Search

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting., Competing Interests: A. Puri is a member of the editorial board of The Bone & Joint Journal. P. Ruggieri reports consulting fees from Exactech and Stryker, unrelated to this study. M. T. Houdek reports consulting fees from Link Orthopedics, unrelated to this study. E. Botello reports consulting fees, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events, and support for attending meetings and/or travel from Zimmer Biomet, all of which are unrelated to this study. G. V. Morris reports consulting fees, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events, and support for attending meetings and/or travel from Implantcast, all of which are unrelated to this study., (© 2024 Jeys et al.)

The aim of this study was to compare the short term clinical and radiological outcomes of imageless robotic and conventional total knee arthroplasty (TKA) and to estimate the accuracy of the two techniques by analysing the outliers after TKA. We have evaluated 200 consecutive knees (158 patients), 100 knees undergoing robotic TKA, and 100 knees treated with conventional TKA. Demographic parameters like age, gender, body mass index, diagnosis and range of motion were obtained. Knee society score (KSS) and Knee society functional score (KSS-F) were used for clinical evaluation. Mechanical alignment (Hip-knee-ankle angle), proximal tibial angle (MPTA), distal femoral angle (LDFA) and tibial slope were analysed for radiological results and outliers were compared between both groups. Outliers were defined when the measured angle exceeded ± 3° from the neutral alignment in each radiological measurement on the final follow-up radiograph.The minimum follow-up was 6 months (range, 6 to 18 months). The preoperative mean HKA angle was 169.7 ± 11.3 ° in robotic group and 169.3 ± 7.3 ° in conventional group. There was significant improvement in HKA, LDFA, MPTA and tibial slope compared to the preoperative values in both the groups (p < 0.01). The number of HKA, LDFA and tibial slope outliers were 31, 29 and 37, respectively, in the conventional group compared to 13, 23 and 17 in the robotic group (p < 0.01). There was a significant improvement in the KSS and KSS-F functional scores postoperatively in both the groups (p < 0.01). However, there was no significant difference in the functional scores between the groups postoperatively (p = 0.08). This study showed excellent improvement with both imageless robotic and conventional TKA, with similar clinical outcomes between both groups. However, radiologically robotic TKA showed better accuracy and consistency with fewer outliers compared with conventional TKA., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: The use of intraoperative CT navigation to manage osteoid osteoma is not common. We report our experience managing osteoid osteoma in the appendicular skeleton using an intraoperative AIRO CT navigation system., Materials & Methods: Between May 2013 and December 2022, 59 patients underwent Navigation-assisted excision of osteoid osteoma in the appendicular skeleton. Our primary study outcome was to assess for recurrence of the tumour with recurrence of symptoms. For our secondary outcomes, we evaluated the complications associated with the procedure and evaluated the histological slides of all patients to see for the presence of nidus., Results: Of the 58 patients available for review, no patient had a lesion recurrence, and all were symptom-free at an average follow-up of 45.6 months (6-100). Two patients (3.5%) had a superficial infection managed conservatively, and 43 patients (74.1%) had the presence of nidus in curetted samples. No patient developed a pathological fracture after the procedure., Conclusion: Using intraoperative CT navigation to manage osteoid osteoma in the appendicular skeleton is safe, minimally invasive, and effective in completely removing the nidus with a negligible complication rate. The absence of nidus on histology should not be a concern to clinicians once thorough burring and verification of excision of nidus has been confirmed intra-operatively., Study Design: Retrospective Case Series., Level of Evidence: Level IV., Competing Interests: The authors declare that they have no conflict of interest., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: The aim of this systematic review was to summarise the evidence for the clinical effectiveness of revision knee arthroplasty (rKA) compared to non-operative treatment for the management of patients with elective, aseptic causes for a failed knee arthroplasty., Methods: MEDLINE, Embase, AMED and PsychINFO were searched from inception to 1st December 2020 for studies on patients considering elective, aseptic rKA. Patient-relevant outcomes (PROs) were defined as implant survivorship, joint function, quality of life (QoL), complications and hospital admission impact., Results: No studies compared elective, aseptic rKA to non-operative management. Forty uncontrolled studies reported on PROs following elective, aseptic rKA (434434 rKA). Pooled estimates for implant survivorship were: 95.5% (95% CI 93.2-97.7%) at 1 year [seven studies (5524 rKA)], 90.8% (95% CI 87.6-94.0%) at 5 years [13 studies (5754 rKA)], 87.4% (95% CI 81.7-93.1%) at 10 years [nine studies (2188 rKA)], and 83.2% (95% CI 76.7-89.7%) at 15 years [two studies (452 rKA)]. Twelve studies (2382 rKA) reported joint function and/or QoL: all found large improvements from baseline to follow-up. Mortality rates were low (0.16% to 2% within 1 year) [four studies (353064 rKA)]. Post-operative complications were common (9.1 to 37.2% at 90 days)., Conclusion: Higher-quality evidence is needed to support patients with decision-making in elective, aseptic rKA. This should include studies comparing operative and non-operative management. Implant survivorship following elective, aseptic rKA was ~ 96% at 1 year, ~ 91% at 5 years and ~ 87% at 10 years. Early complications were common after elective, aseptic rKA and the rates summarised here can be shared with patients during informed consent., Systematic Review Registration: PROSPERO CRD42020196922., (© 2023. The Author(s).)

Objective: Distinguishing non-neoplastic tumour-mimicking pathologies from bone and soft tissue tumours is one of the fundamental aims of a tertiary centre sarcoma multidisciplinary team (MDT) service. In this study, we aim to analyse the incidence of non-neoplastic lesions referred to a tertiary referral service as suspected sarcoma, and to analyse the spectrum of conditions comprising these tumour-mimicking pathologies., Materials and Methods: We conducted a retrospective observational study compiling the biopsy-proven non-neoplastic outcomes of suspected sarcoma cases referred to our MDT in the last year. We identified all referrals made to our service between 1st January 2020 and 31st December 2020 and compiled their histological diagnoses., Results: A total of 976 new cases were referred to our MDT as suspected sarcoma in one year. Of these referrals, 8.6% (84/976) received a biopsy-proven outcome of non-neoplastic pathology. These non-neoplastic outcomes were categorised into the following types of pathology: 32.1% vascular, 31.0% inflammatory, 14.3% traumatic, 6.0% degenerative, 6.0% idiopathic, 4.8% infective, 3.6% metabolic, 1.2% autoimmune, and 1.2% genetic., Conclusion: A significant proportion of pathologies referred to a tertiary centre sarcoma MDT are non-neoplastic in nature. These lesions are made up of a range of pathologies, with vascular and inflammatory conditions being the most common. Our study, the first of its kind, offers clinicians an insight into tumour-mimicking pathologies encountered by a tertiary centre., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose of Study: The use of allografts to reconstruct benign lesions of the proximal femur after curettage has seldom been reported. We report our experience of impaction bone grafting of only allografts combined with osteosynthesis to manage benign lesions involving the proximal femur., Materials and Methods: Between 2013 and 2019, 35 patients of a mean age of 23.8 years (14-41) who had a biopsy proven benign pathology and a median pre-operative Mirels' score of 9 (8-11) were managed using extended curettage, impaction bone grafting of allografts combined with osteosynthesis through a lateral approach. Radiographs were assessed to see for any recurrence at follow-ups, and functional outcomes were assessed using Musculoskeletal Tumour Society (MSTS) score and Harris hip score (HHS)., Results: At a mean follow-up was 41.5 months (23-80), patients demonstrated favorable functional outcomes with a mean MSTS of 28.3 (18-30) and a mean HHS of 94.3 (66-100) at the last follow-up. Two cases (GCT = 1; fibrous dysplasia = 1) had a recurrence of disease. Allografts demonstrated a particular integration pattern on radiographs that involved an intermediate period of lucency followed by consolidation and integration with the parent bone., Conclusion: Impaction grafting of allografts in benign lesions of the proximal femur allows adequate bony consolidation of the cavity after extended curettage and can be effectively used as a permanent solution to manage such lesions in most cases. The intermediate period of lucency seen on radiographs must not be confused for recurrence, and patients must be followed up continuously., Study Design: Retrospective Case Series., Level of Evidence: Level IV., Competing Interests: The authors declare that they have no conflict of interest., (© 2022 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Introduction: We developed a technique using an indigenously designed jig to assist pin placement in producing a stable and long-lasting construct to augment the acetabulum combined with a cemented hip replacement in cases of metastatic destruction of the acetabulum. We describe our novel modified Harrington technique and retrospectively assess our cohort's clinical outcomes and complications., Methods: Between 2006 and 2019, 27 patients with a median age of 69 (49-81) years and a median ASA grade of III (II-IV) were managed using our modified 'Harrington' technique. We assessed outcomes on the following criteria: mechanical complications, post-surgery mobility, and functional outcome using Musculoskeletal Tumour Society Score (MSTS)., Results: At the last follow-up, ten patients were alive with disease [median follow-up of 26 months (12-74)], and 17 patients died of their oncological disease [median follow-up of 15 months (9-22)]. There were no perioperative deaths or intra-operative complications in our series. In total, ten complications were noted in nine patients (33%). Mobility-wise, 13 patients (48%) mobilised unaided, ten patients (37%) required a stick or crutch, two patients (7%) required a frame and two patients (7%) were wheel chair-dependent. The median MSTS score of all patients during their latest follow-up was 18 (8-26)., Conclusion: Our jig-aided modified Harrington reconstruction technique assists in safe placement of antegrade pins in acetabulum during surgery and offers a long-lasting solution to these high-risk patients. The use of large diameter pins, appropriate patient selection, and cage used during construction in the acetabulum demonstrated relief of pain, improved mobility, and favorable functional outcomes with minimal complication rates., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: In high volume centres, audits are essential to ensure good surgical techniques and fracture fixations to avoid complications, revision surgeries and poor outcomes. A method to assess fixations for fractures of different regions employing different implants and surgical demands is a challenge. We present here a simple method of review and follow-up work flow of more than 6000 fixations every year that helped in improving outcomes and also provide training for residents and junior staff., Materials and Methods: The results of 6348 fracture fixations in 2014, led to a trauma review system in January 2015 to classify all fracture fixations by senior consultants into three categories: category A (good fixations); category B (acceptable fixations; need further follow-up); category C (poor/unacceptable fixations needing revision) combined with a teaching program. A strategy was evolved that included the following practices: (1) identifying 'red flag' fractures that led to frequent failures, (2) routine senior surgeons' involvement in such fractures, (3) evolving 'intra-operative checklists', (4) requirement of senior surgeons' intervention if there was a 'fiddle time' of more than 20 min, and (5) approval of post-fixation c-arm image by a senior person before closure. The impact of these rules on the fixations for 2015, 2016 and 2017 were prospectively analysed., Results: In the years 2015, 2016 and 2017 the number of fracture fixations performed were 6579, 6978 and 7012, respectively. There was a significant increase (p < 0.001) in the number of category A fixations (87.7%, 94.6% and 96.3% in 2015, 2016 and 2017, respectively) and also a decrease in the number of category C fixations (2.23%, 0.7% and 0.2% in 2015, 2016 and 2017, respectively). The quality of fixations of the 'red flag' fractures also improved., Conclusion: We present here a very effective, tested, simple and easily reproducible method of audit and follow-up work flow that can be used in all high turnover trauma centres to improve outcomes and can also serve as a teaching resource for junior staff., Study Design: Prospective study., Level of Evidence: Level II., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Postoperative imaging following orthopaedic surgeries is essential in assessing complications post-surgery and also helps plan further treatment. Combining a high degree of clinical insight with appropriate imaging can guide the treating clinician to the correct diagnosis. Imaging is quite challenging because of surgery-related soft tissue changes, especially in the early postoperative period and the presence of metal implants resulting in image scatter and metal artifacts. Newer modalities and advances in imaging have helped overcome shortcomings and assess better, especially in procedures that involve implants. Collaborative decision-making involving radiologists and clinicians has shown to be beneficial and is the way forward. This narrative review discusses the utility of imaging in evaluating postoperative complications following musculoskeletal surgeries with specific relation to trauma, arthroplasty, and tumour by discussing commonly encountered clinical scenarios., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2021 All rights reserved.)

Background: The efficacy and safety of cell salvage for musculoskeletal sarcoma surgery have not been reported, and concerns over re-infusion of tumour cells remain. This study aims to i) describe the intra-operative blood loss and cell salvage reinfusion volumes for lower limb sarcoma and pelvic sarcoma procedures ii) and explore whether there is evidence of tumour cells in reinfused blood., Methods: Retrospective analysis of 109 consecutive surgical procedures for biopsy-proven sarcoma or bone metastasis performed between 1 July 2015 and 30 October 2019. Salvaged blood was processed and reinfused when intraoperative blood loss exceeded 500 ml. Primary bone tumour (n = 86(79%)) and metastasis (n = 23(21%) constituted the study group and surgeries were classified under hemipelvectomy (n = 43(39%)), lower limb endoprosthesis replacement (LLE) (n = 50(46%)) and wide excision surgery (WE) (n = 16(15%)). Microscopic examination of imprint cytology of leuco-depletion(LD) filters, and peripheral smear examination was performed for reinfused blood., Results: Median (IQR) intra-operative blood loss was 1750 (600-3000) ml for hemipelvectomy, 850 (600-1200) ml for LLE, and 1000 (550-2000) ml for WE. Salvaged blood was re-infused in 102 of 109 (94%) patients. The mean (SD) volume of re-infusion was 445(4 2 5) ml for hemipelvectomy, 206(1 3 1) ml for LLE, and 184(1 0 6) ml for WE. In total, 64 of 109 (59%) patients received an allogeneic red blood transfusion within 72 h of surgery. Cytology analysis of imprints taken from the filtered blood available in 95(87%) patients and peripheral smear examination of reinfused blood available in 32(29%) patients did not reveal evidence of tumour cells on microscopic examination of any samples., Conclusion: Our study demonstrates that musculoskeletal sarcoma surgery is associated with significant blood loss, and cell salvage permits reinfusion of autologous blood in most patients. The cytological analysis did not reveal evidence of tumour cells in reinfused blood, consistent with other studies where cell salvage is used for cancer surgery., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s).)

Musculoskeletal sarcomas are rare cancers with an incidence of less than 1% of all cancers. Management of these tumors requires multidisciplinary care comprising of numerous specialists. Critical decisions following collaborative discussion among treating specialists followed by timely communication and starting prompt treatment are vital in delivering care in such rare sarcomas. While musculoskeletal surgeons, radiologists, and clinical oncologists are well known, the role of specialist nurses has been less described. They form a vital pillar in any tertiary sarcoma service by assisting in collaborative care, having consultations in nurse-led clinics, offering psychological support, imparting details of treatment to patient and helping in palliative care. This narrative review focuses on the role of trained specialist nurses in a tertiary sarcoma service and gives insight into their vital role in delivering timely, coordinated, effective care., Competing Interests: The authors declare no conflict of interest., (© 2021 Delhi Orthopedic Association. All rights reserved.)

Background: Delivering uninterrupted cancer treatment to patients with musculoskeletal tumors has been essential during the rapidly evolving coronavirus 2019 (COVID-19) pandemic, as delays in management can be detrimental. Currently, the risk of contracting COVID-19 in hospitals when admitted for surgery and the susceptibility due to adjuvant therapies and associated mortality due to COVID-19 is unknown, but knowledge of these potential risks would help treating clinicians provide appropriate cancer care., Questions/purposes: (1) What is the risk of hospital-acquired COVID-19 in patients with musculoskeletal tumors admitted for surgery during the initial period of the pandemic? (2) What is the associated mortality in patients with musculoskeletal tumors who have contracted COVID-19? (3) Are patients with musculoskeletal tumors who have had neoadjuvant therapy (chemotherapy or radiation) preoperatively at an increased risk of contracting COVID-19? (4) Is a higher American Society of Anesthesiologists (ASA) grade in patients with musculoskeletal tumors associated with an increased risk of contracting COVID-19 when admitted to the hospital for surgery?, Methods: This retrospective, observational study analyzed patients with musculoskeletal tumors who underwent surgery in one of eight specialist centers in the United Kingdom, which included the five designated cancer centers in England, one specialist soft tissue sarcoma center, and two centers from Scotland between March 12, 2020 and May 20, 2020. A total of 347 patients were included, with a median (range) age of 53 years (10 to 94); 60% (207 of 347) were men, and the median ASA grade was II (I to IV). These patients had a median hospital stay of 8 days (0 to 53). Eighteen percent (61 of 347) of patients had received neoadjuvant therapy (8% [27] chemotherapy, 8% [28] radiation, 2% [6] chemotherapy and radiation) preoperatively. The decision to undergo surgery was made in adherence with United Kingdom National Health Service and national orthopaedic oncology guidelines, but specific data with regard to the number of patients within each category are not known. Fifty-nine percent (204 of 347) were negative in PCR testing done 48 hours before the surgical procedure; the remaining 41% (143 of 347) were treated before preoperative PCR testing was made mandatory, but these patients were asymptomatic. All patients were followed for 30 days postoperatively, and none were lost to follow-up during that period. The primary outcome of the study was contracting COVID-19 in the hospital after admission. The secondary outcome was associated mortality after contracting COVID-19 within 30 days of the surgical procedure. In addition, we assessed whether there is any association between ASA grade or neoadjuvant treatment and the chances of contracting COVID-19 in the hospital. Electronic patient record system and simple descriptive statistics were used to analyze both outcomes., Results: Four percent (12 of 347) of patients contracted COVID-19 in the hospital, and 1% (4 of 347) of patients died because of COVID-19-related complications. Patients with musculoskeletal tumors who contracted COVID-19 had increased mortality compared with patients who were asymptomatic or tested negative (odds ratio 55.33 [95% CI 10.60 to 289.01]; p < 0.001).With the numbers we had, we could not show that adjuvant therapy had any association with contracting COVID-19 while in the hospital (OR 0.94 [95% CI 0.20 to 4.38]; p = 0.93). Increased ASA grade was associated with an increased likelihood of contracting COVID-19 (OR 58 [95% CI 5 to 626]; p < 0.001)., Conclusion: Our results show that surgeons must be mindful and inform patients that those with musculoskeletal tumors are at risk of contracting COVID-19 while admitted to the hospital and some may succumb to it. Hospital administrators and governmental agencies should be aware that operations on patients with lower ASA grade appear to have lower risk and should consider restructuring service delivery to ensure that procedures are performed in designated COVID-19-restricted sites. These measures may reduce the likelihood of patients contracting the virus in the hospital, although we cannot confirm a benefit from this study. Future studies should seek to identify factors influencing these outcomes and also compare surgical complications in those patients with and without COVID-19., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article., (Copyright © 2020 by the Association of Bone and Joint Surgeons.)

Introduction: Open tibial fractures are rare and difficult-to-treat injuries because of the involvement of bony, skin and neuromuscular injury along with co-morbidities. Often, during the management of very severe cases these injuries, the question arises, should we amputate or salvage the limb? This question has been explored previously in civilian and military contexts in the US and UK but remains unstudied in the alternative sociocultural and economic context of the developing world., Methods: We studied 78 adult patients with severe open tibial fracture that presented to our institution, a Level 1 trauma center in India, from February 2018 to June 2019. 20 patients underwent above-knee amputation (AKA), 16 underwent below-knee amputation (BKA), and 42 underwent limb salvage. We assessed injury severity using [our institution's] Open Injury Severity Score (GHOISS), which has separate sub-scores for bony injury, skin injury, neuromuscular injury and co-morbidities, and patients were only included with GHOISS > 13. We assessed functional outcome measures as well as economic costs as primary cost levied by our institution and other secondary costs., Results: Salvage (LEFS: mean=51, SF-12 PCS: mean=48, SF-12 MCS: mean=49) provided better outcomes to BKA (LEFS: mean=39, p=0.005, SF-12 PCS: mean=40, p=0.003, SF-12 MCS: mean=43, p=0.052) and AKA (LEFS: mean=31, p<0.001, SF-12 PCS: mean=34, p<0.001, SF-12 MCS: mean=43, p=0.043). Primary costs were higher for limb salvage (index: mean=$3100, total: mean=$4400) than both BKA (index: mean=$2500, p=0.012, total: mean=$2600, p<0.001) and AKA (index: mean=$2800, p=0.020, total: mean=$3200, p<0.001). Secondary costs were higher for limb salvage than both BKA and AKA (p<0.001). Patients who underwent salvage were more likely to return to work at 36 months post-injury compared to below-knee amputees (adjusted OR=0.11, p=0.010)., Conclusions: Limb salvage results in better functional outcomes compared with amputation at a higher upfront cost but a likely lower lifetime cost. Unlike other literature on the topic, amputation carries a heavy mental and physical toll in India, likely due to sociocultural differences and stigma. Amputation is a difficult decision for patients to accept and results in poorer outcomes; therefore, we believe that limbs should be aggressively salvaged in our developing country., Study Design: Therapeutic Level II Prospective Cohort Study., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Like with all cancers, multidisciplinary team (MDT) meetings are the norm in bone and soft tissue tumour (BST) management too. Problem in attendance of specialists due to geographical location is the one of the key barriers to effective functioning of MDTs. To overcome this problem, virtual MDTs involving videoconferencing or telemedicine have been proposed, but however this has been seldom used and tested. The COVID-19 pandemic forced the implementation of virtual MDTs in the Oxford sarcoma service in order to maintain normal service provision. We conducted a survey among the participants to evaluate its efficacy., Methods: An online questionnaire comprising of 24 questions organised into 4 sections was circulated among all participants of the MDT after completion of 8 virtual MDTs. Opinions were sought comparing virtual MDTs to the conventional face-to-face MDTs on various aspects. A total of 36 responses were received and were evaluated., Results: 72.8% were satisfied with the depth of discussion in virtual MDTs and 83.3% felt that the decision-making in diagnosis had not changed following the switch from face-to-face MDTs. About 86% reported to have all essential patient data was available to make decisions and 88.9% were satisfied with the time for discussion of patient issues over virtual platform. Three-fourths of the participants were satisfied (36.1% - highly satisfied; 38.9% - moderately satisfied) with virtual MDTs and 55.6% of them were happy to attend MDTs only by the virtual platform in the future. Regarding future, 77.8% of the participants opined that virtual MDTs would be the future of cancer care and an overwhelming majority (91.7%) felt that the present exercise would serve as a precursor to global MDTs involving specialists from abroad in the future., Conclusion: Our study shows that the forced switch to virtual MDTs in sarcoma care following the unprecedented COVID-19 pandemic to be a viable and effective alternative to conventional face-to-face MDTs. With effective and efficient software in place, virtual MDTs would also facilitate in forming extended MDTs in seeking opinions on complex cases from specialists abroad and can expand cancer care globally.

Road traffic accidents (RTA) account for a significant proportion of mortality and morbidity worldwide, especially the developing countries. 'Hidden pandemics' such as deaths due to RTA often receive minimal attention globally. If not addressed adequately, the forecast looks bleak, especially for the developing countries in the coming decades. Healthcare professionals have an important role in advocating measures to reduce injuries following RTA and, along with like-minded social individuals, can act as a powerful lobby to implement change. Following a 'Public Interest Litigation or PIL' by the Indian Orthopaedic Association (IOA) in 2012 - which challenged the Government to accept responsibility for this glaring problem and form an apex body to enforce road safety - the Supreme Court of India identified the existing road-safety laws to be inadequate. It created an 'Empowered Committee' which oversaw various new road safety measures implemented by respective state governments. A public movement called 'UYIR' (meaning 'life' in Tamil) was launched at Coimbatore to reduce RTA. Early results following the implementation of this program showed promising results with a reduction in major accidents. It emphasized that well-planned programs involving the general public could be the way forward in reducing accidents across the country. Hence, Social Advocacy is crucial when an individual or group supports and influences political, economic, and social decisions. Such advocacy aims to gain support in an adverse environment to create the necessary change for the better., Competing Interests: The authors declare that they have no known competing financial interests that could have appeared to influence the work reported in this paper., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Imaging forms a crucial component in reducing mortality of polytraumatized patients by aiding appropriate diagnosis and guiding the emergency and definitive treatment. With the exponential expansion in the radiological armamentarium and introduction of protocols like Extended focused assessment with sonography for trauma (EFAST) and Whole body Computed tomography (WBCT), the role of imaging has considerably increased. Emergency imaging protocols should be done for rapid diagnosis of life-threatening injuries allowing simultaneous evaluation and resuscitation. Subsequent comprehensive imaging is essential to diagnose the often clinically missed injuries to reduce the overall morbidity. Imaging protocols must adapt to the patient's clinical scenario, which can be dynamically changing. Each trauma team should devise clear guidelines, protocols, and algorithms suitable for their center depending on the local availability of types of equipment and expertise. Radiologists must efficiently communicate and adopt patient-centered approach to ensure early appropriate care to these severely injured patients. Future research should involve multicentre studies to formulate the most appropriate imaging protocol in polytrauma to increase diagnostic accuracy and thereby reduce patient mortality., Competing Interests: None of the authors have any conflict of interest to declare., (© 2021 The Author(s).)

Background: The aim of this article is to study the correlation between preoperative pain sensitivity and postoperative pain and analgesic requirements for patients undergoing primary total knee arthroplasty., Methods: Between December 2018 and April 2019, the pain sensitivity of 178 consecutive patients undergoing primary total knee arthroplasty was assessed preoperatively with a digital algometer. The patients reported the VAS (visual analog scale) score at 3 instances of needle prick (phlebotomy, glucometer blood sugar, intradermal antibiotic test dose), during the range of movements and completed the Depression Anxiety Stress Scale score. Postoperative VAS score, analgesic requirement, and physiotherapy milestones were recorded in all these patients on day 0 to day 4., Results: The average age of the patients was 64.13 years and 69.1% were females. Females had lower mean algometry values (56.12 ± 12.77 [standard deviation]) compared to males (71.09 ± 18.78 [standard deviation]) (P < .001). Higher Depression Anxiety Stress Scale correlated with lower algometry values (P < .001). The postoperative VAS score was 2.54 ± 0.59 on the day of surgery which increased to 3.27 ± 0.69 on day 1 after mobilization (P < .001) and reduced to 1.67 ± 0.62 on day 4. Low algometer score correlated with higher postoperative VAS score (P < .05), increased analgesic requirement, and opioid utilization (P < .001), delay in achieving an optimum range of movements (P < .001) and independent ambulation (P < .001)., Conclusion: Preoperative assessment of pain sensitivity predicts postoperative analgesic requirements and recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively and prolonged physiotherapy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Deferring cancer surgery can have profound adverse effects including patient mortality. During the COVID-19 pandemic, departmental reorganisation and adherence to evolving guidelines enabled provision of uninterrupted surgical care to patients with bone and soft tissue tumours (BST) in need of surgery. We reviewed the outcomes of surgeries on BST during the first two months of the pandemic at one of the tertiary BST centres in the UK., Materials and Methods: Between 12 March 2020 and 12 May 2020, 56 patients of a median age of 57 years (18-87) underwent surgery across two sites: index hospital (n = 27) and COVID-free facility (n = 29). Twenty-five (44.6%) patients were above the age of 60 years and 20 (35.7%) patients were in ASA III and ASA IV category. The decision to offer surgery was made in adherence with the guidelines issued by the NHS, BOOS and BSG., Results: At a minimum follow-up of 30 days post-surgery, 54 (96.4%) patients were recovering well. Thirteen patients (23.2%) had post-operative complications which included four (7.1%) patients developing pulmonary embolism. The majority of complications (12/13 = 92.7%) occurred in ASA III and IV category patients. Four (7.1%) patients contracted COVID-19, of which three required escalation of care due to pulmonary complications and two (3.6%) died. Patients < 60 years of age had significantly less complications than those > 60 years (p < 0.001). Patients operated on in the COVID-free facility had fewer complications compared with those operated on at the index hospital (p < 0.027)., Conclusion: In spite of the favourable results in majority of our patients, our study shows that patients with sarcoma operated at the height of the pandemic are at a risk of contracting COVID-19 and also having associated with mortality. The use of a COVID-free facility, surgery in patients < 60 60 years and in ASA I & II category are associated with better outcomes. If a second wave occurs, a serious consideration should be given to ways of minimising the risk of contracting COVID-19 in these vulnerable patients either by using COVID-free facilities or delaying treatment until peak of infection has passed.

Background: Various open injury scores have been devised to aid the difficult decision of salvage or amputation following open fractures of the lower limb. Our aim of the study was to compare the performance of mangled extremity severity score (MESS), limb salvage index (LSI), orthopaedic trauma association-open fracture classification (OTA-OFC) and Ganga hospital score (GHS) in our population of type IIIB injuries., Materials and Methods: A total of 219 patients with 225 type IIIB open fractures of the tibia were studied prospectively between July 2016 and June 2017. The decision of salvage or amputation was taken by a combined consensus of senior orthopaedic and plastic surgeons, blinded to the scores. All four open injury scores were calculated by an independent reviewer following initial debridement. The follow-up period was one to two  years., Results: After final follow-up, there were 193 (85.7%) successfully salvaged limbs, 19 primary amputations without attempt of debridement (8.4%), three primary delayed amputations within 72 hours (1.3%) and six secondary amputations after 72 hours from initial debridement (2.7%). Of these, four patients died within one  year and were excluded. All four scores performed well for salvage, while GHS was superior when considering amputation. MESS, LSI and OTA-OFC underscored amputations, since these scoring systems award more points for vascular injuries. There were both salvaged and amputated patients around the threshold value of amputation for all scores, which was only acknowledged by GHS in its unique 'grey zone'. It includes patients who are neither easily salvageable nor definitely requiring amputation., Conclusion: The performance of the GHS was superior to MESS, LSI and OTA-OFC in our study, since it was developed for type IIIB injuries and includes the 'grey zone', where decisions need to be undertaken on a case to case basis., Clinical Relevance: GHS has an improved ability to determine amputation in IIIB open tibia fractures.

The alarming global increase in drug-resistant strains plagues the global fight to end tuberculosis (TB), especially in developing countries. The often reported poor treatment outcomes, sequelae, and lack of best practice guidelines in drug-resistant spinal TB poses a significant challenge in its efficient management. While multi-drug chemotherapy is still the primary modality of treatment, surgical intervention is essential in specific scenarios. With limited data on management and outcomes in drug-resistant spinal TB, there is no consensus on the appropriate therapy regarding the number and duration of drugs and therapeutic endpoints of this conundrum. In this light of limited evidence, we have performed a systematic computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases and studies published over the past 30 years on drug-resistance in spinal TB have been analyzed. This systematic review aims to review the current epidemiology, clinical features, updates in clinical diagnostics and chemotherapy, surgical management, and outcomes in drug-resistant spinal TB. We also consolidate potential areas of action and emphasize the need for research and large scale trials in the management of drug-resistant spinal TB., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 Delhi Orthopedic Association. All rights reserved.)

The COVID-19 (Coronavirus disease 2019) pandemic has caused an unprecedented strain on healthcare systems across the globe. Apart from being a major hurdle to delivery of basic healthcare services, this may be associated with potential harm for cancer patients. Usually being immunocompromised, cancer patients are at a higher risk of contracting the disease and with hospitals being a potential source of the infection, an urgent need to reorganise the structure of delivery of cancer care is essential. Cancer departments must balance patient care whilst also minimising transmission among patients and healthcare professionals. The Oxford Sarcoma Service was re-structured based on the guidelines issued by the National Health Service (NHS) and the British Orthopaedic Oncology Society (BOOS) to deliver unhindered care to patients. Prioritising patients who needed urgent surgery, weighing the risk-benefit ratio while delivering adjuvant treatments and conducting regular virtual multi-disciplinary team (MDT) meetings combined with personal protection equipment (PPE) usage by all involved healthcare workers were salient features in terms of ensuring the delivery of effective care during the COVID-19 pandemic. Our new model of modus operandi during this global crisis was effective in delivering high standard of care to patients and might serve as a guide to similar units managing bone and soft tissue tumours., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Noncontiguous multiple tuberculous spondylitis is not uncommon, and most of the reported cases have lesions only on 2 or 3 levels. To the best of our knowledge, multifocal extensive spinal TB involving the whole spine is rarely reported in the literature, which may be presented as asymptomatic and have a higher incidence of neurological complications. It is noticeable that the possibility of TB is considered for any skip lesions involving the spine cautiously. Diagnosis and treatment at early stages would resolve the neurological deficits without operation., Competing Interests: Conflicts of interest The authors have none to declare., (Copyright © 2020 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Purpose: Osteoarthritis of knees with varus deformity is associated with a compensatory valgus deformity of the hindfoot and a lateral loading foot pressure pattern. However, whether this abnormal loading pattern is corrected in total knee arthroplasty (TKA) is unclear., Methods: The alignment and loading pattern of 91 consecutive patients (121 knees) undergoing TKA with pre-operative varus more than 10° were evaluated prospectively with functional outcome scores, static conventional radiography and dynamic pedobarogaphy pre-operatively and 1-year post-operatively. Outcomes assessed were Oxford Knee Scores, American Orthopaedic Foot and Ankle Scores, femorotibial mechanical angle, tibia-hindfoot angle, hindfoot valgus/varus index (VVI), foot line of pressure (LOP) laterality and peak pressure (PP) at both time points., Results: Of 121 knees, 98 (81%) regained normal alignment of the knee and 114 (92%) of the hindfoot. Similarly, PP (p < 0.001), VVI (pre-operative: - 0.29 ± 0.22, post-operative: - 0.04 ± 0.23, p < 0.001) and LOP laterality (pre-operative: 7% medial, post-operative: 96% medial, p < 0.001) all medialised post-operatively. All patients had improved functional outcomes at the knee (pre-operative: 20 ± 2, post-operative: 40 ± 2, p < 0.001) and ankle (pre-operative: 59 ± 10, post-operative: 89 ± 6, p < 0.001)., Conclusion: The present study shows, following the correction of knee varus with TKA, hindfoot alignment and foot loading pattern are both restored in the majority of patients. TKA offers both static and dynamic correction as seen in the hindfoot and loading pattern, respectively., Level of Evidence: Level III: prospective case-control study.

Purpose of the Study: To document and compare the functional outcome of neutral alignment and under-correction after total knee arthroplasty (TKA) in severe varus knees of more than 15° at three and 12 months post-surgery., Materials and Methods: One hundred twenty-four consecutive patients (163 TKAs) of an average age of 61.9 years (52-79) with a pre-operative varus more than 15° were managed with jig-based TKA. Based on the post-operative mechanical femorotibial alignment (FTMA), they were categorised into three groups, namely neutral (180 + 3 ° ), mild varus (173° to 176°) and severe varus (172° and below). The outcomes of these three groups were assessed at three and 12 months by the Oxford knee score and the WOMAC score were calculated and co-related to the extent of correction., Results: At three months, knees in the mild varus group (n = 88) had the best results with an Oxford knee score of 41.76 + 1.44 and a WOMAC score of 19.29 + 2.93 compared to the severe varus group and the neutral alignment group which had Oxford knee scores (OKS) of 37.43 + 2.51 and 31.91 + 3.51 and WOMAC scores of 22.57 + 1.51 and 24.46 + 4.15 respectively. However at 12 months, knees in all the groups (neutral, mild varus, severe varus) had similar good functional outcomes with OKS of 39.08 + 1.68, 39.24 + 1.88, 39.29 + 1.11 and WOMAC scores of 17.42 + 2.15, 16.48 + 2.11, 16.14 + 1.21 respectively. A scatter plot done for post-operative FTMA and the functional outcome score for both scores showed a bell curve with the best outcome corresponding to a FTMA of 175° at 3 months and equal distribution for both scores at 12 months., Conclusion: The results of our study showed that minimal under-correction gave superior functional outcomes at three months. But this advantage was temporary and both, under-correction and neutral alignment achieved equally good outcomes at one year. Considering the increased prosthesis longevity associated with neutral alignment, we propose that neutral alignment must be aimed for during TKA for knees with severe varus., Study Design: Prospective study.

Purpose of the Study: To evaluate the outcomes and complications using cemented megaprosthesis in elderly patients with distal femur nonunions (DFN)., Materials and Methods: Between 2012 and 2016, 24 patients of DFN with an average age of 71.8 years (66-83) and an average 1.9(1-3) prior surgery was managed with distal femur replacement using cemented modular endoprosthesis. Outcomes were analysed on the following criteria: implant status, complications, knee range of motion, Knee Society Score (KSS) and Musculoskeletal Tumor Society (MSTS) score., Results: All patients were extremely satisfied with their outcomes. At an average 22.1 months (10-43) follow-up, patients had an average 69.5° (40°-110°) knee flexion, an average KSS of 75.7 (63-88) and an average MSTS score of 19.3 (17-25). Four patients died at an average 21.3 months after surgery due to causes unrelated to the fracture. One patient (4.1%) had implant-related complication; deep infection which required debridement and intravenous antibiotics. There were no late amputations or peri-operative deaths and no patient had aseptic loosening of components., Conclusion: By permitting immediate full weight-bearing ambulation and with most patients returning to an acceptable functional status, cemented megaprosthesis is a viable and useful single-stage management option in elderly patients with DFN.

Objectives  Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna's technique-a reliable single-stage procedure of combining allograft and free vascularized fibular graft-in treating large posttraumatic bone defects in the distal third of the femur. Study Design  This is a retrospective analysis. Materials and Methods  Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18-49 years) and an average defect of 14.5 cm (range: 9.5-20 cm) in the distal femur were managed by the modified Capanna's technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted. Outcomes and Results  Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5-9), with an average knee flexion of 80 degrees (range: 45-110 degrees) and an average LEFS of 63 (range: 46-72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union. Conclusion  The modified Capanna's technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur. Level of Evidence  Level 4. Level of Clinical Care  Level I tertiary trauma center., Competing Interests: NoteConflict of Interest The study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki. The authors declare no conflict of interest.

Background: Recalcitrant distal femur nonunions (RDFN) are a challenge in management due to factors including poor bone stock, multiple surgeries, metaphyseal bone loss, and joint contractures. There are no specific guidelines in the management of cases of RDFN. Based on our experience, we devised an algorithm and we present the results of 62 cases of RDFN managed following it., Materials and Methods: Our algorithm was formulated after analyzing 34 cases of RDFN and it involved four factors which were hypothesized to influence outcomes namely: distal femoral bone stock, extent of medial void, alignment of the fracture, and stability of fixation. Each factor was addressed specifically to achieve a good outcome. Between 2012 and 2015, 62 patients with RDFN at a mean age of 47.4 years (26-73) and 2.3 prior surgeries (2-6) were managed following the algorithm., Intervention: 58 patients required revision osteosynthesis to improve alignment and achieve a stable fixation. 4 elderly patients with poor bone stock were managed with arthroplasty. Extent of medial void was found to significantly influence surgical decision making. Five patients without medial void required only cancellous autograft bone grafting, 47 patients with < 2 cm void were treated with an allograft fibular strut inserted in the metaphysis and 6 patients with a void > 2 cm were managed with medial plating., Outcomes and Results: 57 patients treated with osteosynthesis achieved union at an average of 7.4 months (6-11) and the 4 patients managed with arthroplasty also had a favourable outcome. One patient who was managed with revision osteosynthesis had a nonunion with an implant failure and needed an arthroplasty procedure. The average LEFS (lower extremity functional score) of all our patients was 67 (51-76) at an average follow-up of 18.2 months (12-33)., Conclusion: Our stepwise surgical algorithm would help surgeons to identify the factors that need to be addressed and guide them towards the interventions that are necessary to achieve a successful outcome while managing cases of RDFN., Level of Evidence: III., Level of Clinical Care: Level I Tertiary trauma centre.