Clinical applications of AI-prediction tools in spine surgery: a narrative review.

Spine surgery has grown into a wide, complex field encompassing trauma surgery to deformity to tumours. Artificial intelligence (AI) based technology has been particularly useful in improving imaging-reporting and detection of predictive patterns. The purpose of this narrative review is to present practical approaches towards implementing upcoming AI spine research for clinicians to help improve practices, clinical throughput, and surgical decision-making.

Stem cells in degenerative lumbar spine disease: a review and focus on utility in Low- and Middle-Income Countries.

Stem cell therapy is a common adjunct in regenerative medicine and has recently seen greater adoption in spinal surgery. Arthrodesis is typically achieved with iliac-crest bone grafts with several adverse events, leading to the development of alternative biomaterials. One such biomaterial is stem cells, which may be equal in terms of effectiveness but with significantly fewer complications. Low- and Middle-Income Countries (LMICs) have seen slow adoption of stem cell therapy due to resource constraints but may benefit the most from these techniques. We conducted a comprehensive review of literature in the PUBMED, Scopus, and Cochrane Library databases on the use of stem cells and stem cell-based biomaterials in spinal surgery. Our review showed promising results, from a variety of methods including augmentation of existing scaffold with mesenchymal stem cells or concentrated bone marrow aspirate. With minimal complications, stem cell augmentation can be a good alternative to existing biomaterial use for spinal fusion and repair.

Long-term functional outcomes after total scapulectomy with dual suspension reconstruction in children - A case series.

Implant reconstruction following scapulectomy in children is a challenging task. Dual suspension reconstruction may offer an alternative but there is a dearth of literature on functional outcomes following this procedure for malignant tumours in children. A retrospective study was conducted at the Aga Khan University Hospital, a tertiary care centre in Karachi, Pakistan. Children with malignant tumours of the scapula who underwent total scapulectomy with dual suspension reconstruction (n=5) between Jan 2009 and June 2015 were included. Mean follow up was 50±13.39 months. There were four boys and one girl having mean age of 11±3.57 years. All patients were Enneking Stage IIB with 4 patients diagnosed as Ewing's Sarcoma and 1 as osteosarcoma. The MSTS scores ranged from 20-25 points, with a median of 23. One patient developed postoperative surgical site infection requiring surgical debridement whereas all patients remained disease-free till last follow up. Our findings suggest that scapulectomy with dual suspension reconstruction achieves satisfactory functional results with low rate of complications.

Musculoskeletal tumours throughout history and beyond: Clinical features, imaging, staging and biopsy.

BACKGROUND: Over the last century, there has been a remarkable development in the study of bone and soft tissue sarcomas. This is primarily due to the improved knowledge of the nature of these lesions and the improved imaging technology. In literature there are many protocols that are being used and all of them have reported various advantages and disadvantages of each technique used. However, there is no set guideline and whatever has been proposed has been developed on the basis of the experience of different centres and different surgeons. OBJECTIVE: The current systematic review was planned to thoroughly evaluate the levels of evidence on which we base decisions for surgical management of lower extremity bone tumours. METHODS: The review included descriptive studies published in the English language. Studies included case reports, case series and experiences of different centres for the surgical management of lower extremity bone tumours. Articles reporting all levels of evidence - Level I to V - were included. PubMed, ERIC, MEDLINE, EMBASE and Cochrane Reviews databases from 2002 to 2012 were searched. RESULTS: Information was gathered and thoroughly studied from 63 articles. There were no Level I studies, 2(3.2%) Level II studies, 47(74.6%) Level III, and the remaining 14(22.2%) studies were Level IV and Level V. CONCLUSIONS: Sarcomas are rarely occurring neoplastic conditions which are present in all age groups but commonly affect young age population. Most are asymptomatic but can present with pain or pathological fracture. These lesions are commonly diagnosed with plain radiographs. CT scan and MRI may be used to delineate anatomy and to quantify the extent of soft tissue involvement. Various advantages and disadvantages associated with each aspect in the management of patients starting from the basic history-taking, physical examination, imaging, biopsy principles, peri-operative laboratory work-up and staging of the cancer were studied. Treatment ranges from conservative to en-block resection including extended curettage. Aggressive tumours should be closely followed up for recurrence and metastasis.

Mobile phones in the orthopedic operating room: Microbial colonization and antimicrobial resistance.

BACKGROUND: Surgical site infections are a major cause of morbidity and mortality following orthopedic surgery. Recent efforts to identify sources of contamination in the operating rooms have implicated mobile phones. AIM: To investigate microbial colonization on the mobile phones of health care professionals in the orthopedic operating room. METHODS: We conducted a cross-sectional study involving culture and sensitivity analysis of swabs taken from the mobile phones of orthopedic and anesthesia attendings, residents, technicians and nurses working in the orthopedic operating rooms over a period of two months. Demographic and cell phone related factors were recorded using a questionnaire and the factors associated with contamination were analyzed. RESULTS: Ninety-three of 100 mobile phones were contaminated. Species isolated were Coagulase-negative Staphylococcus (62%), Micrococcus (41%) and Bacillus (26%). The risk of contamination was increased with mobile covers and cracked screens and decreased by cell phone cleaning. CONCLUSION: Mobile phones belonging to health care workers are frequently contaminated with pathogenic bacteria with the potential of transferring drug resistance to nosocomial pathogens. Studies investigating the relationship to surgical site infections need to be conducted. The concept of "mobile hygiene" involving the change of mobile covers, replacement of cracked screens or even wiping the phone with an alcohol swab could yield the cost-effective balance that contaminated cell phones deserve until they are established as a direct cause of surgical site infections.

A prospective study of the role of bladder scanning and post-void residual volume measurement in improving diagnostic accuracy of cauda equina syndrome.

AIMS: Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. METHODS: A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. RESULTS: The study confirms the low predictive value of 'red flag' symptoms and signs. Of note 'bilateral sciatica' had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed 'low-risk' of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. CONCLUSION: This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677-682.

Workplace violence against doctors involved in clinical care at a tertiary care hospital in Pakistan.

A study was conducted to determine perceptions, attitudes and experience of workplace violence among residents and faculty at a tertiary care centre in Karachi, Pakistan. An anonymous, electronic, self-administered questionnaire was circulated among all residents and faculty members working at Aga Khan University Hospital, Karachi. A standard questionnaire was devised and used, and workplace violence and its types were defined as per World Health Organization (WHO) definitions. An overall response rate of 44.9% was achieved. A total of 53.4% of the respondents reported being victims of some form of workplace violence with verbal abuse being the most prevalent (41.6%) followed by bullying and threat. Most frequent perpetrators were found to be faculty members followed by patients or their attendants. Specialty of respondents was found to be significantly associated with verbal abuse and significantly more females were subjected to sexual harassment, while ethnicity was found to be significantly associated with racial harassment. The results correspond to previously available literature, while they also highlight some findings unique to our culture. We suggest that measures should be taken as per WHO and Joint Commission International Accreditation ( J CIA) recommendations to prevent workplace violence across the country.

Management of stress fractures of the proximal tibia in patients with advance knee osteoarthritis. A case series.

To evaluate the outcome of one stage long stem total knee arthroplasty (TKA) of patients with stress fracture of the proximal tibia of the knee joint. Record of 15 patients, 14 females and one male who underwent one stage long stem TKAfrom the year January 2008 till December 2014 were reviewed retrospectively. Outcome variable was fracture healing which was seen clinically (pain free and postop ambulation) as well as radiologically (union of three out of four cortices). Mean age of the patients were 65 years and the mean BMI was 31. Of the 15 knees 13 had varus malalignment and 2 had valgus malalignment. The mean duration of fracture healing was four and a half months and the mean duration of follow-up was 26 months. All the patients were ambulated full weight bearing with walker. One patient had non-union at fracture site which required bone grafting. Long stem TKA is an effective method of treating tibial stress fractures associated with advance osteoarthritis as it not only restores the normal mechanical alignment but also facilitates fracture healing.

Over a decade of changing trends in surgical mortality; audit from a tertiary care hospital.

OBJECTIVE: A retrospective audit of the trend of mortality in the general surgery service at our hospital over the last decade was conducted to reflect the complexity of cases being seen. METHODS: Mortalities of 8 separate years, a decade apart, namely 1997, 1998, 1999, and 2000 as initial years (Group-I) and 2011, 2012, 2013 and 2014 as recent years (Group-II) were reviewed. RESULTS: Total number of admissions in the service and surgeries performed during these two periods experienced an increase of 50.7% & 64.2 % respectively. The total mortalities showed an increase with 139 (mortality rate 0.96%) seen in Group I to 285 (mortality rate 1.31%) seen in Group II a percentage increase of 105%. Comparing the operative mortality, separately, mortality rate dropped from 1.21% to 1.16% of all surgeries. Analyzing non-operative mortality showed a significant increase from six deaths in Group-I comprising 4.3% to 76 non-operative deaths in Group-II corresponding to 26.7% (p=0.000). Deaths due to Trauma increased from 12.9% to 25.3%, p=0.04, a reversed trend was seen in deaths due to GI Bleeding 11.5% to 3.2%, p=0.001. Significantly more patients in Group-II had higher ASA levels as compared to Group-I (62% vs. 46%, p<0.005). CONCLUSIONS: This study shows an increase in total mortality rate over the years, change was mainly due to an increase in non-operative mortality. Trauma became the predominant cause of death.

Outcome of Judet's quadricepsplasty for knee contractures and the effect of local infiltration of epinephrine on reducing blood loss.

OBJECTIVE: To evaluate the effectiveness of Judet's quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure. METHODS: A retrospective cohort study was conducted in which all cases of knee contractures managed with Judet's quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine (1:400,000) along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judet's outcome, blood loss, drop in hemoglobin and required blood transfusion were noted for all patients and compared between both groups. RESULTS: Most common preceding pathology identified for the development of knee contractures was periarticular fracture while ilizarov application was the most common etiology. Both groups were found similar in all preoperative characteristics except preoperative flexion contracture (p = 0.02). All functional outcome measures including Judet's outcome were similar in both groups. In contrast, duration of surgery (p = 0.01), blood loss (p = 0.02), drop in hemoglobin (p = 0.01) and number of transfusions (p = 0.03) were significantly reduced in epinephrine group. CONCLUSION: Judet's quadricepsplasty is a useful procedure to increase the range of motion of rigid knees and local infiltration of epinephrine is effective in decreasing the amount of subsequent blood loss and transfusion requirements.

Improvement in quality of lifesix months after primary total hip arthroplasty in a Pakistani population.

This prospective, cohort study was carried out to assess the improvement in quality of life of patients undergoing elective primary total hip arthroplasty (THA). It was conducted at the orthopaedic department of the Aga Khan University Hospital, Karachi, from June 2014 to May 2015, and comprised patients who had undergone THA. A total of 89 patients having a mean age of 41.5±12.0 years with a baseline core outcomes measure index (COMI)-hip score of > 3.5 were included. A decrease in COMI-hip score by >3 points six months post-operatively was considered improvement in quality of life. Patient satisfaction with restriction to squatting was assessed separately. The mean reduction in COMI-hip was 4.9±1.3 with 83(93%) patients experiencing significant improvement in quality of life. Age >50 years and American Society of Anaesthesiologists (ASA) level >III was significantly associated with no improvement in quality of life. Most patients were satisfied with their disability to squat irrespective of COMI-hip score. THA was found to be associated with significant improvement in quality of life and COMI-hip score was applicable in our population despite its inability to assess disability with restriction in squatting.

Factors associated with burnout among residents in a developing country.

INTRODUCTION: Recent literature has focused on burnout as a specific job related distress syndrome among physicians and residents having adverse effects on patient care. Local data on burnout is lacking. MATERIALS & METHODS: An online self-administered questionnaire was sent via email to all residents (325) at our institute with and a response rate of 110 (34%) was achieved. Out of these 82 residents consented and completely filled the questionnaires and were included in the analysis. The questionnaire comprised of demographic variables, the Maslach burnout inventory and occupational risk factors. RESULTS: High levels of burnout on at least one subscale were reported by 61(74.4%) residents, in 2 components by 34(41.5%) whereas an alarming 10(12.2%) residents scored high on all three subscales. Among the individual subscales emotional exhaustion was most frequent in 49(59.8%). Among the departments Radiology reported the highest levels (100%) of burnout and low levels were reported by Pediatrics (45%). There was no difference between burnout levels among junior and senior residents. Dissatisfaction with workload, length of work hours, relationship with co-workers and lack of autonomy were significantly associated with high level of burnout. CONCLUSION: High levels of burnout are prevalent among trainee doctors in our part of the world which are comparable with international literature. Efforts to improve the work environment of residents may significantly reduce levels of burnout.

Long term follow-up of a successful lower limb replantation in a 3-year-old child.

Replantation of the lower extremity has controversial indications but nevertheless it may be considered in carefully selected patients who present early and are expected to show good functional recoveries. Here we present a successful replantation in a 3-year-old boy who has made excellent recovery with no functional deficit evident at 12 years of follow-up. He sustained a traumatic amputation at the level of distal tibia when he fell of a "Qing Qi" (motorcycle rickshaw). Replantation was attempted at 8 hours cold ischemia time with the tibia shortened 4 cm and all tendons, vessels, and nerves repaired. Patient required a second procedure during the same hospital stay for skin coverage. Patient made good recovery with ambulation without support at 6 months, less than 3 cm limb length discrepancy, plantar and dorsiflexion power 4/5, and recovery of sensation over the foot. Now at 12 years of follow-up patient has a normal gait and has integrated into society with no functional deficit. Considering the functional outcome of our case, replantation should be attempted whenever possible and feasible especially in children.

Does tranexamic acid reduce blood transfusion following surgery for inter-trochanteric fracture? A randomized control trial.

OBJECTIVE: To compare the frequency of blood transfusion after surgery for fixation of inter-trochanteric fractures in patients given tranexamic acid versus placebo. METHODS: The randomised control trial was conducted at the Aga khan university hospital from May 1 to October 31, 2014, and comprised patients diagnosed with Inter-trochanteric fracture based on X-ray imaging. The patients were randomised into two equal groups based on a computer-generated random number table. The Intervention group received two doses of 10mg/kg body weight of tranexamic acid just before surgery and three hours later intravenously. The Control group received two doses of 10mg/kg body weight of normal saline at similar intervals. Numbers of blood transfusions required postoperatively were noted based on the postoperative haemoglobin readings. RESULTS: There were 100 patients who were divided into groups of 50(50%) each. Mean post-op haemoglobin for the intervention group was 10.2±2.4 g/dl and for the control group it was 8.9±2.4 g/dl (p=0.007). Nine (18%) patients in intervention group required blood transfusion compared to 21(42%) in control group (p=0.009). CONCLUSIONS: Administering tranexamic acid was a useful and safe option for reducing requirement of blood transfusion postoperatively after inter-trochanteric hip fractures.

Effect of continuous passive motion on knee flexion range of motion after total knee arthroplasty.

OBJECTIVE: To compare mean knee flexion in patients on continuous passive motion and those without it after total knee arthroplasty. METHODS: The randomised controlled study was conducted at Aga Khan University Hospital, from July 2013 to June 2014, and comprised patients who underwent total knee arthroplasty. Patients were randomly assigned to either group, with Group A receiving standardised physiotherapy from 1st postoperative day, and Group B receiving physiotherapy and one hour of continuous passive motion twice a day from 1st postoperative day until discharge. Outcome assessment was done on the day of discharge. RESULTS: Of the 76 patients, there were 38(50%) in each group. There were 61(80%) women and 15(20%) men, with a mean age of 65.5±7.9 years in Group A and 61.6±9.1 years in Group B. The mean preoperative knee flexion in Group A was 90.3±13.2° and in Group B it was 96.9±11.5°. Mean maximum flexion at the time of discharge was 96.3±5.7° in Group A and 94.3±8.4° in Group B (p=0.22). The mean length of stay in Group A was 6.1±1.4 days and in Group B it was 8.6±2.4 days (p=0.01). CONCLUSIONS: Continuous passive motion had no influence on knee range of motion after total knee arthroplasty at the time of discharge.

Early experience of dynamic hip screw with spiral blade and locking side plate for the stabilization of trochanteric fractures.

OBJECTIVE: To evaluate early experience with helical hip system in osteoporotic elderly patients with per-trochanteric fractures. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of patients having low-velocity pertrochanteric fractures who were fixed with spiral blade Dynamic Helical Hip Systemfrom July to December 2014 and were followed up for a minimum of 3 months. Demographic variables and clinical outcomes were noted from the medical records whereas operative details were recorded from the operative note. Radiological variables and outcomes were assessed by viewing appropriate pre-operative, post-operative and follow-up radiographs. RESULTS: Of the 32 patients in the study, 14(44%) were men and 18(56%) were women, with an overall mean age of 77.81±7.04 years and mean body mass index of 25.99±4.13 kg/m2. Of the total, 1(3.13%) patient had implant cut-out, 1(3.13%) had myocardial infarctionand 2(6.2) expired. CONCLUSIONS: The introduction of spiral blade dynamic hip screw manifested favourable results and good clinical and radiological outcomes with low cut-out rates.

Single stage bilateral total hip replacement: Is it an option or a risk?

OBJECTIVE: To evaluate safety and feasibility of two-stage total hip arthroplasty and to compare it with single-stage procedure. METHODS: The retrospective study was conducted at The Aga Khan University Hospital and comprised all cases of total hip replacements between January 2001 and December 2014 that were retrieved from the database using International Classification of Diseases (9th Revision) coding. A standardised questionnaire was completed, including patient demographics, primary diagnosis, peri and postoperative morbidity and mortality. Differences among patients\' data were analysed using chi square test for dichotomous variables and student t-test for continuous variables. RESULTS: Of the 48 cases, 34(71%) had single-stage bilateral total hip replacement and 14(29%) had two-stage procedure. The mean hospital stay in the single-stage group was 8.1±3.2 days compared to 19.6±5 days in the other group. The two-stage group required a significantly greater need for transfusion compared to the single-stage group (P<0.05). There was no statistically significant increase in peri or postoperative complication (p> 0.05). CONCLUSIONS: Simultaneous bilateral total hip arthroplasty was found to be a safe and viable option with a decreased transfusion requirement and shorter hospital stay along with no significant increase in morbidity or mortality.

Malrotation after reamed intramedullary nailing with and without a fracture table for closed fractures of the femoral shaft.

OBJECTIVE: To observe the effect of the choice of surgical table on the incidence of malrotation. METHODS: The randomised trial was conducted from July 2012 to January 2013 at the Aga Khan University Hospital, Karachi, during which 74 patients were inducted. Randomisation was done via random allocation software version 1.0.0 and sealed envelopes were used to guide the choice of table. Malrotation was assessed by the operating surgeon using the lesser trochanteric shape signunder intra-operative fluoroscopy. SPSS 19 was used for statistical analysis. RESULTS: The 74 patients in the study were divided into two groups of 37(50%) each using fracture table and the regular table.Overall, there were 55(74%) male and 19(26%) female patients with a mean age of 37±17 years. Overall incidence of malrotation was 13(17.6%). Malrotation was observed in 7(19%)patients in the fracture table group and 6(16%)in the regular table group (p=0.760). CONCLUSIONS: The choice of fracture table did not influence the occurrence or direction of malrotation.

Hip fracture surgery: does time of the day matter? A case-controlled study.

INTRODUCTION: A prevailing perception regarding night time surgery is that the probability of complications may be higher due to decreased availability of support staff, surgeon fatigue and other logistical factors. However there is little data supporting this notion in hip fracture surgery and we studied this in the context of Inter-trochanteric fractures fixed with dynamic hip screws (DHS). METHODS: All patients who underwent DHS fixation for inter-trochanteric fracture from January 2005 to December 2010 were included. Patients were divided into two groups. An after-hours group was defined as an operation done between 5:00 P.M. to 7:00 A.M. and a daytime group was defined as surgery done between 7:00 A.M. to 5:00 P.M. Data was analyzed using SPSS version 19. RESULTS: During this period 194 patients underwent DHS fixation. One hundred and fourteen patients were included in the daytime group and 80 patients in the after-hours group. There was no difference in the rates of wound infection, length of hospital stay, postoperative ambulation status, intra op blood loss, type of anesthesia, and mortality between the two groups. Tip apex index was found to be similar between the two groups. Two patients in the daytime surgery required revision surgery compared to 5 patients in the after-hours group, however this difference was not statistically significant. DISCUSSION: Outcomes in terms of adequacy of fixation, post-operative complications and post-operative 30-day mortality are comparable to routine day time surgery while offering the benefits of early fixation and mobilization to the patient. This also has a positive impact on the financial burden on this population as early fixation translates into decreased length of stay and reduced cost of treatment.