The Clinical Utility of Repeating Magnetic Resonance Imaging (MRI) Scans Within 12 Months in the Management of Lumbosacral Degenerative Disc Disease.

PURPOSE: Magnetic resonance imaging (MRI) is the gold standard investigation for lumbosacral degenerative disc disease. However, there is controversy regarding the clinical value of repeating an MRI scan within 12 months when a patient presents with recurring or changing symptoms. This study measures rates of radiological change in a real-world cohort to guide clinicians when deciding to repeat a scan. METHODS: All patients over a 10-year window in one general hospital who underwent two lumbosacral MRI scans for degenerative disc disease within 12 months of each other were included in the study. All MRI reports were manually reviewed. The level of main vertebral pathology was recorded, along with the location of a disc prolapse. Time intervals between the two scans were calculated, and these were collated into 30-day intervals for analysis. The repeat scans were categorized into three groups: no change, radiological improvement, and radiological deterioration. Patients who had clinically significant deterioration in the form of cauda equina compression on MRI scans were recorded. FINDINGS: Four hundred and eighty-one patients were included for analysis. Three hundred and ninety (81%) showed no change in MRI findings, 18 (3.7%) had improvements in their repeat scans, and 73 (15.3%) demonstrated deterioration in their repeat scans. Of the 73 patients with radiological deterioration, three patients (0.62% of the total) required urgent surgical intervention for cauda equina syndrome (CES). CONCLUSIONS: Though there is no alternative to detailed clinical assessment in determining whether a repeat MRI scan is indicated, the findings demonstrate that repeating MRI within 12 months for patients with lumbosacral degenerative disc disease has a low chance of altering the management plan. Over the 10-year period, only three patients required an urgent change to their clinical management. We believe this data can help guide clinical decision-making when considering a repeat scan.

Epidemiology of Paediatric Trauma During National Lockdown: A Retrospective Study With 12 Months of Follow-Up.

Introduction The COVID-19 pandemic and its associated preventative measures such as national lockdown dramatically changed the daily activities of children. This paper aims to compare the epidemiology of paediatric orthopaedic trauma presentation, management and outcomes during the school closure period with the matched pre-pandemic period in 2019. Methods This was a retrospective cohort study of data collected from the West Yorkshire Trauma Network, comprising a major trauma centre, Leeds General Infirmary, and five peripheral trauma units. All patients aged 0-18 years who required trauma unit management during the school closure period (18 March 2020-25 May 2020) were included. Cases for the matched period in 2019 were analysed for baseline comparison. Patient demographics, mechanism and anatomical location of injury, management and follow-up were assessed. Results In the 2020 and 2019 cohorts, 286 and 575 injuries were observed, respectively. In the 2020 cohort, we observed a 50.3% (n=289) fall in paediatric trauma presentation and a significant proportional reduction in referrals from the emergency department (22% (n=63) versus 53% (n=305); p<0.001). There was also a significant reduction in the average age at presentation by more than one year (p<0.001). Sports-related injuries decreased significantly (n=16 (5.6%) versus n=127 (22.1%); p<0.001). While the proportion of ride-on injuries increased significantly, overall numbers remained similar (n=63 (22%) versus n=61 (10.6%); p<0.0001). Non-accidental injury (NAI) concerns rose significantly (n=9 (3.1%) versus n=4 (0.7%); p=0.01), but the absolute number of confirmed NAI cases stayed the same (n=2). There was a proportional increase in upper limb injuries (64.3% (n=184) versus 58.4% (n=336); p>0.05) and a proportional reduction in lower limb injuries (32.1% (n=92) versus 35.5% (n=204); p>0.05). However, the rate of tibial shaft injuries rose significantly (10.1% (n=29) versus 5.2% (n=30); p=0.02). The use of conservative management increased with a significant delay in average time to surgery from the date of injury (8.5 days versus 3.1 days; p=0.01). Patients who were only followed up with a telephone consultation rose significantly (23% (n= 66) versus 6% (n=35); p<0.001). Re-presentation rate increased significantly (1.4% (n=4) versus 0.2% (n=12); p=0.04). Conclusion Our study showed a reduction in paediatric trauma presentations during the pandemic and a significant reduction in the average age at presentation. This change has been accompanied by a shift in the mechanism and anatomical location of injury, management and subsequent follow-up.

KingMark's dual-marker versus a conventional single-marker templating system: is there a difference in accuracy of predicting final implant sizes and leg lengths?

AIMS: Pre-operative templating for total hip replacement (THR) surgery leads to more accurate implant sizing and positioning. This study aimed to compare the KingMark™ dual-marker system for magnification calibration to the current gold standard single-marker system in accuracy of predicting implant size and restoration of leg length post-operatively. METHODS: This is a retrospective analysis of patients who had primary THR surgery from 2013 to 2019 by a single surgeon. Patients were in two cohorts whose operations were completed at separate healthcare facilities. Patients in the first cohort had pre-operative templating using the KingMark system; patients in the second cohort had templating using a single-marker. For all patients, pre-operative radiographs were reviewed; predicted implants noted; and leg length discrepancies calculated. These were compared to post-operative data. We then tested the null hypothesis that there was no difference between the templating methods for prediction accuracy of implant size and achieving restoration of leg length. RESULTS: A total of 121 patients were included in the KingMark cohort, and 104 were included in the single-marker cohort. In the KingMark cohort, 83.5% of patients had implantation of a cup within one size of that predicted, compared to 71.2% of the single-marker cohort. This superiority was statistically significant. There was a greater proportion of exact cup size predictions in the KingMark cohort, but this was not statistically significant. We did not find any significant difference between the cohorts for stem size, or stem placement, or reduction of leg length discrepancy. CONCLUSION: We have demonstrated statistically significant superiority of the KingMark over a single-marker templating system for predicting cup size in primary THR surgery. For post-operative restoration of leg length, our study did not show any advantage of KingMark templating compared to single-marker templating.

Retrospective Review of Arthroplasty Radiographs: How to Define an Adequate Radiograph.

Introduction Adequacy of postoperative hip and knee radiographs has a direct impact on its interpretation. We undertook a quality improvement project by creating local standards to meet the arthroplasty team expectations for a satisfactory radiograph. The purposes of the study are 1. Assessment of the adequacy of radiographs according to defined criteria, and 2. Correlation of system and patient factors with inadequate radiographs. Methods Stage I: We conducted a single centre, retrospective audit to check the adequacy of a postoperative radiography following a total hip or knee replacement. A total of 100 radiographs were assessed against the nine criteria laid out with the consensus of orthopaedic surgeons and radiologists. Stage II: We created a quality improvement proforma for use in the radiology department. We re-assessed 100 radiographs during the second cycle against the nine criteria to check the adequacy of hip and knee arthroplasty radiographs, Results Stage I: Of 100 radiographs, 51 were from the knee and 49 from the hip arthroplasty group. Sixty-nine radiographs were adequate considering overall criteria, and 31 radiographs were inadequate. The inadequacy in radiographs was related to the visibility of prosthesis, cement or relevant anatomy. Stage II: We created a quality improvement performa for use in radiology department, highlighting the nine initial criteria. One hundred radiographs of hip and knee arthroplasty were re-assessed. Overall, 84 radiographs fulfilled the criteria of being adequate. Conclusion Adequacy of knee and hip arthroplasty radiographs is essential in picking up pathologies that can be missed otherwise. We present simple criteria to improve the adequacy of x-ray and prevent repetition of radiographs.

There is no 'weekend effect' in elective orthopaedic surgery.

Introduction The 'weekend effect' is said to occur when patient outcomes are adversely affected by the day of the week on which they present to hospital or have surgery. However, it is uncertain whether such a phenomenon exists for elective orthopaedic surgery. We investigated whether there is a 'weekend effect' in elective orthopaedic patients. Methods Retrospectively collected data were obtained from our institution's electronic patient records. We collected demographic and International Statistical Classification of Diseases and Related Health Problems tenth revision coding data for all included patients. Multivariate analyses identified covariate-adjusted risk factors, associated with prolonged stays. Thirty-day mortality data were assessed according to the day on which surgery occurred. Results We analysed data for 892 patients over a one-year period. During the year, 457 patients had a total hip and 435 had a total knee replacement; 814 patients (91.3%) underwent surgery during the week, while 78 (8.7%) had surgery on a Saturday. There was no difference in average length of stay between the groups (5.0, 2.6 vs 5.0, 3.4, P = 0.95). Variables associated with prolonged hospitalisation included increasing age (covariate adjusted relative risk 1.02, 95% confidence interval 1.01-1.03, P < 0.001) and an American Society of Anesthesiologists score of 2, (relative risk 1.6, 95% confidence interval 1.15-2.20, P = 0.005). There was one death in a patient who underwent surgery on a Monday. Conclusions There is no 'weekend effect' for elective orthopaedic surgery.

Atypical fractures: An issue of concern or a myth?

Atypical Femoral Fractures (AFF) represent fractures located between the lesser trochanter and the supracondylar flare of a femur. An increasing pool of evidence supports their association with the prolonged use of bisphosphonates, even though a direct correlation is yet to be proved. The purpose of this review is to encapsulate the current evidence associating bisphosphonate use and the development of AFFs, the clinical features related to their presentation, as well as to report the armamentarium of strategies available in the prevention and treatment of AFFs. Based on these evidence, we propose a management algorithm for AFFs, that can serve as a guide for patients presenting with this condition.

Acalculous Phrygian cap cholecystitis.

We report a case of a 53-year-old Caucasian woman who presented with symptoms of cholecystitis; an ultrasound and CT scans showed a mass lesion associated with the gallbladder and no gallstones. Laparoscopic cholecystectomy and further histological analysis confirmed acalculous cholecystitis in a Phrygian cap gallbladder.