Orthopaedic Perspective Research Articles

Radiotherapy for painful shoulder syndrome: aretrospective evaluation.

We evaluated the efficacy of low-dose radiotherapy for painful shoulder syndrome from an orthopedic perspective. Patients with painful shoulder syndrome were recruited for this retrospective clinical quality assessment from January 2011 to December 2017. Patients were treated with alinear accelerator or an orthovoltage device at individual doses of 0.5-1.0 Gy and total doses of 3.0-6.0 Gy. To assess response, we used the von Pannewitz score with five levels: "worsened," "unaffected," "improved," "significantly improved," and "symptom free." "Good treatment success" was defined as "significantly improved" and "symptom free." Within-group and between-group differences were statistically evaluated. Of 236 recruited patients (150 women, 86men; mean age66.3 [range 31-96] years), 180 patients underwent radiotherapy with alinear accelerator and 56with an orthovoltage device. Fractionation was 12 × 0.5 Gy in 120 patients, 6 × 0.5 Gy in 74, and 6 × 1 Gy in 42patients. Treatments were completed in one series for 223 and in two series at least 6weeks apart for 13patients. Of the 236 patients, 163 patients (69.1%) agreed to be re-interviewed at amedian of 10.5 (range 4-60) months after radiotherapy completion. Directly after radiotherapy, 30.9% (73patients) had "good treatment success," which had increased to 55.2% (90patients) at follow-up. Protracted pain improvement with low-dose radiotherapy is possible in painful shoulder syndrome. Patients with refractory pain because of subacromial syndrome or shoulder osteoarthritis should also be evaluated for radiotherapy.

Mechanical study reinforced magnesium-yttrium alloys by eggshell powder using resistance casting

Magnesium-based alloys are relatively new materials for orthopedic implants. One common component that makes magnesium-based alloys biocompatible and chemically stable is the addition of minor compositions of rare earth metals like yttrium to anchor other chemically active components. From an orthopedic perspective, two goals are of primary concern. One is sufficient mechanical support to stabilize the fracture and reduce inflammation. Another is assistance for the transition of osteogenesis and intramembranous ossification for bone production and remodeling. To attain both goals and further improve the current magnesium-yttrium alloys, adding extra ingredients to improve osseointegration is a common and effective approach. By the nature of bone chemistry, calcium is the top choice as calcium is the key element in maintaining bone integrity and biochemical metabolism. In this study, the mechanical behaviors of a calcium-added magnesium-based alloy (Mg-Y3.5 wt%) are investigated by experiments. This inventive idea for the natural source of calcium is obtained from chicken eggs due to their (1) cost-effective and abundant availability, and (2) naturally synthesized calcium carbonate along with a minor content of organic materials. The fabrication processes involved are the ball-milling of eggshells as an additive at 1, 3, and 5 wt%. into magnesium-yttrium alloys and resistance casting to form composites. Material characterization includes microstructural analysis by X-ray diffraction, morphological/elemental analysis via optical microscopy, field emission scanning electron microscopes, energy-dispersive X-ray spectroscopy, mechanical properties by uniaxial compression and Vickers microhardness tests. Experimental results supplemented by statistical and finite element analysis indicate that the new composite exhibits enhanced ductility; and the 3 wt% eggshell-added alloys show better reinforcement of mechanical properties among all samples with an ultimate compression strength of 161.19 MPa, maximum elongation of 17.53 %, and hardness of 457.48 (N/mm2). Note that the comparable mechanical strength of the composite to that of human bones could reduce the stress shielding on bones and further help the process of bone remodeling.

The Recommended Deltoid Intramuscular Injection Sites in the Adult Population: A Cadaveric Pilot Study With an Orthopedic Perspective.

Background and aim The deltoid is a common site for intramuscular injections, but guidelines for administration lack standardization. Global researchers propose various techniques, and recent study reports indicate a 1.5-15% incidence of nerve palsies due to injections. This pilot cadaveric study aimed to standardize the deltoid intramuscular injection sites in the Southeast Asian population. Methods This cadaveric study of a two-year duration was conducted in the Department of Anatomy as an intramural research project in collaboration with the Departments of Anatomy and Orthopedics. In the first year of study, which was the pilot phase of the project, the available six cadavers, i.e., 12 upper extremity specimens were dissected. Anthropometric measurements of deltoid muscle along with the distance of underlying neurovascular structures like the axillary nerve and posterior circumflex humeral artery were measured from neighboring bony landmarks. This article presents the observations of the six cadavers studied in the pilot phase and shall be followed up by another article after the project. Results In adults, in anatomical position, the mean distances of the axillary nerveand posterior circumflex humeral artery from the mid-acromial point are 8.19±0.616 and 8.66±0.968 cm, respectively. The deltoid thickness at 3, 5, and 7 cm from mid-acromial point was observed to be 1.079±0.13 cm (0.5-1.78 cm), 1.599±0.12 cm (1-2.96 cm), and 1.815±1.0 cm (1.2-2.5 cm), respectively. The acquired qualitative and quantitative data were tabulated, graphically represented, and statistically analyzed. Conclusions The deltoid intramuscular injection (IMI) must be given at or below the level of the midpoint of the deltoid muscle, but never in the upper half. We recommend a site, 4 fingerbreadths/9 cm below the mid-acromion point as the safest site to avoid injury to any underlying neurovascular structures.

Treating Hepatitis C Prior to Total Hip Arthroplasty is Cost-effective: A Markov Analysis

BackgroundPatients infected with the hepatitis C virus (HCV) have high complication rates following total hip arthroplasty (THA). Advances in HCV therapy now enable clinicians to eradicate the disease; however, its cost-effectiveness from an orthopaedic perspective remains to be demonstrated. We sought to conduct a cost-effectiveness analysis comparing no therapy to direct-acting antiviral (DAA) therapy prior to THA among HCV-positive patients. MethodsA Markov model was utilized to evaluate the cost-effectiveness of treating HCV with DAA prior to THA. The model was powered with event probabilities, mortality, cost, and quality-adjusted life year (QALY) values for patients with and without HCV that were obtained from the published literature. This included treatment costs, successes of HCV eradication, incidences of superficial or periprosthetic joint infection (PJI), probabilities of utilizing various PJI treatment modalities, PJI treatment success/failures, and mortality rates. The incremental cost-effectiveness ratio was compared to a willingness-to-pay threshold of $50,000/QALY. ResultsOur Markov model indicates that in comparison to no therapy, DAA prior to THA is cost-effective for HCV-positive patients. THA in the setting of no therapy and DAA added 8.06 and 14.39 QALYs at a mean cost of $28,800 and $115,800. The incremental cost-effectiveness ratio associated with HCV DAA in comparison to no therapy was $13,800/QALY, below the willingness-to-pay threshold of $50,000/QALY. ConclusionHepatitis C treatment with DAA prior to THA is cost-effective at all current drug list prices. Given these findings, strong consideration should be given to treating patients for HCV prior to elective THA. Level of EvidenceCost-effectiveness Analysis; Level III.

The crippling effects of a cyberattack at an academic level 1 trauma center: An orthopedic perspective

IntroductionMalicious cyberattacks are increasing in frequency and severity with healthcare institutions spending an average of over 10 million dollars to resolve the consequences of healthcare data breaches. This cost does not include the effect of a downtime event should a healthcare system electronic medical record (EMR) lose functionality. An Academic Level 1 trauma center suffered a cyberattack resulting in a total EMR downtime of 25 days. Orthopedic operative time was used as a surrogate for OR functionality during the event and a framework with specific examples is presented to promote rapid adaptation during downtime events. MethodsOperative time losses were identified by calculating a running average of weekday total in room operative time during a total downtime event secondary to a cyberattack. This data was compared to week-of-the-year matched data from the year prior and the year after the attack. A framework for creating adaptations to a total downtime event was created by repeatedly interviewing different provider groups and identifying how they adjusted care to the challenges faced. ResultsTotal weekday in room operative time during the attack decreased by 53.4% ± 12.2% and 53.2% ± 14.9% when comparing the matched period one year prior and one year after, respectively. Immediate challenges to patient care were identified by small groups of highly motivated individuals, with self-assigned agile teams formed. These teams sequenced system processes, identified failure points, and created real-time solutions. A frequently updated EMR backup mirror and hospital disaster insurance were crucial for mitigating the impact of the cyberattack. ConclusionsCyberattacks are expensive and their downstream effects, including downtime events, can be crippling. Agile team formation, process sequencing, and understanding EMR backup times are tactics used to combat the challenges of a prolonged total downtime event. Level of EvidenceLevel III retrospective cohort

Using e-scooters: An easy way to get home or a nightmare? An orthopedic perspective on e-scooter accidents.

The percentage of e-scooter use quickly escalated in our community due to its convenience, low cost, and eases of use. The number of accidents causing high-energy traumas has also increased. This study aims to describe the demographic char-acteristics and fracture patterns of patients admitted to the emergency department following an e-scooter accident and to identify common, correctable factors that increased the likelihood of accidents. Between January 2022 and August 2022, 43 patients (20 females and 23 males) who were admitted to the emergency department after an e-scooter accident and developed extremity fractures were included. The patients were divided into 2 groups those treated surgically and conservatively. Parameters such as the time of the accident, education level of the user, alcohol use, e-scooter malfunction, and compliance with traffic rules were evaluated. Accidents that led to treatment by surgery mostly occurred between 11 pm and 7 am. Surgically treated patients were mostly high school graduates. Alcohol use and recreational scooter use rates were statistically higher in the operated patients when compared to patients who were treated conservatively. The number of patients who reported a malfunction in the e-scooter was significantly lower in the operated group than in the conservative group. The rates of accidents due to non-compliance with traffic laws, driving at full speed of the e-scooter, use on the driveway, and presence of wet ground at the time of the accident were higher in the surgically treated patient group. Surgically treated patients also had a higher rate of being 1st time e-scooter users. Although governments have introduced many regulations regarding e-scooter use, the current situation seems insufficient in solving the problem. E-scooter users should be further educated about the associated risks. Authorities should tighten their supervision of scooter rental companies and drivers. Nighttime usage conditions should be reviewed, and the use of alcohol should be controlled. The use of helmets should be mandatory. If such regulations are tightened, accident rates can be reduced or high-energy impacts from existing accidents can be avoided. The results suggest that experienced, slow, non-alcoholic, and rule-abiding drivers require less operative treatment. This article will hopefully raise awareness and improve e-scooter regulations.

Lower Extremity Malformations.

Lower Extremity Malformations.

Pelvic Floor Dysfunction from an Orthopedic Perspective: a Review of the Literature

Pelvic Floor Dysfunction from an Orthopedic Perspective: a Review of the Literature

Implementation of online video consultations in a regional health network: a management feasibility analysis from an orthopedic perspective

IntroductionRegional health care networks with interfaces between clinics, general practitioners and patients can act faster when utilizing digital measures. This manuscript describes the establishment of an online video consultation service in a clinic and its broad health care region to exemplify challenges and solutions for potential future approaches from a management perspective.MethodThe underlying pilot project was planned and implemented for follow-up monitoring and consultative presentation of orthopedic and trauma patients within the Bundeswehr Medical Service from 2018 to 2020. With predominantly positive evaluation results regarding quality and acceptance among users, this research investigated organizational and processual aspects including total quality management, strategic control and change management approaches.ResultsThe affected main and subprocesses of patient treatment could be streamlined by the project, as physician recommendations and arrangements could be accelerated and patient travel could be significantly reduced. A SWOT and portfolio analysis showed a high potential for improving existing patient treatment processes for health care enterprises via the use of digital technology. The involved staff should be strategically included at an early stage and continuously involved. By means of a PDCA cycle, the processes of the given project could be exemplarily illustrated with an outlook in the future.DiscussionIt has proven successful to consciously use management approaches to establish telemedical integrated care structures in a health region. Recommendations for the strategic introduction of an online video consultation for regional network strengthening and care development for a patient-oriented increase in efficiency could be compiled.

Comment on an article: “Medications in COVID-19 patients: summarizing the current literature from an orthopaedic perspective”

Comment on an article: “Medications in COVID-19 patients: summarizing the current literature from an orthopaedic perspective”

Advantage of the regenerative potentials of the periosteum especially in children, Oghara experience: A case series

The periosteum is a composite tissue comprising an outer protective fibrovascular layer and an inner cambium regenerative pluripotent layer. The regenerative function of periosteum has been put to clinical use by dental surgeons to manage alveolar ridge reduction and by tissue engineers to produce autologous micrograft and collagen used to manage complex wounds and scars. The essence of this study is to add to the body of knowledge on clinical use of periosteum to treat bone defects from the orthopaedic perspective. We highlight a case series to demonstrate the use of periosteum in managing bone defects caused by benign bone tumour, chronic osteomyelitis, tibial hemimelia and traumatic bone loss of the distal tibia in Delta State University Teaching Hospital, Oghara. Treatment of bone defects by this means is cost effective and the outcome is very satisfactory.
 Key words: Periosteum, mesenchymal stem cells, bone defects, distraction histiogenesis.

Medications in COVID-19 patients: summarizing the current literature from an orthopaedic perspective.

PurposeThe review aims to provide a summary of the current literature regarding common medications prescribed in orthopaedic surgery and their potential implications in COVID-19 patients.MethodsA systematic review was performed using the PRISMA guidelines. All clinical studies, reviews, consensus and guidelines related to the above medications and COVID-19 were included.ResultsA total of 18 articles were included. The use of analgesia, anti-inflammatories, steroids, anticoagulants, antibiotics, vitamin B, vitamin C and vitamin D and their potential impact on COVID-19 patients were reported.ConclusionEight main recommendations were derived from the review. Firstly, paracetamol remains the first line of analgesia and antipyretic. Secondly, there is no need to avoid NSAIDs for COVID-19 patients. Thirdly, opioids have the potential for immunosuppression in addition to respiratory depression and, therefore, should be prescribed with care in COVID-19 patients. Fourthly, patients with conditions where steroids are proven to be efficacious can continue to receive their steroids; otherwise, systemic steroids are not recommended for COVID-19 patients. Fifthly, orthopaedic surgeons following up on COVID-19 patients who are using steroids should continue to follow them up for possible avascular necrosis. Sixthly, whenever possible, oral anticoagulation should be converted to parental heparin. Seventhly, common orthopaedic antibiotics including penicillin and clindamycin are safe to continue for COVID-19 patients. However, for COVID-19 patients, the antibiotics can potentially be switched to macrolides and tetracyclines if the organisms are sensitive. Lastly, prescription for vitamins B, C and D should continue as per usual clinical practice.

Practising orthopedics in COVID times: The way forward

This article highlights the influence of coronavirus pandemic in patient care from an Orthopedic surgeon's perspective and enumerates the modifications in routine practice while providing quality service to the society. The authors have reviewed the recently available articles regarding the changes in orthopedic practice with respect to the coronavirus disease pandemic. Prioritizing surgical treatment of obligatory fractures and conservative management of non-obligatory fracture will be the cornerstone of management strategy in patient care during these troubled times. Formalizing evidence-based protocols for various subsets of orthopedics not only reduces the event-response time lag but also helps in accurate implementation of services for the best patient outcome.

Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective.

PurposeClosed reduction under conscious sedation in the emergency department (ED) has been demonstrated to provide cost-effective, timely care. There has been little research into the efficacy of conscious sedation and reduction from an orthopaedic trauma perspective. This study describes the epidemiology and outcomes associated with fracture conscious sedation and reduction in our level I paediatric ED.MethodsAll fracture patients presenting overnight to our level I trauma centre ED between 01 June 2016 and 30 June 2017 were identified. Patient records were reviewed to determine diagnoses, treatments and outcomes. The rate of repeat intervention after successful conscious sedation and reduction and rate of changes in management in which the orthopaedic resident’s overnight management plan to provide procedural sedation was altered to surgical intervention after morning case review rounds was calculated.ResultsConscious sedation and reduction was performed on a total of 386 patients covering ten fracture types during the course of our study, with distal radius fractures (n = 167, 43.3%) comprising the majority of cases. A total of 53 cases (13.7%, 53/386) lost alignment and required repeat intervention, consisting of 33 cases (8.5%, 33/386) that required repeat surgery and 5.2% (20/386) that required cast wedging. In all, 12 patients (3.1%, 12/386) initially reduced under conscious sedation required a change in management and surgical intervention. There were five cases of growth arrest and two cases of malunion.ConclusionsConscious sedation and reduction provides an alternative to general anaesthesia for many paediatric trauma injuries without compromising patient outcomesLevel of EvidenceIV

Is This "Easy-to-Use" Tool the Best Way to Predict Survival?: Commentary on an article by J.J. Willeumier, MD, et al.: "An Easy-to-Use Prognostic Model for Survival Estimation for Patients with Symptomatic Long Bone Metastases".

Commentary Comparatively speaking, there are more tools for predicting survival in patients with spine metastases than with long bone metastases, but good tools are needed for each1-5. The authors of this study felt strongly enough about this fact that they set out to develop a survival prediction tool for patients with long bone metastases based on their earlier work in the spine. To evaluate this tool, several criteria that define a good survival prediction tool can be examined. First, the data on which it is based must be robust and supported by valid statistical analysis. Second, a truly useful survival predication tool is best if it is easy to use. Less is more here, and the variables should be easily accessible. Third, the tool should provide meaningful survival windows that contribute to clinical decision-making. Unfortunately, there are at least 3 aspects to meaningful survival windows: recovery, durability, and economics; none have been studied adequately to date. Armed with these suggested definitions of a good survival prediction tool, the current tool can be evaluated. There are several strengths. First, the currently reported tool is backed by robust statistical support. Variables were the product of a very large derivation data set (1,520 patients), the resulting tool having been tested successfully in a validation group of 250 patients. Second, it would appear to be “easy to use,” as it is based on only 3 variables. Third, for as much as is known about what we need for meaningful time prognostication, this tool does a good job at tightly separating the patients with very poor survival (median, 2.2 months), from those with poor (median, 4.6 months), fair (median, 10.5 months), and best (median, 21.9 months) survival. A fourth and somewhat unique strength of this tool is its flexibility in allowing adjustment of the clinical profile according to changes in the prognosis for specific primary diseases over time. However, there are several weaknesses with this tool. The very nature of including only orthopaedic and radiation oncology patients, while on the one hand representing an advance from other tools, excludes those managed primarily by medical oncology and confounds by indication, possibly biasing toward better prognosis than would have been observed if all patients were examined. There were also issues with accessibility of the 3 variables, as only 74% of patients had all 3 available. Only 76% had functional scoring available, and of those patients, 47% had scoring derived from chart descriptions; of the other 53%, only approximately half had a Karnofsky Performance Score (KPS) available, the remainder having World Health Organization scores instead. Translated, only 20% of the original derivation group had a KPS available. Prior studies have also shown high variability with respect to the KPS6. Beyond the study criticisms, the reported tool may simply not be so easy to use or even the easiest system available. A report examining bone metastases for the entire skeleton predicted survival with equivalent accuracy utilizing just 2 variables (KPS and primary tumor)5. Some might argue that a tool for the entire skeleton is more practical since it includes the pelvis, where procedures may require a longer recovery time than those of the extremity. Evaluation for brain metastases in this study was done almost exclusively without imaging and was based on clinical assessment. On the other hand, imaging to detect visceral metastases in this study was done in 97% of the patients. Hence, if one is to use this system, a thorough clinical examination to detect intracerebral lesions and imaging of the viscera should be done. Further, additional bone imaging should be obtained for renal cancers to stratify them within the 2 categories based on number of metastases. In summary, the proposed tool is based on a robust derivation database, is statistically valid, and derives from earlier models by this group that have utilized the same 3 variables for spine tumors, applying it now to long bones. It has unique advantages of including orthopaedic and radiation oncology patients, excludes myeloma, and is independent of laboratory results. From an orthopaedic perspective, the usefulness of tools such as this one awaits better understanding of typical recovery courses, durability, and cost-benefit analyses for internal fixation devices versus standard endoprostheses and megaprostheses. Further validation of this tool awaits testing on a larger prospective pool of patients.

The burden of gunshot injuries on orthopaedic healthcare resources in South Africa.

Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective. To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital. This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration ofadmission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered. A total of 111 patients with an average age of 28 years (range 13 - 74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 - 7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient.Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient. This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient cost USD2 940, used just over 3 hours of theatre time per operation, and necessitated a hospital bed for an average period of 9.75 days. Improved understanding of the high incidence of orthopaedic GSWs treated in an SA tertiary care trauma centre and the costs incurred will help the state healthcare system better prioritise orthopaedic trauma funding and training opportunities, while also supporting cost-saving measures, including redirection of financial resources to primary prevention initiatives.

Anatomical and Orthopaedic Perspective of a Block Cervical Vertebra Anatomic, Embryological and Orthopedic Perspective

Anatomical and Orthopaedic Perspective of a Block Cervical Vertebra Anatomic, Embryological and Orthopedic Perspective

Imaging in peri-prosthetic assessment: an orthopaedic perspective.

As imaging techniques are ever-evolving, this article aims to provide a brief overview of the various modalities including their limitations. The ability of imaging for evaluation of implant osseo-integration will be addressed and also the role of imaging in assessing septic and aseptic loosening, with a particular focus on adverse tissue reactions, will be discussed. Specific features when imaging the big joints such as shoulder, hip, knee and ankle joint will also be outlined.Overall, a lack of standardisation and validity was noted and despite the gross variety of imaging modalities, there is no technique covering all aspects required for evaluation of implant fixation and septic and aseptic loosening. Each imaging modality has a role, depending on the information required and anticipated. The choice of imaging technique should not be primarily based on medical considerations but also on availability, accessibility, expertise and costs. Plain radiographs alone have been recommended in cases of suspected peri-prosthetic joint infections, given the lack of evidence for additional imaging techniques in this context. For aseptic loosening, ultrasound and plain radiographs may serve as initial screening tools. Metal artefact reducing sequences (MARS) MRI are advancing cross-sectional imaging and are likely to promote their role in patient evaluation.We conclude that imaging is one essential part in the work-up of patients with total joint replacements, within a specific clinical context. Close teamwork between experienced radiologists and orthopaedic surgeons is required for optimal patient care.Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160058. Originally published online at www.efortopenreviews.org

Pediatric Orthopaedic Providers' Views on Transition From Pediatric to Adult Care.

Surgical specialties are underrepresented in the discussions regarding transition and transfer of patients to adult care. We sought the pediatric orthopaedic perspective on types of patients seen into adulthood, age cut-offs, triggers for transfer, and barriers to transition. We examined provider demographic factors that may influence perspectives. An internet-based survey was sent to all members of the Pediatric Orthopaedic Society of North America and the Pediatric Orthopaedic Practitioner Society. Responses were voluntary and anonymous. Response rates were 27% for the Pediatric Orthopaedic Society of North America and 24% for the Pediatric Orthopaedic Practitioner Society. Most respondents (70%) care for patients over the age of 25 years and many (35%) for patients over the age of 40. The most common conditions cared for were neuromuscular and congenital disorders. Respondents who worked in a fully salaried model reported caring for fewer of these adult patients compared with those working in other types of payment structure (P<0.001). Respondents working in free-standing children's hospitals reported fewer patients over 30 years old compared with nonchildren's hospital settings (P<0.001). There were no significant differences between profit-based and nonprofit settings. The top triggers for transfer to adult providers were: (1) adult comorbidities; (2) transition to medical specialist; and (3) institutional policy. The top barriers to transfer were: (1) lack of qualified adult providers; (2) institutional policy; and (3) on-going surgical issues. Many providers care for older patients, often using external triggers for transfer to adult care. Financial considerations may need to be further explored. Variation in care may be aided by national society guidelines. Level III-survey research.

Spontaneous resolution of avascular necrosis of femoral heads following cure of Cushing's syndrome.

SummaryAvascular necrosis (AVN) is a rare presenting feature of endogenous hypercortisolism. If left untreated, complete collapse of the femoral head may ensue, necessitating hip replacement in up to 70% of patients. The majority of the described patients with AVN due to endogenous hypercortisolaemia required surgical intervention. A 36-year-old female, investigated for right leg pain, reported rapid weight gain, bruising and secondary amenorrhoea. She had abdominal adiposity with violaceous striae, facial plethora and hirsutism, atrophic skin, ecchymosis and proximal myopathy. Investigations confirmed cortisol excess (cortisol following low-dose 48h dexamethasone suppression test 807nmol/L; 24h urinary free cortisol 1443nmol (normal<290nmol)). Adrenocorticotrophic hormone (ACTH) was <5.0pg/mL. CT demonstrated subtle left adrenal gland hypertrophy. Hypercortisolaemia persisted after left adrenalectomy. Histology revealed primary pigmented micronodular adrenal disease. Post-operatively, right leg pain worsened and left leg pain developed, affecting mobility. MRI showed bilateral femoral head AVN. She underwent right adrenalectomy and steroid replacement was commenced. Four months after surgery, leg pain had resolved and mobility was normal. Repeat MRI showed marked improvement of radiological abnormalities in both femoral heads, consistent with spontaneous healing of AVN. We report a case of Cushing’s syndrome due to primary pigmented nodular adrenocortical disease, presenting with symptomatic AVN of both hips. This was managed conservatively from an orthopaedic perspective. Following cure of hypercortisolaemia, the patient experienced excellent recovery and remains symptom free 4 years after adrenalectomy. This is the first report of a favourable outcome over long-term follow-up of a patient with bilateral AVN of the hip, which reversed with treatment of endogenous hypercortisolaemia.Learning pointsAVN of femoral head can be a presenting feature of hypercortisolism, both endogenous and exogenous.Rarely, treatment of hypercortisolaemia can reverse AVN without the need for orthopaedic intervention.Primary pigmented nodular adrenal disease is a rare cause of ACTH-independent Cushing’s syndrome.