Background. Foraminal stenosis is often encountered in patients undergoing decompression for spinal stenosis. Given the increased resection of facets and the presence of the more sensitive dorsal root ganglion, it is hypothesized that patients with foraminal stenosis have poorer postoperative outcomes. Methods. Thirty-one patients undergoing decompression without fusion for lumbar spinal stenosis were evaluated. The degree of foraminal stenosis was determined by 2 independent reviewers for absence of fat around the nerve roots. ImageJ digital imaging software was also used to evaluate the foraminal area. Patients with foraminal stenosis were compared with those without using the Oswestry Disability Index (ODI) and a numerical pain scale for back and leg pain at a minimum of 1 year follow-up. Results. Twenty patients in the foraminal stenosis group were compared with 11 without foraminal stenosis. There were no significant differences between the 2 groups regarding age, sex, comorbidities, number of levels operated on, preoperative ODI, back pain or leg pain scores. The foraminal area was significantly smaller in the foraminal stenosis group. Patients without foraminal stenosis reported significant improvements in ODI (mean 26.0), back pain (mean 3.1) and leg pain scores (mean 5.5). Patients with foraminal stenosis reported significant improvements in ODI (mean 18.8) and leg pain (mean 2.5) but not in back pain (mean 0.3). Comparing the 2 groups, the patients with foraminal stenosis had significantly less improvement in back pain (p = 0.02) and leg pain (p = 0.02). Conclusion. The results of this study suggest that presence of foraminal stenosis is a negative predictor for successful outcome following decompression surgery. This may be related to the increased instability that occurs when a foraminotomy is required. Spinal fusion may reduce this effect, and further study is required. NO DISCLOSURES

Low back pain is the single most common cause for disability in individuals aged 45 years or younger, it carries tremendous weight in socioeconomic considerations. Degenerative aging of the structural components of the spine can be associated with genetic aspects, lifetime of tissue exposure to mechanical stress & loads and environmental factors. Mechanical consequences of the disc degenerative include loss of disc height, segment instability and increase the load on facets joints. All these can lead to degenerative changes and osteophytes that can narrow the spinal canal. Surgery is indicated in patients with spinal stenosis who have intractable pain, altered quality of life, substantially diminished functional capacity, failed non-surgical treatment and are not candidates for non-surgical treatment. The aim was to determine the reasons for refusal of surgery in patients with established degenerative lumber spine pathology eligible for surgery. All patients meeting the study criteria, patients older than 18 years, patients with both clinical and radiological established symptomatic degenerative lumbar spine pathology and patients eligible for surgery but refusing it were recruited. Questionnaire used to investigate reasons why they are refusing surgery. Results 59 were recruited, fifty-one (86.4 %) females and eight (13.6 %) males. Twenty (33.8 %) were between the age of 51 and 60 years, followed by nineteen (32.2 %) between 61 and 70 years, and fourteen (23.7 %) between 71 and 80 years. 43 (72 %) patients had lumber spondylosis complicated by lumber spine stenosis, followed by nine (15.2 %) with lumbar spine spondylolisthesis and four (6.7 %) had adjacent level disease. 28 (47.4 %) were scared of surgery, fifteen (25.4 %) claimed that they are too old for surgery and nine (15.2 %) were not ready. Findings from this study outlined that patients lack information about the spinal surgery. Patients education about spine surgery is needed

Spinal stenosis is a condition resulting in the compression of the neural elements due to narrowing of the spinal canal. Anatomical factors including enlargement of the facet joints, thickening of the ligaments, and bulging or collapse of the intervertebral discs contribute to the compression. Decompression surgery alleviates spinal stenosis through a laminectomy involving the resection of bone and ligament. Spinal decompression surgery requires appropriate planning and variable strategies depending on the specific situation. Given the potential for neural complications, there exist significant barriers to residents and fellows obtaining adequate experience performing spinal decompression in the operating room. Virtual teaching tools exist for learning instrumentation which can enhance the quality of orthopaedic training, building competency and procedural understanding. However, virtual simulation tools are lacking for decompression surgery. The aim of this work was to develop an open-source 3D virtual simulator as a teaching tool to improve orthopaedic training in spinal decompression. A custom step-wise spinal decompression simulator workflow was built using 3D Slicer, an open-source software development platform for medical image visualization and processing. The procedural steps include multimodal patient-specific loading and fusion of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) data, bone threshold-based segmentation, soft tissue segmentation, surgical planning, and a laminectomy and spinal decompression simulation. Fusion of CT and MRI elements was achieved using Fiducial-Based Registration which aligned the scans based on manually placed points allowing for the identification of the relative position of soft and hard tissues. Soft tissue segmentation of the spinal cord, the cerebrospinal fluid, the cauda equina, and the ligamentum flavum was performed using Simple Region Growing Segmentation (with manual adjustment allowed) involving the selection of structures on T1 and/or T2-weighted scans. A high-fidelity 3D model of the bony and soft tissue anatomy was generated with the resulting surgical exposure defined by labeled vertebrae simulating the central surgical incision. Bone and soft tissue resecting tools were developed by customizing manual 3D segmentation tools. Simulating a laminectomy was enabled through bone and ligamentum flavum resection at the site of compression. Elimination of the stenosis enabled decompression of the neural elements simulated by interpolation of the undeformed anatomy above and below the site of compression using Fill Between Slices to reestablish pre-compression neural tissue anatomy. The completed workflow allows patient specific simulation of decompression procedures by staff surgeons, fellows and residents. Qualitatively, good visualization was achieved of merged soft tissue and bony anatomy. Procedural accuracy, the design of resecting tools, and modeling of the impact of bone and ligament removal was found to adequately encompass important challenges in decompression surgery. This software development project has resulted in a well-characterized freely accessible tool for simulating spinal decompression surgery. Future work will integrate and evaluate the simulator within existing orthopaedic resident competency-based curriculum and fellowship training instruction. Best practices for effectively teaching decompression in tight areas of spinal stenosis using virtual simulation will also be investigated in future work

Introduction. In degenerative lumbar spine, it seems possible that foraminal stenosis is over-diagnosed as axial scanning is not performed in the plane of the exiting nerve root. We carried out a two-part study to determine the true incidence of foraminal stenosis. Patients and Methods. Initially we performed a retrospective analysis of radiology reports of conventional Magnetic Resonance Imaging in 100 cases of definite spinal stenosis to determine the incidence of reported ‘foraminal stenosis’. Subsiquently we performed a prospective study of MRI including fine slice T2 and T2 STIR coronal sequences in 100 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional axial and sagittal sequences with the coronal scans. Results. The retrospective analysis found that ‘foraminal stenosis’ was reported by radiologists in 46% using conventional axial and sagittal sequences. In the prospective study of 100 patients suspected of having stenosis, spinal stenosis was reported in 40; degenerative spondylolisthesis in 14; posterolateral disc herniation in 14; normal report in 13; far lateral disc herniation in 7; isthmic (lytic) spondylolisthesis in 6; and degenerative scoliosis in 6. Conventional sequences diagnosed lateral recess stenosis reliably, but also suggested foraminal stenosis in 43%. However, coronal sequences clearly showed no foraminal nerve compression at all. In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 10 of 14 cases. Coronal imaging again showed no foraminal stenosis. Excellent correlation was found in normal spines and in disc herniation. Foraminal nerve compression was confirmed by conventional and coronal imaging only in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation. Conclusion. The addition of coronal MRI proves that foraminal stenosis is over-diagnosed. True foraminal stenosis definitely exists in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation, but we question its existence in spinal stenosis and degenerative spondylolisthesis

Abstract. Purpose. 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. Materials and Methods. 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. Results. 100 patients (M:F = 45:55) with a mean age of 68.5 years (range 60 – 83 years were included in the study. The duration between CT and MRI scans was 98 days(range 0 – 540, SD – 108). There was good correlation between CT and MRI with Kappa scores (k=0.81) and intraobserver Kappa of 0.89 and 0.98 for the two readers. Conclusion. The novel CT based classification correlates well with the MRI grading system and can safely and accurately replace it where required

Introduction. Cardiac events have been found to occur with increased frequency in total joint arthroplasty (TJA) patients >65 y/o without known coronary artery disease (CAD). Avoidance of readmissions for cardiac events is paramount with bundled payment programs. It has been thought that many of these patients may have undiagnosed CAD because of sedentary life styles brought on by chronic osteoarthritis. The purpose of this study is to assess with Coronary Computed Tomographic Angiography (CCTA) the prevalence and severity of CAD in patients >65 y/o for elective TJA. Methods. 126 elective patients that were part of a total hip and knee bundled payment program were referred for cardiac evaluation with CCTA if they were >65 but <70 y/o with a history of heart disease or 2 risk factors or were >70 y/o. CCTA was acquired on all patients unless they had a history of a severe allergic reaction to contrast, GFR <50 ml/min., the presence of atrial fibrillation, or declined the test. All images were evaluated by an experienced reader. Arterial narrowing of 70% diameter or greater was classified as significant CAD. Intermediate lesions <70% were reclassified as significant if CT-FFR (Functional flow reserve) was < or = 0.80. Results. Excluding the 12 patients with known CAD who had stents or coronary artery bypass graft (CABG), the remaining 114 patients were classified into three groups. 34/114 (29.8%) had no CAD (Group A). 75/114 (65.8%) had (Group B). 5/114 (4.4%) had > or = 70% stenosis. Group C included one patient who had <70% stenosis but had CT-FFR <80%. Of 17 patients with known CAD with >70% or heart CT-FFR <80%, or prior stents/CABG, one patient was predicted to be high risk of a cardiac event because of a complex plaque with an ulcer, history of suppressed paroxysmal atrial fibrillation, and withdrawal from apixaban. He was nurse navigated throughout his hospital course and post discharge only to be recalled to the hospital to be rescued with cardiac stenting. Conclusion. Patients >65 y/o having TJA without a cardiac history were found to have a 4.4% prevalence of significant CAD. When added to the patients with known CAD, the overall prevalence was 13.5%. One patient had complex plaque predictive of a cardiac event. As the US population ages and TJA becomes more prevalent with greater pressure to reduce costs by bundling and shifting to outpatient surgery, further data needs to be collected to better understand CAD in TJA patients >65 y/o

Introduction. We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm. Materials and methods. A retrospective study of 19 patients who presented with dual pathology was performed and the patients were assessed with regards to pre and post-operative symptoms, walking distance, and neurological status. Results. There were 17 patients with improvement in the spinal stenotic symptoms following hip replacement to an extent that none required spinal surgery. There were two patients who had spinal surgery after THR, at varying lengths following hip replacements as their spinal stenotic symptoms worsened over time, and had lateral spinal stenosis on MRI. Discussion. In advanced hip osteoarthritis, a fixed flexion deformity may develop at the hip leading to an exaggerated lumbar lordosis in erect posture. In the presence of co-existing spinal stenosis, the exaggerated lumbar lordosis may worsen the spinal stenotic symptoms while standing and walking. Cadaveric & Radiological studies have shown that canal narrowing occurs with increased lordosis/ extension in the lumbar spine. Our findings suggest that when central lumbar spinal stenosis coexists with bilateral hip arthritis and FFD at the hip, THR should be offered first. Successful hip surgery for arthritis correcting significant fixed flexion deformity would lessen the lumbar lordosis, thus correcting the excessive pathological narrowing. If a patient is fit enough, simultaneous bilateral THR via an anterior type of approach makes surgical correction of FFD easier. Although it has been suggested in the literature that patients with spinal stenosis have a increased risk of neurological impairment following THR, we did not find any clear association

Nerve palsy occurring after elective primary total hip arthroplasty (THA) is a devastating complication because of its effect on motor strength, walking ability, potential for pain, and unexpected nature. In general, the nerve distribution involved is the peroneal branch of the sciatic nerve, and the level of involvement is usually mixed motor and sensory. Prior publications have associated limb lengthening, dysplasia and use of the posterior approach to be associated with a higher incidence of nerve palsy. In the literature, the incidence of sciatic nerve palsy is estimated to be 0.2 to 1.9%. We examined the rate of sciatic nerve palsy after THA performed by the joint replacement service at Hospital for Special Surgery between the years 1998–2013. Each case was matched with 2 controls that underwent THA and did not develop postoperative neuropathy. Controls were matched by surgical date having been within 7 days of their matched case's surgery date. Patient and surgical variables were reviewed using data from patient charts and the institution's total joint replacement registry. A multivariable logistic regression model was created to identify potential risk factors for neuropathy following THA while adjusting for potential confounders. We found that, of 39,056 primary THA cases, there were 81 cases of sciatic nerve palsy, giving an incidence of 0.21%. The factors with the greatest odds ratios for nerve palsy were: history of smoking (OR=3.45); history of spinal stenosis (OR=4.45), and time of day of 1PM or later (OR=3.98). We did not find limb lengthening, dysplasia, or type of fixation to be associated with nerve palsy. In conclusion, post-surgical neuropathy has a low incidence after primary THA, but at our institution, was associated with several factors. Spine-related comorbidities, such as spinal stenosis and lumbar spine disease, and smoking history should be closely monitored to inform the patient and surgeon for the potential increased risk of postoperative neuropathy following THA

Obesity is an increasing public health concern associated with increased perioperative complications and expense in lumbar spine fusions. While open and mini-open fusions such as transforaminal lumbar interbody fusion (TLIF) and minimally invasive TLIF (MIS-TLIF) are more challenging in obese patients, new MIS procedures like oblique lateral lumbar interbody fusion (OLLIF) may improve perioperative outcomes in obese patients relative to TLIF and MIS-TLIF. The purpose of this study is to determine the effects of obesity on perioperative outcomes in OLLIF, MIS-TLIF, and TLIF. This is a retrospective cohort study. We included patients who underwent OLLIF, MIS-TLIF, or TLIF on three or fewer spinal levels at a single Minnesota hospital after conservative therapy had failed. Indications included in this study were degenerative disc disease, spondylolisthesis, spondylosis, herniation, stenosis, and scoliosis. We measured demographic information, body mass index (BMI), surgery time, blood loss, and hospital stay. We performed summary statistics to compare perioperative outcomes in MIS-TLIF, OLLIF, and TLIF. We performed multivariate regression to determine the effects of BMI on perioperative outcomes controlling for demographics and number of levels on which surgeries were operated. OLLIF significantly reduces surgery time, blood loss, and hospital stay compared to MIS-TLIF, and TLIF for all levels. MIS-TLIF and TLIF do not differ significantly except for a slight reduction in hospital stay for two-level procedures. On multivariate analysis, a one-point increase in BMI increased surgery time by 0.56 ± 0.47 minutes (p = 0.24) in the OLLIF group, by 2.8 ± 1.43 minutes (p = 0.06) in the MIS-TLIF group, and by 1.7 ± 0.43 minutes (p < 0.001) in the TLIF group. BMI has positive effects on blood loss for TLIF (p < 0.001) but not for OLLIF (p = 0.68) or MIS-TLIF (p = 0.67). BMI does not have significant effects on length of hospital stay for any procedure. Obesity is associated with increased surgery time and blood loss in TLIF and with increased surgery time in MIS-TLIF. Increased surgery time may be associated with increased perioperative complications and cost. In OLLIF, BMI does not affect perioperative outcomes. Therefore, OLLIF may reduce the disparity in outcomes and cost between obese and non-obese patients

Nerve palsy occurring after elective primary total hip arthroplasty is a devastating complication because of its effect on motor strength, walking ability, potential for pain, and unexpected nature. In general, the nerve distribution involved is the peroneal branch of the sciatic nerve, and the level of involvement is usually mixed motor and sensory. Prior publications have associated limb lengthening, dysplasia and use of the posterior approach to be associated with a higher incidence of nerve palsy. In the literature, the incidence of sciatic nerve palsy is estimated to be 0.2–1.9%. We examined the rate of sciatic nerve palsy after THA performed by the joint replacement service at Hospital for Special Surgery between the years 1998 and 2013. Each case was matched with 2 controls that underwent THA and did not develop post-operative neuropathy. Controls were matched by surgical date having been within 7 days of their matched case's surgery date. Patient and surgical variables were reviewed using data from patient charts and the institution's total joint replacement registry. A multivariable logistic regression model was created to identify potential risk factors for neuropathy following THA while adjusting for potential confounders. We found that, of 39,056 primary THA cases, there were 81 cases of sciatic nerve palsy, giving an incidence of 0.21%. The factors with the greatest odds ratios for nerve palsy were: history of smoking (OR=3.45); history of spinal stenosis (OR=4.45), and time of day of 1PM or later (OR=3.98). We did not find limb lengthening, dysplasia, or type of fixation to be associated with nerve palsy. In conclusion, post-surgical neuropathy has a low incidence after primary THA, but at our institution, was associated with several factors. Spine-related comorbidities, such as spinal stenosis and lumbar spine disease, and smoking history should be closely monitored to inform the patient and surgeon for the potential increased risk of post-operative neuropathy following THA

Purpose of study. This RCT is to determine whether or not there is a clinical benefit from inserting a dynamic stabilising implant such as the Wallis ligament on the functional recovery of patients who have undergone lumbar decompression surgery. This Interspinous implant was developed as an anatomically conserving procedure without recourse to lumbar spinal fusion surgery. The biomechanical studies have shown that unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels. The aim of this study was to identify a patential Wallis affect. Methods. Ethicallly approved. Patients were randomized into 2 groups, decompression alone or decompression with wallis interspinous ligament stabilisation. Patients were assessed pre operatively and post operatively every 6 months by VAS pain score and Oswestry Disability Index. Summary of findings. A total of 60 patients were recriuted the study from October 2005. Equal number had been randomized into two groups. The mean age of 54 (24–85) and the average follow is 36 months (6–48). The results were significantly better in decompression plus Wallis group compared to decompression alone, showing a minimal clinical difference compared to the control group. Relationship between findings and existing knowledge: Our results deomonstrate that clincial outcomes are significantly better when a Wallis implant was used in lumbar deompression. Patients experienced less back pain. Overall significance of findings: The Wallis implant represents a successful non fusion stabilisation device in the treatment of degenerative lumbar spine disease with canal stenosis. Minimal soft tissue dissection, quick rehabilitation, low morbidity. The Wallis ligament sucessfully treats spinal stenosis by reducing pain score, preserving mobility, and function

Study Design. A prospective cohort study was carried out looking at the functional outcome and post-procedure translational segmental instability after multi-level lumbar decompression using a Hinge osteotomy technique. Objective. The Hinge osteotomy technique involves unilateral subperiosteal muscle dissection with osteotomy of the base of the spinous processes thereby preserving the integrity of the posterior elements. The objective of this study was to demonstrate the results of this technique clinically and radiologically. Methods. Between February 2005 and February 2007, 120 patients (51 male and 69 female) diagnosed with degenerative and/or congenital lumbar stenosis with a mean age of 64 years, underwent central and bilateral canal decompression using the hinge osteotomy technique. A mean of 2 segments (range 2-4) was decompressed. All patients were followed up for a minimum of three years. Five outcome measures were used: visual analogue scale for leg pain, Likert scale for functional status, symptom specific well-being score, general well-being score, and ODI score. The outcome measures were recorded pre-operatively and at 6 months and 3 years post-operatively. Successful surgical outcome was defined as an improvement in at least four out of five outcome measures. Results. 108 patients (90%) had a successful surgical outcome. There was a statistically significant improvement in all outcome criteria (p< 0.001) when measured at the 6-month post-operative mark as compared to pre-operatively, with further marginal significant improvement (p< 0.05) at 3 years post-surgery. There was no evidence of progressive lumbar segmental instability at 3 years post-operatively. Conclusion. Decompression of multi-level lumbar spine stenosis using the unilateral approach with the Hinge osteotomy technique is a safe approach for multi-level stenosis, with good outcome and no evidence of significant segmental translational spinal instability

Aim. To evaluate morbidity and outcome associated with lumbar spine decompression for central spinal stenosis in the elderly compared with younger age groups. Patients & methods. Case notes review of patients with symptomatic and MRI proven central lumber canal stenosis, under the care of a single surgeon. The study population was 3 age groups: patients < 60 year of age (Group 1, n=21), patients between 60 and 79 years (Group 2, n=54), and > age of 80 years (Group 3, n=15). Data with regard to intra- and post-operative complications and subjective outcome variables were collected. These included pain (VAS), walking distance, Oswestry Disability score (ODI) and patient satisfaction scores. Results. There was a statistically significant improvement in VAS score for leg pain (p<0.05) and back pain (p<0.05) after surgery for each group. All three groups reported improvement in their walking distance. The average walking distance improved by factor 5 in groups 1 and 2 and by factor 2.5 in group 3 (p< 0.05). However the improvement in group 3 was not statistically significant. There was a statistically significant improvement in ODI for all three groups (mean ODI improvement in Group 1, 16 points, Group 2, 23 points and Group 3, 15 points). Overall 96% of patients were satisfied and would consider the same treatment again under similar circumstances. The overall complication was 19% in group 1, 18% in group 2, and 33% in group 3. Conclusions. Surgery for neurogenic claudication in the octogenarian is associated with a higher complication rate. The outcomes however in this patient group are comparable to younger patients. Lumbar decompression surgery in octogenarians is a worthwhile procedure

Objectives. Neurogenic intermittent claudication secondary to lumbar spinal stenosis is a posture dependant complaint typically affecting patients aged 50 years or older. Various treatment options exist for the management of this potentially debilitating condition. Non-surgical treatments: activity modification, exercise, NSAIDs, epidural injections. Surgical treatment options include decompression surgery and interspinous process device surgery. Interspinous process decompression is a relatively new, minimally invasive, stand-alone alternative to conservative and standard surgical decompressive treatments. The aim of this review is to evaluate the use of the X-Stop interspinous implant in all patients with spinal stenosis who were managed using the device in Northern Ireland up to June 2009. Method. We performed a retrospective review of all patients who had the X-Stop device inserted for spinal stenosis by all consultant spinal surgeons in Northern Ireland. Patient demographics, clinical symptomatology, investigative modality, post-operative quality of life, cost effectiveness, complications and long-term outcomes were assessed. Information was collected from patients using a questionnaire which was posted to them, containing the SF-36 generic questionnaire and some additional questions. Results. A total of 23 patients underwent X-stop insertion in Northern Ireland at the time of this review, 19 patients returned their questionnaires and of these 17 were completed in full and therefore included. The mean age of the study population was 60.1 years and all patients included in the study had symptoms of neurogenic claudication secondary to lumbar spinal stenosis confirmed on MRI scan. The average hospital stay was 1.5 days compared to 7.5 days for decompressive laminectomy patients. Also, at a mean follow-up of 17.8 months, 2 patients suffered direct complications of device insertion requiring removal of the implant both of these patients agreed that they would undergo the operation again in the future. SF-36 scores indicate a quality of life improvement which equates to that of other popular orthopaedic operations such as total hip and total knee replacement. X-stop insertion has been shown to be much more cost-effective than decompressive laminectomy in previous studies. Conclusion. Decompression of the lumbar spine with the X-stop interspinous implant device is safe, cost-effective, minimally invasive, and at least as effective at improving symptomatology from lumbar spinal stenosis. It is obviously more invasive than non-surgical techniques, but is less invasive than lumbar decompression procedures, is less destructive to surrounding tissues and if it fails to produce the desired results can be removed easily and the option remains for the patient to under decompression

Aim. Spinal implant-associated infections (SIAI) require combined surgical and antimicrobial treatment and prolonged hospital stay. We evaluated the clinical, laboratory, microbiological and radiological characteristics and treatment approaches in patients with SIAI. Method. Consecutive adult patients with SIAI treated between 2015 and 2017 were prosepctively included. SIAI was defined by: (i) significant microbial growth from intraoperative tissue or sonication fluid, (ii) intraoperative purulence, secondary wound dehiscence or implant on view, (iii) radiographic evidence of infection and fever (>38°C) without other recognized cause, increasing back pain or neurologic impairment, (iv) peri-implant tissue inflammation in histopathology. Results. A total of 60 patients were included, median age was 66 years (range, 28–91 years), 29 (48%) were males. The most common reason for spinal stabilization was spinal canal stenosis in 20 patients (33%) followed by vertebral degenerative disease in 14 (23%). 31 patients (52%) had one or more previous spine surgeries (range, 1–4 interventions). The anatomic site of spinal instrumentation was lumbar/sacral in 26 (43%), cervical in 23 patients (38%), thoracic in 11 (18%). The median number of fused segments was 5 (range, 1–14). Clinical manifestations included wound healing disturbance in 41 patients (68%), increasing back pain in 15 (25%), neurologic impairment in 12 patients (20%) and fever in 14 (23%). Serum CRP was abnormal (>10mg/l) in 46/59 patients (78%). Most (n=54) infections were postsurgical, 5 were hematogenous and 1 was contiguous. Imaging showed epidural, intraspinal or paravertebral abscess in 21/42 patients (50%), implant failure in 9 (21%) and implant loosening in 3 cases (7%). Monomicrobial infection was observed in 41 (68%), polymicrobial in 16 (27%) patients and culture-negative infection in 3 episodes (5%). Predominant causative pathogens were S. aureus (n=19), coagulase-negative staphylococci (n=18) and gram-negative rods (n=16). Surgery was performed in all patients including debridement and implant retention in 39 patients (65%), partial implant exchange in 10 (17%) and complete exchange in 11 (18%). Antimicrobial treatment included biofilm-active substances in 52 patients (87%). The median duration of antimicrobial therapy was 11,7 weeks (range, 6–12 weeks). 14 patients (23%) recieved suppressive therapy for a median duration of 9 months (range 3–12 months). Conclusions. Most SIAI were seen in lumbar/sacral segments and wound healing disturbance and increasing back pain were the most common manifestations. In 95% the causative pathogen was isolated, predominantly staphylococci. In half of the episodes, abscesses were present. All patients underwent surgery and biofilm-active antibiotics were administered in 87%

Developmental dysplasia of the hip (DDH) represents a heterogeneous group of deformities that are commonly associated with secondary osteoarthritis. Affected hips may require total hip arthroplasty (THA) for endstage disease and these cases can present unique challenges for the reconstructive surgeon. While the severity of deformity varies greatly, optimizing THA can be challenging even in the “mildly” dysplastic hip. These disorders are commonly characterised by acetabular deficiency with inadequate coverage of the anterolateral femoral head and proximal femoral abnormalities including excessive femoral antetorsion, coxa valga and femoral stenosis. In more severe cases, major femoral head subluxation or dislocation can add additional complexity to the procedure. In addition to the primary deformities of DDH, secondary deformities from previous acetabular or proximal femoral osteotomies may also impact the primary THA. Primary THA in the DDH hip can be optimised by detailed understanding of the bony anatomy, careful pre-operative planning, and an appropriate spectrum of techniques and implants for the given case. This presentation will review the abnormal hip morphologies encountered in the dysplastic hip and will focus on the more challenging aspects of THA. These include acetabular reconstruction of the severely deficient socket and in the setting of total dislocation, femoral implant procedures combined with corrective osteotomy or shortening, and issues related to arthroplasty in the setting of previous pelvic osteotomy. Despite the complexity of reconstruction for various dysplastic variants the clinical outcomes and survivorship of these procedures are good to excellent for most patients. Nevertheless, more complex procedures are associated with an increased complication rate and this should be considered in the surgical decision-making process

We all aware about overuse syndrome, as compensation of other parts of body. Our famous poet Sa'adi: when part of our body sustains become painful, the other parts can't tolerate and reciprocate. Among our patients who underwent total Knee arthroplasty few of them have pain especially in 1st 3 months (Anterior Knee pain, effusion, ….) but almost 15 – 20 percents are not satisfied enough by this Procedure. In a Cohort historic study on 301 TKA with at least 2 years follow up 47 patients had not enough satisfaction in our clinic we tried to visit them to find out why?. Criteria's we chose, were:. Age. Osteopenia. Sarcopenia. Low back pain. Spinal canal stenosis. Shoulders. Unstable blood pressure. Neuropathy. Eyes dysfunction. We exclude those who had problem by their new knees. 11 patients, all have been over age 68 years, and duration of start of symptoms in knee (s) to the surgery were more than 12 years, clearly showed painful arch of shoulder motion or frozen shoulder or established gleno humeral alone or G.H. and A.C. joints OA. Conclusion. Because of abnormal stand up of long lasting knee OA patients, they start to put pressure on their shoulder to climb on their body. Even their cane or crutches use are not in regular and academic rules. So, we nominate this entity: shoulder knee syndrome as a negative criteria that interferes in out come

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

Introduction. Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and lower extremity weakness. Although previous studies have evaluated the potential benefit of THA on back pain, none have reported the effects of spine disability on functional outcomes and patient satisfaction with THA. Methods. 244 primary THAs (233 patients) with minimum 2-year follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Results. 151 of 244 (62%) patients reported a history of back problems: 35 patients (14%) – history of lumbar surgery, 91 (37%) – daily low back pain, and 97 (40%) – back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without, p=0.0001. Pain relief was reported by 93% versus resumption of activities in 82% of THA patients, p=0.025. Increasing spine disability, as determined by ODI, correlated with poor OHS, p<0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief (R=0.41, p<0.0001), return to activity (R=0.34, p<0.0001), and overall surgical results (ODI, R=0.38, p<0.0001) at 2 years after THA. Patient age, gender, and BMI were not associated with poor THA outcomes. Conclusions. The majority of THA patients have a history of lumbar spine problems. The Oswestry Spine Disability Index, which is the primary outcome measure of spinal disorders, correlated strongly with poor THA outcomes. Moderate and severe lumbar spine disability directly correlated with worse Oxford Hip Scores. Spine disability was directly associated with THA dissatisfaction

Silicon nitride spinal fusion cages have been successfully used in the treatment or correction of stenosis, disc herniation, trauma, and other deformities of the spinal column since 2008. To date over 14,000 devices have been implanted with perioperative and postoperative complication rates of less than 0.2%. This remarkable achievement is due in part to the material itself. Silicon nitride is an ideal interbody material, possessing high strength and fracture toughness, inherent phase stability, biocompatibility, hydrophilicity, excellent radiographic imaging, and bacterial resistance. These characteristics can lead to implants that aid in prevention of nosocomial infections and achieve rapid osteointegration. In this paper, we will review the various in vitro and in vivo studies that demonstrate silicon nitride's effective bacteriostatic and osteointegration characteristics, and compare these to the two most common cage materials – titanium and poly-ether-ether-ketone (PEEK). Human case studies will be also reviewed to contrast the clinical performance of these biomaterials. In comparison to the traditional devices, silicon nitride shows lower infection rates, higher bone apposition, and essentially no fibrous tissue growth on or around the implant. To better understand the mechanisms underlying these benefits, surface characterization studies using scanning electron microscopy coupled with XPS chemical analyses, sessile water drop techniques and streaming zeta potential measurements will be reported. Data from these studies will be discussed in relation to the physiochemical reasons for the observed behavior. Silicon nitride is a non-oxide ceramic in its bulk; but possesses a protective Si-N-O transitional layer at its surface. It will be shown that the chemistry and morphology of this layer can be modified in composition, thickness and structure resulting in marked changes in chemical species, surface charge, isoelectric points and wetting behavior. It is postulated that the needle-like grain structure of silicon nitride coupled with its enhanced wettability play important roles in inhibiting biofilm formation, while its surface chemical environment consisting of silicon diimide Si(NH). 2. , silicic acid Si(OH). 4. , and derivatives of ammonia, NH. 3. , NH. 4. OH, lead to improved bone reformation and bacteriostasis, respectively. Few materials have this combination of properties, making silicon nitride a unique biomaterial that provides improved patient care and outcomes with low comorbidities