Simple prediction method of lumbar lordosis for planning of lumbar corrective surgery: radiological analysis in a Korean population.

PURPOSE: This study aimed at deriving a lordosis predictive equation using the pelvic incidence and to establish a simple prediction method of lumbar lordosis for planning lumbar corrective surgery in Asians. METHODS: Eighty-six asymptomatic volunteers were enrolled in the study. The maximal lumbar lordosis (MLL), lower lumbar lordosis (LLL), pelvic incidence (PI), and sacral slope (SS) were measured. The correlations between the parameters were analyzed using Pearson correlation analysis. Predictive equations of lumbar lordosis through simple regression analysis of the parameters and simple predictive values of lumbar lordosis using PI were derived. RESULTS: The PI strongly correlated with the SS (r = 0.78), and a strong correlation was found between the SS and LLL (r = 0.89), and between the SS and MLL (r = 0.83). Based on these correlations, the predictive equations of lumbar lordosis were found (SS = 0.80 + 0.74 PI (r = 0.78, R (2) = 0.61), LLL = 5.20 + 0.87 SS (r = 0.89, R (2) = 0.80), MLL = 17.41 + 0.96 SS (r = 0.83, R (2) = 0.68). When PI was between 30° to 35°, 40° to 50° and 55° to 60°, the equations predicted that MLL would be PI + 10°, PI + 5° and PI, and LLL would be PI - 5°, PI - 10° and PI - 15°, respectively. CONCLUSION: This simple calculation method can provide a more appropriate and simpler prediction of lumbar lordosis for Asian populations. The prediction of lumbar lordosis should be used as a reference for surgeons planning to restore the lumbar lordosis in lumbar corrective surgery.

Does COVID-19 Infection within 1 Week after Total Knee Arthroplasty Affect Patients' Early Clinical Outcomes? A Matched Case-Control Study.

Recent studies have reported the impact of previous COVID-19 infection on the early clinical outcome after total knee arthroplasty (TKA). However, the timing of infection before the surgery was not constant and a study on patients with COVID-19 infection within 1 week after TKA is lacking. This study aimed to determine the effect of COVID-19 infection within one week after TKA on the postoperative outcomes and to compare the early clinical outcomes to those who were not infected with COVID-19 before and after surgery. No significant differences were observed between the two groups in terms of clinical outcomes or complications. The length of the hospital stay (LOS) was significantly longer for the COVID-19 group than for the non-COVID-19 group (p < 0.05). The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were higher for the study group on postoperative days 9 and 12 than for those in the control group (p < 0.05). However, D-dimer levels were not significantly different between the two groups. We should cautiously consider that COVID-19 infection within 1 week after TKA may be associated with increased ESR, CRP levels, and length of hospital stay, but they are not associated with the worsening of early clinical outcomes or the occurrence of complications.

Changes of upper thoracic curve and shoulder balance in thoracic adolescent idiopathic scoliosis treated by anterior selective thoracic fusion using VATS.

STUDY DESIGN: A retrospective radiographic analysis. OBJECTIVES: To evaluate changes of upper thoracic curve and shoulder balance in thoracic adolescent idiopathic scoliosis patients treated by anterior selective thoracic fusion using video-assisted thoracoscopic surgery and to identify adequacy of earlier criteria of double thoracic (DT) curve for anterior correction. SUMMARY OF BACKGROUND DATA: Although anterior and posterior scoliosis correction show many differences in correction mechanisms, fusion levels, loss of correction etc., the criteria of DT curve was applied without differences. There are no reports about these differences. MATERIALS AND METHODS: Forty patients were followed for a minimum of 3 years (range, 3-8 y). The magnitude and flexibility of upper thoracic, lower thoracic, and the superior portion of the lower thoracic curve were measured using full length standing and side-bending radiographs before surgery, at 1 week postoperatively, and at last follow-up. The correction rate and loss of correction of these curves were calculated and preoperative and postoperative radiographic shoulder heights (RSHs) were measured. RSH was defined as balanced (shoulder height difference <10 mm), mildly imbalanced (10-20 mm), or moderately imbalanced (>20 mm). T1 tilt and coronal balance were also evaluated. Patients were divided into groups based on these factors and postoperative RSH was compared. RESULTS: Flexibility of the upper thoracic curve was 46% and magnitude of the upper thoracic curve was corrected spontaneously from 28.6±7.8 degrees to 17.9±7.0 degrees with a 37.4% correction rate that did not change during follow-up. On average, preoperative left shoulder was 6.3±10.5 mm lower than right shoulder and this changed to 10.4±11.8 mm and 6.0±8.2 mm higher than right shoulder at 1 week postoperatively and at last follow-up, respectively. The group with an upper thoracic curve of ≥30 degrees or a superior portion of the lower thoracic curve of ≥30 degrees preoperatively had a higher left shoulder postoperatively (P=0.016, 0.040). Of the 12 patients with a symmetric or higher left shoulder (≥0 mm) preoperatively, 9 patients had a balanced shoulder (-10-10 mm) and 3 patients showed mild shoulder imbalance (<20 mm) at last follow-up. CONCLUSIONS: Among patients who have DT curve, patients with mild left shoulder elevation (<20 mm) can be treated by anterior correction unless the magnitude of upper thoracic curve or superior portion of lower thoracic curve are ≥30 degrees. For anterior correction, criteria of DT curve might be applied less strictly.

Heterotopic ossification following lumbar total disc replacement.

The main goal of total disc replacement (TDR) is to preserve motion. Despite reports of good clinical outcomes, various degrees of heterotopic ossification after TDR have been reported. The purpose of this study was to investigate the prevalence and its clinical relevance of heterotopic ossification. We evaluated 65 consecutive patients (82 segments) with mean follow-up duration of 45 months (range, 12-88 months). Two kinds of prosthesis, ProDisc® for 75 segments (91.5%) and CHARITE™ for seven segments (8.5%), were used. Patients with heterotopic ossification were compared with those without heterotopic ossification with regard to segmental flexion-extension ROM, VAS and ODI. We analysed the occurrence site by nine zones. Heterotopic ossification was detected in 25 out of 82 segments (30.5%) at a mean follow-up of 17 months. According to McAfee's classification, there was Class-I heterotopic ossification in eight segments (9.8%), Class-II in 12 segments (14.6%), and Class-III in five segments (6.1%). There was no Class-IV heterotopic ossification. There were no significant differences in the segmental ROM, VAS and ODI between the patients with Class-I or Class-II heterotopic ossification and those without heterotopic ossification The segmental ROM in the patients with Class-III heterotopic ossification was significantly decreased compared with the patients without heterotopic ossification (p = 0.018). But VAS and ODI were not significantly different compared with those of patients with no heterotopic ossification. Most heterotopic ossification (82.5%) was detected in the anterior and posterior aspects. In conclusion, most of the heterotopic ossification (Classes I and II) did not affect segmental ROM and clinical outcomes such as pain or function. In Class-III heterotopic ossification segmental ROM was decreased, but it did not affect clinical outcomes.

Local Infiltration Analgesia Versus Femoral Nerve Block for Pain Control in Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is often performed on an outpatient basis; thus, effective pain management is essential to improving patient satisfaction and function. Local infiltration analgesia (LIA) and femoral nerve block (FNB) have been commonly used for pain management in ACLR. However, the comparative efficacy and safety between the 2 techniques remains a topic of controversy. PURPOSE: To compare pain reduction, opioid consumption, and side effects of LIA and FNB after ACLR. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed to identify studies comparing pain on the visual analog scale (a 100-mm scale), total morphine-equivalent consumption, and side effects between the 2 techniques after ACLR at the early postoperative period. The LIA was categorized into intra-articular injection and periarticular injection, and subgroup analyses were performed comparing either intra-articular injection or periarticular injection with FNB. Two reviewers performed study selection, risk-of-bias assessment, and data extraction. RESULTS: A total of 10 studies were included in this systematic review and meta-analysis. In terms of VAS pain scores, our pooled analysis indicated that FNB was significantly more effective at 2 hours postoperatively compared with LIA (mean difference, 8.19 [95% confidence interval (CI), 0.75 to 15.63]; P = .03), with no significant difference between the 2 techniques at 4, 8, and 12 hours postoperatively; however, LIA was significantly more effective at 24 hours postoperatively compared with FNB (mean difference, 5.61 [95% CI, -10.43 to -0.79]; P = .02). Moreover, periarticular injection showed a significant improved VAS pain score compared with FNB at 24 hours postoperatively (mean difference, 11.44 [95% CI, -20.08 to -2.80]; P = .009), and the improvement reached the threshold of minimal clinically important difference of 9.9. Total morphine-equivalent consumption showed no difference between the 2 techniques, and side effects were unable to be quantified for the meta-analysis because of a lack of data. CONCLUSION: Compared with FNB, LIA was not as effective at 2 hours, comparable within 12 hours, and significantly more effective at 24 hours postoperatively for reducing pain after ACLR. Total morphine-equivalent consumption showed no significant differences between the 2 techniques.

Incidence of microbiological contamination of local bone autograft used in posterior lumbar interbody fusion and its association with postoperative spinal infection.

OBJECTIVE: The aim of this study was to examine the results of microbiological cultures from local bone autografts used in posterior lumbar interbody fusion (PLIF) and to identify their association with postoperative spinal infection. METHODS: The authors retrospectively evaluated cases involving 328 patients who had no previous spinal surgeries and underwent PLIF for degenerative diseases with a minimum 1-year follow-up. Local bone was obtained during laminectomy, and microbiological culture was performed immediately prior to bone grafting. The associations between culture results from local bone autografts and postoperative spinal infections were evaluated. RESULTS: The contamination rate of local bone was 4.3% (14 of 328 cases). Coagulase-negative Staphylococcus (29%) was the most common contaminant isolated, followed by Streptococcus species and methicillin-sensitive Staphylococcus aureus. Of 14 patients with positive culture results, 5 (35.7%) had postoperative spinal infections and were treated with intravenous antibiotics for a minimum of 4 weeks. One of these 5 patients also underwent reoperation for debridement during this 4-week period. Regardless of the microbiological culture results, the infection rate after PLIF with local bone autograft was 2.4% (8 of 328 cases), with 5 (62.5%) of 8 patients showing positive results on autograft culture. CONCLUSIONS: The incidence of contamination of local bone autograft during PLIF was considerable, and positive culture results were significantly associated with postoperative spinal infection. Special attention focused on the preparation of local bone for autograft and its microbiological culture will be helpful for the control of postoperative spinal infection.

Mini-Open Anterior Lumbar Interbody Fusion Combined with Lateral Lumbar Interbody Fusion in Corrective Surgery for Adult Spinal Deformity.

STUDY DESIGN: Prospective observational study. PURPOSE: To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity. OVERVIEW OF LITERATURE: Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. METHODS: Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5-S1 or L4-S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. RESULTS: No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°-25°, 23°-42°, and 45°-65°, respectively. CONCLUSIONS: Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery.

Intra-articular repair of an isolated partial articular-surface tear of the subscapularis tendon.

BACKGROUND: Partial-thickness tear of the subscapularis tendon in the articular surface is common. HYPOTHESIS: Intra-articular repair of a partial articular-surface tear of the subscapularis tendon will provide a successful outcome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 29 shoulders with an isolated partial articular-surface tear of the subscapularis tendon without another rotator cuff lesion were treated with arthroscopic intra-articular repair using suture anchors. Biceps tenodesis was performed in 16 patients. Outcomes were prospectively evaluated at a mean of 27 months (range, 19-41 months) using 3 objective (University of California at Los Angeles, American Shoulder and Elbow Surgeons Shoulder Index, Simple Shoulder Test) and 2 subjective (pain and function visual analog scales) measurements. RESULTS: There were 21 men and 8 women, with a mean age of 54 years (range, 41-65 years). Tear widths were small (<1 cm) in 16 shoulders and large (>1 cm) in 13 shoulders. Twenty-six shoulders had articular cartilage erosion on the adjacent humeral head. Lesions of the biceps tendon were noted in 25 patients (partial tear in 15 shoulders; subluxation in 13 shoulders). Shoulder pain scores improved after surgery (5.0 +/- 2.7 to 0.3 +/- 0.7, P < .05). According to American Shoulder and Elbow Surgeons Shoulder Index scores, 18 were excellent; 10, good; and 1, fair. Internal rotation strength deficit improved from 32% to 4%. Twenty-six patients returned to more than 90% of previous activity. There were no surgical complications; tear size and biceps tenodesis did not affect outcome (P > .05). CONCLUSION: Arthroscopic intra-articular repair of a partial articular-surface tear of the subscapularis tendon is an effective procedure that spares the intact tendon attachment in the bursal surface. Short-term outcomes were reliable by both objective and subjective measurements.

The Kim test: a novel test for posteroinferior labral lesion of the shoulder--a comparison to the jerk test.

BACKGROUND: Detection of a posteroinferior labral lesion by physical examination is often difficult. PURPOSE: To introduce a novel diagnostic test for detecting a posteroinferior labral lesion of the shoulder. HYPOTHESIS: The Kim test can detect a posteroinferior labral lesion of the shoulder. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: In 172 painful shoulders, the Kim test was compared with the jerk test and was verified by arthroscopic examination. A sudden onset of posterior shoulder pain and click with or without clunk indicated a positive test result. RESULTS: Thirty-three shoulders had a positive Kim test result, in which 24 had a posteroinferior labral lesion and 9 had a normal posteroinferior labrum. Of 139 shoulders with a negative Kim test result, 6 had a posteroinferior labral tear and 133 had a normal posteroinferior labrum. The sensitivity of the Kim test was 80%, specificity was 94%, positive predictive value was 0.73, and negative predictive value was 0.96. The interexaminer reliability between 2 examiners was 0.91. The accuracy of the jerk test in detecting a posteroinferior labral lesion was the following: sensitivity, 73%; specificity, 98%; positive predictive value, 0.88; and negative predictive value, 0.95. The location of the posterior labral lesion was predominantly posterior in 19 shoulders and predominantly inferior in 11 shoulders. The Kim test was more sensitive in detecting a predominantly inferior labral lesion, whereas the jerk test was more sensitive in detecting a predominantly posterior labral lesion. The sensitivity in detecting a posteroinferior labral lesion increased to 97% when the 2 tests were combined. CONCLUSION: The Kim test is a reliable diagnostic test for detection of a posteroinferior labral lesion.

The Early Result of Cementless Arthroplasty for Femur Neck Fracture in Elderly Patients with Severe Osteoporosis.

PURPOSE: The purposes of the current study were to assess the early results of cementless hip arthroplasty (HA) for femoral neck fractures in elderly patients with severe osteoporosis and to compare the clinical outcomes between those who underwent total HA (THA) or bipolar hemiarthroplasty (BHA). MATERIALS AND METHODS: From April 2011 to May 2012, we performed 87 cementless HAs for displaced femoral neck fractures in elderly patients (≥65 years) with severe osteoporosis. Among them, we studied 70 hips that were able to be followed-up for >24 months. Of these, 34 underwent THA and 36 underwent BHA. Clinical results were evaluated using the Harris hip score (HHS), Koval classification, and radiographs. RESULTS: Only one instance of femoral stem loosening was observed. Additionally, no dislocations were observed and no revision surgeries were required. The mean changes in the functional items of the HHS scores were 2.8 and 5.2 for those who underwent THA and BHA, respectively (P<0.05). According to the Koval classification used for the ambulatory status analysis, the mean perioperative change in the grade was 0.8 (0-4), with no significant differences noted between the THA and BHA groups. CONCLUSION: The early results of cementless HA for femur neck fractures in elderly patients with osteoporosis were satisfactory, and THA was found to have a functional advantage over BHA.

A Broken Drill-bit Fragment Causing Severe Radiating Pain after Cervical Total Disc Replacement: A Case Report.

This is a case report of a 38-year-old man with severe radiating pain on upper extremity after cervical total disc replacement (TDR). We faced an unusual complication that has not been reported yet. He underwent cervical TDR for left central disc protrusion on C5-6. After the surgery, preoperative symptom disappeared. However, at postoperative 1 year, he complained severe right-sided radiating pain that had a sudden onset. On postoperative X-ray, a metal fragment which seemed like a broken drill bit was shown within the spinal canal. To remove that, right-sided anterior microforaminotomy on C5-6 was performed and the metal fragment was removed successfully. After that, anterior fusion was done because the motion of the artificial disc was minimal and the removed structure seemed to attenuate stability during cervical motion. The operation resulted in prompt symptomatic relief. During cervical TDR, particular attention should be paid to the procedures that require using drill-bits.

Postoperative changes in pelvic parameters and sagittal balance in adult isthmic spondylolisthesis.

BACKGROUND: Correction of deformity in adult isthmic spondylolisthesis can affect the pelvic parameters and sagittal balance. OBJECTIVE: To evaluate the correlation with the amount of deformity correction and the subsequent change in pelvic parameters after surgical correction of adult isthmic spondylolisthesis and to determine which deformity parameter most affects the postoperative restoration of spinopelvic sagittal alignment. METHODS: Fifty-eight patients with 1-level isthmic spondylolisthesis were included. Their average age was 55 years (range, 24-76 years). All patients underwent operation by posterior lumbar interbody fusion and posterior instrumentation. The pre- and postoperative sacral slope, pelvic tilt, lumbar lordosis (LL), and sagittal balance were measured, and then the correlation between these parameters and deformity parameters such as slip degree, slip angle, and height of the intervertebral disc (HOD) was evaluated. RESULTS: The slip degree, slip angle, and HOD were significantly recovered after surgery. Pelvic parameters and sagittal balance changed subsequently. Sacral slope was increased by 4.4 degrees, and pelvic tilt was decreased by 4.4 degrees. LL was increased by 5.2 degrees and sagittal balance was displaced 5.6 mm posteriorly. Only the restoration of the HOD showed a significant correlation with the change in LL (r = 0.305, P = .02) and sagittal balance (r = 0.377, P = .004). CONCLUSION: Surgical correction of adult isthmic spondylolisthesis with posterior lumbar interbody fusion and posterior instrumentation resulted in improvement of sacral slope, pelvic tilt, LL, and sagittal balance. Only restoration of the HOD was significantly correlated with improvement of LL and sagittal balance. Therefore we presume it is important to restore the HOD in surgical correction of adult isthmic spondylolisthesis.

Normal patterns of sagittal alignment of the spine in young adults radiological analysis in a Korean population.

STUDY DESIGN: Radiological analysis and classification of normal patterns of sagittal alignment of the spine. OBJECTIVE: To classify the patterns of sagittal alignment of the spine in young asymptomatic adults and analyze the differences in the various spinal and pelvic parameters according to these patterns. SUMMARY OF BACKGROUND DATA: Previous studies reported that the overall sagittal pattern and balance were more important than the normative values. There are few studies on white populations, classifying the normal patterns of sagittal curvature, and no studies on Asian populations. METHODS: Whole spine, standing lateral radiographs of 86 Korean volunteers were taken. The pelvic and spinal parameters (total thoracic kyphosis, horizontal thoracic level, thoracolumbar junctional angle (TLJA), total lumbar lordosis, lower lumbar lordosis, horizontal lumbar level (HLL), lumbar inclination, pelvic tilt, sacral slope (SS), pelvic incidence, spinal balance, spinopelvic balance, and sacropelvic balance) were measured and the correlations of all parameters were analyzed. The volunteers were classified in to three types according to their HLL. The data were analyzed statistically to determine the differences in the parameters and balance between the three types. RESULTS: The HLL showed a significant correlation with the lumbar inclination, junctional level, TLJA, spinal balance, spinopelvic balance, and SS on analyzing the correlation of the parameters. As HLL moved caudally, the TLJA and lumbar inclination increased, whereas the lower lumbar lordosis, pelvic incidence, and SS decreased and spinal balance became more negative. There were no significant differences in total thoracic kyphosis and sacropelvic balance between the three types. CONCLUSION: The patterns of sagittal alignment could be classified into three types showing that the spinal balance becomes more negative, the lumbar inclination and TLJA increase, the SS and pelvic incidence decrease, and lumbar lordotic curves becomes shorter as the patterns of sagittal curvature move toward type 3. This classification in young adults should be considered individually as a reference for surgeons aiming to restore the lumbar lordosis and sagittal alignment in degenerative lumbar fusion surgery.