To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients. A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively. After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL). The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes

Introduction: Soft tissue sarcomas (STS) are rare tumors. A multidisciplinary approach including surgery, chemotherapy and radiation therapy is recommended.

Materials and Methods: In the last 12 years, 249 patients with STS were teated in our Institution. All of them were treted with a multidisciplinary approach using all or some of the previous refered treatments.

Results: The overall local recurrence rate in the group of patients submited to surgery was 25% and this factor was related mostly with contaminated margins. Surgical resections were associted with soft tissue reconstructions when needed.

Radiation therapy was used in both regimens pre and post operativly, chemotherapy was also used in 85% of the patients, and was not dependent of tumor histotype.

23 patients were submited to surgery of lung metastasis.

Survival rates were determined and compared with stage (AJCC), tumor histotype and surgical margins.

Conclusions: Multidisciplinary approach is the recommended treatment for STS.

Aims

Clear cell sarcoma (CCS) of soft-tissue is a rare melanocytic subtype of mesenchymal malignancy. The aim of this study was to investigate the clinical and therapeutic factors associated with increased survival, stratified by clinical stage, in order to determine the optimal treatment.

Aims

Tenosynovial giant cell tumour (TGCT) is one of the most common soft-tissue tumours of the foot and ankle and can behave in a locally aggressive manner. Tumour control can be difficult, despite the various methods of treatment available. Since treatment guidelines are lacking, the aim of this study was to review the multidisciplinary management by presenting the largest series of TGCT of the foot and ankle to date from two specialized sarcoma centres.

Primary bone tumors are rare, complex and highly heterogeneous. Its diagnostic and treatment are a challenge for the multidisciplinary team. Developments on tumor biomarkers, immunohistochemistry, histology, molecular, bioinformatics, and genetics are fundamental for an early diagnosis and identification of prognostic factors. The personalized medicine allows an effective patient tailored treatment. The bone biopsy is essential for diagnosis. Treatment may include systemic therapy and local therapy. Frequently, a limb salvage surgery includes wide resection and reconstruction with endoprosthesis, biological or composites. The risk for local recurrence and distant metastases depends on the primary tumor and treatment response. Cancer patients are living longer and bone metastases are increasing. Bone is the third most frequently location for distant lesions. Bone metastases are associated to pain, pathological fractures, functional impairment, and neurological deficits. It impacts survival and patient quality of life. The treatment of metastatic disease is a challenge due to its complexity and heterogeneity, vascularization, reduced size and limited access. It requires a multidisciplinary treatment and depending on different factors it is palliative or curative-like treatment. For multiple bone metastases it is important to relief pain and increases function in order to provide the best quality of life and expect to prolong survival. Advances in nanotechnology, bioinformatics, and genomics, will increase biomarkers for early detection, prognosis, and targeted treatment effectiveness. We are taking the leap forward in precision medicine and personalized care

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: Bone Joint J 2020;102-B(5):556–567

Aim. Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years. Method. One-hundred sixty-seven patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 49 patients. Of these, seven presented with extensor apparatus deficiency. Results. One patient underwent primary arthrodesis and six patients underwent autologous reconstruction of the extensor apparatus. The principle to reconstruct missing tissue ‘like with like’ was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and three patients received a pedicled medial sural artery perforator gastrocnemius flap, of which one with Achilles tendon. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo knee arthrodesis because of recurrent infection and one patient was lost to follow-up. In parts, results have been published under doi: 10.7150/jbji.47018. Conclusions. A treatment concept and its rationale, based on a single-centre experience, is presented. It differentiates between various types of soft-tissue defects and shows reconstructive options following the concept to reconstruct ‘like with like’. Despite good results 1 year postoperatively, PJI of the knee with extensor apparatus deficiency remains a dreaded combination with a poor long-term outcome

Aims

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

Aim. Accurate and reliable patient information plays a crucial role in the multidisciplinary treatment of malignancies helping to ensure compliance of the patients and their relatives with often long-lasting and stressful treatment. The English version of the online encyclopaedia Wikipedia has been recently reported to be the prominent source of online health information. However, there is little information concerning the quality of information found in Wikipedia. Method. We therefore created a questionnaire concerning of 20 questions asking for scope, completeness and accuracy of information found on osteosarcoma. Three independent observers tested the English version of Wikipedia as well as the patient version and the health professional version of the website of the National Cancer Institute. Answers (scores 0-3) were verified with authoritative resources and international guidelines. Results. The professional version of the NCI scored best with 50 of 60 possible points (mean 2.5 ± 0.83 SD per question), compared to the patient version of the NCI with 40 points (mean 2 ± 1.38 SD) and to the Wikipedia site with 33 points (mean 1.65 ± 1.39 SD). Only the difference between the NCI professional version and Wikipedia was significant (p=0.039). Conclusion. Our study shows that the quality of osteosarcoma-related information found in English Wikipedia is good but inferior to the patient information provided by the National Cancer Institute. Especially in multidisciplinary treated tumours like osteosarcoma accurate and complete information found on Wikipedia might influence patients' compliance with treatment. Therefore national agencies for cancer research like the NCI and international organizations on cancer treatment should check and actualize this website on a regular basis

In bone infections, it is of fundamental importance to wrap any orthopaedic surgical procedure in healthy vascularised soft tissue, in order to allow good healing and to prevent infection recurrence. Vitality of soft tissues around the knee joint can be easily jeopardized in patients undergoing multiple surgical operations as in case of infected arthroprostheses. In addition, there are very few local options in the soft tissue reconstruction of this area, due to the fact that the vascularisation of skin and subcutaneous tissue is based on the genicular arteries’ axes which prohibits the use of random skin flaps. Preoperative planning of cutaneous incisions and reconstructive procedures is mandatory for a correct surgical treatment. We analyze retrospectively a series of 8 patients who underwent soft tissue reconstruction of the knee area with local flaps, considering criteria and indications in the choice of each surgical option. Main variables considered in decision-making were size and location of soft tissue defect, planned orthopaedic surgical procedure, likeliness of the need for further surgery, age, local and general condition of the patient. Flaps employed have been medial gastrocnemius muscular flap, reverse ALT fasciocutaneous flap and the “propeller” freestyle perforator flap. Main complications observed have been partial flap necroses and recurrence of the underlying bone infection. In this work, the authors want to emphasize the importance of a multidisciplinary treatment of bone and prosthetic infections, where the antimicrobial therapy chosen by the Infectious Diseases Specialist must be synergic with an “orthoplastic” surgical procedure, in the effort to reduce the risk of infection persistence or recurrence and to obtain the best possible functional result and quality of life for the patient

Introduction. Infection is disastrous in arthroplasty surgery and requires multidisciplinary treatment and debilitating revision surgery. Between 80-90% of bacterial wound contaminants originate from colony forming units (CFUs) present in operating room air, originating from bacteria shed by personnel present in the operating environment. Steps to reduce bacterial shedding should reduce wound contamination. These steps include the use of unidirectional laminar airflow systems and the introduction of theatre attire modelled on this principle (e.g. total body exhaust suits). Our unit introduced the use of the Stryker Sterishield Personal Protection System helmet used with laminar flow theatre systems. This study compares an enclosed helmet system used with standard gowns, with standard hood and mask attire. Method. 12 simulated hip arthroplasties were performed, six using disposable sterile impermeable gown, hood and mask and a further 6 using a Sterishield helmet and hood. Each 20 minute operation consisted of arm and head movements simulating movements during surgery. Air was sampled at wound level on a sterile draped operating table using a Casella slit sampler, sampling at 700l/minute. Samples were incubated on Blood agar for 48 hours at 37°c and the CFUs grown were counted. Results. Mean number of CFUs for the helmet was 9.33 with hood and mask attire having 49.16 CFUs (S. Ds 6.34 and 26.17; p value 0.0126). In all cases a coagulase negative staphylococcus was isolated. Conclusion. Although the sample size was small, we demonstrated a fivefold increase in the number of CFUs shed when using hood and mask attire compared to personal helmet and sterile hood. We conclude that the helmet system is superior to non-sterile hood and mask at reducing bacterial shedding by theatre personnel

Aims

The aim of this study was to assess the clinical and radiological outcomes of an antiprotrusio acetabular cage (APC) when used in the surgical treatment of periacetabular bone metastases.

Study design. Cross sectional. Objectives. In literature it has been suggested that a strong relationship exists between psychosocial factors and disability in patients with chronic low back pain (CLBP). However, most studies only focus on self reported disability. This study was performed to analyze the relationship between psychological factors and performance based and self-reported disability, as measured with and Functional Capacity Evaluation (FCE) and the Roland Morris Disability Questionnaire (RMDQ), in patients with CLBP. Methods. The study was performed in an outpatient rehabilitation setting. The study sample consisted of 92 patients with CLBP admitted for multidisciplinary treatment. Prior to treatment, all patients completed questionnaires to measure psychological factors (distress, depression, self efficacy, fear avoidance, pain cognitions and coping style) and self-reported disability, and performed a standardized set of tests in FCE. Relationships among the variables were measured by means of Pearson correlation coefficients. Results. Out of 28 relations analyzed, correlations were either non-significant or weak. Correlations between psychosocial factors and FCE were all non-significant, except for one. Results of subgroups will be presented. Conclusion. The suggested strong relationship between psychological factors and performance based and self-reported disability measures could not be confirmed in this study. This may implicate that the relationship between psychological factors and disability may not be as unambiguous as suggested for patients with CLBP

Background Context. In the assessment and treatment of patients with chronic low back pain (CLBP) the bio- psycho-social model is used world wide. Psychological distress has been reported to have a strong relationship with self reported disability. The relationship between psychosocial distress measured with the SCL-90-R and self reported disability measured with the RMDQ has not been investigated. Purpose. To analyze the relationship between psychosocial distress measured with the Symptom Checklist-90-Revised (SCL-90-R) and self reported disability measured with the Roland Morris Disability Questionnaire (RMDQ) in patients with CLBP. Study design/Setting. This cross sectional study was performed in an outpatient pain rehabilitation setting. Patient sample. The study sample consisted of 152 patients with CLBP. Outcome measures. Scores on SCL-90-R and the RMDQ. Methods. All patients admitted for multidisciplinary treatment completed the SCL-90-R and RMDQ prior to treatment. Pearson’s correlation coefficients between SCL-90-R (Global Severity Index and subscales) and RMDQ were calculated. Results. Correlation coefficients between SCL-90-R (Global Severity Index and subscales) and RMDQ ranged from 0.18 to 0.31 (p< 0.05). Conclusion. The relationship between psychosocial distress measured with the SCL-90-R and self reported disability measured with the RMDQ in CLBP patients is weak. For clinical practice it is important to unravel the components and their suggested relationships in the bio-psycho-social model. This research has demonstrated that these relationships cannot be confirmed with the combined use of the SCL-90-R and the RMDQ. Further research is needed to determine which combination of instruments is most suitable to use in clinical practice, and to confirm or refute the suggested impact of psychosocial distress on self reported disability

Introduction Knee injuries are a common presentation to Accident and Emergency departments. Often many injuries that are referred are minor as a result of the difficulty in initial assessment, and cause an unnecessary increase in workload in Orthopaedic clinics. The purpose of this study was to evaluate current practice at our Knee Injury Clinic and to implement changes to make the service more efficient and effective. It forms a completed audit cycle of current practice. Material and methods Part I: We assessed all referrals from our Accident & Emergency department in two separate 4 month periods to the Acute Knee Injury Clinic according to the following criteria (which need fulfilling for referral)-. Recent history of injury associated with one or more of the following:. Acute haemarthrosis. Clinical instability. Disproportionate pain. Locking. Referrals were assessed as fulfilling or not fulfilling the criteria, and also as to the ultimate diagnosed pathology. Part II: From the results of these two audits, a multidisciplinary treatment proforma was created and distributed to Accident and Emergency. This included physiotherapy as a primary treatment option. Referrals were then reassessed as in the previous audits for a 4-month period. Results and conclusions The Acute Knee Injury Pro-forma resulted in a 15% reduction in referrals not fulfilling the criteria (p=< 0.05). This equates to a reduced workload due to inappropriate referrals, while significant injuries such as Cruciate rupture are picked up due to the sensitivity of the criteria. There was a significant increase in patients referred directly from Accident and Emergency to the physiotherapy department, which means minor injuries receive physiotherapy earlier than if they initially came to clinic. The proforma was well received by the junior doctors in Accident and Emergency due to its simplicity. Overall the use of the proforma has improved the standard of care at our unit

Introduction: Synovial sarcoma ranks as the fourth most common sarcoma, but it is uncommon in the hand. Most Synovial Sarcomas arise in para-articular soft tissue such as tendon, tendon sheath and bursa adjacent to the large joints capsules. Arround 60–70% of these tumors involve lower extremity and they frequently affect knee, thigh and foot. The reported incidence for Synovial Sarcoma in hand is only 8.5%. Material and methods: We carried out a retrospective study of 6 hand and forearm sarcomas, of a series of 35 synovial sarcomas surgically treated in our center from 1991 to 1997, with a 6 years follow up (3y.–11y.). 3 patients were male and 3 female, with a mean age of 54 years at the moment of initial diagnosis. Histologically all of them were synovial sarcomas: 4 monophasic and 2 biphasic. The inmunochemistry showed that the neoplasic cells were positive for vimentin, epithelial membrane antigen and cytokeratin. 2 of them were localized in the palmar aspect of the hand (2 ulnar cases and 2 eminence tenar cases), an 2 cases were dorsal. 2 cases were misdiagnosed as benign lesions and treated with tumor excision at another center. Results: Primary treatment consisted of radical local excision of synovial sarcoma of the hand. 5 patients received adjuvant chemotherapy with CYVADIC and radiotherapy. 2 cases of recurrence received a second surgical treatment with forearm amputation. The mean time to recurrence was 12 months. At the end of the follow-up 3 patients developed metastatic disease and 2 of them died. Discussion: Synovial Sarcoma in hand is a highly malignant tumor; due to its morphology they can be misdiagnosed as benign lesions such as aggressive fibromatosis or ganglion cysts. If we diagnose a soft tissue tumor in hand we must practice complementary tests to achieve early diagnosis. It is also important the multidisciplinary treatment of Synovial Sarcoma

Aims

Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years.

Introduction Infection is a disastrous complication of arthroplasty surgery, requiring multidisciplinary treatment and debilitating revision surgery. As between 80–90% of bacterial wound contaminants originate from colony forming units (CFU’s) present in operating room air tending to originate from bacteria shed by personnel present within the operating environment, any steps that can reduce this bacterial shedding should reduce the chances of wound contamination. These steps have included the use of unidirectional downward laminar airflow theatre systems, and the introduction of theatre attire modelled on this principle (e.g. total body exhaust suits). Our unit has introduced the use of the Stryker T4 Personal Protection System helmet in conjunction with laminar flow theatre systems. This study compares an enclosed helmet system used with standard gowns, with standard hood & mask attire. Method 12 simulated hip arthroplasty operations were performed, six using disposable sterile impermeable gown, hood and mask, with a further 6 using the T4 helmet & hood. Each 20 minute operation consisted of a series of arm and head movements simulating movements performed during surgery. Air was sampled at wound level on a sterile draped operating table using a Casella slit sampler, sampling at 700l/minute. Samples were incubated on Blood agar for 48 hours at 37oc & the CFU’s grown were counted. Results The mean number of CFU’s for the helmet was 9.33 with hood and mask attire yielding 49.16 CFU’s (S.Ds 6.34 & 26.17; p value 0.0126). In all cases, the organism isolated was a coagulase negative staphylococcus. Conclusion Although the sample size was small, we demonstrated a fivefold increase in the number of CFU’s shed when using hood and mask attire compared to personal helmet and sterile hood. We conclude that the helmet system is superior to non-sterile hood & mask at reducing bacterial shedding by theatre personnel

Introduction Infection is a disastrous complication of arthroplasty surgery, requiring multidisciplinary treatment and debilitating revision surgery. As between 80–90% of bacterial wound contaminants originate from colony forming units (CFU’s) present in operating room air tending to originate from bacteria shed by personnel present within the operating environment, any steps that can reduce this bacterial shedding should reduce the chances of wound contamination. These steps have included the use of unidirectional downward laminar airflow theatre systems, and the introduction of theatre attire modelled on this principle (e.g. total body exhaust suits). Our unit has introduced the use of the Stryker Sterishield Personal Protection System helmet in conjunction with laminar flow theatre systems. This study compares an enclosed helmet system used with standard gowns, with standard hood & mask attire. Method 12 simulated hip arthroplasty operations were performed, six using disposable sterile impermeable gown, hood and mask, with a further 6 using a Sterishield helmet & hood. Each 20 minute operation consisted of a series of arm and head movements simulating movements performed during surgery. Air was sampled at wound level on a sterile draped operating table using a Casella slit sampler, sampling at 700l/minute. Samples were incubated on Blood agar for 48 hours at 37°c & the CFU’s grown were counted. Results The mean number of CFU’s for the helmet was 9.33 with hood and mask attire having 49.16 CFU’s (S.Ds 6.34 & 26.17; p value 0.0126). In all cases, the organism isolated was a coagulase negative staphylococcus. Conclusion Although the sample size was small, we demonstrated a fivefold increase in the number of CFU’s shed when using hood and mask attire compared to personal helmet and sterile hood. We conclude that the helmet system is superior to non-sterile hood & mask at reducing bacterial shedding by theatre personnel