Purpose: A lack of consensus regarding the radiologic criteria to diagnose spinal non-union limits inferences from clinical research. This systematic review aimed to examine the spectrum of radiologic investigations used to assess lumbar spinal fusion and the definitions of successful spine union used in the spine literature.

Method: We comprehensively searched three electronic databases from 1950 to 2009 (MEDLINE, Embase and the Cochrane Central Register of Controlled Trials) for clinical studies involving posterolateral fusion of the lumbar spine. English-language studies including adult patients and reporting a definition of successful fusion were included. Studies examining the reliability and validity of radiologic investigations were also identified. Key measures included

radiologic investigations,

Results: Among 1165 potentially eligible studies, 91 met our inclusion criteria. Of the studies 78% (n = 71) used plain radiographs to diagnose non-union, 4% (n = 4) used CT scans and 18% (n = 16) used both. Fifty-one studies used both static (xray or CT) and dynamic (flexion-extension xray) images, 35 used only static images and five used only dynamic radiographs. In total, we identified fifty-two different radiographic definitions of successful fusion. More than half of the studies (n = 50, 55%) failed to provide a reference for the definition used. The most common definition of fusion (7 studies) used static radiographs and defined fusion as continuous intertransverse bony bridging with this quality of fusion at all intended levels. Seven studies evaluated reliability of xray criteria but no studies provided complete validation of the definitions. Only 3 studies provided some validation and reliability estimates of thin-slice CT scanning in diagnosing spinal non-union. Significant variability in reliability, sensitivity and specificity exists for all radiologic investigations in the diagnosis of spinal non-union.

Conclusion: The radiologic investigations and definitions of successful posterolateral fusion used in the spine literature vary substantially. Choice of radiologic criteria should be based upon reliability and validity testing. Studies using fusion criteria that have not been shown to be reliable or valid should be interpreted with caution.

Purpose: A significant proportion of spine fusion operations may result in a non-union. Electromagnetic stimulation is a non-invasive method used to promote spine fusion although the efficacy of its use in this regard remains uncertain. The purpose of this systematic review and meta-analysis is to evaluate the effect of electromagnetic stimulation on spine fusion.

Method: Five electronic databases (MEDLINE, Embase, CINAHL, PubMed and the Cochrane Central Register of Controlled Trials) were searched from database inception to July 2009 for randomized controlled trials of electrical stimulation and spinal fusion. In addition, we performed a hand search of four relevant journals from January 2000 to July 2009, the on-line proceedings of the North American Spine Society Annual Meeting from 2002 to 2008 and bibliographies of eligible trials. Trials randomizing adult patients undergoing any type of spine fusion to active treatment with direct current, capacitance coupled or pulsed electromagnetic field stimulation or placebo and reporting on fusion rates were included. Two independent reviewers extracted data regarding clinical outcomes, stimulation device, treatment regimen and methodologic quality.

Results: Of 1650 studies identified seven met the inclusion criteria. Electromagnetic stimulation in lumbar spine fusion was evaluated in five studies and two addressed cervical spine fusions. The use of electromagnetic stimulation in lumbar spine fusion resulted in a significant decrease in the risk of non-union (relative risk 0.60, 95% confidence interval 0.38 to 0.93, p = 0.02, I2 = 57%). The observed reduction in risk of nonunion with electromagnetic stimulation was not affected by smoking or the number of levels fused. Due to limited and conflicting trials, similar effects were not observed in the two studies evaluating cervical spine fusion rates (relative risk 0.85, 95% confidence interval 0.29 to 2.53, p = 0.77, I2 = 56%).

Conclusion: Pooled analysis shows a 40% reduction in the risk of non-union of lumbar spine fusions with the use of electromagnetic stimulation although a similar effect was not observed for fusions of the cervical spine. However, due to study heterogeneity the current indications for the use of electrical stimulation in spine fusion remain somewhat unclear.

Purpose: Identifying optimal treatment strategies in patients with traumatic foot and ankle injuries has been hampered by the variety of different measurement tools and lack of validation of generic and foot-specific functional measures. It remains plausible that the choice of functional outcome measure may influence our ability to accurately measure treatment effects. This prospective observational study aims to correlate the scores across six functional outcome measures in patients with traumatic foot and ankle injuries and to examine agreement of scores and patients’ subjective health status.

Method: Patients with traumatic foot or ankle injuries completed two generic, the SF-12 Health Survey and the Short Musculoskeletal Functional Assessment (SMFA), and four specific health outcome measures, the Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopedic Surgeons (AAOS) Foot and Ankle Questionnaire and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, at a single follow-up visit. Raw scores were calculated and used to assign patients to a categorical functional level (excellent, very good, good, fair or poor). Agreement between the assignments was assessed and Pearson correlation co-efficients were calculated for each pair of outcome scores. Statistical significance was determined using an α of 0.05.

Results: 52 patients (mean age 43.3 ± 16.8 years) were enrolled at a mean follow-up of 15.5 months. All correlations except for that between the AOFAS ankle-hindfoot scale and the mental component of the SF-12 were statistically significant. The strongest correlations were found between the SMFA, FFI, AAOS Foot and Ankle Questionnaire and the FAAM. Despite significant correlation between scores and patients’ subjective functional outcome, there was minimal agreement between assigned categorical functional levels.

Conclusion: The high correlations between scores on the generic and foot-specific functional measures suggest that it is likely unnecessary to use more than one instrument when examining functional outcome in patients with traumatic foot and ankle injuries. Generic tools also appear to function as well as specific scores in this population. However, assignment of patients to a categorical functional level based on raw outcome scores must be performed with caution as the results obtained may not accurately reflect functional outcome.