Socioeconomic, Racial, and Insurance Disparities in Clinical Outcomes After Surgery Among Patients With Idiopathic Scoliosis.

BACKGROUND: Socioeconomic status (SES), race, and insurance type correlate with initial curve severity for patients with idiopathic scoliosis, but less is known regarding how these variables impact surgical outcomes. The objectives of this study were to determine the influence of SES, race, and insurance on preoperative appointment attendance, likelihood of obtaining a preoperative second opinion, brace prescription, missed 6 or 12-month postsurgical appointments, incidence of emergency department visits 0 to 90 days after surgery, and major complications within a year of surgery. METHODS: A review of 421 patients diagnosed with idiopathic scoliosis who underwent surgery at a single high-volume pediatric spinal deformity institution between May 2015 and October 2021 was conducted. Area Deprivation Index, a quantitative measure of SES, was collected. Scores were stratified by quartile; higher scores indicated a lower SES. χ 2 tests for correlation were performed to determine whether clinical outcomes were dependent upon Area Deprivation Index, race, or insurance type; P ≤0.05 was significant. RESULTS: The sample was 313 Caucasian (74%), 69 (16%) black, and 39 (9.3%) other patients. More patients had private versus public insurance (80% vs 20%) and were of higher SES. The likelihood of missing preoperative appointments was higher for black patients ( P = 0.037). Those with lower SES missed more postoperative appointments and received less bracing and second opinions ( P = 0.038, P = 0.017, P = 0.008, respectively). Being black and publicly insured correlated with fewer brace prescriptions ( P < 0.001, P = 0.050) and decreased rates of obtaining second opinions ( P = 0.004,  P = 0.001). CONCLUSION: Patients with idiopathic scoliosis surgery who were Caucasian, privately insured, and of higher SES were more likely to seek preoperative second opinions, be prescribed a brace, and attend postoperative appointments. Recognition of the inherent health care disparities prevalent within each pediatric spine surgery referral region is imperative to better inform local and national institutional level programs to educate and assist patients and families most at risk for disparate access to scoliosis care. LEVEL OF EVIDENCE: Level III; retrospective case-control study.

Sagittal alignment in operative degenerative lumbar spondylolisthesis: a scoping review.

Background: The benefit of surgical intervention over conservative treatment for degenerative lumbar spondylolisthesis (DLS) patients with neurologic symptoms is well-established. However, it is currently unclear what breadth of available evidence exists on regional and global sagittal alignment in DLS surgery. As such, the purpose of the current study is to conduct a scoping review to map and synthesize the DLS literature regarding the current radiographic assessment of sagittal spinal alignment in DLS surgery. Methods: A comprehensive search of the MEDLINE, EMBASE and Cochrane databases from January 1971 to January 2023 was performed for all DLS studies examining sagittal spinal alignment parameters with DLS surgery according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) protocol. Results: From 2,222 studies, a total of 109 studies were included, representing 10,730 patients with an average age of 63.0 years old and average follow-up of 35.1 months postoperatively. Among included studies, 93 (85%), were largely published in the last decade and predominantly represented retrospective cohorts 70 (64%) or case series 22 (20%). A common theme among the reporting of radiographic parameters in the included investigations was the assessment of the magnitude and/or maintenance of a radiographic change postoperatively, with 92 (84%) studies reporting these findings. The majority of studies focused on index DLS level [33 (30%) studies] or lumbar spine radiographic imaging [33 (30%) studies] only. Thirty-seven (34%) studies reported spinopelvic parameters, with only 13 (12%) of included studies assessing 36-inch standing lateral radiographs and overall alignment. Conclusions: There is increasing prevalence of investigations assessing sagittal spinal alignment parameters in DLS surgery. Although, there is an increasing prevalence of studies investigating sagittal spinal alignment parameters in DLS surgery the quality of the currently available literature on this topic is of overall low evidence and largely retrospective in nature. Additionally, there is limited analysis of global sagittal spinal alignment in DLS suggesting that future investigational emphasis should prioritize longitudinally followed large prospective cohorts or multi-centre randomized controlled trials. Attempts at standardizing the radiographic and functional outcome reporting techniques across multi-centre investigations and prospective cohorts will allow for more robust, reproducible analyses of significance to be conducted on DLS patients.

Functional outcomes correlate with sagittal spinal balance in degenerative lumbar spondylolisthesis surgery.

BACKGROUND CONTEXT: Degenerative lumbar spondylolisthesis (DLS) is a debilitating condition associated with poor preoperative functional status. Surgical intervention has been shown to improve functional outcomes in this population though the optimal surgical procedure remains controversial. The importance of maintaining and/or improving sagittal and pelvic spinal balance parameters has received increasing interest in the recent DLS literature. However, little is known about the radiographic parameters most associated with improved functional outcomes among patients undergoing surgery for DLS. PURPOSE: To identify the effect of postoperative sagittal spinal alignment on functional outcome after DLS surgery. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Two-hundred forty-three patients in the Canadian Spine Outcomes and Research Network (CSORN) prospective DLS study database. OUTCOME MEASURES: Baseline and 1-year postoperative leg and back pain on the 10-point Numeric Rating Scale and baseline and 1-year postoperative disability on the Oswestry Disability Index (ODI). METHODS: All enrolled study patients had a DLS diagnosis and underwent decompression in isolation or with posterolateral or interbody fusion. Global and regional radiographic alignment parameters were measured at baseline and 1-year postoperatively including sagittal vertical axis (SVA), pelvic incidence and lumbar lordosis (LL). Both univariate and multiple linear regression was used to assess for the association between radiographic parameters and patient-reported functional outcomes with adjustment for possible confounding baseline patient factors. RESULTS: Two-hundred forty-three patients were available for analysis. Among participants, the mean age was 66 with 63% (153/243) female with the primary surgical indication of neurogenic claudication in 197/243 (81%) of patients. Worse pelvic incidence-LL mismatch was correlated with more severe disability [ODI, 0.134, p<.05), worse leg pain (0.143, p<.05) and worse back pain (0.189, p<.001) 1-year postoperatively. These associations were maintained after adjusting for age, BMI, gender, and preoperative presence of depression (ODI, R2 0.179, ß, 0.25, 95% CI 0.08, 0.42, p=.004; back pain R2 0.152 (ß, 0.05, 95% CI 0.022, 0.07, p<.001; leg pain score R2 0.059, ß, 0.04, 95% CI 0.008, 0.07, p=.014). Likewise, reduction of LL was associated with worse disability (ODI, R2 0.168, ß, 0.04, 95% CI -0.39, -0.02, p=.027) and worse back pain (R2 0.135, ß, -0.04, 95% CI -0.06, -0.01, p=.007). Worsened SVA correlated with worse patient reported functional outcomes (ODI, R2 0.236, ß, 0.12, 95% CI 0.05, 0.20, p=.001). Similarly, an increase (worsening) in SVA resulted in a worse NRS back pain (R2 0.136, ß, 0.01, 95% CI .001, 0.02, p=.029) and worse NRS leg pain (R2 0.065, ß, 0.02, 95% CI 0.002, 0.02, p=.018) scores regardless of surgery type. CONCLUSIONS: Preoperative emphasis on regional and global spinal alignment parameters should be considered in order to optimize functional outcome in lumbar degenerative spondylolisthesis treatment.

Incidence and Recurrence of Deep Spine Surgical Site Infections: A Systematic Review and Meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To determine a pooled incidence rate for deep surgical site infection (SSI) and compare available evidence for deep SSI management among instrumented spinal fusions. SUMMARY OF BACKGROUND DATA: Deep SSI is a common complication of instrumented spinal surgery associated with patient morbidity, poorer long-term outcomes, and higher health care costs. MATERIALS AND METHODS: We systematically searched Medline and Embase and included studies with an adult patient population undergoing posterior instrumented spinal fusion of the thoracic, lumbar, or sacral spine, with a reported outcome of deep SSI. The primary outcome was the incidence of deep SSI. Secondary outcomes included persistent deep SSI after initial debridement, mean number of debridements, and microbiology. The subsequent meta-analysis combined outcomes for surgical site infection using a random-effects model and quantified heterogeneity using the χ 2 test and the I2 statistic. In addition, a qualitative analysis of management strategies was reported. RESULTS: Of 9087 potentially eligible studies, we included 54 studies (37 comparative and 17 noncomparative). The pooled SSI incidence rate was 1.5% (95% CI, 1.1%-1.9%) based on 209,347 index procedures. Up to 25% of patients (95% CI, 16.8%-35.3%), had a persistent infection. These patients require an average of 1.4 (range: 0.8-1.9) additional debridements. Infecting organisms were commonly gram-positive, and among them, staphylococcus aureus was the most frequent (46%). Qualitative analysis suggests implant retention, especially for early deep SSI management. Evidence was limited for other management strategies. CONCLUSIONS: The pooled incidence rate of deep SSI post-thoracolumbar spinal surgery is 1.5%. The rate of recurrence and repeat debridement is at least 12%, up to 25%. Persistent infection is a significant risk, highlighting the need for standardized treatment protocols. Our review further demonstrates heterogeneity in management strategies. Large-scale prospective studies are needed to develop better evidence around deep SSI incidence and management in the instrumented thoracolumbar adult spinal fusion population.

COVID-19 and the transition to virtual teaching sessions in an orthopaedic surgery training program: a survey of resident perspectives.

BACKGROUND: COVID-19 has had a tremendous impact on medical education. Due to concerns of the virus spreading through gatherings of health professionals, in-person conferences and rounds were largely cancelled. The purpose of this study is the evaluate the implementation of an online educational curriculum by a major Canadian orthopaedic surgery residency program in response to COVID-19. METHODS: A survey was distributed to residents of a major Canadian orthopaedic surgery residency program from July 10th to October 24th, 2020. The survey aimed to assess residents' response to this change and to examine the effect that the transition has had on their participation, engagement, and overall educational experience. RESULTS: Altogether, 25 of 28 (89%) residents responded. Respondents generally felt the quality of education was superior (72%), their level of engagement improved (64%), and they were able to acquire more knowledge (68%) with the virtual format. Furthermore, 88% felt there was a greater diversity of topics, and 96% felt there was an increased variety of presenters. Overall, 76% of respondents felt that virtual seminars better met their personal learning objectives. Advantages reported were increased accessibility, greater convenience, and a wider breadth of teaching faculty. Disadvantages included that the virtual sessions felt less personal and lacked dynamic feedback to the presenter. CONCLUSIONS: Results of this survey reveal generally positive attitudes of orthopaedic surgery residents about the transition to virtual learning in the setting of an ongoing pandemic. This early evaluation and feedback provides valuable guidance on how to grow this novel curriculum and bring the frontier of virtual teaching to orthopaedic education long-term.

Preoperative Disc Angle is an Important Predictor of Segmental Lordosis After Degenerative Spondylolisthesis Fusion.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: To determine the effect of interbody cages inserted via posterior approach on segmental lordosis in the setting of preoperative lordotic vs kyphotic discs in patients with lumbar degenerative spondylolisthesis (LDS). METHODS: Retrospective analysis of prospectively collected data on assessment and management of LDS patients from 2 contributing centres. Patients were analyzed preoperatively and at 12-month follow-up with standing lumbar radiographs. Index level segmental lumbar lordosis (SLL), disc angle and global lumbar lordosis was measured. Patients were stratified into 4 groups based on index level disc angle and procedure: preoperative lordotic posterolateral fusion (group L-PLF); preoperative kyphotic PLF (group K-PLF); preoperative lordotic interbody fusion (IF) (group L-IF); preoperative kyphotic IF (group K-IF). RESULTS: A total of 100/111 (90%) patients completed follow-up with 40 in group L-IF and 48 in group K-IF. There were 18 patients in group L-PLF and 5 in group K-PLF. Among patients with preoperatively lordotic disc angles who had a worsening of SLL, group L-IF had worse SLL than group L-PLF patients, with differences persisting at one-year (mean difference 2.30, 95% CI, .3, 4.3, P = .029). Patients in group K-IF achieved improvement in SLL at one-year more frequently than group L-IF (67% vs 44%, P = .046), with similar mean improvement magnitude between groups L-IF and K-IF (-1.1, 95% CI, -3.7, 1.6, P = .415). CONCLUSION: Segmental lordosis worsening was greater with preoperative index lordotic disc angles when an interbody cage was used. Patients who have a kyphotic disc preoperatively gain more lordosis with interbody cage use.

A Review of Strategies to Improve Biomechanical Fixation in the Cervical Spine.

STUDY DESIGN: Systematic review. OBJECTIVES: Review the surgical techniques and construct options aimed at improving the biomechanical strength of cervical constructs. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the MEDLINE, Embase, and Cochrane Library databases was performed to identify all studies examining biomechanical strategies utilized in the osteoporotic cervical spine. Screening was performed in duplicate for all stages of the review process. RESULTS: An initial search returned 3887 articles. After deletion of duplications and review of abstracts and full text, 39 articles met inclusion criteria. Overall, the surgical techniques reviewed aimed at obtaining rigid fixation in the setting of poor bone quality, or dispersing the forces at the bone-implant interface. We identified 6 key techniques to improve biomechanical fixation. These include bicortical fixation, appropriate screw selection (size and trajectory), PMMA augmentation, load sharing techniques, consideration of ancillary fixation around the occipitocervical junction, and supplementing the construct with post-operative collar or halo. CONCLUSION: The summation of the literature highlights a framework of modalities available to surgeons to improve biomechanical fixation in the cervical spine. While these may improve construct strength in the setting of osteoporosis, there is a paucity of evidence available to make recommendations in this patient population.

Management of deep surgical site infections of the spine: a Canadian nationwide survey.

Background: Deep surgical site infections after spinal instrumentation represent a significant source of patient morbidity and poorer outcomes. Given lack of evidence or guidelines on the variety of procedural options in the management of deep spine surgical site infections, the purpose of this survey was to document and investigate the use of these techniques across Canada. Methods: A 34-question survey evaluating surgical techniques for irrigation and debridement in postoperative thoracolumbar infection was distributed to Canadian adult spine surgeons. Results were analyzed qualitatively, and comparisons by specialty, years of training, and number of cases were completed using Fischer's exact tests. We defined consensus as >70% agreement. Results: We received 53 responses (62% response rate) from a comprehensive sample of Canadian adult spine surgeons. There was a consensus to retain hardware (80%) and interbody implants (93%) in acute infection, to retain interbody implants in chronic/recurrent infection (71%), and application of topical antibiotics in recurrent infection (85%). There was consensus on the use of absorbable suture to close fascia in acute (83%) and chronic (87%) infection. Eighty-five percent of surgeons used nonabsorbable materials such as Nylon or staples for skin closure in chronic infection, however, there was no consensus in acute infection. Surgeons varied significantly in type, volume and pressure of fluids, adjuvant solvents, graft management, use of topical antibiotics acutely, and the use of negative pressure wound therapy. Partial hardware exchange was controversial. Additionally, specialty or surgeon experience had no impact on management strategy. Conclusions: This survey demonstrates significant heterogeneity amongst Canadian adult spine surgeons regarding key steps in the surgical management of deep instrumented spine infection, concordant with scarce literature addressing these steps.

Non-collagen pathogenic variants resulting in the osteogenesis imperfecta phenotype in children: a single-country observational cohort study.

BACKGROUND/OBJECTIVES: In England, children (0-18 years) with severe, complex and atypical osteogenesis imperfecta (OI) are managed by four centres (Birmingham, Bristol, London, Sheffield) in a 'Highly Specialised Service' (HSS OI); affected children with a genetic origin for their disease that is not in COL1A1 or COL1A2 form the majority of the 'atypical' group, which has set criteria for entry into the service. We have used the data from the service to assess the range and frequency of non-collagen pathogenic variants resulting in OI in a single country. METHODS: Children with atypical OI were identified through the HSS OI service database. All genetic testing for children with OI in the service were undertaken at the Sheffield Diagnostic Genetics Service. Variant data were extracted and matched to individual patients. This study was done as part of a service evaluation project registered with the Sheffield Children's Hospital Clinical Governance Department. RESULTS: One hundred of 337 children in the HSS met the 'atypical' criteria. Eighty have had genetic testing undertaken; 72 had genetic changes detected, 67 in 13 genes known to be causative for OI. The most frequently affected genes were IFITM5 (22), P3H1 (12), SERPINF1 (8) and BMP1 (6). CONCLUSION: Among children with more severe forms of OI (approximately one-third of all children with OI), around 20% have pathogenic variants in non-collagen genes. IFITM5 was the most commonly affected gene, followed by genes within the P3H1 complex. These data provide additional information regarding the likelihood of different genetic origins of the disease in children with OI, which may influence clinical care.

Damage Control Orthopaedics in Spinal Trauma.

There has been a shift in the management of the polytrauma patients from early total care to damage control orthopaedics (DCO), whereby patients with borderline hemodynamic stability may be temporized with the use of external fixators, traction, or splinting with delayed osteosynthesis of fractures. Recently, there has been an increasing trend toward a middle ground approach of Early Appropriate Care for polytrauma patients. The concepts of DCO for the spine are less clear, and the management of trauma patients with combined pelvic ring and spinal fractures or patients with noncontiguous spinal injuries present unique challenges to the surgeon in prioritization of patient needs. This review outlines the concept of DCO and Early Appropriate Care in the spine, prioritizing patient needs from the emergency department to the operating room. Concepts include the timing of surgery, minimally invasive versus open techniques, and the prioritization of spinal injuries in the setting of other orthopaedic and nonorthopaedic injuries. Contiguous and noncontiguous spinal injuries are considered in construct planning, and the principles are discussed.

Child Abuse with Thoracolumbar Fracture-Dislocation Treated with Pedicle Screw Fixation in a 2-Year-Old: A Case Report.

CASE: A nonverbal 2-year-old boy presented with acute-on-chronic thoracolumbar fracture-subluxation with associated chylothorax and progressive neurologic dysfunction secondary to nonaccidental trauma. We discussed the successful management of this patient with short-segment pedicle screw instrumentation resulting in complete resolution of his chylothoraxes and neurologic impairment. A clinical follow-up is reported out to 12 months after hardware removal. CONCLUSION: Thoracolumbar fracture-subluxation with massive chylothorax is a rare and important presentation of nonaccidental trauma that must be recognized. Temporary pedicle screw fixation is a successful treatment option for young children presenting with this difficult spinal pathology.

Surgical Technique for the Removal of a Bullet From the Sacroiliac Joint in a Child: A Case Report and Literature Review.

CASE: This report presents a logical and effective technique for removing a bullet from the sacroiliac joint (SIJ). The surgery involved a fluoroscopy-guided anterior extraperiosteal lateral window approach. Other than a transient femoral nerve neuropraxia, there were no complications. A literature review identified 3 reports on bullet removal from the SIJ of adult patients. CONCLUSION: An anterior extraperiosteal approach for removing bullets from the SIJ in pediatric patients provides satisfactory results. When deciding whether to remove a bullet from the SIJ, the location, joint diastasis, and patient's age should be considered.

Published randomized controlled trials of surveillance in cancer patients - a systematic review.

With solid tumor cancer survivorship increasing, the number of patients requiring post-treatment surveillance also continues to increase. This highlights the need for evidence-based cancer surveillance guidelines. Ideally, these guidelines would be based on combined high-quality data from randomized controlled trials (RCTs). We present a systematic review of published cancer surveillance RCTs in which we sought to determine the feasibility of data pooling for guideline development. We carried out a systematic search of medical databases for RCTs in which adult patients with solid tumors that had undergone surgical resection with curative intent and had no metastatic disease at presentation, were randomized to different surveillance regimens that assessed effectiveness on overall survival (OS). We extracted study characteristics and primary and secondary outcomes, and assessed risk of bias and validity of evidence with standardized checklist tools. Our search yielded 32,216 articles for review and 18 distinct RCTs were included in the systematic review. The 18 trials resulted in 23 comparisons of surveillance regimens. There was a highlevel of variation between RCTs, including the study populations evaluated, interventions assessed and follow-up periods for the primary outcome. Most studies evaluated colorectal cancer patients (11/18, [61%]). The risk of bias and validity of evidence were variable and inconsistent across studies. This review demonstrated that there is tremendous heterogeneity among RCTs that evaluate effectiveness of different postoperative surveillance regimens in cancer patients, rendering the consolidation of data to inform high-quality cancer surveillance guidelines unfeasible. Future RCTs in the field should focus on consistent methodology and primary outcome definition.

Primary sarcomas of the spine: population-based demographic and survival data in 107 spinal sarcomas over a 23-year period in Ontario, Canada.

BACKGROUND CONTEXT: Spinal sarcomas are a rare, heterogeneous group of mesenchymal tumors. Current literature reporting demographic variables and survival information is limited to small case series, and a single registry with variable treatment modalities and time periods. PURPOSE: We report on population-level data regarding all spinal sarcomas diagnosed over a 23-year period in Ontario, Canada, for the purposes of calculating incidence and prevalence of these tumors. Secondarily, survival is assessed by tumor type as well as adjuvant therapies during this time period. STUDY DESIGN: Retrospective Cohort Study PATIENT SAMPLE: Population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015. OUTCOME MEASURES: Outcome measures include incidence and prevalence of spinal osteosarcoma, Ewing's sarcoma, and chondrosarcoma of the spine, as well as 2-, 5-, 10- and 15-year survival and prevalence of adjuvant therapies. METHODS: Utilizing population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015, ICD codes were searched and available data extracted for the purposes of reporting basic demographic information and calculation of Kaplan Meyer survival curves. Databases include the Ontario Cancer Registry, Discharge Abstract Database, Ontario Health Insurance Plan, National Ambulatory Care Reporting System, Registered Persons DataBase (death) were analyzed. RESULTS: One hundred and seven spinal sarcomas were identified, with a mean incidence was 0.38 sarcomas per million population per year, that was stable over time. The mean prevalence was 8.1 sarcomas per million population. The most common diagnosis was Ewing's sarcoma (48 [44.9%] patients), followed by chondrosarcoma (33 [30.8%] patients), and osteosarcoma (26 [24.3%] patients). Chondrosarcoma had the highest survival rates with 77.2% and 64.2% 5- and 10-year survival rates, respectively, followed by Ewing's sarcoma with 48.1% and 44.9% 5 and 10-year survival and osteosarcoma with 36.0% and 30.9% 5- and 10-year survival. CONCLUSIONS: Spinal sarcoma is a rare disease with variable survival depending on the histologic diagnosis. This population-level study involves a heterogeneous group of patients with variable stages of disease at presentation and variable treatments. Our data fit with the published literature for survival for those treated conservatively and surgically. Our data show considerable improvement in 5- and 10-year mortality when compared with previous population level studies on earlier patient cohorts, likely reflecting improvements in systemic and surgical treatments.

Three-dimensional printing in orthopaedic surgery: a scoping review.

Three-dimensional printing (3DP) has become more frequently used in surgical specialties in recent years. These uses include pre-operative planning, patient-specific instrumentation (PSI), and patient-specific implant production.The purpose of this review was to understand the current uses of 3DP in orthopaedic surgery, the geographical and temporal trends of its use, and its impact on peri-operative outcomesOne-hundred and eight studies (N = 2328) were included, published between 2012 and 2018, with over half based in China.The most commonly used material was titanium.Three-dimensional printing was most commonly reported in trauma (N = 41) and oncology (N = 22). Pre-operative planning was the most common use of 3DP (N = 63), followed by final implants (N = 32) and PSI (N = 22).Take-home message: Overall, 3DP is becoming more common in orthopaedic surgery, with wide range of uses, particularly in complex cases. 3DP may also confer some important peri-operative benefits. Cite this article: EFORT Open Rev 2020;5:430-441. DOI: 10.1302/2058-5241.5.190024.

Causes and Frequencies of Reoperations After Endoprosthetic Reconstructions for Extremity Tumor Surgery: A Systematic Review.

BACKGROUND: Excision of bone tumors and endoprosthetic reconstruction allow patients early weightbearing and a potential functional advantage compared with amputation. These reconstructions do not restore the limb to normal status, however, and patients are subject to complications that may result in revision or loss of the limb. Because better understanding of these complications based on current information might help the patient and surgeon in decision-making, we undertook a systematic review of studies published on this topic. QUESTIONS/PURPOSES: (1) What are the primary modes and proportion of failure of tumor endoprostheses in patients undergoing reconstruction after excision of primary extremity bone sarcomas? METHODS: We systematically searched MEDLINE, Embase, and the Cochrane Library for all studies published from April 15, 1998, to April 15, 2018. Three reviewers independently reviewed studies reporting endoprosthetic reconstruction survival and events requiring revision for primary extremity bone tumors treated with endoprosthetic reconstruction for inclusion and performed independent data extraction. We excluded all studies with fewer than five patients, any systematic review/meta-analyses, and any study not reporting on primary extremity bone tumors. All discrepancies were resolved by the study's senior author. Data extracted from included studies were any reoperation event for wound dehiscence, any operative fixation for a pathologic fracture, and any revision of the primary endoprosthesis for implant wear or breakage, deep infection not amenable to prosthesis retention, or for local recurrence. We assessed the overall quality of the evidence with the Methodological Index for Non-Randomized Studies (MINORS) approach with a higher MINORS score representative of a more methodologically rigorous study with a total possible score of 16 points for noncomparative and 24 points for comparative studies. Forty-nine studies met criteria for inclusion from an initial search return of 904 studies, of which no studies were randomized controlled trials. From a total patient population of 2721, there was a mean followup of 93 months (range, 1-516 months) with loss to followup or death occurring in 447 of 2118 (21%) patients with six studies not providing loss to followup data. The mean MINORS score was 14 for prospective studies and 11 for retrospective studies. RESULTS: Overall, there were 1283 reoperations among the 2721 (47%) patients. Reoperation for mechanical endoprosthetic events (soft tissue dehiscence or periarticular soft tissue instability, aseptic loosening, or implant wear/fracture) occurred in 907 of 2721 (33%) patients. Aseptic loosening occurred at a mean of 75 months (range, 1-376 months) in 212 of 315 patients (67%). Deep infection requiring removal of the initial prosthesis occurred in 247 of 2721 (9%) patients with deep infection occurring at a mean of 24 months (range, 1-372 months) in the 190 infections (77%) with time to infection data available. Local recurrence rates requiring revision or amputation occurred in 129 (5%) of all patients. There was an overall primary endoprosthesis survival rate without any surgical reintervention of 63% among reporting studies at a mean of 79 months followup. CONCLUSIONS: Failures of endoprosthetic reconstructions after extremity tumor surgery are common, most often resulting from implant wear or fracture, aseptic loosening, and infection. Importantly, the aggregated data are the first to attempt to quantify the time to specific complication types within this patient population. Deep infection not amenable to endoprosthesis retention appears to occur approximately 2 years postoperatively in most patients, with aseptic loosening occurring most commonly at 75 months. Although endoprosthetic reconstruction is one of the most common forms of reconstruction after bone tumor resection, the quality of published evidence regarding this procedure is of low quality with high loss to followup and data quality limiting interstudy analysis. The quality of the evidence is low with high loss to followup and inconsistent reporting of times to reintervention events. Although the most common modes of endoprosthetic failure in this population are well known, creation of quality prospective, collaborative databases would assist in clarifying and informing important elements of the followup process for these patients. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Profound Trunnion Wear Resulting in Femoral Head-Neck Dissociation in Total Hip Arthroplasty.

We describe a case of aseptic failure with profound femoral stem trunnion wear and femoral head dissociation nine years after initial primary total hip arthroplasty (THA) with the Stryker Accolade total hip arthroplasty system. Current guidelines for postoperative care and follow-up after THAs as potential intervention points for early detection of prosthetic joint failure are also reviewed.