Publications by authors named "Khalid Al-Hourani"

22 Publications

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In response.

J Orthop Trauma 2021 Jun 28. Epub 2021 Jun 28.

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http://dx.doi.org/10.1097/BOT.0000000000002217DOI Listing
June 2021

Definitive fixation outcomes of open tibial shaft fractures: Systematic review and network meta-analysis.

J Orthop Trauma 2021 Mar 27. Epub 2021 Mar 27.

Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom. Department of Orthopaedic Surgery, The Royal National Orthopaedic Hospital, Stanmore, United Kingdom. Department of Orthopaedic Surgery, McMaster University, Ontario, Canada Department of Orthopaedic Surgery, Boston Medical Center, Boston, USA.

Objectives: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures.

Data Sources: MEDLINE, EMBASE, CENTRAL, OpenGrey.

Study Selection: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type.

Data Extraction: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics and follow up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing (RN), plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and GRADE systems were used for quality analysis.

Data Synthesis: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modelled direct and indirect data was conducted to provide precise estimates (relative risks (RR) and associated 95% confidence intervals (95% CI)).

Results: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43 - 1.05, p=0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared to EF was larger (RR 0.61, 95% CI 0.37 - 1.01, p=0.05, moderate confidence). UN had a lower reoperation risk compared to RN (RR 0.91, 95% CI 0.58 - 1.4, p=0.68, low confidence), however this was not significant and did not demonstrate a clear advantage.

Conclusion: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared to EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002090DOI Listing
March 2021

Acute Compartment Syndrome in Type IIIB Open Tibial Shaft Fractures Utilising a Two-Stage Orthoplastic Approach.

J Orthop Trauma 2021 Mar 22. Epub 2021 Mar 22.

Department of Trauma & Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. Department of Trauma & Orthopaedics, Stanmore Hospital, London, United Kingdom. Department of Trauma & Orthopaedics, Southmead Hospital, Bristol, United Kingdom Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom.

Objective: To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific two-stage orthoplastic protocol.

Design: Consecutive cohort study.Patients/Participants: Ninety-three (n =93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated utilizing a two-stage orthoplastic approach, between August 2015 and January 2018. Following exclusions, eighty-three (n=83) were eligible for analysis.

Intervention: Colloid resuscitation and two-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage one consists of "three-vessel view" early debridement and temporary internal fixation, with stage two consisting of a single-stage fix and flap.

Main Outcome Measurements: Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion and flap failure.

Results: Eighty-three (n = 83) patients were included for analysis. Median age was 45.4 years (Interquartile range (IQR) 35) with a median follow up of 1.6 years (IQR 0.8). Median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of zero (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, eighteen patients (18/83, 21.7%) experienced non-ischaemic arterial injury, five patients (5/83, 6.0%) experienced nonunion, with four patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (p=0.025) and nonunion (p<0.001).

Conclusions: Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a two-stage orthoplastic protocol, which includes early "three-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow up.

Level Of Evidence: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002129DOI Listing
March 2021

Standards of open lower limb fracture care in the United Kingdom.

Injury 2021 Mar 13;52(3):378-383. Epub 2021 Jan 13.

Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom.

Open fractures of the lower limb remain a potentially devastating group of injuries that are challenging to manage. The primary aims of treatment are to optimise limb function and avoid serious complications such as infection and non-union, which are costly for both the patient and healthcare system. The management of these fractures has evolved significantly, and this is evident following the creation of national open fracture guidelines and a formal trauma system. These have served to standardise care for these injuries in the United Kingdom. The aim of this review is to update our colleagues on the current standard of lower limb open fracture care in the United Kingdom, and the impact this has had on patient outcomes.
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http://dx.doi.org/10.1016/j.injury.2021.01.021DOI Listing
March 2021

Short-term rates of radiolucency after primary total shoulder arthroplasty using a cementless metal-backed pegged polyethylene glenoid.

Shoulder Elbow 2020 Dec 6;12(1 Suppl):4-10. Epub 2018 Aug 6.

Department of Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, UK.

Background: Total shoulder arthroplasty has shown good clinical efficacy in treating primary and secondary degenerative conditions of the glenohumeral joint. Glenoid loosening, however, remains the commonest cause of failure. The purpose of this study was to investigate the rate of radiographic periprosthetic lucency associated with the use of an uncemented, pegged, metal-backed polyethylene glenoid component.

Materials And Methods: A retrospective, single-centre study using the Epoca (Synthes, Paoli, Pennsylvania) metal-backed glenoid component. Operations were performed by two experienced consultant upper limb surgeons. Radiographs were analysed for immediate post-operative component seating and periprosthetic radiolucent lines at predefined regular post-operative intervals. Intra- and inter-observer reliability was assessed to improve validity of results.

Results: Mean age and follow-up was 72 (48-91) years and 2.5 years (2-5), respectively. Main indications for total shoulder arthroplasty were primary osteoarthritis, rheumatoid arthritis, revision for failed hemi-arthroplasty and acute fracture. Ninety-six per cent of components were completely seated post-operatively. Fifty-four (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up. Complete post-operative glenoid seating was significantly associated with the absence of later periprosthetic radiolucency (p < 0.01).

Conclusion: This study reports low early radiolucency rates with the pegged, uncemented, metal-backed polyethylene glenoid prosthesis used. Excellent post-operative glenoid seating is associated with a significantly lower rate of radiolucency. Longer follow-up data are required to confirm these early promising results. Therapeutic, level IV.
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http://dx.doi.org/10.1177/1758573218789339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726176PMC
December 2020

A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data.

J Bone Joint Surg Am 2021 02;103(3):265-273

Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada.

Background: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear.

Methods: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection.

Results: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214).

Conclusions: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement.

Level Of Evidence: Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01103DOI Listing
February 2021

Ankle fractures in the elderly: Current concepts.

Injury 2020 Dec 24;51(12):2740-2747. Epub 2020 Oct 24.

Southmead Hospital, Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Road, BS10 5NB, Bristol, United Kingdom.

Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.
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http://dx.doi.org/10.1016/j.injury.2020.10.093DOI Listing
December 2020

The Effect of Simple Cost Effective Interventions in Improving Enhanced Recovery in Neck of Femur Fracture Care.

Cureus 2020 Oct 28;12(10):e11217. Epub 2020 Oct 28.

Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, GBR.

Aim Due to the frequency and high mortality and morbidity associated with neck of femur fractures, pathways of care have been established in the United Kingdom. These include the Enhanced Recovery Program (ERP), which aims to maximise the quality of care whilst reducing their length of stay, and the Best Practice Tariff (BPT) which if adhered to warrants £1335 per neck of femur fracture. We conducted a prospective audit to assess adherence to these pathways in a trauma unit. Methods An audit was carried out between November 2015 and May 2016. The information was obtained from neck of femur fracture proformas, anaesthetic charts and drug charts by two investigators. Results Nine out of the 10 ERP components were adhered to in all 31 patients. This highlighted a deficiency in requesting day one post-operative osteoporosis bloods, which was only carried out in 61.3% of patients. As an intervention, a reminder sticker was placed on the operation note as an intervention. Re-audit following the introduction of the stickers showed a marked improvement of 90%. During the initial admission 38.7% of patients adhered to the BPT. The main area for improvement was fracture prevention assessment, specifically Fracture Risk Assessment Tool (FRAX) scores and Nottingham Hip Fracture Scores. To improve this these sections were highlighted in the proformas to promote their importance. Additionally, a smartphone application was made available to doctors to aid with ease of calculation. Following these interventions, 93% of patients had this data entered, with an improvement in overall tariff attainment to 63.3%. Conclusions The introduction of simple measures is beneficial both for patient safety and economically for hospitals.
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http://dx.doi.org/10.7759/cureus.11217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594660PMC
October 2020

Return to Work Following Total Knee and Hip Arthroplasty: The Effect of Patient Intent and Preoperative Work Status.

J Arthroplasty 2021 02 10;36(2):434-441. Epub 2020 Aug 10.

Department of Trauma & Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.

Background: The ability of total knee and hip arthroplasty (TKA/THA) to facilitate return to work (RTW) when it is the patient's preoperative intent to do so remains unclear. We aimed at determining whether TKA/THA facilitated RTW in patients of working age who intended to return.

Methods: This is a prospective cohort study of 173 consecutive patients <65 years of age, undergoing unilateral TKA (n = 82: median age 58; range, 39-65; 36 [43.9%] male) or THA (n = 91: median age 59; range, 34-65; 42 [46.2%] male) during 2018. Oxford knee/hip scores, Oxford-Activity and Participation Questionnaire, and EuroQol-5 dimension (EQ-5D) scores were measured preoperatively and at 1 year when an employment questionnaire was also completed.

Results: Of patients who intended to RTW, 44 of 52 (84.6%) RTW by 1 year following TKA (at mean 14.8 ± 8.4 weeks) and 53 of 60 (88.3%) following THA (at mean 13.6 ± 7.5 weeks). Failure to RTW despite intent was associated with job physicality for TKA (P = .004) and negative preoperative EQ-5D for THA (P = .01). In patients unable to work before surgery due to joint disease, fewer RTW: 4 of 21 (19.0%) after TKA; and 6 of 17 (35.3%) after THA. Preoperative Oxford knee score >18.5 predicted RTW with 74% sensitivity (P < .001); preoperative Oxford hip score >19.5 predicted RTW with 75% sensitivity (P < .001). Preoperative EQ-5D indices were similarly predictive (P < .001).

Conclusion: In this United Kingdom study, preoperative intent to RTW was the most powerful predictor of actual RTW following TKA/THA. Where patients intend to RTW following TKA/THA, 85% RTW following TKA and 88% following THA.
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http://dx.doi.org/10.1016/j.arth.2020.08.012DOI Listing
February 2021

Proximal Humerus Fractures: Reliability of Neer Versus AO Classification on Plain Radiographs and Computed Tomography.

Cureus 2020 Jun 9;12(6):e8520. Epub 2020 Jun 9.

Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, GBR.

Introduction: Several classifications for proximal humeral fractures exist, with excellent reliability and reproducibility of such classifications being a desirable feature. Despite their widespread use, these systems are variable in both reliability and accuracy. We aimed to, a) assess and compare the reliability of the Neer (complete and abbreviated versions) and Arbeitsgemeinschaft für Osteosynthesefragenbeing (AO) classifications, and b) identify if computed tomography (CT) made any difference to the reliability of Neer and AO classifications when compared to plain radiographs alone.  Materials and methods: This is a single-centre retrospective study identifying all proximal humeral fractures presenting between February 2016 and February 2017 as a result of trauma that subsequently proceeded to CT. Two specialty orthopaedic trainees analysed the plain radiographs as well as CT images over two rounds, spaced two weeks apart. The Neer 16-grade, abbreviated Neer 6-grade and AO classifications were used. Intra- and inter-observer reliability of each classification system was assessed using the Kappa coefficient.  Results: Twenty-two patients were included. The mean age was 62 years (SD 14.5). Management changed in 9/22 patients based on CT. Computed tomography changed Neer-16 type in 16% observations, Neer-6 in 10%, and AO in 23%. This was significant when comparing Neer-6 and AO classifications (p = 0.04). Neer-6 had the best inter-observer reliability (0.737) with the management of one patient changing after CT. On X-ray and CT, intra-observer agreement was substantial, >0.7, using Neer-16 and Neer-6 (p<0.005). Inter-observer agreement for Neer-16 and Neer-6 was substantial, >0.7 (p<0.005). In comparison, intra- and inter-observer agreements for AO were lower on X-ray and CT, 0.4-0.6, (p<0.005).

Conclusion: Our study shows that simplicity is key with a high degree of reliability in the abbreviated Neer classification. Computed tomography allowed greater reliability than radiographs in classifying fractures, affecting management decisions in 41% of patients. The comprehensive Neer classification showed similar intra- and inter-observer reliabilities to AO.
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http://dx.doi.org/10.7759/cureus.8520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346293PMC
June 2020

Plate-Assisted Intramedullary Nailing of Gustilo Type IIIB Open Tibial Diaphyseal Fractures: Does Adjunctive Plate Retention Affect Complication Rate?

J Orthop Trauma 2020 Jul;34(7):363-369

Departments of Orthopaedic Surgery; and.

Objectives: To investigate the complication rates after use of retained adjunctive plate (RAP) fixation with intramedullary nailing of Gustilo-Anderson type IIIB open tibia fractures, as part of a 2-stage orthoplastic approach.

Design: Consecutive cohort study.

Patients/participants: One hundred and thirty-seven consecutive patients with a Gustilo-Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) treated between May 2014 and January 2018. Ninety-eight patients (RAP = 67; non-RAP = 31) met the inclusion criteria and underwent 2-stage reconstruction. All patients were treated using a small fragment adjunctive plate to hold the fracture reduced before intramedullary nailing.

Intervention: At stage 2, the temporary small fragment (in-fix) plate was removed and the site further thoroughly debrided. After this, the fracture is reduced and held with a new small fragment plate to facilitate the definitive intramedullary nailing. This new plate was either retained (RAP) as part of the definitive fixation at second stage or removed before wound coverage.

Main Outcome Measurement: The main outcome measures were reoperation rate, deep infection, nonunion, and flap-related complication.

Results: Six patients (6/98, 6.1%) proceeded to nonunion (RAP 5/67, non-RAP 1/31). This was not significant (P = 0.416). Two hundred twelve operations were undertaken, and the median was 2. Sixteen (16/212, 7.5%) complication-related reoperations were undertaken, affecting 8 patients (8/67, 11.9%) in the RAP group. Eight patients (8/98, 8.2%) developed a deep infection (RAP 6/67, non-RAP 2/31). This was not significant (P = 0.674).

Conclusions: In the context of an orthoplastic approach, the use of a RAP with definitive intramedullary nailing does not seem to significantly increase the rate of deep infection or nonunion in patients with type IIIB open tibial shaft fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001738DOI Listing
July 2020

In Response.

J Orthop Trauma 2019 12;33(12):599-601

On behalf of all authors, Bristol, United Kingdom.

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http://dx.doi.org/10.1097/BOT.0000000000001669DOI Listing
December 2019

Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?

J Orthop Trauma 2019 Dec;33(12):591-597

Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom.

Objective: To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures.

Design: Retrospective comparative cohort study over a 2-year period.

Setting: Level 1 trauma center.

Patients/participants: A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis.

Intervention: Time to initial debridement and definitive management.

Main Outcome Measurement: Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant.

Results: Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion.

Conclusions: Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001562DOI Listing
December 2019

The Predictive Value of Ultrasound Scanning in Certain Hand and Wrist Conditions.

J Hand Surg Asian Pac Vol 2018 Mar;23(1):76-81

‡ Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK.

Background: Fast and accurate diagnosis of conditions of the hand and wrist is essential in guiding management. We aimed to analyse the predictive value of ultrasound in identifying different pathologies in the hand and wrist by correlating pre-operative ultrasound findings with per-operative surgical findings.

Methods: We retrospectively reviewed the case notes of all patients under the care of the senior author on whom a hand/wrist ultrasound had been performed between January 2007-May 2013. Of these only patients who proceeded to surgery were included as this was the correlating endpoint. Positive and negative predictive values (PPV/NPV) and sensitivity and specificity were calculated for ultrasound in identifying (i) post-repair complete tendon ruptures (versus intact repairs with scar adherence), (ii) ganglionic cysts, (iii) soft tissue masses and (iv) nerve injuries.

Results: Of 70 patients who underwent ultrasound, 36 proceeded to surgery. Fifteen patients were post traumatic and the remaining 21 were elective presentations. The median age was 38 (range 14-87) with a 1.25:1 male to female ratio. All results had a 95% confidence interval. Ultrasound had a 100% PPV for identifying post-repair complete tendon ruptures and for ganglionic cysts (sensitivities 75% and 87% respectively). Of our 6 soft tissue masses ultrasound also showed a 100% PPV. For the two nerve injury patients, PPV was 100%.

Conclusions: Our study shows that ultrasound is diagnostic for post-repair tendon ruptures and ganglionic cysts, and shows promising results for benign soft tissue masses and nerve injuries. We propose the use of ultrasound as an extension to physical examination in a dynamic clinic setting.
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http://dx.doi.org/10.1142/S2424835518500108DOI Listing
March 2018

Five-year publication rate of podium presentations at SICOT Annual Conference: an observational study and new objective proposal of conference power.

SICOT J 2017 17;3:36. Epub 2017 May 17.

Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY 14618, USA.

Introduction: The SICOT Conference Committee continually tries to improve the quality of presentations at their annual international meetings. However to the author's best knowledge, no previous study has been undertaken to determine abstract quality. This study aimed to determine the five-year publication rate of presentations made at the 2009 SICOT Annual International Conference (AIC), recognise predictors of full-text publication, identify inconsistencies between presentations and publications, and determine presentation-publication delay.

Methods: We retrieved all 329 oral presentation abstracts from the 2009 SICOT Conference, recorded fundamental study details and conducted a comprehensive, electronic search of Medline and PubMed to determine publication status. For subsequent publications, we examined for inconsistencies between presentation abstracts and full-text publications, whether there were retrospectively identifiable publication predictors and calculated presentation-publication delay.

Results: The five-year publication rate for all presentations was 31.3%, for oral presentations. The average presentation-publication delay was 23.4 months. Observational studies were the most commonly published studies. Publications most commonly resulted from studies related to hip and knee subspecialties.

Conclusion: Our study shows that almost one third of all abstracts presented at SICOT led to a full-text publication. This is a positive outcome particularly when made in comparison to similar studies of other reputable international conferences such as European Federation of Orthopaedics and Traumatology (EFORT) and American Academy of Orthopaedic Surgeons (AAOS). This study re-enforces SICOT's reputation as a world leading international conference with a strict peer-review process yielding high-quality presentations.
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http://dx.doi.org/10.1051/sicotj/2017019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434663PMC
May 2017

Lemierre's syndrome; a rare cause of septic arthritis.

BMJ Case Rep 2017 May 12;2017. Epub 2017 May 12.

Musgrove Park Hospital, Taunton, UK.

Lemierre's syndrome is a rare condition characterised by pharyngitis leading to septic thrombophlebitis of the internal jugular vein. Complications include pulmonary septic emboli, septic arthritis and disseminated intravascular coagulation. The authors present a case of a healthy woman aged 25 years with septic arthritis of the shoulder due to this unusual cause. This diagnosis was made via a combination of clinical, radiological and microbiological findings. It was successfully treated via surgical and antimicrobial interventions. The patient made a good recovery with minimal associated morbidity or loss of function. This case highlights the importance for awareness and high index of suspicion for rarer causes of septic arthritis in young healthy adults as early appropriate intervention maximises prognosis.
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http://dx.doi.org/10.1136/bcr-2017-220110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614224PMC
May 2017

Upper Cervical Epidural Abscess in Clinical Practice: Diagnosis and Management.

Global Spine J 2016 Jun 13;6(4):383-93. Epub 2015 Oct 13.

Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, United States.

Study Design Narrative review. Objective Upper cervical epidural abscess (UCEA) is a rare surgical emergency. Despite increasing incidence, uncertainty remains as to how it should initially be managed. Risk factors for UCEA include immunocompromised hosts, diabetes mellitus, and intravenous drug use. Our objective is to provide a comprehensive overview of the literature including the history, clinical manifestations, diagnosis, and management of UCEA. Methods Using PubMed, studies published prior to 2015 were analyzed. We used the keywords "Upper cervical epidural abscess," "C1 osteomyelitis," "C2 osteomyelitis," "C1 epidural abscess," "C2 epidural abscess." We excluded cases with tuberculosis. Results The review addresses epidemiology, etiology, imaging, microbiology, and diagnosis of this condition. We also address the nonoperative and operative management options and the relative indications for each as reviewed in the literature. Conclusion A high index of suspicion is required to diagnose this rare condition with magnetic resonance imaging being the imaging modality of choice. There has been a shift toward surgical management of this condition in recent times, with favorable outcomes.
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http://dx.doi.org/10.1055/s-0035-1565260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868579PMC
June 2016

Plasma paracetamol concentration at hospital presentation has a dose-dependent relationship with liver injury despite prompt treatment with intravenous acetylcysteine.

Clin Toxicol (Phila) 2016 Jun;54(5):405-10

a NPIS Edinburgh , Royal Infirmary of Edinburgh , Edinburgh , UK ;

Context: Paracetamol (acetaminophen) overdose is a common reason for emergency hospital admission in the UK and the leading cause of acute liver failure in the Western world. Currently, the antidote acetylcysteine (NAC) is administered at a dose determined only by body weight without regard for the body burden of paracetamol.

Objective: To determine whether higher plasma paracetamol concentrations are associated with increased risk of liver injury despite prompt treatment with intravenous NAC.

Methods: Patients admitted to hospital for treatment with intravenous NAC following a single acute paracetamol overdose entered the study if NAC was commenced within 24 h of drug ingestion (N = 727 hospital presentations). Based on the plasma paracetamol concentration at first presentation to hospital, a series of nomograms were created: 0-100, 101-150, 151-200, 201-300, 301-500 and over 501 mg/L. The primary endpoints were acute liver injury (ALI - peak serum ALT activity >150 U/L and double the admission value) and hepatotoxicity (peak ALT >1000 U/L).

Results: ALI and hepatotoxicity were more common in patients with higher admission plasma paracetamol concentrations despite NAC treatment (ALI: nomogram 0-100: 6%, 101-150: 3%, 151-200: 3%, 201-300: 9%, 301-500: 13%, over 501 mg/dL: 27%. p < 0.0001). This dose-response relationship between paracetamol concentration and ALI persisted even in patients treated with NAC within 8 h of overdose (nomogram 0-100: 0%, 101-150: 0.8%, 151-200: 2%, 201-300: 3.6%, 301-500: 12.5%, over 501mg/L: 33%. p < 0.0001) and in patients with normal ALT activity at first presentation (nomogram: 0-100: 0%, 101-150: 1.2%, 151-200: 1.5%, 201-300: 5.3%, 301-500: 10.8% p < 0.0001).

Discussion: Patients with increased concentrations of plasma paracetamol at hospital presentation are at higher risk of liver injury even when intravenous NAC is promptly administered before there is biochemical evidence of toxicity.

Conclusion: This study supports theoretical concerns that the current intravenous dose of NAC may be too low in the setting of higher paracetamol exposure.
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http://dx.doi.org/10.3109/15563650.2016.1159309DOI Listing
June 2016

Upper Cervical Epidural Abscess in a Patient With Parkinson Disease: A Case Report and Review.

Geriatr Orthop Surg Rehabil 2015 Dec;6(4):328-33

Department of Orthopaedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA.

To our knowledge, there are no reports in the literature of patients with Parkinson disease (PD) developing upper cervical spine infections. Our objective is to present a case of upper cervical epidural abscess in a patient with PD and to review upper cervical spine infection. We present the patient's presentation, physical examination, imaging findings, and management as well a review of the literature. A 66-year-old male with PD presented to the emergency department (ED) following referral by a neurologist for a presumed C2 fracture. The preceding history was 1 week of severe neck pain requiring a magnetic resonance imaging (MRI), which was initially interpreted as a C2 fracture. On admission from the ED, further review of the MRI appeared to show anterior prevertebral abscess and an epidural abscess. The patient's neurological examination was at baseline. In the span of 2 days, the patient developed significant motor weakness. A repeat MRI demonstrated expansion of the epidural collection and spinal cord compression. Surgical management consisting of C1 and C2 laminectomy, irrigation, and debridement from anterior and posterior approaches was performed. Postoperatively, the patient did not recover any motor strength and elected to withdraw care and died. Spinal epidural abscess requires a high index of suspicion and needs prompt recognition to prevent neurological impairment. Upper cervical spine infections are rare but can lead to lethal consequences.
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http://dx.doi.org/10.1177/2151458515604356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4647191PMC
December 2015

Management of hangman's fractures and a subaxial compression fracture in two children with osteogenesis imperfecta.

J Surg Orthop Adv 2013 ;22(4):326-9

Department of Orthopaedic Surgery, University of Rochester, Rochester, New York.

Cervical spine fractures in osteogenesis imperfecta are rare. The purpose of this article is to describe the successful outcomes of the nonoperative and operative treatment of C2 pars fracture and operative treatment of C7 compression fracture in two children with osteogenesis imperfecta. Patient 1, a 22-month-old female, had a C2 pars fracture managed nonoperatively with a cervical orthosis. Patient 2, a 15-year-old male, had concurrent C2 pars and C7 compression fractures; the C2 pars fractures were treated operatively via a posterior approach and open reduction and internal fixation, and the C7 compression fracture was treated via a C7 corpectomy, iliac crest strut autograft, and anterior plating from C6 to T1. Patient 1 had delayed union but complete healing at latest follow-up (31 months postpresentation). At latest follow-up, patient 2 remained asymptomatic.
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http://dx.doi.org/10.3113/jsoa.2013.0326DOI Listing
June 2014

Transient long thoracic nerve injury during posterior spinal fusion for adolescent idiopathic scoliosis: A report of two cases.

Indian J Orthop 2013 Nov;47(6):621-3

Scottish National Spine Deformity Centre, Royal Hospital for Sick Children, Edinburgh, EH9 1LF, United Kingdom.

We present the transient long thoracic nerve (LTN) injury during instrumented posterior spinal arthrodesis for idiopathic scoliosis. The suspected mechanism of injury, postoperative course and final outcome is discussed. The LTN is susceptible to injury due to its long and relatively superficial course across the thoracic wall through direct trauma or tension. Radical mastectomies with resection of axillary lymph nodes, first rib resection to treat thoracic outlet syndrome and cardiac surgery can be complicated with LTN injury. LTN injury producing scapular winging has not been reported in association with spinal deformity surgery. We reviewed the medical notes and spinal radiographs of two adolescent patients with idiopathic scoliosis who underwent posterior spinal arthrodesis and developed LTN neuropraxia. Scoliosis surgery was uneventful and intraoperative spinal cord monitoring was stable throughout the procedure. Postoperative neurological examination was otherwise normal, but both patients developed winging of the scapula at 4 and 6 days after spinal arthrodesis, which did not affect shoulder function. Both patients made a good recovery and the scapular winging resolved spontaneously 8 and 11 months following surgery with no residual morbidity. We believe that this LTN was due to positioning of our patients with their head flexed, tilted and rotated toward the contralateral side while the arm was abducted and extended. The use of heavy retractors may have also applied compression or tension to the nerve in one of our patients contributing to the development of neuropraxia. This is an important consideration during spinal deformity surgery to prevent potentially permanent injury to the nerve, which can produce severe shoulder dysfunction and persistent pain.
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http://dx.doi.org/10.4103/0019-5413.121595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868146PMC
November 2013

Anterior shoulder instability associated with coracoid nonunion in patients with a seizure disorder.

J Bone Joint Surg Am 2012 Apr;94(7):e40

The New Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SU, United Kingdom.

Background: An association between coracoid fracture and glenohumeral instability with both a seizure disorder and the subsequent development of coracoid nonunion has not previously been recognized. This is clinically important as patients with a seizure disorder and glenohumeral instability frequently require a primary osseous reconstructive procedure, such as coracoid osteotomy and transfer to the anterior glenoid rim (the Bristow-Latarjet procedure), to address glenoid osseous deficiency. We report on coracoid fracture nonunion in five patients with a seizure disorder and anterior glenohumeral instability and discuss the implications for surgical treatment.

Methods: Coracoid fracture was specifically sought on three-dimensional reconstructions of computed tomography scans in a consecutive series of 234 patients presenting to our unit with recurrent anterior instability. In addition to demographic data, we specifically sought information on any history of shoulder injury, the mechanism of injury, or previous seizure activity in these patients. In patients with a coracoid fracture or nonunion viewed to be at high risk of failure with a soft-tissue procedure, an open osseous reconstructive procedure was performed. The type of operative procedure was determined by the location of the nonunion.

Results: We identified six coracoid fracture nonunions in association with anterior glenohumeral instability in five patients (mean age, 26.8 years; range, twenty-four to thirty years). All patients had instability occurring in association with seizures. In the four shoulders with the anatomic location of the coracoid nonunion at its so-called elbow, a standard Bristow-Latarjet procedure was performed. In the two shoulders in which the nonunion was more distal, an Eden-Hybbinette procedure was performed.

Conclusions: We recommend having a high index of suspicion of coracoid fracture when treating patients with a seizure disorder who have anterior glenohumeral instability. In these patients, preoperative computed tomographic images allow the diagnosis of a coracoid nonunion to be made prior to surgery and help to determine whether there is sufficient intact coracoid bone to allow a Bristow-Latarjet procedure to be performed.
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http://dx.doi.org/10.2106/JBJS.K.00188DOI Listing
April 2012
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