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Background: The surgical treatment of moderate and severe slipped capital femoral epiphysis is controversial. Treatment ranges from pinning in situ to open dislocation and reduction of the slipped epiphysis. The modified Dunn procedure has been associated with variable avascular necrosis with rates, ranging between 0% and 67%. The aim of this study was to evaluate the outcomes and complications of patients who have undergone a subcapital realignment osteotomy (SCRO) in our center., Methods: A retrospective longitudinal study of the osteotomies performed between 2009 and 2019 in a tertiary referral center for Pediatric Orthopedics in Queensland, Australia. Patient demographics, stability, and severity of slip and surgical outcomes were collected., Results: A total of 123 procedures were performed on 116 patients. The mean age was 12.4 years, 65 (56%) patients were male and the mean posterior sloping angle was 60.10 with 93 (75%) being severe slips. There were 51 (41.5%) Loder's stable and 72 (58%) unstable slipped capital femoral epiphysis. Our overall avascular necrosis rate following SCRO was 17.8%. Time between surgery and diagnosis did not have an effect on avascular necrosis., Conclusion: The subcapital realignment osteotomy remains a controversial and complex procedure for the management of moderate and severe slipped capital femoral epiphysis. We found that our cohort demonstrated an avascular necrosis rate in keeping with the existing literature. This indicates that when performed in a high-volume center with experienced surgical staff, it can be an effective treatment option for these patients., Level of Evidence: Level IV., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Study Design: Prospective study of patients undergoing elective spinal deformity surgery with repeated testing for circulating metal ions including preoperative levels acting as controls., Objective: The aim was to determine if levels of particular circulating metal ions are maintained to two years postsurgery including different implant systems and rods., Summary of Background Data: Adults having hip replacements, especially metal-on-metal bearings, may develop high metal ion levels. Pediatric spinal implants are known to cause circulating metal ions, notably titanium, chromium, cobalt, and nickel., Materials and Methods: Fifty-six children having spinal deformity surgery were studied with repeated testing for circulating metal ions, using high-resolution inductively coupled plasma mass spectrometry. Linear mixed-effects models adjusting for repeated measurements over time were used to analyze levels of titanium, cobalt, chromium, and nickel., Results: Titanium levels showed a rapid increase by seven days and a peak at 30 days that was essentially maintained at the two-year assay. At two years, titanium levels were 5.14 times greater compared with the presurgery control level (P<0.0001). Cobalt levels were shown to gradually rise to a peak at 30 days and then slowly decline but remained 1.74 times above mean baseline level at two years (P=0.0004), with a declining trajectory. Chromium and nickel levels rose immediately postoperatively and then steadily declined to baseline by six months and remained at baseline at two years. The five implant systems tested had generally equivalent results., Conclusion: The persistent and rising levels of titanium, in a predominantly female population, is concerning. Titanium is known to cross the placental barrier and enter the circulation of the fetus in rodents and humans, and to accumulate in solid organs especially the liver, spleen, heart, and lymph nodes in humans. This potentially exposes the offspring of mothers with spinal implants to titanium, with potential teratogenic effects., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Prospective 2-year study with operative sampling and in-vitro analysis of chromium ions following spinal surgery in children., Objectives: To measure metal ion levels at preoperative, intraoperative, and postoperative times to determine patterns of metal ion release during instrumented spinal surgery., Summary of Background Data: Raised serum metal ion levels are reported following instrumented spinal fusion in adolescent idiopathic scoliosis. The authors noted raised chromium levels in patients receiving implants that did not contain chromium. This prompted further work to establish the source. The electrosurgery tips used were discovered to contain 17% chromium., Methods: Chromium, cobalt, and titanium levels were measured before, during, and after surgery in serum and local intraoperative fluid samples in 11 children undergoing posterior instrumentation for scoliosis. Administered drugs, cell-saver fluids, and intraoperative fluids, both local and intravenous, were investigated to exclude these as sources of chromium ions. An in-vitro study was also performed to elucidate sources of intraoperative chromium ions., Results: High chromium levels were detected in all samples from the wound irrigation fluid prior to insertion of metal implants. Immediate postoperative chromium serum ion levels were also elevated and returned to baseline by day 30. In-vitro sampling of fluids from test models using electrosurgery revealed high levels of chromium ions CONCLUSION.: This finding of high chromium metal ion concentrations in intraoperative and early postoperative samples provides evidence of chromium release during the dissection phase of spinal surgery. This challenges existing beliefs that metal ion release occurs solely due to implants and now implicates the electrosurgery electrode tips as a source of raised chromium ion levels. Thorough irrigation of the operative site after the dissection phase of surgery to both dilute and reduce the intraoperative chromium ion load is suggested. Alternative electrosurgery electrode tips or other methods to coagulate during surgery could be considered., Level of Evidence: 2.

Background: Many options exist for reconstructing the shoulder after large bony resections of the proximal humerus. One of the more widely used is endoprosthetic replacement. Proximal migration of unconstrained hemiarthroplasty articulations may cause difficulties particularly in the setting of loss of the rotator cuff and/or deltoid musculature. To attempt to overcome these issues, a fixed-fulcrum constrained reverse shoulder replacement option may be considered., Methods: A retrospective review of prospectively collected data from the Queensland Bone and Soft Tissue Sarcoma Service was undertaken to compare the function, implant survivorship, and reoperation rate of constrained reverse and unconstrained hemiarthroplasty-type endoprostheses in patients with tumors., Results: We retrospectively reviewed data on 41 consecutive proximal or total humeral endoprosthetic replacements undertaken between January 2003 and July 2018. One patient was excluded as lost to follow-up prior to 24 months. There were 21 unconstrained implants and 19 constrained shoulder replacements (Stanmore Modular Endoprosthesis Tumour System with Bayley-Walker articulation). Proximal migration of the unconstrained hemiarthroplasty articulation occurred in 8 patients (38%), and dislocation or failure of the constrained mechanism occurred in 5 (26%). Reoperation for implant-related issues was required in 5 patients in the constrained group and none in the unconstrained group. Of the 18 patients alive at the time of review, 12 provided functional scores. The mean follow-up period for surviving patients was 4.2 years (standard deviation, 2.7 years), with a minimum of 2 years' follow-up. Functional scores were similar between the 2 groups., Conclusion: Constrained reverse prostheses were associated with a higher reoperation rate in this series without any functional benefit compared with unconstrained hemiarthroplasty-type articulations. We favor the use of unconstrained hemiarthroplasty-type endoprostheses for reconstruction after resection of destructive lesions of the proximal humerus., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Patients undergoing total knee arthroplasty (TKA) have expected blood loss during and after surgery. The morbidity associated with blood loss and the burden of blood transfusions in adult arthroplasty necessitates preoperative optimization as routine practice. Current literature remains inconclusive on which TKA surgical instrumentation techniques are effective in minimizing perioperative blood loss, and consequently lower transfusion rates. The primary objective of this retrospective review, of a prospective randomized cohort study, was to compare surgical and patient factors, and their influence on blood loss and transfusions rates, between one type of patient-specific instrumentation (PSI), navigated computer-assisted surgery (CAS), and conventional TKA surgical techniques.A cohort of 128 matched patients (38 PSI, 44 CAS, 46 conventional surgeries) were compared. Preoperative factors analyzed included; age, gender, body mass index, preoperative hemoglobin (Hb) (g/L), international normalized ratio, use of anticoagulants and comorbid bleeding diathesis. Maximal Hb drop and transfusion requirements were compared on day 1 to 3. Perioperative factors collected included: surgical time, tourniquet time, drain output, in situ drain time, order of tibia or femoral cut, and intraoperative loss from suction.The three groups did not differ on the preoperative patient demographics examined. The difference between preoperative Hb and the lowest postoperative Hb readings did not differ between study groups ( p  = 0.39).There are no statistically significant differences in blood loss when comparing PSI versus CAS versus conventional TKA. Although emerging evidence on PSI is encouraging, the PSI technique for TKA does not result in reduced blood loss. The study was registered with ClinicalTrials.gov: NCT01145157., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

We present a rare case of delayed diagnosis of osteosarcoma of the medial clavicle in a young man. He presented following a pathological fracture with a falsely reassuring core and fine-needle aspiration biopsy. The initial biopsy was suggestive of an aneurysmal bone cyst and was therefore treated conservatively without further follow-up. The rapid increase in size over the next 8 months triggered a repeat presentation and subsequent repeat biopsy. The open biopsy confirmed high-grade osteosarcoma and the patient underwent claviculectomy with neoadjuvant chemotherapy., (2015 BMJ Publishing Group Ltd.)

Study Design: Prospective pilot study., Objectives: The aim of this study was to measure titanium, niobium and aluminium levels in various intraoperative and postoperative samples to determine patterns of metal ion release that occur within the first month following instrumented spinal fusion. Raised serum metal ion levels are reported following instrumented spinal fusion in adolescent idiopathic scoliosis. The exact topological origin and chronology of metal ion release remains conjectural. Recent literature suggests an immediate rise in serum metal levels within the first postoperative week., Methods: Titanium, niobium and aluminium levels were measured before, during and after surgery in serum and local intraoperative fluid samples obtained from two pediatric patients undergoing posterior correction and instrumentation for scoliosis., Results: Measurable metal ion levels were detected in all local samples obtained from wound irrigation fluid, cell saver blood, and fluid that immersed metal universal reduction screw tabs. Postoperative serum metal ion levels were elevated compared to baseline preoperative levels. In general, metal ion levels were considerably higher in the intraoperative fluid samples compared to those observed in the serum levels., Conclusion: Our findings of contextually high metal ion concentrations in intraoperative and early postoperative samples provide further empirical support of a 'putting-in' phenomenon of metal ion release following instrumented spinal fusion. This challenges existing beliefs that metal ion release occurs during an intermediate 'wearing-in' phase. We recommend thorough irrigation of the operative site prior to wound closure to dilute and remove intraoperative metal ion debris. Possibilities of filtering trace metal ions from cell saver content may be considered.

Purpose: Measurement of serum metal ion levels is used to determine systemic exposure to implant-derived metal debris that may be generated by processes of wear and corrosion. The aim of this study is to investigate predictors of serum metal ion levels in children undergoing instrumented spinal arthrodesis using a titanium alloy, focusing on implant characteristics and instrumentation construct design variables., Methods: This prospective longitudinal cohort study involved 33 children. Serum samples were obtained preoperatively:and at five defined interval periods over the first:two post-operative years. Samples were analysed using high resolution:inductively coupled plasma mass spectrometry to measure titanium, niobium and aluminium concentrations. Instrumentation characteristics were catalogued and construct surface area (SA) measurements calculated using an implant-specific software algorithm tool., Results: Significantly elevated levels of serum titanium and niobium were observed (p< 0.0001), with >95 % of post-operative levels abnormally elevated. Significant predictors of serum titanium and niobium levels included time since surgery, surgical procedure (posterior or anterior fusion), number of levels fused, number of pedicle screws inserted, total rod length, total metal SA, total exposed metal SA and total metal-on-metal SA. All significant instrumentation variables were highly correlated., Conclusions: There is a strong relationship between implant SA and both serum titanium and niobium levels. The direct clinical implications of these findings for patients are uncertain, but remain of concern. Surgeons should be aware of the strong correlation between implant surface area of the chosen construct and the subsequent serum metal ion levels.

Background: Traumatic head injury is the leading cause of mortality and serious morbidity in snow sports and is increasing in incidence. Helmet use in snow sports can reduce the incidence of head injury by up to 60%. Mandatory helmet use is not legislated in most recreational settings for snow sports. This study aimed to quantify the prevalence and trends of helmet use by skiers and snowboarders as well as to investigate predictors of helmet use and reasons why they are worn., Methods: A cross-sectional study including observation of skiers and snowboarders allocated to adult and child groups (5,267 persons), retrospective review of ski patrol accident report forms recorded between 2003 and 2008 (3,984), and completion of specially designed questionnaires by randomly approached snow sport participants (1,029)., Results: In 2008, 16% of adults and 67% of children wore helmets. Helmet use increased for adult and child participants between 2003 and 2008. Children, men, and snowboarders were significantly more likely to wear a helmet than their respective counterparts. Significant predictors of helmet use were level of experience, past major crash requiring medical assistance, snow sport lessons, and location of activity. Key reasons for helmet use and disuse were identified., Discussion: Child helmet use far exceeded adult helmet use. Rates of voluntary helmet use are increasing but many remain unprotected from the benefits of a helmet. Identification of the snow sport participants least likely to wear a helmet and their reasons for not doing so should allow targeted helmet promotion and injury prevention strategies to reduce serious head injuries in snow sports.