What factors are associated with a better restoration of pelvic version after adult spinal deformity surgery?

INTRODUCTION: Poor restoration of pelvic version after adult spinal deformity (ASD) surgery is associated with an increased risk of mechanical complications and worse quality of life. We studied the factors linked to the improvement of postoperative pelvic version. MATERIALS AND METHODS: This is a retrospective analysis of a prospective multicenter ASD database. Selection criteria were: operated patients having preoperative severe pelvic retroversion as per GAP score (Relative Pelvic Version-RPV < - 15°); panlumbar fusions to the pelvis; 2-year follow-up. Group A comprised patients with any postoperative improvement of RPV score, and group B had no improvement. Groups were compared regarding baseline characteristics, surgical factors, and postoperative sagittal parameters. Parametric and non-parametric analyses were employed. RESULTS: 177 patients were studied, median age 67 years (61; 72.5), 83.6% female. Groups were homogeneous in baseline demographics, comorbidities, and preoperative sagittal parameters (p > 0.05). The difference in RPV improvement was 11.56º. Group A (137 patients) underwent a higher percentage of ALIF procedures (OR = 6.66; p = 0.049), and posterior osteotomies (OR = 4.96; p < 0.001) especially tricolumnar (OR = 2.31; p = 0.041). It also showed a lower percentage of TLIF procedures (OR = 0.45; p = 0.028), and posterior decompression (OR = 0.44; p = 0.024). Group A displayed better postoperative L4-S1 angle and relative lumbar lordosis (RLL), leading to improved sacral slope (and RPV), and global alignment (RSA). Group A patients had longer instrumentations (11.45 vs 10; p = 0.047) and hospitalization time (13 vs 11; p = 0.045). All postoperative sagittal parameters remained significantly better in group A through follow-up. However, differences between the groups narrowed over time. CONCLUSIONS: ALIF procedures and posterior column osteotomies improved pelvic version postoperatively, and associated better L4-S1 and lumbar lordosis restoration, indirectly improving all other sagittal parameters. However, these improvements seemed to fade during the 2-year follow-up.

Influence of smoking on patient-reported outcome measures (PROMs) in patients undergoing surgery for adult spinal deformity: a propensity score-matched analysis.

PURPOSE: The purpose of this study was to determine the isolated influence of smoking in patient-reported outcome measures (PROMs) for adult spinal deformity (ASD) surgery excluding known tobacco-related complications. METHODS: Retrospective analysis of a prospective multicenter ASD database. Patients operated on ASD with 2 year post-operative follow-up were included. Former smokers (non-active smokers) and patients developing mechanical or infectious complications were excluded. Changes of PROMs over time were analyzed using mixed models for repeated measures (MMRM). Propensity score matching (PSM) (1:1 ratio, caliper 0.10) was performed without replacement using optimum algorithm, tolerance ≤ 0.001, and estimated with 95% confidence interval (CI). PROMS in both groups were compared by paired t test or Wilcoxon signed-rank test. RESULTS: 692 out of 1246 surgical patients met our inclusion criteria. 153 smokers were matched with 153 non-smokers according to age, BMI, number of fused levels, and global tilt. After PSM both groups were homogeneous regarding baseline parameters, surgical data, and complications (mechanical complications and infection excluded). Smokers had worse baseline results for SRS-total, SRS-pain COMI-back, and ODI; smokers also showed worse 2-year outcomes for SRS-total, SRS-function, SRS-pain, SRS-self-image, and ODI. However, no differences between the two groups were found in the improvement from baseline to 2-year follow-up or in the timing of this improvement (MMRM). The proportion of patients reaching the minimal clinically important difference (MCID) after surgery was similar in the two groups, but the proportion of patients reaching patient acceptable symptom state (PASS) was significantly lower in smokers for SRS-Subtotal, SRS-function, and SRS-image. CONCLUSION: Even in the absence of smoking-related complications, smokers had worse PROMs at baseline and 2 years after surgery with less patients achieving PASS, but similar degrees on improvement compared to non-smokers. The proportion achieving MCID was also similar between the two cohorts.

Partial Two-Stage Exchange for Infected Total Hip Arthroplasty: A Treatment to Take into Account.

INTRODUCTION: Two-stage revision is the gold standard for chronic periprosthetic joint infection (PJI). The removal of well-fixed implants, especially the femoral component, can be extremely difficult and additional osteotomies may be needed, which is time-consuming and results in bone stock loss. When the femoral stem is osseointegrated, there is no clear indication for the use of partial two-stage revision. The primary objective was to assess infection eradication after surgery. METHODS: Retrospective study of specific case series. A total of eight patients with a chronic uncemented PJI, in the setting of complex revision surgeries, were treated with partial two-stage revision, which included selective retention of the well-fixed femoral component and complete acetabular removal. Stem retention was carried out regardless of the bacteria or associated comorbidities. RESULTS: All patients were re-revision cases with at least two previous surgeries (range, 2-4). Complex revisions were performed in five cases (non-articulated spacer) and simple revisions in three cases (articulated spacer). The minimum follow-up time was 24 months (range, 24-132 months). The infection eradication rate at final follow-up was 100%. CONCLUSION: Partial two-stage reconstruction is a promising technique for the treatment of chronic PJI in patients with a well-fixed stem and complex re-revision acetabular procedures. Further prospective studies and prolonged follow-ups are required to confirm our results.

A 5-year follow-up of the effect of corrective surgery in young adults with idiopathic scoliosis.

PURPOSE: The purpose of this study was to determine mid-long-term outcomes (5 years) following surgery for young adult idiopathic scoliosis (YAdIS). METHODS: This is a retrospective review of a prospective, multicenter adult deformity database including patients operated on idiopathic scoliosis by a single posterior approach, age at surgery between 19 and 29 (considered young adults), and 5-year follow-up. Demographic, radiographic and PROMS were analyzed preoperatively, at 2 years and at final follow-up. RESULTS: Forty-two patients were included. Mean preoperative major curve angle was 59.65 ± 18.94. Main coronal curve initial correction was 56.38%, with 6% loss at 5 years. From baseline to 5 years after surgery, there was improvement in all PROMs (P < 0.004)-especially self-image-, except NRS-leg pain. This improvement was present at 6 months for all PROMs except for functional outcomes (SRS-Function and ODI) in which the improvement took place between 6 months and 2 years. In the 2- to 5-year follow-up period, no significant changes were seen in any PROMs. The percentage of patients reaching MCID from baseline at 5 years was: 75% for SRS-image, 45% for SRS-pain, 47.5% for SRS-function, 51.3% for SRS-mental, 42.5% for SRS-total and 15.4% for ODI. Patients reaching PASS at 5 years were: 88.1% for SRS-image, 81% for SRS-pain, 92.9% for SRS-function, 57.1% for SRS-mental, 88.1% for SRS-total, 92.7% for ODI and 69% for NRS pain. 11 minor and 4 major complications were identified. CONCLUSION: YAdIS surgery resulted in an early and significant improvement in PROMs, especially for self-image, significantly reaching MCID and PASS thresholds. These results were maintained during long-term (5-year) follow-up.

Effect of COVID-19 on quality of life of persons aged >70 years with adult spinal deformity: A cross-sectional case-control study.

This observational, cross-sectional case-control study evaluates the impact of coronavirus disease 2019 (COVID-19) on health-related quality of life (HRQoL) in elderly persons who have undergone surgery for adult spinal deformity (ASD). On December 31, 2019, the Chinese authorities first reported severe acute respiratory syndrome coronavirus 2, and on March 11, 2020, it was declared a pandemic. The pandemic seems to have had a negative effect on elderly patients who underwent ASD, in terms of functional and psychological quality of life. We selected patients with ASD aged > 70 years who had undergone surgery between 2010 and 2015 and compared them with age- and sex-matched patients who did not have ASD. We recorded sociodemographic variables, type of surgery, levels of spinal fusion, HRQoL (Scoliosis Research Society-22, Short Form 12 Health Survey, EuroQol-5D [EQ-5], Geriatric Depression Scale [Yesavage] [GDS], Modified Frailty Index-11, and Barthel index), fear of visiting a health center, fear of leaving one's house, and adherence to preventive measures. The study population comprised 174 patients (mean [standard deviation] age, 77.3 [5.9] years; 86% women), of whom 87 had undergone surgery for ASD. The incidence of COVID-19 was higher in patients aged > 85 years (P = .041), urban areas (P = .047), and in patients in long-term care (P = .03). Similarly, no differences were observed for the ability to cope with the pandemic (P > .05). Patients who underwent surgery also had a higher risk of depression (GDS, 6.7 [P = .02]), a lower EQ-5 score (P = .001), a higher body mass index (P = .004), greater consumption of drugs (P < .001), especially opiates (P < .001). Patients who underwent surgery constitute a vulnerable population during the COVID-19 pandemic, with poorer quality of life and had a much higher risk of depression. They are also polymedicated and prefrail, adhere well to COVID-19 preventive measures, and do not seem to fear visiting health centers.

Deep Surgical-Site Infection Following Thoracolumbar Instrumented Spinal Surgery: The Experience of 25 Years.

BACKGROUND: Deep surgical-site infection following thoracolumbar instrumented spinal surgery (DSITIS) is a major complication in spine surgery and its impact on long-term morbidity and mortality is yet to be determined. This article describes the characteristics and evolution of DSITIS in our center over a period of 25 years. METHODS: This single-center, retrospective cohort study included patients diagnosed with DSITIS between January 1992 and December 2016 and with a minimum follow-up after infection diagnosis of 1 year. The Infectious Diseases Society of America criteria and/or Centers for Disease Control and Prevention criteria were used to define DSITIS. Patient data (epidemiological and health status), surgical data, infection characteristics and presentation, isolated microorganisms, required surgical debridements, implant removal, and major complications linked to infection were evaluated. RESULTS: A total of 174 patients (106 females) were included in the analysis. Mean follow-up after infection diagnosis was 40 months (56 patients with over 5 years follow-up). Adolescent idiopathic scoliosis, adult deformity, and degenerative lumbar stenosis were the most frequent etiologies for primary surgery. Presentation of infection was considered early (0-3 months since first surgery) in 59.2% of the cases, delayed (3-24 months) in 11.5%, and late (more than 24 months) in 29.3%. All patients were treated by surgical debridement. More than 1 surgical debridement was necessary in 20.7% of cases. Implants were removed in 46.6% of the patients (72.83% in the first surgical debridement). Most frequently isolated microorganisms were Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes. Major complications appeared in 14.3% of the patients, and over 80% of them required major surgeries to resolve those complications. CONCLUSIONS: Late DSITIS is more frequent than previously reported. In DSITIS culprits, Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes predominate. DSITIS produce a high rate of major complications that usually require major surgery for treatment. LEVEL OF EVIDENCE: 3.

Does Clinical Photography Influence Satisfaction With Surgery in Adult Patients Operated on for Spinal Deformity?

BACKGROUND: Recently published data suggest that showing patients operated on for adolescent idiopathic scoliosis or kyphosis their preoperative and postoperative photographs may enhance their satisfaction and self-image as measured by Scoliosis Research Society Health-Related Quality of Life Questionnaire (SRS-22) scores. No data exist for adult spinal deformity (ASD) surgery. The aim of this study is to determine the effect on patient postoperative satisfaction and self-image of showing adult deformity patients their preoperative and postoperative whole body photographs. METHODS: This was a nonconcurrent prospective study. Patients operated on for ASD with a minimum 2-year postoperative follow-up who had preoperative full-body photographs taken by a professional photographer were included. Two follow-up visits were arranged 7 days apart. In the first visit, patients completed the SRS-22 questionnaire, and full-body standing photographs were taken. In the second visit, patients were asked to complete again questions 4, 6, 10, 14, 19 (self-image), 21, and 22 (satisfaction) of the SRS-22 after seeing their preoperative and postoperative full-body photographs. RESULTS: Thirty patients (28 female) were included. The median age at surgery was 50 years (26-76). The median follow-up was 51 months (24-120). SRS-22 results at first visit were: activity 2.79 ± 0.75; self-image 2.71 ± 0.82; pain 2.53 ± 1.10; mental health 3.08 ± 0.77; satisfaction 3.46 ± 1.20; global 2.74 ± 0.72. SRS22 results at second visit were: self-image 2.9 ± 0.75; satisfaction 4.02 ± 0.97. After seeing the preoperative and final follow-up photographs, patients experienced an improvement in SRS-22 self-image (P = .000) and satisfaction domains (P = .011). CONCLUSIONS: In patients operated on for ASD, showing preoperative and postoperative photographs improves patient satisfaction with surgery and self-image. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Our results could be a starting point for introducing full-body clinical photographs as a routine clinical tool in adult deformity patients undergoing surgery.

Photographic sagittal plane analysis and its clinical correlation after surgery for adult spinal deformity: a preliminary study.

PURPOSE: The aim of this study is to determine the correlation between photographic sagittal parameters and patient-reported outcome measures (PROM) results in adult patients operated on spinal deformity. METHODS: Non-concurrent prospective study. INCLUSION CRITERIA: age at surgery older than 25, minimum 2-year follow-up after a 5 or more level fusion for adult spinal deformity (ASD). Full body lateral standing photographs were taken with adhesive markers placed on ten bony landmarks. SRS-22 and SF-36 questionnaires were completed for every patient. The following photographic parameters were measured: lumbar angle, lumbar curve, thoracic inclination (TI), trunk angle, pelvic tilt, head angle, neck angle, cervicothoracic angle, lumbar vector angle (LVA), dorsal vector angle (DVA), cervical vector angle (CVA), cranial pelvic angle (CrPA), cranial sacral angle (CrSA), fibular inclination angle (FIA) and cranial sagittal vertical axis measured to sacrum (Cr-S), greater trochanter (Cr-GT), knee (Cr-K) and ankle (Cr-A). RESULTS: 65 patients (58 female) operated on ASD in a single institution were included. Age at surgery was 61 years (26-67). Postoperative follow-up was 53 months (24-120). Spearman rank order test showed several significant (p ≤ 0.01) correlations. After multivariate linear regression analysis age, LVA and TI remained as predictors for SRS image scores (corrected r2 0.41), LVA for SRS satisfaction (corrected r2 0.27), CrPA and age for SRS total scores (corrected r2 0.33), FIA and age for SF36 physical functioning (corrected r2 0.36) and CrSA for SF36 role physical (corrected r2 0.14). CONCLUSIONS: Some sagittal photographic parameters may predict mid-term clinical results after ASD surgery.

Is the Cranial Sagittal Vertical Axis (Cr-SVA) a Better Midterm Predictor of Clinical Results Than C7-SVA in Adult Patients Operated on Spinal Deformity After a Minimum 2-Year Follow-Up?

STUDY DESIGN: This is nonconcurrent prospective study approved by the Institutional Research Ethics Committee. OBJECTIVE: The purpose of this study is to determine if the cranial sagittal vertical axis (Cr-SVA) measured in full spine standing radiographs is a better predictor of clinical results than the C7 sagittal vertical axis (C7-SVA) in adult patients operated on spinal deformity with a minimum 2-year follow-up after surgery. SUMMARY OF BACKGROUND DATA: The Cr-SVA has recently been described as a better predictor of health-related quality of life outcomes than the C7-SVA for patients with adult spinal deformity (ASD) before undergoing surgery. This has not been confirmed in patients after ASD surgery. METHODS: Inclusion criteria were age at surgery more than 25 years and a minimum 2-year follow-up after a ≥5 level fusion for ASD. Full-length standing lateral radiographs (including nasion-inion line, spine, and femoral heads) and Scoliosis Research Society 22 Questionnaire and SF36 questionnaires were available for every patient at the final follow-up. The distance from the Cr-SVA to the posterior corner of S1 (Cr-SVA-S) and to the centers of the hip (Cr-SVA-H) was measured and also the C7-SVA, lumbar lordosis, pelvic incidence, pelvic tilt, and PI-LL. RESULTS: Sixty-five patients (58 female individuals) operated on ASD in a single institution were included. Age at surgery was 61 years (26-67). The mean follow-up was 53 months (24-120). Spearman rank-order test showed several significant correlations. After multivariable analysis, only Cr-SVA-S and age persisted as predictors for Scoliosis Research Society (SRS) image scores, Cr-SVA-H for SRS satisfaction, Cr-SVA-H and age for SRS total scores, Cr-SVA-H and age for SF36 Physical Function, Cr-SVA-S for SF36 Role Physical, Cr-SVA-H for SF36 Bodily Pain, and Cr-SVA-H for SF36 Role Emotional. CONCLUSIONS: The Cr-SVA measured in full spine standing radiographs seems to be a better predictor of health-related quality of life outcomes than the C7-SVA for adults operated on spinal deformity >2 years after surgery.

The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method.

PURPOSE: Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. METHODS: Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1-3 and 7-9). RESULTS: Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. CONCLUSIONS: Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. These slides can be retrieved under Electronic Supplementary Material.

Total knee arthroplasty in patients with prior ipsilateral hip arthrodesis.

Only a few articles based on the management of symptomatic knee osteoarthritis in patients with prior ipsilateral hip arthrodesis have been reported, and there are no clear criteria for the best treatment option [to carry out a total knee arthroplasty (TKA)-or to take down the hip fusion and conversion to a total hip arthroplasty-THA, and after that to carry out the TKA]. We report two cases, a 72-year-old male who underwent a left hip arthrodesis at 28 because of a trauma and a 51-year-old woman who underwent a left hip arthrodesis at 9 years because of a congenital dislocation. They presented severe ipsilateral symptomatic knee osteoarthritis. Once the cases were studied and the two therapeutic possibilities were evaluated, we decided to perform TKA. Currently, both patients have no pain, a stable knee with good range of motion and without aseptic loosening radiologic criteria.

Preoperative and postoperative sagittal plane analysis in adult idiopathic scoliosis in patients older than 40 years of age.

BACKGROUND CONTEXT: Most of the papers correlate sagittal radiographic parameters with health-related quality of life (HRQOL) scores for patients with scoliosis. However, we do not know how changes in sagittal profile influence clinical outcomes after surgery in adult population operated for mainly frontal deformity. PURPOSE: This study aimed to analyze spinal sagittal profile in a population operated on adult idiopathic scoliosis (AS) and to describe variations in sagittal parameters after surgery and the association between those variations and clinical outcomes. DESIGN/SETTING: This is a historical cohort study. PATIENT SAMPLE: We included in this study 40 patients operated on AS, older than 40 at the time of surgery (mean age 54.9), and with more than 2-year follow-up (mean 7.4 years). OUTCOME MEASURES: Full-length free-standing radiographs, Scoliosis Research Society 22 (SRS22) and Short Form 36 (SF36) instruments, and satisfaction with outcomes were available at final follow-up. METHODS: Sagittal preoperative and final follow-up radiographic parameters, radiographic correlation with HRQOL scores at final follow-up, and association between satisfaction and changes in sagittal profile were analyzed. A multivariate analysis was performed. No funds were received for this article. RESULTS: Preoperatively, the spinal sagittal plane tended to exhibit kyphosis. Most sagittal parameters did not improve at final follow-up with respect to preoperative values. We saw, after univariate analysis, that worse sagittal profile leads to worse HRQOL, but after multivariate analysis, only spinal tilt (ST) persisted as possible predictor for worse SRS activity scores. Frontal Cobb significantly improved. Most patients (82%) were satisfied with final outcomes. Variations in sagittal profile parameters did not differ between satisfied and dissatisfied patients. CONCLUSIONS: Although most sagittal plane parameters did not improve after surgery, surgical treatment in AS achieves a high satisfaction rate. Good clinical results do not correlate with improving sagittal plane parameters. Sagittal profile measurements are not helpful to decide surgical treatment in patients with mainly frontal deformity.

Síndrome de embolia grasa tras fractura abierta de calcáneo por arma de fuego / Fat embolism syndrome after open calcaneal fracture due to gunshot

El síndrome de embolia grasa es una complicación asociada, por lo general, a fracturas de huesos largos, fracturas de pelvis o procedimientos ortopédicos. Presentamos el caso inusual de un paciente de 24 años con diagnóstico de síndrome de embolia grasa tras sufrir una fractura abierta de calcáneo por arma de fuego de alta energía. Nivel de Evidencia: IV.

Fat embolism syndrome is a complication usually associated with long bone fractures, pelvic fractures and orthopedic procedures. We present the unusual case of a 24-year-old patient with a diagnosis of fat embolism syndrome after an open calcaneal fracture due to gunshot injury. Level of Evidence: IV.

Survivorship analysis after primary fusion for adult scoliosis. Prognostic factors for reoperation.

BACKGROUND CONTEXT: Adult scoliosis surgery is a challenging procedure with high rate of complications and reoperations. Reoperation rates vary widely. Long-term survival for this surgery still remains unknown, and the prognostic factors for reoperation are not well defined. PURPOSE: To assess adult scoliosis surgery survival (without the need of reoperation) after primary fusion in adults with mainly frontal deformity and to define prognostic factors for reoperation. STUDY DESIGN: Survival analysis of a cohort of consecutive adult patients, primarily operated on scoliosis using segmental instrumentation (retrospective cohort study). PATIENT SAMPLE: Fifty-nine patients older than 21 years at primary surgery (median age, 42 years), who presented idiopathic or degenerative curves with frontal Cobb >40° (median preoperative frontal Cobb 59°), more than four-level fusion, and a 2-year minimum postoperative follow-up (median, 8.5 years; 41% patients had a longer than 10-year follow-up). OUTCOME MEASURES: Clinical and preoperative radiographic parameters were analyzed preoperatively and evaluated as prognostic factors for reoperation. METHODS: Survival was estimated using Kaplan-Meier method. Prognostic factors (clinical and radiographic) for reoperation were evaluated. Logistic regression using backward elimination was used for multivariate analysis. RESULTS: Survival was 89.8% at 1 year, 79.4% at 2 years, 73.4% at 3 years, 64% at 5 years, and 60.9% at 10 years. Overall, 21 patients (35.6%) underwent revision surgery. The most common reasons for reoperation were painful/prominent implants, adjacent-segment degeneration, and infection. American Society of Anesthesiologists Type II patients and double surgical approach were associated with a higher revision rate. Preoperative thoracic kyphosis was significantly higher in reoperated patients. CONCLUSIONS: The 10-year survival rate of primary scoliosis surgery in adult patients is 61%. Risk factors identified for reoperation included patients with higher morbidity, double surgical approach, and preoperative thoracic hyperkyphosis.

MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures.

PURPOSE: Posterior ligamentous complex (PLC) components have an orderly sequence of rupture. However, it is still unclear how many structures have to be damaged to consider it disrupted. We aim to establish imaging criteria, which can define the complex as competent or incompetent. METHODS: Prospective study of 74 consecutive vertebral acute traumatic fractures, using X-rays and MRI scan (FS-T2-w/STIR sequences). We analyzed the association between MRI signal (intact, edema, disruption) of each PLC component-facet capsules (FC), interspinous ligaments (ISL), supraspinous ligaments (SSL) and ligamentum flavum (LF)-and the variables: AO/TLICS classification, treatment, surgical findings, interspinous diastasis index (IDI), local kyphosis (LVK) and ISS (TLICS) score. χ2 test and U Mann-Whitney were used for statistics. RESULTS: MR images of ISL edema correlated surgically with intact ligaments or laxity, and were associated with 87.5% of facet distraction, LVK: 11.6º, IDI: 1.2. Images of ISL, SSL or LF disruptions showed in all cases ruptures under surgical examination. Images of SSL disruption associated with LVK: 14.5º, IDI: 1.8. Images of ISL disruption associated with SSL/LF rupture, LVK: 16º, and IDI: 2; while LF disruption showed LVK: 18º, IDI: 1.9. When comparing "competent PLC" (images of facet distraction and ISL edema) with "incompetent PLC" (images of SSL disruption ± ISL or LF disruption) the latest showed more severe scores in every variable (p < 0.001), except neurologic status. CONCLUSION: Following PLC rupture sequence, ISL edema with facet distraction seems not to be enough to define a posterior tension band incompetence. It is the further step of SSL rupture what gives the key to PLC incompetence.

Correlation of radiographic and functional measurements in patients who underwent primary scoliosis surgery in adult age.

STUDY DESIGN: Prospective radiographic and clinical analysis. OBJECTIVE: To evaluate whether radiographic spinopelvic parameters correlate with health-related quality of life (HRQOL) measures, in the long run, in patients operated on scoliosis in adult age. SUMMARY OF BACKGROUND DATA: There are papers that correlate sagittal radiographic parameters with HRQOL scores for healthy spine as well as for some spinal disorders. However, there are limited studies evaluating correlations between HRQOL measures, radiographic spinopelvic parameters, and age in patients operated on scoliosis in adult age. METHODS: Fifty-nine patients, older than 21 years at surgery time (median: 50.2 years), were operated upon at a single center. All of them suffered mainly frontal deformity, idiopathic or degenerative curves, and long fusions, with more than a 2-year follow-up (median:8.5 years). Full-length freestanding radiographs, including the spine and pelvis, and SRS22 and SF36 instruments, were available for every patient at final follow-up. Sagittal and frontal radiographic parameters and age were analyzed for correlation with HRQOL. A multivariate analysis was performed. RESULTS: No significant correlation was found between frontal parameters and HRQOL measures. Spearman rank order test showed correlation (P < 0.001) between Scoliosis Research Society (SRS) activity and sagittal vertical axis (SVA) (r = -0.44), pelvic tilt (PT) (r = -0.49), and age (r = -0.5). SRS total was correlated (P < 0.004) with PT (r = -0.32) and age (r = -0.41). SF36 physical function correlated (P < 0.001) with SVA (r = -0.44), PT (r = -0.45), and age (r = -0.56). After multivariate analysis, only age and PT persisted as possible predictors of worse SRS activity scores. CONCLUSION: After primary surgery for adult scoliosis, frontal radiographic parameters did not correlate with HRQOL measures. In univariate analysis, patient age, SVA, and PT correlated with activity scores, although the correlation coefficients did not reach high values. After multivariate analysis, SVA was not a predictor of function.

Sequential damage assessment of the different components of the posterior ligamentous complex after magnetic resonance imaging interpretation: prospective study 74 traumatic fractures.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To study whether there is a sequential pattern in the posterior ligamentous complex (PLC) rupture caused by deforming traumatic forces by analyzing magnetic resonance (MR) images in a consecutive prospective cohort of patients with traumatic vertebral fracture. SUMMARY OF BACKGROUND DATA: PLC plays an important role in vertebral stability. However, the sequence in which the different components of the PLC tear, in the face of traumatic forces, has not been yet described. METHODS: Prospective study of 74 consecutive vertebral acute traumatic fractures analyzed using radiography and magnetic resonance imaging (MRI) (FS-T2-w/short-tau inversion-recovery [STIR] sequences). Fracture morphology was classified according to the AO classification. Integrity of each PLC component-facet capsules, interspinous ligament (ISL), supraspinous ligament (SSL), and ligamentum flavum (LF)-was assessed and classified as intact, edema, or disruption. ISL edema was further subdivided depending on the extension (>50%/<50%). We analyzed the association between MRI signal and the AO progressive scale of morphological damage. RESULTS: AO type A1/A2 fractures associated with only facet distraction. A3 fractures showed additional ISL edema, usually less than 50%, with neither SSL nor LF disruption. Type B1 fractures associated with facet distraction, ISL edema or disruption, and low rate of SSL/LF disruptions; B2 fractures increased SS/LF disruption rates. Type C fractures associated with facet fracture or dislocation and ISL, SSL, or LF complete rupture. We found high association (P < 0.001) between AO progressive scale and MRI signal. MRI analysis showed that posterior distraction forces begin in the facets and extend throughout the ISL, starting at its posterosuperior margin (finally disinserting the SSL superiorly) and traveling diagonally toward anteroinferior border, finally tearing the LF. CONCLUSION: MR images correlated with AO progressive scale of morphological damage, which showed a progressive orderly rupture sequence among the different PLC components as traumatic forces increased.

Proximal epiphysis of the second metatarsal: normal trait, possible contribution to growth, and clinical implications.

Analysis of 998 dorsoplantar foot radiographs of 231 patients was performed. Age ranged between 0.21 and 19.94 years. The authors proved the existence of a previously nondescribed additional proximal ossification center in the second metatarsal. This additional proximal center was seen in 78 of 998 radiographs, which corresponds with 7 of the 231 patients. If only 111 patients within the age range in which the additional proximal center appears are considered, the true prevalence of the additional proximal center was found in 7 (6.3%) patients. This additional proximal center was found to be bilateral in 4 (57.1%) of these 7 patients. The presence of the proximal center was more common in girls and was associated with index plus metatarsal type (P=.000) and foot pathology, especially flatfoot (P=.000). Age of appearance was 2.3 ± 0.24 years and age of fusion was 5.5 ± 2.2 years. Using a descriptive maturation scale, the authors classified the ossification stages of the additional proximal center in 4 stages: rudimentary, fully formed, partially fused, and fully fused. After creating a mathematical ratio, the authors could not prove that the presence of this additional proximal center increased the length of the second metatarsal or the complete second ray.