To assess the clinical and radiologic outcome of MM patients with thoracic spine involvement and concomitant pathologic sternal fractures with a resultant severe sagittal plane deformity. A prospective cohort study (n=391) was performed over a 7-year period at a national tertiary referral centre for the management of multiple myeloma with spinal involvement. Clinical, serological and pathologic variables, radiologic findings, treatment strategies and outcome measures were prospectively collected. Pre-treatment and post-treatment clinical outcome measures utilised included EQ-5D, VAS, ODI and RMD scoring systems. 13 MM patients presented with a severe symptomatic progressive sagittal plane deformity with a history of pathologic thoracic compression fractures and concomitant pathologic sternal fracture. All patients with concomitant sternal fractures displayed the radiographic features and spinopelvic parameters of positive sagittal malalignment and attempted clinical compensation. All patients had poor health related quality of life measures when assessed. Pathologic sternal fracture in a MM patient with thoracic compression fractures is a risk factor for the development of a severe thoracic kyphotic deformity and sagittal malalignment. This has been demonstrated to be associated with a very poor health related quality of life

Previous studies of osteoarthritic knees have examined the relationship between the variables body mass index (BMI) and weight on the one hand and coronal plane deformity on the other. There is a consensus that weight and BMI are positively correlated to the degree and progression of a varus deformity. However, there does not appear to be a consensus on the effect of these variables on knees with a valgus deformity. Indeed, the view has been expressed that in knees with a severe deformity a relationship might not exist. A review of these studies reveals that in all cases, the alignment of the lower limb was obtained from a standing antero-posterior long leg radiograph. In no cases was the deformity in the sagittal plane measured. This study analyses the relationship between BMI, weight, deformity in the sagittal plane and valgus deformity.

The study group consisted of 73 patients with osteoarthritis and valgus knees. All of them had failed conservative treatment for their symptoms and were listed for navigated TKA. Their weight and height were measured two weeks preoperatively and the BMI calculated. At operation the coronal and sagittal deformities were measured using the Orthopilot^® navigation system (BBraun Aesculap, Tuttlingen). The results were analysed using SPSS 15.

Regression analysis showed a significant relationship (p< 0.05) with a negative correlation between valgus deformity and weight. the correlation coefficient for flexed knees (−0.59) showed a moderately strong relationship whereas that for extended knees (−0.38) showed a relatively weak relationship.

It is acknowledged that there is an increased force on the lateral compartment with increased valgus deformity. a larger deformity causes a larger moment arm about the centre of the knee. this study has shown that at the time of surgery, individuals with lower weights have larger valgus deformities. we postulate, therefore, that when the moment due to the weight of the individual and the length of the moment arm exceeds a certain value, a symptomatic threshold is crossed. in the presence of a fixed flexion deformity, the force on the patella-femoral joint is increased, contributing further to the onset of discomfort.

Further investigation into the subsets of valgus knees appears to be warranted.

This research sought a mathematical model to relate the postero-anterior (PA) and lateral (LAT) views of the spinal curve in scoliosis in an attempt to justify the acquisition of only One X-ray, thereby reducing patient exposure to harmful X-radiation while preserving complete 3D characterization of the spine. Using powerful developments in functional statistics and machine learning, no such relation could be found. Thus, this research sustained the clinical decision to acquire two biplanar X-rays and supported current research in 3D spinal curvature analysis.

Scoliosis is monitored through full spinal X-rays, and this serial protocol causes an increased incidence of cancer development. This research sustains the clinical decision at Hôpital Sainte-Justine in Montréal and elsewhere to acquire postero-anterior (PA) and lateral (LAT) X-rays, despite the increased exposure to X-radiation. Indeed, geometrically, these two views are required to reconstruct the spine in 3D. However, under the assumption of strong physiological patterns between the PA and LAT views of the spinal curve, one of these X-rays may be redundant for some or all patients. The purpose of this study was to seek this a priori assumption.

To this end, a database consisting of three hundred and sixty-nine spinal reconstructions from distinct patients was used. Two powerful geometric modeling approaches were exploited: functional data analysis and minimum noise fractions. These resulted in five comprehensive, uncorrelated and noise-insensitive features in each plane. Simple linear regression yielded no relation that was statistically significant (p< 0.05) and genereralizable to a set of previously unseen samples. Therefore, nonlinear relational modeling was attempted using support vector regression, a recent advance in machine learning theory. This tool was incapable of identifying a robust regression, suggesting that the PA and LAT views are mathematically independent. Thus, this study highlights the necessity of two biplanar X-rays to evaluate scoliotic deformities and fully characterize spinal shape. Further, this study supports the practical insufficiency observed by clinical staff with respect to current 2D scoliosis classifications that has resulted in current efforts to propose 3D classification schemes.

Précis: Gravity Line (GL) measurement by forceplate offers key information on standing balance. In this study x-ray measurements and GL offsets were calculated in two adult: volunteer controls, sagittal plane deformity patients. The deformity group revealed significant pelvic retroversion and posterior sacral displacement regarding GL and heels. However, GL-heel and GL-femoral head offsets were similar indicating that sagittal plane deformity may induce posterior pelvic translation and retroversion in order to maintain an inherent ideal/fixed GL-heel relationship. Introduction: Sagittal spinal imbalance in the adult remains poorly understood and challenging. Limitations of radiographic analysis have lead researchers to apply forceplate technology to enhance the study of spinal balance through evaluation of the gravity line (GL). The aim of this study was to investigate differences between asymptomatic adults and patients with sagittal spinal deformities, with a hypothesis that imbalance would lead to changes in the GL – spinal relationship. Material and Method: This prospective study included 44 asymptomatic subjects (mean 57yo) and 40 patients with sagittal deformities (mean 65yo, inclusion criteria: L1-S1 lordosis< 258, Pelvic Tilt> 208, C7 plumbline> 5 cm). Coronal plane deformities were excluded. Full-length free-standing sagittal radiographs were obtained with simultaneous acquisition of the GL and heel position (by forceplate). Spino-pelvic radiographic parameters were calculated and distances (offsets) from the GL analysed. Group differences were evaluated by independent sample t-tests. Results: Groups did not differ in age, thoracic kyphosis, offsets from femoral heads to heels, femoral heads to GL, and GL to heels. As per inclusion criteria the sagittal deformity group had greater mean C7 plumbline (8cm vs 0cm), increased pelvic tilt (27° vs 13°) and loss of lordosis (46° vs 58°). The sagittal deformity group also had greater pelvic incidence (60° vs 51°), anterior trunk inclination (−3° vs −11°), S1 displacement toward the heels (distance decreased, 87 vs. 46mm). All differences p< 0.001. Discussion: The sagittal spinal deformity group revealed marked differences; the sacrum has a more posterior position in relation to the GL and heels. However, the GL to femoral head offset was not markedly influenced. The additional finding of no change in the GL to heel offset and rather fixed GL-femoral head offset appears to indicate that sagittal spinal deformity induces a posterior sacral translation and pelvic retroversion in order to maintain a fixed GL-heel relationship

Aims. Temporary epiphysiodesis (ED) is commonly applied in children and adolescents to treat leg length discrepancies (LLDs) and tall stature. Traditional Blount staples or modern two-hole plates are used in clinical practice. However, they require accurate planning, precise surgical techniques, and attentive follow-up to achieve the desired outcome without complications. This study reports the results of ED using a novel rigid staple (RigidTack) incorporating safety, as well as technical and procedural success according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework. Methods. A cohort of 56 patients, including 45 unilateral EDs for LLD and 11 bilateral EDs for tall stature, were prospectively analyzed. ED was performed with 222 rigid staples with a mean follow-up of 24.4 months (8 to 49). Patients with a predicted LLD of ≥ 2 cm at skeletal maturity were included. Mean age at surgery was 12.1 years (8 to 14). Correction and complication rates including implant-associated problems, and secondary deformities as well as perioperative parameters, were recorded (IDEAL stage 2a). These results were compared to historical cohorts treated for correction of LLD with two-hole plates or Blount staples. Results. The mean LLD was reduced from 25.2 mm (15 to 45) before surgery to 9.3 mm (6 to 25) at skeletal maturity. Implant-associated complications occurred in 4/56 treatments (7%), and secondary frontal plane deformities were detected in 5/45 legs (11%) of the LLD cohort. Including tall stature patients, the rate increased to 12/67 legs (18%). Sagittal plane deformities were observed during 1/45 LLD treatments (2%). Compared to two-hole plates and Blount staples, similar correction rates were observed in all devices. Lower rates of frontal and sagittal plane deformities were observed using rigid staples. Conclusion. Treatment of LLD using novel rigid staples appears a feasible and promising strategy. Secondary frontal and sagittal plane deformities remain a potential complication, although the rate seems to be lower in patients treated with rigid staples. Further comparative studies are needed to investigate this issue. Cite this article: Bone Joint J 2021;103-B(8):1428–1437

To determine extent of correction in spinal osteotomy for fixed sagittal plane deformity. Radiographic retrospective cohort analysis using standardised standing whole spine radiographs. Level III evidence. 24 patients (14 females/10 males, av. 53.6 yrs) with sagittal plane deformity due to either ankylosing spondylitis (4), idiopathic (12), congenital (1), tumour (2), infectious (1), or posttraumatic (4) aetiologies. Max. 4 yrs follow up. Sagittal balance, lumbar lordosis correction, osteotomy angle, pelvic indices. Chevron (3), pedicle subtraction (17), and vertebral column resection (4) osteotomies were performed with the majority at L3 (9) and L2 (8). The C7-S1 sagittal vertical axis demonstrated a preoperative decompensation averaging 12.0 cm (range -7 to 37) with 55% of patients achieving normal sagittal balance postoperatively. Lumbar lordosis increased from 28.9° (range -28 to 63) to 48.9° (range 12 to 69) (22.3° av. correction). L3 osteotomy angle was largest, average 31° (range, 16 to 47). There were 11 complications comprising; major (1) and minor (1) neurological, junctional kyphosis (3), metalwork problems (2), dural tear (2) and infection (2). Four patients required additional surgery at latest follow-up. Technical outcome was good 11(50%), fair 8(36%), poor 3(14%). Spinal osteotomy is a very effective technique to correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio before undertaking what is a major reconstructive procedure. Most patients are satisfied, particularly when sagittal balance is achieved

To evaluate the correction of complex congenital deformities of the lower limb by six axes deformity analyses and computer assisted correction using the Taylor TM Spatial Frame (TSF), from 1998 to 2000, the authors performed corrections of multiple congenital deformities in 24 lower limbs in 18 patients. There were 9 males and 9 females. There were a total of 29 bone segments, (8 femurs, 21 tibiae) in the 24 lower limbs that were corrected with application of the TSF. Our series included the following diagnoses and deformities: unknown skeletal dysplasia (2), achondroplasia (3), pseudoa-chondroplasia (1), multiple epiphyseal dysplasia (2), spondyloepiphyseal dysplasia (2), fibular hemimelia (3) tibia hemimelia (1), hypophosphatemic rickets (3), and posteromedial bowed tibia (1). The mean age of the patients was 15.4 years (range 0.5 to 35 years). The mean frame time until correction was 20.1 weeks (range 9 to 49 weeks). The mean follow up was 2.4 years (range 2 to 3.4 years). The apex of the deformity was directed posteromedial in 7, anterolateral in 6, medial in 5 and anteromedial in 5 patients. The mean coronal and sagittal plane deformities were 14.60 (range −230 to 400) and 70 (range, −400 to 280), respectively. The average magnitude of the deformity was 21.70 (range 90 to 470), and the plane of the deformity to the coronal plane was −23.30 (range −800 to 400). Eight patients had a mean lower extremity shortening of 12.3 mm (range 5 to 50 mm). One patient had 15° of internal rotation. With application of the TSF and the principles of distraction osteogenesis, we were able to reduce the coronal and sagittal plane deformities to 3.10 and 1.40 respectively. The overall mean magnitude of the deformity was decreased to 3.40. Shortening was corrected to an average of 3 mm. We experienced only 4 complications in the 24 limbs (16.7%). Complications in this patient group included one female patient with hypophosphatemic rickets who had residual deformity with significant lateral mechanical axis deviation due to inadequate translation. In addition, there were two superficial pin tract infections and one delayed union. Computer-assisted six axes deformity planning and TaylorTM Spatial Frame application effectively and safely correct complex congenital and developmental limb deformities and offer significant advantages over the well-established Ilizarov technique

To describe a staged surgical technique to correct significant progressive sagittal malalignment, without the need for 3-column osteotomy, in patients with prior long thoracolumbar instrumentation for scoliosis and to evaluate the radiographic and clinical outcome from this surgical strategy. A small cohort study (n=6) of patients with significant sagittal malalignment following extensive thoracolumbar instrumented fusions for scoliotic deformity. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores. 3 patients had 2-stage anterior release and instrumented fusion followed by a posterior instrumented fusion 3 patients with a large sagittal plane deformity had a 3-stage surgical technique. All patients achieved an excellent correction of sagittal alignment, with no surgical complications and excellent health related quality of life (HRQOL) outcome measures at follow-up. There was no symptomatic non-unions or implant failures including rod breakages. We present a safe and effective surgical strategy to treat the complex problem of progressive sagittal malalignment in the previously instrumented adult deformity patient, avoiding the need for 3-column osteotomies in the lumbar spine

Purpose: To evaluate the efficacy of intramedullary nailing for the treatment of the fractures of the proximal quarter of the tibia with special respect on the reduction accuracy. Patients: This is a retrospective study which was conducted in our institution between October 2004 and March 2007. 30 extrarticular proximal tibia fractures were treated with intramedullary nailing. The mean age of the patients was 27 years (19 to 47). Seven fractures (23%) were open – Gustillo grade I-, twelve fractures (12%) had segmental comminution and six (6%) were bifocal fractures. Static intramedullary nailing was chosen in all cases. Distal dynamization was performed routinely in all fractures at an average of 7 weeks (6 to 12 weeks) after the primary operation. Union of the fracture and the accuracy of the reduction were assessed clinically and radiologically. Results: The average follow up was 16 months (9 to 22). All fractures united without additional procedures. Acceptable alignment was obtained in 28 of 30 fractures (93%). Postoperative angulation was satisfactory (average frontal and sagittal plane deformity of less than 2 degrees) in 26 fractures (87%). Two patients had frontal plane deformities (one 4° varus and one valgus 7°) and two patients had a saaggital plane deformities (7° procuvartum). No significant complication was recorded. Conclusions: The proximity of the upper tibia fracture to the knee makes the treatment of these fractures more challenging. Closed intramedullary nailing combined with special reduction technique is a safe and effective method of managing of the proximal tibia fractures

Neuromuscular scoliosis is a difficult condition to treat. Curve severity, secondary pelvic obliquity and poor respiratory function can make operative treatment and post operative care challenging. The benefits to the child in terms of improved sitting position and trunk posture can be considerable. We present a large consecutive series of patients with neuromuscular scoliosis treated surgically at our institution. The aim of this work was to study the clinical and radiographic impact of surgery for neuromuscular scoliosis. Data was gathered from patient records and radiographs for all cases of neuromuscular scoliosis treated surgically between April 2002 and Feb 2005. 52 cases were identified. They fell into 2 surgical groups: single stage posterior correction and two stage anterior and posterior correction. All posterior instrumentation was transpedicular. Complications, length of stay, and change in severity of sagittal and coronal plane deformity were recorded. Average pre-operative Cobb angle was 85°. There were 16 patients with additional sagittal plane deformity. Average percentage improvement of Cobb angle was 59%. The correction was better in two stage procedures. Pelvic obliquity was improved in those who were obligatory sitters. Fusion rate was 83% for those followed up more than 1 year. ITU stay was longer in single stage procedures. Complication rate was 58%. We have shown that with appropriate patient selection the correction of neuromuscular scoliosis can achieve good results with high fusion rates. Two stage correction confers correctional advantage on those who have sufficient respiratory reserve to tolerate it

The exact mechanism of remodelling of burst fractures is uncertain. We studied the relationship between epidural pressures and remodelling. In a prospective, ethically-approved study in 34 patients with burst fractures at the levels T12 to L4, epidural pressure was measured. Four patients were lost to follow-up. In 18 patients the fractures were due to a fall and in 12 to motor vehicle accidents. The mean age was 37 years. All patients were neurologically intact and treated non-operatively. Plain radiographs and CT scans measuring the sagittal plane deformity and mid-sagittal diameter respectively were obtained. Using a fluoroscopically-guided radio-opaque catheter placed at the normal interspace below the burst fracture, epidural pressure was measured at 2 weeks and at 12 months after the injury. The mean canal compromise shown on CT scan at the time of injury and at follow-up was 43% (32% to 83%) and 28% (44% to 100%) respectively. CT volumetric measurements showed a mean improvement of 10% at follow-up (7% to 16%). The epidural pressures recorded at the time of injury and at follow-up were 16.65 mmHg (2.5 to 30.85) and 5.85mmHg (0 to 10.17) respectively. At 1-year follow-up, the Cobbs angle had progressed by a mean of 2.69° (10° to 60°). The retropulsed burst fracture fragments cause localised constriction of the spinal cord (Venturi effect). Epidural pressure, raised to maintain a constant flow rate across this constriction, has a mechanical effect on the retropulsed fragments, thus promoting remodelling

Introduction Anterior correction of cervical kyphotic deformity in traumatic and degenerative spine is a well established technique. The application of an anterior cervical plate is widely accepted, particularly in multilevel discectomies. However the placement of the cervical plate flush against the cortical margins of the spine remains challenging particularly when there is an underlying subluxation. Contouring the cervical plate with a plate bender is suggested. Others have described the use of an adjustable depth tap (. 1. ). We describe the technique of utilizing the Trimline™ Vertebral Body Distractor in correction of the sagittal plane deformity and maximizing the contact surface between plate and fusion construct. Methods The technique is described in a case each of cervical trauma and degenerative cervical spondylolisthesis. The Trimline™ distractor which utilizes cannulated legs, threaded pins and nuts is used as a direct reduction tool correcting the cervical lordosis, before discectomy. The distractor pins are placed bilaterally in the vertebral bodies at the level of the deformity, and at the level above and below. The distractors are applied bilaterally and reduction undertaken. The distraction device is locked in place whilst the discectomy is performed. Distraction device is removed once graft is in-situ and cervical plate is applied in routine manner. Results Bilateral application of pins and distraction device provides better reduction strength, and better distributes distraction forces minimizing further fracture. This optimizes correction of cervical kyphotic deformity and prevents obstruction of operative view for discectomy and fusion. Discussion Restoration of the normal cervical lordotic curve in traumatic and degenerative spinal disease remains challenging. Flush application of the anterior cervical plate to the anterior border of the spine and graft enhances spinal fusion, stability and alignment. The use of bilateral vertebral body distractor devices to reduce cervical subluxation and enhance implant-bone interface is a novel technique which is safe and not time consuming

Posterior segmental fixation of the cervical spine facilitates fixation in sub-optimal bone, abnormal anatomy, and complex deformity. Compared to lateral mass plates a screw rod construct provides a stable construct in osteoporotic bone or in cases where the lateral masses are fractured or missing. To investigate whether a posterior cervical screw- rod construct is an effective, stable and safe means of posterior cervical fixation. Retrospective evaluation of consecutive patients undergoing a posterior cervical stabilization with a screw- rod construct with clinical and radiographic evaluation. Clinical variables included age, gender, neurologic status, surgical indication, number of levels stabilized, and number of screws. Note was made as to whether a laminectomy was performed and concomitant anterior surgery. Clinical and radiographic assessments were carried out immediately after surgery and at six weeks, three, six, twelve months and annually after surgery. Eighty-three patients had five hundred and seventy-three screws placed from October 1998 to December 2003. Mean patient age was fifty-seven. Mean follow-up was twenty-three months, (one to sixty months). The underlying diagnoses were inflammatory arthritis thirty-three, spondylotic myelopathy twenty-nine and trauma in twenty-one patients. Forty-four patients (53% had motor deficit, forty-seven patients (57%) had sensory deficit. Fixation was carried out over an average of five levels (range – two to eight). Mean number of screws per construct was seven (range – four to fourteen). The instrumentation was successfully implanted in all despite lateral mass deficiencies (fracture, poor bone) and coronal and sagittal plane deformities. Late occipital fixation failure was encountered in one patient. There was no loss of alignment or surgical correction on follow-up radiographs. A posterior screw-rod system allows for treatment of traumatic and degenerative and inflammatory conditions. Crossing the occipitocervical or cervicothoracic junctions is easily afforded. We have had excellent success without complications from screw placement or pseudoarthrosis

Purpose: To describe the role of osteotomies in rigid spinal deformities. Patients and Methods: One hundred fifty six patients with spinal deformities undergoing surgery between March 1998 and August 2005 were identified from our spine registry. Our study cohort included 23 cases where osteotomies were performed for correction. Corrective osteotomies were one of: 1) wedge osteotomy convex based; 2) wedge osteotomy dorsally based; 3) complex wedge or eggshell osteotomy for combined frontal and sagittal plane deformity. Patient’s demographics, type of deformity, underlying conditions, operative results, complications, and need for secondary procedures were documented. Results: Twenty three patients (15%) with rigid curves underwent osteotomies as part of their corrective surgery. Mean age in this cohort was 11.3 years (2–26), 35% were males, 65% females. In 17 of the patients the main deformity was scoliosis, in 5 – kyphosis and in – 1 lordosis. MMC was the leading underlying condition in 4 cases, followed by VACTER syndrome (2), congenital myopathy (2), arthrogryposis and pterygium (2), Neuro-blastoma (1) and other congenital conditions. Operative results were satisfactory in terms of cosmetics, alignment and function. In 3 cases (13%) complications were encountered, with 2 infections requiring debridement, (one requiring hardware removal) and 1 Neurofibromatosis patient undergoing her 8. th. surgical procedure, developing an intraoperative partial neurological injury with nearly full recovery. Conclusions: Osteotomies are an important part of surgery in rigid spinal deformities. These deformities occur frequently in syndromatic children making peri-operative treatment more complex. Osteotomies facilitate better outcome in terms of correction, sagittal and coronal balance and cosmetics. These procedures are highly demanding technically. However, it is our opinion that adequate correction of rigid deformity with the benefit of spinal column shortening by way of osteotomy, is protective from significant neurological traction injuries that otherwise may occur

Anterior instrumentation is an established method of correcting King I adolescent idiopathic scoliosis. Posterior segmental pedicle screw instrumentation, with its more powerful corrective force over hooks, could offer significant advantages. The purpose of our study is to compare the results of anterior instrumentation versus segmental pedicle screw instrumentation in adolescent idiopathic thoracolumbar scoliosis. A retrospective analysis was conducted on 36 consecutive female patients with adolescent idiopathic thoracolumbar scoliosis who had surgery from December 1997. All had a minimum of two year follow-up. Eleven patients had posterior surgery performed on them. Mean age at surgery was similar between both groups. Length of surgery was significantly shorter in the posterior group (189 minutes versus 272 minutes). Length of hospital stay was shorter in the posterior group (6.2 days versus eight days). Estimated blood loss, duration of analgesia, and ICU stay did not differ significantly between the two groups. No complications were encountered in both groups at latest follow-up. The magnitudes and flexibility of the thoracolumbar curves did not differ significantly between the two groups. The number of levels in the major curve was also similar between the groups. Fusion levels were shorter in the anterior group (mean 4.1 versus 5.0). The percentage correction of scoliosis was similar between the two groups at all stages of follow-up, being 74% at one week post-surgery, 70% at six months post-surgery, 68% at one year post-surgery and latest follow-up in the anterior group; and 71% at one week post-surgery, 67% at six months post-surgery, 68% at one year post-surgery, and 67% at latest follow-up in the posterior group. Thoracolumbar sagittal alignment at T11 to L2 was maintained for both groups throughout the follow-up period. The incidence of proximal junctional kyphosis was higher in the posterior group (p < 0.01). In conclusion, surgical correction of both the frontal and sagittal plane deformity are comparable to anterior instrumentation. Shorter length of surgery and hospital stay are the potential benefits of posterior surgery. Posterior segmental pedicle screw instrumentation offers significant advantage, and is a viable alternative to standard anterior instrumentation in idiopathic thoracolumbar scoliosis

Introduction: The anatomy and biomechanics of the thoracic spine is different from the cervical and lumbar spine particularly due to the ribs and sternum which contribute to stability and controlling motion. The role of the sternum and costosternal articulation in the biomechanics of thoracic fracture or deformity correction has not been well studied. The effects of releasing each of these structures, whether alone or in combination, is potentially relevant in the surgical correction of thoracic deformities such as severe kyphosis. The purpose of this study was to investigate the relative effects of releasing the intervertebral disc, the costosternal joint, the sternum, and the facet joints on sagittal thoracic motion and the consequences of altering the sequence of the releases. Methods: Eighteen human torsos were tested in three experiments (A, B, and C) to determine the effect on sagittal motion due to three different sequences of three surgical releases. In Experiment A the release sequence was back to front: Total facetectomy, then radical discectomy, then sternal osteotomy plus costosternal release. In experiment B the release sequence was front to back: Sternal osteotomy plus costosternal release, then radical discectomy, then total facetectomy. In Experiment C, it was disc first: Radical discectomy, then sternal osteotomy plus costosternal release, then total facetectomy. The different sequences allowed separate analysis of each component and the synergistic patterns. In each of the three experiments, the torso was flexed then extended each time by an applied force (25 N) before and after each release. The extent of both angular flex-ion and angular extension were compared to the intact condition, and after each release. Results: Radical discectomy provided the greatest increase (P< 0.05) in range of motion (ROM) as compared to the other two single releases, no matter what the sequence. For paired release combination, the radical discectomy and sternal osteotomy plus costosternal release (as in Experiments B and C) provided a significant (P< 0.05) increase in sagittal ROM compared to the combination of radical discectomy and total facetectomy (Experiment A). In Experiment A, if sternal osteotomy and costosternal release (the final release) had not been carried out, then 42% of the sagittal motion would have been lost compared to the 27% related to the total facetectomy (Experiment B). All of the releases allowed more extension than flexion; the only exception was facetectomy when carried out first as in Experiment A. Conclusions: To increase sagittal thoracic range of motion radical discectomy provided the greatest increase in both extension and total ROM as compared to total facetectomy or sternal osteotomy plus costosternal release, no matter what the sequence. For two releases, the combination of radical discectomy and sternal osteotomy plus costosternal release provided the greatest increase in both extension and total ROM. Total facetectomy was the least useful release. These data have relevance for surgical strategies to correct severe thoracic sagittal plane deformity. The sequence of combined release has important clinical implications

Background: Surgical treatment of spinal deformities is complex and is performed by a limited number of spine surgeons. To obtain adequate radiological and clinical correction, a large amount of clinical experience is required when planning corrective surgery because of the enormous amount of patient related variables, and the many surgical techniques (e.g. rod rotation vs translation, pedicle screws vs hooks, anterior vs posterior). The widely used classification systems (King and Lenke) are useful for documentation of the deformities. Unfortunately explicit guidelines for surgery are not clear. A multi-centre database with pre and postoperative patient data including photographic images and x-rays will be very useful in decision making. It will allow surgeons to find similar cases in the database that will help them in their decision making for surgical planning and execution. Furthermore it will provide extensive data to perform outcome studies, and to develop general treatment guidelines. Surgery for spinal deformities will become more evidence based and less dependent on the individual surgeons judgement. Methods: A modern web-based database system, Scolisoft was developed for documenting patient data and curve characteristics. The system contains patient data (demographics etc), radiological data (AP, Lat, bending films), classification of curve patterns according to the often-used classification systems and information about the surgical procedure. It includes pre and postoperative radiological data and clinical photographs. The patient data can also be stored and printed as a PDF-file, so that it can be used as a patient chart and for patient information purposes. Scolisoft allows the user to select patients based on all the individual characteristics, e.g. curve classification. For pre-operative planning of a specific deformity, a cohort of patients with the same deformity (patient demographics, curve pattern, bending films etc) can be selected and the postoperative results viewed. With the same selection tool, cohorts of patients can be selected for outcome studies. Furthermore Scolisoft provides the possibility of discussing difficult cases with other spine surgeons using the system. Finally, complications are registered according to the existing Scoliosis Research Society complication registry system. Experiences: Data of more than 200 patients have been entered into the former PC application system. The current web based system has 60 cases that have been entered during its trial phase. Most cases have been adolescent or adult idiopathic scoliosis. Forty two surgeons have used the software and eight surgeons have participated in entering cases. The web-based version has shown to be very user friendly. Submitting the radiological and clinical images is easy (but takes some time). All data input is possible by a simple click of the mouse. Therefore it is relatively easy to learn. The system already has the possibility for documenting other spine pathology such as sagittal plane deformities, fractures and spondylolisthesis. Conclusion: Scolisoft is a powerful, user-friendly web-based registry for spinal deformities. It is a very useful tool in planning spinal deformity surgery and research. In this time of evidence-based medicine, it is time to take the planning of scoliosis surgery out of the realm of myth, and this database is a strong step in that direction

Introduction The management of severe pain associated with progressive adult scoliosis remains a challenging problem. Radicular symptoms are often caused by bony foraminal stenosis and significant global and segmental imbalance may exist in both the sagittal and coronal planes. The patients are often elderly and have intercurrent medical conditions. The use of disc space distraction, pedicle screw instrumentation and posterior lumbar interbody fusion (PLIF) with Insert and Rotate prostheses has been shown to be effective in the correction of sagittal plane deformity (. 1. ). The current study examines the safety, clinical and radiological efficacy of this technique in the management of adult multilevel scoliosis. Methods A prospective single cohort observational study of 15 consecutive patients with a degenerative scoliosis of 20 degrees or greater managed using an Insert and Rotate PLIF technique between October 2000 and July 2003. The minimum follow-up was 2 years. Clinical outcome measures included VAS pain score, SF-12, LBOS and Patient Satisfaction survey. Pre- and post-operative measures of radiological sagittal and coronal deformity were manually obtained. Wilcoxon signed-ranks test and Spearman’s non parametric test for correlation were used with significance set at 0.05. Results The median age was 72 years (range: 56–80). Male: female ratio was 6:9. PLIF was carried out at 2 levels in 7 patients, 3–5 levels in 8 patients. Median blood loss was 1100mls for 2 level patients and 2550mls for 3–5 level patients. Operating time was 345mins and 545mins in the 2 and 3–5 level cases respectively. Median pre-operative scoliosis was 31degrees (range: 20–65) and post-operatively measured 14degrees (range: 0–30, p=0.001). Median pre-op VAS of 53 reduced to 20 (p=0.003). LBOS improved from 24 to 37 (p=0.004). A correlation was found between the amount of pre-operative coronal plane deformity and the post-operative VAS (r=0.6, p=0.003). 13 of the 15 patients considered the procedure was worthwhile and that they would have it again under similar circumstances. Early post-operative complications included electrolyte/fluid disturbance in 2 patients, 2 cardiac arrhythmias, one DVT/PE and 2 returns to the O.R. for pain caused by a misplaced pedicle screw or bone graft. One patient developed a progressive scoliosis above the fusion and one a pathological wedge compression fracture. 4 patients required late surgery including 2 who had been fused down to L5 and required extension of their fusion to the sacrum for pain associated with an L5/S1 foraminal stenosis and one who developed a painful non-union. Discussion PLIF with an Insert and Rotate technique following disc space distraction for severe and progressive adult scoliotic deformity is technically difficult and can be associated with significant peri-operative morbidity. Nevertheless, the reported satisfaction rates by the patients in this small series are encouraging and the procedure appears to have achieved substantial correction of global and segmental deformity in both the coronal and sagittal planes. Whether this will be beneficial in the long term requires further study

Aims

The first metatarsal pronation deformity of hallux valgus feet is widely recognized. However, its assessment relies mostly on 3D standing CT scans. Two radiological signs, the first metatarsal round head (RH) and inferior tuberosity position (ITP), have been described, but are seldom used to aid in diagnosis. This study was undertaken to determine the reliability and validity of these two signs for a more convenient and affordable preoperative assessment and postoperative comparison.

Aims

Accurate skeletal age and final adult height prediction methods in paediatric orthopaedics are crucial for determining optimal timing of growth-guiding interventions and minimizing complications in treatments of various conditions. This study aimed to evaluate the accuracy of final adult height predictions using the central peak height (CPH) method with long leg X-rays and four different multiplier tables.