Cross-cultural validation of simplified Chinese version of spine functional index.

BACKGROUND: No effective constructs were available in mainland China to assess the whole spine function. The SFI was developed to evaluate spinal function based on the concept of a single kinetic chain concept for whole spine. The SFI has been translated to Spanish and Turkish with accepted psychometric properties. It is imperative to introduce the SFI in mainland China and further to explore the measurement properties. METHODS: The English versions of the SFI was cross-culturally translated according to international guidelines. Measurement properties (content validity, construct validity and reliability) were tested in accordance with the COSMIN checklists. A total of 271 patients were included in this study, and 61 participants with neck pain and 64 participants with back pain paid a second visit three to seven days later. Confirmatory factor analysis (CFA) and principal factor analysis (PCA) were applied to test the factor structure. The Functional Rating Index (FRI), Neck Disability Index (NDI), Oswestry Disability Index (ODI), SF-12 and a Visual Analogue Scale (VAS) were employed to evaluate the construct validity. Cronbach's alpha and an intra-class correlation coefficient (ICC) were calculated for internal consistency and reproducibility. RESULTS: The means score of SC-SFI was 63.60 in patients with spinal musculoskeletal disorders. A high response rate was acquired (265/271). No item was removed due to abnormal distribution or low item-total correlation. Results of CFA did not support that one-factor structure was in goodness of fit (CMIN/DF = 3.306, NNFI = 0.687, CFI = 0.756, GFI = 0.771 and RMSEA = 0.092). Yet, PCA suggested a one-factor structure was the best, accounting for 32% of the total variance. For structural validity, the SC-SFI correlated highly with the FRI, NDI, ODI, and PF, BP in SF-12 (r = 0.661, 0.610, 0.750, 0.709, 0.605, respectively). All the a priori hypotheses were verified. The Cronbach's alpha for the SC-SFI was 0.91, and ICC was 0.96 (95% CI, 0.94-0.98). Bland-Altman plot also confirmed excellent test-retest reliability. CONCLUSIONS: The SFI has been culturally adapted into SC-SFI with remarkable clinical acceptance, excellent internal consistency, reproducibility, and construct validity when applied to patients with spinal musculoskeletal disorders. The results of current study suggest that SC-SFI can be applied by physicians and researchers to measure whole-spine functional status in mainland China.

Whole-blood gene expression profiling in ankylosing spondylitis identifies novel candidate genes that may contribute to the inflammatory and tissue-destructive disease aspects.

We performed a comprehensive gene expression analysis to identify differentially expressed genes (DEGs) between AS (ankylosing spondylitis) and health controls. A total of 1454 DEGs were obtained, including 919 up-regulated genes and 535 down-regulated genes. There were 218 interactions and 224 pairs in the conPPI network. Topological analysis showed that 11 genes had a close relationship with AS. GO (gene ontology) functional enrichment analysis of the two modules showed that the DEGs in conPPI mainly participated in the biologic process of immune response. The KEGG pathway analysis showed that most DEGs in the two modules were enriched into cell receptor signaling pathway, natural killer cell mediated cytotoxicity and primary immunodeficiency. We hypothesized that these DEGs associated with immune response DEGs might provide basic for depth understanding of the AS development.

Measurement Properties of the Simplified Chinese Version of the Lumbar Spine Instability Questionnaire for Patients With Low Back Pain in Mainland China.

STUDY DESIGN: A prospective study. OBJECTIVE: To develop a simplified Chinese version of Lumbar Spine Instability Questionnaire (SC-LSIQ) and test its measurement properties. SUMMARY OF BACKGROUND DATA: The LSIQ has been translated into several languages. Different versions of LSIQ have proved good reliability and validity in evaluating patients with low back pain. However, there is no simplified Chinese version of LSIQ (SC-LSIQ). MATERIALS AND METHODS: The SC-LSIQ has been translated into a simplified Chinese version according to a standard procedure. A total of 155 patients with low back pain completed the SC-LSIQ along with Oswestry Disability Index, Roland-Morris disability questionnaire, Tampa Scale for Kinesiophobia, and visual analogue scale (VAS). The internal consistency, test-retest reliability, and validity of SC-LSIQ were then calculated to evaluate the measurement properties of SC-LSIQ. RESULTS: The results of SC-LSIQ demonstrated that there was no ceiling or floor effect detected. The Cronbach α coefficient of 0.911 determined a well internal consistency. The intraclass correlation coefficient (0.98) presented an excellent reliability of SC-LSIQ. The Pearson correlation coefficient (r) showed that the SC-LSIQ was excellent correlated to Oswestry Disability Index (r=0.809), Roland-Morris disability questionnaire (r=0.870), and Tampa Scale for Kinesiophobia (r=0.945,). Furthermore, it moderately correlated to visual analogue scale (r=0.586). CONCLUSION: The SC-LSIQ features good internal consistency, reliability, and validity for evaluating Chinese patients with LBP. Results suggest that the SC-LSIQ can be appropriately applied to patients with LBP in routine clinical practice.

Expression and significance of Kruppel-like factor 6 gene in osteosarcoma.

PURPOSE: Osteosarcoma is primary malignant tumour of bone. Kruppel-like factor 6 (KLF6) is a tumor suppressor gene frequently inactivated in a number of human cancers and a ubiquitously expressed zinc-finger transcription factor. The present study aimed to first explore the relationship between the expression level of the KLF6 gene in osteosarcoma and the occurrence of bone tumours. METHODS: KLF6 mRNA and protein expression levels in osteosarcoma and normal bone tissue were assayed by real-time quantitative PCR and immunohistochemistry. KLF6 mRNA and protein expression levels in osteosarcoma cells and normal osteoblasts were detected by semi-quantitative reverse transcription PCR and Western blotting, respectively. RESULTS: Both the expression of KLF6 mRNA and protein in osteosarcoma cells and tissues were significantly lower than that in normal cells and tumour-adjacent tissues. CONCLUSIONS: KLF6 is a putative tumor suppressor gene involved in osteosarcoma which can be used as a new therapeutic target and an important marker for early diagnosis and postoperative monitoring.

Assessment of Sagittal Spinopelvic Balance in a Population of Normal Chinese Children.

STUDY DESIGN: A retrospective study of 257 normal children at a single center from July 2016 to November 2018 was performed. OBJECTIVE: To evaluate the spinopelvic parameters in a population of normal children and adolescents in mainland China. SUMMARY OF BACKGROUND DATA: Values for sagittal parameters of the spine vary significantly by ages and different population. No study has yet quantified the normal measures for children and adolescents in China, or how these measures compare with other populations. METHODS: Pelvic incidence (PI), sacral slope, pelvic tilt, thoracic kyphosis (TK, T5-T12), lumbar lordosis (LL, L1-S1), and sagittal vertical axis were measured and evaluated by whole spine AP&lateral X-ray images. RESULTS: A total of 257 subjects, including 116 boys (45%) and 141 girls (55%) aged 3 to 12 years, were enrolled. Correlation matrix analysis demonstrated that sagittal balance is strongly correlated with age and Risser sign, including PI, a reported fixed parameter. Further investigation showed that PI could be expressed by the equation PI = 26.243+1.153×age. CONCLUSION: PI was not a fixed but a dynamic parameter in the population under 12-year old. Indeed, PI increases with age and bone maturity in childhood. We also found lower PI, pelvic tilt, and sacral slope compared with published studies of adolescents in other countries. These results may aid in the treatment of patients with spinal deformity, to help them achieve a certain degree of sagittal spinopelvic balance. LEVEL OF EVIDENCE: 2.

Low-intensity pulsed ultrasound promotes spinal fusion by regulating macrophage polarization.

BACKGROUND: Spinal fusion is considered the gold standard procedure for treating spinal degeneration, tumors, and trauma. An inflammatory response is an important part of bone repair. We investigated the polarization change of inflammatory macrophages (M1) and resident macrophages (M2) during low-intensity pulsed ultrasound (LIPUS) treatment. METHODS: Thirty male Sprague Dawley rats (age: 12 weeks; weight: 300 g) were used in the study. A rat spinal fusion model was established by surgical procedures. LIPUS treatment (20 min. d, 5 d/wk) was begun 3 days after surgery. The rats were randomly divided into a control group (5 subgroups, 3 rats in each subgroup) and LIPUS group (5 subgroups, 3 rats in each subgroup), and sacrificed on day 3, 5, 7, 10, and 14 after spinal fusion surgery for further evaluation. Bone volume was measured by micro-CT, fusion region was examined by histological analyses, types of macrophages in the fusion area were examined by immunohistochemical staining. Raw264.7 cells and bone marrow-derived macrophages (BMDM) were used in cell experiments. Cells were divided into a control group and LIPUS group. Flow cytometry was used to examine the rate of resident macrophages, and real-time PCR was used to examine the mRNA expression of anti-inflammation genes. RESULTS: LIPUS promoted spinal fusion and stimulated the transition of F4-80+/Mac-2+ (M1) to F4-80+/Mac-2- (M2), leading to the early appearance of resident macrophages. Cell experiments showed CD206+ macrophages (M2) were significantly increased after LIPUS treatment. M2-related genes and anti-inflammation factors (Arg-1, PPAR-γ, and IL-4) were increased after LIPUS treatment. CONCLUSION: The earlier transition from inflammatory to resident macrophage might be one reason for the positive effect of LIPUS on spinal fusion.

Cross-cultural Adaptation and Validation of the Simplified-Chinese Version of Neck Bournemouth Questionnaire for Patients in Mainland China.

STUDY DESIGN: A prospective study. OBJECTIVE: The aim of this study was to develop and assess the internal reliability and structure validity of a simplified Chinese version of the Neck Bournemouth Questionnaire (SC-NBQ) for evaluation of patients with nonspecific neck pain (NP) in mainland China. SUMMARY OF BACKGROUND DATA: The NBQ has been cross-culturally translated into several languages with good internal consistency and construct validity to evaluate low back pain and NP. However, the NBQ has been not translated or validated for Chinese-speaking patients. METHODS: The SC-NBQ was developed by standard cross-translation procedures, and completed by 106 patients with nonspecific NP, along with other self-reported questionnaires, including the Neck Disability Index (NDI), Hospital Anxiety and Depression Scale (HADS), Functional Rating Index (FRI), and 36-Item Short Form Health Survey (SF-36). The internal consistency, test-retest reliability, and construct validity of the SC-NBQ were determined. RESULTS: The NBQ was successfully translated into Chinese. All patients completed the SC-NBQ twice, and the other instruments. Score distribution demonstrated that there was no floor or ceiling effects of the SC-NBQ. Cronbach α coefficient (α = 0.89) and intraclass correlation coefficient (ICC = 0.97) showed good internal consistency and test-retest reliability. A good construct validity was shown by strong correlation with HADS (r = 0.75), NDI (r = 0.82), FRI (r = 0.90) and SF-36 physical functioning (r = 0.75), and bodily pain (r = 0.75) subscales. CONCLUSION: The SC-NBQ demonstrated good internal consistency, test-retest reliability, and construct validity, and may be used for the evaluation of NP in Chinese-speaking patients. LEVEL OF EVIDENCE: 2.

Effects of Low-Intensity Pulsed Ultrasound on Knee Osteoarthritis: A Meta-Analysis of Randomized Clinical Trials.

BACKGROUND: Osteoarthritis (OA) is a common degeneration disease characterized with joint pain. The aim of the present study was to systemically review the effects of LIPUS on pain relief and functional recovery in patients with knee osteoarthritis (OA). METHODS: PubMed, Embase, and Cochrane Library were searched manually for researches on LIPUS treatment in patients with knee OA from 1945 to July 2017. Two investigators independently selected the studies according to the inclusion and exclusion criteria, extracted the concerned data, and assessed the included studies. Meta-analysis was performed to evaluate VAS, WOMAC, and ambulation speed between control and LIPUS groups. RESULTS: Five studies were selected in this study. Compared with control group, LIPUS group received a decrease of pain intensity with moderate heterogeneity (-0.79, 95% CI, -1.57 to 0.00; I2 = 65%, P = 0.04) by VAS and improvement in knee function by WOMAC (-5.30, 95% CI, -2.88 to -7.71; I2 = 44%, P = 0.17). No significant improvement was found in ambulation speed (0.08 m/s, 95% CI, -0.02 to 0.18 m/s; I2 = 68%, P = 0.03). CONCLUSION: The present study includes 5 high quality randomized controlled trials. The result indicated that LIPUS, used to treat knee OA without any adverse effect, had a beneficial effect on pain relief and knee functional recovery. More evidence is needed to prove whether LIPUS is effective in improving walking ability.

Low-intensity pulsed ultrasound promotes spinal fusion and enhances migration and proliferation of MG63s through sonic hedgehog signaling pathway.

Low-intensity pulsed ultrasound (LIPUS) has been found to accelerate the healing process of spinal fusion via a process closely related to osteoblast differentiation and migration. Sonic hedgehog (Shh) signaling plays an important role in development and homeostasis, including a critical function in bone formation. However, its role in spinal fusion during LIPUS treatment is still unknown. This study showed that LIPUS treatment after spinal fusion surgery increased bone formation. The increased bone mass under LIPUS treatment appeared to result from the increased migration and proliferation of osteoblasts, resulting from upregulation of the Shh signaling pathway. In contrast, inhibition of Shh reduced the migratory and proliferative ability of osteoblast-like MG63 cells and blocked the efficacy of LIPUS treatment.

Key Vertebral Pedicle Screw Strategy for the Correction of Flexible Lenke Type 1 Adolescent Idiopathic Scoliosis: A Preliminary Study of a 5-year Minimum Radiographic Follow-up.

STUDY DESIGN: A retrospective clinical and radiographic study. OBJECTIVE: The aim of this study was to evaluate outcomes of the key vertebral pedicle screw strategy (KVPSS) for the correction of flexible Lenke type 1 adolescent idiopathic scoliosis (AIS) with a minimum follow-up of 5 years. SUMMARY OF BACKGROUND DATA: The KVPSS has been described as an alternative screw placement strategy for surgically treating the main thoracic curve in AIS patients. However, there have been no long-term, three-dimensional correction studies of selective thoracic fusion using the KVPSS in Lenke type 1AIS. METHOD: Twenty consecutive patients with Lenke type 1 main thoracic AIS underwent one-stage posterior correction and fusion using the KVPSS. Preoperative and postoperative radiographic and clinical parameters were analyzed. RESULTS: The mean preoperative major thoracic curve was 47.4°â€Š±â€Š5.8°, and mean corrections of 67.0%, 63.4%, and 61.5% were observed at the immediate, 2-year postoperative, and final follow-ups, respectively. Thoracickyphosis decreased significantly from the preoperative period to the immediate postoperative period (P = 0.042) but did not change significantly from the 2-year postoperative follow-up to the final follow-up (P = 0.067). Apical vertebral rotation achieved 34.7% correction and exhibited correction loss of 8.2% at the final follow-up. The average intraoperative blood loss was 802.3 mL, and the mean operative time was 138.6 minutes. SRS-22 scores for self-image and satisfaction improved significantly from the preoperative period to the final follow-up. No neurologic or implant-associated complications were observed in this study. CONCLUSION: The KVPSS is an effective method for correcting Lenke type 1 AIS and achieves satisfactory correction of the deformity. Relative to other approaches, the KVPSS can not only achieve a satisfactory and cost-effective clinical outcome but also reduce both operative time and intraoperative blood loss. LEVEL OF EVIDENCE: 4.

Validations and psychological properties of a simplified Chinese version of pain anxiety symptoms scale (SC-PASS).

The Pain Anxiety Symptoms Scale (PASS) has been developed to evaluate pain anxiety, which leads to avoidance of daily activities and normal movements. However, a simplified Chinese version of PASS is still not available. Physicians are not aware of which patients are prone to anxiety, and what the risk factors are.To cross-culturally adapt the PASS into a simplified Chinese version and test the reliability and validity. Factors affecting pain anxiety were also explored.The PASS was first translated into a simplified Chinese version according to a forward-backward method. Then, validations were tested including content validity, construct validity, and reliability. Content validity was analyzed by response trend. Construct validity was analyzed by confirmatory factor analysis (CFA), exploratory factor analysis, and priori hypotheses testing. Reliability was analyzed by internal consistency and test-retest reliability. Risk factors of catastrophizing were analyzed by performing multivariate liner regression.A total of 219 patients were included in the study. The scores of items were well distributed. Both CFA and exploratory factor analysis suggested a 2nd-order, 4-factor model, accounting for 65.42% of the total variance according to principle component analysis. SC-PASS obtained good reliability with a Cronbach α = 0.92 and ICC = 0.90. College education, long pain duration, and both married and divorced status were risk factors. Factors reduced pain-related anxiety were no medication assumption, female sex, widowed status, non-Han ethnicity, and having no religious belief.The SC-PASS was applicable in Chinese patients and it was suitable for the clinical uses in mainland China.

Low-Intensity Pulsed Ultrasound-Induced Spinal Fusion is Coupled with Enhanced Calcitonin Gene-Related Peptide Expression in Rat Model.

Low-intensity pulsed ultrasound (LIPUS) has been found to accelerate fracture healing. In this study, we analyzed the role of calcitonin gene-related peptide (CGRP) in a rat spinal fusion model treated with LIPUS. The results revealed that LIPUS significantly increases bone formation, and the process was coupled with elevated CGRP innervation. CGRP was located in fibrous tissue, closely surrounding the allograft and newly formed cartilage. The density of CGRP peaked at week 3 after surgery in both the control (non-LIPUS-treated) and LIPUS-treated groups. These results suggest that LIPUS might accelerate spinal fusion by promoting sensory nerve fiber innervation.

Low-intensity pulsed ultrasound promotes endothelial cell-mediated osteogenesis in a conditioned medium coculture system with osteoblasts.

Angiogenesis plays an important role during bone regeneration. Low-intensity pulsed ultrasound (LIPUS) has been proven to accelerate the process of bone fracture healing. However, the mechanism of the effect of LIPUS on bone regeneration is still unclear. In the present study, we used human umbilical vein endothelial cell (HUVEC) and human osteosarcoma cell (MG-63) to investigate the effect of LIPUS stimulation in an endothelial cell-osteoblast coculture system. At the same time, we used transwell and in vitro angiogenesis assay to observe how LIPUS affects endothelial cells. The results demonstrated that LIPUS could significantly increase the migratory ability and promote tube formation in angiogenesis of HUVECs. Furthermore, LIPUS could significantly elevate the expression of osteogenesis-related genes on osteoblasts such as Runt-related transcription factor 2, alkaline phosphatase, Osteorix, and Cyclin-D1, indicating the pro-osteogenesis effect of LIPUS in our coculture system. In conclusion, endothelial cell is involved in LIPUS-accelerated bone regeneration, the positive effect of LIPUS may be transferred via endothelial cells surrounding fracture healing site.

Cervical Sagittal Alignment Limited Adjustment After Selective Posterior Thoracolumbar/Lumbar Curve Correction in Patients With Lenke Type 5C Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A retrospective clinical and radiographic study. OBJECTIVE: The aim of this study was to analyze the radiographic change in cervical sagittal alignment (CSA) and identify the possible factors influencing the postoperative CSA in selective posterior thoracolumbar/lumbar (TL/L) curve correction. SUMMARY OF BACKGROUND DATA: The correlation between the CSA and thoracic sagittal alignment (TSA) is a well-recognized phenomenon in patients with thoracic idiopathic scoliosis. However, little has been published about the influence of TL/L curve instrumentation on CSA. METHODS: Thirty patients with Lenke type 5C adolescent idiopathic scoliosis (AIS) received the selective posterior TL/L curves fusion by pedicle screws. Preoperative and postoperative radiographic and clinical parameters were analyzed. C2-C7 lordosis less than 0 was considered a lordotic cervical spine (LCS), whereas more than 0 was considered a kyphotic cervical spine (KCS). RESULTS: Preoperatively, 43% of patients showed a KCS, whereas the remaining 57% showed a LCS. C2-C7 lordosis was correlated with T1-slope, thoracic kyphosis (TK), and global-TK (Gl-TK) (P < 0.05). The patients in the KCS group showed a smaller T1-slope, TK, and Gl-TK than those in the LCS group. Logistic regression analysis revealed that the T1-slope [odds ratio (OR) = 0.86, P = 0.008] and Gl-TK (OR = 0.90, P = 0.019) were risk factors for developing KCS. In the LCS group, 5 of 12 patients with LCS exhibited KCS after surgery. The T1-slope and Gl-TK in the changed group were considerably smaller than those in the maintained group (P = 0.004 and 0.035, respectively). In the KCS group, 6 of 13 patients with KCS unrecovered to LCS after the operation. The T1-slope in the unrecovered group was smaller than that in the recovered group (P = 0.045). CONCLUSION: C2-C7 lordosis was strongly correlated with the T1-slope. C2-C7 lordosis of Lenke 5C AIS was related to the global TSA rather than TK and proximal TK. As time progresses, spontaneous adjustment of CSA is limited because of the inherent rigidity of the cervical spine. LEVEL OF EVIDENCE: 4.

Comparative Analysis of Interval, Skipped, and Key-vertebral Pedicle Screw Strategies for Correction in Patients With Lenke Type 1 Adolescent Idiopathic Scoliosis.

Pedicle screw constructs have become the mainstay for surgical correction in patients with spinal deformities. To reduce or avoid the risk of pedicle screw-based complications and to decrease the costs associated with pedicle screw instrumentation, some authors have introduced interval, skipped, and key-vertebral pedicle screw strategies for correction. However, there have been no comparisons of outcomes among these 3 pedicle screw-placement strategies.The aim of this study was to compare the correlative clinical outcomes of posterior correction and fusion with pedicle screw fixation using these 3 surgical strategies.Fifty-six consecutive patients with Lenke type 1 adolescent idiopathic scoliosis were included in this study. Twenty patients were treated with the interval pedicle screw strategy (IPSS), 20 with the skipped pedicle screw strategy (SPSS), and 16 with the key-vertebral pedicle screw strategy (KVPSS). Coronal and sagittal radiographs were analyzed before surgery, at 1 week after surgery, and at the last follow-up after surgery.There were no significant differences among the 3 groups regarding preoperative radiographic parameters. No significant difference was found between the IPSS and SPSS groups in correction of the main thoracic curve (70.8% vs 70.0%; P = 0.524). However, there were statistically significant differences between the IPSS and KVPSS groups (70.8% vs 64.9%) and between the SPSS and KVPSS groups (70.0% vs 64.9%) in correction of the main thoracic curve (P < 0.001 for both). Additionally, there were no significant differences among the 3 strategies for sagittal parameters at the immediate postoperative and last postoperative follow-up periods, though there were significant differences in the Cobb angle between the preoperative and immediate postoperative periods among the 3 groups, but not between the immediate postoperative and last follow-up periods. The amount of hospital charges in the SPSS group was significantly higher than those in the IPSS (P < 0.001) and KVPSS groups (P < 0.001). There were also significant differences in operative time between the IPSS and KVPSS groups (P < 0.001) and between the SPSS and KVPSS groups (P < 0.001).Each of the 3 types of pedicle screw strategies for correction in patients with Lenke type 1 adolescent idiopathic scoliosis are effective, with satisfactory coronal and acceptable sagittal plane results. Although the KVPSS does not provide superior operative correction compared with the IPSS and SPSS, it can achieve a satisfactory clinical outcome and is more cost-effective.

Spatiotemporal Changes of Calcitonin Gene-Related Peptide Innervation in Spinal Fusion.

Few studies have investigated the role calcitonin gene-related peptide (CGRP) plays in the process of spinal fusion. The aim of the present study is to observe the temporal and spatial changes of CGRP induced by experimental fusion surgery in rats and elucidate the role of CGRP in spinal fusion. Male Sprague-Dawley rats were used in the study and the specimens were collected on the 7th, 14th, 21st, and 28th day, respectively. Then, histological and immunohistochemical analysis were applied to evaluate the fusion mass and spatiotemporal changes of CGRP chronologically. The results demonstrated that density of CGRP reached peak on the 21st day after surgery and most of the CGRP expression located surrounding the interface of allograft and fibrous tissue where the cells differentiate into osteoblasts, indicating that CGRP might be involved in the process of bone formation and absorption.

Radiological Assessment of the Sacrofemoral Angle: A Novel Method to Measure the Range of Hip Joint Flexion.

BACKGROUND: A quantitative and accurate measurement of the range of hip joint flexion (RHF) is necessarily required in the evaluation of disordered or artificial hip joint function. This study aimed to assess a novel method to measure RHF more accurately and objectively. METHODS: Lateral radiographs were taken of 31 supine men with hip joints extended or flexed. Relevant angles were measured directly from the radiographs. The change in the sacrofemoral angle (SFA) (the angle formed between the axis of the femur and the line tangent to the upper endplate of S1) from hip joint extension to hip joint flexion, was proposed as the RHF. The validity of this method was assessed via concomitant measurements of changes in the femur-horizontal angle (between the axis of the femur and the horizontal line) and the sacrum-horizontal angle (SHA) (between the line tangent to the upper endplate of S1 and the horizontal line), the difference of which should equal the change in the SFA. RESULTS: The mean change in the SFA was 112.5 ± 7.4°, and was independent of participant age, height, weight, or body mass index. The mean changes in the femur-horizontal and SHAs were 123.0 ± 6.4° and 11.4 ± 3.0°, respectively. This confirmed that the change of SFA between hip joint extension and hip joint flexion was equal to the difference between the changes in the femur-horizontal and SHAs. CONCLUSIONS: Using the SFA, to evaluate RHF could prevent compromised measurements due to the movements of pelvis and lumbar spine during hip flexion, and is, therefore, a more accurate and objective method with reasonable reliability and validity.

Spontaneous Thoracic Curve Correction After Selective Posterior Fusion of Thoracolumbar/Lumbar Curves in Lenke 5C Adolescent Idiopathic Scoliosis.

Selective fusion of the thoracolumbar/lumbar (TL/L) curve is an effective method for the treatment of Lenke type 5C curves. Several studies have demonstrated that spontaneous correction of the thoracic curve does indeed occur. However, how this correction occurs after isolated posterior segmental instrumentation of the structural lumbar curve has not been well described. The aim of this study was to evaluate the response of the thoracic curve to selective TL/L curve fusion in patients with Lenke type 5C adolescent idiopathic scoliosis (AIS) and assess the correlative clinical outcomes. Thirty-four consecutive patients with Lenke type 5C AIS were included in this study. All patients underwent selective TL/L curve instrumentation and fusion via the posterior approach. Coronal and sagittal radiographs were analyzed before surgery, at 1 week after surgery and at least 2 years after surgery. The preoperative coronal Cobb angle of the major TL/L curve was 45.4° ± 7.0°, and that of the minor thoracic curve was 25.4° ± 8.8°. The major TL/L and minor thoracic curves were corrected to postoperative angles of 9.5° ± 5.0° and 11.2° ± 5.2°, respectively, and measured 10.5° ± 6.0° and 13.4° ± 7.5° at the follow-up, respectively. The supine side-bending average Cobb angle of the thoracic curve was 9.9°. These results demonstrate satisfactory improvements because of coronal and sagittal restoration. Significant correlations were found between the preoperative and early postoperative conditions and the Cobb angle changes of the minor thoracic curve and the major TL/L curves (r = 0.42, P = 0.01). Significant correlations were also observed between the early and final follow-up postoperative conditions and the Cobb angle changes of the minor thoracic curve and the major TL/L curves (r = 0.57, P < 0.001). Significant correlations were observed between increased thoracic kyphosis (TK) and increased lumbar lordosis (LL) in the preoperative and early postoperative conditions (r = 0.36, P = 0.035) and between increased TK and increased LL in the preoperative and final follow-up postoperative conditions (r = 0.51, P = 0.002). Spontaneous correction of the thoracic curve is a reflection of the TL/L curve correction in Lenke 5C AIS patients. Supine side-bending radiographs are an effective method of predicting the spontaneous correction of thoracic curves. The correction of LL is important for maintaining spinal sagittal alignment.

Sagittal Balance in Adolescent Idiopathic Scoliosis: A Radiographic Study of Spinopelvic Compensation After Selective Posterior Fusion of Thoracolumbar/Lumbar (Lenke 5C) Curves.

The relationship between spinal sagittal alignment and pelvic parameters is well known in adolescent idiopathic scoliosis. However, few studies have reported the sagittal spinopelvic relationship after selective posterior fusion of thoracolumbar/lumbar (TL/L) curves. We evaluated the relationship between spinal sagittal alignment and the pelvis, and analyzed how the pelvic sagittal state is adjusted in Lenke type 5C patients. We conducted a retrospective study of 36 patients with Lenke type 5C curves who received selective posterior TL/L curve fusion. Coronal and spinopelvic sagittal parameters were pre and postoperatively compared. Pearson coefficients were used to analyze the correlation between all spinopelvic sagittal parameters before and after surgery. We also evaluated 3 pelvic morphologies (anteverted, normal, and retroverted) before and after surgery. Preoperatively, the mean pelvic incidence was 46.0°, with a pelvic tilt and sacral slope (SS) of 8.2° and 37.8°, respectively, and 25% (9/36) of patients had an anteverted pelvis, whereas the other 75% had a normal pelvis. Postoperatively, 42% (15/36) of patients had a retroverted pelvis, 53% (19/36) had a normal pelvis, and 2 patients had an anteverted pelvis. Logistic regression analyses yielded 2 factors that were significantly associated with the risk for a postoperative unrecovered anteverted pelvis, including increased lumbar lordosis (LL) (odds ratio [OR] 4.8, P = 0.029) and increased SS (OR 5.6, P = 0.018). Four factors were significantly associated with the risk of a postoperative newly anteverted pelvis, including LL at the final follow-up (OR 6.9, P = 0.009), increased LL (OR 8.9, P = 0.003), LL below fusion (OR 9.4, P = 0.002), and increased SS (OR 11.5, P = 0.001). The pelvic state may be adjusted after selective posterior TL/L curve fusion in Lenke 5C adolescent idiopathic scoliosis patients. It is difficult to improve an anteverted pelvis in patients who have an LL that is increased by more than 11.6° or an SS that is increased by more than 4.7° after surgery. The anteverted pelvic state will generally occur with posterior correction surgery for patients with an LL that is greater than 63.7°, or an LL or SS that is respectively increased by more than 17.6° or 9.0° postoperatively.