Evaluating Pelvic Tilt Using the Pelvic Antero-Posterior Projection Images: A Systematic Review.

BACKGROUND: Pelvic tilt (PT) is a routinely evaluated parameter in hip and spine surgeries, and is usually measured on a sagittal pelvic radiograph. This may not always be feasible due to limitations such as landmark visibility, pelvic anomaly, and hardware presence. Tremendous efforts have been dedicated to using pelvic antero-posterior (AP) radiographs for assessing sagittal PT. Thus, this systematic review aimed to collect these methods and evaluate their performances. METHODS: Two independent reviewers searched the PubMed, Ovid, Cochrane, and Web of Science databases in June 2023 with backward reference trailing (Google Scholar archive). There were 30 studies recruited. Risk of bias was assessed using the prediction model risk of bias assessment tool. The relevant data were tabulated in a standardized form for evaluating either the absolute PT or relative PT. Disagreement was resolved by discussing with the senior author. RESULTS: There were 19 parameters from pelvic AP projection images involved, with 4 studies which used artificial intelligence, eyeball, or statistical shape method not involving a specific parameter. In comparing the PT values from pelvic sagittal images with those extrapolated from antero-posterior projection images, the highest correlation coefficient was found to be 0.91. The mean absolute difference (error) was 2.6°, with a maximum error reaching 10.9°. Most studies supported the feasibility of using AP parameters to calculate changes in PT. CONCLUSIONS: No individual AP parameter was found to precisely estimate absolute PT. However, relative PT can be derived by evaluating serial AP radiographs of a patient in varying postures, employing any AP parameters.

The Sacro-femoral-pubic Angle Is Unreliable to Estimate Pelvic Tilt: A Meta-analysis.

BACKGROUND: The accurate measurement of pelvic tilt is critical in hip and spine surgery. A sagittal pelvic radiograph is most often used to measure pelvic tilt, but this radiograph is not always routinely obtained and does not always allow the measurement of pelvic tilt because of problems with image quality or patient characteristics (such as high BMI or the presence of a spinal deformity). Although a number of recent studies have explored the correlation between pelvic tilt and the sacro-femoral-pubic angle using AP radiographs (SFP method), which aimed to estimate pelvic tilt without a sagittal radiograph, disagreement remains about whether the SFP method is sufficiently valid and reproducible for clinical use. QUESTIONS/PURPOSES: The purpose of this meta-analysis was to evaluate the correlation between SFP and pelvic tilt in the following groups: (1) overall cohort, (2) male and female cohort, and (3) skeletally mature and immature cohorts (young and adult groups, defined as patients older or younger than 20 years). Additionally, we assessed (4) the errors of SFP-estimated pelvic tilt angles and determined (5) measurement reproducibility using the intraclass correlation coefficient. METHODS: This meta-analysis was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in PROSPERO (record ID: CRD42022315673). PubMed, Embase, Cochrane, and Web of Science were screened in July 2022. The following keywords were used: sacral femoral pubic, sacro femoral pubic, or SFP. The exclusion criteria were nonresearch articles such as commentaries or letters and studies that only investigated relative pelvic tilt rather than absolute pelvic tilt. Although the included studies had different patient recruitment strategies, study quality-wise, they all used an adequate amount of radiographs for landmark annotation and applied a correlation analysis for the relationship between the SFP angle and pelvic tilt. Thus, no risk of bias was found. Participant differences were mitigated via subgroup and sensitivity analyses to remove outliers. Publication bias was assessed using the p value of a two-tailed Egger regression test for the asymmetry of funnel plots, as well as the Duval and Tweedie trim and fill method for potential missing publications to impute true correlations. The extracted correlation coefficients r were pooled using the Fisher Z transformation with a significance level of 0.05. Nine studies were included in the meta-analysis, totaling 1247 patients. Four studies were used in the sex-controlled subgroup analysis (312 male and 460 female patients), and all nine studies were included in the age-controlled subgroup analysis (627 adults and 620 young patients). Moreover, a sex-controlled subgroup analysis was conducted in two studies with only young cohorts (190 young male patients and 220 young female patients). RESULTS: The overall pooled correlation coefficient between SFP and pelvic tilt was 0.61, with high interstudy heterogeneity (I 2 = 76%); a correlation coefficient of 0.61 is too low for most clinical applications. The subgroup analysis showed that the female group had a higher correlation coefficient than the male group did (0.72 versus 0.65; p = 0.03), and the adult group had a higher correlation coefficient than the young group (0.70 versus 0.56; p < 0.01). Three studies reported erroneous information about the measured pelvic tilt and calculated pelvic tilt from the SFP angle. The mean absolute error was 4.6° ± 4.5°; in one study, 78% of patients (39 of 50) were within 5° of error, and in another study, the median absolute error was 5.8º, with the highest error at 28.8° (50 female Asian patients). The intrarater intraclass correlation coefficients ranged between 0.87 and 0.97 for the SFP angle and between 0.89 and 0.92 for the pelvic tilt angle, and the interrater intraclass correlation coefficients ranged between 0.84 and 1.00 for the SFP angle and 0.76 and 0.98 for the pelvic tilt angle. However, large confidence intervals were identified, suggesting considerable uncertainty in measurement at the individual radiograph level. CONCLUSION: This meta-analysis of the best-available evidence on this topic found the SFP method to be unreliable to extrapolate sagittal pelvic tilt in any patient group, and it was especially unreliable in the young male group (defined as patients younger than age 20 years). Correlation coefficients generally were too low for clinical use, but we remind readers that even a high correlation coefficient does not alone justify clinical application of a metric such as this, unless further subgroup analyses find low error and low heterogeneity, which was not the case here. Further ethnicity-segregated subgroup analyses with age, sex, and diagnosis controls could be useful in the future to determine whether there are some subgroups in which the SFP method is useful. LEVEL OF EVIDENCE: Level III, diagnostic study.

Overlapping surgery in arthroplasty - a systematic review and meta-analysis.

BACKGROUND: Planned overlapping surgery can improve efficiency, reduce costs and help manage long waiting lists; yet, this practice has been questioned due to patient safety concerns. A systematic review and meta-analysis were performed to answer the question: (1) are there any differences in the risk of postoperative adverse outcomes; and (2) are there any differences in length of stay or length of surgery, in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed either as non-overlapping surgery (NOS) or overlapping surgery (OS). PATIENTS AND METHODS: A systematic search of literature in the databases of MEDLINE, PubMed, Embase and Cochrane from dates of inception was performed. All studies published in English were included. Risk of Bias in Non-randomised Studies-of Interventions (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05. RESULTS: A total of nine studies with 120,625 patients were included for analyses. There were no statistically significant differences for overall rates of postoperative complications, dislocations, fractures, infections, readmissions or revision surgery nor with length of stay or length of surgery (p>0.05). Patient characteristics between groups were similar (p>0.05). DISCUSSION: There were no differences in postoperative adverse outcomes for elective orthopaedic THA and TKA performed as NOS when compared to OS. Operating schedules for OS in elective lower limb arthroplasty appear to be safe, given appropriate patient selection processes and may be a useful method to improve hospital efficiency. Informed consent and preoperative patient education should remain paramount. LEVEL OF EVIDENCE: IV.

Postoperative Atrial Fibrillation After Cardiac Surgery: A Meta-Analysis.

BACKGROUND: Postoperative atrial fibrillation (POAF) is common after cardiac surgery and linked to poorer short-term and long-term outcomes; however, conflicting evidence exists on stroke risk and how the index procedure affects outcomes. This study aims to provide a comprehensive review of the published outcomes of POAF after cardiac surgery, examined as a whole and by index procedure. METHODS: A systematic review of POAF after cardiac surgery was conducted. Outcomes related to POAF were analyzed in a meta-analysis, and aggregate survival data were derived to examine long-term survival. RESULTS: Sixty-one studies with 239,018 patients were identified, the majority (78.7%) undergoing coronary surgery. POAF occurred in 25.5% of patients and was associated with significantly higher rates of early mortality and stroke (odds ratio [OR], 1.74; P < .001; and OR, 2.21, P < .001, respectively) along with longer intensive care and overall hospital length of stay (mean difference 0.8 days, P = .008; and mean difference 2.8 days, P < .001, respectively). After a median of 6.6 years (range, 0.5-20 years), mortality and stroke remained significantly higher for those with POAF (OR, 1.57, P < .001; and OR, 1.81, P = .001). Pooled hazard ratio for long-term mortality was significantly higher for patients who underwent coronary surgery compared with isolated valve surgery. CONCLUSIONS: POAF is common after cardiac surgery and is associated with significantly higher rates of both short-term and long-term stroke and mortality as well as increased hospital stay. Differences in hazard for long-term survival may be due to the underlying pathophysiological risk factors for POAF, which differ by surgical procedure.

Novel Oral Anticoagulants Compared to Warfarin for Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Postoperative atrial fibrillation (POAF) is common after cardiac surgery and contributes to short- and long-term morbidity, particularly thromboembolism. Anticoagulation for sustained or recurrent POAF is suggested to reduce thromboembolism. Novel oral anticoagulants may present a safe alternative to warfarin with further benefits including shorter hospital length of stay and better patient convenience. METHODS: A retrospective analysis was performed on all isolated cases of coronary artery surgery (CABG) at our institution between January 2015 and December 2018, totalling 960 patients. Rates of POAF were examined with particular focus on preoperative factors, postoperative outcomes, and anticoagulation practices. RESULTS: The incidence of POAF was 31.8% (305 patients) and was higher in older patients (67.6±9.4 yrs vs 63.0±10.7 yrs, p<0.001), those with a history of cerebrovascular disease (14.6% vs 8.7%, p=0.02), those with higher CHADS-VASc scores (2.5±1.3 vs 2.8±1.3, p<0.001) those who had a postoperative return to theatre (2.6% vs 0.8%, p=0.002), and those with new renal failure (4.9% vs 1.8%, p=0.02). Off-pump surgery was associated with lower incidence of POAF (29.8% vs 37.1%, p=0.03). Patients who developed POAF had significantly longer admissions than those without (12.6±10.6 days vs 9.3±16.3 days, p<0.001). In total, 106 patients (11.0%) went home anticoagulated; 77 (72.6%) on warfarin and 29 (27.4% on a NOAC). Readmission for bleeding was higher in patients on anticoagulation (1.0% vs 0.0%, p=0.02), but did not drive readmission for pericardial effusion (0.3% vs 0.6%, p=0.55). No bleeding complications occurred in patients who were discharged on a NOAC. Overall mortality at median of 2 years was 1.8% (17 patients) and no mortality occurred in any patient discharged on anticoagulation. CONCLUSION: Postoperative atrial fibrillation is a common adverse event and is linked to higher preoperative and postoperative morbidity. Anticoagulation may be safely started in these patients and use of novel anticoagulation does not appear to increase postoperative complications, although overall numbers are low.

A prospective, matched comparison of ultra-low and standard-dose computed tomography for assessment of renal colic.

OBJECTIVE: To determine the diagnostic accuracy of ultra-low-dose computed tomography (ULDCT) compared with standard-dose CT (SDCT) in the evaluation of patients with clinically suspected renal colic, in addition to secondary features (hydroureteronephrosis, perinephric stranding) and additional pathological entities (renal masses). PATIENTS AND METHODS: A prospective, comparative cohort study was conducted amongst patients presenting to the emergency department with signs and symptoms suggestive of renal or ureteric colic. Patients underwent both SDCT and ULDCT. Single-blinded review of the image sets was performed independently by three board-certified radiologists. RESULTS: Among 21 patients, the effective radiation dose was lower for ULDCT [mean (SD) 1.02 (0.16) mSv] than SDCT [mean (SD) 4.97 (2.02) mSv]. Renal and/or ureteric calculi were detected in 57.1% (12/21) of patients. There were no significant differences in calculus detection and size estimation between ULDCT and SDCT. A higher concordance was observed for ureteric calculi (75%) than renal calculi (38%), mostly due to greater detection of calculi of <3 mm by SDCT. Clinically significant calculi (≥3 mm) were detected by ULDCT with high specificity (97.6%) and sensitivity (100%) compared to overall detection (specificity 91.2%, sensitivity 58.8%). ULDCT and SDCT were highly concordant for detection of secondary features, while ULDCT detected less renal cysts of <2 cm. Inter-observer agreement for the ureteric calculi detection was 93.9% for SDCT and 87.8% for ULDCT. CONCLUSION: ULDCT performed similarly to SDCT for calculus detection and size estimation with reduced radiation exposure. Based on this and other studies, ULDCT should be considered as the first-line modality for evaluation of renal colic in routine practice.

Portable Video Media Versus Standard Verbal Communication in Surgical Teaching: A Prospective, Multicenter, and Randomized Controlled Crossover Trial.

OBJECTIVE: This study aims to evaluate the effectiveness of portable video media (PVM) compared to standard verbal communication (SVC) as a novel adjunct for surgical education of junior medical officers and medical students, in terms of knowledge acquisition and participant satisfaction. BACKGROUND: The effective, continued education of final year medical students and junior doctors is the foundation of quality healthcare. The development of new media technologies and rapid internet streaming has resulted in an opportunity for the integration of PVM into medical education. PVM is an educational platform with the advantage of being standardized, efficient, and readily available. DESIGN: This is a multicenter, prospective, and randomized controlled crossover study. Participants completed a preintervention knowledge test and were then randomized in an allocation ratio of 1:1 to receive surgical education regarding cystoscopy and ureteric stenting for acute renal colic via either PVM or SVC. A 32-point knowledge test and a modified Client Satisfaction Questionnaire-8 were then administered and the participants were then crossed over to the other educational method. The knowledge and satisfaction tests were then readministered. RESULTS: Fifty-four participants were recruited for this study with 27 participants in each group. Both groups had a 18% to 20% increase in knowledge scores following the first intervention p < 0.001 and on crossover there was a further 4% increase in knowledge scores, p < 0.01. There was no significant difference between the groups in knowledge scores before intervention, p = 0.23 after first intervention p = 0.74 or following crossover p = 0.09. After first intervention, participants in the group receiving PVM education first had a significant 8% higher satisfaction score compared to the SVC group, p = 0.023. CONCLUSIONS: Our study has shown that PVM shows similar efficacy in information uptake to traditional forms of education. Furthermore, PVM was shown to have higher satisfaction scores compared to SVC. Further studies will need to evaluate the use of PVM for education in other surgical and medical domains and assess the long-term knowledge retention.