvic junction has been a long-standing challenge due to a combination of anatomic idiosyncrasies and very high biomechanical forces. While first approaches of fusion were determinated by many material and surgical technique-related limitations, the modern idea of stabilization of the lumbosacral junction was largely initiated by the inclusion of the ilium into lumbosacral fusion. While there is a wide spectrum of indications for SPF the chosen technique remains is defined by the individual pathology and surgeons' preference. CONCLUSION: By a constant evolution of both instrumentation hardware and surgical technique better fusion rates paired with improved clinical results could be achieved.

"MCL Repair, Isolated Suture-tape Bracing and No Repair for Grade III MCL Tears During ACL Reconstruction Have Similar Outcome for Combined ACL With MCL Injury: A Randomized Controlled Trial."

PURPOSE: Aim of the study was to compare various MCL management strategies(repair vs isolated suture-tape bracing vs no repair) combined with ACL reconstruction and analyse results of MCL sub-types (femoral/mid-substance/tibial-sided tears) occurring at distinct levels. METHODS: This study is a double blinded prospective randomised controlled trial. 96 consecutive patients with combined ACL and grade III MCL between 2020 and 2023 with minimum follow up of 24 months were included in the study. Chronic MCL and other ligament injuries were excluded, and computer-generated randomisation was done for allotment into three MCL management groups. ACL reconstruction with hamstring autograft was performed and MCL treated by repair in group 1(n=33), isolated suture-tape bracing -group 2(n=32) and no repair-group 3(n=31). At follow-up, stress radiographs were utilized to analyse anterior and medial laxity. IKDC, Lysholm, KOOS scores, duration of surgery and cost of surgery were compared. Also, subgroup analysis was performed to assess outcomes based on location of MCL injury. RESULTS: Demographic data, duration of injury, mode of injury and level of MCL injury is similar across groups. Over all MCL tears-femoral side, mid-substance and tibial side were 58.3%,18.7%and 23.0% respectively. Post-operatively significant improvement in ROM and functional score was observed in all three groups(P=<0.05); however, there was no statistically significant difference between the three groups at final follow-up in anterior tibial translation(P=0.94), medial opening in 0°(P=0.8) & 30°(P=0.64), ROM(P=0.39), IKDC(P=0.17), Lysholm(P=0.14) & KOOS(P=0.68). Three patients in group 2 had stiffness at 3months; two were treated with CPM and physiotherapy and 1 patient needed arthrolysis. Medial opening(00 and 300) was greater in group 3- mid-substance MCL tear patients(P=0.042,0.043). On Minimal clinically important differences (MCID) analysis more than 80% of patients had improvement in range of motion, functional scores and medial opening less than 5mm, suggestive of successful outcome in all the three groups. The duration of surgery was longer in repair group(P=0.001), whereas cost was higher in the suture-tape bracing group(P=0.003). CONCLUSION: Repair, isolated suture-tape bracing and no repair treatments of MCL result in good radiological (medial stress laxity) and functional outcomes when combined with ACL reconstruction. MCL Repair or isolated suture-tape bracing restore better medial side stability. Mid-substance MCL tears may need additional procedure(repair/bracing) to restore medial stability.

An interplay between orthopaedic trauma and pregnancy-A case series of 42 patients.

BACKGROUND: Pregnancy and trauma are complex situations with significant implications for maternal and fetal health. Physical and psychological trauma during pregnancy can lead to pre-term labor, abruptio-placenta, and fetal injury or death. Management of trauma is challenging due to physiological and anatomical changes, which can affect fracture management and the risk of radiation exposure. A multidisciplinary approach is beneficial for patient care. This study aimed to determine the impact of orthopaedic trauma on pregnancy and its outcome, and influence of pregnancy on fracture management. METHODS AND MATERIAL: A retrospective-study was conducted at a Level-1 trauma-care-center, focusing on 54 pregnant women who sustained trauma between January 2015 and December 2022. The study included patients with closed or open fractures, but excluded those without fractures. Forty-two patients were available with minimum 1 year follow-up. Data was collected from hospital records and PACS, including demographic details, emergency care, and laboratory parameters. Changes made in protocol in fracture management due to pregnancy (primary definitive fixation vs staged management), and impact of trauma on pregnancy outcome; mode-of-delivery, maternal and fetal loss were evaluated. RESULTS: The mean age was 30-years (range: 21-43years). Road-traffic-collision was most-common mode-of-injury (66.7 %). 38.1 % were in the first-trimester, 35.7 % in second, and 26.2 % in third-trimester. Eight patients had polytrauma, seven had multiple-injuries, and 27 had isolated-injuries. The maternal-mortality-rate was 0.45 %. Three polytraumatized patients ended up with intrauterine death, two polytrauma patients underwent elective abortion, one patient presented with spontaneous-abortion, and fetal loss was 14.3 % (6-of-42). Out of 42 patients, 10 had open-injuries and 32 had closed-injuries. Nine patients underwent LSCS(lower-segment-caesarean-section), six of them were planned for elective-LSCS due to injury and associated fractures (two patients with pelvic injuries, two neck femur fracture patients, one open distal femur fracture, and one ankle fracture dislocation). CONCLUSION: Orthopaedic trauma during pregnancy can significantly affect pregnancy outcomes and is associated with a notably higher risk of fetal loss. An elective-caesarean-section is recommended for patients with polytrauma, pelvic-injuries, and those who are immobilized for longer-duration. During the third-trimester and in polytraumatized patients, external-fixator-application for lower-limb-injuries is a safe strategy, and definitive fixation could be performed post-delivery.

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review.

BACKGROUND: The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. METHODS: This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. RESULTS: A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). CONCLUSION: A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis; Level IV.

Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Optimizing Management and Minimizing Risk of Osteoporotic Vertebral Fractures - Perspectives of the AO Spine KF Trauma and Infection Group Key Opinion Leaders.

STUDY DESIGN: Literature review with clinical recommendations. OBJECTIVE: To highlight important studies about osteoporotic spinal fractures (OF) that may be integrated into clinical practice based on the assessment of the AO Spine KF Trauma and Infection group key opinion leaders. METHODS: 4 important studies about OF that may affect current clinical practice of spinal surgeons were selected and reviewed with the aim of providing clinical recommendations to streamline the journey of research into clinical practice. Recommendations were graded as strong or conditional following the GRADE methodology. RESULTS: 4 studies were selected. Article 1: a validation of the Osteoporotic Fracture (OF)-score to treat OF fractures. Conditional recommendation to incorporate the OF score in the management of fractures to improve clinical results. Article 2: a randomized multicenter study comparing romosozumab/alendronate vs alendronate to decrease the incidence of new vertebral fractures. Strong recommendation that the group receiving romosozumab/alendronate had a decreased risk of new OF when compared with the alendronate only group only. Article 3: a systematic literature review of spinal orthoses in the management of. Conditional recommendation to prescribe a spinal orthosis to decrease pain and improve quality of life. Article 4: post-traumatic deformity after OF. A conditional recommendation that middle column injury and pre-injury use of steroids may lead to high risk of post-traumatic deformity after OF. CONCLUSIONS: Management of patients with OF is still complex and challenging. This review provides some recommendations that may help surgeons to better manage these patients and improve their clinical practice.

From Modic to Disc Endplate Bone Marrow Complex - The Natural Course and Clinical Implication of Vertebral Endplate Changes.

STUDY DESIGN: Review article. OBJECTIVES: A review of literature on the epidemiology, natural course, pathobiology and clinical implications of vertebral endplate changes. METHODS: A literature search was performed using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the last 10 years were analysed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "Vertebral endplate changes", "Modic changes", "Disc Endplate Bone Marrow complex". RESULTS: The disc, endplate (EP), and bone marrow region of the spine constitute a unified morphological and functional unit, with isolated degeneration of any one structure being uncommon. Disc degeneration causes endplate defects, which result in direct communication and a constant cross-talk between the disc and the vertebral body. This may result in a persistent inflammatory state of the vertebral bone marrow, serving as a major pain generator. This review article focuses on vertebral endplate changes and how the current understanding has progressed from the Modic classification to the Disc Endplate Bone Marrow complex classification. It provides a clear portrayal of the natural course of these alterations and their clinical implications in low back pain. CONCLUSIONS: In light of the heightened interest and current prominence of vertebral endplate changes within the spine community, we must progress beyond the Modic changes to achieve a comprehensive understanding. The DEBM complex classification will play a major part in disc degeneration research and clinical care, representing a considerable advancement in our understanding of the vertebral endplate changes over the classical Modic changes.

Clinical outcomes of primary total knee arthroplasty in non-syphilitic neuroarthropathy of the knee.

PURPOSE: Total knee arthroplasty (TKA) in syphilitic neuroarthropathy using earlier implant designs was associated with poorer outcomes. Literature on TKA for non-syphilitic neuroarthropathy using modern contemporary prosthesis is scarce. We aim to analyse the clinical and radiological outcomes of TKA in neuropathic joints. METHODS: A final cohort of 17 patients (21 knees) with the diagnosis of neuropathic joint undergoing primary TKA between January 2013 to January 2019 were included in the study. The preoperative ambulatory status, range of motion, type of prosthesis, level of constraint and any augmentation used were retrieved from medical records. Radiological evaluation includes Koshino's staging, the magnitude of deformity defined by the Hip-Knee-Ankle (HKA) angle, and any progressive loosening. Pre and postoperative functional scores were obtained by the Knee Society (KSS) and Knee Society Functional Score (KSS-F). Any complications or reoperation were noted till the final follow-up. Preoperative and follow-up functional scores, HKA and range of motion were compared using the paired Samples test. RESULTS: The mean follow-up was 40.2 months (range, 15 to 75 months). Preoperatively, according to the Koshino staging, five knees were in stage 3 (23.8%). The mean HKA angle in valgus knees was 23.60 (range, 11.10 to 42.50) and for the varus knees was 19.30 (range, 4.90 to 39.60). The prosthesis used were posterior stabilized in 7 knees (33.3%), varus-valgus constrained in five knees (23.8%) and a rotating hinge was required in nine knees (42.8%). Metaphyseal sleeves were used along with hinge prosthesis in six knees (28.6%). The mean arc of motion improved from 102.4 ± 22.7 degrees to 105.7 ± 15.5 degrees postoperatively (p = 0.27). The knee society and knee society functional scores improved from 23.3 ± 9.3 and 28.3 ± 12.2 preoperatively to 81.1 ± 5.4 and 80.4 ± 8.5 during the follow up respectively (p < 0.001). There were no progressive radiolucent lines in any knees at the final follow-up. One patient had intraoperative bony medial collateral ligament injury, one patient had deep vein thrombosis after five days from the index surgery and another had postoperative periprosthetic tibial shaft fracture. CONCLUSION: According to our study, the clinical outcomes of TKA for neuroarthropathy show significant improvement with the diagnosis of non-syphilitic neuroarthropathy, utilization of modern constrained prostheses, and early rehabilitation, at medium-term follow-up. Tibial and femoral stems are preferred for equal stress distribution and to prevent early loosening.

Comparative analysis of 'functional excision' of heterotopic ossification around the hip - computed tomography (CT) navigation guided versus conventional excision.

PURPOSE: We aim to analyse and compare the efficacy of the excision of HO around the hip with and without CT-guided navigation. We also aim to compare the functional outcome between CT navigation guided versus conventional excision of HO. PATIENTS AND METHODS: This study is a retrospective analysis of prospectively collected data from 2015 to 2022. There were 23 patients (24 hips) in the final cohort. Intraoperative CT navigation guided excision was performed in 7 hips and conventional excision of HO was done in 17 hips. The HO was classified by Brooker's grading in radiographs. CT scan was taken preoperatively in all patients to exactly identify the volume, location and preoperative planning. The functional outcome was analysed according to Harris Hip Score (HHS) and International Hip Outcome Tool (iHOT) for self-ambulatory patients and improvement in the sitting or nursing care was assessed in patients mobilising with wheelchair or walker support. Any complications or recurrence noted postoperatively and in follow-up were recorded. RESULTS: The mean follow-up was 41.2 months in the CT navigation-guided excision group and 55 months in the conventional excision group. According to Brooker's grading, grade IV was present in 20 hips and grade III in four hips. Twelve patients were self-ambulatory and the other 12 patients were requiring support for mobilisation. There was a significant improvement in the HHS from 21.3 ± 3.7, 18.3 ± 2.5 preoperatively to 75.2 ± 8.3, 72.2 ± 4.3 postoperatively in the CT navigation guided and conventional group respectively (p < 0.001) in the self-ambulatory group. There was one anterior wall and one partial posterior wall fracture in the conventional group. One patient in the conventional group had a deep infection and recurrence. One patient had a superficial infection and another had superficial vein thrombosis in the CT guided excision group. CONCLUSION: Intraoperative CT navigation helps to exactly localize the HO and facilitates safe excision. Functional excision of the HO leads to better nursing care and functional outcomes between both groups.

A novel variant of type-II Monteggia equivalent in an adult: A case report with a 6-year follow-up.

Case: An 18-year-old right-handed male student presented after a road-traffic-accident; he had type-II Monteggia fracture dislocation associated with ipsilateral type-I capitellum fracture and comminuted lateral condyle avulsion fracture. He underwent open reduction and fixation of ulna with 3.5 DCP with autologous olecranon bone grafting and fixation of capitellum using Herbert screw along with lateral collateral ligament (LCL) repair using fiber wire. At 6-years follow-up good outcome was seen without functional restrictions despite 15 degrees of restriction in pronation. Conclusion: Monteggia type-II variant with type-I capitellum fracture and LCL avulsion is a unique combination that represents a novel variant of type-II Monteggia equivalent, which adds to the existing classification of Monteggia equivalents.

Optimizing Tourniquet Pressure in Primary Total Knee Arthroplasty: Limb Occlusion Pressure vs Systolic Blood Pressure Method: A Randomised Controlled Study.

Background: This study aims to systematically compare the efficacy of two distinct approaches that is limb occlusion pressure (LOP) and systolic blood pressure (SBP) in determining the optimal tourniquet pressure for primary total knee arthroplasty. The overarching goal is to identify the method that yields superior outcomes in minimizing post-operative thigh pain while simultaneously reducing complications in our patient population. Methods: 311 patients scheduled for primary total knee replacement (TKR) were randomized in two groups. Group A (LOP) had 154 patients and group B had 157 patients. In group A, LOP was determined for all patients. After adding the safety margin, the tourniquet pressure was determined which was kept during the procedure. By adding 150 mm Hg to SBP in group B, the tourniquet inflation pressure was ascertained. Postoperatively, thigh pain was evaluated from day 1 to day 3 and at 6 weeks. Results: The average tourniquet pressure in group A patients having thigh circumference between 40 and 50 cm was 223.8 mm + - 19.8 mm Hg and in group B it was 262.1 + - 15.9 mm Hg (P < .01). Patients having thigh circumference between 51 and 60 cm had average tourniquet pressure of 240.07 + - 20.1 mm Hg in group A and 264.5 + - 17.4 mm Hg in group B (P < .01). The average tourniquet pressure for patients with thigh circumference more than 60 cm was 296 + /15.3 mm Hg in group A and 267.3 + /19.2 mm Hg in group B (P < 0.01). Conclusion: Tourniquet pressure determination based on the limb occlusion pressure (LOP) method provide less postoperative thigh pain and better range of motion. Graphical Abstract: Optimizing Tourniquet Pressure in Primary Total Knee Replacement: Limb Occlusion Pressure vs Systolic blood pressure method to minimize thigh pain.

Risk predictive score and cord morphology classification for intraoperative neuromonitoring alerts in kyphosis surgery.

BACKGROUND: Intraoperative neuromonitoring (IONM) alert is one of the worrying events of kyphosis corrective surgery, which can result in a postoperative neurological deficit. To our knowledge, there is no risk prediction score to predict such events in patients undergoing kyphosis surgery. PURPOSE: To develop a new preoperative MRI-based cord morphology classification (CMC) and risk prediction score for predicting IONM alerts in patients with kyphotic deformity. STUDY DESIGN: Retrospective analysis of prospectively collected data. PATIENT SAMPLE: About 114 patients undergoing surgical correction for kyphotic deformity. OUTCOME MEASURES: Intraoperative neuromonitoring alerts and postoperative neurological status using AIS grading. METHODS: Kyphotic deformity patients undergoing posterior spinal fusion were retrospectively reviewed. Based on the morphology of the spinal cord and surrounding CSF in MRI, there are 5 types of cord. Type 1 (normal cord): circular cord with surrounding visible CSF between the cord and the apex, Type 2 (flattened cord): cord with <50% distortion at the apex with obliteration of the anterior CSF; Type 3 (deformed cord): cord with >50% distortion at the apex with complete obliteration of the surrounding CSF; Type 4 (stretched cord): the cord is stretched and atrophied over the apex of the curve. Type 5 (translated cord): horizontal translation of the cord at the apex with buckling collapse of the vertebral column. Preoperative radiographs were used to measure the preoperative sagittal cobbs angle, sagittal deformity angular ratio (S-DAR), sagittal vertical axis (SVA), apex of the curve, and type of kyphosis. Clinical data like the duration of symptoms, clinical signs of myelopathy, neurological status (AIS grade), grade of myelopathy using the mJOA score, and type of osteotomy were documented. Multivariate logistic regression was used to determine the risk factors for IONM alerts and the risk prediction score was developed which was validated with new cohort of 30 patients. RESULTS: A total of 114 patients met the inclusion criteria. IONM alerts were documented in 33 patients (28.9%), with full recovery of the signal in 25 patients and a postoperative deficit in 8 patients. Rate of IONM alerts was significantly higher in Type 5 (66%), followed by Type 4 (50%), Type 3 (21.1%), Type 2 (11.1%), and Type 1 (11.1%) (p-value<.001). Based on multiple logistic regression, 7 factors, namely preoperative neurological status, mJOA score≤6, presence of signs of myelopathy, apex of the curve above T5, preoperative sagittal cobbs, S-DAR, and MRI-based CMC, were identified as risk predictors. The value for the risk factors varies from 0 to 4, and the maximum total risk score was 13. The cut-off value of 6 had good sensitivity (84.9%) and specificity (77.8%) indicating a high risk for IONM alerts. The AUC of the predictive model was 0.92, indicating excellent discriminative ability. CONCLUSION: We developed and validated a risk predictive score that identifies patients at risk of IONM alerts during kyphosis surgery. Identification of such high-risk patients (risk score≥6) helps in proper evaluation and preoperative counselling and helps in providing a proper evidence-based reference for treatment strategies.

Does the gut microbiome influence disc health and disease? The interplay between dysbiosis, pathobionts, and disc inflammation: a pilot study.

BACKGROUND CONTEXT: Gut microbiome alterations resulting in inflammatory responses have been implicated in many distant effects on different organs. However, its influence on disc health is still not fully investigated. PURPOSE: Our objective was to document the gut biome in healthy volunteers and patients with disc degeneration and to understand the role of gut dysbiosis on human disc health. STUDY DESIGN: Experimental case-control study. PATIENT SAMPLE: We included 40 patients with disc degeneration (DG) and 20 healthy volunteers (HV). HV comprised of age groups 30 to 60 years with no known record of back pain and no clinical comorbidities, with normal MRI. Diseased group (DG) were patients in the same age group undergoing surgery for disc disease (disc herniation-25; discogenic stenosis-15) and without instability (with Modic-20; and non-Modic-20). OUTCOME MEASURES: N/A. METHODS: We analyzed 16S V3-V4 rDNA gut metagenome from 20 healthy volunteers (HV) and compared the top signature genera from 40 patients with disc degeneration (DG) across Modic and non-Modic groups. Norgen Stool DNA Kit was used for DNA extraction from ∼200 mg of each faecal sample collected using the Norgen Stool Collection Kit.16S V3-V4 rDNA amplicons were generated with universal bacterial primers 341F and 806R and amplified with Q5 High-Fidelity DNA Polymerase. Libraries were sequenced with 250×2 PE to an average of 0.1 million raw reads per sample (Illumina Novaseq 6000). Demultiplexed raw data was assessed with FastQC, and adapter trimmed reads >Q30 reads were processed in the QIME2 pipeline. Serum C-reactive protein (CRP) was measured by the immunoturbimetry method and Fatty acid-binding protein 5 (FABP5) was measured in albumin-globulin-depleted plasma through global proteome analysis. RESULTS: We observed significant gut dysbiosis between HV and DG and also between the Modic and non-Modic groups. In the Modic group, commensals Bifidobacterium and Ruminococcus were significantly depleted, while pathobionts Streptococcus, Prevotella, and Butryvibrio were enriched. Firmicutes/Bacteroidetes ratio was decreased in DG (Modic-0.62, non-Modic-0.43) compared to HV (0.70). Bacteria-producing beneficial short-chain fatty acids were also depleted in DG. Elevated serum CRP and increased FABP5 were observed in DG. CONCLUSION: The study revealed gut dysbiosis, an altered Firmicutes/Bacteroidetes ratio, reduced SCFA-producing bacteria, and increased systemic and local inflammation in association with disc disease, especially in Modic changes. The findings have considerable importance for our understanding and prevention of disc degeneration.

Efficacy and Safety of Ultrasound Guided Inter-semispinal Plane Block for Postoperative Analgesia in Posterior Cervical Laminectomy - A Prospective Randomised Controlled Study.

STUDY DESIGN: Prospective, randomized controlled study. OBJECTIVE: To assess the safety and efficacy of an ultrasound-guided ISP block for postoperative analgesia in posterior cervical laminectomy. METHODS: 88 patients requiring posterior cervical laminectomy were randomized into two groups, those who underwent ISP block with multimodal analgesia (ISPB group) and those with only multimodal analgesia (control group). Demographic details, intraoperative parameters (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used), and postoperative parameters (numeric rating scale, satisfaction score, mobilization time, and complications) were recorded. RESULTS: The total opioid consumption (128.41 + 39.65vs 284.09 + 140.92mcg; P < .001), muscle relaxant usage (46.14 + 6.18 mg vs 59.32 + 3.97 mg; P < .001), surgical duration (128.61 + 26.08/160.23 + 30.99mins; P < .01), and intra-operative blood loss (233.18 + 66.08 mL vs 409.77 + 115.41 mL; P < .01) were significantly less in the ISPB group compared to the control. In the postoperative period, the control group's pain score was significantly higher (P < .001) in the initial 48 hours. The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores were significantly better in the ISPB compared to the control (P < .001). The mean time required to ambulate was statistically less in ISPB (4.30 + 1.64hours) when compared to controls (9.48 + 3.07hours) (P < .001). CONCLUSION: In patients undergoing posterior cervical laminectomy, ISP block is a safe and effective technique with better outcomes than standard multi-modal analgesia alone, in terms of reduced intra-operative opioid requirements and blood loss, better postoperative analgesia, and early mobilization.

Orthopedic postoperative infection profile and antibiotic sensitivity of 2038 patients across 24 countries - Call for region and institution specific surgical antimicrobial prophylaxis.

Purpose: Improper utilization of surgical antimicrobial prophylaxis frequently leads to increased risks of morbidity and mortality.This study aims to understand the common causative organism of postoperative orthopedic infection and document the surgical antimicrobial prophylaxis protocol across various institutions in to order to strengthen surgical antimicrobial prophylaxis practice and provide higher-quality surgical care. Methods: This multicentric multinational retrospective study, includes 24 countries from five different regions (Asia Pacific, South Eastern Africa, Western Africa, Latin America, and Middle East). Patients who developed orthopedic surgical site infection between January 2021 and December 2022 were included. Demographic details, bacterial profile of surgical site infection, and antibiotic sensitivity pattern were documented. Results: 2038 patients from 24 countries were included. Among them 69.7 % were male patients and 64.1 % were between 20 and 60 years. 70.3 % patients underwent trauma surgery and instrumentation was used in 93.5 %. Ceftriaxone was the most common preferred in 53.4 %. Early SSI was seen in 55.2 % and deep SSI in 59.7 %. Western Africa (76 %) and Asia-Pacific (52.8 %) reported a higher number of gram-negative infections whereas gram-positive organisms were predominant in other regions. Most common gram positive organism was Staphylococcus aureus (35 %) and gram-negative was Klebsiella (17.2 %). Majority of the organisms showed variable sensitivity to broad-spectrum antibiotics. Conclusion: Our study strongly proves that every institution has to analyse their surgical site infection microbiological profile and antibiotic sensitivity of the organisms and plan their surgical antimicrobial prophylaxis accordingly. This will help to decrease the rate of surgical site infection, prevent the emergence of multidrug resistance and reduce the economic burden of treatment.

A prospective randomized control trial comparing outcomes of casting, pinning, and plating for distal end of radius fractures (AO type A2, A3, C1, or C2) in the elderly population.

PURPOSE: With this prospective randomized control trial (RCT), we aim to provide the outcome analyses of the three most used treatment modalities for distal end of radius (DER) fracture management in the elderly. METHODS: A prospective randomized control trial was performed. Fifty-two patients with DER fractures (AO A2, A3, C1, or C2) were randomized to the casting (n = 17), percutaneous pinning (n = 18), and the volar plating group (n = 17). Radiological measurements measured were radial inclination (RI), radial height (RH), volar tilt (VT), and ulnar variance (UV). The outcome was measured based on range-of-motion, grip strength, Patient-Related-Wrist-Evaluation (PRWE) score, and the Quick-Disabilities-of-the-Arm-Shoulder-Hand (QDASH) score. RESULTS: Immediate post-operative and 1-year-follow-up X-rays showed a significant difference measurement between the groups (p < 0.05). Pairwise comparisons of the casting and pinning groups (p < 0.05) and the casting and plating groups (p < 0.05) revealed significant differences at the 1-year follow-up, but not the pinning and plating groups (p > 0.05). The analysis found significant differences in clinical outcomes after 1 month of follow-up, with the plating group outperforming the other two (p > 0.05). However, after a year of follow-up, all groups had comparable outcomes; however, the plating group showed improved palmar flexion (p < 0.001), radial deviation (p < 0.001), and a lower PRWE score (p < 0.05), indicating better wrist function. Complications were more in casting group. CONCLUSION: The study found a radiologically significant difference between groups throughout the follow-up, but it did not affect functional results. Clinical outcomes were similar across the groups, with plating showing better palmar flexion and radial deviation. Grip strength was also better in the plating group, but statistically insignificant. The study suggests plating should be chosen over other treatments for high-demand patients.

Comparison of imageless robotic assisted total knee arthroplasty and conventional total knee arthroplasty: early clinical and radiological outcomes of 200 knees.

The aim of this study was to compare the short term clinical and radiological outcomes of imageless robotic and conventional total knee arthroplasty (TKA) and to estimate the accuracy of the two techniques by analysing the outliers after TKA. We have evaluated 200 consecutive knees (158 patients), 100 knees undergoing robotic TKA, and 100 knees treated with conventional TKA. Demographic parameters like age, gender, body mass index, diagnosis and range of motion were obtained. Knee society score (KSS) and Knee society functional score (KSS-F) were used for clinical evaluation. Mechanical alignment (Hip-knee-ankle angle), proximal tibial angle (MPTA), distal femoral angle (LDFA) and tibial slope were analysed for radiological results and outliers were compared between both groups. Outliers were defined when the measured angle exceeded ± 3° from the neutral alignment in each radiological measurement on the final follow-up radiograph.The minimum follow-up was 6 months (range, 6 to 18 months). The preoperative mean HKA angle was 169.7 ± 11.3° in robotic group and 169.3 ± 7.3° in conventional group. There was significant improvement in HKA, LDFA, MPTA and tibial slope compared to the preoperative values in both the groups (p < 0.01). The number of HKA, LDFA and tibial slope outliers were 31, 29 and 37, respectively, in the conventional group compared to 13, 23 and 17 in the robotic group (p < 0.01). There was a significant improvement in the KSS and KSS-F functional scores postoperatively in both the groups (p < 0.01). However, there was no significant difference in the functional scores between the groups postoperatively (p = 0.08). This study showed excellent improvement with both imageless robotic and conventional TKA, with similar clinical outcomes between both groups. However, radiologically robotic TKA showed better accuracy and consistency with fewer outliers compared with conventional TKA.

Does Magnetic Resonance Imaging Predict Neurological Deficit in Patients with Traumatic Lower Lumbar Fractures?

STUDY DESIGN: A retrospective cohort study. PURPOSE: This study aimed to understand the role of magnetic resonance imaging (MRI) in predicting neurological deficits in traumatic lower lumbar fractures (LLFs; L3-L5). OVERVIEW OF LITERATURE: Despite studies on the radiological risk factors for neurological deficits in thoracolumbar fractures, very few have focused on LLFs. Moreover, the potential utility of MRI in LLFs has not been evaluated. METHODS: In total, 108 patients who underwent surgery for traumatic LLFs between January 2010 and January 2020 were reviewed to obtain their demographic details, injury level, and neurology status at the time of presentation (American Spinal Injury Association [ASIA] grade). Preoperative computed tomography scans were used to measure parameters such as anterior vertebral body height, posterior vertebral body height, loss of vertebral body height, local kyphosis, retropulsion of fracture fragment, interpedicular distance, canal compromise, sagittal transverse ratio, and presence of vertical lamina fracture. MRI was used to measure the canal encroachment ratio (CER), cross-sectional area of the thecal sac (CSAT), and presence of an epidural hematoma. RESULTS: Of the 108 patients, 9 (8.3%) had ASIA A, 4 (3.7%) had ASIA B, 17 (15.7%) had ASIA C, 21 (19.4%) had ASIA D, and 57 (52.9%) had ASIA E neurology upon admission. The Thoracolumbar Injury Classification and Severity score (p =0.000), CER (p =0.050), and CSAT (p =0.019) were found to be independently associated with neurological deficits on the multivariate analysis. The receiver operating characteristic curves showed that only CER (area under the curve [AUC], 0.926; 95% confidence interval [CI], 0.860-0.968) and CSAT (AUC, 0.963; 95% CI, 0.908-0.990) had good discriminatory ability, with the optimal cutoff of 50% and 65.3 mm2, respectively. CONCLUSIONS: Based on the results, the optimal cutoff values of CER >50% and CSAT >65.3 mm2 can predict the incidence of neurological deficits in LLFs.

Functional and Radiological Outcomes of All-Posterior Surgical Correction of Dystrophic Curves in Patients with Neurofibromatosis Type 1.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To determine outcomes following all-posterior surgery using computed tomography navigation, hybrid stabilization, and multiple anchor point techniques in patients with neurofibromatosis type 1 (NF-1) and dystrophic scoliosis. OVERVIEW OF LITERATURE: Previous studies favored antero-posterior fusion as the most reliable method; however, approaching the spine anteriorly was fraught with significant complications. With the advent of computer assisted navigation and multiple anchor point method, posterior only approach is reporting successful outcomes. METHODS: This study included patients who underwent all-posterior surgical deformity correction for dystrophic NF-1 curves. Coronal and sagittal Cobbs angles, apical rotation, and the presence of dystrophic features were evaluated before surgery. Postoperatively, sagittal, coronal, and axial correction, implant position, and implant densities were evaluated. The decline in curve correction and implant-related complications were evaluated at follow-up. Clinical outcomes were evaluated using the Scoliosis Research Society-22 revised index. RESULTS: This study involved 50 patients with a mean age of 13.6 years and a mean follow-up duration of 5.52 years. With a mean coronal flexibility of 18.7%, the mean apical vertebral rotation (AVR), preoperative coronal Cobb angle, and sagittal kyphosis were 27.4°, 64.01°, and 47.70°, respectively. The postoperative mean coronal Cobb angle was 30.17° (p <0.05), and the sagittal kyphosis angle was 25.4° (p <0.05). The average AVR correction rate was 41.3%. The correction remained significant at the final mean follow-up, with a coronal Cobb angle of 34.14° and sagittal kyphosis of 25.02° (p <0.05). The average implant density was 1.41, with 46% of patients having a high implant density (HID). The HID had a markedly higher mean curve correction (29.30° vs. 38.05°, p <0.05) and a lower mean loss of correction (5.7° vs. 3.8°, p <0.05). CONCLUSIONS: Utilizing computer-assisted navigation, hybrid instrumentation, and multiple anchor point technique and attaining high implant densities, this study demonstrates successful outcomes following posterior-only surgical correction of dystrophic scoliosis in patients with NF-1.