A pragmatic single centre retrospective comparative review of complication profile between PEEK cages and Zero-P cage screw constructs.

BACKGROUND: Anterior Decompression and Fusion (ACDF) is a common surgery recommended for symptomatic cervical degenerative disc disease after failed conservative care. There is no consensus on the choice of implants, and it varies between surgeons. This study aims to analyse the early complications following ACDF performed using a standalone cage versus a Zero-P (Cage Screw - (CS)) construct for patients with cervical degenerative disc disease. METHODS: A total of 162 patients underwent an ACDF between August 2016 and July 2018. There were 83 patients (111 cervical disc levels) with standalone cage (SA) and 79 patients (111 cervical disc levels) with cage-screw (CS) fixation. There was no difference between the groups in terms of age, gender, and levels of surgery. The follow-up ranged from 2 months to 24 months. Complications, both clinical and radiological, were assessed between the groups. RESULTS: Both the SA and Zero-P (CS) groups were subdivided into single and multilevel surgery. Complications encountered in the SA group were temporary swallowing problems 10, hoarseness of voice 3, cage migration 1, delayed union 1, Horner's syndrome 1, cage subsidence 2. In the CS group swallowing problems 4, hoarseness of voice 4, CSF leak 1, recurrent symptoms 1. The observed difference in the incidence of complications between the groups did not reach statistical significance. Univariate analysis between the groups did not show any difference in the improvement of cervical sagittal balance, fusion rate, subsidence, and complications encountered. Multivariate logistic regression analysis for complications showed no difference between the groups when assessed for smoking, gender, age, Charlson comorbidity index, levels of surgery, fusion status, Odom score, or the type of implant. CONCLUSION: In this short-term study, the standalone (SA) cages showed no difference in their complication profile in comparison to a cage-screw construct for both single and multilevel ACDF. Standalone cages might be a cost-effective option without increased complication risks. Nevertheless, we propose a longer-term follow-up with a prospective randomized trial for further evaluation of this finding.

Mortality risk of surgically managing orthopaedic trauma during the COVID-19 pandemic.

AIMS: It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site. METHODS: The primary outcome measure was 30-day mortality. Secondary measures included complications of surgery, COVID-19 infection, and length of stay. Multiple variables were assessed for their contribution to the 30-day mortality. In total, 433 patients were included with a mean age of 65 years; 45% were male, and 90% were Caucasian. RESULTS: Overall mortality was 7.6% for all patients and 15.9% for femoral neck fractures. The mortality rate increased from 7.5% to 44.2% in patients with fracture neck of femur and a COVID-19 infection. The COVID-19 rate in the 30-day postoperative period was 11%. COVID-19 infection, age, and Charlson Comorbidity Index were independent risk factor for mortality. CONCLUSION: There was a significant risk of contracting COVID-19 due to being admitted to hospital. Using a site which was not treating COVID-19 respiratory patients for surgery did not identify a difference with respect to mortality, nosocomial COVID-19 infection, or length of stay. The COVID-19 pandemic significantly increases perioperative mortality risk in patients with fractured neck of femora but patients with other injuries were not at increased risk. Cite this article: Bone Jt Open 2021;2(5):330-336.

Traumatic hip dislocation in the paediatric population: A case series from a specialist centre.

INTRODUCTION: Traumatic hip dislocation is a rare injury in the paediatric population. It can occur after high energy trauma, but also after lower energy injuries especially in younger children. Posterior dislocation is the most common pattern of hip dislocation. In most cases, closed reduction is successful, but occasionally open reduction is required to achieve concentric reduction. The aim of our study was to present the 10-year experience from a Level-1 Trauma Paediatric Hospital and to comment on how our experience correlates with the current literature. PATIENTS AND METHODS: This is a retrospective case series of all paediatric patients (< 16 years old) with a traumatic hip dislocation presented and/or treated at our institution, between the 1st of January 2010 and 31st August 2020. RESULTS: Thirteen cases of traumatic hip dislocation were identified. There were 7 females. The mean age was 9.8 years. Typically, younger patients were involved in lower energy injuries. The direction of hip dislocation was posterior in ten cases. Associated injuries were seen in eight patients. All cases underwent closed reduction, which was successful in nine cases. Mean time to reduction was 6.8 hours. Post reduction imaging with CT and/or MRI was performed in all cases. There was residual subluxation in three cases, requiring open reduction. In one case with unrecognised undisplaced physeal injury, closed reduction resulted in a Delbet type 1 hip fracture. Two cases developed avascular necrosis (AVN). CONCLUSIONS: Traumatic paediatric hip dislocation is a rare injury. A target of 6 hours for reduction should be employed as this will reduce the risk of AVN in those who have not permanently damaged the vessels at the time of injury. We advocate all attempts for closed reduction to be performed in an operating theatre with the use of an image intensifier to help identifying associated injuries and confirm concentric reduction. If closed reduction fails, open reduction is required. Post-reduction MRI is an important adjunct to recognise associated soft tissue injuries. Follow up of patients should continue for 2 years as a minimum to help detect AVN.

Prosthetic Neck Fracture in Exeter V40 Stems: A Report of Two Cases and Review of Literature.

This report contains 2 acute fractures of the Exeter V40 stem with 2 different types of neck fracture, one at the subcapital level and another at the base of the neck. A review of relevant literature provides an insight into a similar pattern of failures reported in a certain subset of cases. We hypothesize that for high-BMI cases, attention to proper preoperative templating is mandatory. The operating surgeon should try to restore offset without having to use a long head in this subgroup of patients. We feel that trying to compensate for the offset with a long head may lead to high-stress concentration in the neck. This, in turn, may be responsible for the failure of the stem, as seen in the reported cases. We advocate, based on the literature, the need to recreate the offset carefully with as big a stem as possible to avoid these unique and rare complications. Reducing such failures may further improve the overall survivorship of the V40 Exeter stem.

Different Patellar Indices and Their Role in Decision-Making: An MRI-Based Study.

Magnetic resonance imaging (MRI) of knee has become the integral part of knee evaluation, hence any MRI based study adds more value if it helps in the decision-making process, especially for surgery in treating patellofemoral pain. We tried to determine normal patellar indices using knee MR images and the correlation between them and also compared the results with different ethnic population. We analyzed the prospectively collected MR images of 117 knees/patients, and Insall-Salvati (IS) index, modified IS index, patellotrochlear (PT) index, and patellophyseal (PP) index were calculated. Two standard deviations from the mean were used to define the normal and abnormal patellar position. Cohen's kappa values were used to assess the agreement between the indices and the correlation between them was analyzed using Pearson's correlation. The mean values for IS index, modified IS index, PT index, and PP index were 1.00, 1.53, 0.40, and 0.58, respectively. There was very good agreement between PT index and PP index. There was weak correlation between all the indices except the one between PT and PP indices which had a strong negative correlation. Based on commonly used methodology, there were 4% of asymptomatic patients who were outside the standardized cut-off values and different indices classified different knees as abnormal. This indicates patellar position should be one among the many other factors, not as a sole factor when making a surgical decision in patellofemoral pain. We also noted that the indices compared fairly with other populations. Further research is needed to determine the clinical applicability of these indices.

Salvage of failed in-situ pinning in severe unstable slipped capital femoral physis by surgical dislocation and capital realignment.

AIMS: We describe surgical dislocation with capital realignment as an option for management of failed in-situ pinning in children with severe unstable slipped capital femoral physis. PATIENTS AND METHODS: A retrospective data collection from our hospital hip database retrieved 7 patients with severe unstable slipped capital femoral physis who had failed in-situ pinning with severe deformity and grossly restricted movements. The failure of pinning in-situ was due to slip progression with inadequate screw purchase in four patients, stress fracture of the femoral neck in one patient, and screw head impingement in two patients. All these patients under went open surgical dislocation, removal of the screws, followed by sub-capital realignment and fixation. RESULTS: The average age at presentation was 11.9 years (10-14 years). The mean follow-up was 50.14 months (25-66 months). Four patients who had pre-existing avascular necrosis at presentation underwent second stage hinged distraction of the hip joint. Preoperatively, the mean Modified Harris Hip Score (MHHS) was 19.57 (0-56) and the mean Non-Arthritic Hip Score (NAHS) was 21.07 (5-51.5) respectively. The mean MHHS at the last follow-up visit was 88.97 (71-96) and NAHS was 84.28 (69.5-91) respectively. CONCLUSION: Allowing the hip to heal in its anatomical position is the best possible correction we could give for any patient with severe slipped capital femoral epiphysis. We found that surgical dislocation for those with failed in-situ pining proved to be an effective bailout option for restoration of anatomy and function.

Moderate and severe SCFE (Slipped Capital Femoral Epiphysis) arthroscopic osteoplasty vs open neck osteotomy-a retrospective analysis of results.

AIM: We intend to compare the outcomes of arthroscopic osteoplasty with open neck osteotomy for correction of the hip impingement and improvement of hip function in children with moderate to severe healed Slipped Capital Femoral Epiphysis (SCFE). Our aim is to verify if arthroscopic osteoplasty could achieve the same outcome as open procedures. PATIENTS AND METHODS: A retrospective analysis of the hospital hip database retrieved 187 cases of SCFE from 2006 to 2013. We found 12 patients underwent open neck osteotomy and deformity correction for moderate/ severe healed SCFE and ten underwent arthroscopic osteoplasty of the hip. We compared the outcomes between these groups. RESULTS: In the arthroscopy cohort, the mean age at surgery was 15.8 years (range 13-19 years) and mean follow-up was 46.1 months (range 33-66 months). In the neck osteotomy group, the mean age at surgery was 14.6 years (11-20 years) and mean duration of follow-up was 49 months (36-60 months). The outcomes in arthroscopic osteoplasty group vs. open neck osteotomy were as follows: antero-posterior (AP) slip angle 9.2° (0.3°- 28.8°) vs 10.8° (1°-17.9°) (p = 0.0003), lateral slip angle 44.8° (36.5°-64.2°) vs 13.5° (1°-28.5°) (p = 0.00001), oblique plane deformity 47.1° (40.2°-53.5°) vs 16.7° (1°-28.6°) (p = 0.0003), alpha angle 61.88° (52.1°-123°) vs.34.6° (23.2°-45.6°) (p = 0.0003), anterior offset 0 mm (0 mm-2 mm) vs. 5 mm (2-13 mm) (p = 0.0003), modified Harris hip score (MHHS) 75.5 (58.75-96.8) vs. 90 (86.2-99) (p = 0.003), non-arthroplasty hip score (NAHS) 67.12 (18.75-100) vs. 92.1 (81.25-100) (p = 0.002), internal rotation 20° (0-20°) vs. 50° (30°-70°) (p = 0.0002), respectively. CONCLUSION: Even though the radiographic correction lagged behind in the arthroscopic group, the functional outcomes achieved did convey the gain of function in this cohort. In carefully selected cases, arthroscopy could be a less invasive procedure which has desirable outcomes.

Avascular necrosis post unstable slipped capital femoral epiphysis: a treatment algorithm with staged hinged hip distraction: mid-term results.

BACKGROUND: Management of avascular necrosis (AVN) of the femoral head in slipped capital femoral epiphysis (SCFE) is difficult. We proposed to ascertain if staged hip distraction could prevent collapse and recover the femoral head. METHODS: A retrospective review of the hip database retrieved 16 children with unstable SCFE and AVN. All underwent capital realignment by surgical dislocation followed by 2nd-stage hinged hip distraction. Patient demographics and radiographic parameters of deformity, AVN and arthritis were collected. The patients scored their hip function both before and after intervention and at follow-up using the modified Harris Hip Score and Nonarthritic Hip score. RESULTS: 7 boys and 9 girls formed the study group (n = 16). The average age at surgery was 12.7 years (9-16 years). 8 rights hips and 8 left hips were involved. The average follow-up was 45 months (33-66 months). Group A (n = 7) had hip distraction only if the follow-up radiographs showed AVN changes and collapse. Based on the observations in Group A, the protocol was changed for Group B. Group B (n = 9) underwent hip distraction at 6 weeks of capital realignment for avascularity of the femoral head. In Group A, all patients had further collapse and advanced arthritis at follow-up. In Group B all patients had hip joint space restored and good hip function without pain at follow-up. CONCLUSIONS: Pre-emptive application of hip distractor for those children with proven lack of blood flow to the femoral head is a potential option to stall the progression of AVN and to help recover useful hip function.

Does the Surgeon-reported Outcome Correlate with Patient-reported Outcome after Total Knee Arthroplasty? A Cohort Study.

BACKGROUND: Total knee arthroplasty (TKA) has been proved to be a successful and cost-effective treatment for improving pain and function in patients with knee arthritis. Total knee arthroplasty (TKA) is one of the most common orthopaedic surgeries performed worldwide and advancement in surgical techniques and prosthetic designs have improved the patient outcomes. However, concerns and priorities of patients and surgeons relating to joint replacement may differ. MATERIALS AND METHODS: 306 TKAs in 223 patients were evaluated for functional outcome using surgeon reported American Knee Society Knee Score (KS)/Functional Score (FS) and patient-reported Oxford Knee Score (OKS). We have also assessed the correlation between FS and OKS at midterm follow up. RESULTS: The mean preoperative KS, FS, and OKS in 223 patients were 42.76, 42.4, and 38.84 and the midterm mean KS, FS, and OKS were 84.29, 73.40, and 30.26, respectively. There was a statistically significant improvement in the KS, FS, and OKS at midterm follow up in Category A (CAT A) (bilateral TKA or unilateral with asymptomatic contralateral knee), CAT B (unilateral TKA with symptomatic other knee) and CAT C (inflammatory arthritis). Overall, the correlation between the midterm FS and OKS was fair. However, in CAT A and CAT B, there was no significant correlation between FS and OKS, but CAT C had a strong correlation. There was a statistically significant improvement in the KS, FS, and OKS when midterm follow up scores were compared with preoperative scores. However, no significant correlation between the American knee society FS and OKS in osteoarthritic patients at midterm follow up signifies acceptable outcome may vary between patients and physicians. CONCLUSION: All patients should be counseled preoperatively to assess their expectations and sensitize them to information regarding the expected functional outcome following TKA in their cultural context.

Minimally invasive (MIS) Tönnis osteotomy- A technical annotation and review of short term results.

AIMS: We detail a modified single incision approach to perform the Tonnis triple pelvic osteotomy by a minimally invasive approach. PATIENTS AND METHODS: 12 children underwent minimally invasive Tonnis Osteotomy. There were five boys and seven girls in this study group. Average age was 11 years (9-15 years) at the time of surgery. Mean follow-up was 20.5 months (13-39 months). RESULTS: The average preoperative Antero-Posterior (AP) Centre Edge (CE) angle was -8.8° (-38.6°-18°), the average post-operative AP CE angle was 29.7° (25.1°-43.7°). The average preoperative lateral CE angle was -4.7° (-16°-0°), the average postoperative Lateral CE angle was 28.5° (21.3°-37.4°). The Sharp's angle before and after surgery were 55.7° (51.3°-66°) and 32.4° (16.1°-40.1°) respectively. The mean Tönnis angle before and after the osteotomy were 28.86° (19.7°-43.4°) and 6.3° (0.5°-9.4°) respectively. There was one major complication with sciatic nerve palsy which is in the recovery phase on followup and six minor complications including two cases of transient lateral femoral cutaneous nerve injury, two cases of ischial non-union, over granulation of the wound in one case, and metalwork irritation in one case. CONCLUSION: We have described a minimally invasive Tonnis osteotomy as a viable option based on our results. This technique is recommended for those who are conversant with the traditional pelvicosteotomies.

Can Pixel Value Ratio be Used in the Assessment of Ceramic Bone Substitute Incorporation? Observations from a Pilot Study.

BACKGROUND: Assessment of bone graft substitute incorporation is critical in the clinical decision making process and requires special investigations. We examined if the pixel value ratio (PVR) obtained in routine follow-up digital radiographs could be used for such assessment. MATERIAL/METHODS: Radiographic images were acquired using either computed radiography or flat panel digital radiography systems. The PVR from radiographs of thirty children with ceramic bone substitute grafting were analyzed using the software from the picture archival and communication system (PACS) workstation. Graft incorporation was also assessed using the van Hemert scale. Three independent observers (A, B, C) measured PVRs at two different time points during the first and the last follow-up visits. PVR was compared with the van Hemert scale scores and analyzed using Spearman's rank correlation. RESULTS: The mean intra-observer reliability was 0.8996, and inter-observer reliabilities were 0.69 (A vs. C), 0.78 (A vs. B), and 0.85 (B vs. C) for the first follow-up visit and 0.74 (A vs. C), 0.82 (A vs. B), and 0.70 (B vs. C) for the last follow-up measurements. Spearman's correlation showed a strong negative association between PVR values and van Hemert scale scores, as the healing process advanced on serial measurements at each follow-up (r=-0.94, n=60, z=-7.24, p≤0.0001). The reliability of the PVR measurements was assessed using an aluminum step wedge and ceramic graft. CONCLUSIONS: PVR is potentially a reliable indicator of bone graft incorporation and can aid in clinical decision making provided standard radiographic techniques are used.

Late correction of neck deformity in healed severe slipped capital femoral epiphysis: short-term clinical outcomes.

PURPOSE: Contemporary methods for the management of neck deformity following a healed severe slipped capital femoral epiphysis (SCFE) include subcapital neck osteotomy. METHODS: 18 patients with chronic severe SCFE in the oblique plane (mean slip angle = 70°) constituted the study group. 6 patients with an open physis underwent modified Dunn capital realignment and 12 patients with a closed physis underwent surgical dislocation with a corrective neck osteotomy. 10 patients already had an in-situ pinning. RESULTS: The mean follow-up was 4.5 years (3-6 years). The mean preoperative modified Harris Hip Score (mHHS) and nonarthritic hip score (NAHS) were 24 and 40 respectively, followed by a score of 89 and 92 respectively at the last follow-up (p = 0.0002). Radiologically, all the parameters showed a significant correction. The mean pre- and postoperative values of alpha angle were 79.8 and 34.5 respectively (p = 0.0002); AP slip angle being 36.7 and 14.8 (p = 0.002); lateral slip angle being 54.2 and 13.6 (p = 0.0002); oblique plane slip angle being 70.7 and 20.8 (p = 0.0002) and centre trochanter distance being -6.9 and 1.2 (p = 0.002). The major complications seen were nonunion of the neck osteotomy (n = 1/12) and chondrolysis (n = 1/6) in the modified Dunn's group. The overall complication rate was 11%. There was no statistically significant difference in outcome between the 2 groups clinically and radiologically. CONCLUSIONS: Femoral neck osteotomy is a potentially rewarding technique to correct severe neck deformities and restoring hip function in the short term.

Bone marrow extract as a growth supplement for human iliac apophyseal chondrocyte culture.

BACKGROUND & OBJECTIVES: Human bone marrow is rich in various growth factors which may support the chondrocyte growth. This study was conducted to compare the culture characteristics of human growth plate chondrocyte in foetal bovine serum (FBS) and human autologous bone marrow extract (BME) in monolayer culture. METHODS: Iliac crest apophyseal cartilage was harvested from four donors, aged between two and nine years, undergoing hip surgery. Chondrocytes were propagated under two culture conditions, with 10 per cent FBS and 10 per cent autologous BME harvested from the same donors. Cells were harvested at 7, 14 and 21 days to assess viability, morphology, cell count and immunocytochemistry. RESULTS: With an initial seeding density of 2500 cells/cm 2 , the average yield in monolayer cultured with FBS was 3.35 × 10 5 , 5.9 × 10 5 , 14.1 × 10 5 and BME was 0.66 × 10 5 , 1.57 × 10 5 and 3.48 × 10 5 at 7, 14 and 21 days, respectively. Viability was 98.21 per cent with FBS and 97.45 per cent with BME at 21 days. In BME supplemented cultures, hyaline phenotype was maintained up to 21 days. The yield was higher in the FBS supplemented group; however, the phenotype could not be maintained by the FBS group as long as BME group. INTERPRETATION & CONCLUSIONS: Autologous BME was found to be a safer alternative to FBS for human studies. BME could maintain the hyaline phenotype for a longer time. Ways to enhance the cell yield needs to be explored in future studies.

Nonunion in a distal radius metaphyseal fracture in a child: Role of intact periosteal sleeve in management.

We present an adolescent with distal radius nonunion following an open fracture and failed surgery which eventually united when the length and stability was restored for eight weeks duration. The intact periosteal sleeve at the nonunion site formed new bone when its tension was restored by gradual differential distraction. This case report highlights the possibility of stimulating bony union in an established atrophic nonunion by distracting the minimally disturbed soft tissue and thick osteogenic periosteal envelope in the paediatric age group.

Triphasic ceramic scaffold in paediatric and adolescent bone defects.

We evaluated novel triphasic hydroxyapatite tricalcium phosphate calcium silicate scaffold (HASi) in the management of paediatric bone defects. Their main advantage is considered to be adequate strength and stimulation of bone formation without resorting to autograft. A total of 42 children younger than 16 years of age were recruited over a period of 1 year and were treated with this synthetic bone substitute as a stand-alone graft for pelvic, femur, calcaneal and ulnar osteotomies, cystic bone lesions, subtalar arthrodesis and segmental bone defects. Forty children, 22 boys and 18 girls, mean age 8.3 years and a mean follow-up of 18.51 months, were available for evaluation. Analysis showed that younger age, cancellous defects and no internal fixation were associated with significantly faster healing. Partial incorporation was observed in 22.5% and complete incorporation in 77.5% of cases at 18 months of follow-up. Sex, type of defect, BMI and the shape of the ceramic graft did not significantly affect the rate of healing. Complications attributable to HASi included four nonunions, three of which were diaphyseal. HASi was found to be safe in children with cancellous or benign cavitatory defects. It is not suitable for diaphyseal and segmental bone defects as a stand-alone graft.

Is there a role for Ender's nailing of paediatric femoral fractures in a resource-restricted hospital set-up?

Paediatric femur fractures are managed with the titanium elastic nail system (TENS) in the 5-16-year age group. TENS is costly and not easily available in public hospitals. This study compares TENS nailing with stainless-steel Ender's nail fixation of paediatric femur fractures. A retrospective analysis of patient records from 2006 to 2008 yielded 31 children, 5-16 years of age, who underwent flexible nailing for isolated femur fractures. Sixteen children underwent Ender's nailing and 15 underwent TENS nailing. A significant difference in the coronal plane deformity was found in the TENS nailing group compared with Ender's nailing. The union time and time to weight bearing were significantly shorter for Ender's nailing than TENS nailing. The outcome according to Flynn's criteria was significantly better in the Ender's nailing group. The results of Ender's nailing in paediatric femur fractures were comparable with TENS, with a rapid healing time and reduced angular malunion.

Sjögren-Larsson syndrome--unusual presentation with pathological femoral neck fracture: a case report.

Patients with Sjögren-Larsson syndrome, an autosomal recessive syndrome characterized by ichthyosis, spastic diplegia/quadriplegia, mental retardation and ocular features that include pigmentary changes in the retina, rarely present to the orthopaedic surgeon. We detail a rare and unusual presentation of Sjögren-Larsson syndrome in an adolescent boy with bilateral femoral neck fractures.

A retrospective analysis of loss of reduction in operated supracondylar humerus fractures.

BACKGROUND: Loss of reduction following closed or open reduction of displaced supracondylar fractures of the humerus in children varies widely and is considered dependent on stability of the fracture pattern, Gartland type, number and configuration of pins for fixation, technical errors, adequacy of initial reduction, and timing of the surgery. This study was aimed to evaluate the factors responsible for failure of reduction in operated pediatric supracondylar fracture humerus. MATERIALS AND METHODS: We retrospectively assessed loss of reduction by evaluating changes in Baumann's angle, change in lateral rotation percentage, and anterior humeral line in 77 consecutive children who were treated with multiple Kirschner wire fixation and were available for followup. The intraoperative radiographs were compared with those taken immediately after surgery and 3 weeks postoperatively. Multivariate logistic regression analysis was performed by STATA 10. RESULTS: Reduction was lost in 18.2% of the patients. Technical errors were significantly higher in those who lost reduction (P = 0.001; Odds Ratio: 57.63). Lateral pins had a significantly higher risk of losing reduction than cross pins (P = 0.029; Odds Ratio: 7.73). Other factors including stability of fracture configuration were not significantly different in the two groups. CONCLUSIONS: The stability of fracture fixation in supracondylar fractures in children is dependent on a technically good pinning. Cross pinning provides a more stable fixation than lateral entry pins. Fracture pattern and accuracy of reduction were not important factors in determining the stability of fixation.