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Introduction and Objective: Thoracic disc calcification is a radiological finding which may be incidental or diagnosed in patients presenting with myelopathy due to spinal cord compression. We performed a study to analyze the imaging patterns of calcified thoracic discs (CTDs). Patients and Methods: A retrospective review of the spinal and radiology database of a tertiary referral orthopedic hospital was conducted for the incidence of CTDs between 2007 and 2020. Patients' demographics and radiological findings were recorded. The relationship between disc size, morphology, spinal cord compression, and management was assessed. Results: Fifty-one cases of CTDs were identified. The mean size of CTD was 806.2 mm3 (range: 144-2340). The most common level of disc calcification was T9-T10 (24%) in 12 patients. Thoracic disc calcifications in our series commonly involved disc "protrusion" in 67% (34 patients), followed by "mushroom" type in 31% (16 patients) and "extrusion" in 2% (1 patient). 37% (19 patients) had spinal cord compression with 12% (6 patients) undergoing surgical interventions. There was no statistically significant difference in the mean sizes of CTD between the groups with and without spinal cord compression (P = 0.566, independent sample t-test). Patients with "mushroom" type calcification were more likely to have surgical intervention (P = 0.01, Fisher's exact test). Conclusion: Thoracic disc calcifications, while common, can still be underdiagnosed till late myelopathic deterioration. Care of the elderly physicians, spinal surgeons, and radiologists need to be aware of them to guide diagnosis and management. Our study demonstrates that disc morphology plays a vital role in myelopathic presentation and therefore determines the need for surgical intervention instead of the absolute size of disc calcification.

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Aims: this study compared the patient and microbiological profile of prosthetic joint infection (PJI) for patients treated with two-stage revision for knee arthroplasty with that of lower-limb endoprostheses for oncological resection. Patient and methods: a total of 118 patients were treated with two-stage revision surgery for infected knee arthroplasty and lower-limb endoprostheses between 1999 and 2019. A total of 74 patients had two-stage revision for PJI of knee arthroplasty, and 44 had two-stage revision of oncology knee endoprostheses. There were 68 men and 50 women. The mean ages of the arthroplasty and oncology cohorts were 70.2 years (range of 50-89) and 36.1 years (range of 12-78) respectively ( p < 0 .01). Patient host and extremity criteria were categorized according to the Musculoskeletal Infection Society (MSIS) host and extremity staging system. The patient microbiological culture, the incidence of polymicrobial infection, and multidrug resistance (MDR) were analysed and recorded. Results: polymicrobial infection was reported in 16 % (12 patients) of knee arthroplasty PJI cases and in 14.5 % (8 patients) of endoprostheses PJI cases ( p = 0 .783). There was a significantly higher incidence of MDR in endoprostheses PJI, isolated in 36.4 % of cultures, compared with knee arthroplasty PJI (17.2 %, p = 0 .01). Gram-positive organisms were isolated in more than 80 % of cultures from both cohorts. Coagulase-negative Staphylococcus (CoNS) was the most common Gram-positive organism, and Escherichia coli was the most common Gram-negative organism in both groups. According to the MSIS staging system, the host and extremity grades of the oncology PJI cohort were significantly worse than those for the arthroplasty PJI cohort ( p < 0 .05). Conclusion: empirical antibiotic prophylaxis against PJI in orthopaedic oncology is based upon PJI in arthroplasty, despite oncology patients presenting with worse host and extremity staging. CoNS was the most common infective organism in both groups; however, pathogens showing MDR were significantly more prevalent in oncological PJI of the knee. Therefore, empirical broad-spectrum treatment is recommended in oncological patients following revision surgery.

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Osteoid osteomas are mostly solitary. We report a case of metachronous osteoid osteoma of mid-diaphysis of fibula followed by distal humeral osteoid osteoma after a 7-year interval.

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BACKGROUND: Non-invasive expandable endoprostheses (NIEPR) utilize an external electromagnetic field to drive an innate mechanical gearbox. This lengthens the extremity following oncological resections in children with a predicted limb length discrepancy (LLD), facilitating limb-salvage. This review was conducted to assess NIEPR implant survival rates and identify modes of implant failure unique to these prostheses. METHODS: Medline, EMBASE and the Cochrane Library databases were searched for all manuscripts evaluating implant survival of NIEPRs implanted into skeletally immature patients following resection of extremity sarcomas. Minimum follow-up of 12 months or implant failure was required for inclusion. Failures were classified using the latest ISOLS classification and exact implant-specific failure modality was also identified. RESULTS: 19 studies met inclusion criteria. Mean age was 10.0 years (7.7 - 11.4 years). The most common locations for NIEPR implantation were the distal femur (343, 76.7%) and proximal tibia (53, 119%). Mean follow-up was 65.3 months (19.4 - 163 months). The overall implant revision rate was 46.2% (0 - 100%); implant specific revisions included maximal prosthesis lengthening with persistent LLD (10.4%), failed extension mechanism (6.1%), implant fracture (7.7%), hinge fracture (1.4%) and bushing wear (0.9%). Persistent clinically significant (>20 mm) LLD at final follow-up was present in 19.2% (0 - 50%) of patients. The mean MSTS score was 85.1% (66.7-96.3%) at final follow-up. CONCLUSION: Implant-related failures are the most common reason for NIEPR revision. Implant reliability appears to be improved with current designs. A sub-classification to the current classification system based on implant-specific failures for NIEPRs is proposed.

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Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the anterior aspect of the knee in the context of a patient presenting with a sinus and periprosthetic joint infection (PJI) or extensor mechanism failure. The aim of this study was twofold: firstly, to evaluate the outcomes of gastrocnemius flaps performed by appropriately trained orthopaedic surgeons in the context of PJI and, secondly, to evaluate the infection-free survival of this patient group. Patients and methods: We retrospectively reviewed 30 patients who underwent gastrocnemius flap reconstruction during staged revision total knee arthroplasty for prosthetic joint infection (PJI). All flaps were performed by an orthopaedic surgeon with orthoplastics training. Patients had a mean age of 68.9 years (range 50-84) and were followed up for a mean of 50.4 months (range 2-128 months). A total of 29 patients (97 %) were categorized into Musculoskeletal Infection Society (MSIS) local extremity grade 3 (greater than two compromising factors), and 52 % of PJIs were polymicrobial. The primary outcome measure was flap failure, and the secondary outcome measure was recurrent infection. Results: Flap survival was 100 % with no failures or early returns to theatre for flap problems such as necrosis or haematoma. Overall infection-free survival during the study period was 48 % (13 of 27 infected cases). Using limb salvage as the outcome, 77 % (23 of 30 patients) retained the limb. Infection recurrence occurred in 48 % (10 patients) in the type B3 cohort and 67 % (4 patients) in the type C3 cohort ( p = 0.65 ). Conclusions: The surgical technique for a gastrocnemius myofascial flap is reliable and reproducible when performed by appropriately trained orthopaedic surgeons, even in high-risk groups. However, the risks of recurrent infection and amputation remain high within our series due to poor host and extremity factors.

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INTRODUCTION: The impact of preoperative glycated haemoglobin (HbA1c) in patients undergoing gastrointestinal and hepatobiliary surgery is unclear as data is limited. METHODS: Patients undergoing gastrointestinal surgery attending pre-assessment screening (PAS) clinics from August to September 2016 at the Queen Elizabeth Hospital Birmingham (QEHB) were identifi ed. Outcome measure was postoperative complications as defi ned by the Clavien-Dindo classifi cation system. RESULTS: In this study, 381 patients were included, of which 48% (181/381) had HbA1c measured. Of these, 27% (49/181) had a HbA1c ≥ 48 mmol/mol. Overall complications were 14% and major complication rates were 3% (11/381). In unadjusted models, patients with HbA1c ≥ 48 mmol/mol had signifi cantly higher rates of overall complications (odds ratio [OR] = 2.82, 95% confi dence interval [CI] = 1.22-6.49; p = 0.015). In adjusted models, only surgical grade was predictive of overall complications. In patients undergoing major surgery (n = 93), there were signifi cantly higher rates of overall complications in patients with HbA1c ≥ 48 mmol/mol as compared to those with HbA1c < 48 mmol/mol (63% vs. 46%, p = 0.043). CONCLUSION: Utility of HbA1c to stratify patients undergoing gastrointestinal and hepatobiliary surgery into high-risk clinics is limited from this study. Future studies should aim to validate these fi ndings in much larger cohorts.

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BACKGROUND: Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. METHODS: This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. RESULTS: This study included 370 patients, of which 11% (41/370) had eGFR of <60 ml/min/1.73 m2. Patients with eGFR < 60 ml/min/1.73 m2 were more likely to have ASA grade 3/4 (p < 0.001) and >2 comorbidities (p < 0.001). Overall complication rates were 15% (54/370), with no significant difference in overall (p=0.644) and major complication rates (p=0.831) between both groups. In adjusted models, only surgery grade was predictive of overall complications. Preoperative eGFR did not impact on overall complications (HR: 0.89, 95% CI: 0.45-1.54; p=0.2). CONCLUSIONS: Preoperative eGFR does not appear to impact on postoperative complications in patients undergoing elective gastrointestinal surgeries, even when stratified by surgery grade. These findings will help preassessment clinics in risk stratification and optimisation of perioperative care of patients.

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BACKGROUND: At Queen Elizabeth Hospital Birmingham (QEHB), no specific protocol to stratify patients by body mass index (BMI) exists. This study sought to evaluate outcomes following gastrointestinal surgery. METHODS: Patients undergoing gastrointestinal surgery attending preassessment screening clinic (PAS) from August to September 2016 at the QEHB were identified. Primary outcome was postoperative complications. Secondary outcomes were major complications and 30-day readmission rates. RESULTS: Of 368 patients preassessed, 31% (116/368) were overweight and 35% (130/368) were obese. Median age was 57 (range: 17-93). There was no difference of BMI between the low risk and high risk clinics. Patients in high risk clinic had significantly higher rates of comorbidities, major surgical grades, and malignancy as the indication for surgery. Overall complication rates were 14% (52/368), with 3% (10/368) having major complications (Clavien-Dindo Grades III-IV). Whilst BMI was associated with comorbidity (p = 0.03) and ASA grade (p < 0.001), it was not associated with worse outcomes. Patients attending high risk clinic had significantly higher rates of complications. CONCLUSIONS: Surgery grade was found to be an independent risk factor of complication rates. Use of BMI as an independent factor for preassessment level is not justified from our cohort.

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