Low dose CT-based spatial analysis (CTSA) to measure implant migration after ceramic hip resurfacing arthroplasty (HRA): a phantom study

Implant migration is a predictor of arthroplasty survivorship. It is crucial to monitor the migration of novel hip prostheses within premarket clinical investigations. RSA is the gold standard method, but requires calibrated radiographs using specialised equipment. A commercial computed tomography micromotion analysis solution is a promising alternative but is not yet available for use with monobloc ceramic implants. This study aimed to develop and validate a CT-based spatial analysis (CTSA) method for use with ceramic implants. A phantom study was undertaken to assess accuracy and precision. A ceramic hip resurfacing arthroplasty (HRA) and 20 tantalum beads were implanted into a synthetic hip model and mounted onto a 6-degree of freedom motion stage. The hip was repeatedly scanned with a low dose CT protocol, with imposed micromovements. Data were interrogated using a semiautomated technique. The effective radiation dose for each scan was estimated to be 0.25 mSv. For the head implant, precision ranged between 0.11 and 0.28 mm for translations and 0.34°-0.42° for rotations. For the cup implant, precision ranged between 0.08 and 0.11 mm and 0.19° and 0.42°. For the head, accuracy ranged between 0.04 and 0.18 mm for translations and 0.28°-0.46° for rotations. For the cup, accuracy ranged between 0.04 and 0.08 mm and 0.17° and 0.43°. This in vitro study demonstrates that low dose CTSA of a ceramic HRA is similar in accuracy to RSA. CT is ubiquitous, and this method may be an alternative to RSA to measure prosthesis migration

Actinomycosis complicating sigmoid diverticular disease: a case report

A 63-year-old Caucasian woman was admitted to hospital as hypotensive with abdominal tenderness and vaginal discharge. Laboratory investigations showed microcytic anaemia, low albumin and high white cell count. Computerised tomography scans revealed small bowel dilatation, sigmoid diverticula, ascites and pelvic fluid. The endometrial pipelle was positive and vaginal swab was negative for actinomyces. Post mortem examination revealed widespread sigmoid diverticular disease and bowel perforation with an intense inflammation. Actinomycotic granules were noted in the diverticular inflammatory debris, pelvic abscess and lung sections. Clinical course and histomorphological findings favour the perforating sigmoid diverticular actinomycosis as an origin of the systemic infection

Hip capsule biomechanics after arthroplasty - the effect of implant, approach and surgical repair

Aims The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional THA, and surgical approach on ligament function. Materials and Methods Eight paired cadaveric hip joints were skeletonized but retained the hip capsule. Capsular ROM restraint during controlled internal rotation (IR) and external rotation (ER) was measured before and after HRA, DM-THA, and conventional THA, with a posterior (right hips) and anterior capsulotomy (left hips). Results Hip resurfacing provided a near-native ROM with between 5° to 17° increase in IR/ER ROM compared with the native hip for the different positions tested, which was a 9% to 33% increase. DM-THA generated a 9° to 61° (18% to 121%) increase in ROM. Conventional THA generated a 52° to 100° (94% to 199%) increase in ROM. Thus, for conventional THA, the capsule function that exerts a limit on ROM is lost. It is restored to some extent by DM-THA, and almost fully restored by hip resurfacing. In positions of low flexion/extension, the posterior capsulotomy provided more normal function than the anterior, possibly because the capsule was shortened during posterior repair. However, in deep flexion positions, the anterior capsulotomy functioned better. Conclusion Native head-size and capsular repair preserves capsular function after arthroplasty. The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments

Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty.

INTRODUCTION: Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty. MATERIALS AND METHODS: Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety. RESULTS: Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001). CONCLUSIONS: For scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world

How to prioritize patients and redesign care to safely resume planned surgery during the COVID-19 pandemic.

AIMS: Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. METHODS: A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. RESULTS: A total of 1,142 patients were included, 47 declined surgery, and 110 were deemed high-risk or requiring specialist resources. In the ten-week study period, 28 high-risk patients underwent surgery, during which 68% (13/19) of Priority 2 (P2, surgery within one month) patients underwent surgery, and 15% (3/20) of P3 ( three months) groups. Of the 1,032 low-risk patients, 322 patients underwent surgery. Overall, 21 P3 and P4 patients were expedited to 'Urgent' based on biopsychosocial factors identified by the SPAG. During the study period, 91% (19/21) of the Urgent group, 52% (49/95) of P2, 36% (70/196) of P3, and 26% (184/720) of P4 underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. CONCLUSION: Our widely generalizable model enabled the restart of planned surgery during the COVID-19 pandemic, without compromising patient safety or excluding high-risk or complex cases. Patients classified as Urgent or P2 were most likely to undergo surgery, including those deemed high-risk. This model, which includes assessment of biopsychosocial factors alongside disease severity, can assist in equitably prioritizing the substantial list of patients now awaiting planned orthopaedic surgery worldwide. Cite this article: Bone Jt Open 2021;2(2):134-140

Radiomics for Precision Diagnosis of FAI: How Close Are We to Clinical Translation? A Multi-Center Validation of a Single-Center Trained Model

Background: Femoroacetabular impingement (FAI) is a complex hip disorder characterized by abnormal contact between the femoral head and acetabulum, often leading to joint damage, chronic pain, and early-onset osteoarthritis. Despite MRI being the imaging modality of choice, diagnosis remains challenging due to subjective interpretation, lack of standardized imaging criteria, and difficulty differentiating symptomatic from asymptomatic cases. This study aimed to develop and externally validate radiomics-based machine learning (ML) models capable of classifying healthy, asymptomatic, and symptomatic FAI cases with high diagnostic accuracy and generalizability. Methods: A total of 82 hip MRI datasets (31 symptomatic, 31 asymptomatic, 20 healthy) from a single center were used for training and cross-validation. Radiomic features were extracted from four segmented anatomical regions (femur, acetabulum, gluteus medius, gluteus maximus). A four-step feature selection pipeline was implemented, followed by training 16 ML classifiers. External validation was conducted on a separate multi-center cohort of 185 symptomatic FAI cases acquired with heterogeneous MRI protocols. Results: The best-performing models achieved a cross-validation accuracy of up to 90.9% in distinguishing among healthy, asymptomatic, and symptomatic hips. External validation on the independent multi-center cohort demonstrated 100% accuracy in identifying symptomatic FAI cases. Since this metric reflects performance on symptomatic cases only, it should be interpreted as a detection rate (true positive rate) rather than overall multi-class accuracy. Gini index-based feature selection consistently outperformed F-statistic-based methods across all the models. Conclusions: This is the first study to systematically integrate radiomics and multiple ML models for FAI classification for these three phenotypes, trained on a single-center dataset and externally validated on multi-institutional MRI data. The demonstrated robustness and generalizability of radiomic features support their use in clinical workflows and future large-scale studies targeting standardized, data-driven FAI diagnosis

A multicentre national study of the effectiveness of virtual fracture clinic management of orthopaedic trauma during the COVID-19 pandemic (MAVCOV):a cross-sectional study protocol

Aims: Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.Methods: This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the 'second wave' (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation.Ethics and dissemination: The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit.</p

A Delphi consensus statement for digital surgery

The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term 'digital surgery'. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and <30% unimportant. A final online meeting was held to discuss consensus statements. The definition of digital surgery as the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support, or training, to improve outcomes and reduce harm achieved 100% consensus agreement. We highlight key ethical issues concerning data, privacy, confidentiality and public trust, consent, law, litigation and liability, and commercial partnerships within digital surgery and identify barriers and research goals for future practice. Developers and users of digital surgery must not only have an awareness of the ethical issues surrounding digital applications in healthcare, but also the ethical considerations unique to digital surgery. Future research into these issues must involve all digital surgery stakeholders including patients

IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit. Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

AIMS: This international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients. METHODS: A multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1(st) March-31(st) May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded. RESULTS: A total of 7090 patients were included, with a mean age of 82.2 (range 50-104) years and 4959 (70%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) became positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p=0.001), residential care (OR 2.15, p<0.001), inpatient fall (OR 2.23, p=0.003), cancer (OR 0.63, p=0.009), ASA grade 4-5 (OR 1.59, p=0.008; OR 8.28, p<0.001), and longer admission (OR 1.06 for each increasing day, p<0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p<0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p<0.001). Increasing age (HR 1.03, p=0.028), male sex (HR 2.35, p<0.001), renal disease (HR 1.53, p=0.017), and pulmonary disease (HR 1.45, p=0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders. CONCLUSION: The prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher mortality risk