Aims

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).

Aims

A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

The August 2024 Spine Roundup³⁶⁰ looks at: Laminectomy adjacent to instrumented fusion increases adjacent segment disease; Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: a retrospective multicentre study; Lumbar vertebral body tethering: single-centre outcomes and reoperations in a consecutive series of 106 patients; Machine-learning algorithms for predicting Cobb angle beyond 25° in female adolescent idiopathic scoliosis patients; Pain in adolescent idiopathic scoliosis; Teriparatide prevents surgery for osteoporotic vertebral compression fracture.

The June 2024 Spine Roundup³⁶⁰ looks at: Intraoperative navigation increases the projected lifetime cancer risk in patients undergoing surgery for adolescent idiopathic scoliosis; Intrawound vancomycin powder reduces delayed deep surgical site infections following posterior spinal fusion for adolescent idiopathic scoliosis; Characterizing negative online reviews of spine surgeons; Proximal junctional failure after surgical instrumentation in adult spinal deformity: biomechanical assessment of proximal instrumentation stiffness; Nutritional supplementation and wound healing: a randomized controlled trial.

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 lumbar interbody fusion; Decision-making in the treatment of degenerative lumbar spondylolisthesis of L4/L5; Does the interfacing angle between pedicle screws and support rods affect clinical outcomes after posterior thoracolumbar fusion?; Returning to the grind: how workload influences recovery post-lumbar spine surgery; Securing the spine: a leap forward with s2 alar-iliac screws in adult spinal deformity surgery

Aims

This systematic review aims to identify 3D predictors derived from biplanar reconstruction, and to describe current methods for improving curve prediction in patients with mild adolescent idiopathic scoliosis.

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

Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.

Aims

To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

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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.

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 lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial

Aims

Spinopelvic characteristics influence the hip’s biomechanical behaviour. However, to date there is little knowledge defining what ‘normal’ spinopelvic characteristics are. This study aims to determine how static spinopelvic characteristics change with age and ethnicity among asymptomatic, healthy individuals.

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This study aimed to evaluate rasterstereography of the spine as a diagnostic test for adolescent idiopathic soliosis (AIS), and to compare its results with those obtained using a scoliometer.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality. Cite this article: Bone Joint J 2023;105-B(4):361–364

Aims

The prevalence of scoliosis is not known in patients with idiopathic short stature, and the impact of treatment with recombinant human growth hormone on those with scoliosis remains controversial. We investigated the prevalence of scoliosis radiologically in children with idiopathic short stature, and the impact of treatment with growth hormone in a cross-sectional and retrospective cohort study.

Aims. Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL. Methods. We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves. Results. The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains. Conclusion. In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis. Cite this article: Bone Joint J 2023;105-B(2):166–171

Aims

Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford.

Aims

Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature.

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected.

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Aims

To develop and internally validate a preoperative clinical prediction model for acute adjacent vertebral fracture (AVF) after vertebral augmentation to support preoperative decision-making, named the after vertebral augmentation (AVA) score.

Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Aims

Anchorage of pedicle screw rod instrumentation in the elderly spine with poor bone quality remains challenging. Our study aims to evaluate how the screw bone anchorage is affected by screw design, bone quality, loading conditions, and cementing techniques.

Aims

The aim of this study was to determine whether there is an increased prevalence of scoliosis in patients who have suffered from a haematopoietic malignancy in childhood.

Aims. To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach. Methods. Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded. Results. The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient. Conclusion. Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J 2021;103-B(7):1309–1316

Aims. Although lumbosacral transitional vertebrae (LSTV) are well-documented, few large-scale studies have investigated thoracolumbar transitional vertebrae (TLTV) and spinal numerical variants. This study sought to establish the prevalence of numerical variants and to evaluate their relationship with clinical problems. Methods. A total of 1,179 patients who had undergone thoracic, abdominal, and pelvic CT scanning were divided into groups according to the number of thoracic and lumbar vertebrae, and the presence or absence of TLTV or LSTV. The prevalence of spinal anomalies was noted. The relationship of spinal anomalies to clinical symptoms (low back pain, Japanese Orthopaedic Association score, Roland-Morris Disability Questionnaire) and degenerative spondylolisthesis (DS) was also investigated. Results. Normal vertebral morphology (12 thoracic and five lumbar vertebrae without TLTV and LSTV) was present in 531 male (76.7%) and 369 female patients (75.8%). Thoracolumbar transitional vertebrae were present in 15.8% of males and 16.0% of females. LSTV were present in 7.1% of males and 9.0% of females. The prevalence of the anomaly of 16 presacral mobile vertebrae (total number of thoracolumbar vertebrae and TLTV) without LSTV was 1.0% in males and 4.1% in females, and that of the anomaly of 18 vertebrae without LSTV was 5.3% in males and 1.2% in females. The prevalence of DS was significantly higher in females with a total of 16 vertebrae than in those with normal morphology. There was no significant correlation between a spinal anomaly and clinical symptoms. Conclusion. Overall, 24% of subjects had anomalies in the thoracolumbar region: the type of anomaly differed between males and females, which could have significant implications for spinal surgery. A decreased number of vertebrae was associated with DS: numerical variants may potentially be a clinical problem. Cite this article: Bone Joint J 2021;103-B(7):1301–1308

Aims. To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele. Methods. We reviewed 12 consecutive patients (7M:5F; mean age 12.4 years (9.2 to 16.8)) including demographic details, spinopelvic parameters, surgical correction, and perioperative data. We assessed the impact of surgery on patient outcomes using the Spina Bifida Spine Questionnaire and a qualitative questionnaire. Results. The mean follow-up was 5.4 years (2 to 14.9). Nine patients had kyphoscoliosis, two lordoscoliosis, and one kyphosis. All patients had a thoracolumbar deformity. Mean scoliosis corrected from 89.6° (47° to 151°) to 46.5° (17° to 85°; p < 0.001). Mean kyphosis corrected from 79.5° (40° to 135°) to 49° (36° to 65°; p < 0.001). Mean pelvic obliquity corrected from 19.5° (8° to 46°) to 9.8° (0° to 20°; p < 0.001). Coronal and sagittal balance restored to normal. Complication rate was 58.3% (seven patients) with no neurological deficits, implant failure, or revision surgery. The degree of preoperative spinal deformity, especially kyphosis and lordosis, correlated with increased blood loss and prolonged hospital/intensive care unit stay. The patients reported improvement in function, physical appearance, and pain after surgery. The parents reported decrease in need for everyday care. Conclusion. Anterior spinal fusion achieved satisfactory deformity correction with high perioperative complication rates, but no long-term sequelae among children with high level myelomeningocele. This resulted in physical and functional improvement and high reported satisfaction. Cite this article: Bone Joint J 2021;103-B(6):1133–1141

Aims

The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults.

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Aims. To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management. Methods. We reviewed 88 consecutive patients with a severe Scheuermann's kyphosis who had undergone posterior spinal fusion with closing wedge osteotomies and hybrid instrumentation. There were 55 males and 33 females with a mean age of 15.9 years (12.0 to 24.7) at the time of surgery. We recorded their demographics, spinopelvic parameters, surgical correction, and perioperative data, and assessed the impact of surgical complications on outcome using the Scoliosis Research Society (SRS)-22 questionnaire. Results. The mean follow-up was 8.4 years (2 to 14.9). There were 85 patients (96.6%) with a thoracic deformity. Posterior spinal fusion with closing-wedge osteotomies and hybrid instrumentation was used in 86 patients; two patients underwent combined anterior and posterior spinal fusion. The mean kyphosis was corrected from 94.5° to 47.5° (p < 0.001). Coronal and sagittal balance returned to normal. The rate of complications was 12.5%: there were no neurological deficits, implant failure, or revision surgery. SRS-22 scores improved from a mean 3.6 (1.3 to 4.1) to 4.6 (4.2 to 5.0) at two years (p < 0.001) with a high rate of patient satisfaction. Non-smokers and patients with lower preoperative SRS-22 scores showed greater improvement in their quality of life. Sagittal pelvic balance did not change after correction of the kyphosis and correlated with lumbar lordosis but not with thoracic or thoracolumbar kyphosis. Conclusion. Posterior spinal fusion using hybrid instrumentation, closing-wedge osteotomies, and iliac bone grafting achieves satisfactory correction of a severe kyphosis resulting in improvements in physical and mental health and a high degree of patient-reported satisfaction. Cite this article: Bone Joint J 2021;103-B(1):148–156

Aims

The aim of this study was to investigate whether including the stages of ulnar physeal closure in Sanders stage 7 aids in a more accurate assessment for brace weaning in patients with adolescent idiopathic scoliosis (AIS).

Aims

Spinal fusion remains the gold standard in the treatment of idiopathic scoliosis. However, anterior vertebral body tethering (AVBT) is gaining widespread interest, despite the limited data on its efficacy. The aim of our study was to determine the clinical efficacy of AVBT in skeletally immature patients with idiopathic scoliosis.

Aims

To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).

Aims

The aim of this study was to systematically compare the safety and accuracy of robot-assisted (RA) technique with conventional freehand with/without fluoroscopy-assisted (CT) pedicle screw insertion for spine disease.

Aims

Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

Aims

The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL).

Aims

The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL.

Aims

The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.

Aims

The timing of surgical fixation in spinal fractures is a contentious topic. Existing literature suggests that early stabilization leads to reduced morbidity, improved neurological outcomes, and shorter hospital stay. However, the quality of evidence is low and equivocal with regard to the safety of early fixation in the severely injured patient. This paper compares complication profiles between spinal fractures treated with early fixation and those treated with late fixation.

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal.

There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced.

Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described.

The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery.

Cite this article: Bone Joint J 2020;102-B(5):568–572.

Aims

The direct posterior approach with subperiosteal dissection of the paraspinal muscles from the vertebrae is considered to be the standard approach for the surgical treatment of adolescent idiopathic scoliosis (AIS). We investigated whether or not a minimally-invasive surgery (MIS) technique could offer improved results.

Aims

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform.

Aims

Computer-based applications are increasingly being used by orthopaedic surgeons in their clinical practice. With the integration of technology in surgery, augmented reality (AR) may become an important tool for surgeons in the future. By superimposing a digital image on a user’s view of the physical world, this technology shows great promise in orthopaedics. The aim of this review is to investigate the current and potential uses of AR in orthopaedics.

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

Aims. 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. Materials and Methods. 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. Results. Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion. In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44

Aims

The purpose of this study was to evaluate spinopelvic mechanics from standing and sitting positions in subjects with and without femoroacetabular impingement (FAI). We hypothesize that FAI patients will experience less flexion at the lumbar spine and more flexion at the hip whilst changing from standing to sitting positions than subjects without FAI. This increase in hip flexion may contribute to symptomatology in FAI.

Aims

Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of early-onset scoliosis (EOS). The primary aim of this study was to evaluate the performance of these devices in the prevention of progression of the deformity. A secondary aim was to record the rate of complications.

Aims. The surgical treatment of tuberculosis (TB) of the spine consists of debridement and reconstruction of the anterior column. Loss of correction is the most significant challenge. Our aim was to report the outcome of single-stage posterior surgery using bone allografts in the management of this condition. Patients and Methods. The study involved 24 patients with thoracolumbar TB who underwent single-stage posterior spinal surgery with a cortical bone allograft for anterior column reconstruction and posterior instrumentation between 2008 and 2015. A unilateral approach was used for 21 patients with active TB, and a bilateral approach with decompression and closing-opening wedge osteotomy was used for three patients with healed TB. Results. A median of 1.25 vertebrae were removed (interquartile range (IQR) 1 to 1.75) and the median number of levels that were instrumented was five (IQR 3 to 6). The median operating time was 280 minutes (IQR 230 to 315) and the median blood loss was 700 ml (IQR 350 to 900). The median postoperative kyphosis was 8.5° (IQR 0° to 15°) with a mean correction of the kyphosis of 71.6%. Good neurological recovery occurred, with only two patients (8%) requiring assistance to walk at a mean follow-up of 24 months (9 to 50), at which time there was a mean improvement in disability, as assessed by the Oswestry Disability Index, of 83% (90% to 72%). Conclusion. The posterior-only approach using cortical allografts for anterior column reconstruction achieved good clinical and radiological outcomes. Differentiation should be made between flexible (active) and rigid (healed) TB spine. Cite this article: Bone Joint J 2018;100-B:1208–13

Aims

Although we often encounter patients with an aortic aneurysm who also have diffuse idiopathic skeletal hyperostosis (DISH), there are no reports to date of an association between these two conditions and the pathogenesis of DISH remains unknown. This study therefore evaluated the prevalence of DISH in patients with a thoracic aortic aneurysm (AA).

Tuberculosis (TB) remains endemic in many parts of the developing world and is increasingly seen in the developed world due to migration. A total of 1.3 million people die annually from the disease. Spinal TB is the most common musculoskeletal manifestation, affecting about 1 to 2% of all cases of TB. The coexistence of HIV, which is endemic in some regions, adds to the burden and the complexity of management.

This review discusses the epidemiology, clinical presentation, diagnosis, impact of HIV and both the medical and surgical options in the management of spinal TB.

Cite this article: Bone Joint J 2018;100-B:425–31.

Adolescent idiopathic scoliosis (AIS) is a complex 3D deformity of the spine. Its prevalence is between 2% and 3% in the general population, with almost 10% of patients requiring some form of treatment and up to 0.1% undergoing surgery. The cosmetic aspect of the deformity is the biggest concern to the patient and is often accompanied by psychosocial distress. In addition, severe curves can cause cardiopulmonary distress. With proven benefits from surgery, the aims of treatment are to improve the cosmetic and functional outcomes. Obtaining correction in the coronal plane is not the only important endpoint anymore. With better understanding of spinal biomechanics and the long-term effects of multiplanar imbalance, we now know that sagittal balance is equally, if not more, important. Better correction of deformities has also been facilitated by an improvement in the design of implants and a better understanding of metallurgy. Understanding the unique character of each deformity is important. In addition, using the most appropriate implant and applying all the principles of correction in a bespoke manner is important to achieve optimum correction.

In this article, we review the current concepts in AIS surgery.

Cite this article: Bone Joint J 2018;100-B:415–24.

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 fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine.

Aims

The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (sd 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications.

Aims

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy.

Aims

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.

The mucopolysaccharidoses (MPS) are a group of inherited lysosomal storage disorders with clinical manifestations relevant to the orthopaedic surgeon. Our aim was to review the recent advances in their management and the implications for surgical practice.

The current literature about MPSs is summarised, emphasising orthopaedic complications and their management.

Recent advances in the diagnosis and management of MPSs include the recognition of slowly progressive, late presenting subtypes, developments in life-prolonging systemic treatment and potentially new indications for surgical treatment. The outcomes of surgery in these patients are not yet validated and some procedures have a high rate of complications which differ from those in patients who do not have a MPS.

The diagnosis of a MPS should be considered in adolescents or young adults with a previously unrecognised dysplasia of the hip. Surgeons treating patients with a MPS should report their experience and studies should include the assessment of function and quality of life to guide treatment.

Cite this article: Bone Joint J 2017;99-B:1132–9

Aims

We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique.

Aims

There is no consensus about the best method of achieving equal leg lengths at total hip arthroplasty (THA) in patients with Crowe type-IV developmental dysplasia of the hip (DDH). We reviewed our experience of a consecutive series of patients who underwent THA for this indication.

Aims

In the United Kingdom, lower incidences of intraspinal abnormalities in patients with early onset idiopathic scoliosis have been observed than in studies in other countries. We aimed to determine the rates of these abnormalities in United Kingdom patients diagnosed with idiopathic scoliosis before the age of 11 years.

Objectives

The objective of this study was to assess the association between whole body sagittal balance and risk of falls in elderly patients who have sought treatment for back pain. Balanced spinal sagittal alignment is known to be important for the prevention of falls. However, spinal sagittal imbalance can be markedly compensated by the lower extremities, and whole body sagittal balance including the lower extremities should be assessed to evaluate actual imbalances related to falls.

Aims

Lumbar fusion is known to reduce the variation in pelvic tilt between standing and sitting. A flexible lumbo-pelvic unit increases the stability of total hip arthroplasty (THA) when seated by increasing anterior clearance and acetabular anteversion, thereby preventing impingement of the prosthesis. Lumbar fusion may eliminate this protective pelvic movement. The effect of lumbar fusion on the stability of total hip arthroplasty has not previously been investigated.

Objectives. Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients. Patients and Methods. Patients with single-level acute osteoporotic vertebral compression fracture at thoracolumbar junction (T10 to L2) were followed. If the patients were not satisfied with acute pain reduction after a three-week conservative treatment, vertebroplasty was recommended. Pain assessment was carried out at the time of diagnosis, as well as three, four, six, and 12 weeks after the diagnosis. The effect of vertebroplasty, compared with conservative treatment, on back pain (visual analogue score, VAS) was analysed with the use of analysis-of-covariance models that adjusted for pre-operative VAS scores. Results. A total of 342 patients finished the 12-week follow-up, and 120 patients underwent vertebroplasty (35.1%). The effect of vertebroplasty over conservative treatment was significant regardless of age, body mass index, medical comorbidity, previous fracture, pain duration, bone mineral density, degree of vertebral body compression, and canal encroachment. However, the effect of vertebroplasty was not significant at all time points in patients with increased sagittal vertical axis. Conclusions. For single-level acute osteoporotic vertebral compression fractures, the effect of vertebroplasty was less favourable in patients with increased sagittal vertical axis (> 5 cm) possible due to aggravation of kyphotic stress from walking imbalance. Cite this article: Y-C. Kim, D. H. Bok, H-G. Chang, S. W. Kim, M. S. Park, J. K. Oh, J. Kim, T-H. Kim. Increased sagittal vertical axis is associated with less effective control of acute pain following vertebroplasty. Bone Joint Res 2016;5:544–551. DOI: 10.1302/2046-3758.511.BJR-2016-0135.R1

Aims. Patients with multiple myeloma (MM) develop deposits in the spine which may lead to vertebral compression fractures (VCFs). Our aim was to establish which spinopelvic parameters are associated with the greatest disability in patients with spinal myeloma and VCFs. Patients and Methods. We performed a retrospective cross-sectional review of 148 consecutive patients (87 male, 61 female) with spinal myeloma and analysed correlations between spinopelvic parameters and patient-reported outcome scores. The mean age of the patients was 65.5 years (37 to 91) and the mean number of vertebrae involved was 3.7 (1 to 15). Results. The thoracolumbar region was most commonly affected (109 patients, 73.6%), and was the site of most posterior vertebral wall defects (47 patients, 31.8%). Poorer Oswestry Disability Index scores correlated with an increased sagittal vertical axis (p = 0.006), an increased number of VCFs (p = 0.035) and sternal involvement (p = 0.012). Poorer EuroQol visual analogue scale scores correlated with posterior vertebral wall defects in the thoracolumbar region (p = 0.012). The sagittal vertical axis increased with the number of fractures and kyphosis in the thoracolumbar (p = 0.009) and lumbar (p < 0.001) regions. Conclusions. In MM, patients with VCFs have poorer clinical scores at presentation in the presence of sagittal imbalance. Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis. Patients with MM should be screened for spinal lesions early. Cite this article: Bone Joint J 2016;98-B:1234–9

Aims

There is a paucity of information on the pre-operative coronal imbalance in patients with degenerative lumbar scoliosis (DLS) and its influence on surgical outcomes.

Aims

We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with early-onset scoliosis.

Aims

Loosening of pedicle screws is a major complication of posterior spinal stabilisation, especially in the osteoporotic spine. Our aim was to evaluate the effect of cement augmentation compared with extended dorsal instrumentation on the stability of posterior spinal fixation.

Aims. The aims of our study were to provide long-term information on the behaviour of the thoracolumbar/lumbar (TL/L) curve after thoracic anterior correction and fusion (ASF) and to determine the impact of ASF on pulmonary function. Patients and Methods. A total of 41 patients (four males, 37 females) with main thoracic (MT) adolescent idiopathic scoliosis (AIS) treated with ASF were included. Mean age at surgery was 15.2 years (11 to 27). Mean follow-up period was 13.5 years (10 to 18). Results. For the TL/L curve, the mean curve flexibility evaluated with supine pre-operative bending radiographs was 78.6% (standard deviation 16.5%), with no significant loss of correction observed. On comparing patients with an increase of the TL/L curve increase (> 4º, n = 9, 22%) to those without, significant differences were observed in the correction rate of the MT curve at the final follow-up (p = 0.011), correction loss of the MT curve (p = 0.003) and the proportion of patients who had semi-rigid instrumentation (p = 0.003). Pre-operative percentage predicted forced vital capacity (%FVC) was 80%, dropping to 72% at final follow-up (p < 0.001). The Scoliosis Research Society questionnaire score was not significantly different between patients with and without a TL/L curve increase (p = 0.606). Spontaneous lumbar curve correction (SLCC) was maintained up to 18 years following selective ASF in most patients and demonstrated significant correlation with maintenance of MT curve correction. Conclusion. Maintenance of MT curve correction using rigid instrumentation provided stable SLCC over time. An observed 8% decrease in %FVC indicates that ASF should be reserved for patients with no or only mild pulmonary impairment. Cite this article: Bone Joint J 2016;98-B:997–1002

Aims

To clarify the asymmetrical ossification of the epiphyseal ring between the convex and concave sides in patients with adolescent idiopathic scoliosis (AIS).

Aims. The aim of this study is to introduce and investigate the efficacy and feasibility of a new vertebral osteotomy technique, vertebral column decancellation (VCD), for rigid thoracolumbar kyphotic deformity (TLKD) secondary to ankylosing spondylitis (AS). . Patients and Methods. We took 39 patients from between January 2009 and January 2013 (26 male, 13 female, mean age 37.4 years, 28 to 54) with AS and a TLKD who underwent VCD (VCD group) and compared their outcome with 45 patients (31 male, 14 female, mean age 34.8 years, 23 to 47) with AS and TLKD, who underwent pedicle subtraction osteotomy (PSO group), according to the same selection criteria. The technique of VCD was performed at single vertebral level in the thoracolumbar region of AS patients according to classification of AS kyphotic deformity. Pre- and post-operative chin-brow vertical angle (CBVA), sagittal vertical axis (SVA) and sagittal Cobb angle in the thoracolumbar region were reviewed in the VCD and PSO groups. Intra- , post-operative and general complications were analysed in both group. Results. lf patients could lie on their backs and walk with horizontal vision and sagittal profile, radiographic parameters improved significantly post-operatively in both groups. No major acute complications such as death or complete paralysis occurred in either group. In the VCD group, five patients (12.8%) experienced complications such as severe CSF leak (n = 4), deep wound infection (n = 1) and in one patient a transient neurological deficit occurred. In the PSO group, eight patients (17.8%) suffered conditions such as severe CSF leak (n = 5), infections (n = 2) and sagittal translation at osteotomy site (n = 1). Scoliosis Research Society outcomes instrument (SRS-22) improved significantly in both groups. All patients achieved solid fusion at latest follow-up and no implant failures were noted in either group. Take home message: The VCD technique is a new, safe and effective strategy for correction of rigid TLKD in AS patients. The main advantage of the new correction mechanism is that it achieved a satisfactory correction by controlled anterior column opening and posterior column closing, avoiding the occurrence of sagittal translation. Cite this article: Bone Joint J 2016;98-B:672–8

Aims. A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS) treated between 1989 and 2000 with anterior correction and fusion surgery using dual-rod instrumentation were reviewed. . Patients and Methods. Radiographic parameters and clinical outcomes were compared among patients with lowest instrumented vertebra (LIV) at the lower end vertebra (LEV; EV group) (n = 13) and those treated by short fusion (S group), with LIV one level proximal to EV (n = 17 patients). . Results. The allocation of the surgical technique was determined by the flexibility of the TL/L curves and/or neutral vertebrae located one level above LEV as determined on preoperative radiographs. If these requirements were met a short fusion was performed. The mean follow-up period was 21.4 years (16 to 27). The mean correction rate at final follow-up was significantly lower in the S group (74 . sd. 11%) than in the EV group (88 . sd. 13%) (p = 0.004).Coronal and sagittal balance, thoracic kyphosis, lumbar lordosis, and clinical outcomes evaluated by the Scoliosis Research Society-22 questionnaire scores were equivalent between the two groups. . Conclusion. Short fusion strategy, which uses LIV one level proximal to LEV can be considered as an alternative to the conventional strategy, which includes LEV in the fusion, when highly flexible TL/L curves are confirmed and/or neutral vertebrae are located one level above LEV in patients with thoracolumbar/lumbar AIS curves. Take home message: Short fusion strategy can be considered as an alternative to the conventional strategy in patients with thoracolumbar/lumbar AIS curves undergoing anterior spinal fusion with dual-rod instrumentation. Cite this article: Bone Joint J 2016;98-B:402–9

Aims. Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed non-operatively or operatively in our institution. Methods. In all 16 patients were included (eight female: eight male; 50% male), of whom nine had Hurler, five Morquio and two Hunter syndrome. Six patients were treated non-operatively (mean age at presentation of 6.3 years; 0.4 to 12.9); mean kyphotic progression +1.5. o. /year; mean follow-up of 3.1 years (1 to 5.1) and ten patients operatively (mean age at presentation of 4.7 years; 0.9 to 14.4); mean kyphotic progression 10.8. o. /year; mean follow-up of 8.2 years; 4.8 to 11.8) by circumferential arthrodesis with posterior instrumentation in patients with flexible deformities (n = 6). Results. In the surgical group (mean age at surgery of 6.6 years; 2.4 to 16.8); mean post-operative follow-up of 6.3 years (3.5 to 10.3), mean pre-operative thoracolumbar kyphosis of 74.3. o. (42. o. to 110. o. ) was corrected to mean of 28.6. o. (0. o. to 65. o. ) post-operatively, relating to a mean deformity correction of 66.9% (31% to 100%). Surgical complications included a deep wound infection treated by early debridement, apical non-union treated by posterior re-grafting, and stable adjacent segment spondylolisthesis managed non-operatively. Thoracolumbar kyphosis > +38. o. at initial presentation was identified as predicting progressively severe deformity with 90% sensitivity and 83% specificity. Discussion. This study demonstrates that severe thoracolumbar kyphosis in patients with MPS can be effectively treated by circumferential arthrodesis. Severity of kyphosis at initial presentation may predict progression of thoracolumbar deformity. Patients with MPS may be particularly susceptible to post-operative complications due to the underlying connective tissue disorder and inherent immunological compromise. Take home message: Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses with thoracolumbar kyphosis managed non-operatively or operatively in our institution. Cite this article: Bone Joint J 2016;98-B:229–37

Aims. The authors present the results of a cohort study of 60 adult patients presenting sequentially over a period of 15 years from 1997 to 2012 to our hospital for treatment of thoracic and/or lumbar vertebral burst fractures, but without neurological deficit. . Method. All patients were treated by early mobilisation within the limits of pain, early bracing for patient confidence and all progress in mobilisation was recorded on video. Initial hospital stay was one week. Subsequent reviews were made on an outpatient basis. . Results. The mean duration from admission to final follow-up was three months, and longer follow-up was undertaken telephonically. The mean kyphosis deformity on arrival was 17.4° (5° to 29°); mean kyphosis at final discharge three months later was 19.5° (1° to 28°). Spinal canal encroachment had no influence on successful functional recovery. . Discussion. Pain has not been a significant problem for any patient, irrespective of the degree of kyphosis and no patient has a self-perception of clinical deformity. In all, 11 patients took occasional analgesia. All patients returned to their original work level or better. Two patients died 2.5 years after treatment, from unrelated causes. Take home message: The natural history of thoracolumbar burst fractures without neurology would appear to be benign. Cite this article: Bone Joint J 2016;98-B:97–101

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: Bone Joint J 2016;98-B(1 Suppl A):23–6.

Aims

We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis.

Methods. 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. Results. 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). . Discussion. The radiological and functional outcomes of both implant removal and retention were similar. Although screw breakage may occur, the implants may not need to be removed. Take home message: Implant removal may not be needed for patients with burst fractures of the thoracolumbar and lumbar spine after fixation without fusion. However, information should be provided beforehand regarding the possibility of screw breakage. Cite this article: Bone Joint J 2016;98-B:109–16

A self-control ratio, the spine-pelvis index (SPI), was proposed for the assessment of patients with adolescent idiopathic scoliosis (AIS) in this study. The aim was to evaluate the disproportionate growth between the spine and pelvis in these patients using SPI. A total of 64 female patients with thoracic AIS were randomly enrolled between December 2010 and October 2012 (mean age 13 years, standard deviation (sd) 2.17; 9 to 18) and a further 73 healthy female patients with a mean age of 12.4 years (mean age 12.4 years, sd 2.24; 9 to 18), were randomly selected from a normal control database at our centre. The radiographic parameters measured included length of spine (LOS), height of spine (HOS), length of thoracic vertebrae (LOT), height of thoracic vertebrae (HOT), width of pelvis (WOP), height of pelvis (HOP) and width of thorax (WOT). SPI was defined as the ratio LOS/HOP. The SPI and LOT/HOP in patients with AIS showed a significant increase when compared with normal girls (p < 0.001 and p < 0.001 respectively), implying an abnormal pattern of growth of the spine relative to the pelvis in patients with AIS.

No significant difference in SPI was found in different age groups in the control group, making the SPI an age-independent parameter with a mean value of 2.219 (2.164 to 2.239). We also found that the SPI was not related to maturity in the control group.

This study, for the first time, used a self-control ratio to confirm the disproportionate patterns of growth of the spine and pelvis in patients with thoracic AIS, highlighting that the SPI is not affected by age or maturity.

Cite this article: Bone Joint J 2015;97-B:1668–74.

Percutaneous placement of pedicle screws is a well-established technique, however, no studies have compared percutaneous and open placement of screws in the thoracic spine. The aim of this cadaveric study was to compare the accuracy and safety of these techniques at the thoracic spinal level. A total of 288 screws were inserted in 16 (eight cadavers, 144 screws in percutaneous and eight cadavers, 144 screws in open). Pedicle perforations and fractures were documented subsequent to wide laminectomy followed by skeletalisation of the vertebrae. The perforations were classified as grade 0: no perforation, grade 1: < 2 mm perforation, grade 2: 2 mm to 4 mm perforation and grade 3: > 4 mm perforation. In the percutaneous group, the perforation rate was 11.1% with 15 (10.4%) grade 1 and one (0.7%) grade 2 perforations. In the open group, the perforation rate was 8.3% (12 screws) and all were grade 1. This difference was not significant (p = 0.45). There were 19 (13.2%) pedicle fractures in the percutaneous group and 21 (14.6%) in the open group (p = 0.73). In summary, the safety of percutaneous fluoroscopy-guided pedicle screw placement in the thoracic spine between T4 and T12 is similar to that of the conventional open technique.

Cite this article: Bone Joint J 2015;97-B:1555–61.

Cardiac disease in patients with ankylosing spondylitis (AS) has previously been studied but not in patients with a kyphosis or in those who have undergone an operation to correct it.

The aim of this study was to measure the post-operative changes in cardiac function of patients with an AS kyphosis after pedicle subtraction osteotomy (PSO).

The original cohort consisted of 39 patients (33 men, six women). Of these, four patients (two men, two women) were lost to follow-up leaving 35 patients (31 men, four women) to study. The mean age of the remaining patients was 37.4 years (22.3 to 47.8) and their mean duration of AS was 17.0 years (4.6 to 26.4). Echocardiographic measurements, resting heart rate (RHR), physical function score (PFS), and full-length standing spinal radiographs were obtained before surgery and at the two-year follow-up.

The mean pre-operative RHR was 80.2 bpm (60.6 to 112.3) which dropped to a mean of 73.7 bpm (60.7 to 90.6) at the two-year follow-up (p = 0.0000). Of 15 patients with normal ventricular function pre-operatively, two developed mild left ventricular diastolic dysfunction (LVDD) at the two-year follow-up. Of 20 patients with mild LVDD pre-operatively only five had this post-operatively. Overall, 15 patients had normal LV diastolic function before their operation and 28 patients had normal LV function at the two-year follow-up.

The clinical improvement was 15 out of 20 (75.0%): cardiac function in patients with AS whose kyphosis was treated by PSO was significantly improved.

Cite this article: Bone Joint J 2015;97-B:1405–10.