Excessive posterior placement of upper instrumented vertebra relative to lower instrumented vertebra as a predictor of proximal junction kyphosis after selective spinal fusion for adolescent idiopathic scoliosis Lenke type 5C curves.

PURPOSE: We defined sagittal S-line tilt (SSLT) as the tilt of the line connecting the upper instrumented vertebra and the lower instrumented vertebra. This study aimed to: (1) examine the correlation between SSLT and proximal junctional angle (PJA) change values, and (2) determine the cut-off value of SSLT with respect to proximal junctional kyphosis (PJK) occurrence. METHODS: Eighty-six consecutive patients (81 female and 5 male; mean age: 15.8 years) with Lenke 5C AIS who underwent posterior selective spinal fusion. Pearson's correlation coefficients were used to examine the relationship between preoperative SSLT and changes in PJA from preoperative to 2 years postoperative. The impact of SSLT on PJK at 2 years after surgery was assessed using a receiver operating characteristic (ROC) curve. RESULTS: We observed a moderate positive correlation between preoperative SSLT and change in PJA (R = 0.541, P < 0.001). We identified 18 patients (21%) with PJK at 2 years postoperative. Mean preoperative SSLT in the PJK group and the non-PJK group differed significantly at 23.3 ± 4.1° and 16.1 ± 5.0°, respectively (P < 0.001). The cut-off value of preoperative SSLT for PJK at 2 years postoperative was 18° in ROC curve analysis, with a sensitivity of 94%, specificity of 68%, and area under the ROC curve of 0.868. CONCLUSION: In selective lumbar fusion for AIS Lenke type 5C curves, preoperative SSLT was significantly correlated with PJA change from preoperative to 2 years postoperative. SSLT was a predictor of PJK occurrence, with a cut-off value of 18°.

Adjacent segment degeneration at a minimum 2-year follow-up after posterior lumbar interbody fusion: the impact of sagittal spinal proportion: a retrospective case series.

Study Design: A retrospective cohort study. Purpose: To investigate the sagittal plane configuration of the entire spine and its association with the risk of adjacent segment degeneration (ASD) after posterior lumbar interbody fusion (PLIF). Overview of Literature: Although PLIF has demonstrated satisfactory clinical outcomes, it is associated with ASD. However, the geometric mechanical changes that contribute to the occurrence of ASD are not well characterized. Methods: Radiological parameters were extracted from the whole lateral radiographs. Patients were divided into two groups: the ASD group (segmental kyphosis of ≥10º, and/or a ≥50% loss of disc height, and/or ≥3 mm of anteroposterior translation) and the non-ASD group. Results: All 112 included patients underwent PLIF for lumbar degenerative diseases. The minimum follow-up period was 2 years, with an average follow-up time of 63.6 months. Fifty-two patients (46.4%) were classified into the ASD group and of these, 13 required reoperation due to failure of conservative treatment. Patients with ASD exhibited significantly more caudal and posterior inflection vertebrae (IV), while the lumbar apical vertebra was significantly more caudal immediately after surgery. The IV position was identified as a significant risk factor for ASD, and the ASD incidence was significantly higher in the group where IV ≤5 (L1 vertebral body) than in the group where IV ≥5.5 (T12-L1 disc) (69.0% vs. 38.6%). Conclusions: The IV position is a significant risk factor for ASD development. Although it is difficult to control intraoperative IV levels, we note a high risk of ASD in patients with IV lower than T12-L1.

Spinal cord injury in high-risk complex adult spinal deformity surgery: review of incidence and outcomes from the Scoli-RISK-1 study.

STUDY DESIGN: Clinical case series. OBJECTIVE: To describe the cause, treatment and outcome of 6 cases of perioperative spinal cord injury (SCI) in high-risk adult deformity surgery. SETTING: Adult spinal deformity patients were enrolled in the multi-center Scoli-RISK-1 cohort study. METHODS: A total of 272 patients who underwent complex adult deformity surgery were enrolled in the prospective, multi-center Scoli-RISK-1 cohort study. Clinical follow up data were available up to a maximum of 2 years after index surgery. Cases of perioperative SCI were identified and an extensive case review was performed. RESULTS: Six individuals with SCI were identified from the Scoli-RISK-1 database (2.2%). Two cases occurred intraoperatively and four cases occurred postoperatively. The first case was an incomplete SCI due to a direct intraoperative insult and was treated postoperatively with Riluzole. The second SCI case was caused by a compression injury due to overcorrection of the deformity. Three cases of incomplete SCI occurred; one case of postoperative hematoma, one case of proximal junctional kyphosis (PJK) and one case of adjacent segment disc herniation. All cases of post-operative incomplete SCI were managed with revision decompression and resulted in excellent clinical recovery. One case of incomplete SCI resulted from infection and PJK. The patient's treatment was complicated by a delay in revision and the patient suffered persistent neurological deficits up to six weeks following the onset of SCI. CONCLUSION: Despite the low incidence in high-risk adult deformity surgeries, perioperative SCI can result in devastating consequences. Thus, appropriate postoperative care, follow up and timely management of SCI are essential.

A phase 3, randomized, double-blind, sham-controlled trial of SI-6603 (condoliase) in patients with radicular leg pain associated with lumbar disc herniation.

BACKGROUND CONTEXT: SI-6603 (condoliase) is a chemonucleolytic agent approved in Japan in 2018 for the treatment of lumbar disc herniation (LDH) associated with radicular leg pain. Condoliase, a mucopolysaccharidase with high substrate specificity for glycosaminoglycans (GAGs), offers a unique mechanism of action through the degradation of GAGs in the nucleus pulposus. As LDH management is currently limited to conservative approaches and surgical intervention, condoliase could offer a less invasive treatment option than surgery for patients with LDH. PURPOSE: The Discover 6603 study (NCT03607838) evaluated the efficacy and safety of a single-dose injection of SI-6603 (condoliase) vs sham for the treatment of radicular leg pain associated with LDH. STUDY DESIGN/SETTING: A randomized, double-blind, sham-controlled, phase 3 study conducted across 41 sites in the United States. PATIENT SAMPLE: Male and female participants (N=352; aged 30-70 years) with contained posterolateral LDH and unilateral radiculopathy/radicular leg pain for greater than 6 weeks. OUTCOME MEASURES: The primary endpoint was the change from baseline (CFB) in average worst leg pain score at 13 weeks, assessed using the 100-mm visual analogue scale. Key secondary endpoints were CFB in average worst leg pain score at 52 weeks, herniation volume at 13 weeks, and Oswestry Disability Index (ODI) score at 13 weeks. Safety evaluations included adverse events (AEs) and imaging findings. METHODS: Participants were randomized 1:1 to receive a single intradiscal injection of condoliase (1.25 units) or sham injection followed by 52 weeks of observation. The primary and key secondary endpoints were assessed using a mixed model for repeated measures (MMRM) analysis and a protocol-specified multiple imputation (MI) sensitivity analysis on the modified intention-to-treat (mITT) population. A prespecified serial gatekeeping algorithm was used for multiple comparisons. Safety endpoints included AEs, laboratory tests, vital signs, imaging (by X-ray and magnetic resonance imaging [MRI]), and occurrence of posttreatment lumbar surgery. RESULTS: Of the 352 randomized participants, 341 constituted the mITT population (condoliase n=169; sham n=172) and the safety population (condoliase n=167; sham n=174). For the primary endpoint, the condoliase group showed significantly greater improvement in CFB in worst leg pain at Week 13 (least squares mean [LSM] CFB: -41.7) compared with sham injection (-34.2; LSM difference: -7.5; 95% confidence interval [CI]: -14.1, -0.9; p=.0263) based on the MMRM analysis. CFB in worst leg pain at Week 52 favored condoliase vs sham, but the difference was not statistically significant (p=.0558), which halted the serial gatekeeping testing algorithm and dictated that the CFB in herniation volume and ODI scores at Week 13 would be considered nonsignificant, regardless of their p-values. Treatment group differences in CFB in herniation volume and ODI score favored the condoliase group vs sham at all timepoints. The MI sensitivity analysis showed differences in CFB in worst leg pain at Week 13 (p=.0223) and Week 52 (p=.0433) in favor of the condoliase group. Treatment-emergent AEs (TEAEs) were more common in the condoliase group (≥1 TEAE: 71.9%; ≥1 treatment-related TEAE: 28.1%) compared with the sham group (≥1 TEAE: 60.3%; ≥1 treatment-related TEAE: 10.3%). Of the TEAEs, spinal MRI abnormalities and back pain occurred most frequently. No treatment-related serious AEs occurred. CONCLUSIONS: Condoliase met its primary endpoint of significantly improving radicular leg pain at Week 13 and was generally well tolerated in patients with LDH. Chemonucleolysis with condoliase has the potential to provide a less invasive treatment option than surgery for those unresponsive to conservative treatment strategies.

Relationship between the perioperative prognostic nutritional index and postoperative gait function in elderly hip fractures.

Objectives: We investigated the relationship between the perioperative nutritional status and postoperative walking ability in patients with hip fractures. Methods: We included 246 surgically treated elderly patients with hip fractures who were ambulatory before the injury. Patients were divided into two groups: group A, who were able to walk at discharge, and group B, who were unable to walk at discharge. We pair-matched these two groups according to age, preoperative subdivided walking ability, and fracture site to form groups A' and B'. The prognostic nutritional index (PNI; PNI = 10 × serum albumin (g/dL) + 0.005 × blood total lymphocyte count (/mm³)) before surgery and 1 day, 1 week, and 2 weeks after surgery and energy intake 1 and 2 weeks after surgery were compared. Results: After adjustments for age, preoperative subdivided walking ability, and fracture site, there were 51 patients in group A' (mean age 84.6 years) and 51 patients in group B' (mean age 84.7 years). In group A'/group B', PNI was 43.38/42.60 (P = 0.19) before surgery, 33.87/33.31 (P = 0.44) 1 day after surgery, 34.99/32.35 (P = 0.01) 1 week after surgery, and 37.33/35.69 (P = 0.15) 2 weeks after surgery. Energy intake was 1380.8/1203.1 kcal (P = 0.01) 1 week after surgery and 1382.0/1335.6 kcal (P = 0.60) 2 weeks after surgery. Conclusions: PNI and energy intake at 1 week postoperatively were associated with early postoperative nutrition and the recovery of walking ability.

Implications of the diagnosis of locomotive syndrome stage 3 for long-term care.

Objectives: Locomotive syndrome stage 3 (LS3), which has been established recently, may imply a greater need for care than LS stage 0 (LS0), LS stage 1 (LS1), and LS stage 2 (LS2). The relationship between LS3 and long-term care in Japan is unclear. Therefore, this study aimed to examine this relationship. Methods: A total of 531 patients (314 women and 217 men; mean age, 75 years) who were not classified as requiring long-term care and underwent musculoskeletal examinations in 2012 were grouped according to their LS stage. Group L comprised patients with LS3 and Group N comprised those with LS0, LS1, and LS2. We compared these groups according to their epidemiology results and long-term care requirements from 2013 to 2018. Results: Fifty-nine patients (11.1%) were diagnosed with LS3. Group L comprised more patients (50.8%) who required long-term care than Group N (17.8%) (P < 0.001). Group L also comprised more patients with vertebral fractures and knee osteoarthritis than Group N (33.9% vs 19.5% [P = 0.011] and 78% vs 56.4% [P < 0.001], respectively). A Cox proportional hazards model and Kaplan-Meier analysis revealed a significant difference in the need for nursing care between Groups L and N (log-rank test, P < 0.001; hazard ratio, 2.236; 95% confidence interval, 1.451-3.447). Conclusions: Between 2012 and 2018, 50% of patients with LS3 required nursing care. Therefore, LS3 is a high-risk condition that necessitates interventions. Approaches to vertebral fractures and osteoarthritis of the knee could be key.

Impact of implant positions in total knee arthroplasty on the postoperative knee kinematics of tibial rotation.

Introduction: In total knee arthroplasty (TKA), the implant positions and knee kinematics, as well as the manifestation of medial pivot motion, play pivotal roles in determining postoperative clinical outcomes. The purpose of the current study was to analyze the correlation between knee kinematics, which was measured during TKA and implant positions derived using computed tomography (CT) examination after TKA. Methods: This study comprised 64 patients (76 knees) who underwent primary TKA between 2015 and 2022. A navigation system was used in TKA procedures, and intraoperative knee kinematics were automatically calculated with it. Utilizing three-dimensional evaluation software, positioning of implants was quantified with CT images taken pre- and post-operatively. Multiple regression analyses were employed to explore the impact of femoral component position (FP) and tibial component position (TP) on knee kinematics, focusing on the extent of tibial rotational motion (TRM) during passive knee motion. Results: FP affected TRM between knee extension and 90° flexion (p = 0.003, 95 % confidence interval [CI]: 0.315-1.384) and between knee extension and full flexion (p = 0.0002, 95 % CI: 0.654-1.844) after TKA. FP in internal rotation positively affected internal TRM after TKA. TP was not associated with TRM. Conclusions: Findings of the current study suggest that FP in internal rotation positively impacts knee kinematics after TKA.

Enhancing the Unicompartmental Knee Arthroplasty Safety via Finite Element Analysis of Coronary Plane Alignment: A Case Report.

Although Oxford unicompartmental knee arthroplasty is often used to successfully treat patients with knee osteoarthritis isolated at the medial compartment, we present a case of fracture just below the tibial keel caused by either a shift in medial loading position or an increased amount of tibial osteotomy. Finite element analysis was used to determine which factor was more important. First, a 3D-surface model of the patient's tibia and the implant shape were created using computed tomography-Digital Imaging and Communications in Medicine (CT-DICOM) data taken preoperatively. The finite element analysis found that following unicompartmental knee arthroplasty, the cortical stress (normal, 5.8 MPa) on the medial tibial metaphyseal cortex increased as the load point moved medially (3 and 12 mm medially: 7.0 and 10.7 MPa, respectively) but was mild with increased tibial bone resection (2 and 6 mm lower: 6.1 and 6.5 MPa, respectively). Implanting the femoral component more medially than the preoperative plan increases stresses in the medial cortex of the tibia and may cause fractures.

Cost-Effectiveness of Corrective Fusion Surgeries for Adult Spinal Deformities: Does Unexpected Revision Surgery Affect Cost-Effectiveness?

Introduction: Previous research has demonstrated that mid- to long-term health-related quality of life following corrective fusion surgery for adult spinal deformity (ASD) can be improved by appropriate revision surgery. In this study, we aim to compare the cost-effectiveness of corrective fusion surgery for ASD with and without unexpected revision surgery 5 years postoperatively. Methods: In total, 79 patients with ASD (mean age, 68.7 years) who underwent corrective fusion surgery between 2013 and 2015 were included in this study. Cost-effectiveness was evaluated based on the cost of obtaining 1 quality-adjusted life year (QALY). Patients were divided into two groups according to the presence or absence of unexpected revision surgery following corrective fusion and were subjected for comparison. Results: As per our study findings, 26 (33%) of the 79 ASD patients underwent unexpected revision surgery during the first 5 years following surgery. Although there was no significant difference in terms of inpatient medical costs at the time of initial surgery for 5 years after surgery between the two groups (no-revision group, revision group; inpatient medical costs at the time of initial surgery: USD 69,854 vs. USD 72,685, P=0.344), the total medical expenses up to 5 years after surgery were found to be higher in the revision group (USD 72,704 vs. USD 104,287, P<0.001). The medical expenses required to improve 1 QALY 5 years after surgery were USD 178,476 in the no-revision group, whereas it was USD 222,081 in the revision group. Conclusions: Although the total medical expenses were higher in the revision group, no significant difference was observed in the cumulative QALY improvement between the revision and no-revision groups. Moreover, the medical expenses required to improve 1 QALY were higher in the revision group, with a difference of approximately 20%.

Opioid Use Prior to Adult Spine Deformity Correction Surgery is Associated With Worse Pre- and Postoperative Back Pain and Prolonged Opioid Demands.

STUDY DESIGN: Prospective multicenter database post-hoc analysis. OBJECTIVES: Opioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity. METHODS: Patients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up. RESULT: Of the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P = .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P = .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P = .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P = .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P = .632) were observed. CONCLUSIONS: In this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs.

Wound Closure and Wound Dressings in Adult Spinal Deformity Surgery From the AO Spine Surveillance of Post-Operative Management.

STUDY DESIGN: An e-mail-based online survey for adult spinal deformity (ASD) surgeons. OBJECTIVE: Wound closure and dressing techniques may vary according to the discretion of the surgeon as well as geographical location. However, there are no reports on most common methods. The purpose of this study is to clarify the consensus. METHODS: An online survey was distributed via email to AO Spine members. Responses from 164 ASD surgeons were surveyed. The regions were divided into 5 regions: Europe and South Africa (ESA), North America (NA), Asia Pacific (AP), Latin America (LA), and Middle East and North Africa (MENA). Wound closure methods were evaluated by glue(G), staples(S), external non-absorbable sutures (ENS), tapes(T), and only subcuticular absorbable suture (SAS). Wound Dressings consisted of dry dressing (D), plastic occlusive dressing (PO), G, Dermabond Prineo (DP). RESULTS: The number of respondents were 57 in ESA, 33 in NA, 36 in AP, 22 in LA, and 16 in MENA. S (36.4%) was the most used wound closure method. This was followed by ENS (26.2%), SAS (14.4%), G (11.8%), and T (11.3%). S use was highest in ESA (44.3%), NA (28.6%), AP (31.7%), and MENA (58.8%). D was used by 50% of surgeons postoperatively. AP were most likely to use PO (36%). 21% of NA used DP, while between 0%-9% of surgeons used it in the rest of the world. CONCLUSION: Wound closure and dressings methods differ in the region. There are no current guidelines with these choices. Future studies should seek to standardize these choices.

Impact of the sagittal spinopelvic and coronal lower extremity alignments on clinical outcomes after medial unicompartmental knee arthroplasty.

Introduction: We evaluated whether the clinical outcomes, including postoperative knee range of motion (ROM), after unicompartmental knee arthroplasty (UKA) were associated with the sagittal spinopelvic parameters and coronal alignment of the full lower extremity. Methods: Forty-two patients (50 knees: six men, seven knees; 36 women, 43 knees) who underwent medial UKA between April 2015 and December 2022 were included. Preoperative radiographic examinations of the index for sagittal spinopelvic alignment included the sagittal vertical axis (SVA), lumbar lordosis, sacral slope (SS), pelvic tilt (PT), and pelvic incidence. The anteroposterior hip-knee-ankle angle (HKAA) was calculated. The relationship of clinical outcomes and the risk of knee flexion angle ≤125° and knee flexion contracture ≥10° 1-year post-UKA with radiographic parameters were evaluated. Results: Preoperative HKA angle affected postoperative knee flexion angle ≤125° (p = 0.017, 95% confidence interval [CI]: 0.473-0.930) in logistic regression analysis. Patients with a knee flexion angle ≤125° had a higher preoperative HKAA (9.8 ± 3.0°), higher SVA (83.8 ± 37.0 mm), and lower SS (23.7 ± 9.0°) than those with a flexion angle >125° (preoperative HKAA: 6.6 ± 4.0°, SVA: 40.3 ± 46.5 mm, SS: 32.0 ± 6.3°) (p = 0.029, 0.012, and 0.004, respectively). PT related to postoperative knee flexion contracture ≥10° (p = 0.010, 95% CI: 0.770-0.965) in the logistic regression analysis. Patients with flexion contracture ≥10° had higher PT (35.0 ± 6.6°) and SVA (82.2 ± 40.5 mm) than those with flexion contracture <10° (PT, 19.3 ± 9.0°; SVA, 42.4 ± 46.5 mm) (p = 0.001 and 0.028, respectively). The postoperative clinical outcome was correlated with the postoperative knee flexion angle and SVA (p = 0.036 and 0.020, respectively). Conclusions: The preoperative HKAA affected postoperative knee flexion angle, and the knee flexion contracture and clinical outcomes post-UKA were associated with PT and SVA, respectively. To predict outcomes for knee ROM and clinical scores after UKA, radiographic examination, including the sagittal spinopelvic parameters and the coronal view of the full lower extremity, is essential.

Femoral trochlear groove cartilage damage after open-wedge high tibial osteotomy is associated with the change in patellar height relative to the femoral condyle.

BACKGROUND: Medial open-wedge high tibial osteotomy (OWHTO) is performed for isolated medial compartment osteoarthritis or osteonecrosis of the knee and correction of varus deformity of the full lower extremity. OWHTO may induce sagittal parameter changes, including these in the tibial posterior slope (TPS), patellar height (PH), and patellofemoral joint problems. This study aimed to identify radiographic parameters associated with patellofemoral cartilage damage after OWHTO. HYPOTHESIS: The patellofemoral joint cartilage worsens after OWHTO and is adversely affected by PH changes. PATIENTS AND METHODS: Twenty patients (25 knees) who underwent primary OWHTO and subsequent implant removal surgery, including second-look arthroscopy for evaluation of the patellofemoral cartilage condition were enrolled. The patients were received 12 to 35 months of postoperative follow-up, and categorized into two groups according to whether patellofemoral cartilage damage worsened. TPS and PH parameters, including the Insall-Salvati, Blackburne-Peel, Caton-Deschamps, and modified Blumensaat (MBI) indices, were measured on lateral knee radiographs. The hip-knee-ankle and medial proximal tibial angles were measured using an anteroposterior radiograph of the full lower extremity. The extent of change from preoperative to postoperative (Δ) was calculated for all indices. RESULTS: Eleven knees (44%) had worsening cartilage conditions in the femoral trochlear groove, with>1-degree of deterioration in the International Cartilage Repair Society grade. The radiographic measure for predicting patellofemoral cartilage deterioration was ΔMBI (95% confidence interval [CI]: 3.53×10-14-0.812, p=0.047). PF cartilage damage tended to progress in ΔMBI<-0.145. The postoperative TPS and HKAA in patients with deterioration in patellofemoral cartilage damage was greater than that in patients without deterioration in patellofemoral cartilage damage (p=0.037 and 0.038, respectively). DISCUSSION: The patellofemoral cartilage damage tends to progress after OWHTO. ΔMBI is a factor for predicting worsening patellofemoral cartilage condition. However, attention should be paid to the excessive posterior slope as high TPS and valgus alignment as valgus HKAA because intraoperative control of MBI is impossible. LEVEL OF EVIDENCE: IV, retrospective study.

Background factors for intra-operative hypotension during hip fracture repair surgery in the elderly under spinal anesthesia managed by orthopedic surgeons: A retrospective case-control study.

BACKGROUND: Spinal anesthesia is used for femoral trochanteric fracture surgery, but frequently induces hypotension and the causative factors remain unclear. We examined background factors for the use of an intraoperative vasopressor in elderly patients receiving spinal anesthesia for femoral trochanteric fracture surgery. METHODS: We retrospectively analyzed 203 patients >75 years (mean age, 87.9 years) with femoral trochanteric fractures who underwent short nail fixation under orthopedically managed spinal anesthesia at our hospital between April 2020 and July 2023. Patients were divided into two groups: group A (intraoperative vasopressor) and group B (no vasopressor). The following data were compared: age, sex, height, weight, body mass index, antihypertensive medication, years of experience as a primary surgeon, bupivacaine dose, puncture level, anesthesia time, operation time, hemoglobin level and blood urea nitrogen/creatinine ratio on the day of surgery, brain natriuretic peptide level, left ventricular ejection fraction, and percentage of patients operated on the day of transport. RESULTS: There were 65 patients in group A and 138 in group B. The average dose of bupivacaine was 11.7 mg. In a univariate analysis, group A was slightly younger (87.0 vs. 88.3 years), had a higher blood urea nitrogen/creatinine ratio (27.1 vs. 24.5), more frequently received ß-blockers (14.1% vs. 5.8 %) and diuretic medications (21.9% vs. 11.6 %), and had a higher puncture level. A logistic regression analysis identified younger age (p = 0.02) and diuretic medication (p = 0.001) as independent risk factors in group A. Vasopressor use was more frequent at a higher puncture level in group A (57 % for L2/3, 33 % for L3/4, 15 % for L4/5, 0 % for L5/S). CONCLUSIONS: Spinal anesthesia-induced hypotension is attributed to volume deficit or extensive sympathetic blockade and may be prevented by avoiding high puncture levels and increasing preoperative fluid supplementation in patients on diuretics. There is currently no consensus on anesthetic dosages.

Psychological Factors Can Affect the Clinical Outcome of Chemonucleolysis with Condoliase in Patients with Lumbar Disk Herniation.

Introduction: Condoliase-based chemonucleolysis is a minimally invasive intermediate treatment option between conservative approaches and surgical interventions for lumbar disk herniation (LDH). In this study, the effects of psychological factors on the clinical outcomes of condoliase therapy for LDH were assessed. Methods: This study involved patients with LDH who received condoliase injections over a 1-year follow-up period. Data from the visual analog scale (VAS) scores for leg and back pain, Oswestry Disability Index, and Hospital Anxiety and Depression Scale (HADS), which was utilized for the psychological assessment, were collected. Using magnetic resonance imaging, changes in disk height and degeneration were evaluated. Data were assessed at baseline and 1-month, 3-month, and 1-year follow-ups. Condoliase therapy was considered effective in patients whose VAS score for leg pain improved by ≥50% at 1 year from baseline and who did not require surgery. The patients were divided into two groups: those who reported effective treatment (Group E) and those who did not (Group I). Between these two groups, comparative analyses were carried out. Results: In this study, a total of 102 patients (70 men; mean age, 43.8±18.2 years) were included. Condoliase therapy was effective in 76 patients (74.5%). Thirty-five patients (34.3%) showed psychological factors (HADS-Anxiety [HADS-A]≥8 or HADS-Depression [HADS-D]≥8) preoperatively and had a significantly lower rate of effectiveness than did those without psychological factors. Group I demonstrated significantly higher baseline back pain VAS, HADS, and HADS-D scores when compared with Group E. Logistic regression analysis identified females and the baseline HADS-D score as independent factors that were related to the effectiveness of condoliase therapy. Conclusions: The patients with psychological factors tended to experience residual pain resulting in adverse effects on the clinical outcomes of chemonucleolysis with condoliase.

Invasion Patterns and Long-Term Clinical Outcomes of Diffuse Tenosynovial Giant Cell Tumor of the Ankle Joint.

BACKGROUND: The invasion patterns and long-term outcomes of diffuse tenosynovial giant cell tumor (D-TSGCT) of the ankle joint remain unclear. METHODS: Seven patients who visited our department between 2011 and 2023 and were diagnosed with D-TSGCT of the ankle joint by contrast-enhanced MRI and a pathological diagnosis were included. The invasion patterns of ankle D-TSGCT on MRI were investigated. The recurrence rate and clinical symptoms were examined in five patients followed up for more than seven years after total resection. RESULTS: In seven patients (1 male/6 females, mean age 37.0±16.6 years, range 15-57 years) with D-TSGCT of the ankle joint, contrast-enhanced MRI at the initial presentation showed invasion within the ankle joint, extending along the tendon sheath, within the talocalcaneal joint, and in the tarsal sinus in 100% of cases, around the deltoid ligament in 86%, within the plantar surface in 43%, invasion of the interosseous membrane in 57%, around the Achilles tendon in 29%, and scalloping on the talocrural joint in 43%. The mean time from mass awareness to the first visit was 51.9±80.0 months (range 1-240 months). Gross total resection, defined as the removal of all tumors as gauged by MRI, was initially performed on 6/7 patients. One patient underwent partial resection of only the anterior part of the tumor. Of the six cases in which gross total resection was performed, 5 had long-term follow-up of more than seven years post-operatively, and one case is still only one year post-operatively. The long-term results of five patients followed for more than seven years after total resection were as follows: a mean follow-up period of 125 months (range 89-171 months), a 100% recurrence rate, a mean time to recurrence of 27.5±19.2 months (range 7-60 months), and a 16% reoperation rate. In the last follow-up, osteoarthritic changes were observed radiographically in 2/5 patients (40%), both of whom had scalloping of the talocrural joint on MRI at the time of the initial diagnosis. Four of the five patients (80%) had no clinical symptoms in the last follow-up. CONCLUSION: Ankle D-TSGCT presents with a strong local infiltrative pattern inside and outside the ankle joint along the tendon sheath, radical resection may be difficult, and the recurrence rate may be higher than previously reported. On the other hand, there are many cases that remain free of clinical symptoms in the long term after recurrence, and surgical indications for ankle D-TSGCT need to consider function preservation as well as recurrence rates.

Evaluation of the changes in waistline asymmetry using digital photography in adolescents with idiopathic thoracolumbar/lumbar scoliosis after corrective surgery.

PURPOSE: Waist line asymmetry is a major cosmetic concern in patients with adolescent idiopathic scoliosis (AIS). The primary surgical goal in patients with AIS is to correct spinal deformities and prevent further progression while maintaining global alignment. Additionally, an important objective of surgical treatment is to address physical appearance by reducing asymmetry. This study aimed to evaluate changes in waistline asymmetry using digital photographs in adolescents with thoracolumbar/lumbar (TL/L) scoliosis who underwent corrective surgery. METHODS: We retrospectively analyzed the data of patients with Lenke types 5C and 6C AIS who underwent posterior fusion surgery with at least 2 years of follow-up. Waist line asymmetry was assessed using digital photography. The waist angle ratio (WAR), waist height angle (WHA), and waistline depth ratio (WLDR) were measured pre- and postoperatively. Radiographic parameters and the revised 22-item Scoliosis Research Society Questionnaire (SRS-22r) were also evaluated. RESULTS: Forty-two patients (40 females and 2 males; 34 with type 5C and 8 with type 6C) were included in the study. The WAR, WHA, and WLDR significantly improved after surgery (0.873 → 0.977, - 2.0° → 1.4°, and 0.321 → 0.899, respectively). Every waistline parameter moderately correlated with the apical vertebral translation of the TL/L curve (WAR: r = - 0.398, WHA: r = - 0.442, and WLDR: r = - 0.692), whereas no correlations were observed with the TL/L curve magnitude. No correlations were observed between the photographic parameters and SRS-22r scores. CONCLUSION: Lateral displacement of the apical vertebra on the TL/L curve correlated with waistline asymmetry. Preoperative waistline asymmetry improved with scoliosis correction. LEVEL OF EVIDENCE: Level 4.