The objective of this study is to provide an up-to-date review of the outcomes of revision total ankle arthroplasty (TAA). Relevant studies published over the last decade were reviewed. Twelve studies were included. At a median follow-up of 4 years, the median survival and reoperation rates were 86% and 16%, respectively. Significant postoperative improvements in patient-reported outcome measures were recorded in 6 studies. Significant improvement in alignment was documented in 1 study only. Revision TAA is a safe procedure that can produce good outcomes. Nevertheless, data relating to long-term outcome are still limited in quantity and duration.

Background Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm 2 . Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages.

BACKGROUND:The literature on the outcome of revision total ankle arthroplasty (TAA) remains limited. In this study, we aimed to report the clinical and radiographic outcomes of revision TAA at a high-volume center in the United Kingdom. METHODS:This study was a retrospective review of 28 patients who underwent 29 revision TAAs using the INBONE II Total Ankle System (Wright Medical Technology/Stryker). Demographic, radiographic, and patient-reported outcome measure data were analyzed. RESULTS:The mean duration from primary TAA to revision was 87.5 months (range, 16 to 223 months). The main indication for the revision was aseptic loosening after the primary TAA (83%). Additional procedures were required in 76% of ankles. At a mean follow-up of 40 months (range, 24 to 60 months), the infection rate was 7%, the reoperation rate was 7%, and the implant survival rate was 97%. A significant postoperative improvement in the radiographic component alignment measures was observed. The subsidence, loosening, and heterotopic ossification rates in this study were comparable with those in other reports and did not influence the clinical outcome. A significant improvement was observed in the Manchester-Oxford Foot Questionnaire (MOXFQ) in all domains and the EuroQol-5 Dimensions (EQ-5D) in 3 domains at 24 months postoperatively. CONCLUSIONS:Revision TAA using the INBONE II prosthesis was associated with good short-term survival and improvement in postoperative scores at 2 years. Maintenance of the postoperatively improved alignment was documented at the follow-up. The results of this study support the notion that revision TAA is a satisfactory option for failed primary TAA. LEVEL OF EVIDENCE:Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Abstract Aim The European Society for Vascular Surgery defines iliac artery aneurysms (IAA) as beyond 1.5 times its normal diameter. Common iliac arteries (CIA) beyond 1.8cm in men and 1.5cm in women are considered aneurysmal. This study aimed to assess outcomes following IAA rupture as their natural history is poorly understood and treatment recommendations based on low-level evidence. Method Patients with IAAs at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included aneurysm rupture, rupture diameter, post-operative complications, 30-day, 1-year and 5-year mortality rates. Statistical analysis with SPSS® was performed using chi-squared tests. Results Of 203 patients included, 90.6% were men and median(IQR) age at detection was 77 (71–83). Co-morbidities included hypertension (54.2%), hyperlipidaemia (42.9%) and ischaemic heart disease (35.5%). IAA were in the CIA (85.2%), IIA (21.7%) and EIA (2.0%), mostly asymptomatic (78.8%). Overall IAA rupture rate was 7.9% with CIA (81.2%) and EIA (18.8%). Mean (SD) diameters at rupture were 4.6 (2.4)cm for CIA and 4.6 (3.0)cm for IIA. Post-operative major adverse cardiovascular events (MACE) more frequently occurred following repair of ruptured compared to unruptured IAA (33.3% vs 3.5%, p=.011). Mortality at 30-days, 1-year and 5-years postoperatively were higher following repair of ruptured vs unruptured aneurysms (88.9%, 88.9%, 100% vs 1.2%, 10.6%, 36.1% respectively). Conclusions Early detection and elective treatment of IAA aneurysms before they approach 4.6cm may reduce rupture risk, morbidity and mortality associated with emergency repair following rupture.

Abstract Aim The European Society for Vascular Surgery defines common iliac artery (CIA) aneurysms as greater than 1.8cm in men and 1.5cm in women. Their reported growth rate is 1–4mm/year depending on their diameter. This study aimed to assess the natural history and surveillance intervals for CIA aneurysms as intervention threshold is based on low-quality evidence. Method Patients diagnosed with an IAA at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included diameter-based mean aneurysm growth rates and median surveillance intervals. Statistical analysis with SPSS® was performed using chi-squared tests. Results Of the 203 patients included, 90.6% were men and median (IQR) age at detection was 77 (71–83). IAA were located in the CIA (85.2%), IIA (21.7%) and EIA (2.0%) with the majority being asymptomatic (78.8%). CT was most frequently used as the imaging modality for IAA surveillance (66.3%), followed by ultrasound scan (29.8%) and MRA (3.9%). Growth rate for CIA aneurysms measuring 1.0–1.9cm were -2.1mm/year, 2.0–2.9cm were 0.8mm/year, 3.0–3.9cm were 3.5mm/year, 4.0–4.9cm were 9.4mm/year, 5.0–5.9cm were 2.9mm/year and >6.0cm were 13.8mm/year. Median surveillance intervals for CIA aneurysms at 1.0–1.9cm were 12-monthly, 2.0–2.9cm were 11-monthly, 3.0–3.9cm were 5-monthly, 4.0–4.9cm were 5-monthly, 5.0–5.9cm were 5.5-monthly and >6.0cm were 14.5-monthly. Mean(SD) CIA diameter at rupture was 4.6 (2.4)cm. Conclusions CIA aneurysms demonstrate faster growth rates as they enlarge and may require more frequent clinical assessments, surveillance, and consideration for repair prior to rupture.

This is a systematic review of the non-operative treatment for Achilles tendon rupture aimed at assessing the effect of early weightbearing, controlled motion and orthosis removal on 5 outcome measures. The literature was searched for relevant RCTs and prospective cohort studies. The primary outcome measure was the re-rupture rate. The secondary outcome measures were the rates for DVT, duration before return to work (RTW), return to sports (RTS) and the mean Achilles Tendon Rupture Score (ATRS). Eighteen publications reporting a total of 1068 patients were reviewed. The pooled rates were: re-rupture: 7.3%, DVT: 5.5%, RTW: 10.3 weeks, RTS: 47.7% and ATRS: 78.7. Early compared to late weightbearing was associated with significantly lower rates of DVT, RTW and ATRS but no difference in the rates of re-rupture and RTS. Early controlled motion compared to no motion was associated with significantly lower rates of re-rupture, RTW and ATRS but no difference in the rates of DVT and RTS. Early compared to late orthosis removal was associated with significantly higher rates of re-rupture and ATRS as well as a lower rate of RTW but no difference in the rates of DVT and RTS. The findings relating to re-rupture, DVT, RTW and RTS support the adoption of early weightbearing and controlled motion in the non-operative treatment for Achilles tendon rupture. Early removal of orthosis is not advisable due to an increased risk of re-rupture. The ATRS results were considered inconclusive probably due to inconsistencies in the reporting or heterogeneity in the study population.

Objective: To report a case of AHLE and to describe the management and outcome. Background: AHLE is a rare form of acute demyelinating leukoencephalopathy characterized by rapid fulminant inflammation of white matter with punctuate hemorrhages. Cross reactivity between myelin antigens and viral or bacterial antigens likely induce an immunological response. Patients present with focal neurological deficits and rapidly progressive encephalopathy. The morbidity and mortality rates are high. Design/Methods: NA Results: A 35-year-old Saudi female presented with a one-day history of left-sided hemiparesis following an upper respiratory tract infection. She was afebrile with a normal general examination. She was alert, oriented, dysarthric with left sided hemiparesis. MRI brain with gadolinium showed extensive right-sided vasogenic edema with 8 mm of midline shift but no mass, enhancement or diffusion restriction. Cerebrospinal analysis was not attempted. WBC was 14.4 ×10 9 /L (3.90–11.0) with 78% neutrophils, hemoglobin 97 g/L (110–160), platelets of 123 × 10 9 /L (155–435) and hemoglobin electrophoresis suggestive of thalassemia trait. Renal and hepatic profiles were normal. The following day she developed signs of increased intracranial pressure. A CT brain showed impending uncal herniation. A decompressive craniectomy with brain biopsy was performed. Pathology showed perivascular neutrophilic inflammation with foci of perivascular hemorrhage. Immunohistochemistry with anti-neuronal filament antibodies showed preservation of axons and many axonal spheroids. Stains for microorganisms and cultures were negative. Autoimmune antibodies, dengue serology and malaria blood film were negative. She was treated with intravenous methylprednisolone 1.0 gram daily for 5 days and therapeutic plasma exchange (TPE) 5 exchanges of 75 ml/kg followed by 21 days of intravenous cyclophosphamide 100 mg/m 2 and oral prednisolone 1 mg/kg. She experienced complications of seizures and klebsiella meningoencephalitis. She was discharged on day 115, ambulatory with left arm weakness. Conclusions: Aggressive immunosuppression with high dosage cyclophosphamide combined with TPE, high dosage corticosteroids and an early decompressive craniotomy afforded this patient a favorable outcome. Disclosure: Dr. Balubaid has nothing to disclose. Dr. Badawi has nothing to disclose. Dr. Al Hindi has nothing to disclose. Dr. Jamjoom has nothing to disclose. Dr. Kurdi has nothing to disclose. Dr. Al Said has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Novartis. Dr. Wazzan has nothing to disclose. Dr. Cupler has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Sanofi; Novartis.

The aim was to assess contemporary management of slipped capital femoral epiphysis (SCFE) by surveying members of the British Society of Children9s Orthopaedic Surgery (BSCOS). A questionnaire with 5 case vignettes was used. Two questions examined the timing of surgery for an acute unstable SCFE in a child presenting at 6 hours and at 48 hours after start of symptoms. Two further questions explored the preferred method of fixation in mild and severe stable SCFE. The final question examined the management of the contralateral normal hip. Responses were entered into an Excel spreadsheet and the data w analysed using a chi-squared test. The response rate was 56% (110/196). 88.2% (97/110) responded that if a child presented with an acute unstable SCFE within 6 hours, they would treat it within 24 hours of presentation, compared with 40.9% (45/110) for one presenting 48 hours after the onset of symptoms (P There are significant differences in opinions between BSCOS members as to the optimal management of SCFE in children. This reflects the variable recommendations and quality in the current scientific literature. Further research is therefore required to determine best practice and enable consensus to be reached.

INTRODUCTION We aim to assess the impact of the quantity of intradiscal cement leak during kyphoplasty on the rate of progression of degenerative changes in the affected disc. METHODS Of 316 kyphoplasty procedures, we identified 32 episodes of intradiscal cement leak in 26 patients. The quantity of cement leaked was graded from Ito IV. Disc degenerative changes were assessed at presentation and follow-up using radiographical scoring and magnetic resonance imaging (MRI) grading systems. Data for low-grade leaks (grade I) were compared with the medium- and high-grade leaks (grades II-IV) using a chi-squared test. RESULTS Median follow-up radiographic and MRI assessments were made at 18 and 21 months, respectively. Medium- and high-grade leaks were associated with a significantly higher radiographic disc degeneration scores compared with low-grade leaks (P= 0.04295) but no difference was found in MRI disc degeneration grades and in adjacent vertebral fracture rates. CONCLUSIONS Our findings indicate that the quantity of cement leaking into the disc space significantly influences the rate of progression of disc degeneration.

We read with great interest the article by Amiri et al. [ [1] Amiri A.R. Kanesalingam K. Cro S. Casey A.T.H. Level of evidence of clinical spinal research and its correlation with journal impact factor. Spine J. 2013; 13: 1148-1153 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar ]. The article examined the level of evidence (LOE) of spine research published during 2010 in five major spine journals (The Spine Journal, Spine, European Spine Journal, Journal of Neurosurgery: Spine, and Journal of Spinal Disorders and Techniques). The authors concluded that articles published in spine journals with higher impact factor (IF) contain a larger proportion of studies with high LOE. We felt that it would be of interest to explore this point further by assessing LOE of spine research published in the four highest impact medical journals (HIMJs). These journals and their IF are as follows: New England Journal of Medicine (NEJM; IF=51.66), Lancet (IF=39.06), Journal of American Medical Association (JAMA; IF=29.98), and British Medical Journal (BMJ; IF=17.22) [ [2] Medical Journal Impact Factors. 2013. Available at: http://impactfactor.weebly.com. Accessed December 1, 2013. Google Scholar ].

Good quality clinical research is fundamental for the practice of evidence-based medicine (EBM). Level of evidence (LOE) is a tool used to assess the quality and design of clinical research. It is generally accepted that publications with a high LOE are likely to be more valid and have greater impact on clinical practice. In recent years, there has been a growing interest in the assessment of the LOE in publications from the Kingdom of Saudi Arabia (KSA),1,2 in major specialty journals,3,4 and from different countries.5 Up to date information on the quality of neurosurgery research in KSA is still lacking. This study aimed at evaluating the LOE in Saudi neurosurgical publications, and comparing this with the international literature, and with KSA publications from other specialties.

S meetings allow professionals working in the same field to share knowledge and to rapidly disseminate new research findings. The publication rate of abstracts presented at a scientific meeting, also known as the abstract to publication ratio, is a way to assess the scientific impact of a meeting. This was examined for a number of disciplines, and the average publication rate was found to be 45%.1 Over the last decade many scientific societies were established in the Kingdom of Saudi Arabia (KSA) and most have been organizing regular annual scientific meetings. However, there is a lack of information evaluating the publication rates of abstracts presented during any of the Saudi medical society’s scientific meetings. The objectives of this study are to determine the publication rates and the factors predictive of publication of abstracts presented during the annual meetings of the Saudi Association of Neurological Surgery (SANS), a national scientific society established in 2007. The study was carried out at the Department of Surgery, King Khalid National Guard Hospital, Jeddah, KSA between January and February 2013. Abstracts of papers that were orally presented during the first 6 SANS Annual Meetings (2007-2012) were collected from the program and abstract books of each meeting. The presentations’ titles and the authors’ names were searched in “PubMed” and “Google Scholar” to identify the presentations that were published as full articles in peer-reviewed journals. We excluded presentations that were carried out by invited international guest speakers. The following data were collected for each presentation: the year, the presenter’s rank, the presenter’s center, the center’s university status, the center’s region, and the presentation’s subspecialty. The following data were collected for each published article: the publishing journal, whether the journal was neuroscience-related or general, and whether it originated from KSA or from outside KSA. In addition, using GraphPad QuickCalcs Software chi square calculator, the influence of the year of presentation, the presenter’s rank, the center’s university status, the center’s region, and the presentation’s subspecialty on the publication rates were examined statistically for significance. The total number of oral presentations during the first 6 SANS Annual Meetings were 273. The distribution of the total presentations in relation to the year, the presenter’s rank, the center’s university status, the center’s region, and the presentation’s subspecialty are summarized in Table 1. The most frequently presenting KSA centers and their presentation numbers were: King Khalid University Hospital, Riyadh: 37 (14%), King Fahad Medical City, Riyadh: 35 (13%), King Faisal Specialist Hospital and Research Centre, Riyadh: 32 (12%), King Fahad University Hospital, Khobar: 22 (8%), King Khalid National Guard Hospital, Jeddah: 14 (5%), King Abdulaziz University Hospital, Jeddah: 14 (5%), King Fahad Specialist Hospital, Dammam: 14 (5%), and Taibah University, Madinah: 11 (4%). The most frequently presenting countries outside KSA and their presentation numbers were: Egypt: 15 (5%), United Arab Emirates: 5 (2%), Lebanon: 4 (1%), and Oman: 2 (1%). The total number of articles that were published in peer-reviewed journals was 35. Hence, the abstract to publication ratio for papers presented during the first 6 SANS annual scientific meetings was 13%. The timing of publication and the article numbers were: prior to presentation 5 (14%), within the same year of presentation: 12 (34%), one year later: 12 (34%), 2 years later: 5 (14%), and 3 years later: one (3%). The median time between presentation and publication, excluding articles that were published prior to presentation, was one year. The publishing journals and the article numbers were: neuroscience-related journals: 26 (74%), general journals: 9 (26%), journals from KSA: 11 (31%), and journals from outside KSA: 24 (69%). The most common publishing journals and the article numbers were: Neurosciences (Riyadh): 8 (23%), British Journal of Neurosurgery: 3 (9%), Neurosurgery: 2 (6%), Surgical Neurology: 2 (6%), Minimally Invasive Neurosurgery: 2 (6%), Childs Nervous System: 2 (6%), and the Saudi Medical Journal: 2 (6%). Researchers in general are fully aware of the importance of publishing their presentations as full articles in peer-reviewed journals. Abstracts that are not subsequently published as articles are unlikely to reach their maximal potential readership limiting their benefits to the medical community. This can lead to wastage of resources as other researchers may duplicate the work. Compared to articles, abstracts tend to lack details in the description of materials and methods making it difficult for other researchers to understand

BACKGROUND:Coronary artery targets are essential for referral acceptance to achieve complete coronary revascularization. PATIENTS AND METHODS:A prospective double-blind study was carried out to determine whether the addition of nitroglycerin to cold blood hyperkalemic cardioplegia would optimize the size and number of coronary artery targets during conventional coronary bypass grafting. RESULTS:A total of 60 adult elective coronary artery bypass grafting cases were enrolled; 30 in group N (nitroglycerin added to cardioplegia) and 30 in group C (controls). The number of bypassed vessels ranged from 2 to 5 with a mean of 3.63. In a comparison between groups N and C, the average number of grafts per patient (3.67 ± 0.77 vs. 3.67 ± 0.92); the average performed/predicted ratio for coronary artery bypass grafting targets (0.96 ± 0.18 vs. 1.02 ± 0.31); and the average intraoperatively measured luminal diameter of the bypassed coronary artery targets (1.55 ± 0.23 vs. 1.51 ± 0.23) showed no significant difference between the two groups, except that the luminal diameter of the obtuse marginal II artery was larger in group C compared to group N ( P = 0.037). CONCLUSIONS:The addition of nitroglycerin to cardioplegia did not show any benefit, either quantitatively or qualitatively, for optimizing coronary artery bypass grafting targets.

We report a child with osteopetrosis, oxycephaly and Chiari type I malformation who presented with raised intracranial pressure. During cranial expansion surgery the patient developed sudden cardiac arrest which we believe was probably related to the Chiari malformation. The case highlights a previously unrecognized association between osteopetrosis, craniosynostosis and a persistently open fontanelle at age 4 years. In addition it supports the existing literature in emphasizing the need for careful preoperative work up, choice of approach and operative technique in children with complex craniosynostosis and Chiari malformation.