The effect of lumbar spinal fusion on native acetabular anteinclination in standing position.

PURPOSE: The complex and dynamic spinopelvic interplay is not well understood. The aims of the present study were to investigate the following: (1) whether native acetabular anteinclination (AI) in standing position changes following lumbar spinal fusion (LSF); (2) potential correlations between AI change (ΔAI) and several spinopelvic parameters such as the change in lumbar lordosis (ΔLL), pelvic tilt (ΔPT), and anterior pelvic plane angle (ΔaPP). METHODS: A total of 485 patients (Males: 262, Females: 223) with an average age of 64 ± 13 years who underwent a primary LSF were identified from our institutional database. The difference (Δ) between pre-and postoperative acetabular anteinclination (AI), lumbar lordosis (LL), anterior pelvic plane angle (aPP), sacral slope (SS), and pelvic tilt (PT) were measured on a standing lateral radiograph (EOS®) and compared to find the effect of LSF on the lumbopelvic geometry. RESULTS: Following LSF, the average absolute ΔAI was 5.4 ± 4 (0 to 26)°, ΔLL: 5.5 ± 4 (0 to 27)°, ΔaPP: 5.4 ± 4 (0 to 38)°, ΔPT: 7 ± 5 (0 to 33)° and ΔSS: 5.3 ± 4 (0 to 33)°. No significant differences were observed between LSF levels. A ΔAI ≥ 10° was observed in 66 (13.6%) and ΔAI ≥ 20° in 5 (1%) patients. The Pearson correlation demonstrated a strong negative correlation of ΔAI with ΔLL (r = 0.72, p < .001). CONCLUSION: Clinical decision-making should consider the relationship between native anteinclination and lumbar lordosis to reduce the risk of functional acetabular component malalignment in patients with concomitant hip and spine pathology. LEVEL OF EVIDENCE: Retrospective case-control study, Level III.

Clavicular hook plate versus dog-bone technique for acute high-grade acromioclavicular joint dislocation: a retrospective cohort study comparing clinical outcome scores, complications, and costs.

INTRODUCTION: Arthroscopically assisted coracoclavicular (CC) ligament fixation techniques have been promoted as providing superior outcomes for the treatment of acute high-grade acromioclavicular joint (ACJ) dislocations. Nevertheless, there is a lack of high-level evidence for clinically relevant benefits. At our institute, orthopaedic surgeons use an arthroscopically assisted coracoclavicular ligament fixation technique (DB), while general trauma surgeons use a clavicular hook plate (cHP) technique. The aim of the study was to compare clinical outcomes, complication rates, and costs between the two groups. MATERIALS AND METHODS: The hospital database was searched for patients treated for acute traumatic high-grade (Rockwood Typ ≥ III) ACJ dislocation using either a cHP or arthroscopically assisted DB technique between 2010 and 2019. Seventy-nine patients could be included (56 patients in the cHP group and 23 in the DB group). QuickDASH scores, subjective shoulder value (SSV) scores, pain scores (numerical pain rating scale 10), and complication rates were retrospectively collected through phone interviews and by screening patient charts as well as surgical reports. Costs per patient were obtained from the hospital's accounting system. RESULTS: Mean follow-up was 54 ± 33.7 and 45 ± 21.7 months in the cHP and DB group, respectively. QuickDASH and SSV scores did not differ, but patients in the cHP group reported significantly lower pain scores (p = 0.033). More patients reported hypertrophic or disturbing scars (p = 0.49) and sensibility disturbances (p = 0.007) in the cHP group. Three patients suffered from a frozen shoulder in the DB group (p = 0.023). CONCLUSION: Patient-reported outcomes are excellent after long-term follow-up for both techniques. There are no clinically relevant differences in clinical outcome scores based on our results and a review of the literature. Both techniques certainly have their benefits regarding secondary outcome measures. LEVEL OF CLINICAL EVIDENCE: Level 3, retrospective cohort study.

Proximal humeral fracture-dislocation: Outcome analysis in osteosynthesis and arthroplasties.

PURPOSE: Proximal humeral fracture-dislocations (PHFD) are challenging to treat. In older patients, usually arthroplasty is performed. In younger patients, osteosynthesis is chosen. This study presents functional outcomes of these different treatment modalities. METHODS: All patients operated for PHFD from 2010 until 2017 were included. Osteosynthesis was performed in younger patients and if reconstruction was possible. Either an open deltopectoral approach or a minimal invasive plate osteosynthesis (MIPO) was performed. Hemiarthroplasty (HA) was done if reconstruction of the tubercles was possible, age was below 63 years and no signs of osteoarthritis were present. In all other cases, a reverse total shoulder arthroplasty (rTSA) was done. The primary endpoint was functional outcome assessed with the QuickDASH Score (QDS). Secondary outcomes were subjective shoulder value (SSV), complications, revisions, and conversion into arthroplasty. RESULTS: The mean follow-up of 40 patients was 56 ± 24 months. The mean QDS was 4.5 (0.6-9.1) and the mean SSV was 90 (80-98.6). Of these, 33 patients (mean age: 50) had an osteosynthesis, 25 were treated with MIPO. Only 18% were converted into an arthroplasty after a mean of 22 months. Among them, 7 patients received a primary arthroplasty (mean age: 68), no revisions were recorded. Subgroup analysis showed functional outcome deficits in avascular necrosis (AVN) compared to no AVN (p = 0.021), revision surgery compared to no revision (p = 0.040) and in HA compared to rTSA (p = 0.007). CONCLUSION: Both osteosynthesis and primary arthroplasty after PHFD can lead to good or even excellent functional outcome. Revision rates in osteosynthesis are high. Revision procedures or secondary conversion into arthroplasty after failed osteosynthesis decrease outcome scores significantly.

Shoulder arthroplasty for proximal humeral fracture treatment: a retrospective functional outcome analysis.

PURPOSE: Following proximal humeral fractures hemiarthroplasty (HA) or reversed total shoulder arthroplasty (rTSA) are performed if osteosynthesis or conservative treatment is not possible. HA has been reported to result in decreased functional outcomes compared with rTSA. Secondary shoulder arthroplasty, performed after a different initial treatment, has also been associated with inferior outcomes. METHODS: Patients recieving a shoulder arthroplasty related to a proximal humeral fracture from 2010 to 2019 were included. A retrospective analysis of functional outcomes was performed using QuickDASH and subjective shoulder value (SSV). RESULTS: The mean [standard deviation (SD)] follow-up time among the 82 included patients was 48 (28) months. The mean age was 70 (10) years. The mean age for HA was significantly different from rTSA [57 (9) and 72 (21) years; p < .001]. The mean QuickDASH score for primary arthroplasty was 11 (2) versus 12 (16) for secondary arthroplasty (p = .313). The mean SSV for primary arthroplasty was 84 (22) versus 82 (17) for secondary arthroplasty (p = .578). The mean QuickDASH score for HA was 24 (36) versus 9 (15) for rTSA (p = .346). The mean SSV for HA was 70 (34) versus 86 (17) for rTSA (p = .578). CONCLUSION: Functional outcomes after fracture-related shoulder arthroplasty were excellent in an older population, even when performed secondarily after failed primary osteosynthesis or conservative treatment. No significant differences in shoulder function were identified between rTSA and HA, likely due to restrictive indications for HA.

Real-time assessment of anteroposterior stability of spinal segments.

PURPOSE: While anteroposterior instability of spinal segments is regarded as an important biomechanical aspect in the clinical evaluation of lumbar pathologies, the reliability of the available diagnostic tools is limited and an intraoperative method to quantify stability is lacking. The aim of this study was to develop and validate an instrument to measure the anteroposterior stability of a spinal segments in real-time. METHODS: Torsi of five fresh-frozen human cadavers were used for this study. After pedicle screw insertion, a specifically modified reposition tool composed with load and linear sensors was used to measure the segmental anteroposterior motion caused by 100 N anterior and posterior force during 5 loading cycles on either side of the instrumentation by two different operators. The spinal segments were then resected from the torsi and anteroposterior loading with ± 100 N was repeated in an advanced biomechanical spine testing setup as a reference measurement. The Inter-correlation coefficient (ICC) was used for validation of the "intraoperative" device. RESULTS: Inter-operator repeatability of the measurements showed an ICC of 0.93 (p < 0.0001) and the bilateral (left-right) comparison had an ICC of 0.73 (p < 0.0001). The ICC resulting from the comparison to the reference measurement was 0.82 (p < 0.0001) without offset correction, and 0.9 (p < 0.0001) with offset correction. The ICC converged at this value already after two of the five performed loading cycles. CONCLUSION: An accurate and reliable measurement tool is developed and validated for real-time quantification of anteroposterior stability of spinal segments and serves as a basis for future intraoperative use.

Concept for Minimally Invasive Hook Plate Stabilisation of the Acromioclavicular Joint.

AIMS: Despite the availability of various operative procedures, hook plates are still one of the main implants used for the treatment of acromioclavicular (AC) joint dislocation. The aim of this report is to present a novel minimally invasive operation technique for AC hook plate fixation. The functional outcomes of patients operated upon with this technique are presented. PATIENTS AND METHODS: A retrospective analysis was performed for 5 patients who were operated upon with minimally invasive hook plate fixation. The QuickDASH score (QDS) and subjective shoulder value (SSV) were used to express functional outcomes, and the numeric rating scale (NRS) was used to evaluate pain. RESULTS: The mean (SD) follow-up was 30±7 months. Patients were hospitalized for a mean of 3±1 days and operated upon for a mean of 54±7 minutes. Functional outcomes measured with the QDS showed a median (IQR) of 2.3 (0 - 6.8) and a median SSV relative to the healthy side of 95% (89 - 100). The median NRS was 0 (0 - 0). CONCLUSION: Minimally invasive hook plate fixation for acromioclavicular joint dislocation led to excellent functional outcome scores without complications in a small case series of 5 patients.

Sex-related trends in participation and performance in the 'Swiss Bike Masters' from 1994-2012.

General participation in contests such as ultra-marathons and ultra-triathlons has increased considerably over the past 30 years, especially among women. This study investigated performance trends in the Swiss Bike Masters, one of the first and most prestigious mountain bike, ultra-endurance races in its class, with comparisons of participation and performance trends to similar races. The development of performance in the Swiss Bike Masters held between 1994 and 2012 was investigated by analysing the number of finishers, their age, sex, and cycling speed. Between 1994 and 2009, the athletes had to cover 120 kilometers with a total difference in altitude of 5,000 meters. Since 2010, the race distance was shortened to 105 kilometers and the total difference in altitude was reduced to 4,400 meters. The total men participating and total finishing decreased significantly, while women's participation has remained low. The age of the annual winners and the annual top three finishers showed no changes over time. Performances of the annual fastest women improved, while performances of the annual fastest men remained unchanged. To summarize, rate of finishing has decreased for men and has been stable, but low, among women. The sex difference in cycling speed for the best cyclists has decreased across the years.

The age-related performance decline in ultraendurance mountain biking.

The age-related changes in ultraendurance performance have been previously examined for running and triathlon but not mountain biking. The aims of this study were (i) to describe the performance trends and (ii) to analyze the age-related performance decline in ultraendurance mountain biking in a 120-km ultraendurance mountain bike race the "Swiss Bike Masters" from 1995 to 2009 in 9,325 male athletes. The mean (±SD) race time decreased from 590 ± 80 min to 529 ± 88 min for overall finishers and from 415 ± 8 min to 359 ± 16 min for the top 10 finishers, respectively. The mean (±SD) age of all finishers significantly (P < 0.001) increased from 31.6 ± 6.5 years to 37.9 ± 8.9 years, while the age of the top 10 remained stable at 30.0 ± 1.6 years. The race time of mountain bikers aged between 25 and 34 years was significantly (P < 0.01) faster compared with the race time of older age groups. The age-related decline in performance in endurance mountain bikers in the "Swiss Bike Masters" appears to start earlier compared with other ultraendurance sports.

A Simple Preoperative Score Predicting Failure Following Decompression Surgery for Degenerative Lumbar Spinal Stenosis.

BACKGROUND CONTEXT: Proper patient selection is crucial for the outcome of surgically treated degenerative lumbar spinal stenosis (DLSS). Nevertheless, there is still not a clear consensus regarding the optimal treatment option for patients with DLSS. PURPOSE: To investigate the treatment failure rate and introduce a simple, preoperative score to aid surgical decision-making. STUDY DESIGN/SETTING: Retrospective observational study. PATIENT SAMPLE: Four hundred forty-five patients who underwent surgical decompression for DLSS. OUTCOME MEASURES: Treatment failure (defined as conversion to a fusion of a previously decompressed level) of lumbar decompression. MATERIALS AND METHODS: Several risk factors associated with worse outcomes and treatment failures, such as age, body mass index, smoking status, previous surgery, low back pain (LBP), facet joint effusion, disk degeneration, fatty infiltration of the paraspinal muscles, the presence of degenerative spondylolisthesis and the facet angulation, were investigated. RESULTS: At a mean follow-up of 44±31 months, 6.5% (29/445) of the patients underwent revision surgery with spinal fusion at an average of 3±9 months following the lumbar decompression due to low back or leg pain. The baseline LBP (≥7) [odds ratio (OR)=5.4, P <0.001], the presence of facet joint effusion (>2 mm) in magnetic resonance imaging (OR=4.2, P <0.001), and disk degeneration (Pfirrmann >4) (OR=3.2, P =0.03) were associated with an increased risk for treatment failure following decompression for DLSS. The receiver operating characteristic curve analysis demonstrated that a score≥6 points yielded a sensitivity of 90% and specificity of 64% for predicting a treatment failure following lumbar decompression for DLSS in the present cohort. CONCLUSIONS: The newly introduced score quantifying amounts of LBP, facet effusions, and disk degeneration, could predict treatment failure and the need for revision surgery for DLSS patients undergoing lumbar decompression without fusion. Patients with scores >6 have a high chance of needing fusion following decompression surgery. LEVEL OF EVIDENCE: Retrospective observational study, Level III.

The biomechanical consequence of posterior interventions at the thoracolumbar spine on the passively stabilized flexed posture.

In the flexed end-of-range position (e.g., during slumped sitting), the trunk is passively stabilized. Little is known about the biomechanical consequence of posterior approaches on passive stabilization. The aim of this study is to investigate the effect of posterior surgical interventions on local and distant spinal regions. While being fixed at the pelvis, five human torsos were passively flexed. The change in spinal angulation at Th4, Th12, L4 and S1 was measured after level-wise longitudinal incisions of the thoracolumbar fascia, the paraspinal muscles, horizontal incisions of the inter- & supraspinous ligaments (ISL/SSL) and horizontal incision of the thoracolumbar fascia and the paraspinal muscles. Lumbar angulation (Th12-S1) was increased by 0.3° for fascia, 0.5° for muscle and 0.8° for ISL/SSL-incisions per lumbar level. The effect of level-wise incisions at the lumbar spine was 1.4, 3.5 and 2.6 times greater compared to thoracic interventions for fascia, muscle and ISL/SSL respectively. The combined midline interventions at the lumbar spine were associated with 2.2° extension of the thoracic spine. Horizontal incision of the fascia increased spinal angulation by 0.3°, while horizontal muscle incision resulted in a collapse of 4/5 specimens. The thoracolumbar fascia, the paraspinal muscle and the ISL/SSL are important passive stabilizers for the trunk in the flexed end-of-range position. Lumbar interventions needed for approaches to the spine have a larger effect on spinal posture than thoracic interventions and the increase of spinal angulation at the level of the intervention is partially compensated at the neighboring spinal regions.

Pelvic fixation in surgical correction of neuromuscular scoliosis.

Background: Surgical correction of neuromuscular scoliosis can be associated with high complication rates, including such associated with pelvic fixation. Up to now it is debated whether and when to include the pelvis into the fusion construct. Therefore, we aimed to illuminate when pelvic fixation is beneficial in surgical correction of neuromuscular scoliosis. Methods: A prospective cohort of 49 patients (mean age 13 ± 3 y, 63% females, follow up 56 months, range 24-215) who underwent correction of neuromuscular scoliosis including S1/the ileum (n = 18) or without (n = 31) pelvic fixation were included. The outcome was measured with analysis of radiological parameters, clinical improvement and complication/revision rates. Subgroup analysis was performed to find if non-ambulatory patients with gross motor function classification system (GMFCS) levels >III, with larger scoliotic curves (>60°) and moderate pelvic obliquities up to 35° benefit from pelvic fixation. Results: There was no significant difference in complications when comparing patients with (9 out of 18 patients, 50%) or without (9 out of 31 patients, 29%) fixation to the pelvis (p = .219). Wheelchair bound patients (GMFCS >III) with cobb angles greater than 60° and pelvic obliquity less than 35° (n = 20) revealed no differences in amount of clinical improvement of ambulation with (n = 9) or without (n = 11) pelvic fixation (p: n.s.). And even complication or revision rates where not different in those two groups. Conclusion: Pelvic fixation does not seem obligatory in wheelchair bound patients per definition. Even with pelvic obliquities up to 35° and large scoliotic curves >60°, avoiding pelvic fixation does not result in higher revision rate or worse clinical outcomes.

Biomechanical considerations of the posterior surgical approach to the lumbar spine.

BACKGROUND CONTEXT: The effect of the posterior midline approach to the lumbar spine, relevance of inter- and supraspinous ligament (ISL&SSL) sparing, and potential of different wound closure techniques are largely unknown despite their common use. PURPOSE: The aim of this study was to quantify the effect of the posterior approach, ISL&SSL resection, and different suture techniques. STUDY DESIGN: Biomechanical cadaveric study. METHODS: Five fresh frozen human torsi were stabilized at the pelvis in the erect position. The torsi were passively loaded into the forward bending position and the sagittal angulation of the sacrum, L4 and T12 were measured after a level-wise posterior surgical approach from L5/S1 to T12/L1 and after a level-wise ISL&SSL dissection of the same sequence. The measurements were repeated after the surgical closure of the thoracolumbar fascia with and without suturing the fascia to the spinous processes. RESULTS: Passive spinal flexion was increased by 0.8±0.3° with every spinal level accessed by the posterior approach. With each additional ISL&SSL resection, a total increase of 1.6±0.4° was recorded. Suturing of the thoracolumbar fascia reduced this loss of resistance against lumbar flexion by 70%. If the ISL&SSL were resected, fascial closure reduced the lumbar flexion by 40% only. In both settings, suturing the fascia to the spinous processes did not result in a significantly different result (p=.523 and p=.730 respectively). CONCLUSION: Each level accessed by a posterior midline approach is directly related to a loss of resistance against passive spinal flexion. Additional resection of ISL&SSL multiplies it by a factor of two. CLINICAL SIGNIFICANCE: The surgical closure of the thoracolumbar fascia can reduce the above mentioned loss of resistance partially. Suturing the fascia to the spinal processes does not result in improved passive stability.

Operative Treatment of Proximal Humeral Fracture-dislocations Through an Anterolateral Deltoid Split Approach.

BACKGROUND: Proximal humeral fracture-dislocations (PHFD) are a special entity in proximal humeral fracture treatment. The aim of this study is to present our minimally invasive plate osteosynthesis (MIPO) technique through an anterolateral deltoid split approach. In addition, we performed a retrospective cohort study analyzing the patient reported functional outcome and complications. METHODS: A single center cohort study was performed. All patients operated through a deltoid split approach for PHFD between 2009 and 2016 were eligible for inclusion. The primary endpoint was subjective shoulder function measured with QuickDASH and subjective shoulder value (SSV). Secondary endpoints were complications and implant-related irritation. RESULTS: 28 patients were included. The mean age was 49 (SD ± 10.3). The mean follow-up was 48 months (SD ± 23.7). The mean QuickDASH score was 6.8 (SD ±7.8) and the mean SSV was 86 (SD ±14.6). Four patients had a conversion into a reversed arthroplasty (14%), one patient (4%) a shortening of secondary perforated screws, four patients an early re-osteosynthesis (14%), four patients (14%) developed an AVN and in one patient damage of the axillary nerve was observed. 21 patients (75%) had their implant removed. CONCLUSION: Patient reported functional results after humeral head preservation and internal fixation of PHFDs through an anterolateral deltoid spilt approach are promising. However, there is a high rate of re-operations either because of complications or for implant removal. Comparing our data to literature these rates are not depending on the approach chosen.

Proximal tibiofibular joint dislocation associated with tibial shaft fractures - 7 Cases.

OBJECTIVE: Lower leg fractures of the tibia with or without fracture of the fibula are very common. Proximal tibiofibular joint (PTFJ) dislocation is a very rare injury that can occur together with a tibia shaft fracture. As there is only scarce literature about this injury available, we would like to present our experience with the treatment of this entity. METHODS: We present a small case series of seven patients. In most cases, the tibia fracture was nailed in a closed technique. After distal locking the proximal fibula was exposed by a lateral approach exposing and preserving the peroneal nerve. After anatomical reduction into the corresponding articular facet of the proximal tibia, the fibula was transfixed to the tibia with a positioning screw. This indirectly provided a correct length and rotation of the tibia, which could finally be locked to the nail by inserting the proximal locking bolts. The positioning screw was removed after six weeks prior to full loading. Six of seven patients had been followed up by at least 7 months post-treatment. RESULTS: Out of 663 prospectively collected tibia shaft fractures treated at our institution from 1/2001 to 7/2014, we found seven patients with associated PTFJ dislocation. All except one had been caused by a high energy trauma. After one year, five patients showed excellent results with full range of motion and returning to their sporting activities as before the accident. Two patients have impaired function due to associated injuries. None complained of persistent pain or instability of the PTFJ. CONCLUSION: PTFJ dislocation with tibia shaft fracture can easily be overlooked if one is not familiar with this injury. It is important to diagnose and treat this uncommon dislocation anatomically to achieve good results. Otherwise, as the literature shows, it can lead to chronic instability of the proximal fibula with snapping, proximal fibular pain and even peroneal nerve palsy. Furthermore in complex tibial fractures correct length and rotation only can be restored after referencing with the fibula. We recommend a high index of suspicion of this injury with high energy tibia shaft fractures especially in cases with intact fibula.