Introduction:The prevalence of scoliosis is not known in patients with idiopathic short stature, and the impact of treatment with recombinant human growth hormone on those with scoliosis remains controversial.
Methods: We investigated the prevalence of scoliosis radiologically in children with idiopathic short stature, and the impact of treatment with growth hormone in a cross-sectional and retrospective cohort study. A total of 2,053 children with idiopathic short stature and 4,106 age- and sex-matched (1:2) children without short stature with available whole-spine radiographs were enrolled in the cross-sectional study.
Results: In the cross-sectional study, there was an unexpectedly higher prevalence of scoliosis (33.1% (681/2,053) vs 8.52% (350/4,106)) in children with idiopathic short stature compared with controls (odds ratio 3.722; p < 0.001), although most cases were mild. In the longitudinal study, children with idiopathic short stature had a higher risk of the development and progression of scoliosis than the controls. Among children with idiopathic short stature without scoliosis at baseline, treatment with growth hormone significantly increased the risk of developing scoliosis (p = 0.015) and the need for bracing (p < 0.001). Among those with idiopathic short stature and scoliosis at baseline, treatment with growth hormone did not increase the risk of progression of the scoliosis, the need for bracing, or surgery. The impact of treatment with growth hormone on scoliosis in children with idiopathic short stature was considered controllable. However, physicians should pay close attention to the assessment of spinal curves in these children.

Introduction: Pedicle screws, crucial for stabilizing the spine, are commonly used despite challenges posed by conditions such as osteoporosis. Robotic assistance has emerged as a valuable tool, significantly enhancing safety through precise pedicle screw placement. Methods: A total of 200 patients underwent diverse thoracic and lumbar instrumentation and fusion procedures. All surgeries, conducted by a single surgeon, involved intraoperative robotic registration and image acquisition. A comparative analysis between the initial 100 cases and the subsequent 100 cases was performed using the unpaired t-test or Mann Whitney’s U-test, evaluating time per screw, robot time, blood loss, and radiation dose. Additionally, the impact of case order on these variables was explored by comparing cases starting before and after 2 pm.
Results: The study cohort, with a mean age of 47.4 ± 18.6 years and 49.5% female, exhibited no significant differences in time per screw, robot time, or blood loss between the first and second 100 patients. Furthermore, no significant distinctions were observed in blood loss, robot time, and time per screw between cases starting before and after 2 pm. These findings indicate that case order minimally affects the efficiency of robotic spine surgery. Conclusion: The analysis of operational variables, including time per screw, robot time, and blood loss, suggests that the learning curve for robotic spine surgery is not significant. Importantly, case order does not substantially impact operative efficiency. This study underscores the potential for a swift adoption of robotic assistance in spinal surgeries with enhanced precision and safety.

Introduction/Background: As per the British Orthopaedic Association, the ischaemic tourniquet time(TT) should ideally be less than 120 minutes and can only be extended beyond this after a clinical assessment of the relative risks and benefits. We reviewed the safe use of tourniquet intraoperatively at Worthing hospital in two different theatres.

Aim: The aim of the audit was to review the safe use of tourniquet time in the two trauma theatres(Theatre 8 & Theatre 9) in Worthing hospital.

Materials and Methods: We did a retrospective data analysis of 40 patients in each theatre from March 2022 until June 2022.

Results: There was minimal documentation of tourniquet time in the operation notes throughout (less than 10 percent). The compliance rate was 97.5 percent in theatre 8 and 95 percent in theatre 9. There was no justification in clinical notes in cases where torniquet time was exceeded.

Conclusion: In our audit, there was a systematic lack of documentation of the need for a tourniquet and documentation around tourniquet use.

Recommendations/Implications: There is a need for teaching the importance of documenting TT in every operation when it is needed, justifying a TT above the limit of 120 minutes and re-audit to look at the impact of our intervention on the rate of compliance of the BOA guidelines on the safe use of intraoperative tourniquet

Disclosure: No conflicts of interest.

Introduction: Robotic assistance has enhanced safety margins in spine surgery by enabling precise placement of pedicle screws, even for surgeons with limited experience in spine procedures. We attempted to determine if surgeon experience and the manner of insertion may influence the difference in planned and executed trajectories of pedicle screws inserted with robotic assistance. Methods: We analyzed 1000 pedicle screws in 200 patients by comparing postoperative CT scans with preoperative planned trajectories. Two independent observers, blinded to the study, overlapped the two images, measuring the angle between the planned and executed trajectories. Differences in these angles were assessed based on surgeon experience and the method of screw insertion (robotic arm guide vs. guidewires) using the student’s t-test. Results: The overall accuracy of screw placement was 99.8%. No significant differences were observed in the angles between the planned and executed trajectories when comparing the experience of the surgeon or the method of insertion. Conclusion: Surgeon experience and the manner of insertion did not significantly impact the accuracy of pedicle screw placement, affirming the robot's utility in enhancing patient safety.

Background: Knee and hip replacement have revolutionised orthopaedic medicine by providing individuals with surgeries resulting in pain relief, improved mobility and a better quality of life. NHS Fife has been collecting routine data since 1998 on patient demographics, surgeries, recovery time, follow-ups, and outcomes, including complications. Methods: The available data was cleaned using the programming language R. Two main elements of the data-cleaning procedure were eliminating fields with blank variables and grouping variables with similar meanings, providing a standardisation for the collected information. Subsequently, cleaned dataset files were merged to produce consolidated datasets for hip and knee replacements. Results: Data was available for 14,524 replacement surgeries performed in NHS Fife between 1998 and 2021. The original dataset consisted of several unique-structured files covering distinct periods and representing primary surgery, follow-ups, infections, mortality, and revision for THR and TKR. The rigorous data merging resulted in converting this complex collection of files into one single streamlined file for each of the five categories and each type of surgery (THR and TKR). Discussion: This work reports the challenges and strategies to clean the routinely collected data. The structured files can now be linked to studies across different datasets like social care, prescriptions, and primary care. It can also develop future machine learning models to assess the risk of multiple primary and revision hip and knee replacements and their outcomes.

Research metrics are crucial in assessing the impact and performance of the published literature. Journal Level Metrics (JLM) such as the h-index of the analysed journals, total citations, total documents, citable documents, references and external citations per document are considered crucial indicators of journals. We hypothesize that journals in medicine receive more citations than those in surgical journals like orthopedic surgery and hence have better JLM. This study aims to assess and compare the JLM of Medical and Surgical journals between two time zones, 2017-2019 vs. 2020-2022, i.e., pre and post-COVID-19 pandemic period. A cross-sectional bibliometric analysis of the top-ranked Orthopaedic, Medical, and Surgical journals was undertaken based on traditional JLM, using the SCImago database from 2017 to 2022. Our analysis focused on identifying trends in the h-index of the analysed journals, total citations, total documents, citable documents, references and external citations per document. Overall, Medical journals were found to have higher JLM than Surgical and Orthopaedic journals. The h-index of Surgical journals, Medical journals and Orthopaedic journals were comparable between the two periods (pre and -post-COVID-19 pandemic); Total Cites (3 years), total documents (2017), total documents (3 years), total references, and citable documents (3 years) of Surgical journals, Medical journals and Orthopaedic journals were significantly higher in the period 2020-2022. Medical journals have higher JLM than Surgical and Orthopaedic journals. Journal of Bone and Joint Surgery (Am), Annals of Surgery and Diabetes Care were the most published journals in Orthopaedics, General Surgery and Medicine-related topics respectively.

Purpose: Osteosarcoma is a malignant tumor originating in children and adolescents. Recent advances suggest the necessity of developing new therapies to improve patient prognosis rather than intensifying anti-tumor chemotherapy. Some genes are essential for tumor growth and predicting poor prognosis in patients; however, their roles in osteosarcoma remain unclear.Methods:Three osteosarcoma datasets with sufficient clinical information were obtained from public databases. Essential genes for osteosarcoma were identified through genome-scale CRISPR screening of the datasets. A tumor essential gene pair (CRGP) signature was constructed using minimum absolute shrinkage and selection operator regression based on prognosis-related CRGPs. Differences in immunity, metabolism, and ferroptosis among CRGP signature groups of patients were evaluated. Finally, SubMap analysis was used to assess patient response to immunotherapy in the CRGP signature groups.Results: The CRGP signature reliably predicts overall survival of osteosarcoma patients. CRGP features are also associated with the metastatic status of osteosarcoma patients and can be used for further risk stratification of metastatic patients. Immunotherapy is more likely to benefit patients in the low-risk CRGP group.Conclusions: The signature based on tumor essential gene pairs can assess the prognosis of osteosarcoma patients.

Objective: The expression of zonulin is increased in osteoporosis patients, but its mechanisms in bone loss has not been revealed.
Methods: Blood and clinical information were collected from postmenopausal women. Immunohistochemistry was used to detect the expression of zonulin and intestinal epithelial barrier permeability in OVX mice. Flow cytometry was used to detect the intestinal lamina propria lymphocytes CD4+T cells. Intestinal organoid culture was used to clarify the effect of zonulin on intestinal barrier.
Results: Zonulin was significantly increased in postmenopausal osteoporosis patients (88.5 ± 25.4ng/ml vs 22.4±13.76 ng/ml, p < 0.01). Bone mineral density was inversely proportional to serum zonulin level in postmenopausal women. In vivo experiments, OVX mice had significantly increased serum zonulin (78.2 ± 19.8ng/ml), intestinal epithelial ZO-1 and claudin-5 expression, and inflammatory factors TNF-α and IL-17A expression. The expression of TNF-α and IL-17A in intestinal epithelium was up-regulated. Flow cytometry analysis showed that the proportion of Th17 cells in lamina propria lymphocytes was significantly increased(7.5±0.51% vs 2.3±0.53%，p<0.05). Transcriptome analysis showed that zonulin accelerated the expression of MHCII in intestinal epithelial cells through IL-17 signaling pathway. After targeting zonulin with larazotide acetate, 16s rRNA analysis showed that intestinal flora dysbiosis was restored, and flow cytometry showed that Th17 cell differentiation in intestinal lamina propria lymphocytes was decreased.
Conclusion: Zonulin aggravated intestinal inflammation and induced IL-17 differentiation by regulating the intestinal barrier to promote translocation of gut microbiota through paracellular pathways and targeting MHCII expression in intestinal epithelial cells through IL-17 signaling pathway, leading to osteoporosis.

Mutant TP53 is a promising therapeutic target in cancers. Considering the current challenges facing the clinical treatment of cancer, as well as the urgent need to identify novel therapeutic targets in osteosarcomas, we aimed to evaluate the clinical significance of mutant TP53 in osteosarcoma patients and to explore the therapeutic effect of targeting mutant TP53 in osteosarcomas. We performed a meta-analysis to investigate the relationship between mutant TP53 and the overall survival of patients with osteosarcoma. A CRISPR-Cas9 system and a TP53 inhibitor, NSC59984, were also used to specifically knock-out and inhibit mutant TP53 in the human osteosarcoma cell lines, KHOS and KHOSR2. The meta-analysis demonstrated that mutations in the TP53 gene could be used to predict a poor 2-year survival in osteosarcoma patients. We also demonstrated that the expression of mutant TP53 in human osteosarcoma cell lines can be efficiently knocked-out using CRISPR-Cas9, and this decreased the proliferation, migration, and tumor formation activity of these osteosarcoma cells. Moreover, drug sensitivity to doxorubicin was increased in these TP53 knock-out osteosarcoma cells. NSC59984 also showed similar anti-tumor effects as CRISPR-Cas9 targeted TP53 in the osteosarcoma cells in vitro. We have also demonstrated that the knock-out or inhibition of mutant TP53 decreased the expression of the oncogene IGF-1R, anti-apoptotic proteins Bcl-2 and Survivin in osteosarcoma cells. Collectively, these results suggest that mutant TP53 is a promising therapeutic target in osteosarcomas. Therefore, further studies exploring novel strategies to target mutant TP53 may help improve the treatment outcomes of osteosarcoma patients in the clinic.

Clinical risk management (CRM) is the basis for systemic improvement of healthcare quality and safety. CRM system is a set of tools, structures, processes and measures aimed at identifying, analyzing and responding to clinical risks. In the era of digital transformation in healthcare software tools are becoming most compelling, but their effectiveness depends on ability to solve changeable and highly specialized tasks. An electronic CRM system for trauma and orthopedic hospitals (CRM-TO) have been developed, containing four decision support modules: “Hospital adverse events (HAEs) prevention”, "Diagnostics and treatment", "HAE prevention audit" and "Incident analysis". The first two modules are based on the automation of clinical guidelines related to the HAE prevention, diagnosis and treatment. The third module is designed to control the HAE prevention by an auditor (clinical expert); the fourth module supports the standardized incident analysis including criteria for HAE in-hospital nature, its severity, contributing factors and proposals for HAE risk mitigation. The CRM-TO system is supplemented by a set of HAE triggers, the prevention and incident registries, as well as quality and safety indicators, that are calculated automatically on the basis of registry data and statistical parameters. The CRM-TO system is built as a user-configurable information system, in which interfaces, security policy rules, the database structure and business logic can be configured. Flexible system configuration and graphic user interface allow the clinical experts to compose complex knowledge artifacts directly working with the system, without engagement of knowledge engineers.

Introduction: This study seeks to ascertain the preferences and techniques used for bone reconstruction and lengthening among professionals in Brazil and Latin America. Methods: An electronic questionnaire was used (59 questions). It was applied among groups of specialists in the field of bone reconstruction and lengthening. Results: From 823 doctors, 123 orthopedic surgeons who perform bone reconstruction and lengthening procedures responded to our questionnaire, from Brazil (101), Argentina (3), Bolivia (1), Chile (4), Colombia (1), Costa Rica (1), Mexico (7), Uruguay (1) and Paraguay (1). 92.98% of the specialists had a fellowship in Bone Reconstruction but overlapped with other subspecialties that included 68.42% in Trauma, 30.70% in Pediatric Orthopedics, 24.56% in Knee or Hip, 13.16% in Foot and Ankle, 0.88% in Hand. 66.67% of the participants work in both public and private services, 11.40% only in public services and 21.93% in private services. Concerning indications for circular fixation, acute trauma had 53.51% (frequent or very frequent), infection (86.85%), post-traumatic deformities (76.32%), congenital deformities (48.25%) and deformities secondary to metabolic/acquired disorders (28.07%). Pre-operative planning is still predominantly in printed films (58.77% frequent and very frequent). The circular fixator model used is mostly the original circular frame, with the hexapodal frames having a low representation. Conclusions: We found that reconstruction techniques are being used in latinoamerican countries, for adult and pediatric patients, trauma is still the major indication. However, there is increasing representation of virtual planning and still rare is the use of more expensive devices such as the hexapodal frames.

Traumatic heterotopic ossification (THO) is a devastating sequela following traumatic injuries and orthopedic surgeries. To date, the exact molecular mechanism of THO formation is still unclear, which hinders the development of effective treatments. The process of THO formation is believed to recapitulate a series of spatiotemporal cellular and signaling events that occur during skeletal development. The Notch signaling pathway is a critical genetic regulator in embryological bone development and fracture healing. However, few data are available concerning whether Notch signaling regulates THO development and maturation. Herein, we first demonstrated that several Notch target genes were upregulated in both mouse and human THO tissues. We further isolated tissue-resident mesenchymal progenitor cells (TMPCs) which contribute to THO under inflammatory insult, and found that sustained Notch signaling inhibition by the gamma-secretase inhibitor-DAPT reduced proliferation, osteogenic and chondrogenic differentiation of TMPCs in a time-dependent manner. Moreover, DAPT administration within 3 weeks could inhibit ectopic cartilage and bone formation in a mouse THO model without affecting the total body bone mass. Collectively, our data suggest that the Notch pathway serves as an important therapeutic target during THO formation and sustained gamma-secretase inhibition by DAPT has great potential in repressing chondrogenic and osteogenic differentiation of TMPCs, providing new insight into THO prophylaxis and treatment.

Fractures of long bones unite without any complication except for 2% to 10% which may lead to delayed or non-union. Management of delayed union of fractures poses a great challenge for orthopaedic surgeons. Tissue Engineering and Regenerative Medicine (TERM) has revolutionized the era to use of biological substances to treat diseases minimally invasively. Various studies and research have proved the osteogenic activity of PRP. The growth factors present in the PRP induce the locally available resilient progenitor or stem cells and convert the atrophic environment into a trophic environment. We investigated the safety and efficacy of autologous platelet-rich plasma (PRP) injection in the delayed union of long bone fractures. A total of 25 cases of delayed union of long bone fractures were augmented with 3 doses of autologous PRP in every 3 weekly intervals and were followed up for 12 months. All the cases were documented with pre- and post-procedural and 12th-month visual analogue score (VAS) and Warden’s score. Of 25 cases, 21 (84.00%) showed good fracture union with adequate callus formation by 10 – 12 weeks. No complications were noted due to autologous PRP application other than poor outcomes in 3 cases (2 cases of non-union, 1 case of implant failure, and 1 case of lost in follow-up). The mean pre-procedural VAS and Warden’s score at final follow-up showed statistically significant results (p<0.05). Autologous injection of PRP is safe and effective in managing delayed union of long bone fractures.

Abstract

Purpose:

To compare between immediate and delay weight bearing with the use of Hydroxyapatite-coated Schanz pins in external fixation as regard osteointegration and pin tract infection.

Methods and materials:

Our protocol included 43 adult patients: all treated for nonunion or deformity by uniplanar external fixation and Hydroxyapatite-Coated Schanz pins for fixation. We compared pins osteointegration and pin tract infection rate and timing in 2 groups based on duration of delay for weight bearing of 6 weeks. Group A (16 patients): immediate post-operative weight bearing “early group”. Group B (29 patients): weight bearing delayed for 6 weeks “6w group”.

Results:

Patients were followed up on a weekly basis from week 0 to week 30. There was non-significant difference between both groups as regards age, sex, diagnosis, number of pins, distribution and duration of external fixation (p>0.05).
There was significant difference between both groups as regards timing of infection (p<0.05),duration of infection (p<0.001) , number of infected pins (p<0.001), grade of infection (p=0.05). and treatment of infection (p<0.05).

Conclusion:

The results of 6 weeks duration of delayed weightbearing is superior to the results of immediate post-operative weightbearing in adult patients treated for nonunion or deformity by uniplanar external fixation (orthofix or similar devices) and Hydroxyapatite- Coated Schanz pins regarding osteointegration and pin tract infection rate and timing.