Is there a role for elbow arthrodesis in 21st Century - Current concepts and overview of surgical techniques

Elbow arthrodesis is uncommon and is usually performed as a salvage procedure to provide a stable elbow. There is a significant gap in the literature about the indications, contraindications, fusion angle, technical tips, and reversibility of the procedure. This review addresses these questions in a evidence based manner, based on the published literature.     

How Are Indeterminate Pulmonary Nodules at Diagnosis Associated with Survival in Patients with High-Grade Osteosarcoma?

BackgroundPulmonary metastases are a poor prognostic factor in patients with osteosarcoma; however, the clinical significance of subcentimeter lung nodules and whether they represent a tumor is not fully known. Because the clinician is faced with decisions regarding biopsy, resection, or observation of lung nodules and the potential impact they have on decisions about resection of the primary tumor, this remains an area of uncertainty in patient treatment. Surgical management of the primary tumor is tailored to prognosis, and it is unclear how aggressively patients with indeterminate pulmonary nodules (IPNs), defined as nodules smaller than 1 cm at presentation, should be treated. There is a clear need to better understand the clinical importance of these nodules.Questions/purposes(1) What percentage of patients with high-grade osteosarcoma and spindle cell sarcoma of bone have IPNs at diagnosis? (2) Are IPNs at diagnosis associated with worse metastasis-free and overall survival? (3) Are there any clinical or radiologic factors associated with worse overall survival in patients with IPN?MethodsBetween 2008 and 2016, 484 patients with a first presentation of osteosarcoma or spindle cell sarcoma of bone were retrospectively identified from an institutional database. Patients with the following were excluded: treatment at another institution (6%, 27 of 484), death related to complications of neoadjuvant chemotherapy (1%, 3 of 484), Grade 1 or 2 on final pathology (4%, 21 of 484) and lack of staging chest CT available for review (0.4%, 2 of 484). All patients with abnormalities on their staging chest CT underwent imaging re-review by a senior radiology consultant and were divided into three groups for comparison: no metastases (70%, 302 of 431), IPN (16%, 68 of 431), and metastases (14%, 61 of 431) at the time of diagnosis. A random subset of CT scans was reviewed by a senior radiology registrar and there was very good agreement between the two reviewers (κ = 0.88). Demographic and oncologic variables as well as treatment details and clinical course were gleaned from a longitudinally maintained institutional database. The three groups did not differ with regard to age, gender, subtype, presence of pathological fracture, tumor site, or chemotherapy-induced necrosis. They differed according to local control strategy and tumor size, with a larger proportion of patients in the metastases group presenting with larger tumor size and undergoing nonoperative treatment. There was no differential loss to follow-up among the three groups. Two percent (6 of 302) of patients with no metastases, no patients with IPN, and 2% (1 of 61) of patients with metastases were lost to follow-up at 1 year postdiagnosis but were not known to have died. Individual treatment decisions were determined as part of a multidisciplinary conference, but in general, patients without obvious metastases received (neo)adjuvant chemotherapy and surgical resection for local control. Patients in the no metastases and IPN groups did not differ in local control strategy. For patients in the IPN group, staging CT images were inspected for IPN characteristics including number, distribution, size, location, presence of mineralization, and shape. Subsequent chest CT images were examined by the same radiologist to reevaluate known nodules for interval change in size and to identify the presence of new nodules. A random subset of chest CT scans were re-reviewed by a senior radiology resident (κ = 0.62). The association of demographic and oncologic variables with metastasis-free and overall survival was first explored using the Kaplan-Meier method (log-rank test) in univariable analyses. All variables that were statistically significant (p < 0.05) in univariable analyses were entered into Cox regression multivariable analyses.ResultsFollowing re-review of staging chest CTs, IPNs were found in 16% (68 of 431) of patients, while an additional 14% (61 of 431) of patients had lung metastases (parenchymal nodules 10 mm or larger). After controlling for potential confounding variables like local control strategy, tumor size, and chemotherapy-induced necrosis, we found that the presence of an IPN was associated with worse overall survival and a higher incidence of metastases (hazard ratio 1.9 [95% CI 1.3 to 2.8]; p = 0.001 and HR 3.6 [95% CI 2.5 to 5.2]; p < 0.001, respectively). Two-year overall survival for patients with no metastases, IPN, or metastases was 83% [95% CI 78 to 87], 65% [95% CI 52 to 75] and 45% [95% CI 32 to 57], respectively (p = 0.001). In 74% (50 of 68) of patients with IPNs, it became apparent that they were true metastatic lesions at a median of 5.3 months. Eighty-six percent (43 of 50) of these patients had disease progression by 2 years after diagnosis. In multivariable analysis, local control strategy and tumor subtype correlated with overall survival for patients with IPNs. Patients who were treated nonoperatively and who had a secondary sarcoma had worse outcomes (HR 3.6 [95% CI 1.5 to 8.3]; p = 0.003 and HR 3.4 [95% CI 1.1 to 10.0]; p = 0.03). The presence of nodule mineralization was associated with improved overall survival in the univariable analysis (87% [95% CI 39 to 98] versus 57% [95% CI 43 to 69]; p = 0.008), however, because we could not control for other factors in a multivariable analysis, the relationship between mineralization and survival could not be determined. We were unable to detect an association between any other nodule radiologic features and survival.ConclusionThe findings show that the presence of IPNs at diagnosis is associated with poorer survival of affected patients compared with those with normal staging chest CTs. IPNs noted at presentation in patients with high-grade osteosarcoma and spindle cell sarcoma of bone should be discussed with the patient and be considered when making treatment decisions. Further work is required to elucidate how the nodules should be managed.Level of EvidenceLevel III, prognostic study.     

Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study

BackgroundFor displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF.MethodsA nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge.ResultsBy visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients’ propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively).ConclusionOur research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.     

Utility of computed tomography angiography in traumatic lower limb injury: Review of clinical impact in level 1 trauma centre

IntroductionCT angiography (CTA) is efficient and accurate in detecting lower limb vascular injury in the setting of trauma (1-6). Less clear is the in-practice correlation between appropriate indications for these examinations and subsequent clinical impacts.Materials and MethodsAll CT leg angiography acquired from January 2016 through April 2019 were reviewed via retrospective search. Studies not acquired for trauma were excluded. Imaging and reports were reviewed to assess for vascular injury. Electronic medical records were reviewed to assess the presence or absence of classical ‘hard’ or ‘soft’ signs of vascular injury and whether vascular intervention was undertaken.ResultsA total of 347 lower limb injuries were identified in 273 men and 74 women. Mean age was 41.5 years ranging from 15-95 years. 268 cases were fractures with 177 open injuries. 301 of injuries were secondary to blunt trauma, 31 penetrating injury occurred and 15 cases were ascribed to blast/gunshot injury.74 (21.3%) studies were deemed to have a positive finding of vascular injury, 249 (71.8%) were reported as negative and 24 (6.9%) were indeterminate. Of the cases with positive findings, 26 underwent intervention (7.4% of all patients undergoing CTA). No patients with negative CTA required intervention, while three (3, 0.8% of total) with indeterminate findings required intervention.Where there were no clinical signs (absence of any hard or soft signs) 249 CTA's were performed and none required any form of intervention.ConclusionIn the absence of clinical signs of vessel injury, CT angiography is unlikely to demonstrate vascular injury requiring intervention in the setting of lower limb trauma.     

The management of patients admitted to hospital with vertebral fragility fractures: experience from a UK university hospital

IntroductionPatients that require hospital admission for vertebral fragility fractures were older, multimorbid, frail, have cognitive impairment and were in severe pain. This study aimed to describe the hospital treatment received in one UK university hospital with the purpose of proposing what hospital services should look like.MethodThis was an observational study of adults aged 50 years and over admitted to hospital over 12 months with an acute vertebral fragility fracture. Information was collected from patients and electronic health records on their presentation and hospital care.Results90 patients were recruited into the study. 69% presented to hospital 24 h after the onset of their severe acute back pain. 38% had a concomitant medical diagnosis, such as an ongoing infection. X-ray of the spine was the most common imaging of choice to diagnose a fracture. There was variation in the content of the radiology reports. 46% or patients were managed on geriatric medicine wards, 39% on general medical wards, and followed by 14% on spinal surgical wards. Patients cared for by medical teams were older, frailer, had a higher prevalence of cognitive impairment, more dependent for daily living and less mobile compared to those under the care of the spinal surgical team. Many patients on medical wards had input from spinal surgical team and vice versa. 9% proceeded to have vertebral augmentation. Despite many in severe pain, only a third were prescribed opioids with the median dose of morphine-equivalent was 10-20 mg daily for the first three days of admission. While in hospital, 31% developed a medical complication, with infection being the most common one. On discharge, 76% still required opioids and only 56% had a plan for their bone health.DiscussionImprovements could be made to hospital vertebral fracture care. Many did not receive adequate pain relief and appropriate assessments to reduce their future fall and fracture risk. Most were medically managed. Quality standards and re-organising care in hip fracture has led to improved outcomes. A similar approach in vertebral fragility fractures might also deliver improved outcomes.     

Surgical site infection following surgery for spinal deformity: About 102 patients

IntroductionComplex spinal surgery is known to be at risk of complications. Surgical site infection is a serious complication in spine surgery and its frequency is significantly increased in adult spinal deformity correction. The aim of this study is to identify patients’ characteristics and risk factors of surgical site infection (SSI) following an osteotomy.MethodsThis is a single-center retrospective study of patients who underwent an osteotomy between January 2015 and December 2017. Surgical site infection diagnosis was based upon patient's clinical evidence of infection, biologic parameters, microbiological criteria and/or image findings.ResultsIn total, 102 patients were eligible and 70 were women (68.6%). Mean age was 65 years old (27–83 years) and mean body mass index (BMI) was 26.14 kg.m⁻² (18.4–44.1). Eleven patients were in the SSI group and 91 in the No-SSI group. The mean Schwab grade was 1.5 (1–4) in the SSI group vs. 1.4 (1–5) in the No-SSI group (P = 0.435). The mean operative time was on 201.9 minutes (67–377). Mean length of stay was 20.6 days (10–73) in the SSI group vs. 15 days (5–44) in the No-SSI group (P = 0.041). Favorable outcome was found in 10 patients (90.9%) in the SSI group.ConclusionCorrection surgery for adult spinal deformity with osteotomies carries a high risk of complications specially SSI. Identification of risk factors, prevention and medical management of SSI should be well assessed.     

Radiologic and Demographic Characteristics of Patients With Plantar Calcaneal Spur

Many people with heel pain in the general population are often diagnosed with plantar calcaneal spurs (PCS). The aim of this study was to evaluate the radiological and demographic characteristics of PCS patients and to compare the differences with the control group. In 2018, 420 patients with weightbearing lateral ankle X-ray images were included in the study. The patients were divided into 2 groups as PCS group and control group. Groups were compared age and age group (20-29, 30-39, 40-49, 50-59, 60-69, 70 and over) weight, height, body mass index (<25, 25-30, >30), chronic diseases as demographically and were also compared radiologically as calcaneal inclination angle (CIA), lateral talocalcaneal angle (LTCA), Bohler angle and Gissane angle. A statistically significant relationship was found between gender and PCS. Plantar calcaneal spur is more common in females than in males (X²:8.101, p < .03). PCS was less common in patients with BMI <25 and 25-29.9, whereas PCS is more common in patients with BMI >30 (X²:7.698, p < .021). Although the CIA angle was within normal limits in both groups, it was significantly lower in patients with PCS than in the control group(p < .05). There was no statistically significant difference between the 2 groups in terms of age, chronic disease, LTCA, Bohler angle, Gissane angle. Female gender and obesity are among the risk factors for PCS formation. CIA may have an important role in PCS formation. In order to clarify the etiology and pathophysiology of PCS, further studies with radiological features are needed.     

Risk factors for postoperative ileus after oblique lateral interbody fusion: a multivariate analysis

Background ContextOblique lateral interbody fusion (OLIF)–has become a widely used, efficient surgical tool for various degenerative lumbar conditions. Postoperative ileus (POI) is a relatively common complication after anterior lumbar interbody fusion due to the manipulation of the intestine during the surgical approach. However, to our knowledge, little is known about POI following OLIF even though it also involves bowel manipulation during a surgical procedure.PurposeTo assess the incidence of POI and identify independent risk factors for POI development after OLIF.Study Design/SettingRetrospective cohort study.Patient SampleAll consecutive patients who underwent OLIF and percutaneous pedicle screw instrumentation from August 2012 until October 2019 at a single institutionOutcome MeasuresPatient demographics (sex, age, body weight, height, and body mass index), comorbidities (diabetes mellitus, gastroesophageal reflux disease, antithrombotic medication, previous abdominal surgery, and previous lumbar surgery), and perioperative details (preoperative diagnosis, number of levels fused, inadvertent endplate fracture during cage insertion, type of interbody graft, intraoperative estimated blood loss, duration of surgery and anesthesia, the amount of intraoperative remifentanil and propofol used as anesthetic agents, the total postoperative retroperitoneal closed-suction drainage output, and the cumulative opioid dosage administered in the first 72 hours postoperatively).MethodsPOI was defined as 2 or more of the following at 72 hours postoperatively: (1) ongoing nausea or vomiting postoperatively, (2) the absence of flatus over last 24-hour period, (3) inability to tolerate an oral diet over last 24-hour period, (4) ongoing abdominal distention postoperatively, and (5) radiological confirmation. The subjects were divided into 2 groups: patients with POI and those without POI. Binary logistic regression analyses were performed on demographics, comorbidities, and perioperative factors to identify independent risk factors for POI.ResultsEighteen (3.9%) of 460 patients experienced POI after OLIF and percutaneous pedicle screw instrumentation. Patients with POI had a significantly longer postoperative length of hospital stay than those without POI (8.61 ± 2.66 vs 6.48 ± 2.64, p = .001). Multivariate logistic regression analysis identified inadvertent endplate fracture (adjusted odds ratio = 6.017, p = .001) and the amount of intraoperative remifentanil (adjusted odds ratio = 1.057, p = .024) as independent risk factors for the occurrence of POI following OLIF.ConclusionThis study identified inadvertent endplate fracture and the amount of intraoperative remifentanil as independent risk factors for the development of POI after OLIF.     

A clinical calculator for predicting intraoperative blood loss and transfusion risk in spine tumor patients

BACKGROUND CONTEXTSurgery for vertebral column tumors is commonly associated with intraoperative blood loss (IOBL) exceeding 2 liters and the need for transfusion of allogeneic blood products. Transfusion of allogeneic blood, while necessary, is not benign, and has been associated with increased rates of wound complication, venous thromboembolism, delirium, and death.PURPOSETo develop a prediction tool capable of predicting IOBL and risk of requiring allogeneic transfusion in patients undergoing surgery for vertebral column tumors.STUDY DESIGN/SETTINGRetrospective, single-center study.PATIENT SAMPLEConsecutive series of 274 patients undergoing 350 unique operations for primary or metastatic spinal column tumors over a 46-month period at a comprehensive cancer centerOUTCOME MEASURESIOBL (in mL), use of intraoperative blood products, and intraoperative blood products transfused.METHODSWe identified IOBL and transfusions, along with demographic data, preoperative laboratory data, and surgical procedures performed. Independent predictors of IOBL and transfusion risk were identified using multivariable regression.RESULTSMean age at surgery was 57.0±13.6 years, 53.1% were male, and 67.1% were treated for metastatic lesions. Independent predictors of IOBL included en bloc resection (p<.001), surgical invasiveness (β=25.43 per point; p<0.001), and preoperative albumin (β=?244.86 per g/dL; p=0.011). Predictors of transfusion risk included preoperative hematocrit (odds ratio [OR]=0.88 per %; 95% confidence interval [CI, 0.84, 0.93]; p<0.001), preoperative MCHgb (OR=0.88 per pg; 95% CI [0.78, 1.00]; p=0.048), preoperative red cell distribution width (OR=1.32 per %; 95% CI [1.13, 1.55]; p<0.001), en bloc resection (OR=3.17; 95%CI [1.33, 7.54]; p=0.009), and surgical invasiveness (OR=1.08 per point; [1.06; 1.11]; p<0.001). The transfusion model showed a good fit of the data with an optimism-corrected area under the curve of 0.819. A freely available, web-based calculator was developed for the transfusion risk model (https://jhuspine3.shinyapps.io/TRUST/).CONCLUSIONSHere we present the first clinical calculator for intraoperative blood loss and transfusion risk in patients being treated for primary or metastatic vertebral column tumors. Surgical invasiveness and preoperative microcytic anemia most strongly predict transfusion risk. The resultant calculators may prove clinically useful for surgeons counseling patients about their individual risk of requiring allogeneic transfusion.