Outcomes of Geriatric Hip Fractures in a Tertiary Referral Center in Malaysia During the COVID-19 Pandemic.

Introduction With the advancing age of the population, there are an increasing number of patients with geriatric hip fractures. Despite the advancement of surgical knowledge and improvement of implant designs to treat geriatric hip fractures, mortality and morbidity remain high among these frail patients. In conjunction with the COVID-19 pandemic, the collateral damage dealt to these patients remains unknown as scarce resources are funneled to deal with the pandemic. This study is geared to investigate the surgical outcomes of patients with geriatric hip fractures who were admitted during the initial phase of the COVID-19 pandemic. Methods This retrospective study was carried out at Hospital Kuala Lumpur, the largest public hospital in the capital of Malaysia, from March 1, 2020, to March 1, 2021. All patients of age 60 years and above were screened for suitability. Only patients who had undergone surgical intervention during the study period were included in this study. Patients' demographic data, mechanism of injury, waiting time for surgery, type of surgery, complications and ambulatory status were obtained from the medical records. Univariate analysis was performed to determine the factors associated with complications as well as the post-operative ambulatory status of the patients. Results A total of 52 patients were included in this study, with a median age of 72 years. The majority of the patients were Chinese (n=21, 40.4%). This was followed by Malay and Indian (n=14, 26.9% each) and other ethnicity (n=3, 5.8%). More than three-quarters of the patients had a trivial injury such as a fall due to a miss-step (n=16, 30.8%) and slip (n=16, 30.8%) and a fall due to dizziness (n=8, 15.4%). Only 12 patients (23.1%) sustained hip fractures due to trauma. The median time to surgery for these patients was 5 days (interquartile range: 4 days). Most of these patients underwent total hip replacement (n=30, 57.7%). This was followed by unipolar hemiarthroplasty (n=11, 21.2%), bipolar hemiarthroplasty (n=10, 19.2%) and internal fixation (n=1, 1.9%). Among these patients, six of them had documented complications. There were periprosthetic joint infection (n=2, 3.8%), dislocation (n=2, 3.8%), hematoma formation (n=1, 1.9%) and seroma (n=1, 1.9%). Six months after the surgery, most of the patients were able to ambulate, albeit some patients required walking aid such as walking stick and walking frame. Univariate analysis showed that all the factors were not associated with the complications and the post-operative ambulatory status of the patients. Conclusion  The incidence of geriatric hip fractures remains high during the COVID-19 pandemic despite the movement control order (MCO) being enforced in Malaysia. With prompt surgical intervention, most of the patients can regain ambulatory status, albeit with a walking aid.

Thoracic Extraosseous Epidural Venous Haemangioma Arising From Nerve Root in a Nasopharyngeal Carcinoma Survivor: A Case Report.

A 66-year-old man presented to the outpatient clinic with back pain and progressive bilateral lower limb weakness over a period of 6 months. Magnetic resonance imaging showed a large extraosseous epidural lesion at T6-T7 arising from the left T6 spinal nerve root complicated with cord compression leading to cord oedema. The lesion was excised en bloc and histopathological examination revealed benign venous haemangioma. We report this rare case of venous epidural haemangioma to be considered as a differential diagnosis in a patient with a background of previous lumbar discectomy surgery and who was a nasopharyngeal carcinoma survivor.

Diagnostic Accuracy and Adequacy of Computed Tomography Versus Fluoroscopy-Guided Percutaneous Transpedicular Biopsy of Spinal Lesions.

Background Transpedicular biopsy of spinal lesions is imperative for the generation of a definite diagnosis. Thus far, literature comparing the accuracy and adequacy between fluoroscopy-guided and computed tomography (CT)-guided transpedicular biopsy of spinal lesions is scarce. We aim to compare the accuracy and adequacy of samples collected with the two techniques at the largest tertiary hospital in Malaysia. Materials and methods A total of 60 patients (37 patients with spinal infection and 23 patients with spinal tumour) underwent percutaneous transpedicular biopsy of spinal lesions from January 2013 to December 2017 at a tertiary centre. Demographic data, biopsy method (fluoroscopy-guided and CT-guided), diagnosis, adequacy, and accuracy of samples obtained were assessed. Results Among the 60 samples obtained, only two samples (3.3%) were deemed inadequate. There were 10 biopsy samples (16.7%) that were inaccurate. There was no statistical difference between fluoroscopy-guided and CT-guided transpedicular biopsy in terms of accuracy (p = 0.731) and adequacy (p = 0.492). Conclusions Fluoroscopy-guided and CT-guided transpedicular biopsy of spinal lesions offer similar accuracy and adequacy. Fluoroscopy-guided biopsy of the spinal lesion will be an option for spine surgeons when CT-guided biopsy is not available.

Spinal growth modulation with an anterolateral flexible tether in an immature bovine model: disc health and motion preservation.

STUDY DESIGN: An immature bovine model was used to evaluate multilevel anterolateral flexible tethering in a growing spine. OBJECTIVE: To evaluate radiographic, biochemical, histologic, and biomechanical results of tethered spinal growth. SUMMARY OF BACKGROUND DATA: An anterolateral flexible tether has been shown to create a kyphotic and scoliotic spinal deformity in calves. Subsequent disc health and spinal motion has not been analyzed. METHODS: Four consecutive thoracic vertebral bodies (T6-T9) were instrumented anteriorly in 36 1-month-old calves. Seventeen animals (Tether Group) were instrumented with a vertebral staple-two screw construct connected by 2 flexible stainless steel cables. Nineteen animals (Control Group) were instrumented with 1 vertebral body screw with no connecting cable. After a 6-month survival period, the spines were harvest en-bloc and underwent radiographic, computed tomography, biochemical, histologic, and biomechanical analysis. RESULTS: On average, 37.6 degrees +/- 10.6 degrees of coronal and 18.0 degrees +/- 9.9 degrees of sagittal deformity was created in the Tether Group, with significant vertebral wedging toward the tether (P < 0.001). Disc thickness decreased significantly in the Tether Group (P < 0.001), however, disc wedging was not observed. There was no change in gross morphologic disc health or disc water content (P = 0.73). However, proteoglycan synthesis was significantly greater in the tethered discs compared with controls (P < 0.001), and collagen type distribution was different with a trend toward increased type II collagen present on the tethered side of the disc (P = 0.09). Tethers significantly increased spinal stiffness in lateral bending and in flexion/extension (P < 0.05) without affecting torsional stiffness, however, after tether removal range of motion returned to control values. CONCLUSION: Tethering resulted in vertebral wedging while maintaining spinal flexibility. Although changes in proteoglycan synthesis, collagen type distribution, and disc thickness were observed, the tethered discs had similar water content to control discs and did not demonstrate gross morphologic signs of degeneration. Growth modulation is an attractive treatment option for growing patients with scoliosis, avoiding multilevel fusions or brace wear. Strategies for fusionless scoliosis correction should preserve disc health, as adolescent patients will rely on these discs for decades after treatment.

Perioperative complications after surgical correction in neuromuscular scoliosis.

PURPOSE: To evaluate the perioperative complications associated with surgical correction in neuromuscular scoliosis and to identify the risk factors associated with these complications. METHODS: A retrospective review of the hospital charts of patients with neuromuscular scoliosis who underwent surgical correction at a medical center was performed. RESULTS: Data was available on a total of 175 patients. The overall perioperative complication rate was 33.1% (96 complications in 58 patients). Complications were subdivided into pulmonary issues (19.4%), wound and implant infections (9.7%), cardiovascular complications (4.0%), intraoperative neurological changes (4.6%), miscellaneous complications (5.7%), and problematic instrumentation (3.4%). No patient had an identifiable permanent postoperative change in neurological status. The complication rate in patients who underwent single-stage procedures (37.4%) was found lower than that in patients who underwent staged procedures (57.1%). There were no deaths during the perioperative period. CONCLUSIONS: Patients with neuromuscular scoliosis are at high risk of developing perioperative complications after surgical correction of their deformity (overall rate, 33.1%).

Biomechanical comparison of the screw-bone interface: optimization of 1 and 2 screw constructs by varying screw diameter.

STUDY DESIGN: In vitro biomechanical investigation of 1 and 2-screw anterior scoliosis constructs with varying screw diameters. OBJECTIVE: To determine a possible optimal configuration of screw number and diameter at varying levels within the thoracic spine for anterior vertebral body fixation. SUMMARY OF BACKGROUND DATA: Single-rod systems are typical in anterior thoracic and thoracolumbar correction of adolescent idiopathic scoliosis; although dual rod systems may offer more flexural stability. Loss of fixation remains problematic, particularly in the proximal thoracic vertebrae, and it remains unclear how screw diameter or the number of screws within the vertebrae affect fixation. METHODS: Individual vertebral levels from 10 cadaveric thoracic spines were randomly assigned to either 1 or 2 screws of 5, 6, or 7-mm diameter. Bone-screw interface failures were created in coronal plane cantilever plow, and failure loads were compared across vertebral levels for each instrumentation method. RESULTS: Two-screw constructs had significantly higher failure loads than single-screw constructs, while increasing screw diameter also produced significant changes in fixation strength. Two-screws had improved performance in the mid and lower thoracic spine, while a single screw was more stable in the upper thoracic spine. CONCLUSIONS: Failure modes for 1-screw constructs almost entirely (89%) showed gradual plowing through the bone, whereas acute fracture through the vertebral body or pedicles were common forms of failure (85%) for 2-screw constructs.

Multilevel spinal growth modulation with an anterolateral flexible tether in an immature bovine model.

STUDY DESIGN: A bovine model was used to evaluate the effects of a multilevel anterolateral flexible tether in a growing spine. OBJECTIVE: To evaluate the radiographic changes in a growing spine with a multilevel anterolateral tether. SUMMARY OF BACKGROUND DATA: Spinal growth modulation has long been considered as a conceptually attractive and elegant possible alternative to arthrodesis in the treatment of idiopathic scoliosis. Although some experimental studies have described spinal growth modulation, few have described a purely mechanical tether. Clinical studies of spinal epiphysiodesis have described inconsistent curve stabilization and/or correction. METHODS: A total of 33 one-month-old male calves underwent a single thoracotomy and placement of vertebral screws at T6-T9. In 11 animals, one screw per level was connected by a 3/16 in. stainless steel cable (single tether). In 11 animals, two screws per level were connected by two cables (double tether). In the remaining 11 animals, single screws in each level were left unconnected (control). After 6 months, the spines were harvested and underwent radiographic analysis. RESULTS: In the control group, there was little change in the coronal and sagittal measurements during the survival period. In the single tether group, there was variable instrumentation fixation and inconsistent creation of coronal deformity, which ranged from 0 degrees to 31 degrees. The double-tether group had more consistent creation of deformity, ranging from 23 degrees to 57 degrees. CONCLUSIONS: Given adequate bony fixation, a flexible lateral spinal tether can affect growth modulation. This technique of growth modulation may serve as a future fusionless method of correction in a growing patient with scoliosis.

Thoracic vertebral screw impingement on the aorta in an in vivo bovine model.

STUDY DESIGN: A bovine model was used to evaluate the effects of thoracic vertebral screw impingement of the aorta. OBJECTIVES: To evaluate the histologic and biomechanical changes in aortic wall tissue that was severely impinged by abutting instrumentation. SUMMARY OF BACKGROUND DATA: Case reports of vascular injury associated with spinal instrumentation generally describe intraoperative injury; some report delayed presentation of large vessel damage. Risks associated with placing instrumentation adjacent to large vessels are largely unknown. METHODS: Six 1-month-old calves underwent left-sided thoracotomies, exposing the anterior thoracic spine and aorta. With the heads removed, screws were inserted in reverse fashion into T6 through T11, leaving the screw tips 1 cm proud and abutting the aorta. After 3, 6, or 12 months (2 calves each), the spines were resected with the adjacent aorta and underwent radiographic, histologic, and biomechanical testing. RESULTS: Computed tomography revealed varying degrees of vessel impingement. Although there were no frank ruptures, 96% of aortic specimens showed histopathologic changes, including 52% with wall thinning; 43% were no longer impinged, yet 60% of these had increased collagen (scar). Biomechanical testing of screw-impinged aortas demonstrated a lower failure stress (1.2 +/- 0.5 N/mm vs. 1.8 +/- 0.4 N/mm, P = 0.016) but no difference in failure strain (42 +/- 9% vs. 32 +/- 10%, P = 0.06) than controls. CONCLUSIONS: Major impingement of vertebral screws on the aorta caused acute and chronic histopathologic and biomechanical changes in the vessel wall. This model represents a severe form of vessel penetration by a screw that confirms such a "worst case" scenario results in marked compromise of the vessel wall integrity. The sequelae of less severe impingement are unknown.