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Background Postoperative analgesia after knee arthroplasty forms a basis for an optimal range of motion after surgery. Femoral nerve blocks are established as a sensory nerve blockade but at the expense of quadriceps weakness delaying postoperative mobilization. The adductor canal block (ACB) similarly provides sensory blockade but preserves quadriceps function. If ACB is performed intraoperatively, it would reduce the time and cost needed for ACBs. This study aimed at investigating possible landmarks making it feasible to perform ACB intraoperatively. Material and methods Twenty-seven knees were used. The superior pole of the patella, medial epicondyle, and adductor tubercle was proposed as landmarks to perform the ACB through a medial parapatellar approach. A needle was directed toward the adductor tubercle until a tactile feedback was felt. Ten to 15 mL India ink were injected using this technique. The adductor canal was dissected to visualize the ink spread and determine whether the saphenous nerve and the nerve to vastus medialis were exposed to the ink. Results The anatomic landmarks were easily identified in all knees. The ACB resulted in the saphenous nerve and nerve to vastus medialis being bathed in ink consistently. A volumetric relationship was noted with the injectate. No injury to the neurovascular structures was observed. Conclusions An accurate and safe technique with reliable anatomic landmarks was presented to perform an ACB. In addition, an increase in injected ink volume correlated to an increase in the spread of ink; thus, we postulate that 10 mL of local anesthetic may be sufficient for an adequate regional block.

Highlight risk factors for pseudarthrosis in long-segment spinal fusions, collect the approaches carried to address this complication. Patients with ASD and fusion of ≥ 4 levels with minimum follow-up (FU) of ≥ 2 years were included. Full-body X-rays were done preoperatively

A normal sagittal vertical axis (SVA) after spinal deformity correction can yield mechanical complications of up to 30%. Post-operative compensatory pelvic orientation can produce a normal SVA. We assess relative pelvic version (RPV), an individualised measure, for persistent post-operative compensatory measures.Adult spinal deformity (ASD) patients who were treated operatively, with a normal SVA ( ± 50 mm) at 6-week follow-up were included, who were then followed-up after 2 years. These only included patients with fusion of 4 vertebrae extending to L5 or below. Six-week subgroups were made regarding pelvis orientation, relative pelvic version (RPV: anteversion, aligned, moderate or severe retroversion) with analysis of patient-related outcome measures (PROMs), complications and spino-pelvic sagittal parameters.At 6 weeks, 140 patients met the inclusion criteria, 5 (3.6%) patients had anteversion, 59 (42.1%) were aligned, 60 (42.9%) had moderate retroversion and 16 (11.4%) patients had severe retroversion. Follow-up after 2 years demonstrated increased RPV in all groups except the severe RPV group who were more likely to develop SVA 50 mm. Complications occurred in all groups. Significant 2-year differences were observed between moderate and severe RPV for back pain and PROMs but not between other RPV groups.Adult spinal deformity patients with a normal SVA after spino-pelvic instrumentation carry a significant risk of retroversion progression post-operatively, followed by increased positive sagittal balance. Relative pelvic version (RPV) measurements when categorised into anteversion, aligned, moderate retroversion and severe retroversion at 6 weeks were predictive of PROMs at 2 years.

Purpose To evaluate the pain and functional effect of the COVID-19 pandemic on patients with ASD reflected by their response to SRS-22, ODI, and SF-36 questionnaires. Methods Patients who had stable pain and functional outcome scores over the preceding 2 years were enrolled in a local prospectively collected adult spinal deformity (ASD) database. A reanalysis of their SRS22, ODI and SF-36 data 14 days into confinement were compared to their last pre-confinement scores. Results 89 patients were included in this study (average age 60.7 years, 91% female) with an average time from last FU until confinement of 9.6 months. The ODI total score worsened by 5 points post-confinement with no difference seen in personal care, walking and social life. In contrast, the SRS-22 score showed small improvements in function/activity and satisfaction, but no significant differences for the other domains. Similarly, the SF-36 showed small improvements in physical function, physical and emotional role, vitality and PCS. Conclusion The global COVID-19 pandemic and ensuing confinement had variable overall effects on ASD patients, without the expected marked worsening. In addition, this study illustrates that the SRS-22 questionnaire is less influenced by environmental and psychological factors than the ODI supporting its objectivity and accuracy in the evaluation of the QoL of ASD patients.

Purpose: To review the literature on the value of basivertebral nerve abla-tion in the treatment of chronic low back pain. Materials and Method: A systematic review and meta-analysis of the English literature to March 2020 was undertaken. The inclusion criteria were patients with discogenic back pain of more than 3 months duration with modic type 1 or 2 change and suc-cessful disc block or discogram. Primary outcomes were VAS pain, ODI, EQ-5D and SF36 improvement. Secondary outcomes were complications. Results: 6 studies were included, all funded by the same company, but oth-erwise of low bias. All studies showed significant improvement in all scores over the first 3 months with evidence these would be maintained over the longer term. There was one reported compression fracture, but otherwise no significant adverse events. Conclusion: This study supports the conclusion that radiofrequency ablation of the basivertebral nerve is a safe and effective treatment for discogenic chronic low back pain.

Introduction The primary purpose of this review was to evaluate patient and physician preference and satisfaction for teleconsultation in orthopaedic surgery compared to traditional face-to-face consultation. In addition, we evaluated the effects of teleconsultation on patient length of visit, healthcare costs, range of motion (ROM), pain, quality of life (QOL), and ongoing management plans. Methods A systematic review of MEDLINE, Embase, Web of Science, and Cochrane Library was conducted according to PRISMA guidelines. Randomised control trials and case control studies comparing teleconsultation with traditional, face-to-face consultation in the management of orthopaedic conditions were included. The primary outcome measures were patient and physician preference and satisfaction. Secondary outcomes included patient length of visit, healthcare costs, ROM, pain, QOL, and ongoing management plans. Results A total of 13 articles meeting the eligibility criteria were included for systematic review and 8 for meta-analysis. There was no significant difference in patient satisfaction, length of visit, or time spent with the physician between the telemedicine and in-office control group. The mean difference of patient preference for telemedicine was significantly higher in the telemedicine group compared to the in-office visit group (OR 1.44, 95% CI 1.12–1.87, p = 0.005). Discussion Telemedicine was not inferior to face-to-face office visits in regard to patient and physician preference and satisfaction. Therefore, it would be an effective adjunct to face-to-face office visits, serving as a mechanism of triage and long-term continuity of care.

Objective To report the outcomes of halo femoral traction (HFT) used for 1 week between anterior release and definitive posterior fusion in adolescents with severe rigid scoliosis. Methods A retrospective single-center review of 22 consecutive patients (mean age at surgery, 14.1 years; range, 10.5–18.2 years; 17 girls) with severe, rigid scoliosis treated with anterior release, followed by HFT for 7 days prior to posterior instrumented fusion. Cobb angles were measured preoperatively, 1 week after anterior release and traction, after posterior fusion, and at a minimum 2-year follow-up. Complications were recorded. Results Mean preoperative Cobb angle was 97° (range, 80°–118°), correcting to 52° with anterior release and HFT and 31° after posterior fusion. This equated to a 68% deformity correction and was maintained at final follow-up. Three traction-related complications were experienced, including 1 case of neck pain and 2 cases of brachial plexopathy that resolved with traction weight reduction. Conclusions Three-staged deformity correction using HFT for 1 week only offers gradual correction of the spine over sufficient time to optimize deformity correction yet minimizes neurologic dysfunction.

Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons. Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined. Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier. Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.

Objective To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis. Methods This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded. Results Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9 patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up. Conclusions Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

Aims There is inconsistent evidence on whether prior spinal fusion surgery adversely impacts outcomes following total hip arthroplasty (THA). We conducted a systematic review and meta-analysis to assess the association between pre-existing spinal fusion surgery and the rate of complications following primary THA. Methods We searched MEDLINE, Embase, Web of Science, and Cochrane Library up to October 2019 for randomized controlled trials (RCTs) and observational studies comparing outcomes of dislocation, revision, or reasons for revision in patients following primary THA with or without pre-existing spinal fusion surgery. Furthermore, we compared short (two or less levels) or long (three or more levels) spinal fusions to no fusion. Summary measures of association were relative risks (RRs) (with 95% confidence intervals (CIs)). Results We identified ten articles corresponding to nine unique observational studies comprising of 1,992,366 primary THAs. No RCTs were identified. There were 32,945 cases of spinal fusion and 1,752,362 non-cases. Comparing prior spinal fusion versus no spinal fusion in primary THA, RRs (95% CI) for dislocation was 2.23 (1.81 to 2.74; seven studies), revision 2.14 (1.63 to 2.83; five studies), periprosthetic joint infection 1.71 (1.53 to 1.92; four studies), periprosthetic fracture 1.52 (1.28 to 1.81; three studies), aseptic loosening 1.76 (1.54 to 2.01; three studies), and any complications 2.82 (1.37 to 5.80; three studies) were identified. Both short and long spinal fusions, when compared with no fusion, were associated dislocation, revision, or reasons for revision. Conclusions Patients with prior spinal fusion are at risk of adverse events following primary THA. Measures that reduce the risk of these complications should be considered in this high-risk population when undergoing primary THA. These patients should also be counselled appropriately around their risks of undergoing THA. Cite this article: Bone Joint J 2020;102-B(6):664–670.

BACKGROUND Sacrectomy carries significant risk of bleeding; however, specific risk factors, apart from medical comorbidities and tumor type, for this life-threatening complication remain unclear. This study describes two cases of massive bleeding, including one death during sacrectomy attributable to adherence of the internal iliac vein (IIV) and its neuroforaminal tributaries from sacral insufficiency fractures. OBSERVATIONS The authors presented two cases involving patients who received sacrectomy for a chordoma and experienced massive bleeding from the IIV due to adherence of the IIV and its neuroforaminal tributaries around sacral insufficiency fractures. They assessed their institution’s previous two decades’ experience of sacrectomies to determine risk factors for massive bleeding and performed anatomical dissection of 20 hemipelvises, which revealed the close proximity of the IIV to the sacral foraminae and the consistency of neuroforaminal tributaries arising from the foraminae. LESSONS Sacral insufficiency fractures may cause scarring that adheres to the IIV and its neuroforaminal tributaries, which risks massive bleeding during sacrectomy.

Objective: To compare the radiological and functional outcomes and complications of adult spinal deformity patients who underwent a pedicle subtraction osteotomy (PSO) below L2 but categorized according to their construct where either 2-rod or multiple-rod construct is applied.Methods: Sixty-seven patients met the inclusion criteria, and were categorized into 3 groups: 2 rods (2R), multiple rods around the PSO (MRP), multiple rods around the PSO and lumbosacral junction (MRL). Demographic data, operative parameters, spinopelvic parameters, functional outcomes, and complications were collected.Results: Health-related quality of life scores showed a better outcome at 6 months and last follow-up visits in the MRP and MRL groups which were noted on different domains of Scoliosis Research Society-22 questionnaire, 36-item Short Form Health Surve, and Oswestry Disability Index scores (p < 0.05). The 3 groups showed similar rates of rod-related complications with no significant difference (p = 0.95). And inside each group, distribution of complications between pseudarthrosis with revision and rod fracture without revision was also similar (p = 0.99).Conclusion: The use of multiple rods across the PSO did not show a better outcome when compared to single rods in terms of incidence and types of mechanical complications. However, better postoperative coronal alignment and health-related quality of life scores in the multiple rods group could be seen demonstrating an improved functional outcome.

Background The global adoption of teleconsultation has been expedited as a result of the COVID-19 pandemic. By allowing remote communication, teleconsultation may help limit the spread of the virus while maintaining the crucial patient-provider relationship. Objective The aim of this study is to evaluate the value of teleconsultation compared to in-person visits in the management of elective orthopedic and spinal procedures. Methods This was a prospective observational cohort study of 853 patients receiving orthopedic and spinal care at a private outpatient clinic in New Zealand. Patients were randomly divided into two groups: (1) patients receiving telephone consultation remotely, and (2) patients receiving in-person office consultations at the outpatient clinic. All patients received telephone consultations for 4 weeks during the mandated COVID-19 lockdown, followed by 4 weeks of telephone or in-person consultation. Patient preference, satisfaction, and duration of visit were recorded. Comparisons of patient preference between groups, visit type, sex, and location were performed using chi-square tests; similarly, satisfaction scores and visit durations were compared using a general linear model. Results We report that 91% (353/388) of patients in the telephone group preferred teleconsultation over in-person office visits during the COVID-19 lockdown (P Conclusions Patients who use telephone consultations are more likely to prefer it over traditional, in-person visits in the future. This increased preference, coupled with higher patient satisfaction scores and shorter duration of visits, suggests that teleconsultation has a role in orthopedic surgery, which may even extend beyond the COVID-19 pandemic.

BACKGROUND Periprosthetic fractures are becoming increasingly common, often leading to poor patient outcomes. The aim of this study was to identify risk factors associated with periprosthetic femoral fractures (PPFFx). METHODS Two independent reviewers conducted a systematic review of the databases MEDLINE, Embase and Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the earliest available date to December 2017. We included all clinical articles reporting more than 100 post-operative PPFFx around total hip arthroplasty (THA). Outcomes included demographics, fracture type, risk factors and time to fracture. RESULTS A total of 12 868 PPFFx were reported across 18 eligible studies; 64% occurred following primary THA and 36% occurred after revision THA, and 66% of all fractures were in females. Vancouver B2 fractures were the most common type (39%). We found the odds of sustaining a PPFFx is significantly lower after a primary THA compared to revision THA (odds ratio 0.31, 95% confidence interval 0.24-0.40, P

Wound closure after wide, local excision of an appendicular soft‐tissue sarcoma (STS) can be challenging. This study evaluates the value of magnetic resonance imaging (MRI)‐based tumour parameters in planning wound closure. A total of 71 patients with a primary limb‐based STS, excluding vascular or osseous involvement, excluding the shoulder or hand and hip or foot were included. Axial MRI images were used to measure the circumferences and cross‐sectional areas of the limb, bone, and tumour. The tumour diameter, length, and depth at the level of maximal tumour dimension were measured to identify the tumour's relative contribution to the planning of optimal wound closure management through primary closure (PC) or reconstructive surgery (RS). Eighteen patients required planned wound RS. Wound complications occurred in 14% overall. Tumours, which were closed by PC, were of significantly greater depth, shorter radial diameter, and shorter tumour circumference relative to those closed by RS. On multivariate analysis, tumour depth was the greatest contributory factor in predicting type of wound closure. A quantitative analysis of MRI‐based tumour parameters demonstrates tumour depth as the most predictive factor in planning for the type of wound closure and may prove beneficial in providing greater insight into planned wound management of sarcoma resection.

Aim To review the published literature on the treatment of aneurysmal bone cysts (ABCs). Method A systematic review of the English literature to April 2019 for all articles, with a minimum of three patients and 2-year follow-up, reporting on the treatment of spinal ABCs. The various treatment options were compared for the rates of recurrence, complications and mortality. Results Twenty-one articles and 272 patients (mean age 16.9 years, range 3-67) were included in this review. The overall recurrence rate for ABCs following all treatments is 12.8%. This is highest in those lesions described as being treated with isolated surgiflo injection into the lesion (100%), decompression/laminectomy (42.3%), partial excision/resection (35.7%) and curettage alone (25.0%). Radiotherapy alone or in conjunction with operative intervention offers excellent cure rates. Adjuncts to operative intervention, including cryotherapy or phenol reduce the recurrence rates, whereas embolization does not. The most common complications are persistent neurological deficits, spinal deformity, and continued pain. The overall mortality rates are low (1.5%). The reoperation rates are higher in surgical than non-surgical treatments and most are performed for progressive deformity. Discussion ABCs are highly radiosensitive. However, with the unknown longer-term risk of radiotherapy, surgical treatments, ideally with complete resection, and the use of adjunctive therapies such as cryotherapy or phenol, offer the best chance of cure. SAE is a useful adjunct to reduce intraoperative bleeding, but this study suggests that it only modestly improves recurrence rates. Newer techniques including bisphosphonate and doxycycline administration offer potential benefits, but their efficacy requires further investigation.

To assess pain, health-related quality of life (HRQOL) scores and sagittal parameters of adult spinal deformity (ASD)-operated patients in the context of their analgesic consumption especially opioids (narcotics) over the first year postoperative period. In total, 372 patients from a multicenter database were stratified into 3 groups at baseline: 241 patients in the minimal group (no analgesic, or NSAIDs/narcotics weekly or less), 64 in the NSAIDs every day group and 67 in the narcotics every day group. HRQOL and back and leg pain scores were evaluated at 6 months and 1 year postoperatively. Also several sagittal alignment parameters were assessed. Significant improvements in pain and HRQOL scores were observed across all 3 groups by 1 year (P

Anastomotic leakage following colorectal surgery remains a frequent complication. We report a rare case of a fatal epidural abscess caused by a colo-epidural fistula complicating a laparoscopic proctectomy.A 62 year-old-man presented with weight loss, pelvic sepsis and neurological dysfunction four months after closing of the ileostomy following a laparoscopic proctectomy for a rectal adenocarcinoma one year ago. Cross-sectional imaging confirmed an epidural abscess caused by a chronic colorectal anastomotic leak. Systemic antibiotics and laparotomy with defunctioning pelvic loop colostomy were performed. Unfortunately, this management to control the major spinal infection failed. Epidural decompression and debridement was not possible due to his poor condition and the patient subsequently died.Colo-epidural fistula can occur as a consequence of colorectal anastomotic leakage. Prior to frank neurology symptoms and sepsis, patients may present with only a low-grade fever. Without prompt and aggressive management of colo-epidural infection, this severe complication can lead to paraplegia and death.

BACKGROUND: Mid-term clinical and radiological evaluation of a carbon-fiber cage in multilevel cervical spondylosis (MCS). Anterior cervical corpectomy and fusion (ACCF) using titanium mesh cages (TMC) has shown satisfactory outcomes, but with subsidence of up to 20%. Conventional long-fiber carbon fiber cages have shown a safe profile in discectomy/fusion (ACDF) but with minimal data in the setting of corpectomy. METHODS: Retrospective review of a single centre multi-surgeon cohort of MCS patients from 2007–2012. Follow-up period was a minimum of 3.5 years, mean 6 years. Outcomes included peri-operative, clinical [Nurick, European Myelopathy, Visual Analogue Scores (VAS), modified Japanese Orthopaedic Association (mJOA) scores and radiographic (C2C7, Cobb & ROM angles)]. RESULTS: A total of 102 consecutive patients were included. Mean length of stay was 5.5 (SD 3.5) days, blood loss 322 (SD 358) mL and operative time 98 (SD 31) min. Corpectomy levels included 72 single-level ACCF and 30 multiple ACCF. Fourteen had peri-operative complications. Three patients required early cage revisions. Mean pain scores improved from VAS neck 4.6 to 2.6 (P3 mm across the instrumented level were present in 5 patients, all of which displayed fusion of either grade 1 or 2. 7 had C2C7 kyphosis. Severe subsidence (>3 mm) was seen in 9 cases (13%). CONCLUSIONS: Mid-term outcomes of this carbon-fiber cage indicate that it is safe and durable for the treatment of MCS with a similar radiological profile to that of TMC.

Study Design Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. Objective To Validate Schwab's classification accuracy for surgical indication, and to evaluate a simplified sagittal modifier. Summary of Background Data The SRS-Schwab Radiologic Classification based on clinical impact parameters, offers 27 different sagittal classification possibilities regarding sagittal vertical alignment (SVA), pelvic tilt (PT), and pelvic incidence–lumbar lordosis (PI-LL). The high number of classification possibilities makes it complex to use. Methods Inclusion criteria were ASD patients, presenting at least 1 criteria: Cobb ≥ 20°, SVA ≥ 5 cm, thoracic kyphosis ≥ 60°, or PT ≥ 25°. A total of 1,004 patients (410 nonoperative and 594 operative) were classified regarding SVA, PT, and PI-LL (0, +, ++), and 27 possibilities were identified. Categories were formed by adding the number of + signs, considering PT, SVA, and PI-LL. Three specific categories were identified: Aligned: 0 +; Moderate deformity: 1 to 3+; and Severe deformity: 4 to 6+. A χ-square test was performed for surgical indication (operated or not) and an analysis of variance was performed to evaluate the relationship between categories and Oswestry Disability Index (ODI). Probability Results Significant differences for HRQoL scores and surgical indication were found in the 27 sagittal parameter possibilities. For nonoperative patients, 230 (56.1%) were classified as aligned, 145 (35.4%) as moderate, and 35 (8.5%) as severe. For operative patients, there were 200 (33.7%), 215 (36.2%), and 179 (30.1%) in each respective subgroup. For HRQoL scores and surgical indication, no significant differences were found within each category, but significant differences were found when comparing the subgroups. Conclusions Despite the correlation between SRS-Schwab classification and surgical indication, it is complex to use, with a total of 27 possibilities regarding sagittal modifiers. This simplification into three categories offers more readability, without losing any significant information, and could replace Schwab sagittal modifiers. In association with other parameters, they could be used for decision-making. Level of Evidence Level II.

To understand the typical presentation, risk factors, location and size, treatment, neurological recovery and survival of spontaneous spinal epidural haematomas (SSEH) in children. A systematic review of the English literature from 1 January 1960 to 1 March 2018 was performed on children aged 18 years and younger. Individual patient data were extracted and collated. Outcome measures were mode of presentation, risk factors, initial neurological findings, initial presumed diagnosis, diagnostic investigations, site and size of the SSEH, treatment, neurological recovery and survival. Thirty-one publications and 36 patients were reviewed. All age groups were affected. 83% of patients did not have a known risk factor. Back pain was reported in 61% and neurological dysfunction in 97% of patients, although not all articles defined these parameters. Initially 28% of patients were suspected of having an alternative diagnosis. All patients had an MRI and/or CT scan confirming the diagnosis. The cervical-thoracic region was most commonly affected, and the average haematoma size extended across 6.3 vertebral levels. Surgical decompression was performed in 72% of patients. Neurological function improved in 83% of patients. Two patients died as a consequence of their SSEH. SSEHs affect all paediatric age groups and typically present with neurological dysfunction and/or back pain. The initial diagnosis is incorrect in up to 28% of cases, but cross-sectional spinal imaging is diagnostic. Most SSEHs are located in the cervico-thoracic region and affect multiple spinal levels. The treatment depends on whether the patient has a bleeding disorder and their neurological status. These slides can be retrieved under Electronic Supplementary Material.

To describe the origin of the vessels supplying the anterior sub-axial cervical vertebrae (C3–C7) to further understand their potential influence on anterior bone loss after anterior cervical spinal surgery. Cadaveric dissection was performed on ten adult human necks after latex perfusion of their subclavian, common carotid and vertebral arteries. The nutrient vessels of the sub-axial cervical spine were identified and traced to their origin. The course and distribution of these vessels and their nutrient foraminae are described. In all cases the anterior nutrient vessels were derived from the thyro-cervical trunk with branches that passed over the longus coli muscles forming a leash of vessels in the pre-vertebral fascia which subsequently extended in a frond-like pattern to pass onto the anterior aspect of vertebrae. The more cranial the cervical level the fewer the number of nutrient vessels and foraminae. The distribution of the foraminae on the anterior vertebral body followed the oblique supero-medial course of the nutrient vessels. Nutrient vessels perforate the cervical vertebrae on their anterior surface. These are derived from a leash of vessels that lie within the pre-vertebral fascia overlying the longus coli muscles. The origin of these vessels is the ascending cervical artery with a variable contribution from the transverse cervical artery.

Structural failure of the spine adjacent to the level of a previous spinal fusion is commonly observed. It may be defined by the radiologic degree of adjacent deformity, often termed junctional level kyphosis, proximal junctional kyphosis or junctional level failure, or the symptomatic failure of the spine above the level of an operation, termed adjacent segment disease (ASD). ASD can be further specified according to its anatomical location of failure, which provides insight into the specific pathological cause of failure and the optimal subsequent management. This chapter describes the anatomical and pathological classification of ASD in order to help clinicians understand the cause of failure and thereby reduce its rate and offer a treatment algorithm if it occurs.

The prevalence of adult spinal deformity (ASD) is increasing worldwide, driven by changing patient demographics, as well as an increased capacity to diagnose and treat this condition. ASD carries the worst healthcare burden of all chronic conditions including arthritis, chronic lung disease, congestive heart failure, diabetes and ischaemic heart disease. Recent advances in diagnostic and treatment modalities have resulted in an increase in surgical intervention for this condition. To be successful, however, a comprehensive understanding of the functional deficits caused by ASD must be recognised by those clinicians managing such patients. This chapter provides an overview of the functional deficits caused by ASD and its treatment.

BACKGROUND Periprosthetic femoral fractures around total hip arthroplasty (THA) are increasing annually, and are a major cause for revision surgery in the New Zealand Joint Registry (NZJR). The aim of this study was to determine the timing and risk factors for periprosthetic femoral fractures in THA requiring revision surgery in the NZJR. METHODS All patients with a primary THA who sustained a periprosthetic femoral fracture requiring revision THA recorded in the NZJR were reviewed to determine age, gender, body mass index, American Society of Anesthesiologists (ASA) rating and femoral stem fixation (cemented or uncemented). Revision rates were calculated per 100 component years (cy), and risk factors determined in the first 90 days, and beyond. RESULTS Between 1999 and 2017, there were 713 revision THA for periprosthetic femoral fractures. Early revision THA was significantly associated with ASA score and body mass index ≥40. There was no gender difference (P = 0.274). The revision rate in uncemented femoral stems (1.12/100 cy) was significantly higher (p

Purpose: The global adoption of teleconsultation has been expedited as a result of the COVID-19 pandemic. By allowing remote communication, teleconsultation may help limit the spread of the virus while maintaining the crucial patient-provider relationship. The purpose of this study is to evaluate the value of teleconsultation compared to in-person visits in the management of elective orthopaedic and spinal procedures.Methods: This was a prospective observational cohort study of 853 patients receiving orthopaedic and spinal care at a private outpatient clinic in New Zealand. Patients were randomly divided into two groups: (1) patients receiving telephone consultation remotely; and (2) patients receiving in-person office consultations at the outpatient clinic. All patients received telephone consultations for four weeks during the mandated COVID-19 lockdown, followed by four weeks of telephone or in-person consultation. Patient preference, satisfaction, and duration of visit were recorded. Comparisons of patient preference between groups, visit type, sex, and location were performed using Chi-square tests; similarly, satisfaction scores and visit durations were compared using a general linear model. Results: We report that 91% of patients in the telephone group preferred teleconsultation over in-person office visits during the COVID-19 lockdown (p=0.000). A combined-group analysis shows that 55.3% of all patients preferred teleconsultation compared to 31.2% who preferred in-person office visits (p=0.000). Patients in the telephone group reported significantly higher satisfaction scores (9.95 +/- 0.04, 95% CI [9.87-10.03]) compared to patients in the in-person group (9.53 +/- 0.04, 95% CI [9.45-9.62]; p=0.000). Additionally, in-person consultations were significantly longer in duration compared to telephone consultations, with a mean visit time of 6.70 min +/-0.18, 95% CI [6.32-7.02] compared to 5.10 min +/-0.17, 95% CI [4.73-5.42], respectively (p=0.000).Conclusion: Patients who utilize telephone consultations are more likely to prefer it over traditional, in-person visits in the future. This increased preference, coupled with higher patient satisfaction scores and shorter duration of visits, suggests that teleconsultation has a role in orthopaedic surgery, which may even extend beyond the COVID-19 pandemic.

Background The aim of this study was to compare the relative performance of total hip replacement constructs and discern if there is substantial variability in performance in currently commonly used prostheses in the New Zealand Joint Registry (NZJR) using a noninferiority analysis. Methods All patients who underwent a primary total hip replacement (THR) registered in the NZJR between 1st January 1999 to June 2020 were identified. Using a noninferiority analysis, the performance of hip prostheses were compared with the best performing contemporary construct. Construct failure was estimated using the 1-Kaplan Meier survival function method to estimate net failure. The difference in failure between the contemporary benchmark and other constructs was examined. Results In total 135,432 THR were recorded comprising 1035 different THR constructs. Notably 328 constructs were used just once. Forty-eight constructs (62,251 THR) had > 500 procedures at risk at 3 years post-primary of which 28 were inferior by at least 20% relative risk of which, 10 were inferior by at least 100% relative risk. Sixteen constructs were identified with > 500 procedures at risk at 10 years with 9 inferior by at least 20%, of which one was inferior by > 100% relative risk. There were fewer constructs noninferior to the best practice benchmark when we performed analysis by gender. In females at 10 years, from 5 constructs with > 500 constructs at risk, 2 were inferior at the 20% margin. In males at 10 years, there were only 2 eligible constructs of which one was inferior at the 20% margin. Conclusions We discerned that there is substantial variability in construct performance and at most time points, just over half of constructs are inferior to the best performing construct by at least 20%. These results can facilitate informed decision-making when considering THR surgery.

Objectives in scoliosis corrective surgery include restoration of normal sagittal and coronal parameters to achieve patient satisfaction. HRQLs improvements remain limited after corrective surgery. The aim of this study was to evaluate the HRQL subclass variability specific to the sagittal and coronal correction in adult scoliosis surgery. This multi-centre prospective analysis of consecutive adult spinal deformity (ASD) patients, from five European centres, only included multilevel instrumentation for scoliosis. d-(delta) values for each parameter represented pre to post-operative changes. Parameters included demographics, baseline, 1- and 2-year. HRQL outcomes (Oswestry disability index (ODI), Scoliosis Research Society (SRS)-22 and Short Form (SF36)), sagittal correction including relative spinopelvic alignment (dRSA) and coronal correction including major Cobb (dCobb) angles. A total of 353 patients reached 1-year and 2-year follow up. All HRQL total scores significantly improved postoperatively, including ODI, SRS-22 and SF36. HRQL subclasses which displayed persistent improvements correlated to dRSA included sex-life, self-image, fatigue, vitality, social functioning. The only HRQL subclass improvement that correlated with dCobb was self-image. Adult scoliosis surgery improves overall HRQL, having a minimal effect on each variable. Importantly, greater coronal deformity correction affects only greater self-image scores, whereas with greater sagittal correction there are many greater HRQL sub-class impacts. Correction and restoration of coronal balance is one of the surgical goals in adult scoliosis but the degree to which Cobb angle is corrected, apart from self-image, does not correlate with gains in sub-classes of HRQL. These results need to be taken into account when planning surgery.

BackgroundTo assess the feasibility, safety and efficacy of a percutaneous doughnut vertebroplasty of circumferential aggressive vertebral hemangiomas (VHs).MethodsWe retrospectively reviewed our prospectively collected database of patients with VHs treated with vertebroplasty between January 2009 and January 2018. Patient demographics, clinical presentations and procedural details were recorded. All patients underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI). All vertebroplasties were performed under conscious sedation in the prone position, predominantly using biplane fluoroscopic guidance. A clinical and imaging evaluation (early CT scan and MRI) as well as a final follow-up clinical assessment was performed.ResultsTwenty-two patients with aggressive VHs who underwent circumferential vertebroplasty with cementation of the entire vertebral body and at least one posterior hemi-arch were included (six males, mean age 53 years). At 3 months follow-up, nine patients (41%) had complete, 11 (50%) had partial and two (9%) had no resolution of pain. Nine of 14 patients had a decrease in venous swelling on MRI. No complications were observed. Five patients (23%) underwent adjunctive surgery within 1 year for persistence or worsening of neurological symptoms. Clinical and radiographic improvements were maintained to final follow-up.ConclusionsDoughnut vertebroplasty offers a mini-invasive, safe and effective treatment of aggressive circumferential VHs. This technique improves pain in over 90% of patients as well as a reduction in radicular and neurological symptoms associated with a tendency to regression of the compressive epidural venous component of these lesions.

Background: Wiltse approaches have been shown to reduce operative blood loss and enhance recovery in lumbar spinal surgery; however, their efficacy in neuromuscular scoliosis (NMS) deformity correction has never been assessed. Thus, the purpose of this study was to compare the outcomes of deformity correction requiring pelvic fixation in NMS performed through a Wiltse approach in contrast to a standard midline approach. Methods: This is a retrospective review of 24 consecutive children with NMS undergoing deformity correction by a single surgeon in our institution. Patient demographic data, operative time, blood loss, curve correction, length of stay, and complications were recorded. Results: In 16 children, the procedure was performed through a Wiltse approach and in 8 through a midline approach. There was no significant difference in age, sex, preoperative Cobb angle, or number of levels fused. Patients who underwent a Wiltse approach had significantly less blood loss yet similar curve correction. The hospital length of stay and complication rate were not significantly different between the groups. Conclusions: A modified Wiltse approach can be safely used for NMS deformity correction. This approach achieves similar curve corrections to a traditional midline approach with less blood loss and no need for iliac screw connectors. Level of Evidence: 3.

Background: 3D-printed or additive manufactured acetabular implants are an exciting new technology being used in hip surgery with increasing frequency especially in complex acetabular reconstructions. However, the performance of acetabular components produced by this method for primary THR is unknown. Methods: 41,272 uncemented cups in primary THR for OA were identified in the NZJR for the purposed of this study. There were 39,080 uncemented cups in the control group (15,798 Pinnacle cups, 12,724 Trident cups and 10,558 RM Pressfit cups) compared to 2192 3D-printed uncemented implants (1397 Delta TT cups, 640 Ti Por and 155 Polymax cups). All-cause revision rates and reasons for revision were examined. Kaplan-Meier survival analysis was performed. Results: 3D-printed cups were inserted into younger, fitter patients with a higher mean BMI compared to those in the control group ( p < 0.001). The overall all-cause revision rate for 3D-printed cups was not significantly different to the controls: 0.77/100 cys (95% CI 0.59–1) compared to 0.55/100 cys (95% CI 0.52–0.58) in the control group ( p = 0.058, Hazards ratio 1.29, 95% CI 0.992–1.678). There was no difference in aseptic cup loosening or deep infection rates between either group or indeed individual implant designs. Conclusions: 3D-printed uncemented cups provide reliable survivorship and clinical results in primary THR comparable to established designs manufactured by traditional means. The theoretical concerns of increased rates of fatigue failure or deep infection are unsubstantiated.

STUDY DESIGN This work was a systematic review. OBJECTIVE The objective of this work was to review the literature on the outcomes of en bloc resection of isolated spinal metastasis. SUMMARY Of background data: En bloc resection of isolated spinal metastasis is rarely performed and its utility debated, with the last review of the literature being performed over a decade ago. With significant advances in adjunctive oncology treatments, an updated review of whether there remains a role for this type of surgery is necessary. METHODS The authors performed a systematic review of English literature over the last decade on en bloc resection of isolated spinal metastasis in adults using the PubMed, Google Scholar, OVID, and Cochrane database. They excluded studies with

Assess the outcome of a standardised protocol for the treatment of post-operative wound infection in patients undergoing deformity correction for neuro-muscular scoliosis (NMS). Retrospective review of 443 consecutive patients with a minimum 18 months' follow-up, following a primary posterior deformity correction for NMS. In patients who developed a wound complication, the patient demographic and comorbidities, causative pathogen, number of re-operations, length of stay (LOS), rate of cure, and complications were analysed. Forty-four patients (9.9%) developed a wound infection. Marginally more infections were mono-microbial (23) than poly-microbial (21). Coagulase negative staphylococcus and Staphylococcus aureus were the most commonly cultured pathogens. Seventeen patients were treated with antibiotics alone, while 27 patients also required surgical debridement. The average LOS for those treated with antibiotics alone was 12 days (range: 9-15 days), in contrast to those requiring debridement, which was 35 days (range: 35-70 days). All patients were cured from their infection and ultimately achieved fusion. Infection is common in NMS deformity correction. This is marginally more common as a mono-microbial than poly-microbial infection with most pathogens being staphylococcal in origin. Our defined treatment strategy resulted in a cure for all patients and capacity for all patients to achieve fusion.

BACKGROUND: Both adult spinal deformity (ASD) and obesity are growing concerns internationally. This study therefore aims to determine the effect of increasing body mass index (BMI) on the pain and function of patients with ASD. METHODS: A retrospective review of prospectively collected data from a multicentre European database was undertaken. Initially a univariate analysis was performed on the effect of BMI on the initial presentation of functional scores in patients with ASD. The functional scores included the Numerical Rating Scale (NRS) back and leg score, Core Outcome Measures Index (COMI) back score, SRS22 total score, Short Form 36 (SF-36) [general health, physical component score (PCS) and mental component score (MCS)] and Oswestry Disability Index (ODI) score (including all domains). Subsequently a multivariate analysis controlling for age, sex, comorbidities, employment status, smoking status and radiological parameters [coronal cobb, coronal balance, sagittal balance, global tilt, and pelvic incidence minus lumbar lordosis (PI − LL) mismatch] was performed. RESULTS: A total of 1,004 patients were included in this study (166 male, 838 female). On univariate analysis a statistically significant (P0.05). CONCLUSIONS: Increasing BMI has a significant adverse effect on the pain and functioning of patients with ASD. Clinicians should recognise this association and treat patients accordingly.

IntroductionA review of ballistic gelatin calibration standards has highlighted that data used from studies with different calibrations methods may not be able to be compared. Calibration of ballistic gelatin did not occur until the mid-1980s when Fackler recognised the deficiencies of uncalibrated gelatin. He determined that the calibration standard should be 85±5 mm of ball bearing penetration for a 180 m/s impact velocity. This study looks to improve on and optimise current ballistic gelatin calibration standardsMethodsNine 0.177 cal (4.5 mm) spheres were fired using a Daisy Powerline air rifle at velocities between 134 m/s and 224 m/s at 25 gelatin blocks (n=225). Velocities were measured using an Oehler Model 36 Chronograph with three Model 57 screens. Depth of penetration (DoP) was measured from the entry surface to the back end of the sphere via a Mitutoyo Absolute vernier calliper.ResultsThe R-squared regression model showed that all batches had a close fit to the regression line. Using the R-squared regression model, the equation y=0.584x – 20.02 (where x is the velocity) returned a DoP of 84.918 mm for a 180 m/s impact and therefore needed minimal adjustment to align with Fackler’s 85 mm DoP. The equation can be adjusted to y=0.584x – 20.12 to return a DoP of 85 mm for 180 m/s.ConclusionsWe propose that the calibration standard of ballistic gelatin with 4.5 mm spheres is DoP=0.584x – 20.12 where DoP is the depth of penetration (mm) and x is the impact velocity (m/s), The measured DoP should be within 5% of the calculated DoP.

Objective. To determine the effect on the need for transfusion when intravenous tranexamic acid (TXA) is administered intraoperatively in patients undergoing total hip arthroplasty (THA). Method. A prospective, double blinded, randomised control trial of 88 patients undergoing THA was randomly allocated to receive 1 g of intravenous TXA or normal saline on induction of anaesthesia. All patients received spinal anaesthesia. The primary outcome measure was transfusion rate, and the secondary outcomes were intraoperative blood loss, haemoglobin levels, length of hospital stay, functional scores, and thromboembolic complications. Results. 19.0% of patients given TXA required a blood transfusion, compared with 20.5% given placebo (p=0.87). Secondary outcomes included mean intraoperative blood loss, which was 536.5 ml in the TXA group and 469.8 ml in the placebo group (p=0.276). Day 1 haemoglobin levels were 108.9 g/l in the TXA group versus 104.3 g/l in the placebo group (p=0.114). Day 4 haemoglobin levels were 105.0 g/l and 99.8 g/l, respectively (p=0.130). The mean length of stay in those who received TXA was 4.3days, compared with 4.8days in those given placebo (p=0.20). The Oxford Hip Score showed a mean improvement over a 1-year period of 25.9 points in those who received TXA, compared with 26.7 points in those who received placebo (p=0.679). There were two treatment emergent adverse events: a pulmonary embolism (TXA) and a myocardial infarction (placebo). Conclusions. 1 g IV TXA administered on induction did not significantly reduce the need for blood transfusion, postoperative blood loss, functional scores, or the length of stay in patients undergoing THA. This trial is registered with ACTRN12610001065088.

STUDY DESIGN Prospective cohort study OBJECTIVE.: To understand the efficacy of a tail-gating technique (TGT) to mirror the normal spinal growth of children with early-onset scoliosis (EOS) treated with magnetically controlled growing rods (MCGR). SUMMARY OF BACKGROUND DATA MCGR allow outpatient distraction and guided spinal growth without the need for repeat surgery. Two techniques (maximal and targeted) are currently employed to determine the distraction amount, however the efficacy of each is unknown. This study specifically assesses the ability of targeted distraction to achieve physiological growth. METHODS We performed a retrospective review of European children treated with MCGR using a TGT and analyzed the post-operative clinical and radiographic outcomes, including the sitting height, standing height, coronal Cobb angle, T1-T12 and T1-S1 height. Furthermore, we compared the post-operative sitting/standing height ratio every 6 months to those reported for normal age- and sex-matched European children. RESULTS Thirty-five children were included with a mean follow-up of 3.4 years (1.8-5.8 years). All clinical and radiographic parameters significantly (P

STUDY DESIGN Retrospective, longitudinal observational study. PURPOSE To describe the natural history of anterior bone loss (ABL) in cervical disc arthroplasty (CDA) and introduce a classification system for its assessment. OVERVIEW OF LITERATURE ABL has recently been recognized as a complication of CDA, but its cause and clinical effects remain unknown. METHODS Patients with non-keeled CDA (146) were retrospectively reviewed. X-rays were examined at 6 weeks, 3, 6, 9, 12, 18, and 24 months, and annually thereafter for a minimum of 5 years. These were compared with the initial postoperative X-rays to determine the ABL. Visual Analog Scale pain scores were recorded at 3 months and 5 years. Neck Disability Index was recorded at postoperative 5 years. The natural history was determined and a classification system was introduced. RESULTS Complete radiological assessment was available for 114 patients with 156 cervical disc replacements (CDRs) and 309 endplates (average age, 45.3 years; minimum, 28 years; maximum, 65 years; 57% females). ABL occurred in 57.1% of CDRs (45.5% mild, 8.3% moderate, and 3.2% severe) and commenced within 3 months of the operation and followed a benign course, with improvement in the bone stock after initial bone resorption. There was no relationship between ABL degree and pain or functional outcome, and no implants were revised. CONCLUSIONS ABL is common (57.1%). It occurs at an early stage (within 3 months) and typically follows a non-progressive natural history with stable radiographic features after the first year. Most ABL cases are mild, but severe ABL occurs in approximately 3% of CDAs. ABL does not affect the patients' clinical outcome or the requirement for revision surgery. Surgeons should thus treat patients undergoing CDA considering ABL.

BACKGROUND Vertical shear fractures are unstable and potentially life-threatening injuries that require urgent reduction and stabilization. The aim of this study was to compare the biomechanical efficacy of three different external fixation pin configurations for vertical shear pelvic fractures in a cadaveric model. We hypothesized that a modified external fixation pin configuration with a crestal (CR) pin in the stable hemipelvis and bilateral supra-acetabular (SA) pins provides the greatest overall stability to axial loading. METHODS The force to failure within a standard standing axial load (maximum 650 N) was tested on 10 human cadaveric pelvises with vertical shear fractures. Three pin configurations were compared including iliac crest (IC), SA and a modified SA frame with a third CR pin on the stable hemipelvis. Both displacement at the posterior pelvis at 650 N and force to failure of >25 mm displacement was recorded. RESULTS The mean force to failure was highest with CR (499 N), then IC (350 N) and then SA (265 N) pin configurations, being statistically non-significant (P = 0.165). The minimum force to failure followed a similar trend with 296, 68 and 43 N for CR, IC and SA, respectively. About 1/4 CR, 1/4 IC and 2/9 SA pins sustained 650 N or more without failure. CONCLUSION It was shown that this new design may reliably withstand a seated physiological load of 250 N. However, none of the three pin configurations tested can reliably withstand a standing load of 650 N. Further experiments are needed to quantify these findings under physiological loading.

Background:Femoral component offset influences the torque forces exerted on a femoral stem and may therefore adversely affect femoral component survival. This study investigated the influence of femoral component offset on revision rates for primary total hip replacements (THR) registered on the New Zealand Joint Registry (NZJR).Methods:There were 106,139 primary THRs registered, resulting in 4960 revisions for any cause. There were 46,242 THRs performed using the five commonest femoral components listed on the NZJR. A total of 41,100 were done for primary osteoarthritis of which 40,548 had all the offset information available for analysis. We defined low offset as < 42 mm, standard as 42–48 mm and high offset as > 48 mm offset and examined revision rates according to the reasons for revision. We performed survival analyses for both cemented and uncemented femoral components grouped by the different offsets.Results:The all-cause revision rate was 0.54/100 component years (cys). Stems with < 42 mm offset had a revision rate of 0.58/100 cys (mean 0.58; 95% confidence interval (CI) 0.53–0.63), 42–48 mm offset 0.47 (95% CI 0.43–0.52) and > 48 mm offset 0.67 (95% CI 0.57–0.79). There was no significant difference in all-cause revision rates between varying stem offsets in uncemented stems adjusting for age and gender. In cemented stems both high and low offset stems were more likely to be revised. Uncemented stems of all offsets were more likely to undergo revision for femoral fracture.Conclusions:Femoral component offset affects the overall all-cause revision rate of the most commonly used cemented stem, but not uncemented stem designs. In cemented stems offset influences the rate of revision for loosening and periprosthetic fractures.

Introduction: The requirement for lateral plate fixation in the presence of a hip arthroplasty stem is increasing, yet the optimal plate construct necessary to reduce inter-prosthetic strain and prevent subsequent fractures is unknown. Therefore, the purpose of this study was to determine the optimal position of a lateral femoral plate in relation to a femoral stem. Methods: We used 4th Generation Composite Sawbones®, a collarless polished cemented femoral stem and a broad Peri-loc™ plate with varying overlap of the stem. Each construct was subjected to torsion, axial compression and 3-point lateral bending, with the strain measured at the tip of the femoral stem and the force-to-failure recorded. Results: In all three loading directions a plate, which extended at least two shaft diameters proximal to the tip of the stem, experienced the lowest strain ( p < 0.001). Constructs with no overlap, and particularly those with a small gap between the tip of the stem and the proximal extent of the plate experienced the highest strain ( p < 0.001). This high strain resulted in lower forces required to cause fracture in the clinically significant scenarios of femoral torsion and lateral bending. Conclusions: Optimal plate fixation is achieved by extending a lateral femoral plate at least two shaft diameters proximal to the tip of the stem and using a spread of proximal screws. Distal fixation increases the strain experienced at the tip of the stem and higher strains are noted the smaller the gap between the proximal extent of the femoral plate and the tip of stem.

To analyse the complication profile of magnetically controlled growing rods (MCGRs) in early onset scoliosis (EOS). This is a systematic review using PUBMED, Medline, Embase, Google Scholar and the Cochrane Library (keywords: MAGEC, Magnetically controlled growing rods and EOS) of all studies written in English with a minimum of five patients and a 1-year follow-up. We evaluated coronal correction, growth progression (T1–S1, T1–T12) and complications. Fifteen studies (336 patients) were included (42.5% male, mean age 7.9 years, average follow-up 29.7 months). Coronal improvement was achieved in all studies (pre-operative 64.8°, latest follow-up 34.9° p = 0.000), as was growth progression (p = 0.001). Mean complication rate was 44.5%, excluding the 50.8% medical complication rate. The unplanned revision rate was 33%. The most common complications were anchor pull-out (11.8%), implant failure (11.7%) and rod breakage (10.6%). There was no significant difference between primary (39.8%) and conversion (33.3%) procedures (p = 0.462). There was a non-statistically significant increased complication rate with single rods (40 vs. 27% p = 0.588). MCGRs improve coronal deformity and maintain spinal growth, but carry a 44.5% complication and 33% unplanned revision rate. Conversion procedures do not increase this risk. Single rods should be avoided. These slides can be retrieved under Electronic Supplementary material.

Aims The intra-articular administration of tranexamic acid (TXA) has been shown to be effective in reducing blood loss in unicompartmental knee arthroplasty and anterior cruciate reconstruction. The effects on human articular cartilage, however, remains unknown. Our aim, in this study, was to investigate any detrimental effect of TXA on chondrocytes, and to establish if there was a safe dose for its use in clinical practice. The hypothesis was that TXA would cause a dose-dependent damage to human articular cartilage. Materials and Methods The cellular morphology, adhesion, metabolic activity, and viability of human chondrocytes when increasing the concentration (0 mg/ml to 40 mg/ml) and length of exposure to TXA (0 to 12 hours) were analyzed in a 2D model. This was then repeated, excluding cellular adhesion, in a 3D model and confirmed in viable samples of articular cartilage. Results Increasing concentrations above 20 mg/ml resulted in atypical morphology, reduced cellular adhesion and metabolic activity associated with increased chondrocyte death. However, the cell matrix was not affected by the concentration of TXA or the length of exposure, and offered cellular protection for concentrations below 20 mg/ml. Conclusion These results show that when in vitro chondrocytes are exposed to higher concentrations of TXA, such as that expected following recommended intra-articular administration, cytotoxicity is observed. This effect is dose-dependent, such that a tissue concentration of 10 mg/ml to 20 mg/ml could be expected to be safe. Cite this article: Bone Joint J 2018;100-B:404–12.

Objectives To quantify the magnitude, frequency, duration and distribution of head impact exposure in a women’s rugby league competition. Design Prospective cohort study. Methods Twenty-one players had a wireless impact measuring device (X2Biosystems XPatch) behind their right ear during match participation. Head impact data were collected and downloaded for analysis. Median peak linear and rotational accelerations and impact locations between player positions were assessed using a Friedman repeated measures ANOVA on ranks with a Wilcoxon signed-rank test for post hoc analysis with a Bonferroni correction. Results A total of 1659 impacts to the head >10g were recorded (range 10g–91g) over the nine competition matches. There was a mean of 184 ± 18 impacts per-match resulting in a mean of 14 ± 12 impacts per-player per-match. The No. 8 prop recorded a mean of 29 ± 27 impacts per-match, the No. 12 second-row forward recorded the highest median peak resultant linear acceleration (16g) per-match and the No. 11 second-row forward recorded the highest median peak resultant rotational acceleration (3696 rad/s2). Conclusions Our cohort of 21 female rugby league athletes were exposed to repetitive sub-concussive head impact exposure with an average of 14 impacts per-player per-match. Forwards were exposed to more impacts per-match than backs and these impacts were of higher magnitude. Most impacts occurred on the side of the head and were sustained during the second half of the game. Clinicians, coaches and players should be aware of the rates and magnitude of head impacts in female rugby league athletes.

To present a case of aggressive sacral osteoblastoma (OB) treated with neoadjuvant denosumab therapy and en bloc resection. Case report of a 14-year-old male with an aggressive OB affecting the superior articular process of the left first sacral segment. The lesion was lytic and metabolically active and involved the left-sided posterior elements of S1–S3 with extension into the spinal canal, affecting the left S1, S2, S3, S4 and S5 nerve roots. He was treated for 1 month with neoadjuvant denosumab followed by en bloc resection. Denosumab therapy caused regression of the tumour and converted the diffuse infiltrative mass into a well-defined solid (osteoma-like) structure, aiding surgical resection and preserving the S1, S4 and S5 nerve roots. Histologically, the treated lesion showed abundant sclerotic woven bone and osteoblasts with absence of osteoclasts. A short course of denosumab caused tumour regression, ossification and conversion of an aggressive OB into a sclerotic, well-defined lesion thus aiding surgical resection and preservation of neural structures. Neoadjuvant therapy reduced osteoclast numbers but PET showed that the lesion remained FDG avid post-therapy.

To assess the efficacy of bisphosphonate therapy in the management of spinal aneurysmal bone cysts (ABCs). A prospective study of six consecutive patients aged between 7 and 22 years with spinal ABCs treated with pamidronate (1 mg/kg) or zoledronate (4 mg). A visual analogue scale (VAS) for pain and radiological (contrast-enhanced MRI and CT scan at 3 and 6 months, then yearly X-rays) follow-up was continued for a minimum of 6 years. One patient with an unstable C2/3 failed to respond to a single dose of bisphosphonate and required surgical resection and stabilisation with autologous bone grafting. Another, with a thoraco-lumbar ABC, experienced progression of neurological dysfunction after one cycle of bisphosphonate and, therefore, required surgical resection and stabilisation. In all other patients pain progressively improved and was resolved after two to four cycles (VAS 7.3–0). These patients all showed reduction in peri-lesional oedema and increased ossification by 3 months. No patients have had a recurrence within the timeframe of this study. Bisphosphonate therapy can be used as the definitive treatment of spinal ABCs, except in patients with instability or progressive neurology, where surgical intervention is required. Clinicians should expect a patients symptoms to rapidly improve, their bone oedema to resolve by 3 months and their lesion to partially or completely ossify by 6–12 months.