The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes.Aims
Methods
Aims. To determine whether obesity and malnutrition have a synergistic effect on outcomes from skeletal trauma or elective orthopaedic surgery. Methods. Electronic databases including MEDLINE, Global Health, Embase, Web of Science, ScienceDirect, and PEDRo were searched up to 14 April 2024, as well as conference proceedings and the reference lists of included studies. Studies were appraised using tools according to study design, including the Oxford Levels of Evidence, the Institute of Health Economics case series quality appraisal checklist, and the CLARITY checklist for cohort studies. Studies were eligible if they reported the effects of combined malnutrition and obesity on outcomes from skeletal trauma or elective orthopaedic surgery. Results. A total of eight studies (106,319 patients) were included. These carried moderate to high risk of bias. Combined obesity and malnutrition did not lead to worse outcomes in patients undergoing total shoulder arthroplasty or repair of proximal humeral fractures (two retrospective cohort studies). Three studies (two retrospective cohort studies, one case series) found that malnourishment and obesity had a synergistic effect and led to poor outcomes in total hip or knee arthroplasty, including longer length of stay and higher complication rates. One retrospective cohort study pertaining to posterior
To report the development of the technique for minimally invasive lumbar decompression using robotic-assisted navigation. Robotic planning software was used to map out bone removal for a laminar decompression after registration of CT scan images of one cadaveric specimen. A specialized acorn-shaped bone removal robotic drill was used to complete a robotic lumbar laminectomy. Post-procedure advanced imaging was obtained to compare actual bony decompression to the surgical plan. After confirming accuracy of the technique, a minimally invasive robotic-assisted laminectomy was performed on one 72-year-old female patient with lumbar spinal stenosis. Postoperative advanced imaging was obtained to confirm the decompression.Aims
Methods
The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs. We retrospectively investigated data extracted from the Diagnosis Procedure Combination database, a representative inpatient database in Japan. The data from April 2010 to March 2020 were used for this study. We included all patients who had undergone any combination of laminectomy, laminoplasty, discectomy, and/or spinal arthrodesis.Aims
Methods
People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials.Aims
Methods
We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences. The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded.Aims
Methods
Aims. Dual-mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a rare complication of DM that is believed to have decreased with contemporary implants. This study aimed to report incidence, treatment, and outcomes of contemporary DM IPD. Methods. A total of 1,453 DM components were implanted at a single academic institution between January 2010 and December 2021: 695 in primary and 758 in revision THA. Of these, 49 presented with a dislocation of the large DM head and five presented with an IPD. At the time of closed reduction of the large DM dislocation, six additional IPDs occurred. The mean age was 64 years (SD 9.6), 54.5% were female (n = 6), and mean follow-up was 4.2 years (SD 1.8). Of the 11 IPDs, seven had a history of instability, five had abductor insufficiency, four had prior
Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability. Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired Aims
Methods
The April 2024 Spine Roundup. 360. looks at: Lengthening behaviour of magnetically controlled growing rods in early-onset scoliosis: a multicentre study; LDL, cholesterol, and statins usage cause pseudarthrosis following
Excessive posterior pelvic tilt (PT) may increase the risk of anterior instability after total hip arthroplasty (THA). The aim of this study was to investigate the changes in PT occurring from the preoperative supine to postoperative standing position following THA, and identify factors associated with significant changes in PT. Supine PT was measured on preoperative CT scans and standing PT was measured on preoperative and one-year postoperative standing lateral radiographs in 933 patients who underwent primary THA. Negative values indicate posterior PT. Patients with > 13° of posterior PT from preoperative supine to postoperative standing (ΔPT ≤ -13°) radiographs, which corresponds to approximately a 10° increase in functional anteversion of the acetabular component, were compared with patients with less change (ΔPT > -13°). Logistic regression analysis was used to assess preoperative demographic and spinopelvic parameters predictive of PT changes of ≤ -13°. The area under receiver operating characteristic curve (AUC) determined the diagnostic accuracy of the predictive factors.Aims
Methods
The February 2024 Spine Roundup360 looks at: Surgeon assessment of bone – any good?; Robotics reduces radiation exposure in some spinal surgery; Interbody fusion cage versus anterior lumbar interbody fusion with posterior instrumentation; Is robotic-assisted pedicle screw placement an answer to the learning curve?; Acute non-traumatic spinal subarachnoid haematomas: a report of five cases and a systematic review of the literature; Is L4-L5 lateral interbody fusion safe and effective?
Aims. The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral
The December 2023 Spine Roundup. 360. looks at: Does size matter in adolescent pedicle screws?; Effect of
The October 2023 Spine Roundup. 360. looks at: Cutting through surgical smoke: the science of cleaner air in spinal operations; Unlocking success: key factors in thoracic spine decompression and fusion for ossification of the posterior longitudinal ligament; Deep learning algorithm for identifying cervical cord compression due to degenerative canal stenosis on radiography; Surgeon experience influences robotics learning curve for minimally invasive
Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted. As part of the SpInOuT-F study, a pilot randomized trial was carried out across five NHS hospitals. Patients were randomized to either spinal decompression alone or spinal decompression plus instrumented fusion. Patient-reported outcome measures were collected at baseline and three months. The intended sample size was 60 patients.Aims
Methods
The June 2023 Spine Roundup. 360. looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and
The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial.Aims
Methods
The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system. The authors reviewed the prospectively collected data on 196 adult patients who had pedicle screws implanted with robot-navigated assistance (RNA) using the Mazor X Stealth system between June 2019 and March 2022. Pedicle screws were implanted by one experienced spinal surgeon after completion of a learning period. The accuracy of pedicle screw placement was determined using intraoperative 3D fluoroscopy.Aims
Methods
It has been well documented in the arthroplasty literature that lumbar degenerative disc disease (DDD) contributes to abnormal spinopelvic motion. However, the relationship between the severity or pattern of hip osteoarthritis (OA) as measured on an anteroposterior (AP) pelvic view and spinopelvic biomechanics has not been well investigated. Therefore, the aim of the study is to examine the association between the severity and pattern of hip OA and spinopelvic motion. A retrospective chart review was conducted to identify patients undergoing primary total hip arthroplasty (THA). Plain AP pelvic radiographs were reviewed to document the morphological characteristic of osteoarthritic hips. Lateral spine-pelvis-hip sitting and standing plain radiographs were used to measure sacral slope (SS) and pelvic femoral angle (PFA) in each position. Lumbar disc spaces were measured to determine the presence of DDD. The difference between sitting and standing SS and PFA were calculated to quantify spinopelvic motion (ΔSS) and hip motion (ΔPFA), respectively. Univariate analysis and Pearson correlation were used to identify morphological hip characteristics associated with changes in spinopelvic motion.Aims
Methods
Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS.Aims
Methods
The February 2023 Spine Roundup. 360. looks at: S2AI screws: At what cost?; Just how good is spinal deformity surgery?; Is 80 years of age too late in the day for spine surgery?; Factors affecting the accuracy of pedicle screw placement in robot-assisted surgery; Factors causing delay in discharge in patients eligible for ambulatory
The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion. The Swedish Spinal Stenosis Study (SSSS) was conducted between 2006 and 2012 at five public and two private hospitals. Six centres participated in this two-year MRI follow-up. We randomized 222 patients with central lumbar spinal stenosis at one or two adjacent levels into two groups, decompression alone and decompression with fusion. The presence or absence of a preoperative spondylolisthesis was noted. A new stenosis on two-year MRI was used as the primary outcome, defined as a dural sac cross-sectional area ≤ 75 mm2 at the operated level (restenosis) and/or at the level above (proximal adjacent level stenosis).Aims
Methods
In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.Aims
Methods
Adverse spinal motion or balance (spine mobility) and adverse pelvic mobility, in combination, are often referred to as adverse spinopelvic mobility (SPM). A stiff lumbar spine, large posterior standing pelvic tilt, and severe sagittal spinal deformity have been identified as risk factors for increased hip instability. Adverse SPM can create functional malposition of the acetabular components and hence is an instability risk. Adverse pelvic mobility is often, but not always, associated with abnormal spinal motion parameters. Dislocation rates for dual-mobility articulations (DMAs) have been reported to be between 0% and 1.1%. The aim of this study was to determine the early survivorship from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) of patients with adverse SPM who received a DMA. A multicentre study was performed using data from 227 patients undergoing primary total hip arthroplasty (THA), enrolled consecutively. All the patients who had one or more adverse spine or pelvic mobility parameter had a DMA inserted at the time of their surgery. The mean age was 76 years (22 to 93) and 63% were female (n = 145). At a mean of 14 months (5 to 31) postoperatively, the AOANJRR was analyzed for follow-up information. Reasons for revision and types of revision were identified.Aims
Methods
The aim of this study was to evaluate the incidence of liner malseating in two commonly used dual-mobility (DM) designs. Secondary aims included determining the risk of dislocation, survival, and clinical outcomes. We retrospectively identified 256 primary total hip arthroplasties (THAs) that included a DM component (144 Stryker MDM and 112 Zimmer-Biomet G7) in 233 patients, performed between January 2012 and December 2019. Postoperative radiographs were reviewed independently for malseating of the liner by five reviewers. The mean age of the patients at the time of THA was 66 years (18 to 93), 166 (65%) were female, and the mean BMI was 30 kg/m2 (17 to 57). The mean follow-up was 3.5 years (2.0 to 9.2).Aims
Methods
Prior studies have identified that malseating of a modular dual mobility liner can occur, with previous reported incidences between 5.8% and 16.4%. The aim of this study was to determine the incidence of malseating in dual mobility implants at our institution, assess for risk factors for liner malseating, and investigate whether liner malseating has any impact on clinical outcomes after surgery. We retrospectively reviewed the radiographs of 239 primary and revision total hip arthroplasties with a modular dual mobility liner. Two independent reviewers assessed radiographs for each patient twice for evidence of malseating, with a third observer acting as a tiebreaker. Univariate analysis was conducted to determine risk factors for malseating with Youden’s index used to identify cut-off points. Cohen’s kappa test was used to measure interobserver and intraobserver reliability.Aims
Methods
In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article:
Aims. Patients with spinal pathology who undergo total hip arthroplasty (THA) have an increased risk of dislocation and revision. The aim of this study was to determine if the use of the Hip-Spine Classification system in these patients would result in a decreased rate of postoperative dislocation in patients with spinal pathology. Methods. This prospective, multicentre study evaluated 3,777 consecutive patients undergoing THA by three surgeons, between January 2014 and December 2019. They were categorized using The Hip-Spine Classification system: group 1 with normal spinal alignment; group 2 with a flatback deformity, group 2A with normal spinal mobility, and group 2B with a stiff spine. Flatback deformity was defined by a pelvic incidence minus lumbar lordosis of > 10°, and spinal stiffness was defined by < 10° change in sacral slope from standing to seated. Each category determined a patient-specific component positioning. Survivorship free of dislocation was recorded and spinopelvic measurements were compared for reliability using intraclass correlation coefficient. Results. A total of 2,081 patients met the inclusion criteria. There were 987 group 1A, 232 group 1B, 715 group 2A, and 147 group 2B patients. A total of 70 patients had a
Due to the opioid epidemic in the USA, our service progressively decreased the number of opioid tablets prescribed at discharge after primary hip (THA) and knee (TKA) arthroplasty. The goal of this study was to analyze the effect on total morphine milligram equivalents (MMEs) prescribed and post-discharge opioid repeat prescriptions. We retrospectively reviewed 19,428 patients undergoing a primary THA or TKA between 1 February 2016 and 31 December 2019. Two reductions in the number of opioid tablets prescribed at discharge were implemented over this time; as such, we analyzed three periods (P1, P2, and P3) with different routine discharge MME (750, 520, and 320 MMEs, respectively). We investigated 90-day refill rates, refill MMEs, and whether discharge MMEs were associated with represcribing in a multivariate model.Aims
Methods
Total hip arthroplasty (THA) patients undergoing or having a prior lumbar spine fusion (LSF) have an increased risk of mechanical complications. The aim of this registry-based, retrospective comparative cohort study is to assess the longer term survival of THA in patients who have undergone a LSF during a 17-year period (2000 to 2017). A registry-based population study was conducted on 679 patients who underwent both THA and LSF surgeries. Patients were identified from the regional arthroplasty data base and cross linked to patients with LSF from the regional hospital discharge database between 2000 and 2017. Demographic data, diagnosis leading to primary THA, primary implant survival, perioperative complications, number and causes of failure, and patients requiring revision arthroplasty were collated and compared. For comparison, data from 67,919 primary THAs performed during the same time time period were also retrieved and analyzed.Aims
Methods
Aims. As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion. Methods. We retrospectively reviewed 584 patients who had undergone lumbar spinal fusion for degenerative lumbar spinal disease. The 'simple' group (SG) consisted of patients who had undergone one- or two-level posterior
Aims. To determine the effectiveness of prone traction radiographs in predicting postoperative slip distance, slip angle, changes in disc height, and lordosis after surgery for degenerative spondylolisthesis of the lumbar spine. Methods. A total of 63 consecutive patients with a degenerative spondylolisthesis and preoperative prone traction radiographs obtained since 2010 were studied. Slip distance, slip angle, disc height, segmental lordosis, and global lordosis (L1 to S1) were measured on preoperative lateral standing radiographs, flexion-extension lateral radiographs, prone traction lateral radiographs, and postoperative lateral standing radiographs. Patients were divided into two groups: posterolateral fusion or posterolateral fusion with interbody fusion. Results. The mean changes in segmental lordosis and global lordosis were 7.1° (SD 6.7°) and 2.9° (SD 9.9°) respectively for the interbody fusion group, and 0.8° (SD 5.1°) and -0.4° (SD 10.1°) respectively for the posterolateral fusion-only group. Segmental lordosis (ρ = 0.794, p < 0.001) corrected by interbody fusion correlated best with prone traction radiographs. Global lumbar lordosis (ρ = 0.788, p < 0.001) correlated best with the interbody fusion group and preoperative lateral standing radiographs. The least difference in slip distance (-0.3 mm (SD 1.7 mm), p < 0.001), slip angle (0.9° (SD 5.2°), p < 0.001), and disc height (0.02 mm (SD 2.4 mm), p < 0.001) was seen between prone traction and postoperative radiographs. Regression analyses suggested that prone traction parameters best predicted correction of slip distance (Corrected Akaike’s Information Criterion (AICc) = 37.336) and disc height (AICc = 58.096), while correction of slip angle (AICc = 26.453) was best predicted by extension radiographs. Receiver operating characteristic (ROC) cut-off showed, with 68.3% sensitivity and 64.5% specificity, that to achieve a 3.0° increase in segmental lordotic angle, patients with a prone traction disc height of 8.5 mm needed an interbody fusion. Conclusion. Prone traction radiographs best predict the slip distance and disc height correction achieved by interbody
Aims. There is evidence that prior
Patients with abnormal spinopelvic mobility are at increased risk for instability. Measuring the change in sacral slope (ΔSS) can help determine spinopelvic mobility preoperatively. Sacral slope (SS) should decrease at least 10° to demonstrate adequate posterior pelvic tilt. There is potential for different ΔSS measurements in the same patient based on sitting posture. The purpose of this study was to determine the effect of sitting posture on the ΔSS in patients undergoing total hip arthroplasty (THA). In total, 51 patients undergoing THA were reviewed to quantify the variability in preoperative spinopelvic mobility when measuring two different sitting positions using SS for planning.Aims
Methods
The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic. A prospective cohort study was undertaken between 17 March 2020 and 30 April 2020 and compared with retrospective data from same time period in 2019. We compared the number of patients requiring acute hospital admission or orthopaedic referrals and indications of referrals from our admission sheets and obtained operative data from our theatre software.Aims
Methods
There is inconsistent evidence on whether prior spinal fusion surgery adversely impacts outcomes following total hip arthroplasty (THA). We conducted a systematic review and meta-analysis to assess the association between pre-existing spinal fusion surgery and the rate of complications following primary THA. We searched MEDLINE, Embase, Web of Science, and Cochrane Library up to October 2019 for randomized controlled trials (RCTs) and observational studies comparing outcomes of dislocation, revision, or reasons for revision in patients following primary THA with or without pre-existing spinal fusion surgery. Furthermore, we compared short (two or less levels) or long (three or more levels) spinal fusions to no fusion. Summary measures of association were relative risks (RRs) (with 95% confidence intervals (CIs)).Aims
Methods
Chronic low back pain due to degenerative disc disease is sometimes treated with fusion. We compared the outcome of three different fusion techniques in the Swedish Spine Register: noninstrumented posterolateral fusion (PLF), instrumented posterolateral fusion (IPLF), and interbody fusion (IBF). A total of 2874 patients who were operated on at one or two lumbar levels were followed for a mean of 9.2 years (3.6 to 19.1) for any additional lumbar spine surgery. Patient-reported outcome data were available preoperatively (n = 2874) and at one year (n = 2274), two years (n = 1958), and a mean of 6.9 years (n = 1518) postoperatively and consisted of global assessment and visual analogue scales of leg and back pain, Oswestry Disability Index, EuroQol five-dimensional index, 36-Item Short-Form Health Survey, and satisfaction with treatment. Statistical analyses were performed with competing-risks proportional hazards regression or analysis of covariance, adjusted for baseline variables.Aims
Patients and Methods
The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses.Aims
Patients and Methods
The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT. Between 2012 and 2017, 12 171 patients with degenerative lumbar diseases underwent primary lumbar spine surgery. We investigated five categories of potential predictors: patient factors (sex, age, body mass index, and primary disease), surgical factors (surgical procedures, operative time, and estimated blood loss), types of DT (inaccessible for suturing/clipping and the presence of cauda equina/nerve root herniation), repair techniques (suturing, clipping, fibrin glue, polyethylene glycol (PEG) hydrogel, and polyglycolic acid sheet), and postoperative management (drainage duration). Postoperative complications were evaluated in terms of dural leak, prolonged bed rest, headache, nausea/vomiting, delayed wound healing, postoperative neurological deficit, surgical site infection (SSI), and reoperation for DT. We performed multivariable regression analyses to evaluate the predictors of postoperative complications associated with DT.Aims
Patients and Methods
This study of patients with osteoarthritis (OA) of the hip aimed to: 1) characterize the contribution of the hip, spinopelvic complex, and lumbar spine when moving from the standing to the sitting position; 2) assess whether abnormal spinopelvic mobility is associated with worse symptoms; and 3) identify whether spinopelvic mobility can be predicted from static anatomical radiological parameters. A total of 122 patients with end-stage OA of the hip awaiting total hip arthroplasty (THA) were prospectively studied. Patient-reported outcome measures (PROMs; Oxford Hip Score, Oswestry Disability Index, and Veterans RAND 12-Item Health Survey Score) and clinical data were collected. Sagittal spinopelvic mobility was calculated as the change from the standing to sitting position using the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA), and acetabular anteinclination (AI) from lateral radiographs. The interaction of the different parameters was assessed. PROMs were compared between patients with normal spinopelvic mobility (10° ≤ ∆PT ≤ 30°) or abnormal spinopelvic mobility (stiff: ∆PT < ± 10°; hypermobile: ∆PT > ± 30°). Multiple regression and receiver operating characteristic (ROC) curve analyses were used to test for possible predictors of spinopelvic mobility.Aims
Patients and Methods
While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA. Prospectively collected data on 111 patients undergoing revision THA for recurrent instability from January 2014 to January 2017 at two institutions were included (protocol group) and matched 1:1 to 111 revisions specifically performed for instability not using this protocol (control group). Mean follow-up was 2.8 years. Protocol patients underwent standardized preoperative imaging including supine and standing anteroposterior (AP) pelvis and lateral radiographs. Each case was scored according to the Hip-Spine Classification in Revision THA.Aims
Patients and Methods
There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research. Cite this article:
Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded.Aims
Patients and Methods
Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining.Aims
Materials and Methods
Aims. Concurrent hip and spine pathologies can alter the biomechanics of spinopelvic mobility in primary total hip arthroplasty (THA). This study examines how differences in pelvic orientation of patients with spine fusions can increase the risk of dislocation risk after THA. Patients and Methods. We identified 84 patients (97 THAs) between 1998 and 2015 who had undergone spinal fusion prior to primary THA. Patients were stratified into three groups depending on the length of
The aims of this study were to measure sagittal standing and sitting lumbar-pelvic-femoral alignment in patients before and following total hip arthroplasty (THA), and to consider what preoperative factors may influence a change in postoperative pelvic position. A total of 161 patients were considered for inclusion. Patients had a mean age of the remaining 61 years (Aims
Patients and Methods
The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients. A decision analysis model was used to evaluate the cost-effectiveness of using DM components in patients who would be at high risk for dislocation within one year of THA. Direct and indirect costs of dislocation, incremental costs of using DM components, quality-adjusted life-year (QALY) values, and the probabilities of dislocation were derived from published data. The incremental cost-effectiveness ratio (ICER) was established with a willingness-to-pay threshold of $100 000/QALY. Sensitivity analysis was used to examine the impact of variation.Aims
Patients and Methods
Calcium sulphate has traditionally been used as a filler of dead space arising during surgery. Various complications have been described following the use of Stimulan bio-absorbable calcium sulphate beads. This study is a prospective observational study to assess the safety profile of these beads when used in revision arthroplasty, comparing the complication rates with those reported in the literature. A total of 755 patients who underwent 456 revision total knee arthroplasties (TKA) and 299 revision total hip arthroplasties (THA), with a mean follow-up of 35 months (0 to 78) were included in the study.Aims
Methods
It is important to consider sagittal pelvic rotation when introducing
the acetabular component at total hip arthroplasty (THA). The purpose
of this study was to identify patients who are at risk of unfavourable
pelvic mobility, which could result in poor outcomes after THA. A consecutive series of 4042 patients undergoing THA had lateral
functional radiographs and a low-dose CT scan to measure supine
pelvic tilt, pelvic incidence, standing pelvic tilt, flexed-seated
pelvic tilt, standing lumbar lordotic angle, flexed-seated lumbar
lordotic angle, and lumbar flexion. Changes in pelvic tilt from
supine-to-standing positions and supine-to-flexed-seated positions
were determined. A change in pelvic tilt of 13° between positions was
deemed unfavourable as it alters functional anteversion by 10° and
effectively places the acetabular component outside the safe zone
of orientation.Aims
Patients and Methods
The aim of this study was to investigate the clinical and radiographic
outcomes of microendoscopic laminotomy in patients with lumbar stenosis
and concurrent degenerative spondylolisthesis (DS), and to determine
the effect of this procedure on spinal stability. A total of 304 consecutive patients with single-level lumbar
DS with concomitant stenosis underwent microendoscopic laminotomy
without fusion between January 2004 and December 2010. Patients
were divided into two groups, those with and without advanced DS
based on the degree of spondylolisthesis and dynamic instability. A
total of 242 patients met the inclusion criteria. There were 101
men and 141 women. Their mean age was 68.1 years (46 to 85). Outcome
was assessed using the Japanese Orthopaedic Association and Roland
Morris Disability Questionnaire scores, a visual analogue score
for pain and the Short Form Health-36 score. The radiographic outcome
was assessed by measuring the slip and the disc height. The clinical
and radiographic parameters were evaluated at a mean follow-up of
4.6 years (3 to 7.5).Aims
Patients and Methods
Objectives. Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical
Aims. We compared the clinical and radiological outcomes of using a
polyetheretherketone cage with (TiPEEK) and without a titanium coating
(PEEK) for instrumented transforaminal
To evaluate the incidence of primary venous thromboembolism (VTE),
epidural haematoma, surgical site infection (SSI), and 90-day mortality
after elective spinal surgery, and the effect of two protocols for
prophylaxis. A total of 2181 adults underwent 2366 elective spinal procedures
between January 2007 and January 2012. All patients wore anti-embolic
stockings, mobilised early and were kept adequately hydrated. In
addition, 29% (689) of these were given low molecular weight heparin
(LMWH) while in hospital. SSI surveillance was undertaken using the
Centers for Disease Control and Prevention criteria.Aims
Patients and Methods
The National Institute for Health and Care Excellence
has issued guidelines that state fusion for non-specific low back
pain should only be performed as part of a randomised controlled
trial, and that lumbar disc replacement should not be performed.
Thus, spinal fusion and disc replacement will no longer be routine
forms of treatment for patients with low back pain. This annotation
considers the evidence upon which these guidelines are based. Cite this article:
Aims. Minimally invasive transforaminal
Objectives. The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery. Methods. A total of 17 DBM products were used as search terms in two available databases: Embase and PubMed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. All articles that reported the clinical use of a DBM-product in trauma and orthopaedic related surgery were included. Results. The literature search resulted in 823 manuscripts of which 64 manuscripts met the final inclusion criteria. The included manuscripts consisted of four randomised controlled trials (level I), eight cohort studies (level III) and 49 case-series (level IV). No clinical studies were found for ten DBM products, and most DBM products were only used in combination with other grafting materials. DBM products were most extensively investigated in spinal surgery, showing limited level I evidence that supports the use Grafton DBM (Osteotech, Eatontown, New Jersey) as a bone graft extender in posterolateral
Aims.
Many studies have investigated the kinematics of the lumbar spine and the morphological features of the lumbar discs. However, the segment-dependent immediate changes of the lumbar intervertebral space height during flexion-extension motion are still unclear. This study examined the changes of intervertebral space height during flexion-extension motion of lumbar specimens. First, we validated the accuracy and repeatability of a custom-made mechanical loading equipment set-up. Eight lumbar specimens underwent CT scanning in flexion, neural, and extension positions by using the equipment set-up. The changes in the disc height and distance between adjacent two pedicle screw entry points (DASEP) of the posterior approach at different lumbar levels (L3/4, L4/5 and L5/S1) were examined on three-dimensional lumbar models, which were reconstructed from the CT images.Objectives
Methods
Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients. CT scans were performed on 36 LSS patients (12 central canal stenosis (CCS), 12 lateral recess stenosis (LRS), and 12 foraminal stenosis (FS)) at L4-L5, and on 12 normal (control) subjects. Mimics 14.01 workstation was used to reconstruct 3D models of the L4-L5 vertebrae and discs. SCV and NFD were measured after 1 mm, 2 mm, 3 mm, 4 mm, or 5 mm pedicle-lengthening osteotomies at L4 and/or L5. One-way analysis of variance was used to examine between-group differences.Objectives
Methods
We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis. The MEDLINE, EMBASE and Cochrane Library databases were searched using defined search terms. The primary outcome measure was spinal fusion, assessed as success or failure in accordance with radiograph, MRI or CT scan review at 24-month follow-up. The secondary outcome measure was time to fusion.Objectives
Methods
The purpose of this prospective study was to evaluate the outcomes
of coccygectomy for patients with chronic coccydynia. Between 2007 and 2011, 98 patients underwent coccygectomy for
chronic coccydynia. The patients were aged >
18 years, had coccygeal
pain, local tenderness and a radiological abnormality, and had failed
conservative management. Outcome measures were the Short Form 36
(SF-36), the Oswestry Disability Index (ODI) and a visual analogue
scale (VAS) for pain. Secondary analysis compared the pre-operative
features and the outcomes of patients with successful and failed
treatment, two years post-operatively. The threshold for success
was based on a minimum clinically important difference (MCID) on
the ODI of 20 points. All other patients, including those lost to
follow-up, were classified as failures.Aims
Patients and Methods
An extensive review of the spinal and arthroplasty
literature was undertaken to evaluate the effectiveness of local
antibiotic irrigation during surgery. The efficacy of antibiotic
irrigation for the prevention of acute post-operative infection
after total joint arthroplasty was evaluated retrospectively in
2293 arthroplasties (1990 patients) between January 2004 and December
2013. The mean follow-up was 73 months (20 to 139). One surgeon
performed all the procedures with minimal post-operative infection. The intra-operative protocol included an irrigation solution
of normal saline with vancomycin 1000 mg/l and polymyxin 250 000
units/l at the rate of 2 l per hour. No patient required re-admission
for primary infection or further antibiotic treatment. Two morbidly obese
patients (two total hip arthroplasties) developed subcutaneous fat
necrosis requiring debridement and one was revised because the deep
capsular sutures were contaminated by the draining subcutaneous
haematoma. One patient who had undergone total knee arthroplasty
had unrecognised damage to the lateral superior geniculate artery
and developed a haematoma that became infected secondarily four
months after the surgery and underwent revision. The use of antibiotic irrigation during arthroplasty surgery
has been highly effective for the prevention of infection in the
author’s practice. However, it should be understood that any routine
prophylactic use of antibiotics may result in resistant organisms,
and the wise stewardship of the use of antibiotics is an important
part of surgical practice. Cite this article:
The aims of this study were to evaluate the clinical and radiological
outcomes of instrumented posterolateral fusion (PLF) performed in
patients with rheumatoid arthritis (RA). A total of 40 patients with RA and 134 patients without RA underwent
instrumented PLF for spinal stenosis between January 2003 and December
2011. The two groups were matched for age, gender, bone mineral
density, the history of smoking and diabetes, and number of fusion
segments. The clinical outcomes measures included the visual analogue scale
(VAS) and the Korean Oswestry Disability Index (KODI), scored before
surgery, one year and two years after surgery. Radiological outcomes
were evaluated for problems of fixation, nonunion, and adjacent
segment disease (ASD). The mean follow-up was 36.4 months in the RA
group and 39.1 months in the non-RA group.Aims
Methods
The continual cycle of bone formation and resorption
is carried out by osteoblasts, osteocytes, and osteoclasts under
the direction of the bone-signaling pathway. In certain situations
the host cycle of bone repair is insufficient and requires the assistance
of bone grafts and their substitutes. The fundamental properties
of a bone graft are osteoconduction, osteoinduction, osteogenesis,
and structural support. Options for bone grafting include autogenous
and allograft bone and the various isolated or combined substitutes
of calcium sulphate, calcium phosphate, tricalcium phosphate, and
coralline hydroxyapatite. Not all bone grafts will have the same
properties. As a result, understanding the requirements of the clinical
situation and specific properties of the various types of bone grafts
is necessary to identify the ideal graft. We present a review of
the bone repair process and properties of bone grafts and their
substitutes to help guide the clinician in the decision making process. Cite this article:
In this study of patients who underwent internal fixation without
fusion for a burst thoracolumbar or lumbar fracture, we compared
the serial changes in the injured disc height (DH), and the fractured
vertebral body height (VBH) and kyphotic angle between patients
in whom the implants were removed and those in whom they were not. Radiological
parameters such as injured DH, fractured VBH and kyphotic angle
were measured. Functional outcomes were evaluated using the Greenough
low back outcome scale and a VAS scale for pain. Between June 1996 and May 2012, 69 patients were analysed retrospectively;
47 were included in the implant removal group and 22 in the implant
retention group. After a mean follow-up of 66 months (48 to 107),
eight patients (36.3%) in the implant retention group had screw
breakage. There was no screw breakage in the implant removal group.
All radiological and functional outcomes were similar between these
two groups. Although solid union of the fractured vertebrae was
achieved, the kyphotic angle and the anterior third of the injured
DH changed significantly with time (p <
0.05). Methods
Results
We evaluated the impact of
The aim of this study was to determine whether
obesity affects pain, surgical and functional outcomes following lumbar
spinal fusion for low back pain (LBP). A systematic literature review and meta-analysis was made of
those studies that compared the outcome of lumbar spinal fusion
for LBP in obese and non-obese patients. A total of 17 studies were
included in the meta-analysis. There was no difference in the pain
and functional outcomes. Lumbar spinal fusion in the obese patient resulted
in a statistically significantly greater intra-operative blood loss
(weighted mean difference: 54.04 ml; 95% confidence interval (CI)
15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio:
1.91; 95% CI 1.68 to 2.18; n = 43858; p <
0.001) and longer duration
of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p <
0.001). Obese
patients have greater intra-operative blood loss, more complications
and longer duration of surgery but pain and functional outcome are
similar to non-obese patients. Based on these results, obesity is
not a contraindication to lumbar spinal fusion. Cite this article:
We undertook a retrospective study investigating
the accuracy and safety of percutaneous pedicle screws placed under
fluoroscopic guidance in the lumbosacral junction and lumbar spine.
The CT scans of patients were chosen from two centres: European
patients from University Medical Center Hamburg-Eppendorf, Germany,
and Asian patients from the University of Malaya, Malaysia. Screw
perforations were classified into grades 0, 1, 2 and 3. A total
of 880 percutaneous pedicle screws from 203 patients were analysed:
614 screws from 144 European patients and 266 screws from 59 Asian
patients. The mean age of the patients was 58.8 years (16 to 91)
and there were 103 men and 100 women. The total rate of perforation
was 9.9% (87 screws) with 7.4% grade 1, 2.0% grade 2 and 0.5% grade
3 perforations. The rate of perforation in Europeans was 10.4% and
in Asians was 8.6%, with no significant difference between the two
(p = 0.42). The rate of perforation was the highest in S1 (19.4%)
followed by L5 (14.9%). The accuracy and safety of percutaneous
pedicle screw placement are comparable to those cited in the literature
for the open method of pedicle screw placement. Greater caution
must be taken during the insertion of L5 and S1 percutaneous pedicle
screws owing to their more angulated pedicles, the anatomical variations
in their vertebral bodies and the morphology of the spinal canal
at this location. Cite this article:
The April 2015 Spine Roundup360 looks at: Hyperostotic spine in injury; App based back pain control; Interspinous process devices should be avoided in claudication; Robot assisted pedicle screws: fad or advance?; Vancomycin antibiotic power in spinal surgery; What to do with that burst fracture?; Increasing complexity of spinal fractures in major trauma pathways; Vitamin D and spinal fractures
Using the United States Nationwide Inpatient
Sample, we identified national trends in revision spinal fusion
along with a comprehensive comparison of comorbidities, inpatient
complications and surgical factors of revision spinal fusion compared
to primary spinal fusion. In 2009, there were 410 158 primary spinal fusion discharges
and 22 128 revision spinal fusion discharges. Between 2002 and 2009,
primary fusion increased at a higher rate compared with revision
fusion (56.4% In the multivariable logistic regression model for all spinal
fusions, depression (odds ratio (OR) 1.53, p <
0.001), psychotic
disorders (OR 1.49, p <
0.001), deficiency anaemias (OR 1.35,
p <
0.001) and smoking (OR 1.10, p = 0.006) had a greater chance
of occurrence in revision spinal fusion discharges than in primary
fusion discharges, adjusting for other variables. In terms of complications,
after adjusting for all significant comorbidities, this study found
that dural tears (OR 1.41; p <
0.001) and surgical site infections
(OR 3.40; p <
0.001) had a greater chance of occurrence in revision
spinal fusion discharges than in primary fusion discharges (p <
0.001). A p-value <
0.01 was considered significant in all final
analyses. Cite this article:
Little information is available about the incidence
and outcome of incidental dural tears associated with microendoscopic
lumbar decompressive surgery. We prospectively examined the incidence
of dural tears and their influence on the outcome six months post-operatively
in 555 consecutive patients (mean age 47.4 years (13 to 89)) who
underwent this form of surgery. The incidence of dural tears was
5.05% (28/555). The risk factors were the age of the patient and
the procedure of bilateral decompression via a unilateral approach.
The rate of recovery of the Japanese Orthopaedic Association score
in patients with dural tears was significantly lower than that in
those without a tear (77.7% Cite this article:
The April 2014 Spine Roundup360 looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?
Despite the increasing prevalence of sleep apnoea,
little information is available regarding its impact on the peri-operative
outcome of patients undergoing posterior
