The absence of reporting standards and a lack of objective, performance-based outcomes following intramedullary nailing of tibial shaft fractures: findings from a scoping review into 179 articles.

PURPOSE: This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes. METHODS: PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised. RESULTS: Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes. CONCLUSION: The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.

Migration patterns of acetabular cups: a systematic review and meta-analysis of RSA studies.

BACKGROUND AND PURPOSE: We conducted a systematic review and meta-analysis of RSA studies to investigate the early and long-term migration patterns of acetabular cups and the influence of implant factors on cup migration over time. METHODS: We performed a systematic search of PubMed, Embase, and Scopus databases to identify all RSA studies of cup migration following primary total hip replacement (THR). Proximal migration at 3 and 6 months, 1, 2, 5, and 10 years were considered for analysis. Implant factors investigated included fixation type, head size, bearing surface, uncemented coating design, and the decade of RSA introduction. RESULTS: 47 studies reported the proximal migration of 83 cohorts (2,328 cups). Besides 1 threaded cup design, no implant factor investigated was found to significantly influence proximal migration. The mean pooled 2-year proximal migration of cemented cups (0.14 mm, 95% confidence interval [CI] 0.08-0.20) was not significantly different from uncemented cups (0.12 mm, CI 0.04-0.19). The mean pooled proximal migration at 6 months was 0.11 mm (CI 0.06-0.16) and there was no significant increase between 6 months and 2 years (0.015 mm, CI 0.000-0.030). 27 of 75 cohorts (36%) reported mean proximal migration greater than 0.2 mm at 2 years, which has previously been identified as a predictor of implants at risk of long-term loosening. CONCLUSION: Our meta-analysis demonstrated that the majority of cup migration occurs within the first 6 months. With one exception, no implant factors influenced the 2-year proximal migration of acetabular cups. 36% of studies with 2-year migration were considered at risk of long-term loosening. Further investigation and comparison against long-term survivorship data would validate 6-month and/or 1-year proximal migration measurements as an earlier predictor of long-term loosening than the current 2-year threshold.

Predicting rupture locations of ascending aortic aneurysms using CT-based finite element models.

Accurate rupture risk assessment of ascending aortic aneurysms is important for reducing aneurysm-related mortality. More recently, computational models have been shown to better predict rupture risk than diameter-based measurements. However, it remains unclear whether finite element (FE) models of the ascending aorta can predict rupture location, and over what timeframe those predictions are reliable. The aim of this study was to evaluate FE models of the ascending aorta generated from computed tomography (CT) scans in predicting rupture location. Pre- and post-rupture CT scans were obtained of 12 patients who underwent emergency surgical repair for ascending aorta rupture with varying time intervals between scans (20 days - 6 years). A rigid iterative closest point (ICP) registration was used to overlay post-rupture aortic geometries with pre-rupture FE models and directly compare predicted regions of high equivalent strain with actual rupture. The FE model predicted the rupture location in the 5 patients with the shortest time intervals between the pre- and post-rupture scans (20 days - 2 years, 3 months). However, rupture location was not predicted in the 4/5 patients with greater than 3 years between scans. Achieving a physiological equivalent strain distribution in the FE model was highly dependent on the resolution of the pre-rupture scan and whether contrast agent was present. The results suggest there may be a time interval beyond which FE predictions of rupture location may not be reliable. The results in this study may help clinical validation of FE models of ascending aortic aneurysms predicting rupture risk.

The Accuracy of Percutaneous Sacro-Iliac Screw Fixation for Pelvic Ring Injuries using the Lateral view as the Corner Stone for Screw Placement: A Prospective Cohort Study.

This paper has been temporarily removed by the publisher, Wolters-Kluwer, as it may have been published in error. We regret any confusion this may have caused.

Quality of life and frailty outcomes following surgical and transcatheter aortic valve replacement.

BACKGROUND: Our objective was to report on the prospective outcomes in the areas of depression, quality of life, angina, and frailty in SAVR and TAVR patients with aortic stenosis undergoing aortic valve intervention. METHODS: We recruited 300 patients across 3 groups (TAVR, SAVR, and CABG) over 12 months. Depression, quality of life, frailty, and angina were assessed followed by propensity score matching. RESULTS: Using logistical regression when all patient factors considered for all patients who had SAVR and TAVR, the only preoperative factors that impacted on 1 year mortality was hypertension and STS score. Quality of life improvements within each group over 12 months was significant (p value = 0.0001). Depression at 12 months between groups (p value = 0.0395) and within each group was significant (p value = 0.0073 for SAVR and 0.0001 for TAVR). Angina was most frequent in TAVR at 12 months in the QL (p = 0.0001), PL (p = 0.0007), and improvement was significant in the QL (SAVR p = 0.0010, TAVR p = 0.0001) and PL (SAVR p = 0.0002), TAVR p = 0.0007) domains in both groups. Frailty at 12 months improved in both groups, but was greatest in TAVR (p value = 0.00126). CONCLUSIONS: This 12 months follow up of cardiac surgical patients has revealed significant improvement in PROMs and frailty in all groups by 3 months postoperative regardless of surgical or transcatheter approach. Outcome measures of quality of life and frailty could be utilized as a measure of outcome more regularly in patients undergoing aortic valve surgery regardless of approach.

Clinical Outcomes in Surgical and Transcatheter Aortic Valve Replacement: An ANZSCTS Database Review 2001-2019.

BACKGROUND: Since the last formal publication reporting on the findings of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database on surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in 2016, transcatheter approaches have become common practice. There has been an increase in use of TAVR following large, randomised control trials that only report on short-term outcomes in a selective cohort. This study aims to report on primary outcome measures and identify complications associated with SAVR and TAVR from a large national database. METHODS: From the ANZSCTS database (2001-19), 14,097 SAVR and 1,194 TAVR patients were identified with clinical details and 30-day follow-up available. The primary endpoint was the composite of all-cause mortality and/or permanent stroke at 30 days. Secondary endpoints were post-procedure complications requiring treatment. Logistical regression followed by propensity score matching was performed. RESULTS: Using logistical regression when all patient factors considered for all patients who had SAVR and TAVR, the only preoperative factors that had an impact on 30-day mortality was cerebrovascular disease, respiratory disease, preoperative dialysis, angina, and hypertension. Primary outcome 30-day mortality rate was 1.83% in the SAVR group, and 1.68% in patients in the TAVR group, p=0.7001, and permanent stroke was seen in 1.07% patients in the SAVR group, and 1.26% patients in the TAVR group. Acute limb ischaemia, aortic dissection, ventricular tachycardia, bradyarrhythmia and heart block were more common following TAVR (p<0.001), while reintubation and atrial arrhythmia were more common following SAVR (p<0.001). CONCLUSIONS: In the real world SAVR and TAVR have been used in very different patient groups and it is difficult to compare as different baseline characteristics and complications. The two patient groups maintain similarities in primary and secondary endpoints, but differences in life threatening and life altering morbidity remains significant. Collection of SAVR and TAVR data in a combined database may help to better capture and compare these complications and institute strategies to prevent them.

RSA Measurements of Implant Instability in a Paprosky III Pelvic Defect with Discontinuity: A Case Report.

CASE: We report a case of acetabular reconstruction for a large defect with pelvic discontinuity that underwent 4 revisions for dislocations over a 3-year period. This allowed assessment of implant stability both on imaging, using measurements on plain radiographs and radiostereometric analysis (RSA) against both ilium and ischium, and direct assessment during each surgery. Only implant stability measured with RSA correlated with intraoperative revision findings. CONCLUSION: This case underlines the role of RSA in assessing early acetabular implant stability in pelvic discontinuity and the importance of assessing the stability of the implant against both ilium and ischium.

The susceptibility of the aortic root: porcine aortic rupture testing under cardiopulmonary bypass.

BACKGROUND: In our earlier study on the functional limits of the aneurysmal aortic root we determined the pig root is susceptible to failure at high aortic pressures levels. We established a pig rupture model using cardiopulmonary bypass to determine the most susceptible region of the aortic root under the highest pressures achievable using continuous flow, and what changes occur in these regions on a macroscopic and histological level. This information may help guide clinical management of aortic root and ascending aorta pathology. METHODS: Five pigs underwent 4D flow MRI imaging pre surgery to determine vasopressor induced wall sheer stress and flow parameters. All pigs were then placed on cardiopulmonary bypass (CPB) via median sternotomy, and maximal aortic root and ascending aorta flows were initiated until rupture or failure, to determine the most susceptible region of the aorta. The heart was explanted and analysed histologically to determine if histological changes mirror the macroscopic observations. RESULTS: The magnetic resonance imaging (MRI) aortic flow and wall sheer stress (WSS) increased significantly in all regions of the aorta, and the median maximal pressures obtained during cardiopulmonary bypass was 497 mmHg and median maximal flows was 3.96 L/m. The area of failure in all experiments was the non-coronary cusp of the aortic valve. Collagen and elastin composition (%) was greatest in the proximal regions of the aorta. Collagen I and III showed greatest content in the inner aortic root and ascending aorta regions. CONCLUSIONS: This unique porcine model shows that the aortic root is most susceptible to failure at high continuous aortic pressures, supported histologically by different changes in collagen content and subtypes in the aortic root. With further analysis, this information could guide management of the aortic root in disease.

Histological regional analysis of the aortic root and thoracic ascending aorta: a complete analysis of aneurysms from root to arch.

BACKGROUND: Although aortic root and ascending aortic aneurysms are treated the same, they differ in embryological development and pathological processes. This study examines the microscopic structural differences between aortic root and ascending aortic aneurysms, correlating these features to the macroscopic pathophysiological processes. METHODS: We obtained surgical samples from ascending aortic aneurysms (n = 11), aortic root aneurysms (n = 3), and non-aneurysmal patients (n = 7), Aortic collagen and elastin content were examined via histological analysis, and immunohistochemistry techniques used to determine collagen I, III, and IV subtypes. Analysis was via observational features, and colour deconvolution quantification techniques. RESULTS: Elastin fiber disruption and fragmentation was the most extensive in the proximal aneurysmal regions. Medial fibrosis and collagen density increased in proximal aneurysmal regions and aortic root aneurysms (p < 0.005). Collagen I was seen in highest quantity in aortic root aneurysms. Collagen I content was greatest in the sinus tissue regions compared to the valvular and ostial regions (p < 0.005) Collagen III and IV quantification did not vary greatly. The most susceptible regions to ultrastructural changes in disease are the proximal ascending aorta and aortic root. CONCLUSIONS: The aortic root differs histologically from the ascending aorta confirming its unique composition in aneurysm pathology. These findings should prompt further evaluation on the influence of this altered structure on function which could potentially guide clinical management.

Cranial neurosurgical robotics.

OBJECT: The purpose of this review is to highlight the major factors limiting the progress of robotics development in the field of cranial neurosurgery. METHODS: A literature search was performed focused on published reports of any Neurosurgical technology developed for use in cranial neurosurgery. Technology was reviewed and assessed for strengths and weaknesses, use in patients and whether or not the project was active or closed. RESULTS: Published reports of 24 robots are discussed going back to 1985. In total, there were 9 robots used in patients (PUMA, Robot Hand, EXPERT, Neuromate, Evolution 1, ROSA, iSYS1, NeuroArm and NeuRobot) and only 2 active today (ROSA, NeuroArm). Of all clinically active systems, only three were used in more than 30 patients (ROSA, iSYS1 & NeuroArm). Projects were limited by cost, technology adoption, and clinical utility to actually improve workflow. The most common use of developed robots is for Stereotaxis. CONCLUSIONS: There is a clear void in the area of cranial neurosurgery regarding robotics technology despite success in other fields of surgery. Significant factors such as cost, technology limitations, market size and regulatory pathway all contribute to a steep gradient for success.

The burden of cycling-related trauma to the orthopaedic and trauma department of a level 1 trauma hospital in Adelaide, South Australia.

BACKGROUND: With the fourth largest metropolitan population density, motor vehicle drivers in Adelaide, South Australia, record the most number of motor vehicle insurance claims in Australia. Previous studies have shown a rise in cycling-related emergency department presentations from 2005 to 2010. There is no specific data available specifically related to South Australia. Our institution is the largest level 1 trauma centre in South Australia and Northern Territory and has a local geographic pool of the central metropolitan region of Adelaide. The aims of this study were to establish the demographics of cycling-related presentations to our institution that involved the admission of a patient under the Orthopaedic and Trauma service. Secondary aims were to investigate whether there were any common variables among these presentations that could be modified to prevent or reduce the morbidity of cycling-related trauma. METHODS: A prospective study was performed at our institution from 1 March 2018 until 31 December 2019 of all inpatient admissions under the Orthopaedics and Trauma department, where the patient was injured as a cyclist. We collated patient-reported information about the accident and their cycling habits. RESULTS: One hundred and ten patients were included in the study. One hundred and thirty-one injuries were recorded, requiring 89 surgical procedures. Eighty were upper limb injuries (61%), 49 were lower limb (37%), and 2 injuries occurred in either the spine or ribs. The most common reason for the accident was excessive cyclist speed. CONCLUSIONS: The majority of cyclists admitted to our unit with orthopaedic injuries were male patients who assessed themselves as experienced riders, and yet still were involved in accidents that resulted predominantly from episodes of poor judgement. Speed is a common and avoidable factor involved in the presentation of orthopaedic-related trauma to the public system. Involvement of other vehicles was relatively uncommon, as was poor weather; upper limb injuries predominate in this group.

The use of denosumab in the setting of acute pathological fracture through giant cell tumour of bone.

BACKGROUND: Denosumab (XgevaTM) is a fully human antibody to RANK-Ligand, an important signal mediator in the pathogenesis of giant cell tumour of bone (GCTB). The use of denosumab in the treatment of GCTB has changed the way in which these tumours are managed over the past years. CASE PRESENTATION: Described is the case of an acute fracture through a GCTB of the distal radius of a fit and well 32-year-old, non-smoking, female patient following a simple fall onto her outstretched, dominant hand. The aim was to enable joint sparing management for the patient, as opposed to an acute fusion procedure of the carpus. The patient underwent percutaneous k-wire fixation with application of plaster and immediate commencement with denosumab to halt the activity of the GCTB. Bone healing was rapid; plaster and k-wires were removed after 6 weeks. At 6 months denosumab, was ceased and an open curettage and grafting procedure of the tumour bed was undertaken (using MIIG X3, Wright Medical, aqueous calcium sulphate as graft material). CONCLUSIONS: The use of denosumab in the acute setting of pathological fracture through giant cell tumour of bone allowing joint salvage has not been previously described. The treatment was well tolerated and functional outcomes are excellent, with very promising 4-year follow-up. This novel approach may allow for more joint sparing strategies in the future for other patients in this difficult situation. Further cases will need to be gathered to establish this technique as a suitable treatment pathway.

The functional limits of the aneurysmal aortic root. A unique pressure testing apparatus.

BACKGROUND: The aortic root has unique embryological development and is a highly sophisticated and complex structure. In studies that report on the biomechanical characteristics of the thoracic aorta, distinction between the aortic root and ascending aorta regions is nonexistent. Our objective is to determine the maximal pressures at which dissection occurs or tissue failure occurs in the aortic root compared to that of the ascending aorta in the presence of aortic aneurysms. This may help guide preoperative monitoring, diagnosis and the decision for operative intervention for aortic root aneurysms in the normal and susceptible populations. METHODS: We developed a simple aortic root and ascending aorta pressure testing unit in series. Ten fresh porcine hearts were obtained from the local abattoir (n = 5 aortic root and n = 5 ascending aorta for comparison). Using a saline filled needle and syringe, artificial fluid-filled aneurysms were created between the intima and medial layers of the aortic root. The aorta lumen was then progressively filled with saline solution. Pressure measurement was taken at time of loss of tissue integrity, obvious tissue dissection or aneurysm rupture, and the tissue structure was then visually examined. RESULTS: In the aortic root, mean maximal pressure (mmHg) at tissue failure was 208 mmHg. Macroscopic examination revealed luminal tears around the coronary ostia in 2/5 specimens, and in all specimens, there was propagation of the dissection in the aortic root in a circumferential direction. In all ascending aorta specimens, the maximal aortic pressures exceeded 300 mmHg without tissue failure or dissection, and eventual apparatus failure. CONCLUSION: Our results indicate that the aneurysmal aortic root tissues are at greater risk of rupture and dissection propagation at lower aortic pressure. With further analysis, this could guide clinical and surgical management.

Acetabular Component Migration Measured Using Radiostereometric Analysis Following Revision Total Hip Arthroplasty: A Scoping Review.

* Radiostereometric analysis (RSA) studies of acetabular component migration following revision total hip arthroplasty (THA) have a large variation in their methodology and reporting of results, and, therefore, they may not be directly comparable. Standardization of RSA reporting is recommended. * In our review of RSA studies, there was a trend for cemented acetabular components to have larger amounts of early proximal migration than uncemented acetabular components. Results regarding cemented and uncemented components should be reported separately. * Cohorts that addressed larger acetabular defects were associated with a larger amount of early migration. * Reporting the migration result at 1 and 2 years postoperatively may enable earlier identification of poorly performing implants.

Accuracy of EBRA-cup measurements after reconstruction of severe acetabular defects at revision THR.

Radiostereometric analysis (RSA) is the most accurate method of measuring component migration using radiographs but is restricted to use in prospective studies. Ein-Bild-Roentgen-analyze (EBRA)-Cup can be used retrospectively, but its accuracy to measure component migration following revision is unknown. This study aimed to determine the accuracy of EBRA-Cup measurements of uncemented acetabular component migration after revision total hip replacement (THR). The secondary aim was to compare the number of cases identified using EBRA-Cup and RSA as having proximally migrated above and below 1 mm at 2 years postoperatively. EBRA-Cup measurements were performed on plain antero-posterior pelvic radiographs taken at the same time as RSA radiographs in a prospective cohort of 53 hips undergoing acetabular revision. At 2 years, the mean difference between the RSA and EBRA-Cup measurements for 17 components used to treat pelvic discontinuity was 0.90 mm, significantly greater than the mean difference of 0.28 mm for 36 components without discontinuity (P = .0001). The mean difference between the RSA and EBRA-Cup measurements at 2 years for hips that were reconstructed with an acetabular component alone, 0.28 mm, was significantly lower than hips that were reconstructed with an acetabular component in combination with an augment and/or cage, 0.74 mm (P = .0005). In conclusion, EBRA-Cup can accurately measure migration of uncemented acetabular components used at revision THR. The presence of pelvic discontinuity, and addition of augments and cages, significantly influenced the accuracy of EBRA-Cup measurements. EBRA-Cup and RSA had good agreement on classification of components that migrated proximally above or below 1 mm at 2 years, with 100% sensitivity, and 87% specificity.

The Stability of the Porous Tantalum Components Used in Revision THA to Treat Severe Acetabular Defects: A Radiostereometric Analysis Study.

BACKGROUND: The acetabular components used in revision total hip arthroplasty (THA) to treat severe acetabular bone defects have high rates of re-revision at mid to long-term follow-up. Early translation of acetabular components used in revision THA is a good predictor of later loosening, and radiostereometric analysis (RSA) is the most sensitive method to measure migration. The objectives of the present study were to use RSA to compare the migration of the porous tantalum acetabular components used to treat severe bone defects with the previously established acceptable proximal translation threshold of ≤1 mm within 2 years, and to determine the effect on migration of the addition of inferior screws through the component into the ischium or pubis. METHODS: RSA was utilized to measure the migration of 55 porous tantalum components used to treat severe acetabular defects (28 Paprosky IIIA, 27 Paprosky IIIB; 21 hips with pelvic discontinuity) at a mean follow-up of 4 years (range, 2 to 12 years). RESULTS: Forty-eight of the 55 components migrated less than the threshold that predicts later loosening (>1 mm) and 50 had not been re-revised at the time of the latest follow-up. Seven components, none of which had inferior screw fixation, exceeded the translation threshold. Of these, 6 were implanted to treat pelvic discontinuity. Of those 6 components, 5 were re-revised for loosening related to patient symptoms. At 2 years, the absolute median proximal translation of components with inferior screw fixation was |0.3| mm (range, |0.1| to |0.9| mm), compared with |0.4| mm (range, |0.03| to |16.4| mm) for those without inferior screws (p = 0.04). CONCLUSIONS: As measured with use of RSA, the majority of porous tantalum acetabular components used in a revision THA to treat severe acetabular defects had acceptable early migration. This predicts good long-term survivorship of these components. The use of inferior screws further improved acetabular component fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Implantable Micro-Caged Device for Direct Local Delivery of Agents.

Local and controlled delivery of therapeutic agents directly into focally afflicted tissues is the ideal for the treatment of diseases that require direct interventions. However, current options are obtrusive, difficult to implement, and limited in their scope of utilization; the optimal solution requires a method that may be optimized for available therapies and is designed for exact delivery. To address these needs, we propose the Biocage, a customizable implantable local drug delivery platform. The device is a needle-sized porous container capable of encasing therapeutic molecules and matrices of interest to be eluted into the region of interest over time. The Biocage was fabricated using the Nanoscribe Photonic Professional GT 3D laser lithography system, a two-photon polymerization (2PP) 3D printer capable of micron-level precision on a millimeter scale. We demonstrate the build consistency and features of the fabricated device; its ability to release molecules; and a method for its accurate, stable delivery in mouse brain tissue. The Biocage provides a powerful tool for customizable and precise delivery of therapeutic agents into target tissues.

Autologous Heat Shock Protein Peptide Vaccination for Newly Diagnosed Glioblastoma: Impact of Peripheral PD-L1 Expression on Response to Therapy.

Purpose: Standard therapy for newly diagnosed glioblastoma (GBM) is surgical resection, followed by concurrent radiotherapy and temozolomide chemotherapy. In this phase II clinical trial, the addition of an autologous heat-shock protein vaccine to standard therapy was evaluated. Tumor-induced immunosuppression, mediated by expression of PD-L1 on tumor and circulating immune cells, may impact the efficacy of vaccination. Expression of PD-L1 on peripheral myeloid cells was evaluated for the first time as a predictor of survival.Experimental Design: In this single arm, phase II study, adult patients with GBM underwent surgical resection followed by standard radiation and chemotherapy. Autologous vaccine (Prophage) was generated from resected tumors and delivered in weekly vaccinations after completion of radiotherapy. The primary endpoint was overall survival.Results: Forty-six patients received the vaccine with a median overall survival of 23.8 months [95% confidence interval (CI), 19.8-30.2]. Median overall survival for patients with high PD-L1 expression on myeloid cells was 18.0 months (95% CI, 10.0-23.3) as compared with 44.7 months (95% CI, incalculable) for patients with low PD-L1 expression (hazard ratio 3.3; 95% CI, 1.4-8.6; P = 0.007). A multivariate proportional hazards model revealed MGMT methylation, Karnofsky performance status, and PD-L1 expression as the primary independent predictors of survival.Conclusions: Vaccination with autologous tumor-derived heat shock proteins may improve survival for GBM patients when combined with standard therapy and warrants further study. Systemic immunosuppression mediated by peripheral myeloid expression of PD-L1 is a recently identified factor that may significantly impact vaccine efficacy. Clin Cancer Res; 23(14); 3575-84. ©2017 AACR.