To compare preoperative and postoperative Health Related Quality of Life (HRQoL) scores in operated Adolescent Idiopathic Scoliosis (AIS) patients with and without concomitant isthmic spondylolisthesis. A retrospective study of a prospective cohort of 464 individuals undergoing AIS surgery between 2008 and 2018 was performed. All patients undergoing surgery for AIS with a minimum 2-year follow-up were included. We excluded patients with prior or concomitant surgery for spondylolisthesis. HRQoL scores were measured using the SRS-22 questionnaire. Comparisons were performed between AIS patients with vs. without concomitant spondylolisthesis treated non-surgically. AIS surgery was performed for 36 patients (15.2 ±2.5 y.o) with concomitant isthmic spondylolisthesis, and 428 patients (15.5 ±2.4 y.o) without concomitant spondylolisthesis. The two groups were similar in terms of age, sex, preoperative and postoperative Cobb angles. Preoperative and postoperative HRQoL scores were similar between the two groups. HRQoL improved significantly for all domains in both groups, except for pain in patients with spondylolisthesis. There was no need for surgical treatment of the spondylolisthesis and no slip progression during the follow-up duration after AIS surgery. Patients undergoing surgical treatment of AIS with non-surgical management of a concomitant isthmic spondylolisthesis can expect improvement in HRQoL scores, similar to that observed in patients without concomitant spondylolisthesis

Posterior lumber interbody fusion (PLIF) has the theoretical advantage of optimising foraminal decompression, improving sagittal alignment and providing a more consistent fusion mass in adult patients with isthmic spondylolisthesis (IS) compared to posterolateral fusion (PLF). Previous studies with only short-term follow-up have not shown a difference between fusion techniques. An observational cohort study was performed of a single surgeon's patients treating IS over a ten year period (52 patients), using either PLF (21 pts) or PLIF (31pts). Preoperative and 12-month data were collected prospectively, and long-term follow-up was by mailed questionnaire. Preoperative patient characteristics between the two groups were not significantly different. Average follow-up was 7 years, 10 months, and 81% of questionnaires were returned. Outcome measures were Roland Morris Disability Questionnaire (RMDQ), Low Back Outcome Score (LBOS), SF-12v2 and SF-6D R2. The SF-6D R2 is a “whole of health” measure. PLIF provided better short- and long-term results than PLF. The PLIF group had significantly better LBOS scores in the long term, and non-significantly better RMDQ scores in the long term. As measured by RMDQ Minimum Clinically Important Difference (MCID) short term set at 4, RMDQ MCID set at 8, the LBOS MCID set at 7.5 points and by SF-12v2 physical component score (PCS), PLIF patients performed better than PLF patients. When analysing single level fusions alone, the difference is more pronounced, with PCS, mental component scores and SF-6D R2 all being significantly better in the PLIF group rather than the PLF group. This paper strongly supports the use of PLIF to obtain equivalent or superior clinical outcomes when compared to PLF for spinal fusion for lumbar isthmic spondylolisthesis. The results of this study are the first to report to such long-term follow-up comparing these two procedures

7% of adolescent idiopathic scoliosis (AIS) patients also present with a pars defect. To date, there are no available data on the results of fusion ending proximal to a spondylolysis in the setting of AIS. The aim of this study was to analyze the outcomes of posterior spinal fusion (PSF) in this patient cohort, to investigate if maintaining the lytic segment unfused represents a safe option. Retrospective review of all patients who received PSF for AIS, presented with a spondylolysis or spondylolisthesis and had a min. 2-years follow-up. Demographic data, instrumented levels and preoperative radiographic data were collected. Mechanical complications, coronal or sagittal parameters, amount of slippage and pain levels were evaluated. Data from 22 patients were available (age 14.4 ± 2.5 years), 18 Lenke 1–2 and four Lenke 3–6. Five patients (24%) had an isthmic spondylolisthesis, all Meyerding I. The mean preoperative Cobb angle of the instrumented curves was 58 ± 13°. For 18 patients the lowest instrumented vertebra (LIV) was the last touched vertebra (LTV); for two LIV was distal to the LTV; for two, LIV was one level proximal to the LTV. The number of segments between the LIV and the lytic vertebra ranged from 1 to 6. At the last follow-up, no complications were observed. The residual curve below the instrumentation measured 8.5 ± 6.4°, the lordosis below the instrumented levels was 51.4 ± 13°. The magnitude of the isthmic spondylolisthesis remained constant for all included patients. Three patients reported minimal occasional low back pain. The LTV can be safely used as LIV when performing PSF for the management of AIS in patients with L5 spondylolysis

Introduction. In degenerative lumbar spine, it seems possible that foraminal stenosis is over-diagnosed as axial scanning is not performed in the plane of the exiting nerve root. We carried out a two-part study to determine the true incidence of foraminal stenosis. Patients and Methods. Initially we performed a retrospective analysis of radiology reports of conventional Magnetic Resonance Imaging in 100 cases of definite spinal stenosis to determine the incidence of reported ‘foraminal stenosis’. Subsiquently we performed a prospective study of MRI including fine slice T2 and T2 STIR coronal sequences in 100 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional axial and sagittal sequences with the coronal scans. Results. The retrospective analysis found that ‘foraminal stenosis’ was reported by radiologists in 46% using conventional axial and sagittal sequences. In the prospective study of 100 patients suspected of having stenosis, spinal stenosis was reported in 40; degenerative spondylolisthesis in 14; posterolateral disc herniation in 14; normal report in 13; far lateral disc herniation in 7; isthmic (lytic) spondylolisthesis in 6; and degenerative scoliosis in 6. Conventional sequences diagnosed lateral recess stenosis reliably, but also suggested foraminal stenosis in 43%. However, coronal sequences clearly showed no foraminal nerve compression at all. In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 10 of 14 cases. Coronal imaging again showed no foraminal stenosis. Excellent correlation was found in normal spines and in disc herniation. Foraminal nerve compression was confirmed by conventional and coronal imaging only in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation. Conclusion. The addition of coronal MRI proves that foraminal stenosis is over-diagnosed. True foraminal stenosis definitely exists in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation, but we question its existence in spinal stenosis and degenerative spondylolisthesis

Instability currently represents the most frequent cause for revision total knee replacement. Instability can be primary from the standpoint of inadequately performed collateral and/or posterior cruciate ligament balancing during primary total knee replacement or it may be secondary to malalignment secondary to loosening and settling of the implants which can develop later progressive instability. Revision surgery must take into consideration any component malalignment that may have primarily contributed to instability. Also, collateral ligament integrity may change following total knee replacement slightly after complete correction of a severe deformity that presents rarely as instability after several months. Care should be given to assessing collateral ligament integrity. This can be done during physical examination by manual or radiological stress testing to see if the mediolateral stress of the knee comes to a good endpoint. If there is no sense of a palpable endpoint, then the surgeon must assume structural incompetency of the medial or lateral collateral ligament or both. In posterior cruciate ligament retaining knees, anteroposterior instability must be assessed. For instability, most revisions will require a posterior cruciate substituting design or a constrained unlinked condylar design. Occasionally, a posterior cruciate ligament preserving design can be used in situations where the bone-stock is well preserved and the posterior cruciate ligament shows excellent structural integrity. However, if the patient displays considerable global instability, a linked, rotating platform constrained total knee replacement design will be required. Recent data has shown that the rotating hinges work quite well in restoring stability to the knee with maintenance of the clinical results over a considerable length of time. Revision can range from simple polyethylene insert exchange to a thicker dimension, isolated component revision or complete revision of both femoral and tibial devices. During revision surgery, laminar spreaders may be utilised to assess the flexion and extension spaces after the tibial platform is restored. If a symmetric flexion and extension space is achieved, then the collateral ligaments are intact. Depending on the remaining existing bone stock, a posterior stabilised or constrained condylar unlinked prosthesis may be used for implantation. In cases with considerable asymmetry or a large flexion/extension mismatch, a rotating hinge design should be utilised. Intramedullary stems should be utilised in most cases when bone integrity is suspect and insufficient. Currently, stems should be placed cementless to permit easier future revision. Cementing the stems is only recommended if there is lack of intramedullary isthmic support or there is a hip prosthetic stem that prohibits a stem from engaging the isthmic cortex. However, it should be realised that later revision of the fully cemented revision implant may be quite difficult. Infection should be ruled out by aspiration off of antibiotics prior to any revision operation, especially if loosening of the components represents the cause of instability early. The surgeon should attempt to restore collateral ligament balance whenever possible as this yields the best clinical result

Instability currently represents the most frequent cause for revision total knee replacement. Instability can be primary from the standpoint of inadequately performed collateral and/or posterior cruciate ligament balancing during primary total knee replacement or it may be secondary to malalignment secondary to loosening which can develop later progressive instability. Revision surgery must take into consideration any component malalignment that may have primarily contributed to instability. Care should be given to assessing collateral ligament integrity. This can be done during physical examination by manual or radiological stress testing to see if the mediolateral stress of the knee comes to a good endpoint. If there is no sense of a palpable endpoint, then the surgeon must assume structural incompetency of the medial or lateral collateral ligament or both. In posterior cruciate ligament retaining knees, anteroposterior instability must be assessed. For instability, most revisions will require a posterior cruciate substituting design or a constrained unlinked condylar design that, although sometimes a posterior cruciate ligament preserving design can be used in situations where the bone-stock is well preserved. However, if the patient displays considerable global instability, a linked, rotating platform constrained total knee replacement design will be required. Recent data has shown that the rotating hinges work quite well in restoring stability to the knee with maintenance of the clinical results over a considerable length of time. During revision surgery, laminar spreaders may be utilised to assess the flexion and extension spaces after the tibial platform is restored. If a symmetric flexion and extension space is achieved, then the collateral ligaments are intact. Depending on the remaining existing bone stock, a posterior stabilised or constrained condylar unlinked prosthesis may be used for implantation. In cases with considerable asymmetry or a large flexion/extension mismatch, then a rotating hinge design should be utilised. Intramedullary stems should be utilised in most cases when bone integrity is suspect and insufficient. Currently, stems should be placed cementless to permit easier future revision. Cementing the stems is only recommended if there is lack of intramedullary isthmic support or there is a hip prosthetic stem that prohibits a stem from engaging the isthmic cortex. However, it should be realised that later revision of the fully cemented revision implant may be quite difficult. Infection should be ruled out by aspiration off of antibiotics prior to any revision operation, especially if loosening of the components represents the cause of instability. The surgeon should attempt to restore collateral ligament balance whenever possible as this yields the best clinical result

Revision of the failed femoral component of a total hip arthroplasty can be challenging. Multiple reconstructive options are available and the operation itself can be particularly difficult and thus meticulous pre-operative planning is required to pick the right “tool” for the case at hand. The Paprosky Femoral Classification is useful as it helps the surgeon determine what bone stock is available for fixation and hence, which type of femoral reconstruction is most appropriate. Monoblock, fully porous coated diaphyseal engaging femoral components are the “work-horse” of femoral revision and are used in my practice for approximately 70% of reconstructions. These stems are associated with problems, in the following situations: The canal diameter is greater than 18mm; There is less than 4cm available for distal fixation in the isthmus; There is proximal femoral remodeling into retroversion. When the limits of monoblock stems are exceeded, we use modular tapered femoral components. These stems in general allow for better fixation in short isthmic segments and the bi-body nature allows for independent positioning of the proximal body, which is particularly helpful when the femur has remodeled into retroversion

Instability currently represents the most frequent cause for revision total knee replacement. Instability can be primary from the standpoint of inadequately performed collateral and/or posterior cruciate ligament balancing during primary total knee replacement or it may be secondary to malalignment secondary to loosening which can develop later progressive instability. Revision surgery must take into consideration any component malalignment that may have primarily contributed to instability. Care should be given to assessing collateral ligament integrity. This can be done during physical examination by radiological stress testing to see if the mediolateral stress of the knee comes to a good endpoint. If there is no sense of a palpable endpoint, then the surgeon must assume structural incompetency of the medial or lateral collateral ligament or both. In posterior cruciate retaining knees, anteroposterior instability must be assessed. For instability, must revisions will require a posterior cruciate substituting design or a constrained condylar design that are unlinked. However, if the patient displays considerable global instability, a linked, rotating platform constrained total knee replacement design will be required. Recent data has shown that the rotating hinges work quite well in restoring stability to the knee with maintenance of the clinical results over a considerable length of time. During revision surgery, laminar spreaders may be utilised to assess the flexion and extension spaces after the tibial platform is restored. If a symmetric flexion and extension space are achieved, then the collateral ligaments are intact. Depending on the remaining existing bone stock, a posterior stabilised or constrained condylar unlinked prosthesis may be used for implantation. If there is considerable asymmetry or a large flexion/extension mismatch, then a rotating hinge design should be utilised. Intramedullary stems should be utilised in most cases when bone integrity is suspect and insufficient. Currently, stems should be placed cementless to permit easier future revision. Cementing the stems is only recommended if there is lack of intramedullary isthmic support. However, revision of fully cemented revision implants may be quite difficult later. Infection should be ruled out by aspiration off of antibiotics prior to any revision operation, especially if loosening of the components represents the cause of instability. The surgeon should attempt to restore collateral ligament balance whenever possible as this yields the best clinical result

Aims

The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting.