Multidirectional instability of the shoulder: a systematic review with a novel classification.

Purpose: A variety of instabilities are grouped under multidirectional instability (MDI) of the shoulder. This makes understanding its diagnostic process, presentation and treatment difficult due to lack of evidence-based consensus. This review aims to propose a novel classification for subtypes of MDI. Methods: A systematic search was performed on PubMed Medline and Embase. A combination of the following 'MeSH' and 'non-MesH' search terms were used: (1) Glenohumeral joint[tiab] OR Glenohumeral[tiab] OR Shoulder[tiab] OR Shoulder joint[tiab] OR Shoulder[MeSH] OR Shoulder joint[MeSH], (2) Multidirectional[tiab], (3) Instability[tiab] OR Joint instability[MeSH]. Sixty-eight publications which met our criteria were included. Results: There was a high degree of heterogeneity in the definition of MDI. Thirty-one studies (46%) included a trauma etiology in the definition, while 23 studies (34%) did not. Twenty-five studies (37%) excluded patients with labral or bony injuries. Only 15 (22%) studies defined MDI as a global instability (instability in all directions), while 28 (41%) studies considered MDI to be instability in two directions, of which one had to include the inferior direction. Six (9%) studies included the presence of global ligamentous laxity as part of the definition. To improve scientific accuracy, the authors propose a novel AB classification which considers traumatic etiology and the presence of hyperlaxity when subdividing MDI. Conclusion: MDI is defined as symptomatic instability of the shoulder joint in two or more directions. A comprehensive classification system that considers predisposing trauma and the presence of hyperlaxity can provide a more precise assessment of the various existing subtypes of MDI. Level of Evidence: III.

Does Patient Blood Management Affect Outcomes in Metastatic Spine Tumour Surgery? A Review of Current Concepts.

STUDY DESIGN: Narrative review. OBJECTIVE: The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients. METHODS: A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included. RESULTS: A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS. CONCLUSION: Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS. LEVEL OF EVIDENCE: Not applicable.

Implant and construct decision-making in metastatic spine tumour surgery: a review of current concepts with a decision-making algorithm.

STUDY DESIGN: Narrative Review. OBJECTIVE: Metastatic spine tumour surgery (MSTS) is an important treatment modality of metastatic spinal disease (MSD). Increase in MSTS has been due to improvements in our oncological treatment, as patients have increased longevity and even those with poorer comorbidities are now being considered for surgery. However, there is currently no guideline on how MSTS surgeons should select the appropriate levels to instrument, and which type of implants should be utilised. METHODS: The current literature on MSTS was reviewed to study implant and construct decision making factors, with a view to write this narrative review. All studies that were related to instrumentation in MSTS were included. RESULTS: A total of 58 studies were included in this review. We discuss novel decision-making models that should be taken into account when planning for surgery in patients undergoing MSTS. These factors include the quality of bone for instrumentation, the extent of the construct required for MSTS patients, the use of cement augmentation and the choice of implant. Various studies have advocated for the use of these modalities and demonstrated better outcomes in MSTS patients when used appropriately. CONCLUSION: We have established a new instrumentation algorithm that should be taken into consideration for patients undergoing MSTS. It serves as an important guide for surgeons treating MSTS, with the continuous evolvement of our treatment capacity in MSD.

Vacuum assisted closure and local drug delivery systems in spinal infections: A review of current evidence.

Background: Spinal infections are still showing increased incidence throughout the years as our surgical capabilities increase, coupled with an overall aging population with greater number of chronic comorbidities. The management of spinal infection is of utmost importance, due to high rates of morbidity and mortality, on top of the general difficulty in eradicating spinal infection due to the ease of hematogenous spread in the spine. We aim to summarize the utility of vacuum-assisted closure (VAC) and local drug delivery systems (LDDS) in the management of spinal infections. Methods: A narrative review was conducted. All studies that were related to the use of VAC and LDDS in Spinal Infections were included in the study. Results: A total of 62 studies were included in this review. We discussed the utility of VAC as a tool for the management of wounds requiring secondary closure, as well as how it is increasingly being used after primary closure as prophylaxis for surgical site infections in high-risk wounds of patients undergoing spinal surgery. The role of LDDS in spinal infections was also discussed, with preliminary studies showing good outcomes when patients were treated with various novel LDDS. Conclusions: We have summarized and given our recommendations for the use of VAC and LDDS for spinal infections. A treatment algorithm has also been established, to act as a guide for spine surgeons to follow when tackling various spinal infections in day-to-day clinical practice.

A deep learning-based technique for the diagnosis of epidural spinal cord compression on thoracolumbar CT.

PURPOSE: To develop a deep learning (DL) model for epidural spinal cord compression (ESCC) on CT, which will aid earlier ESCC diagnosis for less experienced clinicians. METHODS: We retrospectively collected CT and MRI data from adult patients with suspected ESCC at a tertiary referral institute from 2007 till 2020. A total of 183 patients were used for training/validation of the DL model. A separate test set of 40 patients was used for DL model evaluation and comprised 60 staging CT and matched MRI scans performed with an interval of up to 2 months. DL model performance was compared to eight readers: one musculoskeletal radiologist, two body radiologists, one spine surgeon, and four trainee spine surgeons. Diagnostic performance was evaluated using inter-rater agreement, sensitivity, specificity and AUC. RESULTS: Overall, 3115 axial CT slices were assessed. The DL model showed high kappa of 0.872 for normal, low and high-grade ESCC (trichotomous), which was superior compared to a body radiologist (R4, κ = 0.667) and all four trainee spine surgeons (κ range = 0.625-0.838)(all p < 0.001). In addition, for dichotomous normal versus any grade of ESCC detection, the DL model showed high kappa (κ = 0.879), sensitivity (91.82), specificity (92.01) and AUC (0.919), with the latter AUC superior to all readers (AUC range = 0.732-0.859, all p < 0.001). CONCLUSION: A deep learning model for the objective assessment of ESCC on CT had comparable or superior performance to radiologists and spine surgeons. Earlier diagnosis of ESCC on CT could reduce treatment delays, which are associated with poor outcomes, increased costs, and reduced survival.

Hip Fracture Management Using External Fixation-A Systematic Review.

INTRODUCTION: Patients with significant comorbidities have high general anaesthetic risks and are often thought to be undesirable candidates for general anaesthesia and, therefore, surgery. External fixation uses local or regional anaesthesia, and allows patients with significant comorbidities to avoid the risks of general anaesthesia. It has been described to be successful in the management of high-risk patients with intertrochanteric fractures. However, published data have been derived from small case series, and no published literature has attempted to analyse them in totality. This review aims to pool together these case series, and to evaluate the outcomes and complications of external fixation when performed in high-risk patients with intertrochanteric fractures. MATERIALS AND METHODS: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) guidelines. All studies that reported the outcomes of external fixation for intertrochanteric fractures of high-risk patients were included. RESULTS: A total of 13 publications, involving 687 patients, were included in the review. All the studies reported postoperative radiological reduction and complete fracture healing with reduction of limb length discrepancy. One study using parallel placement of proximal fixation screws showed shorter operative duration as compared to convergent placement. Another study mentioned that there was no significant difference in mortality rates between patients with stable fractures and those with unstable fractures who underwent external fixation. All the studies reported a decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. CONCLUSION: External fixation is promising and useful especially in the management of high-risk patients with intertrochanteric fractures. The procedure can help with radiological reduction of the fracture, reduction of limb length discrepancy, reduction of operative duration, decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. The procedure is versatile and seems to be able to accommodate both stable and unstable fractures. However, unstable fractures may be associated with greater postoperative morbidity, and it may be worthwhile to prognosticate based on the stability of the patients' fracture for better risk-benefit analysis preoperatively. Shorter operative times can also be achieved through parallel proximal pin placement, without impact on mortality or morbidity.

The Outcomes of Distal Femoral Varus Osteotomy in Patellofemoral Instability: A Systematic Review and Meta-Analysis.

Distal femoral varus osteotomies have been novelly described in the recent years to be successful in the management of patellofemoral instability with genu valgum. However, these publications are limited to case reports and small case series and no published literature have attempted to analyze them in totality. The current review aims to pool together these small case series to evaluate the outcomes and complications of distal varus femoral osteotomies when performed for patellofemoral instability. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. All studies that reported the outcomes of distal femoral varus osteotomy for patellofemoral instability were included. A total of five publications were included in the review, which included a total of 73 patients. All of the studies reported improvement in the radiological outcomes for genu valgum correction and patellofemoral instability. One study using opening wedge osteotomy reported a decrease in Caton-Deschamps index postoperatively, while another study using closing wedge osteotomy reported maintenance of the Caton-Deschamps index postoperatively. Second look arthroscopy showed an improvement in the status of the chondral lesions of the medial facet of the patellar undersurface, the lateral facet of the patellar undersurface and the trochlear groove 2 years postoperatively. All studies also reported a decrease in the risk of recurrence of patellofemoral instability, reduction in pain, and an improvement in all the clinical outcomes knee scores. Distal femoral varus osteotomy is promising and useful in the management of patellofemoral instability with genu valgum. The procedure can allow for radiological correction of the genu valgum and patellofemoral instability, reduction in the risk of recurrence of patellofemoral instability, reduction in pain, improvement in clinical knee outcome scores, and improvement in the status of the chondral lesions in the patellofemoral joint. It is highly versatile and could accommodate varying degrees of correction. These improvements in radiological and clinical outcomes can be seen in studies for both closing wedge and opening wedge distal femoral osteotomies. However, opening wedge osteotomies appear to decrease the patellar height as compared with closing wedge osteotomies which maintain the patellar height; therefore, the patellar height should be assessed preoperatively prior to deciding whether to perform an opening wedge or closing wedge distal femoral varus osteotomy. The Level of Evidence for this study is IV.