Minimally Invasive Surgery For Management of Bunionette Deformity (Tailor's Bunion) Using Fifth Metatarsal Osteotomies: A Systematic Review and Meta-Analysis.

Background: There has been increasing interest in the use of percutaneous or minimally invasive osteotomy techniques for bunionette correction. The aim of this systematic review was to investigate the clinical and radiographic outcomes following percutaneous or minimally invasive surgery for bunionette deformity correction. Methods: A systematic review following PRISMA guidelines was undertaken. All clinical studies published in MEDLINE, Embase, PubMed, and the Cochrane Library Database from inception until December 2023 reporting on the use of percutaneous or minimally invasive osteotomy techniques for bunionette deformity correction were included. The primary outcome was radiographic deformity correction. A meta-analysis of clinical and radiographic outcomes was performed to assess the mean difference following surgery. Risk of bias was assessed using the ROBINS-I tool. Results: A total of 942 potential studies were identified, of which 18 were included encompassing 714 feet in 580 patients. There were no comparative studies identified. The majority of studies (n = 14/18) used an unfixed distal osteotomy technique. All studies showed a statistically significant improvement in clinical outcomes (American Orthopaedic Foot & Ankle Society ankle-hindfoot score and visual analog scale for pain) and radiologic outcomes (fourth-fifth intermetatarsal angle and fifth metatarsophalangeal angle). Complication rates ranged from 0% to 21.4%. The nonunion rate was 0% to 5.6%. Overall risk of bias was low to moderate. The most common complication was development of a hypertrophic callus that tended to resorb over time without needing further surgical intervention. Conclusion: The results of this systematic review must be considered in light of the methodologic limitations of the studies analyzed-including additional procedures performed at the same time as the bunionette correction, lack of comparative studies, and heterogeneity of the case series included. Despite these limitations, our review suggests that percutaneous techniques for bunionette deformity correction are generally clinically safe and associated with improvement in radiographic alignment and patient-reported outcome measures.

Thoracolumbar fusions for adult lumbar deformity show superior QALY gain and lower costs compared with upper thoracic fusions.

PURPOSE: Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion. METHODS: ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively. RESULTS: Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p = 0.01), lower surgical invasiveness (- 30; p < 0.001), and shorter OR time (- 35 min; p = 0.01). Index and total costs were 20% lower in the TL than in the UT group (p < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain (p = 0.03) than UT fusions. CONCLUSION: In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions. LEVEL OF EVIDENCE: III.

A Meta-Analysis of Surgical Outcomes in 25727 Patients Undergoing Anterior Cervical Discectomy and Fusion or Anterior Cervical Corpectomy and Fusion for Cervical Deformity.

STUDY DESIGN: Systematic Review. OBJECTIVES: To evaluate which cervical deformity correction technique between anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) produces better clinical, radiographic, and operative outcomes. METHODS: We conducted a meta-analysis comparing studies involving ACDF and ACCF. Adult patients with either original or previously treated cervical spine deformities were included. Two independent reviewers categorized extracted data into clinical, radiographic, and operative outcomes, including complications. Clinical assessments included patient-reported outcomes; radiographic evaluations examined C2-C7 Cobb angle, T1 slope, T1-CL, C2-7 SVA, and graft stability. Surgical measures included surgery duration, blood loss, hospital stay, and complications. RESULTS: 26 studies (25727 patients) met inclusion criteria and were extracted. Of these, 14 studies (19077 patients) with low risk of bias were included in meta-analysis. ACDF and ACCF similarly improve clinical outcomes in terms of JOA and NDI, but ACDF is significantly better at achieving lower VAS neck scores. ACDF is also more advantageous for improving cervical lordosis and minimizing the incidence of graft complications. While there is no significant difference between approaches for most surgical complications, ACDF is favorable for reducing operative time, intraoperative blood loss, and length of hospital stay. CONCLUSIONS: While both techniques benefit cervical deformity patients, when both techniques are feasible, ACDF may be superior with respect to VAS neck scores, cervical lordosis, graft complications and certain perioperative outcomes. Further studies are recommended to address outcome variability and refine surgical approach selection.

Comparison of three artificial intelligence algorithms for automatic cobb angle measurement using teaching data specific to three disease groups.

Spinal deformities, including adolescent idiopathic scoliosis (AIS) and adult spinal deformity (ASD), affect many patients. The measurement of the Cobb angle on coronal radiographs is essential for their diagnosis and treatment planning. To enhance the precision of Cobb angle measurements for both AIS and ASD, we developed three distinct artificial intelligence (AI) algorithms: AIS/ASD-trained AI (trained with both AIS and ASD cases); AIS-trained AI (trained solely on AIS cases); ASD-trained AI (trained solely on ASD cases). We used 1612 whole-spine radiographs, including 1029 AIS and 583 ASD cases with variable postures, as teaching data. We measured the major and two minor curves. To assess the accuracy, we used 285 radiographs (159 AIS and 126 ASD) as a test set and calculated the mean absolute error (MAE) and intraclass correlation coefficient (ICC) between each AI algorithm and the average of manual measurements by four spine experts. The AIS/ASD-trained AI showed the highest accuracy among the three AI algorithms. This result suggested that learning across multiple diseases rather than disease-specific training may be an efficient AI learning method. The presented AI algorithm has the potential to reduce errors in Cobb angle measurements and improve the quality of clinical practice.

Osteotomy combined with anterior cruciate ligament reconstruction for anterior cruciate ligament injury and biplanar deformity.

BACKGROUND: It has been confirmed that the increased posterior tibial slope over 12 degrees is a risk factor for anterior cruciate ligament injury, and varus deformity can aggravate the progression of medial osteoarthritis. AIM: To evaluate the efficacy of modified high tibial osteotomy (HTO) and anterior cruciate ligament reconstruction (ACLR) in the treatment of anterior cruciate ligament (ACL) injuries with varus deformities and increased posterior tibial slope (PTS) based on clinical and imaging data. METHODS: The patient data in this retrospective study were collected from 2019 to 2021. A total of 6 patients were diagnosed with ACL injury combined with varus deformities and increased PTS. All patients underwent modified open wedge HTO and ACLR. The degree of correction of varus deformity and the PTS was evaluated by radiography and magnetic resonance imaging. RESULTS: All 6 patients (6 knee joints) were followed up for an average of 20.8 ± 3.7 months. The average age at surgery was 29.5 ± 3.8 years. At the last follow-up, all patients resumed competitive sports. The International Knee Documentation Committee score increased from 50.3 ± 3.1 to 87.0 ± 2.8, the Lysholm score increased from 43.8 ± 4.9 to 86 ± 3.1, and the Tegner activity level increased from 2.2 ± 0.7 to 7.0 ± 0.6. The average movement distance of the tibia anterior translation was 4.8 ± 1.1 mm, medial proximal tibial angle (MPTA) was 88.9 ± 1.3° at the last follow-up, and the PTS was 8.4 ± 1.4°, both of which were significantly higher than those before surgery (P < 0.05). CONCLUSION: Modified open wedge HTO combined with ACLR can effectively treat patients with ACL ruptures with an associated increased PTS and varus deformity. The short-term effect is significant, but the long-term effect requires further follow-up.

Structural alterations in scales of Capoeta capoeta (Güldenstädt, 1773) from heavy metal-contaminated river water.

Heavy metal pollution, especially in freshwater, is a serious problem for aquatic organisms and human health. In this study, the scales of Capoeta capoeta living in the Karasu River (Turkey), which is estimated to be contaminated with pollutants, especially heavy metals, were examined for structural anomalies. Two stations on the river were selected for this purpose. Fish and surface water samples were taken at the stations. The heavy metal analyses were carried out in the water and the fish tissue. Heavy metal pollution was detected in the surface water. It was also observed that some heavy metals (As, Cu, Cd, Cr, Mn, Pb, Ni, Zn) accumulate in the fish tissue. Significant structural differences were observed on the dorsal surface of the scales, such as interrupted primary radii, damaged circuli, damaged focus, damaged anterior scale margin, broken focus, deformed scale structure, scattered chromatophores, dilatation of primary radii, loss of focus, damaged annuli, symmetry shift in the lateral line canal, eroded circuli, damaged posterior scale margin, double focus, branching in the primary radii, asymmetric circuli, incomplete annuli and interrupted secondary radii in each of the fish collected from the contaminated site. Heavy metals are suspected to be responsible for the structural anomalies in the scales. Based on these observations, it can be said that fish scales can be used as an effective indicator of water quality.

Latest knowledge on a comprehensive understanding of cervical deformity and selection of effective treatment methods using recent classification systems: a narrative review.

Surgical treatment for patients with cervical spine deformities is challenging for both patients and doctors. For successful surgical treatment, mastery of processes is important to objectively evaluate and classify the degree of deformity. Recently, efforts have been increasing to systematically understand, evaluate, and effectively treat complex cervical spine deformities. Various parameters are being developed to quantify and objectively evaluate the degree of cervical spine deformity, and classification methods are being introduced to help establish the treatment scope by categorizing it according to the degree of deformity. However, a comprehensive and systematic understanding of complex deformities using only the currently introduced classification methods and related knowledge is not easy. Through this review, we aimed to introduce various classification methods and their pros and cons to evaluate cervical deformities, analyze their meaning, and provide a basic understanding of the evaluation and classification of patients with cervical spine deformities. This review also aimed to aid in the decision-making process for the treatment of cervical spine deformities by presenting a structured treatment algorithm based on recently known classification systems and lay the foundation for efficient treatment.

Optimizing preoperative bone health assessment for adult spinal deformity: a prospective correlation analysis of intraoperative pedicle screw insertion torque and imaging modalities in Japan.

Study Design: Prospective cohort study. Purpose: This study aimed to identify the optimal preoperative bone health assessment for adult spinal deformity (ASD) surgery through correlation analysis between intraoperative pedicle screw (PS) insertion torque and various bone quality measures, including bone mineral density (BMD) assessed by dual-energy X-ray absorptiometry (DEXA), Hounsfield unit (HU) by computed tomography (CT), and vertebral bone quality (VBQ) score by magnetic resonance imaging. Overview of Literature: Existing data on optimal assessment tools for ASD surgery are limited. Methods: The study included patients with ASD aged >60 years who underwent spinal corrective fusion surgery from the lower thoracic spine to the pelvis. The intraoperative PS insertion torque was measured using a torque meter. Pearson correlation coefficients were calculated between the PS insertion torque and the BMD, HU, and VBQ score. Preoperative bone quality was compared between the proximal junctional failure (PJF) and non-PJF groups. Results: Thirty-one patients with 177 PS at T10, T11, and T12 were analyzed. The PS insertion torque showed a moderate positive correlation with lumbar spine BMD (r=0.59-0.69, p<0.01), total hip BMD (0.58-0.62, p<0.01), and HU value (r=0.58-0.66, p<0.01). However, the VBQ score did not show significant correlation (r=-0.28 to -0.23, p >0.05). Notably, a strong correlation was found between the PS insertion torque and the HU value for screws of the same size (r=0.71 and 0.74, p<0.01). The HU value at T12 and the PS insertion torque at T10 were significantly lower in the PJF group than in the non-PJF group. Conclusions: This study demonstrates a positive correlation between the PS insertion torque and HU value in the lower thoracic spine and a moderate correlation with BMD but not the VBQ score. Preoperative assessment using DEXA and CT is crucial for optimizing bone health management in ASD surgery.

Step-cut osteotomy for cubitus varus deformity with application of patient-specific instrument in children: a preliminary report.

PURPOSE: The step-cut osteotomy has been recognized as a valuable approach for addressing cubitus varus deformity, albeit one that necessitates technical proficiency. This study aims to evaluate the efficacy of the modified step-cut osteotomy technique in conjunction with patient-specific instruments by clinical and radiological assessment. METHODS: We conducted a retrospective review of patients who underwent modified step-cut osteotomy with the use of patient-specific instruments in conjunction with Kirschner wires fixation for the correction of cubitus varus deformity between April 2016 and April 2022. Follow-up was performed for a minimum of two years, during which pre-operative and post-operative clinical and radiological parameters were compared. RESULTS: Fifteen patients were enrolled in this study. The mean pre-operative humeral-elbow-wrist (HEW) of the affected side was -21.7° (ranging from -14° to -34°), while the normal side was 9.4° (ranging from 5° to 15°). The post-operation HEW of affected side was 9° (ranging from 4° to 16°). There was no significant difference between the normal side and affected side after operation (p = 0.74). Pre-operative range of motion in the affected side was 130°, while the post-operative range of motion was 132°. Fourteen patients (93.3%) were pleased with the overall appearance of their elbow. None lazy-S deformity was observed in these cases. There were no major complications. CONCLUSION: The modified step-cut osteotomy technique, utilizing patient-specific instrument in conjunction with Kirschner wires fixation was found to be a safe, reliable, and technically easy procedure for correcting cubitus varus deformity.

Evaluation of the use of tranexamic acid in the postoperative period in patients with scoliosis undergoing posterior fusion.

Scoliosis is the most prevalent type of spinal deformity, with a 2-3% prevalence in the general population. Moreover, surgery for scoliotic deformity may result in severe blood loss and, consequently, the need for blood transfusions, thereby increasing surgical morbidity and the rate of complications. Several antifibrinolytic drugs, such as tranexamic acid, have been regarded as safe and effective options for reducing blood loss. Therefore, the present study aimed to analyse the effectiveness of this drug for controlling bleeding when used intraoperatively and in the first 48 h after surgery. A prospective randomized study of a cohort of patients included in a mass event for scoliosis treatment using PSF was performed. Twenty-eight patients were analysed and divided into two groups: 14 patients were selected for intraoperative and postoperative use of tranexamic acid (TXA), and the other 14 were selected only during the intraoperative period. The drainage bleeding rate, length of hospital stay, number of transfused blood units, and rate of adverse clinical effects were compared. All the patients involved had similar numbers of fusion levels addressed and similar scoliosis profiles. The postoperative bleeding rate through the drain did not significantly differ between the two groups (p > 0.05). There was no significant difference in the number of transfused blood units between the groups (p = 0.473); however, in absolute numbers, patients in the control group received more transfusions. The length of hospital stay was fairly similar between the groups, with no statistically significant difference. Furthermore, the groups had similar adverse effects (p = 0.440), with the exception of nausea and vomiting, which were twice as common in the TXA group postoperatively than in the control group. No significant differences were found in the use of TXA during the first 48 postoperative hours or in postoperative outcomes.

Closing the Gap: Exploring the Role of Cap Grafts in Tracheocutaneous Fistula Closure.

Exploring the Role of Cap Grafts in tracheocutaneous fistula Closure. A tracheocutaneous fistula (TCF) is an abnormal connection that forms between the trachea (windpipe) and the skin of the neck. If spontaneous closure does not occur, fibrosis of the surrounding tissue may result in a persistent TCF and in some cases, iatrogenic laryngotracheal stenosis at the level of tracheostoma, the so-called A-frame deformity. In all 5 patients, Conchal cartilage was harvested. The new de-epithelialized stoma is measured, and the previously harvested graft is cut to match the defect. Passing through the centre of the tracheal cartilage and into the centre of the auricular cartilage graft, 3-0 PDS, horizontal mattress sutures are placed sequentially around the periphery of the graft, stabilised with Right SCM flap and skin was closed in layers. In each of the five cases, we achieved a resounding success by skilfully closing the fistulas and meticulously restoring the structural integrity. Equally noteworthy, all patients expressed contentment with the cosmetic outcomes at both the donor site and the neck region, deeming it as an acceptable aesthetic result.

Spinopelvic Parameters in the Elderly: Does Inadequate Correction Portend Worse Outcomes?

Introduction: This study aimed to compare the outcomes of corrective fusion for adult spinal deformity (ASD) in older people using two different sagittal correction goals: the conventional formula of "pelvic incidence (PI)-lumbar lordosis (LL) mismatch <10°" and an undercorrection strategy based on the range of 10°≤PI-LL≤20°. Methods: A total of 102 consecutive patients (11 male and 91 female patients; mean age, 72.0 years) aged above 65 years with scoliosis >20° or LL<20° who had undergone long-segment fusion from the lower thoracic spine to the pelvis for ASD and had been followed-up for a minimum of two years at our institution since March 2013 were included in this retrospective study. After excluding patients with PI-LL≤-10° on postoperative standing radiographs, the remaining patients were divided into two groups: 31 patients with 10°≤PI-LL≤20° (U group) and 63 patients with -10°

Evaluating the prevalence of psychiatric comorbidities associated with pediatric scoliosis utilizing ResearchMatch.

PURPOSE: The goal of this study is to characterize the self-reported prevalence of psychiatric comorbidities among patients with adolescent scoliosis. METHODS: Eligible patients across the US were surveyed using ResearchMatch, a validated online platform. The survey collected patient demographics, type of scoliosis, scoliosis treatment received, and the mental health diagnoses and interventions. RESULTS: Nearly all (98%) of the 162 respondents were patients themselves, the remainder of which were parents. The majority of whom were female (93%), Caucasian (85%), and diagnosed with idiopathic scoliosis (63%). The median age of diagnosis was 13 (IQR 11-18). Most respondents had mild to moderate scoliosis (65%), and 17% received surgical treatment. 76 of 158 (48%) responded that scoliosis affected their overall mental health, and 92 (58%) had received a mental health diagnosis-76% were diagnosed after their scoliosis diagnosis. Of the 92 with mental health diagnoses, the most common diagnoses were clinical depression (83%), anxiety (71%), negative body image (62%). Over 80% of patients received medical treatment or therapy. Of those with depression, 38.4% received counseling and 45.2% received medication. 52% of the respondents also had immediate family members with mental health diagnoses, with siblings (48%) having the highest proportion. CONCLUSION: According to the CDC, the prevalence of US teenagers with diagnosed depression was found to be 3.9% and anxiety disorder to be 4.7%, notably higher among adolescent girls. In this national sample, over half of adolescent scoliosis patients report psychiatric comorbidity, often diagnosed years later. The most prevalent psychiatric condition is depression, anxiety, and body-image disturbances. These findings highlight the importance of awareness of the psychiatric impact of adolescent scoliosis, and importance of screening and treatment of comorbid mental health conditions. LEVEL OF EVIDENCE: IV.

The Limping Child: A Guide for the Trainees.

Limping is a common presenting complaint in children. Despite this, it remains to be a diagnostic challenge for treating physicians due to an expanded list of etiologies. It arises from a spectrum of disorders, ranging from physiological variations of gait at different stages of development to systemic causes, such as inflammatory diseases or musculoskeletal infections. On rare occasions, non-musculoskeletal causes could result in limping. The diagnostic challenge increases in younger age children where a detailed physical examination that helps identify the exact source of pathology may not be possible. In older patients who have a well-developed gait cycle, the physical assessment might be easier. Clinical assessment in a child presenting with a limp includes gait analysis, which is essential to guide the appropriate request of diagnostic laboratory tests and imaging studies. In this paper, we provide a practical guide for a trainee in General Pediatric and Pediatric Rheumatology on an approach to a limping child, aiming to identify the common causes of limping and to describe normal and abnormal gait cycles. We also discuss other diagnostic considerations in the assessment of these children.

Ultrasound-based Measurement of the Intra-scaphoid angle.

INTRODUCTION: Ultrasound is gaining popularity for diagnosing scaphoid fractures. However, it hasn't been used to assess fracture displacement, such as humpback deformity. We propose a sonographic method to measure the intra-scaphoid angle, potentially serving as an alternative to CT scans for detecting fragment malposition after a scaphoid fracture. METHODS: We recruited 11 healthy adult volunteers without wrist pathology and performed bilateral wrist ultrasounds, totaling 22 examinations. Each wrist was splinted at 50 ° extension and fully supinated. Two hand surgeons independently performed the ultrasounds. All images were then evaluated separately by two evaluators. The following measurements were taken: 1. Inter-poles distance (IPD): Distance between the summits of the two scaphoid poles on the palmar cortex. 2. Palmar cortical intra-scaphoid angle (PCISA): Angle between the two summits and the deepest point of the waist on the palmar cortex. Measurements were compared for inter-investigator and inter-evaluator reliability using the intraclass correlation coefficient (ICC). RESULTS: The study included four males and seven females, with an average age of 35 years (range 21-56). The mean PCISA was 142 ° (SD 10 °) and the mean IPD was 16.3 mm (SD 2.1 mm). Differences in IPD measurements averaged 0.3 mm (range 0-5.2 mm) among investigators and 1.0 mm (range 0.1-3.8 mm) among evaluators. For PCISA, the differences averaged 4 ° (range 0-17 °) among investigators and 6 ° (range 0-15 °) among evaluators. The ICC for IPD was 0.804 (investigators) and 0.572 (evaluators); for PCISA, it was 0.704 (investigators) and 0.602 (evaluators). CONCLUSION: This study presents a cost-effective and accessible sonographic technique to measure the intra-scaphoid angle. Further research is required to assess its effectiveness in scaphoid fractures and compare it to CT-based measurements like the H/L ratio, LISA, and DCA.

Preoperative Planning of Lumbar Lordosis for Adult Degenerative Scoliosis Surgery in the Chinese Population.

OBJECTIVE: Pelvic incidence minus lumbar lordosis mismatch (PI-LL) is directly related to poor quality of life in adult degenerative scoliosis (ADS) patients. The purpose of the study was to determine the most appropriate postoperative PI-LL value for patients with ADS. METHODS: The medical records of patients with ADS in our department were retrospectively collected. The data included age, sex, body mass index, age-adjusted Charlson comorbidity index, osteopenia, length of hospital stay, operative duration, estimated blood loss, American Society of Anaesthesiologists score, number of fusion levels, lumbar lordosis, sagittal vertical axis, pelvic incidence, PI-LL, SRS-22 score, ODI score, and mechanical complications. RESULTS: A total of 316 patients were enrolled. PI-LL, lumbar lordosis, sagittal vertical axis, SRS-22 score, ODI score at the time of last follow-up were 20.7±8.5°, 23.4±14.1°, 4.0±2.1 cm, 3.7±0.9, and 18.1±5.5, respectively. In terms of mechanical complications, 88 patients (27.8%), 34 patients (10.8%), and 19 patients (6.0%) had proximal junctional kyphosis, distal junctional kyphosis, and implant-related complications, respectively. In the fully adjusted model, compared with 0 grade PI-LL group and ++ grade PI-LL group, + grade PI-LL group had the best clinical outcomes and the fewest mechanical complications. The stability of these conclusions was verified in sensitivity analyses. CONCLUSIONS: Optimal PI-LL value should be 10°-20° after corrective surgery in patients with adult degenerative scoliosis, which is associated with excellent clinical outcomes and lower complication rates. Previous criteria may be at risk of overcorrection, which may lead to proximal junctional kyphosis.

Developing a risk score to inform the use of rhBMP-2 in adult spinal deformity surgery.

BACKGROUND: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has not shown superior benefit overall in cost-effectiveness during adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING: Retrospective PURPOSE: Generate a risk score for pseudarthrosis to inform the utilization of rhBMP-2, balancing costs against quality of life and complications. METHODS: ASD patients with 3-year data were included. Quality of life gained was calculated from ODI to SF-6D and translated to quality-adjusted life years (QALYs). Cost was calculated using the PearlDiver database and CMS definitions for complications and comorbidities. Established weights were generated for predictive variables via logistic regression to yield a predictive risk score for pseudarthrosis that accounted for frailty, diabetes, depression, ASA grade, thoracolumbar kyphosis and three-column osteotomy use. Risk score categories, established via conditional inference tree (CIT)-derived thresholds were tested for cost-utility of rhBMP-2 usage, controlling for age, prior fusion, and baseline deformity and disability. RESULTS: 64% of ASD patients received rhBMP-2 (308/481). There were 17 (3.5%) patients that developed pseudarthrosis. rhBMP-2 use overall did not lower pseudarthrosis rates (OR: 0.5, [0.2-1.3]). Pseudarthrosis rates for each risk category were: No Risk (NoR) 0%; Low-Risk (LowR) 1.6%; Moderate Risk (ModR) 9.3%; High-Risk (HighR) 24.3%. Patients receiving rhBMP-2 had similar QALYs overall to those that did not (0.163 vs. 0.171, p = .65). rhBMP-2 usage had worse cost-utility in the LowR cohort (p < .001). In ModR patients, rhBMP-2 usage had equivocal cost-utility ($53,398 vs. $61,581, p = .232). In the HighR cohort, the cost-utility was reduced via rhBMP-2 usage ($98,328 vs. $211,091, p < .001). CONCLUSION: Our study shows rhBMP-2 demonstrates effective cost-utility for individuals at high risk for developing pseudarthrosis. The generated score can aid spine surgeons in the assessment of risk and enhance justification for the strategic use of rhBMP-2 in the appropriate clinical contexts. LEVEL OF EVIDENCE: III.

Improved postural control in a patient having adult spinal deformity and previous thoraco-lumbar scoliosis surgery: a Chiropractic Biophysics® case report.

Background: There is evidence indicating patients with spinal deformity have impaired postural control and balance issues. Often, previous surgical intervention excludes the older patient from further invasive procedures leaving them with limited treatment options. The purpose of this case is to report on the clinically significant improvement in postural control as measured by force plate after a multimodal treatment program of Chiropractic Biophysics® (CBP®) posture rehabilitation as well as balance rehabilitation in an elderly patient with long-standing spinal deformity including thoracic hyperkyphosis and a T10-L4 Harrington rod instrumentation for thoracolumbar scoliosis. Case Description: A 69-year-old female presented with the main complaint of balance and gait impairment as well as back pain and headaches. Balance assessment on a force plate showed impaired balance, in the vestibular challenging condition (eyed closed; standing on foam). Radiography showed a forward stooped posture and surgical hardware. Treatment was directed at posture by CBP methods and balance rehabilitation by a whole-body vibration exercise program. Treatment progressed over a 10-month period. The patient experienced relief of back pains and headaches. There was a clinically significant improvement in posturography including a 102 cm reduction in center of pressure (COP) path length. There was an inch reduction in forward sagittal stoop. Conclusions: A non-surgical rehabilitation program demonstrated a clinically significant improvement in balance performance in an elderly female diagnosed with osteopenia, spinal deformity, and previous spine deformity surgery. This approach to improving postural stability is important and further investigations should be undertaken.

Impact of preoperative age-adjusted sagittal imbalance on radiographic and clinical outcomes following 1-level minimally invasive transforaminal lumbar interbody fusion for degenerative spondylolisthesis.

OBJECTIVE: Prior studies investigating the use of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for treatment of degenerative lumbar conditions and concomitant sagittal deformity have not stratified patients by preoperative pelvic incidence (PI)-lumbar lordosis (LL) mismatch, which is the earliest parameter to deteriorate in mild sagittal deformity. Thus, the aim of the present study was to determine the impact of preoperative PI-LL mismatch on clinical outcomes and sagittal balance restoration among patients undergoing MI-TLIF for degenerative spondylolisthesis (DS). METHODS: Consecutive adult patients undergoing primary 1-level MI-TLIF between April 2017 and April 2022 for DS with ≥ 6 months radiographic follow-up were included. Patient-reported outcome measures (PROMs) included the Oswestry Disability Index, visual analog scale (VAS), 12-Item Short-Form Health Survey (SF-12), and Patient-Reported Outcomes Measurement Information System at preoperative, early postoperative (< 6 months), and late postoperative (≥ 6 months) time points. The minimal clinically important difference (MCID) for PROMs was also evaluated. Radiographic parameters included PI, LL, pelvic tilt (PT), and sagittal vertical axis (SVA). Patients were categorized into balanced and unbalanced groups based on preoperative PI-LL mismatch according to age-adjusted alignment goals. Changes in radiographic parameters and PROMs were evaluated. RESULTS: Eighty patients were included (L4-5 82.5%, grade I spondylolisthesis 82.5%, unbalanced 58.8%). Mean clinical and radiographic follow-up were 17.0 and 8.3 months, respectively. The average preoperative PI-LL was 18.8° in the unbalanced group and -3.3° in the balanced group. Patients with preoperative PI-LL mismatch had significantly worse preoperative PT (26.2° vs 16.4°, p < 0.001) and SVA (53.2 vs 9.0 mm, p = 0.001) compared with balanced patients. Patients with preoperative PI-LL mismatch also showed significantly worse PI-LL (16.0° vs 0.54°, p < 0.001), PT (25.9° vs 18.7°, p < 0.001), and SVA (49.4 vs 22.8 mm, p = 0.013) at long-term follow-up. No significant radiographic improvement was observed among unbalanced patients. All patients demonstrated significant improvements in all PROMs (p < 0.05) except for SF-12 mental component score. Achievement of MCID for VAS back score was significantly greater among patients with preoperative PI-LL mismatch (85.7% vs 65.5%, p = 0.045). CONCLUSIONS: Although 1-level MI-TLIF did not restore sagittal alignment in patients with preoperative PI-LL mismatch, patients presenting with DS can expect significant improvement in PROMs following 1-level MI-TLIF regardless of preoperative alignment or extent of correction. Thus, attaining good clinical outcomes in patients with mild sagittal imbalance may not require addressing imbalance directly.