Comparative analysis of femoral bone loss: uncemented vs. cemented aseptic stem loosening in first-time revision surgery-a retrospective evaluation of 215 patients.

INTRODUCTION: The integrity of the femoral bone is crucial when considering reconstructive options for the first-time revision of a total hip arthroplasty (THA). Aseptic loosening of primary stems, whether cemented or uncemented, significantly affects the volume and quality of resultant femoral bone loss. This study evaluates the impact of the initial fixation method on femoral bone defect patterns by comparing the extent of bone loss. MATERIALS AND METHODS: A retrospective cohort of 215 patients with either cemented or uncemented stems, indicated for aseptic stem loosening, and undergoing first-time stem revision from 2010 to 2022 at our institution was analyzed. Femoral bone loss extent at first-time revision was preoperatively gauged using radiographs and categorized by the Paprosky classification. Survival probabilities pre-first-time revision for both stem types were calculated using Kaplan-Meier methods. Hazard ratios were applied to compare the risk of initial revision for uncemented versus cemented stems within the first and subsequent 2nd to 10th years post-primary implantation. RESULTS: Cemented stems were associated with a higher occurrence of significant bone defects of type 3a (23.53% vs. 14.02%, p = .108), 3b (39.22% vs. 1.22%, p < .001), and 4 (3.92% vs. 0.00%) compared to uncemented stems. Conversely, smaller defects of type 1 and 2 were more prevalent in uncemented stem loosening (84.76% vs. 33.33%, p < .001). Notably, cemented stems exhibited a significantly prolonged revision-free period over the complete decade following primary insertion (p < .001). The unadjusted risk of first-time revision due to stem loosening showed a tendency to an increase in uncemented stems within the initial postoperative year (HR 5.55, 95% CI 0.74; 41.67, p = .096), and an adjusted risk of 2.1 (95% CI 0.26; 16.53, p = .488). However, these differences did not reach statistical significance. In the subsequent 2nd-10th years, the risk was lower compared to cemented stems (HR 2.35, 95% CI 1.39; 3.99, p = .002). CONCLUSIONS: Uncemented primary stems necessitating first-time revision due to aseptic loosening demonstrated notably smaller femoral bone defects in comparison to primary cemented stems.

[Cervical Spine Injuries]. / Verletzungen der oberen Halswirbelsäule.

Around a third of all cervical spine injuries occur in the upper cervical spine in the area between the occiput and the second cervical vertebra. The latter being the most common location of the injury with around 70%. But also atlas fractures, occipital condyle fractures, traumatic spondylolisthesis of C2, atypical fractures in the corpus area as well as atlantooccipital and atlantoaxial ligamentous lesions should be mentioned in connection with injuries in this area. In many cases, conservative therapy regimen is possible. In unstable or displaced injuries, however, surgical intervention is required, with various surgical procedures being used. The frequency, diagnostics, classification, and standard therapy of the individual entities are presented in detail in this continuing medical education article.

In idiopathic scoliosis distances of spinal cord to thoracic pedicle are within 2 mm in a large region of the thoracic apex.

Despite a 15% misplacement rate of screws in idiopathic scoliosis surgery, little is known about the relationship between pedicles and nerve structures in the entire thoracic curve. This study aimed to explore the spinal cord's proximity to the pedicle wall at each thoracic vertebra in the entire thoracic curve, while considering different anatomical changes. Spinal cord to medial pedicle distances were measured on magnetic resonance imaging in 73 patients who underwent posterior spinal fusion with pedicle screw instrumentation. Associations with different variables were examined. A total of 51 patients (69.9%) showed a distance within 2 mm at the apex vertebra on the concave side, more than 50% had a distance within 2 mm in the next thoracic vertebra level above and below, and more than 25% two levels above and below. Weak correlations were found between proximity of the spinal cord at the apex vertebra and vertebra's level and Cobb angle on the concave side (r = - 0.310, P = 0.008, r = 0.380, P = 0.001, respectively). These results emphasize the importance of thorough assessment when placing thoracic pedicle screws in idiopathic scoliosis patients. Further research is warranted to develop surgical strategies aimed at preventing potentially neurological complications resulting from screw misplacement.

Abdominal Aortic Calcification is Associated with Degeneration of The Paraspinal Muscles - A Retrospective cross-sectional Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To analyze the relationship of abdominal aortic calcification (AAC) and a reduction in the cross-sectional area (CSA) and the fatty infiltration (FI) of the paravertebral muscles in patients undergoing lumbar fusion surgery. BACKGROUND: Both AAC and paraspinal muscle degeneration have been shown to be associated with poorer outcomes after surgical treatment of degenerative diseases of the lumbar spine. However, there is a lack of data on the association between AAC and paraspinal muscle changes in patients undergoing spine surgery. METHODS: We retrospectively analyzed patients undergoing lumbar fusion for degenerative spinal pathologies. Muscular and spinal degeneration were measured on magnetic resonance imaging (MRI). AAC was classified on lateral lumbar radiographs. The association of AAC and paraspinal muscle composition was assessed by a multivariate regression analysis adjusted for age, sex, body mass index (BMI), comorbidities, and lumbar degeneration. RESULTS: A total of 301 patients was included. Patients with AAC showed significantly higher degrees of intervertebral disc and facet joint degeneration as well as higher total endplate scores at the L3/4 level. The univariable regression analysis showed a significant positive correlation between the degree of AAC and the FI of the erector spinae (b=0.530, P<0.001) and multifidus (b=0.730, P<0.001). The multivariable regression analysis showed a significant positive correlation between the degree of AAC and the FI of the erector spinae (b=0.270, P=0.006) and a significant negative correlation between the degree of AAC and the CSA of the psoas muscle (b=-0.260, P=0.003). CONCLUSION: This study demonstrates a significant and independent association between AAC and degeneration of the erector spinae and the psoas muscles in patients undergoing lumbar fusion. As both AAC and degeneration of paraspinal muscles impact postoperative outcomes negatively, preoperative assessment of AAC may aid in identifying patients at higher risk after lumbar surgery.

Schober test is not a valid assessment tool for lumbar mobility.

The Schober test is considered reliable in evaluating lumbar mobility and its impairment. Especially in patients with chronic low back pain (cLBP) identification of functional restriction is important. We aimed to investigate whether the 5 cm Schober cut-off provides a valid distinction between unrestricted and restricted mobility in participants with and without cLBP (18-65 years). cLBP is defined as LBP persisting for ≥ 12 weeks. We analyzed agreement between the Schober test with two measurement devices (Epionics SPINE®; Idiag M360®) and the influence of lumbar lordosis (LL) on their agreement. Also, the sensitivity and specificity of the Schober test was evaluated. For 187 participants (49.6%) Epionics SPINE® RoF and Schober test matched (either ≥ 5 cm; > 40.8° RoF or ≤ 5 cm; < 40.8° RoF), for 190 participants (50.4%) the two measurements did not. Idiag M360® RoF of 190 participants (50.4%) showed corresponding results (either ≥ 5 cm; > 46.0° RoF or ≤ 5 cm; < 46.0° RoF). Non-agreement was seen in 187 participants (49.6%). LL differed significantly in the Epionics SPINE® cohort (p < 0.001). Regarding the Epionics SPINE® cohort, Schober test showed a sensitivity of 79.6% with a specificity of 36.1%. For the Idiag M360® cohort, Schober test showed a sensitivity of 68.2% and a specificity of 46.6%. Our results do not establish a consistent matching between Schober test and the device measurements. Therefore, Schober test may not be valid to predict impairment of lumbar mobility. We recommend Schober test as an add-on in monitoring of an individual relative to its case.

Influences of lumbo-sacral transitional vertebrae for anterior lumbar interbody fusion.

Lumbo-sacral transitional vertebrae (LSTV) are frequent congenital variances of the spine and are associated with increased spinal degeneration. Nevertheless, there is a lack of data whether bony alterations associated with LSTV result in reduced segmental restoration of lordosis when performing ALIF. 58 patients with monosegmental stand-alone ALIF in the spinal segment between the 24th and 25th vertebra (L5/S1)/(L5/L6) where included. Of these, 17 patients had LSTV and were matched to a control population by age and sex. Pelvic incidence, pelvic tilt, sagittal vertical axis, lumbar lordosis, segmental lordosis, disc height and depth were compared. LSTV-patients had a significantly reduced segmental lordosis L4/5 (p = 0.028) and L5/S1/(L5/L6) (p = 0.041) preoperatively. ALIF resulted in a significant increase in segmental lordosis L5/S1 (p < 0.001). Postoperatively, the preoperatively reduced segmental lordosis was no longer significantly different in segments L4/5 (p = 0.349) and L5/S1/(L5/6) (p = 0.576). ALIF is associated with a significant increase in segmental lordosis in the treated segment even in patients with LSTV. Therefore, ALIF is a sufficient intervention for restoring the segmental lordosis in these patients as well.

Cartilage Destruction by Hemophilic Arthropathy Can Be Prevented by Inhibition of the Ferroptosis Pathway in Human Chondrocytes.

(1) Background: Around 50% of hemophilia patients develop severe arthropathy, with even subclinical hemorrhage in childhood potentially leading to intra-articular iron deposition, synovia proliferation, neoangiogenesis, and eventual damage to articular cartilage and subchondral bone. Treatments typically include coagulation factor substitution, radiosynoviorthesis, and joint replacement for advanced cases. This study aims to elucidate programmed cell death mechanisms in hemophilic arthropathy (HA) to identify novel treatments. (2) Methods: Human chondrocytes were exposed to lysed/non-lysed erythrocytes, ferroptosis inducer ML-162, cytokines (IL-1ß, TNFα), and ferric citrate, then assessed for metabolic activity, DNA content, and cell death using Alamar Blue, cyQUANT, and Sytox assays. Three-dimensional spheroids served as a cartilage model to study the effects of erythrocytes and ML-162. (3) Results: Erythrocytes caused significant cell death in 2D cultures (p < 0.001) and damaged 3D chondrocyte spheroids. Iron citrate and erythrocytes reduced chondrocyte DNA content (p < 0.001). The ferroptosis pathway was implicated in cell death, with no effects from apoptosis and necroptosis inhibitors. (4) Conclusions: This study offers insights into HA's cell death pathway, suggesting ferroptosis inhibitors as potential therapies. Further studies are needed to evaluate their efficacy against the chronic effects of HA.

Microbial spectrum, patient-specific factors, and diagnostics in implant-related postoperative spondylodiscitis.

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. Methods: Patients treated for IPOS from January 2006 to December 2020 were included. Patient demographics, parameters upon admission and discharge, radiological imaging, and microbiological results were retrieved from medical records. CT and MRI were analyzed for epidural, paravertebral, and intervertebral abscess formation, vertebral destruction, and endplate involvement. Pathogens were identified by CT-guided or intraoperative biopsy, intraoperative tissue sampling, or implant sonication. Results: A total of 32 cases of IPOS with a mean patient age of 68.7 years (37.6 to 84.1) were included. Diabetes, age > 60 years, and history of infection were identified as risk factors. Patient presentation upon admission included a mean body temperature of 36.7°C (36.1 to 38.0), back pain at rest (mean visual analogue scale (VAS) mean 5/10) and when mobile (mean VAS 6/10), as well as elevated levels of CRP (mean 76.8 mg/l (0.4 to 202.9)) and white blood cell count (mean 9.2 units/nl (2.6 to 32.8)). Pathogens were identified by CT-guided or conventional biopsy, intraoperative tissue sampling, or sonication, and Gram-positive cocci presented as the most common among them. Antibiotic therapy was established in all cases with pathogen-specific treatment in 23 (71.9%) subjects. Overall 27 (84.4%) patients received treatment by debridement, decompression, and fusion of the affected segment. Conclusion: Cases of IPOS are rare and share similarities with spontaneous spondylodiscitis. While procedures such as CT-guided biopsy and sonication are valuable tools in the diagnosis of IPOS, MRI and intraoperative tissue sampling remain the gold standard. Research on known principles of PJI such as implant retention versus implant exchange need to be expanded to the field of spine surgery.

Examining the Role of Paraspinal Musculature in Post-Operative Disability after Lumbar Fusion Surgery for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective analysis of prospectively enrolled patients. OBJECTIVE: To evaluate the relationship between paraspinal muscle (PM) atrophy and Oswestry Disability Index (ODI) improvement after spinal fusion surgery for degenerative lumbar spondylolisthesis (DLS). BACKGROUND: Atrophy of the PM is linked to multiple spinal conditions, sagittal malalignment, and increased postoperative complications. However, only limited evidence for the effect on patient-reported outcomes exists. METHODS: Patients with DLS undergoing decompression and fusion surgery were analyzed. Patients with missing follow-up, no imaging, or inadequate image quality were excluded. The Oswestry Disability Index (ODI) was assessed preoperatively and two years postoperatively. A cross-sectional area of the PM was measured on a T2-weighted Magnetic Resonance Imaging (MRI) sequence at the upper endplate of L4. Based on the literature, a 10-point improvement cut-off was defined as the minimum clinically important difference (MCID). Patients with a baseline ODI below the MCID were excluded. Logistic regression was used to calculate the association between fatty infiltration (FI) of the PM and improvement in ODI, adjusted for age, sex, and body mass index (BMI). RESULTS: 133 patients were included in the final analysis, with only two lost to follow-up. The median age was 68 years (IQR 62 - 73). The median preoperative ODI was 23 (IQR 17 - 28), and 76.7% of patients showed improvement in their ODI score by at least 10 points. In the multivariable regression, FI of the erector spinae and multifidus increased the risk of not achieving clinically relevant ODI improvement (P=0.01 and P<0.001, respectively). No significant association was found for the psoas muscle (P=0.158). CONCLUSIONS: This study demonstrates that FI of the erector spinae and multifidus, is significantly associated with less likelihood of clinically relevant ODI improvement following decompression and fusion. Further research is needed to assess the effect of interventions.

Adolescent idiopathic scoliosis is associated with muscle area asymmetries in the lumbar spine.

PURPOSE: While the etiopathogenesis of adolescent idiopathic scoliosis (AIS) remains unclear, it is assumed that muscular asymmetries contribute to curve progression. As previous studies have found asymmetries of the thoracic paraspinal muscles in AIS patients, our study's aim was to analyze differences in the erector spinae, multifidus, quadratus lumborum, and psoas muscles of the lumbar spine depending on the curve's radiographic characteristics. METHODS: We retrospectively included all patients who received posterior reposition spondylodesis for AIS treatment at our institution. Patients were classified according to the Lenke classification. Muscle cross-sectional areas were obtained from magnetic resonance imaging of the lumbar spine. Data were analyzed with the Wilcoxon rank sum test, the Kruskal-Wallis test with post hoc testing, or the Spearman's correlation coefficient. RESULTS: Seventy-four (14 males and 60 females) AIS patients with a median age of 16 (IQR ± 4) years and a mean Cobb angle of 56.0° (± 18.0°) were included. In curve types Lenke 1 and 2 (n = 45), the erector spinae (p < 0.001) and multifidus (p < 0.001) muscles had a significantly larger cross-sectional area on the convex side, whereas the quadratus lumborum (p = 0.034) and psoas (p < 0.001) muscles each had a significantly larger cross-sectional area on the lumbar contralateral side. CONCLUSION: Our results show an asymmetry of the lumbar spine's muscles which depends on both the convexity and the extent of the scoliotic curve. While our results cannot prove whether these differences are the deformity's cause or effect, they may contribute to a better understanding of AIS pathogenesis and may allow for more specific preoperative physiotherapy.

The influence of lumbo-sacral transitional vertebrae in developmental dysplasia of the hip: a matched pair analysis.

Lumbo-sacral transitional vertebrae (LSTV) are the most common congenital alteration of the lumbo-sacral junction and known to significantly influence pelvic anatomy. However, the influence of LSTV on dysplasia of the hip (DDH) and the surgical treatment by periacetabular osteotomy (PAO) remains unknown. We retrospectively examined standardized standing anterior-posterior pelvic radiographs of 170 patients in 185 PAO procedures. Radiographs were examined for LSTV, lateral-central-edge-angle (LCEA), Tönnis-angle (TA), femoral-head-extrusion index (FHEI), and anterior-wall-index (AWI) and posterior-wall-index (PWI). Patients with LSTV were compared to an age- and sex-matched control group. Patient-reported outcome measurements (PROMs) were evaluated pre- and in the mean 63.0 months (range 47-81 months) postoperatively. 43 patients (25.3%) had LSTV. Patients with LSTV had significantly greater PWI (p = 0.025) compared to the matched control group. No significant differences were seen in AWI (p = 0.374), LCEA (p = 0.664), TA (p = 0.667), and FHEI (p = 0.886). Between the two groups, no significant differences were detected in pre- or postoperative PROMs. Due to the increased dorsal femoral head coverage in patients with LSTV and DDH compared to patients with sole DDH, a more pronounced ventral tilting might be performed in those patients with prominent posterior wall sign to avoid anterior undercoverage, which is a significant predictor for premature conversion to hip arthroplasty after PAO. However, anterior overcoverage or acetabular retroversion must be avoided due to the risk of femoroacetabular impingement. Patients with LSTV reported similar functional outcomes and activity after PAO as the control group. Therefore, even for patients with concomitant LSTV, which are frequent with one-fourth in our cohort, PAO is an efficient treatment option to improve clinical symptoms caused by DDH.

Clustered Occurrence of Osteitis Condensans Ilii in Patients with Symptomatic Hip Dysplasia.

BACKGROUND: Osteitis condensans ilii (OCI) is a relatively rare benign disease of the lower anterior sacroiliac joint (SIJ) region that can cause symptoms such as low back pain (LBP), lateral hip pain and nonspecific hip or thigh pain. Its exact pathoetiology remains to be clarified. The aim of this study is to determine the prevalence of OCI in patients with symptomatic developmental dysplasia of the hip (DDH) undergoing periacetabular osteotomy (PAO) to identify potential clustering of OCI in a with altered biomechanics of hip and SIJs. METHODS: A retrospective investigation of all patients who underwent periacetabular osteotomy in a tertiary reference hospital from January 2015 to December 2020. Clinical and demographic data were retrieved from the hospital's internal medical records. Radiographs and magnetic resonance images (MRIs) were reviewed for the presence of OCI. A t-test for independent variables was conducted to identify differences between patients with and without OCI. A binary logistic regression model was established to determine the influence of age, sex and body mass index (BMI) on the presence of OCI. RESULTS: The final analysis included 306 patients (81% female). In 21.2% of the patients (f: 22.6%; m: 15.5%), OCI was present. BMI was significantly higher in patients with OCI (23.7 kg/m2 vs. 25.0 kg/m2; p = 0.044). Binary logistic regression revealed that a higher BMI increased the likelihood of sclerosis in typical osteitis condensans locations, OR = 1.104 (95%-CI [1.024, 1.191]), as did female sex, OR = 2.832 (95%-CI [1.091, 7.352]. CONCLUSIONS: Our study revealed a considerably higher prevalence of OCI in patients with DDH than in the general population. Furthermore, BMI was shown to have an influence on the occurrence of OCI. These results support the theory that OCI is attributable to altered mechanical loading of the SIJs. Clinicians should be aware that OCI is common in patients with DDH and a potential cause of LBP, lateral hip pain and nonspecific hip or thigh pain.

Avoiding Spinal Implant Failures in Osteoporotic Patients: A Narrative Review.

STUDY DESIGN: Narrative review. OBJECTIVES: With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review's purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. METHODS: We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. RESULTS: Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. CONCLUSIONS: As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.

Finger-Floor Distance Is Not a Valid Parameter for the Assessment of Lumbar Mobility.

Low back pain (LBP) could be associated with a reduced lumbar mobility. For the evaluation of lumbar flexibility, parameters such as finger-floor distance (FFD) are historically established. However, the extent of the correlation of FFD to lumbar flexibility or other involved joint kinematics such as pelvic motion, as well as the influence of LBP, is not yet known. We conducted a prospective cross-sectional observation study with 523 participants included (167 with LBP > 12 weeks, 356 asymptomatic). LBP-participants were matched for sex, age, height, and body-mass-index with an asymptomatic control cohort, resulting in two cohorts with 120 participants each. The FFD in maximal trunk flexion was measured. The Epionics-SPINE measurement-system was used to evaluate the pelvic and lumbar Range-of-Flexion (RoF), and the correlation of FFD to pelvic- and lumbar-RoF was evaluated. In an asymptomatic sub-cohort of 12 participants, we examined the individual correlation of FFD to pelvic- and lumbar-RoF under gradual trunk flexion. Participants with LBP showed a significantly reduced pelvic-RoF (p < 0.001) and lumbar-RoF (p < 0.001) as well as an increased FFD (p < 0.001) compared to the asymptomatic control cohort. Asymptomatic participants exhibited a weak correlation of FFD to pelvic-RoF and lumbar-RoF (r < 0.500). LBP patients revealed a moderate correlation of FFD to pelvic-RoF (male: p < 0.001, r = -0.653, female: p < 0.001, r = -0.649) and sex-dependent to lumbar-RoF (male: p < 0.001, r = -0.604, female: p = 0.012, r = -0.256). In the sub-cohort of 12 participants, gradual trunk flexion showed a strong correlation of FFD to pelvic-RoF (p < 0.001, r = -0.895) but a moderate correlation to lumbar-RoF (p < 0.001, r = -0.602). The differences in FFD in an individual patient, assuming consistent hip function, may be attributed partially to the differences in lumbar flexibility. However, the absolute values of FFD do not qualify as a measure for lumbar mobility. Rather, using validated non-invasive measurement devices should be considered.

Safe Zones for Spinopelvic Screws in Patients With Lumbosacral Transitional Vertebra.

STUDY DESIGN: Retrospective matched-pair analysis. OBJECTIVES: Lumbosacral transitional vertebrae (LSTV) have a reported prevalence of 4-36% in the population. The safe zones for screw placement for spinopelvic fusion in adult spinal deformity surgery for patients with LSTV have not been described in the literature. Our study aimed to assess the safety of S1-pedicle screw (S1PS), S2-alar screw (S2AS), S2-alar-iliac screw (S2AIS), and iliac screw (IS) placement in patients with LSTV. METHODS: Out of the 819 examined patients, 49 patients with LSTV were included in our retrospective analysis with a matched pair control group. We used the 3-dimensional planning tool mediCAD for screw placement of S1PS, S2AS, S2AIS, IS with different angles, length and diameters. RESULTS: We evaluated a total of 10 192 screw trajectories. No serious complications occurred due to the trajectories used for S1PS. LSTV increased the risk of vessel injury for S2AS trajectories (P = .001) but not for S2AIS (P = .526). Besides the presence of an LSTV, the screw trajectory had a major influence on the frequency of serious complications. CONCLUSIONS: Sacral anchoring of long spinal constructions using S1PS, S2AS, S2AIS and IS is also possible in the presence of LSTV. For S2AS the trajectory with 30° lateral and caudal angulation of 10° showed the least vascular injuries and the least sacro-iliac-joint violations in patients with LSTV. S2AIS trajectories with 40° lateral and 0° sagittal angulation reduced the risk of serious complications in our patients collective with LSTV.

Validation of the TLICS and AOSpine injury score for surgical management of paediatric traumatic spinal injuries.

INTRODUCTION: Fractures of the thoracolumbar spine in children are rare. Consequently, classification systems providing detailed treatment recommendations as already established in adults are still lacking in the paediatric population. We aimed to evaluate the validity and reliability of the thoracolumbar injury classification and severity score system (TLICS) and the AOSpine injury score in paediatric patients presenting with a traumatic fracture of the thoracolumbar spine. MATERIALS AND METHODS: Patients younger than 18 years presenting with a traumatic thoracolumbar fracture at a large academic trauma centre between 2010 and 2020 were included retrospectively. Demographic and clinical data were retrieved from electronic medical reports. The AOSpine injury score and TLICS were calculated using plain radiography, magnetic resonance imaging, and/or computed tomography. RESULTS: Sixty patients with 167 fractures were included. Surgical treatment was performed in 14 patients. The mean AOSpine injury score was 1.49 ± 2.0, the mean TLICS was 1.32 ± 1.65. A significant correlation between the classification systems was found (Spearman r = 0.975, p < 0.001). Interrater reliability analysis revealed Kappa values of 0.868 for the TLICS and 0.860 for the AOSpine injury score (p < 0.001). Contingency table analysis showed a sensitivity of 1.00 and specificity of 0.94 for the AOSpine injury score and a sensitivity of 0.90 and specificity of 0.90 for the TLICS in predicting the performed treatment. CONCLUSIONS: Our results confirm that the TLICS is a valid classification system for determining treatment decisions in paediatric patients and show slightly higher accuracy of the AOSpine injury score as well as high interrater reliabilities for both classification systems.

Scientific Productivity of University Orthopaedics and Trauma Surgery in Germany, Austria, and Switzerland. / Wissenschaftliche Produktivität der universitären Orthopädie und Unfallchirurgie in der DACH-Region.

BACKGROUND: Despite major achievements, such as the development of hip prostheses, scientific productivity in orthopaedics and trauma surgery has hardly been investigated. Our study's aim therefore was to analyse the correlation between the leading physicians' h-index and their academic rang, in order to determine whether this objective measure of scientific accomplishments correlates with clinical position. METHODS: All physicians in leading positions at university hospitals' orthopaedics or trauma surgery departments in Germany, Austria, and Switzerland were included. Year of habilitation, number of publications and citations as well as h-index were collected from September to November 2020. RESULTS: A total of 844 leading physicians at 46 university hospitals were included. Professors had the highest number of total publications (117.4 ± 124.8, p < 0.001) and highest h-index (20.1 ± 10.1, p < 0.001). We found significant differences in the total number of publications (p = 0.001), publications in the last three years (p < 0.001), and h-index (p < 0.001) between the three investigated nations, with all parameters being highest in Switzerland. CONCLUSION: Our study shows that increasing scientific productivity is correlated with academic success. The country-specific differences indicate significant differences in the value of scientific activity in daily clinical routine.

Lumbosacral transitional vertebrae alter the distribution of lumbar mobility-Preliminary results of a radiographic evaluation.

BACKGROUND: Lumbo-sacral transitional vertebrae (LSTV) are one of the most common congenital variances of the spine. They are associated with an increased frequency of degeneration in the cranial adjacent segment. Hypermobility and concomitant increased loads are discussed as a possible reason for segmental degeneration. We therefore examined the lumbar and segmental motion distribution in patients with LSTV with flexion-extension radiographs. METHODS: A retrospective study of 51 patients with osteochondrosis L5/S1 with flexion and extension radiographs was performed. Of these, 17 patients had LSTV and were matched 1:1 for age and sex with patients without LSTV out of the collective of the remaining 34 patients. The lumbar and segmental range of motion (RoM) by segmental lordosis angle and the segmental wedge angle were determined. Normal distribution of parameters was observed by Kolmogorov-Smirnov-test. Parametric data were compared by paired T-test. Non-parametric data were compared by Wilcoxon-rank-sum-test. Correlations were observed using Spearman's Rank correlation coefficient. A p-value <0.05 was stated as statistically significant. RESULTS: Patients with LSTV had mean age of 52.2±10.9, control group of 48.9±10.3. Both groups included 7 females and 10 males. Patients with LSTV presented with reduced RoM of the lumbar spine (LSTV 37.3°±19.2°, control 52.1°±20.5°, p = 0.065), however effects were statistically insignificant. LSTV significantly decreased segmental RoM in the transitional segment (LSTV 1.8°±2.7°, control 6.7°±6.0°, p = 0.003). Lumbar motion distribution differed significantly; while RoM was decreased in the transitional segment, (LSTV 5.7%, control 16.2%, p = 0.002), the distribution of lumbar motion to the cranial adjacent segment was increased (LSTV 30.7%, control 21.6%, p = 0.007). CONCLUSION: Patients with LSTV show a reduced RoM in the transitional segment and a significantly increased motion distribution to the cranial adjacent segment in flexion-extension radiographs. The increased proportion of mobility in the cranial adjacent segment possibly explain the higher rates of degeneration within the segment.

Periacetabular Osteotomy and Postoperative Pregnancy-Is There an Influence on the Mode of Birth?

As a surgical treatment option in symptomatic developmental dysplasia of the hip, periacetabular osteotomy (PAO) is often performed in female patients of childbearing age. Yet, to date, little is known about the procedure's influence on postoperative pregnancies and the mode of delivery. Our study's aim therefore was to investigate patient and physician decision making in women after PAO. We invited all patients who had undergone PAO in our institution from January 2015 to June 2017 to participate in a paper-based survey. Of these, we included all female patients and performed a retrospective chart review as well as analysis of pre- and postoperative radiological imaging. A total of 87 patients were included, 20 of whom gave birth to 26 children after PAO. The mean overall follow-up was 5.3 ± 0.8 years. Four (20.0%) patients reported that their obstetrician was concerned due to their history of PAO. The mean time before the first child's birth was 2.9 ± 1.3 years. Eleven (55.0%) patients underwent cesarean section for the first delivery after PAO, three of whom reported their history of PAO as the reason for this type of delivery. Patients with a history of PAO have a higher risk of delivering a child by cesarean section compared with the general population, in which the rate of cesarean section is reported to be 29.7%. As cesarean sections are associated with increased morbidity and mortality compared with vaginal deliveries, evidence-based recommendations for pregnancies after pelvic osteotomy are needed.