Lower limb reconstruction (LLR) has a profound impact on patients, affecting multiple areas of their lives. Many patient-reported outcome measures (PROMs) are employed to assess these impacts; however, there are concerns that they do not adequately capture all outcomes important to patients, and may lack content validity in this context. This review explored whether PROMs used with adults requiring, undergoing, or after undergoing LLR exhibited content validity and adequately captured outcomes considered relevant and important to patients. A total of 37 PROMs were identified. Systematic searches were performed to retrieve content validity studies in the adult LLR population, and hand-searches used to find PROM development studies. Content validity assessments for each measure were performed following Consensus-based Standards for the selection of health measurement Instruments (COSMIN) guidelines. A mapping exercise compared all PROMs to a conceptual framework previously developed by the study team (‘the PROLLIT framework’) to explore whether each PROM covered important and relevant concepts.Aims
Methods
There are concerns that patient-reported outcome measures (PROMs) currently used for adults requiring, undergoing or after undergoing lower limb reconstruction (LLR) are not adequately capturing the range of experiences important to these patients. The ‘Patient-Reported Outcome Measure for Lower Limb Reconstruction’ (PROLLIT) study developed a conceptual framework of outcomes identified as important and relevant by adult LLR patients. This review explored whether existing PROMs address these outcomes, and exhibit content validity in this population. A range of key PROMs was selected (n=32). Systematic and hand-searches were employed to find studies assessing content validity of these PROMs in the adult LLR population, along with PROM content and development information. A systematic review of content validity of the measures was carried out following ‘COnsensus-based Standards for the selection of health Measurement Instruments’ (COSMIN) guidance, alongside conceptual mapping of the content of the PROMs against the PROLLIT conceptual framework.Introduction
Materials & Methods
Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy.Aims
Methods
Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon. SOFFT is a multicentre, pragmatic, two-arm parallel-group, non-inferiority, randomized controlled trial. Participants will be assigned 1:1 to receive either tension suture fixation or tension band wiring. 280 adult participants will be recruited. The primary outcome will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at four months post-randomization. Secondary outcome measures include DASH (at 12, 18, and 24 months), pain, Net Promotor Score (patient satisfaction), EuroQol five-dimension five-level score (EQ-5D-5L), radiological union, complications, elbow range of motion, and re-operations related to the injury or to remove metalwork. An economic evaluation will assess the cost-effectiveness of treatments.Aims
Methods
No clinical CT based classification system is currently in use for Lumbar Foraminal Stenosis. MRI scanners are not easily available, are expensive and may be contraindicated in an increasing number of patients. This study aims to propose and evaluate the reproducibility of a novel CT based classification for lumbar foraminal stenosis. The grading was developed as 4 grades. Normal foramen – Grade 0, Anteroposterior(AP)/Superoinferior (SI)(single plane) fat compression – Grade 1, Both AP/SI compression (two planes) – Grade 2 (both AP and SI) without distortion of nerve root, Grade 2 with distortion of nerve root – Grade 3. 800 lumbar foramen of a cohort of 100 random patients over the age of 60 who had undergone both CT and MRI scans were reviewed by two radiologists independently to assess agreement of the novel CT classification against the MRI based grading system of Lee et al. Interobserver(n=400) and intraobserver agreement(n=160) was also evaluated. Agreement analysis was performed using the Weighted Kappa statistic.Abstract
Purpose
Materials and Methods
Total hip arthroplasty (THA) candidates have received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid administration documentation and are now implementing opioid-sparing protocols (OSP) into THA integrated care pathways (ICP). Here we evaluate the effectiveness of a novel OSP in primary THA at out institution. Between January 2019 to April 2019, all patients undergoing primary THA were placed under a novel OSP (Table 1). Patient demographics, inpatient/surgical factors, and inpatient opiate administration events were collected. A historical 2:1 cohort was subsequently derived from patients undergoing THA between January 2018 to August 2018. Opiate administration events collected from our EDW were converted into Morphine Milligram Equivalences (MMEs) and transformed into average MME's per patient per 24-hour interval. Nursing documented visual analog scale (VAS) pain scores were also queried and averaged per patient per 12-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) Short Forms tool was utilized.Introduction
Methods
Neural axis anomalies in idiopathic scoliosis (AIS) are well documented, with prevalence of 7% in adolescents; 20% in early-onset and up to 40% in congenital, the case for pre-operative MRI of brainstem to sacrum is well made in these groups. SK is rarer than AIS and the prevalence of anomalies is not defined. The case for routine MRI scan is unclear. A recent report concluded that routine MRI was not indicated, although this was based on only 23 MRI scans in 85 patients. At our institution all patients are undergo whole spine MRI following a diagnosis of SK. We aimed to assess the incidence of significant neural anomalies in Scheuermann's Kyphosis. Using a keyword search for “Scheuermann”, we reviewed all SK patients' MRI reports over the past 6 years. 117 MRI scans were identified. 13 patients did not fulfil the radiological criteria for SK and thus 104 (73M: 31F) scans were reviewed. 14 (13%) of 104 scans showed unexpected Significant abnormal findings. There were 8 (8%) with neural axis anomalies: 4 syrinxes; 1 cord anomaly; 2 cerebellar descents and 1 cerebellar tumour. All these patients had normal neurological examination except one with examination consistent with a known diagnosis of Parkinson's. A further 6 patients had non-neural anomalies. The presence of neural axis anomalies may influence the management of a patient with SK. Neurological compromise during correction is higher in patients with neural axis anomalies and this risk can often be partially mitigated by a preceding neurosurgical procedure (such as foramen magnum decompression or shunt). Furthermore it is well described that these anomalies often occur in patients who demonstrate a normal neurological examination. This study confirms this. Given that MRI is widely available and considering the devastating life implications of neurological injury, we advise pre-operative MRI scan in all SK patents.
We describe the prevalence of spondylolisthesis in Scheuermann's Kyphosis (SK) from retrospective review of 104 SK patients over 6 years. All patients referred to our institution for symptomatic SK undergo MRI scan from hindbrain to sacrum. Our MRI database was reviewed for all SK patients. All scans with spondylolisthesis were re-analysed. 117 scans were identified, 13 patients did not fulfil the MRI criteria for SK and thus 104 (74M: 31F) scans of SK are reported. There were 5 spondylolisthesis (1 cervical and 4 lumbosacral). Of the 4 lumbosacral there were 2 Meyerding grade-1; 1 grade-2 and 1 grade-5 spondyloptosis). An overall rate of 5% for listhesis was therefore found. The prevalence of spondylolisthesis is around 3% in the general population based on a CT study of 510 patients (Belfi 2006) and Fredrickson's (1984 and 2003) prospective study of 500 children. We describe the prevalence in SK patients being higher at 5%. This may be related to the adaptive change of increased lumbar lordosis in SK, certainly it supports the previous description higher rates of spondylolysis in SK.
The K2M MESA Rail is a new implant with a unique beam-like design which provides increased rigidity compared with a standard circular rod of equivalent diameter potentially allowing greater control and maintenance of correction. The aim of this study was to review our early experience of this implant. We retrospectively reviewed the case notes and radiographs of all consecutive cases of spinal deformity correction in which at least one rail was used. All radiological measurements were made according to the Scoliosis Research Society definitions. Since June 2012 thirty-three cases of spinal deformity correction were performed using the K2M Rail system. One case was excluded as there were no pre-operative radiographs. Median age was 15 years; there were 23 females. There were 26 scoliosis cases of which two had associated Chiari malformation, three were neuromuscular, and the remainder were adolescent idiopathic cases. Six patients had kyphotic deformity secondary to Scheuermann's disease. Mean length of follow-up was 16 months. In the scoliosis cases the mean pre-operative Cobb angle of the major curve was 58.6° with a mean correction of 35.6°. The mean post-operative thoracic kyphosis was 21.1°. The median number of levels included in the correction was 13. Bilateral rails were used in four cases, the remainder had one rail on the concave side and a contralateral rod. No patients required an anterior release or staged surgery. All kyphosis cases had posterior apical corrective osteotomies. The mean pre-operative thoracic kyphosis was 75.5° with a mean correction of 31°. The median number of levels included in the correction was 11. Four patients had bilateral rails. No patients required anterior release. Complications: two patients had prominent hardware. One patient had a malpositioned screw causing nerve root irritation, which was removed. There were three superficial infections, which settled with antibiotics. There were no cases of implant breakage, screw pull-out, or loss of correction. The K2M MESA Rail is a powerful new implant design which helps to achieve and maintain satisfactory correction of complex spinal deformity, and is particularly strong at correcting kyphotic deformity. It also enables restoration of normal thoracic kyphosis, particularly in idiopathic thoracic curves, which tend to be lordosing. This may prevent thoracic flat back and potential long-term sequelae. Early results show that the system is as safe and effective as other posterior deformity correction implants on the market, however, it requires further prospective follow-up to ascertain its outcomes in the long-term.
To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS). In 2011, 6 males and 2 females had Magec rods, with an average age of 8.5 years (2.9–12.7 years), 7 patients had dual rods, and 1 had single. The main cause of EOS was idiopathic scoliosis (n=6), followed by Congenital (n=1), and Syndromic (n=1). Average follow up was 19.4 months (14–26 months). 4 of these patients had their previous Paediatric Isola growing rods exchanged to Magec, and 1 patient had an exchange from single to Dual Magec rods.Aim:
Methods:
To measure truncal parameters for patients treated with growing rod systems for early onset scoliosis (EOS). 44 patients underwent growth rod surgery for EOS between 1999 and 2013 (24 females and 20 males). 27 patients had idiopathic scoliosis, 13 congenital, 3 syndromic and 1 neuromuscular. 26 patients had Paediatric Isola, 8 had Paediatric Expedium, 4 had dual growth rods with domino's and 9 each had VEPTR and MAGEC rods systems. Medical records and radiographs were analysed. Cobb angle, T1-T12 and T1-S1 length, coronal and sagittal balance, apical vertical translation (AVT), space available for the lung (SAL) and shoulder balance were measured.Aim:
Methods:
Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation. The aim of our study was to review our long term results of arthroscopic treatment of osteochondral lesions of the talus. 65 patients underwent arthroscopic treatment of the OCL between 1993 and 2000. There were 46(71%) men and 19(29%) women. The mean age at surgery was 34.2 years. The right side was affected in 43 patients and the left side in 22 patients.Aim
Materials and methods
Comparison between Aprotinin and Tranexamic acid on blood conservation in scoliosis surgery. There is no difference in the control of blood loss between 2 drugs.Purpose
Null hypothesis
Retrospective review of fusion rates using Grafton DBM/allografts only in AIS. Medical records of 30 consecutive patients at an average age of 19(18-24)were reviewed. All patients had segmental fixation with dual rod and pedicle screw construct followed by decortication supplemented with matrix strips/allograft chips. Minimum follow up 1.5 years, average of 2 years (1.5-3). First follow up at 3 months postoperatively and than 6 months subsequently. All patients were evaluated using criteria described by Betz et al for “possible pseudoarthrosis” which included persistent back pain, defects in the fusion mass, loosening of pedicle screws, junctional kyphosis and curve progression of more than 10 degrees from initial standing postoperative PA views. There were no infections. Average time to clinically and radiographically evident fusion was 12 months (range 10-16). Radiographically visible unfused facet joints were encountered in 3 patients towards the end of the construct. One patient had extension of the construct to treat junctional kyphosis. Other two remained asymptomatic. None had Progression of deformity. One patient developed pars defect at level below construct and was treated with extension of fusion.Purpose
Methods
Retrospective review of growth sparing spinal instrumentation. Medical records of 30 children with spinal deformity treated were evaluated. There were 14 male and 16 female patients at an average age of 4.9 years (1-14) at the time of presentation. These included 18 idiopathic, 11 congenital and a 14 year old with delayed growth having GH treatment. All patients underwent dual growing rod construct using hook and pedicle screw instrumentation. Extensions were carried out at approximately 6 monthly intervals. Average follow up was 4.2 years (2-8.5) with an average of 7.3(3-15) extension/exchange procedures per patient. Average immediate postoperative Cobb angle was 29(15-55) from a preoperative Cobb of 68(55-100) and this was maintained to a final mean Cobb angle of 30(15-60). Average gain in T1-S1 length was 5.7(3.5-9.8) cm. Five patients had final fusion at an average age of 15.5 years. There were no infections following primary operation. Out of 249 procedures including extensions/exchange, there were 9(4.5%) episodes of deep infection in 7 patients requiring debridement. Four patients (13%) had revisions for rod breakage/screw loosening/hook pullout/junctional kyphosis and three(10%) had prominent implants.Purpose
Methods and results
Spinal cord injury following trauma is initially dealt with by acute hospitals. The early management including stabilization is usually performed by these centres. This is followed by onward referral to one of the Regional Spinal Injury Units. There is concern of both sides of the fence regarding mobilization following spinal cord injury. The acute hospitals want to avoid the problems of prolonged recumbency and the Regional Spinal Injury Units wish to avoid the problems of early aggressive mobilization. Therefore, we set out to discover if there was a standard approach to mobilising these patients following surgical stabilization, because of the oversubscribed resources of the spinal injury units and the wish to start mobilizing the injured as soon as possible. A comparative audit of the Regional Spinal Injury Units in the UK and North American Units. Regional Spinal Injury Units in United Kingdom and North America Clear Management Plan Mobilisation Schedule We had replies from all Regional Spinal Injury Units in the UK and from seven in North America. The Regional Spinal Injury Units all had differing approaches. Only a few were able to convey a clear management plan and mobilization schedule. Whereas the North American Units provided a ‘mobilize as able’ plan in all cases. The North American Units had a ‘mobilize as able’ policy, whereas the UK units had a mixed approach. A coherent collaboration between the spinal surgeons stabilizing these injuries and the spinal injury units providing rehabilitation would improve patient management.
To assess adverse events related to XLIF approach in lumbar degenerative disease. Recently novel minimally disruptive spine procedure eXtreme lateral Interbody Fusion i.e XLIF has been developed. It is 90 (off the midline true lateral approach, which allows large graft placement, excellent disc height restoration and indirect decompression at the stenotic motion segment. We describe our experience in 28 patients. Retrospective review of records of patients undergoing surgery between July 2008- Jan 2010. Presenting complaints, number of levels performed and complications (medical, approach, or implant related) were audited. Results: 28 patients (17 female: 11 male) with median age of 47 yrs, range (38-75) formed the study group. Average stay was 4 days. All patients had MRI of lumbar spine. 2/3 rd patients had low back pain as their presenting complaint. All patients had nerve monitoring through out the procedure. There were 12 single, 15 two level and 1 three level cases (total 45 levels). 14/28 patients underwent plating at the same time. EBL was 100ml. There were 11/45 adverse events (24.4%). 6 events were approach, 4 were implant bone interface and 1 medical related. Major complication occurred in 1 patient (3.6%). 2/3 rd of patients, were better after the surgery. Almost negligible blood loss, low infection rate and short average stay seemed to work in favour of this approach. Complications are there as (with any new procedure) our results indicate, but these are manageable and less common with this technique. This did not require Ethics approval and there was no grant or industry support for the above.
On review of the 550 other scans the average age was 51.9 years old. The incidence of SBO within this group is 10%. Only 6% of these patients were under 18. Out of these 33 patients 30.3% (10 patients) had SBO. Over 18 the incidence of SBO was only 8.5%.
In perfroming hip resurfacing arthroplasty, concern has been expressed as to the proximity of the femoral neurovascular bundle during the anterior capsulotomy and the risk of damage during this maneuver. We therefore aimed to identify the proximity of the femoral nerve, artery and vein during an anterior capsulotomy done during a hip resurfacing procedure using the posterior approach. A standard posterior approach was performed in 5 fresh frozen cadavic limbs. An anterior incision was then used to measure the distance of the femoral neurovascular structures to the anterior capsule. Measurements from the most posterior aspect of the vessels and nerves to the most anterior aspect of the anterior capsule were taken prior to hip dislocation. The femoral head was then dislocated, and measurements were made with the hip in both flexion and extension. In a separate group of eleven patients that underwent routine MR imaging of the hip, measurements were taken to assess the proximity of the anterior joint capsule to the femoral neurovascular bundle, by a specialist musculoskeletal radiologist who had no prior knowledge of the results obtained during the cadaveric dissection All 5 cadaveric limbs were utilised. 3 were male and 2 were female. The average age was 72.4 years (range 56–84). The patients whom underwent routine MR imaging incorporated 6 males and 5 females with a mean age of 43.7 years (age range 18–64 years). There was no significant difference between the mean distances to the nerve (p=0.21), artery (p=0.21) or vein (p=0.65) between the MR and cadaveric groups. Prior to dislocation the femoral artery and vein were closest to the anterior capsule (mean distance of 21mm) and the femoral nerve was the furthest away (mean distance 25mm). Following dislocation there was a significant increase (25mm to 31mm) in mean distance to the femoral nerve when the superior capsule was cut with the hip in a flexed position (p=0.01) and to the femoral artery in flexion (increase mean distance from 21mm to 35mm) (p<
0.0001) and in extension(increase mean distance from 21mm to 31mm) (p=0.005). When the inferior capsule was cut, there was a significant increase (25mm to 31mm) in mean distance to the femoral nerve and femoral artery when the hip was dislocated and the capsule cut with the hip in flexion (increase mean distance from 21mm to 27mm) (p=0.019) and in extension(increase mean distance from 21mm to 28mm) (p=0.015). This study suggests that the neurovascular structures are relatively well protected during an anterior capsulotomy performed during hip resurfacing. The procedure may be safer if the capsulotomy is performed with the hip dislocated and the hip in a flexed position while cutting the antero-superior aspect and in an extended position while cutting the antero-inferior aspect.
