Validation of the AO Spine CROST (Clinician Reported Outcome Spine Trauma) in the clinical setting.

PURPOSE: To evaluate feasibility, internal consistency, inter-rater reliability, and prospective validity of AO Spine CROST (Clinician Reported Outcome Spine Trauma) in the clinical setting. METHODS: Patients were included from four trauma centers. Two surgeons with substantial amount of experience in spine trauma care were included from each center. Two separate questionnaires were administered at baseline, 6-months and 1-year: one to surgeons (mainly CROST) and another to patients (AO Spine PROST-Patient Reported Outcome Spine Trauma). Descriptive statistics were used to analyze patient characteristics and feasibility, Cronbach's α for internal consistency. Inter-rater reliability through exact agreement, Kappa statistics and Intraclass Correlation Coefficient (ICC). Prospective analysis, and relationships between CROST and PROST were explored through descriptive statistics and Spearman correlations. RESULTS: In total, 92 patients were included. CROST showed excellent feasibility results. Internal consistency (α = 0.58-0.70) and reliability (ICC = 0.52 and 0.55) were moderate. Mean total scores between surgeons only differed 0.2-0.9 with exact agreement 48.9-57.6%. Exact agreement per CROST item showed good results (73.9-98.9%). Kappa statistics revealed moderate agreement for most CROST items. In the prospective analysis a trend was only seen when no concerns at all were expressed by the surgeon (CROST = 0), and moderate to strong positive Spearman correlations were found between CROST at baseline and the scores at follow-up (rs = 0.41-0.64). Comparing the CROST with PROST showed no specific association, nor any Spearman correlations (rs = -0.33-0.07). CONCLUSIONS: The AO Spine CROST showed moderate validity in a true clinical setting including patients from the daily clinical practice.

Clinical outcomes of primary total knee arthroplasty in non-syphilitic neuroarthropathy of the knee.

PURPOSE: Total knee arthroplasty (TKA) in syphilitic neuroarthropathy using earlier implant designs was associated with poorer outcomes. Literature on TKA for non-syphilitic neuroarthropathy using modern contemporary prosthesis is scarce. We aim to analyse the clinical and radiological outcomes of TKA in neuropathic joints. METHODS: A final cohort of 17 patients (21 knees) with the diagnosis of neuropathic joint undergoing primary TKA between January 2013 to January 2019 were included in the study. The preoperative ambulatory status, range of motion, type of prosthesis, level of constraint and any augmentation used were retrieved from medical records. Radiological evaluation includes Koshino's staging, the magnitude of deformity defined by the Hip-Knee-Ankle (HKA) angle, and any progressive loosening. Pre and postoperative functional scores were obtained by the Knee Society (KSS) and Knee Society Functional Score (KSS-F). Any complications or reoperation were noted till the final follow-up. Preoperative and follow-up functional scores, HKA and range of motion were compared using the paired Samples test. RESULTS: The mean follow-up was 40.2 months (range, 15 to 75 months). Preoperatively, according to the Koshino staging, five knees were in stage 3 (23.8%). The mean HKA angle in valgus knees was 23.60 (range, 11.10 to 42.50) and for the varus knees was 19.30 (range, 4.90 to 39.60). The prosthesis used were posterior stabilized in 7 knees (33.3%), varus-valgus constrained in five knees (23.8%) and a rotating hinge was required in nine knees (42.8%). Metaphyseal sleeves were used along with hinge prosthesis in six knees (28.6%). The mean arc of motion improved from 102.4 ± 22.7 degrees to 105.7 ± 15.5 degrees postoperatively (p = 0.27). The knee society and knee society functional scores improved from 23.3 ± 9.3 and 28.3 ± 12.2 preoperatively to 81.1 ± 5.4 and 80.4 ± 8.5 during the follow up respectively (p < 0.001). There were no progressive radiolucent lines in any knees at the final follow-up. One patient had intraoperative bony medial collateral ligament injury, one patient had deep vein thrombosis after five days from the index surgery and another had postoperative periprosthetic tibial shaft fracture. CONCLUSION: According to our study, the clinical outcomes of TKA for neuroarthropathy show significant improvement with the diagnosis of non-syphilitic neuroarthropathy, utilization of modern constrained prostheses, and early rehabilitation, at medium-term follow-up. Tibial and femoral stems are preferred for equal stress distribution and to prevent early loosening.

Outcome determinants for coronal shear fractures of the distal humerus.

PURPOSE: Coronal shear fractures of the distal humerus involving the capitellum and trochlea are rare injuries. Internal fixation with headless compression screws provides a stable construct facilitating early mobilisation. Our study aimed to identify the key determinants of both radiological and functional outcomes of patients with distal humerus coronal shear fractures treated with internal fixation. METHODS: A retrospective analysis of 61 patients with distal humerus coronal shear fractures who were treated surgically was done. Demographics, fracture morphology, time to surgery, operative details such as surgical approach and implant used, quality of reduction, time to union, and associated complications from hospital records. Radiological outcomes were assessed using plain radiographs, and the functional outcomes were by Oxford Elbow Score (OES) and Mayo Elbow Performance Index (MEPI). RESULTS: Patients with anatomical reduction of the fracture had better functional outcomes and range of motion. The presence of posterior comminution of capitellum resulted in poorer outcomes (p = 0.03). Delayed presentation did not alter the outcome when the anatomical reduction was achieved. Myositis ossificans was noted in nine patients and non-union in five patients. Two patients developed avascular necrosis of the capitellum and arthritis of the elbow joint. CONCLUSION: Anatomical reduction and posterior comminution are the two key determinants of the functional outcome in these coronal shear fractures of the distal humerus. Early mobilisation following a stable fixation is crucial in achieving a good outcome.

Outcomes of conversion total hip arthroplasty for failed fixation of intertrochanteric fractures with monoblock distal-loading reconstruction stem.

PURPOSE: The aim of our study was to analyze the clinical and radiological outcomes of conversion total hip arthroplasty (THA) for failed fixation of proximal femur fractures with monoblock grit-blasted titanium reconstruction stem (Wagner self-locking stem, Zimmer). PATIENTS AND METHODS: Thirty-nine patients were included in this retrospective analysis undergoing conversion THA for failed cephalomedullary nail or dynamic hip screw fixation for intertrochanteric fractures from January 2017 to January 2022. The clinical evaluation was done using Harris hip score. The radiological outcomes measured were subsidence, level of osteointegration, stem-canal fill ratio and heterotopic bone formation. The complications were noted postoperatively and during the follow-up. RESULTS: The mean follow-up at the end of the study was 27.8 months (range, 14-72 months). There was a significant improvement in the Harris hip score over serial follow-ups (p < 0.001), but after 2 years, there was no statistically significant difference (p = 0.46). According to Engh's criteria, stable ingrowth was noted in 35 stems, fibrous stable ingrowth was noted in 4 stems and no patients had progressive subsidence and unstable stem. The mean stem-canal fill percentages were 91.8 ± 5.4% at the mid-stem and 80.3 ± 11.5% at the stem tip. Heterotopic ossification Brooker grade 2 was noted in 8 patients, and no patients had grade 3 or 4 heterotopic ossification. There were 7 (17.9%) intraoperative periprosthetic fractures, and greater trochanteric avulsion was noted in 2 patients in the follow-up. CONCLUSION: Conversion THA using monoblock tapered distal loading stems bypasses the calcar deficiency and gives stable fixation in failed fixation of intertrochanteric fractures. It gives good radiological outcome and significant improvement in the clinical outcomes compared to the preoperative disability. However, caution should be noted for risk of intraoperative periprosthetic fractures in this subgroup of patients.

A prospective randomized control trial comparing outcomes of casting, pinning, and plating for distal end of radius fractures (AO type A2, A3, C1, or C2) in the elderly population.

PURPOSE: With this prospective randomized control trial (RCT), we aim to provide the outcome analyses of the three most used treatment modalities for distal end of radius (DER) fracture management in the elderly. METHODS: A prospective randomized control trial was performed. Fifty-two patients with DER fractures (AO A2, A3, C1, or C2) were randomized to the casting (n = 17), percutaneous pinning (n = 18), and the volar plating group (n = 17). Radiological measurements measured were radial inclination (RI), radial height (RH), volar tilt (VT), and ulnar variance (UV). The outcome was measured based on range-of-motion, grip strength, Patient-Related-Wrist-Evaluation (PRWE) score, and the Quick-Disabilities-of-the-Arm-Shoulder-Hand (QDASH) score. RESULTS: Immediate post-operative and 1-year-follow-up X-rays showed a significant difference measurement between the groups (p < 0.05). Pairwise comparisons of the casting and pinning groups (p < 0.05) and the casting and plating groups (p < 0.05) revealed significant differences at the 1-year follow-up, but not the pinning and plating groups (p > 0.05). The analysis found significant differences in clinical outcomes after 1 month of follow-up, with the plating group outperforming the other two (p > 0.05). However, after a year of follow-up, all groups had comparable outcomes; however, the plating group showed improved palmar flexion (p < 0.001), radial deviation (p < 0.001), and a lower PRWE score (p < 0.05), indicating better wrist function. Complications were more in casting group. CONCLUSION: The study found a radiologically significant difference between groups throughout the follow-up, but it did not affect functional results. Clinical outcomes were similar across the groups, with plating showing better palmar flexion and radial deviation. Grip strength was also better in the plating group, but statistically insignificant. The study suggests plating should be chosen over other treatments for high-demand patients.

An international validation of the AO spine subaxial injury classification system.

PURPOSE: To validate the AO Spine Subaxial Injury Classification System with participants of various experience levels, subspecialties, and geographic regions. METHODS: A live webinar was organized in 2020 for validation of the AO Spine Subaxial Injury Classification System. The validation consisted of 41 unique subaxial cervical spine injuries with associated computed tomography scans and key images. Intraobserver reproducibility and interobserver reliability of the AO Spine Subaxial Injury Classification System were calculated for injury morphology, injury subtype, and facet injury. The reliability and reproducibility of the classification system were categorized as slight (ƙ = 0-0.20), fair (ƙ = 0.21-0.40), moderate (ƙ = 0.41-0.60), substantial (ƙ = 0.61-0.80), or excellent (ƙ = > 0.80) as determined by the Landis and Koch classification. RESULTS: A total of 203 AO Spine members participated in the AO Spine Subaxial Injury Classification System validation. The percent of participants accurately classifying each injury was over 90% for fracture morphology and fracture subtype on both assessments. The interobserver reliability for fracture morphology was excellent (ƙ = 0.87), while fracture subtype (ƙ = 0.80) and facet injury were substantial (ƙ = 0.74). The intraobserver reproducibility for fracture morphology and subtype were excellent (ƙ = 0.85, 0.88, respectively), while reproducibility for facet injuries was substantial (ƙ = 0.76). CONCLUSION: The AO Spine Subaxial Injury Classification System demonstrated excellent interobserver reliability and intraobserver reproducibility for fracture morphology, substantial reliability and reproducibility for facet injuries, and excellent reproducibility with substantial reliability for injury subtype.

Health professionals' perspective on the applicability of AO Spine PROST (patient reported outcome Spine trauma) in people with a motor-complete traumatic or non-traumatic spinal cord injury.

PURPOSE: The AO Spine PROST (Patient Reported Outcome Spine Trauma) was developed for people with spine trauma and minor or no neurological impairment. The purpose is to investigate health professionals' perspective on the applicability of the AO Spine PROST for people with motor-complete traumatic or non-traumatic spinal cord injury (SCI), using a discussion meeting and international survey study. METHODS: A discussion meeting with SCI rehabilitation physicians in the Netherlands was performed, followed by a worldwide online survey among the AO Spine International community, involved in the care of people with SCI. Participants rated the comprehensibility, relevance, acceptability, feasibility and completeness of the AO Spine PROST on a 1-5 point scale (5 most positive). Comments could be provided per question. RESULTS: The discussion meeting was attended by 13 SCI rehabilitation physicians. The survey was completed by 196 participants. Comprehensibility (mean ± SD: 4.1 ± 0.8), acceptability (4.0 ± 0.8), relevance (3.9 ± 0.8), completeness (3.9 ± 0.8), and feasibility (4.1 ± 0.7) of the AO Spine PROST were rated positively for use in people with motor-complete traumatic or non-traumatic SCI. Only a few participants questioned the relevance of items on the lower extremities (e.g., walking) or missed items on pulmonary functioning and complications. Some recommendations were made for improvement in instructions, terminology and examples of the tool. CONCLUSION: Health professionals found the AO Spine PROST generally applicable for people with motor-complete traumatic or non-traumatic SCI. This study provides further evidence for the use of the AO Spine PROST in spine trauma care, rehabilitation and research, as well as suggestions for its further development.

A Comparison of Outcomes of Culture positive and Culture negative Acute Knee Prosthetic Joint Infection following Debridement, Antibiotics and Implant Retention (DAIR).

PURPOSE: We aim to compare the outcome of culture-positive (CP PJI) and culture-negative (CN PJI) acute knee prosthetic joint infection (PJI) following debridement, antibiotics and implant retention (DAIR) with polyethylene insert exchange. We also aim to analyze the factors associated with the successful outcome of DAIR and the influence of failed DAIR on the outcome of subsequent two-stage revision arthroplasty. METHODS: We performed a retrospective review of 36 consecutive patients who underwent DAIR for acute PJI between January 2013 and January 2018. The patient's demographic data, McPherson grade, surgical details, laboratory and microbiology data were retrieved from the medical records. All the patients have been followed up for a minimum of 3 years or until re-operation, revision or death and any complications, incidence of DAIR failure, revision and mortality were noted. RESULTS: The mean follow-up was 4.9 ± 2.4 years. Among the 36 patients, 16 had CP PJI and 20 had CN PJI. Among the 16 patients with CP PJI, 8 patients had success with DAIR and 8 patients had a recurrence of infection (50%) at a mean of 21 months (range, 2 weeks to 55 months). Among the 20 patients with CN PJI, 14 patients had success with DAIR and 6 patients had a recurrence of infection [30% (6/20)] at a mean of 69 months (range, 13-221 months) (p < .05). The Kaplan-Meir survival analysis showed survivorship did not vary significantly between both groups (p > .05). Univariate regression analysis showed symptom duration of more than one month found to be significantly associated with the DAIR failure. There was no difference in failure rate after DAIR between age, Charlson comorbidity index, early postoperative versus acute hematogenous group and type of organism grown. Ten out of 14 DAIR failures were successfully managed with two-stage revision surgery with no recurrence of infection till the final follow-up. In the remaining 4 patients, one underwent re-debridement, two underwent arthrodesis and one was left with an antibiotic cement spacer. CONCLUSION: DAIR with polyethylene exchange will give comparable results irrespective of the culture positivity. Symptom duration of more than 30 days for DAIR is significantly associated with DAIR failure. DAIR failures can be successfully managed with two-stage revision.

Transient paraplegia in lumbar spine surgery-a potential complication following erector spinae plane block.

PURPOSE: Erector spinae plane block (ESPB) has gained popularity over recent years and is being increasingly used in spine surgery for pain management. To date, no major neurological complications have been reported. We present here two patients who developed transient postoperative paraplegia and discuss the possible causes of this phenomenon. METHODS: Patients, who underwent preoperative bilateral ESPB as an adjunct to general anesthesia for elective lumbar spine surgery at our institution between January 2017 and December 2020, were retrospectively identified. Among them, only patients who developed postoperative motor and sensory deficits were finally included. RESULTS: Overall, two patients [of 316 who underwent ESPB (0.6%)] developed complete motor and sensory deficits in bilateral lower limbs postoperatively. In both patients, the surgery was uncomplicated. Ninety minutes following recovery from general anesthesia, both patients showed gradual neurological recovery in a distal-to-proximal pattern, with complete motor recovery preceding the sensory improvement. Since the surgical procedure was performed at the cauda equine level, transient paraplegia in these patients could only attributed to ESPB. CONCLUSION: Transient paraplegia following ESPB (due to anterior spread of the local anesthetic agent into the epidural space) has never been reported, and both anesthetists and surgeons must be aware of this possible complication.

Influence of endplate avulsion and Modic changes on the inflammation profile of herniated discs: a proteomic and bioinformatic approach.

PURPOSE: The aim of this observational radiographic and proteomic study is to explore the influence of both Modic change (MC) and endplate avulsion (EPA) on the inflammation profile of herniated discs using a proteomic and bioinformatics approach. METHODS: Fifteen nucleus pulposus (NP) harvested from surgery underwent LC-MS/MC analysis, the proteome was subsequently scanned for inflammatory pathways using a bioinformatics approach. All proteins that were identified in inflammatory pathways and Gene Ontology and present in > 7 samples were integrated in a multiple regression analysis with MC and EPA as predictors. Significant proteins were imputed in an interaction and pathway analysis. RESULTS: Compared to annulus fibrosus tear (AFT), six proteins were significantly altered in EPA: catalase, Fibrinogen beta chain, protein disulfide-isomerase, pigment epithelium-derived factor, osteoprotegerin and lower expression of antithrombin-III, all of which corresponded to an upregulation of pathways involved in coagulation and detoxification of reactive oxygen species (ROS). Moreover, the presence of MC resulted in a significant alteration of nine proteins compared to patients without MC. Patients with MC showed a significantly higher expression of clusterin and lumican, and lower expression of catalase, complement factor B, Fibrinogen beta chain, protein disulfide-isomerase, periostin, Alpha-1-antitrypsin and pigment epithelium-derived factor. Together these altered protein expressions resulted in a downregulation of pathways involved in detoxification of ROS, complement system and immune system. Results were verified by Immunohistochemistry with CD68 cell counts. CONCLUSION: Both EPA and MC status significantly influence disc inflammation. The beneficial inflammatory signature of EPA illustrates that endplate pathology does not necessarily have to worsen the outcome, but the pathological inflammatory state is dependent on the presence of MC.

SPINE20 recommendations 2021: spine care for people's health and prosperity.

PURPOSE: The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. METHODS: On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. RESULTS: In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. CONCLUSIONS: SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

Insertional versus non-insertional tendoachilles tears: a comparative analysis of various predisposing factors and outcome following a repair.

BACKGROUND: Association of tendon degeneration, pre-existing posterior heel pain, Haglund's bump, retrocalcaneal spur, and mode of injury varies for the insertional and non-insertional type of tendoachilles tears (TA). PURPOSE: The study compares the various predisposing factors that determine the distinct type of TA tear and the outcome following a repair. METHODS: This is a retrospective study of the patients who underwent tendoachilles repair during January 2012-June 2018. Patients above 18 years with a minimum follow-up of two years were included. Patients with calcaneal tuberosity avulsions, prior surgeries, and open injuries were excluded. Patients were divided into groups 1 (insertional tears (IT)) and 2 (non-insertional tears (NIT)), and further subdivided based on the tendon degeneration (as D-degenerative and N-normal sub types) from ultrasound findings. AOFAS score and predisposing factors like degeneration, posterior heel pain, Haglund's bump, spur, and mechanism of injury were compared between the groups. RESULTS: The study included N = 146 with a mean age of 51.6 years and mean follow-up of 38.6 (range 24 to 96) months. IT associated with degeneration (IT-D) had a trivial fall as the predominant mechanism (P < 0.001). All patients had significant postoperative improvement of scores with no significant difference between the groups (P = 0.59) and subgroups (P = 0.27).75.34% had degenerative tendon, of which 64.5% were in the IT group and the rest in the NIT group (P = 0.02). 51.4% patients had a Haglund bump in the IT group and n.s. (P = 0.9). Forty-seven percent of patients had pre-existing posterior heel pain, 68% in IT and 32% in NIT (P = 0.04). Subgroup analysis revealed 65% of patients were in the IT-D subgroup (P < 0.001). CONCLUSION: Predisposing factors like posterior heel pain, tendon degeneration, and trivial trauma have a strong propensity for insertional TA tear. In contrast, the prominence of Haglund's bump does not predispose to a distinct type of TA tears. The outcome following a surgical repair-yields good results with no difference between the two groups.

Arthroscopic capsular release versus manipulation under anaesthesia for treating frozen shoulder - a prospective randomised study.

PURPOSE: Arthroscopic capsular release (ACR) and Manipulation under anaesthesia(MUA) have been widely used in the treatment of frozen shoulder (FS). However, there is only limited Level-I evidence to prefer ACR over MUA. The purpose of our study was to conduct a randomised trial comparing ACR versus MUA to assess the difference in outcome, complications and cost-effectiveness of both procedures. METHODS: From May 2020 to June 2021, patients presenting with FS were randomised into two groups ACR (n = 44) and MUA (n = 41). Patients with arthritis, full-thickness cuff tears, history of trauma/previous surgery around the shoulder were excluded from the study. Range of movement (ROM), pain grading using visual analogue scale (VAS), functional scores- UCLA, CONSTANT and EuroQol-5D scores were measured pre-operatively and post-operatively. MRI was done at three weeks post-operatively for screening complications of either procedure. Quality-adjusted life years (QALY) was used for cost-analysis. RESULTS: Post-operatively, patients had significant improvement in pain, ROM and functional scores in both groups (P < 0.001) with no significant difference between groups at 24 weeks of follow-up. Diabetic patients undergoing ACR had lesser improvement in abduction and external rotation when compared to non-diabetic patients. Labral tears in MUA group and bone bruises in ACR group were the most common complications noted on the post-operative MRI. For ACR cost per QALY gained was 896 USD while that for MUA was 424 USD. CONCLUSION: Both ACR and MUA resulted in good improvement in pain and shoulder function. Good outcomes, simple technique and better cost-effectiveness would still make MUA an attractive option over ACR for treating FS.

Posterior-only stabilization versus global reconstruction in thoracic and thoracolumbar spinal tuberculosis; a prospective randomized study.

PURPOSE: Although the guidelines for surgical indications in spinal tuberculosis (TB) are well-established, ambiguity still exists in deciding between posterior-only stabilization and global reconstruction in thoracic and thoracolumbar (TL) disease especially in patients with borderline vertebral destruction. The current prospective, randomized study was thus planned to compare safety and efficacy of these two surgical interventions. METHODS: Patients, aged between 18 and 65 years, with spinal TB involving thoracic and TL spine with pre-operative vertebral body loss (VBL) between 0.5 and 1 were randomly allocated into two groups [groups A (who underwent posterior-only stabilization) and B (global reconstruction through a single-stage all-posterior approach). Patient's demographic data, clinical, intra-operative and post-operative details were recorded. Minimum follow-up period was two years. Neurological assessment was performed using ASIA impairment scale. Functional outcome measurements included VAS and ODI scores (pre-operative and final follow-up). Radiological measurements included Cobb's angle, kyphosis correction, loss of correction, angle loss rate and fusion time. RESULTS: Fifty-eight patients (groups A and B = 29 each) were included. Mean age in groups A and B was 48.3 ± 16.5 years and 51.2 ± 11.7 years. Mean surgical duration was significantly shorter in group A (119.9 ± 14.1 minutes; p = 0.0001). Mean follow-up duration was 35.5 ± 6.4 months. There was no statistically significant difference in neurological outcome at final follow-up between the groups (p > 0.05). Group A demonstrated significantly better ODI at final follow-up (13.8 ± 2.9 vs 16.2 ± 4.1; p = 0.02). Immediate post-operative correction (6.8° ± 5.6) and maintenance of kyphosis correction at final follow-up [loss of correction (2.1° ± 1.7) and angle loss rate (16.3 ± 14.9%)] were marginally better in group B (p > 0.05). Mean fusion time in groups A and B was 7.8 ± 1.5 and 8.4 ± 1.6 months (p > 0.05). A sub-group analysis in group B between autograft and metallic cages for anterior reconstruction did not show significant difference in radiological outcome (p > 0.05). CONCLUSION: All-posterior surgeries (posterior-only stabilization or global reconstruction) represent an effective approach in the management of TB disease affecting thoracic and TL vertebrae. For a pre-operative VBL between 0.5 and 1, clinical (including neurological), functional and radiological outcomes following both these surgeries (posterior-only stabilization and global reconstruction) are comparable.

Rising within the leadership of an orthopaedic society: learning from the presidents.

Orthopaedic societies, with their diverse membership from across the world, serve a mission to endorse the progress and innovation in the field of orthopaedics and traumatology with a focus on improving patient care, as well as to encourage and develop education, teaching and research. Such organizations, whether small or large, have been successful in meeting the professional, educational and training needs of its members. The past and future presidents of these societies share insights addressing their professional experiences, lessons learnt and their vision for future leaders of the field. The objective of this article is to summarize the thoughts of presidents of orthopaedic societies from around the globe and to inspire younger and aspiring members of the global orthopaedic fraternity.

Correlation of factors affecting correction of meniscal extrusion and outcome after medial meniscus root repair.

INTRODUCTION: Meniscus extrusion in medial meniscus posterior root tears (MMPRT) is a consistent MRI finding and correction of extrusion is a primary objective of the meniscal root repair. The purpose of the study is to evaluate feasibility of correction of extrusion and correlation of various factors affecting the postoperative extrusion correction and outcomes in all degenerative medial meniscus posterior roots (MMPRTs). METHODS: A retrospective study of patients who presented with degenerative MMPRTs following trivial incident (Jun 2014 and Aug 2018) and included isolated Laprade type 2 root tear with extrusion in MRI. Patients with ligament injuries, tricompartmental arthritis, malalignment (> 50) and irreparable meniscal tears excluded. All patients underwent arthroscopic trans-tibial tunnel suture pull-out repair. A screening MRI was taken at a 6-month follow-up and functional scores (IKDC and Lysholm's) at final follow-up. The effects of age, gender, duration of symptoms, hip-knee-ankle angle on weight-bearing X-rays, ICRS grading of cartilage status, and MRI data (extrusion distance, tunnel location and healing status of meniscus) on outcomes were analysed. RESULTS: MMPRT (n = 54) with a mean follow-up of 34.6 months (24-48). Mean functional outcomes improved postoperatively IKDC (43.40 ± 5.16-78.65 ± 5.11, p < 0.001) and Lysholm's (65.27 ± 4.28-83.16 ± 4.83, p < 0.001) scores at final follow-up. 57.4% (31) had good correction of extrusion, 3.7% (2) no correction and 38.8% (21) showed increase in extrusion postoperatively. Of all the factors we explored, age, ICRS (low grade) and knee varus (less 2.5 degree) affected extrusion correction. Patients with healed (41 patients), partially healed (9 patients) and anatomic tunnel placement (46 patients) had better extrusion correction than those with non-healing (4 patients) and non-anatomical tunnel (8 patients). CONCLUSION: Patients younger than 50 years, with low grade cartilage damage (ICRS 1, 2), lower KL grade and varus alignment (< 2.50) had good correction of extrusion. Correction of extrusion/progression of extrusion did not influence the clinical outcome at the short-term. The progression of meniscal extrusion is inevitable even after successful repair in elderly and high-risk patients. STUDY DESIGN: Retrospective Case series, level of evidence IV.

Presence of preoperative Modic changes and severity of endplate damage score are independent risk factors for developing postoperative surgical site infection: a retrospective case-control study of 1124 patients.

PURPOSE: There is increasing evidence of an association between Modic changes (MC) and subclinical infection. However, the association of MC with postoperative surgical site infection (SSI) has not been adequately probed. This study primarily aimed to investigate a probable association between preoperative MC, total endplate damage score (TEPS), and SSI. METHODS: A retrospective analysis of 1124 patients who underwent surgery in a single institution (2016-2018) was performed, using both univariate and multiple logistic regression analyses to identify independent risk factors for SSI. RESULTS: The prevalence of SSI was 4% (44/1124 patients), with no association with age or sex. The prevalence of MC in the SSI group was significantly higher-79.54% (35/44) compared to 58.79% (635/1080) (p value = 0.006) in the control group with no specific relation to type or location of MC. A higher TEPS was associated with SSI (p value = 0.009). A receiver operating characteristic (ROC) curve for TEPS values to assess predictiveness of SSI showed TEPS ≥ 5.5 to have a better sensitivity of 84% than 72% for a TEPS ≥ 6.5. Univariate analysis showed TEPS > 6 (odds ratio 3.887) to have a stronger association with SSI than the presence of MC (odds ratio 2.725). Among various types of surgeries, discectomy had a higher association with SSI (p value = 0.03) when compared to fusion (p value = 0.071). However, multiple logistic regression analysis revealed only TEPS > 6, presence of MC and hypothyroidism as independent risk factors for SSI. CONCLUSION: Our data suggest that preoperative MC and TEPS > 6 are independent risk factors for developing surgical site infections. MC could be foci of chronic subclinical infection and not mere markers of degeneration, as initially described.

Variation in global treatment for subaxial cervical spine isolated unilateral facet fractures.

PURPOSE: To determine the variation in the global treatment practices for subaxial unilateral cervical spine facet fractures based on surgeon experience, practice setting, and surgical subspecialty. METHODS: A survey was sent to 272 members of the AO Spine Subaxial Injury Classification System Validation Group worldwide. Questions surveyed surgeon preferences with regard to diagnostic work-up and treatment of fracture types F1-F3, according to the AO Spine Subaxial Cervical Spine Injury Classification System, with various associated neurologic injuries. RESULTS: A total of 161 responses were received. Academic surgeons use the facet portion of the AO Spine classification system less frequently (61.6%) compared to hospital-employed and private practice surgeons (81.1% and 81.8%, respectively) (p = 0.029). The overall consensus was in favor of operative treatment for any facet fracture with radicular symptoms (N2) and for any fractures categorized as F2N2 and above. For F3N0 fractures, significantly less surgeons from Africa/Asia/Middle East (49%) and Europe (59.2%) chose operative treatment than from North/Latin/South America (74.1%) (p = 0.025). For F3N1 fractures, significantly less surgeons from Africa/Asia/Middle East (52%) and Europe (63.3%) recommended operative treatment than from North/Latin/South America (84.5%) (p = 0.001). More than 95% of surgeons included CT in their work-up of facet fractures, regardless of the type. No statistically significant differences were seen in the need for MRI to decide treatment. CONCLUSION: Considerable agreement exists between surgeon preferences with regard to unilateral facet fracture management with few exceptions. F2N2 fracture subtypes and subtypes with radiculopathy (N2) appear to be the threshold for operative treatment.

Regional and experiential differences in surgeon preference for the treatment of cervical facet injuries: a case study survey with the AO Spine Cervical Classification Validation Group.

PURPOSE: The management of cervical facet dislocation injuries remains controversial. The main purpose of this investigation was to identify whether a surgeon's geographic location or years in practice influences their preferred management of traumatic cervical facet dislocation injuries. METHODS: A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. The survey included clinical case scenarios of cervical facet dislocation injuries and asked responders to select preferences among various diagnostic and management options. RESULTS: A total of 189 complete responses were received. Over 50% of responding surgeons in each region elected to initiate management of cervical facet dislocation injuries with an MRI, with 6 case exceptions. Overall, there was considerable agreement between American and European responders regarding management of these injuries, with only 3 cases exhibiting a significant difference. Additionally, results also exhibited considerable management agreement between those with ≤ 10 and > 10 years of practice experience, with only 2 case exceptions noted. CONCLUSION: More than half of responders, regardless of geographical location or practice experience, identified MRI as a screening imaging modality when managing cervical facet dislocation injuries, regardless of the status of the spinal cord and prior to any additional intervention. Additionally, a majority of surgeons would elect an anterior approach for the surgical management of these injuries. The study found overall agreement in management preferences of cervical facet dislocation injuries around the globe.

SPINE20 A global advocacy group promoting evidence-based spine care of value.

PURPOSE: The Global Burden of Diseases (GBD) Studies have estimated that low back pain is one of the costliest ailments worldwide. Subsequent to GBD publications, leadership of the four largest global spine societies agreed to form SPINE20. This article introduces the concept of SPINE20, the recommendations, and the future of this global advocacy group linked to G20 annual summits. METHODS: The founders of SPINE20 advocacy group coordinated with G20 Saudi Arabia to conduct the SPINE20 summit in 2020. The summit was intended to promote evidence-based recommendations to use the most reliable information from high-level research. Eight areas of importance to mitigate spine disorders were identified through a voting process of the participating societies. Twelve recommendations were discussed and vetted. RESULTS: The areas of immediate concern were "Aging spine," "Future of spine care," "Spinal cord injuries," "Children and adolescent spine," "Spine-related disability," "Spine Educational Standards," "Patient safety," and "Burden on economy." Twelve recommendations were created and endorsed by 31/33 spine societies and 2 journals globally during a vetted process through the SPINE20.org website and during the virtual inaugural meeting November 10-11, 2020 held from the G20 platform. CONCLUSIONS: This is the first time that international spine societies have joined to support actions to mitigate the burden of spine disorders across the globe. SPINE20 seeks to change awareness and treatment of spine pain by supporting local projects that implement value-based practices with healthcare policies that are culturally sensitive based on scientific evidence.