Postoperative Radiographs Research Articles

First Tarsometatarsal Alignment May Self-Correct After Triple Arthrodesis in Progressive Collapsing Foot Deformity.

Triple arthrodesis is commonly used to correct rigid progressive collapsing foot deformity (PCFD). These patients often have associated first tarsometatarsal (TMT) instability on lateral weightbearing radiographs. It has not been well established if it is necessary to add first TMT arthrodesis to adequately correct the overall deformity. This study retrospectively examined pre- and postoperative radiographs of PCFD patients with first TMT instability that were managed by triple arthrodesis alone. All triple arthrodesis cases were searched for a single surgeon between 2013 and 2021. Inclusion criteria were patients with PCFD who underwent triple arthrodesis without first TMT joint fusion. Preoperative radiographs were examined for first TMT joint instability, demonstrated by plantar gapping of the first metatarsal-medial cuneiform angle or first metatarsal dorsal subluxation at the TMT joint. Measurement of sagittal first metatarsal-medial cuneiform angle and first metatarsal subluxation as described by King and Toolan was performed. Twenty patients satisfied the inclusion criteria. Six patients did not demonstrate at least 30% improvement of one or both measurements of first TMT instability postoperatively and were considered failures. Fourteen patients demonstrated correction of their first TMT joint instability. Average follow-up was 5.0 (range, 1.8-9.4) years. The first metatarsal-medial cuneiform angle improved from 3.8 to 1.1 degrees (P < .05). The first metatarsal subluxation corrected from 4.1 to 1.5 mm (P < .05). One patient showed radiographic evidence of arthritis in the first TMT joint at final follow-up. Seventy percent of patients with PCFD with asymptomatic first TMT joint instability demonstrated correction of first TMT radiographic instability with isolated triple arthrodesis. This was maintained at 5-year mean follow-up. In cases of PCFD with medial column instability, triple arthrodesis alone may be adequate to restore overall alignment.

COMPARISON OF FIXATION USING SCREWS AND SUTURE BUTTONS IN THE TREATMENT OF DISTAL TIBIOFIBULAR DIASTASIS ASSOCIATED WITH ANKLE FRACTURES

Purpose: We aimed to compare the treatment results of fixation using screws and a suture button when treating distal tibiofibular joint diastasis combined with ankle fractures Materials and Methods: A retrospective study was conducted on 30 patients with ankle fractures who were treated with screws and 34 patients who were treated with suture buttons for distal tibiofibular joint diastasis. Postoperative clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, and radiologic outcomes were evaluated by measuring tibiofibular clear space, tibiofibular overlap, and medial clear space on pre- and post-operative radiographs. The average length of hospital stay, whether surgery was performed to remove the internal fixation, the time of weight bearing, and whether the internal fixation was damaged were investigated. Results: One year after surgery, the average AOFAS score showed no statistically significant difference between the screw surgery group and the suture button surgery group. The averages of tibiofibular clear space, tibiofibular overlap, and medial clear space measured immediately postoperatively did not show statistically significant differences between the screw surgery group and the suture button surgery group, but the measurements taken 1 year after surgery were significantly different statistically. Screw removal surgery was performed in all cases in the screw surgery group. In the screw surgery group, there were 3 cases of screw breakage and 3 cases of surgical wound infection, and the length of hospitalization and the postoperative weight-bearing start time in the screw surgery group were longer. Conclusion: When treating distal tibiofibular joint diastasis, the screw surgery group and the suture button surgery group showed no statistically significant difference in clinical outcomes measured by AOFAS 1 year after surgery, but the suture button surgery group had better results in radiological evaluation and in complication frequency.

Three-dimensional acetabular reorientation during periacetabular osteotomy: an intraoperative navigation method using an external fixator for periacetabular osteotomy.

Bernese periacetabular osteotomy (PAO) is an effective procedure for treating acetabular dysplasia. However, limited visual control of the acetabular position during surgery may result in under- or overcorrection or changes in acetabular version resulting in residual dysplasia or femoroacetabular impingement. Thus, we wanted to develop a simple and straightforward navigation method that provides information about acetabular correction in all three planes during surgery. Intraoperatively, acetabular coordinates are shown in coronal, sagittal, and transverse plane by two perpendicular tubes of an external fixator mounted onto a third tube that is fixed to the mobilized acetabular fragment with two Schanz screws. The application and fixation of the external fixator on the pelvis are demonstrated in this article. We used this analog navigation method on 27 PAOs, where we mainly performed a lateral rotational correction. The pre- and postoperative radiographs of these 27 hips were analyzed regarding the radiological hip parameters, taking into account the pelvic tilt. The mean preoperative lateral center edge angle (LCEA) of the 27 PAOs improved from 16° (+-6) to a mean of 34° (+-6°) and the mean acetabular index (AI) was corrected from 15° (+-4) to 2° (+-4). This implements highly physiologic postoperative values for lateral coverage in this population. In this case series, no postoperative acetabular retroversion was measured in any of the 27 PAOs. Three-dimensional control of the acetabular orientation during periacetabular osteotomy is important to avoid over- and undercorrection. Using a fixateur externe as an analog navigation method this three-dimensional control can be implemented intraoperatively for PAOs.

Survivorship and Functional Outcomes After Complex Primary Total Knee Arthroplasty With Contemporary Rotating-Hinge Implants

Background: Initial fixed-bearing hinge designs for primary total knee arthroplasty (TKA) had high rates of aseptic loosening. There are limited data on contemporary rotating-hinge implants. Purpose: We sought to determine survivorship and functional outcomes of contemporary rotating-hinge implants used in primary TKA. Methods: Retrospective review identified 54 primary rotating-hinge TKAs implanted in 49 patients from 2014 to 2018 at a single institution. Patients identified were 76% women, the mean body mass index was 29 kg/m2, the mean age was 65 years, and the mean follow-up was 3 years. The primary diagnosis for TKA in all cases was severe instability and ligamentous compromise. Secondary diagnoses included post-traumatic osteoarthritis (11, 20%), neurologic disease (10, 19%), inflammatory arthritis (10, 19%), connective tissue disease (3, 6%), valgus deformity (16, 30%), varus deformity (2, 4%), and recurvatum (2, 4%). Preoperative, postoperative (within 6 weeks), and most recent radiographs were reviewed. In this study, we collected preoperative, 1-year, and 2-year patient-reported outcome measures (PROMs) for patients with primary rotating-hinge TKA. Patient-reported outcome measures were prospectively collected, including the Knee Injury and Osteoarthritis Outcome Survey for Joint Replacement (KOOS JR) scores and the Mental (MCS) and Physical Component Scores (PCS) of the Veterans RAND 12-Item Health Survey (VR-12). Kaplan-Meier analysis was used to determine implant survivorship. Results: Reoperation was required in 6% (3/54); indications included periprosthetic joint infection (1), peripatellar fibrosis (1), and periprosthetic femur fracture (1). At both 2 and 5 years, survivorship free from all-cause reoperation was 95% and from revision for aseptic loosening was 100%. Mean KOOS JR scores increased from 47 preoperatively to 65 at 2 years postoperatively. On radiographic review, there were no progressive radiolucent lines consistent with aseptic loosening at final follow-up. Conclusion: The findings of this single-center, multi-surgeon retrospective case series on the use of rotating-hinge implants for primary TKA suggest excellent 2-year survivorship free from reoperation and no revisions for aseptic loosening. We report modest improvement in a variety of PROMs at 1-year and 2-year follow-up. Despite improvement, clinical outcomes were poor for a primary implant. Longer-term follow-up is required to monitor the durability of primary hinges.

Synthetic cartilage implant vs. first metatarsophalangeal arthrodesis for the treatment of hallux rigidus.

This study evaluated the outcome of the Cartiva synthetic cartilage implant (SCI) in the treatment of hallux rigidus. In the present retrospective matched case-control study, we compared 18 patients with Cartiva SCI (mean follow-up: 17.7 months) to 18 patients with metatarsophalangeal joint arthrodesis (mean follow-up: 20 months) using multiple function measures, along with four specified visual analog subscales for pain. Pre- and postoperative radiographs were compared, and radiographic abnormalities were documented. We observed no significant differences in function measures between groups. While both groups experienced significant pain reduction, the arthrodesis group reported significantly lower exertion pain than the Cartiva SCI group (p = 0.004). Radiographic abnormalities, including implant site enlargement (6/18, 33.3%), erosive changes of the metatarsal bone (11/18, 61.1%) or articular surfaces (10/18, 55.6%), and bright sclerotic margins (12/18, 66.7%), occurred in the Cartiva SCI group. The present study showed good functional results and a high satisfaction rate after MTP joint arthrodesis, which is considered the gold standard surgical treatment for higher grade hallux rigidus. While the Cartiva SCI group did not show significant differences from the arthrodesis in most aspects of function and clinical scores, the arthrodesis group tended to have better results in terms of satisfaction, residual pain, and revision rate. Even after the short follow-up period, there were some remarkable radiographic findings in the Cartiva SCI group, the long-term effects of which are not yet evident, but which may lead to implant loss. Cartiva SCI has advantages for patients who prioritize postoperative mobility, but the potential risks should be considered in the patient's informed consent. Therefore, the present study highlights the importance of MTP joint arthrodesis for the treatment of hallux rigidus. Level IV - Retrospective matched case-control study.

The Utility of Magnetic Resonance Imaging-based Vertebral Bone Quality Scores as a Predictor of Cage Subsidence Following Transforaminal and Posterior Lumbar Interbody Fusion.

Retrospective study. The objectives were to determine whether vertebral bone quality (VBQ) scores are associated with interbody cage subsidence following transforaminal (TLIF) and posterior (PLIF) lumbar interbody fusions and whether there is a clinically sensitive threshold for subsidence. Interbody cage subsidence following lumbar fusion is a complication that can generate poor surgical outcomes. Prior research has correlated cage subsidence with bone mineral density. VBQ scores derived from magnetic resonance imaging (MRI) have been proposed as a tool for measuring bone mineral density, offering a potential new and convenient preoperative risk assessment tool for subsidence. The study involved patients undergoing single-level PLIF or TLIF between 2007 and 2022. Exclusions were for nondegenerative diagnoses, multilevel/revision surgeries, inadequate radiographs, missing immediate postoperative radiographs, and preoperative MRI studies older than 1 year. VBQ was calculated at L1-L4 from preoperative T1-weighted MRI images. Subsidence was assessed by changes in disc height (DH; >2mm difference) and segmental lordosis (SL; >5 degrees difference) between immediate weight-bearing postoperative and latest postoperative lateral radiographs. Statistical analysis included descriptive and inferential statistics. Subsidence was observed in 27% (SL parameter) and 47% (DH parameter) of 51 total patients. VBQ scores were significantly associated with cage subsidence based on both SL (odds ratio = 7.750, P = 0.012; correlation coefficient = 0.382, P = 0.006) and DH (odds ratio = 4.074, P = 0.026; correlation coefficient = 0.258, P = 0.057) in the combined TLIF/PLIF cohorts. In the cohort of 36 patients undergoing TLIF, a VBQ of 2.70 yielded 100.0% sensitivity and 46.2% specificity in detecting subsidence with SL measurement (area under the curve = 0.812, P < 0.001) and 86.7% sensitivity and 47.6% specificity with the DH measurement (area under the curve = 0.692, P = 0.033). We found that MRI-based VBQ scores are effective predictors of cage subsidence following TLIF surgery. A VBQ score of 2.70 demonstrated a reliable model and high sensitivity for doing so, identifying a potential clinical threshold for preoperative subsidence risk assessment. Level III.

Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures

To review and summarize the projections of radiographic images during cephalomedullary nailing fixation for intertrochanteric femoral fractures, and to propose a set of three projections as standard requirement in immediate postoperative fluoroscopy. Papers on intertrochanteric femoral fractures treated with cephalomedullary nailing fixation that published in a three-year period of 2021-2023 in four leading English orthopedic trauma journals were searched in PubMed. The presented radiographic pictures were identified and scrutinized as whether they were in standard anteroposterior and/or lateral projections of the implanted nails. The nonstandard presence percentage was calculated. Combined with clinical experience, the standard anteroposterior and lateral perspective images of femoral neck, the current situation of radiographic imaging in the operation of cephalomedullary nails, the literature analysis of nonstandard images, the impact of limb rotation on image interpretation, and the characteristics of anteromedial 30° oblique perspective were summarized and analyzed. The presence of nonstandard radiographic pictures is 32.1% in anteroposterior view and 69.2% in lateral view in leading orthopedic trauma journals. In cephalomedullary nailing fixation operation of intertrochanteric femoral fractures, it is reasonable to use the radiographic images of the implanted nails to represent the fractured head-neck, as the head-neck implant (lag screw or helical blade) is aimed to put into centrally in femoral head in lateral projection. Limb rotation or nonstandard projections produced distortion of images, which interfers the surgeons' judgement of fracture reduction quality and the measurement of implant position parameters in femoral head (such as neck-shaft angle and tip-apex distance), and finally lead to a meaningless comparison with the accurate normal value. The 30° anteromedial oblique view from the true lateral (set as 0°) is a tangential projection of the cortices at the anteromedial inferior corner, which gives a clear profile for the determination of cortical apposition status and mechanical support. It is essential to get firstly the true standard lateral fluoroscopy of the nail (shown as a line), then rotate the C-arm to 90° and 30° to get anteroposterior and anteromedial oblique views, and use these three immediate postoperative radiographies as the baseline for evaluation of operative quality and follow-up comparisons. As for real-time monitoring of surgical steps, intraoperative fluoroscopy follows the "Enough is Good" principle, but as for immediate postoperative data storage and basis for operative quality evaluation and baseline for follow-up comparison, it is recommended to obtain a set of three standard radiographic pictures in anteroposterior, true lateral, and 30° anteromedial oblique fluoroscopic projections.

Possible effects of lumbar stabilization surgery on sagittal alignment, disability and quality of life

BackgroundIn order to restore the individual's health in lumbar stabilization surgeries, it is aimed to bring the sagittal alignment closer to normal values, to eliminate the findings, and thus to increase the quality of life of the individual by reducing the disability level. The aim of this study is to measure the effects of lumbar region stabilization surgeries performed in our clinic on some angular values in the spine, disability and quality of life. Preoperative (preop) and postoperative (postop) radiographs of 30 individuals over the age of 40 who applied to our clinic with various lumbar region complaints and underwent lumbar stabilization surgery between the years 2020–2022 were taken. Lumbar lordosis, pelvic tilt, sacral slope and pelvic inclination angles were measured from the images obtained. The Visual Analog Scale was used to measure the pain of individuals, the Oswestry Disability Index to measure the disability level, and the Nottingham Health Profile questionnaire to measure the quality of life. Preop and postop data were analyzed with the SPSS 23.0 program and p < 0.05 was considered significant.ResultsThe lumbar lordosis angles of individuals who underwent lumbar stabilization surgery approached normal values and the difference between preop–postop lumbar lordosis angle averages was significant (p < 0.05); It was observed that the harmony between the lumbar lordosis and pelvic inclination angles increased, the pain decreased and the difference between preop–postop pain values was significant (p < 0.05), disability levels decreased and quality of life increased.ConclusionsThe decrease in the level of disability and the increase in the quality of life seen in individuals who underwent lumbar stabilization surgery were associated with the decrease in pain; The changes in angular values are considered to be clinically significant.

ROLE OF POSTOPERATIVE CT SCAN IN ASSESSING SYNDESMOTIC REDUCTION IN ANKLE INJURIES

Background: Accurate syndesmotic reduction is necessary for achieving joint congruity and better functional outcomes. Radiographs alone don’t suffice, and CT scans are required for the evaluation of postoperative syndesmotic reduction. Methods: All patients who underwent ankle syndesmotic reduction and fixation from December 2019 to July 2021 were taken into the study. Predefined measurements were taken in postoperative radiographs and axial CT images were taken postoperatively. Sensitivity and specificity of X-rays when compared to CT scan were evaluated. Results: Twenty eight patients were included in the study and 13 cases were found to have syndesmotic malreduction in radiographs as per TCS and TFO in AP view and TFO and MCS measurements in mortise view. Five out of 28 cases were found to have syndesmotic malreduction in CT axial cuts as per standard anterior and posterior measurements. Hence 17.85% cases were malreduced in our study as per the gold standard (CT scan). The incidence of syndesmotic malreduction after fixation was 17.85%. Radiographs had a sensitivity of 60% and specificity of 56.5% in detecting malreduction. Conclusion: CT scan is necessary to accurately diagnose syndesmotic malreduction after open reduction and internal fixation of ankle fractures with associated syndesmotic injuries.

Assessing the Reliability of Postoperative Cross-Table Radiographs Compared to CT Scans for Measuring Acetabular Anteversion Angle Following Total Hip Arthroplasty.

This study aimed to evaluate acetabular anteversion following total hip arthroplasty (THA) using cross-table lateral radiographs and CT scans and to determine the reliability of cross-table lateral radiographs compared to computed tomography (CT) scans for measuring acetabular anteversion. We conducted a cross-sectional study of patients undergoing THA at Justice K.S. Hegde Charitable Hospital, Deralakatte, Mangalore, from January 2020 to June 2021. Radiographs are typically taken in both anteroposterior (AP) and lateral views after THA. However, for this study, a cross-table lateral view was used instead of the usual lateral radiograph to measure the angle of anteversion. The anteversion was calculated using the method described by Woo and Morrey. Additionally, CT scans were performed on all patients as part of the study protocol. The anteversion measured in these scans was compared to that in the cross-table radiographs to assess the latter's reliability for routine use. The risk of radiation exposure from CT scans was minimized by adhering to the ALARA (As Low as Reasonably Achievable) principle, with only axial sections of the acetabular cup being scanned. The results show that the radiographic acetabular anteversion and CT scan measurements have a mean difference of 0.3036. There is a positive correlation between these measurements. The p-value is not statistically significant (p=0.698). Therefore, the measurements are correlated with each other with a linear relationship (r=0.919). For anteversion measurements using the X-ray method, the mean was 27.16 degrees with a standard deviation of ±9.49. The median was 27.26 degrees, ranging from 10.27 to 42.58 degrees. In comparison, the CT method yielded a mean anteversion of 27.40 degrees with a standard deviation of ±8.50 degrees. The median was 27.64 degrees, ranging from 12.35 to 43.11 degrees. Cross-table lateral radiographs are a reliable and comparable method to CT scans for measuring acetabular anteversion following total hip arthroplasty.

Medial augmentation of distal femur fractures using the contralateral distal femur locking plate: A technical note.

Lateral locking plates are commonly employed for the fixation of distal femur fractures. However, scenarios involving medial comminution, extremely distal fractures, periprosthetic fractures, or nonunion could necessitate medial augmentation. This study explores the possibility of using lateral distal femoral locking plate systems for medial fixation by employing the contralateral plate. This study presents a technical note on the application of lateral distal femur locking systems for medial augmentation in patients as indicated by current literature findings. Postoperative imaging modalities, including radiography and computed tomography (CT), were used to assess the plates' fit to the distal femur. Three cases following the specified technical note are presented. The various plate systems, all comprising distal femur locking systems, demonstrated adaptability to the medial femur anatomy as confirmed by intraoperative visualization and postoperative radiographs, including two-dimensional and three-dimensional CT scans. It has also been possible to achieve at least 3 independent fixation points regardless of the size of the medial condyle. Locking distal femoral plates can be a viable option for medial augmentation in indicated cases, achieving anatomical adaptation to the distal femur. This provides robust augmentation without the need for additional instruments beyond those used for the lateral cortex.

Clinical perioperative outcomes in 39 cats after single session bilateral femoral head and neck excision.

The aim of the study was to evaluate the perioperative outcomes and complications of single session bilateral femoral head and neck excision (FHNE) in cats for treatment of bilateral coxofemoral joint disease. The medical records of cats undergoing a single session bilateral FHNE were identified and the history, signalment, diagnosis, surgery reports, anesthetic records, postoperative radiographs, postoperative examinations, complications and outcomes were recorded. A total of 39 cats undergoing a single session bilateral FHNE were included. Bilateral slipped capital femoral epiphysis was the most commonly diagnosed etiology. All cats were discharged within 48 h of the procedure. One major complication and five minor complications were reported. All but one cat returned to normal activity and no owners reported concerns after the 2-week postoperative recheck. Single session bilateral FHNE is a viable surgical option for the treatment of bilateral coxofemoral disease in cats that results in a quick return to function, especially when other options are not indicated, available or affordable.

Cross-Screw Fixation in Isolated Medial Malleolar Fractures.

Isolated medial malleolar fractures are observed less often than are lateral malleolar fractures, bimalleolar fractures, and trimalleolar fractures. The aim of treatment is to provide anatomical reduction, protect this reduction until the fracture heals, and to regain normal ankle function. The aim of our study was to evaluate the clinical and radiological outcomes of patients with isolated medial malleolus fracture treated with cross-screw fixation. The study included 13 patients: 9 males with a mean age of 37.1 years (range, 25-64 years) and 4 females with a mean age of 40.2 years (range, 24-62 years) who were treated with the cross-screw fixation method for an isolated medial malleolar fracture. The fracture union status was evaluated on the 3-month postoperative radiographs, and the functional outcomes with the American Orthopaedic Foot and Ankle Scale (AOFAS) ankle score. The mean AOFAS score was 82 at 3 months postoperatively, evaluated as an excellent outcome in 2 patients, good in 9, and fair in 2. At the 24th month postoperatively, the mean AOFAS score was determined to be 92.2, evaluated as excellent in 11 patients and good in 2. On palpation of the medial malleolus, the mean VAS pain score was 2 (range, 1-3.8) at 3 months postoperatively, and a mean of 0.6 (range, 0.2-3) at 24 months. Cross-screw fixation can be preferred for the fixation of isolated medial malleolar fractures as it causes less soft-tissue damage because it can be performed percutaneously, and the screw head has a low profile, thereby eliminating the need for a Kirschner wire to be applied together with the screw to prevent rotational deformity.

The Impact of Leg Length and Offset Change on Dislocation Risk Following Primary Total Hip Arthroplasty

BackgroundSoft tissue management in total hip arthroplasty includes appropriate restoration and/or alteration of leg length (LL) and offset to re-establish natural hip biomechanics. The purpose of this study was to evaluate the effect of LL and offset-derived variables in a multivariable survival model for dislocation. MethodsClinical, surgical, and radiographic data was retrospectively acquired for 12,582 patients undergoing primary total hip arthroplasty at a single institution from 1998 to 2018. There were twelve variables derived from preoperative and postoperative radiographs related to LL and offset that were measured using a validated automated algorithm. These measurements, as well as other modifiable and nonmodifiable surgical, clinical, and demographic factors, were used to determine hazard ratios for dislocation risk. ResultsNone of the LL or offset variables conferred significant risk or protective benefit for dislocation risk. By contrast, all other variables included in the multivariable model demonstrated a statistically significant effect on dislocation risk with a minimum effect size of 28% (range 0.72 to 1.54) (sex, surgical approach, acetabular liner type, femoral head size, neurologic disease, spine disease, and prior spine surgery). ConclusionsContrary to traditional teaching and our hypothesis, operative changes in LL and offset did not demonstrate any clinically or statistically significant effect in this large and well-characterized cohort. This does not imply that these variables are not important in individual cases, but rather suggests the overall impact of LL and offset changes is relatively minor for dislocation risk compared to other variables that were found to be highly clinically and statistically significant in this population. These results may also suggest that surgeons do a good job of restoring native LL and offset for patients, which may mitigate their analyzed impact.

Estimation of carbon emissions associated with tibial plateau levelling osteotomies in 10 dogs

ObjectiveTo describe a method of estimating the carbon emissions resulting from 10 clinical canine surgical procedures. Study designProspective observational cohort study. AnimalsA total of 10 adult client-owned dogs presenting to two private referral centres in the UK for tibial plateau levelling osteotomy (TPLO) using either isoflurane or sevoflurane for maintenance of anaesthesia. MethodsSingle-use consumables, pharmaceuticals and waste streams were recorded. Volatile anaesthetic use was calculated based on fresh gas flow (FGF) and vaporizer setting. Travel of owners and staff involved in the procedure was recorded (the latter adjusted by procedure length relative to working day). Energy use was calculated based on the clinic’s monthly usage adjusted for floor area of rooms used. Overnight hospitalisation, kennelling consumables and a revisit for postoperative radiography were excluded. Carbon accounting was performed using published carbon conversion factors (‘bottom-up analysis’) if available, or conversion factors based on cost (‘top-down’). Data are presented as median (range) and totals per emission category. ResultsCarbon emissions from all cases amounted to 667.2 kgCO2e. In these two clinics, median carbon emissions from a canine TPLO were 63.5 (47.6–93) kgCO2e, which is equivalent to driving 372 km (231 miles) in an average UK passenger car. Travel accounted for 30.1% of carbon emissions. Volatile anaesthetics accounted for 21.4% of carbon emissions, with other pharmaceuticals accounting for 24.0%. Consumables, building energy and waste disposal accounted for 19.7%, 3.9% and 0.9% of carbon emissions, respectively. Conclusionsand clinical relevanceand clinical relevance Likely carbon hotspots for canine orthopaedic procedures include travel and pharmaceuticals, particularly volatile anaesthetic agents. Carbon reductions should focus on reducing travel emissions, streamlining pharmaceutical use and lower-carbon anaesthetic techniques. Future research should focus on improving carbon accounting methodology and widening the range of cases assessed.

Development of a virtual surgical plan for reverse shoulder arthroplasty as a treatment for complex proximal humerus fracture in an elderly patient

IntroductionFracture reduction, implant selection and tuberosity reattachment propose significant challenges in reverse shoulder arthroplasty (RSA) for proximal humerus fractures (PHFs). It is hypothesised that preoperative virtual surgical planning (VSP) can improve implant positioning and tuberosity reattachment, resulting in better functional outcomes, reduced surgery time, and decreased complication risk. Therefore, this study aims to develop, implement, and evaluate a VSP protocol for RSA in complex PHFs. MethodsThe VSP protocol is developed using 3D medical image processing software based on CT scans from four previously treated patients with RSA for complex PHF. Next, the VSP was applied prospectively in a patient with a PHF planned for RSA. Evaluation was done using an expert opinion questionnaire evaluating surgical confidence, a comparison between implant positioning on postoperative radiographs and the VSP, functional outcomes and the Oxford Shoulder Score (OSS). ResultsThe study showed that VSP is a useful preoperative tool to optimize clinical outcome by digital fracture reduction, determination of surgical cuts, calculating implant size and height, and optimising tuberosity shape and reattachment. After two and six months, the patient showed good functional outcomes (OSS: 48/48 points), healing of tuberosities, and had minimal pain complaints. ConclusionVSP for RSA in PHF might create a more thorough preoperative understanding of the fracture pattern and implant and fracture fragment placement. Further investigative study would be required to demonstrate this.

Predictability in Achieving Target Intervertebral Lordosis Using Personalized Interbody Implants.

Lumbar lordosis distribution has become a pivotal factor in re-establishing the foundational alignment of the lumbar spine. This can directly influence overall sagittal alignment, leading to improved long-term outcomes for patients. Despite the wide availability of hyperlordotic stock cages intended to achieve optimal postoperative alignment, there is a lack of correlation between the lordotic shape of a cage and the resultant intervertebral alignment. Recently, personalized spine surgery has witnessed significant advancements, including 3D-printed personalized interbody implants, which are customized to the surgeon's treatment and alignment goals. This study evaluates the reliability of 3D-printed patient-specific interbody implants to achieve the planned postoperative intervertebral alignment. This is a retrospective study of 217 patients with spinal deformity or degenerative conditions. Patients were included if they received 3D-printed personalized interbody implants. The desired intervertebral lordosis (IVL) angle was prescribed into the device design for each personalized interbody (IVL goal). Standing postoperative radiographs were measured, and the IVL offset was calculated as IVL achieved minus IVL goal. In this patient population, 365 personalized interbodies were implanted, including 145 anterior lumbar interbody fusions (ALIFs), 99 lateral lumbar interbody fusions (LLIFs), and 121 transforaminal lumbar interbody fusions. Among the 365 treated levels, IVL offset was 1.1° ± 4.4° (mean ± SD). IVL was achieved within 5° of the plan in 299 levels (81.9%). IVL offset depended on the approach of the lumbar interbody fusion and was achieved within 5° for 85.9% of LLIF, 82.6% of transforaminal lumbar interbody fusions and 78.6% of ALIFs. Ten levels (2.7%) missed the planned IVL by >10°. ALIF and LLIF levels in which the plan was missed by more than 5° tended to be overcorrected. This study supports the use of 3D-printed personalized interbody implants to achieve planned sagittal intervertebral alignment. Personalized interbody implants can consistently achieve IVL goals and potentially impact foundational lumbar alignment.

Radiographic characterization of OPLL progression in patients receiving laminoplasty with a minimum of two-years follow-up

Ossification of the posterior longitudinal ligament (OPLL) is a common cause of degenerative cervical myelopathy (DCM) in Asian populations. Characterization of OPLL progression following laminoplasty remains limited in the literature. 29 patients with OPLL received cervical laminoplasty and a minimum of 2-years follow-up. Clinical and radiological surveillance occurred at 3-months, 6-months, 12-months post-op and then at yearly intervals. Transverse (anteroposterior) diameter and sagittal length of OPLL in relation to their cervical vertebral level of localisation was assessed upon immediate post-op radiographs compared to those obtained at subsequent follow-up. OPLL progression was defined as an increase in transverse dimensions and/or length by ≥ 2 mm. The average period of clinical follow-up was 6.7 ± 3.3 years. Upon latest follow-up, 79% of patients demonstrated at least 2 mm of transverse or longitudinal progression of OPLL. This corresponded to 2-years and 5-year progression rates of 54% and 71% respectively. OPLL located over C5 demonstrated the greatest transverse progression rate at (0.24 ± 0.34 mm / year). The mean overall longitudinal progression rate was 1.61 ± 2.06 mm / year. No patients experienced neurological decline resulting from OPLL progression requiring revision decompression during the period of post-operative observation. Characterizing transverse and longitudinal progression by cervical level via radiographs has implications in surgical planning for OPLL and should be consolidated upon post-operative CT/MRI scans as well as larger sample sizes.

Head-Shaft Angle Influences Isometric Shoulder Strength Levels after Intramedullary Nailing of Proximal Humerus Fractures: A Pilot Study.

Proximal humerus fractures are common fractures of the elderly population which can lead to long-term compromise of a patient's shoulder function. Closed reduction and internal fixation with intramedullary nailing is a well-established surgical technique yielding good outcomes, as perceived by patients, obtained via Patient-Reported Outcome Measures, and objectified by clinical shoulder testing. Apart from conventional range-of-motion testing and clinical shoulder tests, strength testing of the shoulder is a yet-neglected but meaningful and standardizable outcome parameter. In this study, isometric shoulder strength is evaluated in relation to fracture morphology/postoperative reduction quality as well as with patient-reported outcomes. 25 patients (mean age 73.2 ± 10.5 years) underwent isometrics strength-testing of the shoulder joint in the scapular plane (abduction) as well as in the sagittal plane (flexion) as well as hand-grip strength-testing at 4.5 ± 1.88 years follow-up. Pre- and postoperative radiographs were analysed. Patients completed ASES and CMS questionnaires. Patients exhibited a decrease in abduction and flexion force (-24.47% and -25.30%, respectively, p < 0.001) using the contralateral, uninjured arm as reference. Abduction force tended to be decreased in three- and four-part fractures. Patient satisfaction correlated negatively with the relatively reduced force of the affected arm. Varus-angulated humeral heads produced significantly lower abduction force output than valgus- or physiologic angulation (p = 0.014), whereas flexion force was unaffected (p = 0.468). The anatomical reduction had no influence on shoulder strength. Proximal humerus fractures may cause a significant reduction in shoulder function, both reported by patients and objectified by shoulder strength testing. Varus head angulation demonstrated the greatest loss of shoulder strength and should be avoided to ensure proper functioning. Further, strength testing seems a valuable outcome parameter for a thorough shoulder examination with easy obtainability.

Thick-shell sulcus-deepening trochleoplasty for recurrent patellar dislocation leads to clinically meaningful improvements and high patient satisfaction in adolescents with open physes

ObjectivesTo evaluate clinical and radiological outcomes of thick-shell, sulcus-deepening trochleoplasty in patients with open distal femoral physes and less than two years of growth remaining. We hypothesized that patients would have clinical and radiographic improvements in addition to high patient-reported outcomes following thick-shell, sulcus-deepening trochleoplasty. MethodsBone age was determined on preoperative magnetic resonance imaging (MRI) using the Pennock Knee Bone Age Atlas. Pre- and postoperative radiographs were used to measure the anatomic lateral distal femoral angle (aLDFA) and Blumensaat angle. International Knee Documentation Committee (IKDC), Kujala, and numerical patient satisfaction scores were assessed. Pre- and postoperative aLDFA and Blumensaat angles as well as patient-reported outcomes were analyzed via the Wilcoxon signed-rank test. ResultsSeventeen adolescents (21 knees) with DeJour Types B and D trochlear dysplasia and open distal femoral physes underwent Dejour thick-shell, sulcus-deepening trochleoplasty at a single institution. In twelve females (16 knees, 76.2%) the median chronological and bone ages at the time of operation were 14.9 and 14.3 years, respectively. In 5 males (5 knees, 27.7%), the median chronological and bone ages at the time of operation were 15.7 and 15.2 years, respectively. Mean follow-up time was 64 months postoperatively. Physes were closed in all knees at the time of final clinical and radiographic follow-up. The mean change in aLDFA and Blumensaat Angle was 0.73 (p ​= ​0.1074, 95% CI -0.09–1.57) and 0.88° (p ​= ​0.0477, 95% CI 0.10–1.88), respectively. Median IKDC scores improved from 57.3 preoperatively to 90.9 postoperatively, for a mean difference of 26.1 (p ​= ​0.00064, 95% CI 18.0–34.2). Median Kujala scores improved from 55.0 preoperatively to 95.0 postoperatively, for a mean change of 30.2 (p ​= ​0.0008, 95% CI 19.6–40.8). Overall mean numerical patient satisfaction was high (mean 9.26/10). One of 21 knees (4.8%) underwent additional surgery to address recurrent patellar instability. ConclusionThick-shell sulcus-deepening trochleoplasty for addressing recurrent lateral patellar instability in patients with open distal femoral physes and less than two years of growth remaining is safe and provides clinically meaningful improvements in addition to high patient satisfaction when combined with other patellar stabilization procedures. Level of evidenceIV, Retrospective Case Series.