The impact of the SARS-CoV-2 pandemic on referral characteristics in a national tertiary spinal injuries unit.

BACKGROUND: The SARS-CoV-2 pandemic has had profound implications on healthcare institutions. AIMS: This study aims to assess and compare referral patterns during COVID-19 to corresponding dates for the preceding 3 years (2017-2019), in order to preemptively coordinate the logistics of the surgical unit for similar future experiences. METHODS: Retrospective review for our institution, a national tertiary referral centre for spine pathology. Two distinct time-points were chosen to represent the varied levels of social restriction during the current pandemic: (i) study period 1 (SP1) from 11 November 2020 to 08 June 2020 represents a national lockdown, and (ii) study period 2 (SP2) from 09 June 2020 to 09 September 2020 indicates an easing of restrictions. Both periods were compared to corresponding dates (CP1: 11 March-08 June and CP2 09 June-09 September) for the preceding 3 years (2017-2019). Data collected included age, gender, and mechanism of injury (MOI) for descriptive analyses. MOIs were categorised into disc disease, cyclist, road-traffic-accident (RTA), falls < 2 m, falls > 2 m, malignancy, sporting injuries, and miscellaneous. RESULTS: All MOI categories witnessed a reduction in referral numbers during SP1: disc disease (-29%), cyclist (-5%), RTAs (-66%), falls < 2 m (-39%), falls > 2 m (-17%), malignancy (-33%), sporting injuries (-100%), and miscellaneous (-58%). Four of 8 categories (RTAs, falls < 2 m, malignancy, miscellaneous) showed a trend towards return of pre-lockdown values during SP2. Two categories (disc disease, falls > 2 m) showed a further reduction (-34%, -27%) during SP2. One category (sporting injuries) portrayed a complete return to normal values during SP2 while a notable increase in cyclist-related referrals was witnessed (+ 63%) when compared with corresponding dates of previous years. CONCLUSION: Spinal injury continues to occur across almost all categories, albeit at considerably reduced numbers. RTAs and falls remained the most common MOI. Awareness needs to be drawn to the reduction of malignancy-related referrals to dissuade people with such symptoms from avoiding presentation to hospital over periods of social restrictions.

The Use of Halo Gravity Traction in Severe, Stiff Scoliosis.

PURPOSE: The correction of severe, stiff scoliosis in children is challenging. One method used to reduce the risk is preoperative halo gravity traction (HGT). In this study, the authors sought to define the efficiency and safety of HGT and characterize the chronology of the correction seen. METHOD: A consecutive group of pediatric patients with severe spinal deformities was treated with HGT before definitive correction. A standard protocol with the daily addition of weight to 50% of body weight at 3 weeks was used. Traction remained in place until signs of impending neurological complication or 6 weeks, whichever was sooner. RESULTS: Twenty-four patients were included with a mean age of 11.8 years. The mean coronal deformity was 123 degrees, with a T1-L5 height of 234 mm. The mean duration of traction was 42 days with a mean improvement in height of 72 mm with 82% occurring over the first 3 weeks. Hundred percent of the angular and 98% of T1-L5 height correction was reached by 6 weeks.One patient showed early signs of a cranial nerve palsy prompting early surgery and 8 patients showed pin loosening, 1 of which required revision of their halo. One patient underwent a slower progression of traction because of transitory urinary disturbance. Following fusion, angular correction of the major curve was 49%. CONCLUSION: HGT is a safe treatment for severe, stiff scoliosis because it can respond to early signs of impending neurological impairment. The first 3 weeks of treatment, reaching 50% of body weight as a traction force accounts for 80% of correction, with the remaining 20% in the following 2 weeks. At least 4 weeks of traction is recommended when following this protocol.

Early limited instrumentation of scoliosis in Duchenne muscular dystrophy: is a single-rod construct sufficient?

BACKGROUND CONTEXT: Correction of scoliotic deformity in Duchenne muscular dystrophy (DMD) is performed to maintain adequate seating posture and facilitate comfort. Delaying surgery can predispose to greater morbidity as DMD exhibits progressive cardiorespiratory compromise. Early limited instrumentation may provide a solution to optimize patients with this condition. PURPOSE: The aim was to assess outcomes for a cohort of DMD patients who had posterior single-rod instrumentation and bilateral spinal fusion of their neuromuscular scoliotic deformity. STUDY DESIGN: This was a retrospective cohort study. PATIENT SAMPLE: Forty-one consecutive patients were included. OUTCOME MEASURES: Perioperative morbidity, seating outcomes, pulmonary function, deformity correction, and instrumentation integrity were assessed. METHODS: Clinical and radiographic review was performed. RESULTS: No perioperative mortality or neurologic deterioration was encountered. Total surgical time was 96 minutes, mean total blood loss was 2.3l, mean intensive care unit stay was 41 hours, and overall length of stay was 11 days. Mean Cobb angle improved from 24.3° to 15.6°, pelvic obliquity improved from 7° preoperatively to 5° postoperatively. Three patients had failure of fixation at a mean of 3.5 years. Forced vital capacity was 60% preoperatively and 56% at 1 year, forced expiratory volume/1 second was 67% and 62% at 1 year postoperatively. Seating and posture was satisfactory in all these patients. CONCLUSIONS: The authors advocate early operative intervention using a limited instrumentation technique in patients with DMD to maintain seating balance and minimize perioperative morbidity.

Management of simultaneous bilateral neck of femur fractures in an elderly patient.

Simultaneous bilateral neck of femur fracture is rare. There have been few reports of such a condition in the literature. This uncommon pattern of injury has been associated with high-energy trauma, underlying bone disease, and seizure disorders. We describe our experience of such a condition involving an elderly patient with significant cardiovascular comorbidity. The operative approach involved single-stage repair of both the involved joints. Bilateral uncemented hemi-arthroplasty was performed using a single tray of sterile surgical instruments and 2 sterile drapes. We report a satisfactory outcome. Uncemented arthroplasty should be considered in such a case so as to minimize the risk of a possible bone cement implantation syndrome.

Locking plate fixation for proximal humerus fractures.

Locking plates are increasingly used to surgically treat proximal humerus fractures. Knowledge of the bone quality of the proximal humerus is important. Studies have shown the medial and dorsal aspects of the proximal humeral head to have the highest bone strength, and this should be exploited by fixation techniques, particularly in elderly patients with osteoporosis. The goals of surgery for proximal humeral fractures should involve minimal soft tissue dissection and achieve anatomic reduction of the head complex with sufficient stability to allow for early shoulder mobilization. This article reviews various treatment options, in particular locking plate fixation. Locking plate fixation is associated with a high complication rate, such as avascular necrosis (7.9%), screw cutout (11.6%), and revision surgery (13.7%). These complications are frequently due to the varus deformation of the humeral head. Strategic screw placement in the humeral head would minimize the possibility of loss of fracture reduction and potential hardware complications. Locking plate fixation is a good surgical option for the management of proximal humerus fractures. Complications can be avoided by using better bone stock and by careful screw placement in the humeral head.

Femoroacetabular impingement after slipped capital femoral epiphysis: does slip severity predict clinical symptoms?

BACKGROUND: Femoroacetabular impingement (FAI) may be common after slipped capital femoral epiphysis though the actual frequency is unknown. The purpose of this study was to determine the frequency of symptomatic FAI in young adults after slipped capital femoral epiphysis and define its relationship with slip severity. METHODS: We retrospectively reviewed a consecutive series of 49 patients (65 hips) to determine patient and slip characteristics and treatments. Patients were then recalled for clinical and radiographic review to assess symptoms, particularly impingement, and outcomes after skeletal maturity. RESULTS: Thirty-six patients (49 hips) were reviewed clinically and radiographically with a mean follow-up of 6.1 years (range: 2.2 to 13.1 y). All patients had reached skeletal maturity. Thirty-one percent (15/49) of patients complained of hip pain or stiffness, whereas 32% (16/49) had clinical signs of impingement. The Southwick slip angle and grade of slip or Loder's classification of physeal stability were not predictive of impingement at follow-up. The anterior head-neck offset angle (alpha angle) correlated most strongly with FAI (r=0.26). No pre-slips or prophylactically pinned hips developed clinical impingement in this review. CONCLUSIONS: In the absence of radiographic indicators to predict FAI, we advocate all but those hips pinned prophylactically or for pre-slip should be followed into adulthood and clinically monitored for impingement. Grade of slip in adolescence cannot be used as a predictive tool for FAI later in life. LEVEL OF EVIDENCE: Level II, retrospective study.

Transarticular stabilization of the immature femoral head: assessment of a novel surgical approach to the dislocating pediatric hip in a porcine model.

BACKGROUND: Acetabular dysplasia and hip instability are common in neuromuscular diseases such as spina bifida and cerebral palsy due to deranged muscle function around the hip. Occasionally in developmental dysplasia of the hip, persistent instability may be difficult to manage by standard treatments. It is in these contexts that we wished to investigate whether a dislocatable hip could be stabilized by means of a transarticular suture acting as a reconstructed ligamentum teres. The aim of this study was to investigate and assess the iatrogenic damage caused by such a procedure on the immature proximal femoral physis, epiphysis, and hip joint. METHODS: Four- to 6-week-old mixed breed European pigs (n = 18) were used in the study. Six animals with normal hips underwent the stabilization procedure to the right hip joint, the left hips serving as controls. The remaining 12 pigs were subjected to a model of hip dysplasia on the right hip. After 6 weeks, the dysplasia stimulus was removed, and half of the animals underwent the hip stabilization procedure, the remaining 6 animals served as a control for "untreated dysplasia." Animals underwent serial pelvic radiography until euthanasia at 18 weeks of age. Postoperative, morphometric, radiographic, and histological analyses were performed. RESULTS: The dysplasia model consistently produced an increase in the acetabular index, femoral head subluxation, and growth retardation of the capital epiphysis. We observed no detrimental effect on the capital ossific nucleus, proximal femoral physis, or acetabular development in terms of radiographic, morphometric, or histological findings after the transarticular suture procedure. CONCLUSIONS: The surgical technique of drilling across the immature porcine hip did not result in avascular necrosis of the femoral head, osseous bar formation across the proximal femoral physis, proximal femoral metaphyseal growth disturbance, chondrolysis, or disturbance in normal acetabular development. CLINICAL RELEVANCE: The described technique may be a useful augment to the definitive stabilization of the recalcitrant dysplastic or unstable hip where standard operative measures alone are likely to be unsuccessful.