The case for decreased surgeon-reported complications due to surgical volume and fellowship status in the treatment of geriatric hip fracture: An analysis of the ABOS database.

INTRODUCTION: American orthopaedists are increasingly seeking fellowship sub-specialization. One proposed benefit of fellowship training is decrease in complications, however, few studies have investigated the rates of medical and surgical complications for hip fracture patients between orthopedists from different fellowship backgrounds. This study aims to investigate the effect of fellowship training and case volume on medical and surgical outcomes of patient following hip fracture surgical intervention. METHODS: 1999-2016 American Board of Orthopedic Surgery (ABOS) Part II Examination Case List data were used to assess patients treated by trauma or adult reconstruction fellowship-trained orthopedists versus all-other orthopaedists. Rates of surgeon-reported medical and surgical adverse events were compared between the three surgeon cohorts. Using binary multivariate logistic regression to control of demographic factors, independent factors were evaluated for their effect on surgical complications. RESULTS: Data from 73,427 patients were assessed. An increasing number of hip fractures are being treated by trauma fellowship trained surgeons (9.43% in 1999-2004 to 60.92% in 2011-2016). In multivariate analysis, there was no significant difference in type of fellowship, however, surgeons with increased case volume saw significantly decreased odds of complications (16-30 cases: OR = 0.91; 95% CI: 0.85-0.97; p = 0.003; 31+ cases: OR = 0.68; 95% CI: 0.61-0.76; p<0.001). Femoral neck hip fractures were associated with increased odds of surgical complications. DISCUSSION: Despite minor differences in incidence of surgical complications between different fellowship trained orthopaedists, there is no major difference in overall risk of surgical complications for hip fracture patients based on fellowship status of early orthopaedic surgeons. However, case volume does significantly decrease the risk of surgical complications among these patients and may stand as a proxy for fellowship training. Fellows required to take hip fracture call as part of their training regardless of fellowship status exhibited decreased complication risk for hip fracture patients, thus highlighting the importance of additional training.

A 15-year follow-up study of hip bone mineral density and associations with leisure time physical activity. The Tromsø Study 2001-2016.

AIMS: The aim was to investigate the long-term association between leisure time physical activity and hip areal bone mineral density (aBMD), in addition to change in hip aBMD over time, in 32-86 years old women and men. METHODS: Data were retrieved from the 2001, 2007-2008, and 2015-2016 surveys of the Tromsø Study, a longitudinal population study in Norway. Leisure time physical activity was assessed by the four-level Saltin-Grimby Physical Activity Level Scale which refers to physical exertion in the past twelve months. Hip aBMD was assessed by Dual-Energy X-ray Absorptiometry. Linear Mixed Model analysis was used to examine long-term associations between physical activity and hip aBMD (n = 6324). In addition, the annual change in hip aBMD was analyzed in a subsample of 3199 participants. RESULTS: Physical activity was significantly and positively associated with total hip aBMD in the overall cohort (p<0.005). Participants who reported vigorous activity had 28.20 mg/cm2 higher aBMD than those who were inactive (95% CI 14.71; 41.69, controlled for confounders), and even light physical activity was associated with higher aBMD than inactivity (8.32 mg/cm2, 95% CI 4.89; 11.76). Associations between physical activity and femoral neck aBMD yielded similar results. Hip aBMD decreased with age in both sexes, although more prominently in women. From 2001 to 2007-2008, aBMD changed by -5.76 mg/cm2 per year (95% CI -6.08; -5.44) in women, and -2.31 mg/cm2 (95% CI -2.69; -1.93), in men. From 2007-2008 to 2015-2016, the change was -4.45 mg/cm2 per year (95% CI -4.84; -4.06) in women, and -1.45 mg/cm2 (95% CI -1.92; -0.98) in men. CONCLUSIONS: In this cohort of adult men and women, physical activity levels were positively associated with hip aBMD in a dose-response relationship. Hip aBMD decreased with age, although more pronounced in women than men.

Factors Associated With Increased Mortality in Severe Abdominopelvic Injury.

BACKGROUND: Associated injuries are thought to increase mortality in patients with severe abdominopelvic trauma. This study aimed to identify clinical factors contributing to increased mortality in patients with severe abdominopelvic trauma, with the hypothesis that a greater number of concomitant injuries would result in increased mortality. METHODS: This was a retrospective review of the Trauma Quality Improvement Program (TQIP) database of patients ≥ 18 years with severe abdominopelvic trauma defined as having an abdominal Abbreviated Injury Score (AIS) ≥ 3 with pelvic fractures and/or iliac vessel injury (2015-2017). Primary outcome was in-hospital mortality based on concomitant body region injuries. Secondary outcomes included mortality at 6 h, 6 to 24 h, and after 24 h based on concomitant injuries, procedures performed, and transfusion requirements. RESULTS: A total of 185,257 patients were included in this study. Survivors had more severely injured body regions than non-survivors (4 vs. 3, P < 0.001). Among those who died within 6 h, 28.5% of patients required a thoracic procedure and 43% required laparotomy compared to 6.3% and 22.1% among those who died after 24 h (P < 0.001). Head AIS ≥ 3 was the only body region that significantly contributed to overall mortality (OR 1.26, P < 0.001) along with laparotomy (OR 3.02, P < 0.001), neurosurgical procedures (2.82, P < 0.001) and thoracic procedures (2.28, P < 0.001). Non-survivors who died in < 6 h and 6-24 h had greater pRBC requirements than those who died after 24 h (15.5 and 19.5 vs. 8 units, P < 0.001). CONCLUSION: Increased number of body regions injured does not contribute to greater mortality. Uncontrolled noncompressible torso hemorrhage rather than the burden of concomitant injuries is the major contributor to the high mortality associated with severe abdominopelvic injury.

Preoperative spinopelvic hypermobility resolves following total hip arthroplasty.

AIMS: Spinopelvic mobility plays an important role in functional acetabular component position following total hip arthroplasty (THA). The primary aim of this study was to determine if spinopelvic hypermobility persists or resolves following THA. Our second aim was to identify patient demographic or radiological factors associated with hypermobility and resolution of hypermobility after THA. METHODS: This study investigated patients with preoperative posterior hypermobility, defined as a change in sacral slope (SS) from standing to sitting (ΔSSstand-sit) ≥ 30°. Radiological spinopelvic parameters, including SS, pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, anterior pelvic plane tilt (APPt), and spinopelvic tilt (SPT), were measured on preoperative imaging, and at six weeks and a minimum of one year postoperatively. The severity of bilateral hip osteoarthritis (OA) was graded using Kellgren-Lawrence criteria. RESULTS: A total of 136 patients were identified as having preoperative spinopelvic hypermobility. At one year after THA, 95% (129/136) of patients were no longer categorized as hypermobile on standing and sitting radiographs (ΔSSstand-sit < 30°). Mean ΔSSstand-sit decreased from 36.4° (SD 5.1°) at baseline to 21.4° (SD 6.6°) at one year (p < 0.001). Mean SSseated increased from baseline (11.4° (SD 8.8°)) to one year after THA by 11.5° (SD 7.4°) (p < 0.001), which correlates to an 8.5° (SD 5.5°) mean decrease in seated functional cup anteversion. Contralateral hip OA was the only radiological predictor of hypermobility persisting at one year after surgery. The overall reoperation rate was 1.5%. CONCLUSION: Spinopelvic hypermobility was found to resolve in the majority (95%) of patients one year after THA. The increase in SSseated was clinically significant, suggesting that current target recommendations for the hypermobile patient (decreased anteversion and inclination) should be revisited. Cite this article: Bone Joint J 2021;103-B(12):1766-1773.

The Hip-Spine Challenge.

➤: The proper diagnosis and treatment of patients with concurrent hip and spine pathological processes can be challenging because of the substantial overlap in symptomatology. ➤: There is no consensus on which pathological condition should be addressed first. ➤: Factors such as advanced spinal degeneration, deformity, and prior fusion alter the biomechanics of the spinopelvic unit. Attention should be paid to recognizing these issues during the work-up for a total hip arthroplasty as they can result in an increased risk of dislocation. ➤: In patients with concurrent spine and hip degeneration, the surgeon must pay close attention to appropriate implant positioning and have consideration for implants with enhanced stability to minimize the risk of dislocation. ➤: A proper understanding of sagittal balance and restoration of this balance is integral to improving patient outcomes following spinal surgery. ➤: The advent of new imaging modalities, increased awareness of spinopelvic mobility, as well as a better understanding of sagittal alignment will hopefully improve our treatment of patients with hip-spine syndrome.

Correlation of Acetabular Anteversion and Thoracic Kyphosis Postoperatively with Proximal Junctional Failure in Adult Spinal Deformity Fused to Pelvis.

OBJECTIVES: To investigate whether the immediate thoracic kyphosis (TK) and acetabular anteversion (AA) postoperatively are correlated with proximal junctional failure (PJF) in adult spinal deformity (ASD) patients underwent surgical treatment. METHODS: This is a retrospective study. Following institutional ethics approval, a total of 57 patients (49 Female, eight Male) with ASD underwent surgery fused to sacroiliac bone (S1, S2, or ilium) from March 2014 to January 2019 were included. All of those patients were followed up for at least 2 years. Demographic, radiographic and surgical data were recorded. The maximum range of flexion motion (F-ROM) and extension motion (E-ROM) actively of hip joints was measured and recorded at pre- and postoperation. The sum of F-ROM and E-ROM was defined as the range of hip motion (H-ROM). Receiver operating characteristic (ROC) curve analysis was used to obtain the cut off value of parameters for PJF. A Kaplan-Meier curve and log-rank test were used to analyze the differences in PJF-free survival. RESULTS: In all, 14 patients developed PJF during follow-up. Comparisons between patients with and without PJF showed significant differences in immediate TK (P < 0.001) and AA (P = 0.027) postoperatively. ROC curve analysis determined an optimal threshold of 13° for immediate AA postoperatively (sensitivity = 74.3%, specificity = 85.7%, area under the ROC curve [AUC] = 0.806, 95% CI [0.686-0.926]). Nineteen patients with post-AA ≤13° were assigned into the observational group, and 38 patients with post-AA >13° were being as the control group. Patients in the observational group had smaller H-ROM (P = 0.016) and F-ROM (P < 0.001), but much larger E-ROM (P < 0.001). There were 10 patients showing PJF in the observational group and four in the control group (10/9 vs 4/34, P < 0.001). PJF-free survival time significantly decreased in the observational group (P = 0.001, log-rank test). Furthermore, patients in the observational group had much larger TK (post-TK, P = 0.015). The optimal threshold for post-TK (sensitivity = 85.7%, specificity = 76.7%; AUC = 0.823, 95% CI [0.672-0.974]) was 28.1° after the ROC curve was analyzed. In the observational group, those patients with post-TK ≥28.1° had significantly higher incidence of PJF (9/2 vs 1/7, P < 0.001) than those with post-TK < 28.1°. Moreover, PJF-free survival time in those patients significantly decreased (P = 0.001, log-rank test). CONCLUSIONS: ASD patients with acetabular anteversion of ≤13° at early postoperation may suffer significantly restricted hip motion and much higher incidence of PJF during follow-up, moreover, in those patients, postoperative TK ≥28.1° would be a significant risk factor for PJF developing.

Pubertal Suppression, Bone Mass, and Body Composition in Youth With Gender Dysphoria.

BACKGROUND AND OBJECTIVES: Puberty onset and development contribute substantially to adolescents' bone mass and body composition. Our objective with this study was to examine the effects of gonadotropin-releasing hormone agonists (GnRHa) on these puberty-induced changes among youth with gender dysphoria (GD). METHODS: Medical records of the endocrine diversity clinic in an academic children's hospital were reviewed for youth with GD seen from January 2006 to April 2017 with at least 1 baseline dual-energy radiograph absorptiometry measurement. RESULTS: At baseline, transgender females had lower lumbar spine (LS) and left total hip (LTH) areal bone mineral density (aBMD) and LS bone mineral apparent density (BMAD) z scores. Only 44.7% of transgender youth were vitamin D sufficient. Baseline vitamin D status was associated with LS, LTH aBMD, and LS BMAD z scores. Post-GnRHa assessments revealed a significant drop in LS and LTH aBMD z scores (transgender males and transgender females) without fractures and LS BMAD (transgender males), an increase in gynoid (fat percentage), and android (fat percentage) (transgender males and transgender females), and no changes in BMI z score. CONCLUSIONS: GnRHa monotherapy negatively affected bone mineral density of youth with GD without evidence of fractures or changes in BMI z score. Transgender youth body fat redistribution (android versus gynoid) were in keeping with their affirmed gender. The majority of transgender youth had vitamin D insufficiency or deficiency with baseline status associated with bone mineral density. Vitamin D supplementation should be considered for all youth with GD.

Pelvic incidence and pelvic tilt can be calculated using either the femoral heads or acetabular domes in patients with hip osteoarthritis.

AIMS: The aim of the study was to compare two methods of calculating pelvic incidence (PI) and pelvic tilt (PT), either by using the femoral heads or acetabular domes to determine the bicoxofemoral axis, in patients with unilateral or bilateral primary hip osteoarthritis (OA). METHODS: PI and PT were measured on standing lateral radiographs of the spine in two groups: 50 patients with unilateral (Group I) and 50 patients with bilateral hip OA (Group II), using the femoral heads or acetabular domes to define the bicoxofemoral axis. Agreement between the methods was determined by intraclass correlation coefficient (ICC) and the standard error of measurement (SEm). The intraobserver reproducibility and interobserver reliability of the two methods were analyzed on 31 radiographs in both groups to calculate ICC and SEm. RESULTS: In both groups, excellent agreement between the two methods was obtained, with ICC of 0.99 and SEm 0.3° for Group I, and ICC 0.99 and SEm 0.4° for Group II. The intraobserver reproducibility was excellent for both methods in both groups, with an ICC of at least 0.97 and SEm not exceeding 0.8°. The study also revealed excellent interobserver reliability for both methods in both groups, with ICC 0.99 and SEm 0.5° or less. CONCLUSION: Either the femoral heads or acetabular domes can be used to define the bicoxofemoral axis on the lateral standing radiographs of the spine for measuring PI and PT in patients with idiopathic unilateral or bilateral hip OA. Cite this article: Bone Joint J 2021;103-B(8):1345-1350.

The Evaluation of Sagittal Pelvic-Femoral Kinematics in Patients with Cam-Type Femoracetabular Impingement.

OBJECTIVE: To investigate the sagittal hip-pelvic kinematics in symptomatic cam-type femoroacetabular impingement (FAI) patients in the process of sitting down and compare their difference between patients with sitting pain complaint and those without. METHODS: Twenty-nine symptomatic cam-type FAI patients were recruited from our clinic between May 2018 and October 2018. Patients were categorized into two groups depending on whether they complain of pain in prolonged sitting or not. The pelvic-femoral measurements were assessed with a set of lateral pelvic radiography in sitting and standing respectively. Pelvic incidence (PI), sacral slope (SS), and proximal femoral shaft angle (PFSA) were measured on lateral pelvic radiography, and then pelvic tilting, apparent hip flexion, true hip flexion, and the pelvic-femoral ratio were calculated to investigate the kinematic change from standing to sitting position. Demographic measurements, hip morphology measurements, functional measurements, visual analog scale (VAS), and pelvic-femoral measurements were compared between the two groups. RESULTS: Thirteen cases without sitting pain complaint and 16 cases with sitting pain complaint were stratified to Group N and Group P respectively. No was significant difference in age, body mass index (BMI), and gender between the two groups. Hip morphology measurements (α angle and lateral center-edge angle) and functional measurements (iHOT-12) showed no significant difference between the two groups. However, the mean VAS of pain while sitting was 0.5 ± 0.4 and 1.6 ± 0.6 in Group N and Group P respectively (P = 0.005). Patients with sitting pain complaint have increased pelvic PI compared to those without (50.1° ± 6.5° and 44.2° ± 7.6°, P = 0. 042). The changes in SS (pelvic tilting) from standing to sitting in Group N was significantly larger than that in Group P (21.8° ± 7.0° and 15.1° ± 6.5°, P = 0.012). Although no significant difference in apparent hip flexion and true hip flexion was found. Patients without sitting pain complaint demonstrated a higher pelvic-femoral ratio (22.8% ± 7.9% and 16.1% ± 7.5%, P = 0.010) compared to those with sitting pain complaint. CONCLUSION: Sagittal pelvic-femoral kinematics could have an influence on the symptomology of cam-type FAI. The small PI and insufficient sagittal pelvic tilting in the process of sitting down could be related to the complaint of sitting pain in patients with symptomatic cam-type FAI.

Type 2 Diabetes and Change in Total Hip Bone Area and Bone Mineral Density in Swedish Men and Women Older Than 55 Years.

CONTEXT: In a cross-sectional study, we found an association between type 2 diabetes mellitus (T2DM) and smaller bone area together with greater bone mineral density (BMD) at the total hip. OBJECTIVE: This work aims to investigate these associations longitudinally, by studying T2DM status (no T2DM n = 1521, incident T2DM n = 119, or prevalent T2DM n = 106) in relation to changes in total hip bone area and BMD. METHODS: In 3 cohorts, the Swedish Mammography Cohort Clinical (SMCC; n = 1060), Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS; n = 483), and Uppsala Longitudinal Study of Adult Men (ULSAM; n = 203), with repeat assessment of T2DM status and dual energy x-ray absorptiometry (DXA) measurements of total hip bone area and BMD on average 8 years apart, a linear regression model was used to assess the effect of T2DM status on change in bone area and BMD at the total hip. RESULTS: After meta-analysis, the change in bone area at the total hip was 0.5% lower among those with incident T2DM compared to those without T2DM (-0.18 cm2; 95% CI, -0.30 to -0.06). The change in bone area was similar among those with prevalent T2DM compared to those without (0.00 cm2; 95% CI, -0.13 to 0.13). For BMD, the combined estimate was 0.004 g/cm2 (95% CI, -0.006 to 0.014) among those with incident T2DM and 0.010 g/cm2 (95% CI, -0.000 to 0.020) among those with prevalent T2DM, compared to those without T2DM. CONCLUSION: Those with incident T2DM have a lower expansion in bone area at the total hip compared to those without T2DM.

The intraoperative use of a calliper predicts leg length and offset after total hip arthroplasty. Component subsidence influences the leg length.

BACKGROUND: The purpose of total hip arthroplasty (THA) post-surgery and proper physiotherapy is positive recovery for the patient. Consideration is given to hip replacement biomechanics by ensuring no discrepancies in limb length (LL) and a stable prosthesis. Therefore, the patient must have proper preoperative planning and communication and a clear understanding of what to expect. METHODS: A prospective series of 59 THA operated by a single surgeon via Hardinge approach was studied, using an intraoperative calliper (CAL) to predict the change of LL and offset. We compared the results of the intraoperative changes before and after THA implantation with the reference of these values on anteroposterior x-ray pelvis. The importance of leg length balance and a good offset restoration is questioned, and the effect of component subsidence on leg length is considered. RESULTS: The average preoperative leg length discrepancy was -6.0 mm, postoperatively +3.6 mm. There was a strong correlation between the CAL measurements and the values on the x-ray (LL, r=0.873, p<0.01; offset, r=0.542, p<0.01). Reliability is better for limb length than for offset. These results are comparable within the literature and the statistical results from other studies reviewed. In addition, we evaluate the importance of subsidence of the prosthesis components for long-term results. CONCLUSION: The intraoperative use of CAL gives excellent results in predicting the final LL and offset after THA. Considering subsidence of prosthesis components, a target zone around +5 mm might be more suitable for leg length directly postoperatively. Moreover, surgeons must discuss the topic of leg length discrepancy (LLD) intensively with the patient pre-operatively. LEVEL OF EVIDENCE: Level 4, prospective cohort study.

Truncal Changes in Patients Suffering Severe Hip or Knee Osteoarthritis: A Surface Topography Study.

BACKGROUD: Osteoarthritis (OA) of the hip and knee is a degenerative disease with complications, including reduced range of motion and pain. Although OA of the hip and knee is common, there are few studies that investigated if patients with this condition had affected morphological truncal parameters. The objectives of this study were to compare the morphology of the spine and the pelvis of patients with hip or knee OA to that of a control group (CG) and to comment on the proposed mechanisms of these changes and the clinical effects on patients. METHODS: This study included three groups of individuals. The first group consisted of 34 patients (15 men and 19 women with a mean age of 67.62 ± 8.28 years) suffering from hip OA. The second group consisted of 45 patients (11 men and 34 women with a mean age of 72.47 ± 7.0 years) suffering from knee OA. These patients were compared with a CG, which consisted of 25 individuals (13 men and 12 women with a mean age of 69.28 ± 10.11 years). The DIERS formetric 4D analysis system was used to calculate several truncal parameters in all planes. All analyses were accomplished using the SPSS ver. 17.0, and p < 0.05 was used to determine statistical significance. RESULTS: Patients with hip OA presented with significantly increased values than those in the CG for sagittal imbalance, scoliosis angle, vertebral rotation, trunk torsion, and pelvic obliquity, and decreased values than those in the CG for fleche lombaire. Patients with knee OA presented with significantly increased values than those in the CG for sagittal imbalance, apical deviation, scoliosis angle, vertebral rotation, trunk torsion, and pelvic obliquity. Patients with hip or knee OA, compared to the CG, had greater forward inclination of the spine, greater scoliosis, greater vertebral rotation and trunk torsion, and greater obliquity of the pelvis at the frontal plane. CONCLUSIONS: Patients with severe hip or knee OA could have truncal morphology alterations, in addition to reduced hip or knee range of motion and pain. These alterations could cause significant negative effects, which may then seriously affect the patients' quality of life.

The impact of sagittal imbalance on walking in patients with lumbar spinal canal stenosis.

PURPOSE: Gait and posture disorder severely impedes the quality of life of affected patients with lumbar spinal canal stenosis (LSCS). Despite the major health concern, there is a paucity of literature about the relationships among spatiotemporal gait parameters and spinal sagittal parameters. This is a cross sectional study performed in a single tertiary referral center to determine the relationships among spatiotemporal gait parameters and spinal sagittal parameters in patients with LSCS. METHODS: A total of 164 consecutive patients with LSCS, 87 men and 77 women with mean age of 70.7 years, were enrolled. Spatiotemporal gait parameters were studied using a gait analysis system. Spinal sagittal parameters were studied including sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic inclination (PI), and pelvic tilt (PT) both in the neutral and stepped positions. RESULTS: SVA was significantly larger in the stepped position than in the neutral position (neutral position, 72.5 mm; stepped position, 96.8 mm; p = 0.003). Parameters regarding the pelvis exhibited significant differences, which could represent pelvic anteversion in the stepped position. By stepwise multiple regression analysis, the prediction models, containing SVA (neutral) and PT (stepped) for double supporting phase, exhibited statistical significance, and accounted for approximately 50% of the variance. CONCLUSIONS: The present study provides statistically established evidence of correlation among spatiotemporal gait parameters and spinal sagittal parameters. Differences between sagittal parameters in neutral and stepped position may stand for the postural control during gait cycle, and increased SVA in neutral position and increased PT in stepped position may correlate with prolonged double supporting phase.

The Variation of the Pelvis in Unilateral Crowe Type IV Developmental Dysplasia of the Hip.

OBJECTIVE: To investigate variation of the pelvis in unilateral Crowe type IV developmental dysplasia of the hip (DDH) and analyze the reliability of pelvic landmarks. METHODS: We retrospectively received preoperative anteroposterior pelvic radiographs for 89 adult patients with unilateral Crowe type IV DDH at our institution between September 2008 and May 2019. Forty-eight patients without a false acetabulum was type IVA and 41 with a false acetabulum was type IVB. The heights of the ilium, acetabulum, and ischium areas in affected and unaffected sides were measured. The ratios of the three areas in entire pelvis are calculated. The discrepancies of bilateral iliac crest, inferior sacroiliac articulation, teardrop, and ischial tuberosity on the bisector of the pelvis were also measured. RESULTS: The mean heights of the ilium, acetabulum, ischium areas in the affected side were 74.4, 88.6, and 37.0 mm, respectively, in type IVA group and 77.7, 83.5, and 37.8 mm, respectively, in type IVB group. The heights in the unaffected side were 82.1, 84.6, and 43.8 mm, respectively, in type IVA group and 84.6, 82.0, and 44.0 mm, respectively, in type IVB group. The ratios of the ilium, acetabulum, ischium areas in affected side of Crowe type IVA group were 0.37, 0.44, and 0.19, respectively, and the ratios in unaffected side were 0.39, 0.40, and 0.21, respectively. The ratios in affected side of Crowe type IVB group were 0.39, 0.42, and 0.19, respectively, and the ratios in unaffected side were 0.40, 0.39, and 0.21, respectively. The discrepancies of bilateral iliac crest, inferior sacroiliac articulation, teardrop, and ischial tuberosity on the line of the bisector of the pelvis in Crowe type IVA group were 5.6, 5.2, 2.0, and 7.1 mm, respectively. Those in Crowe type IVB group were 8.1, 3.5, 3.5, and 4.9 mm, respectively. CONCLUSIONS: Pelvic asymmetry was a common occurrence in unilateral Crowe type IV DDH in adults. Furthermore, it should be reliable to use teardrop as pelvic landmark to balance leg length discrepancy in preoperative planning.

Consequences of Hyperthyroidism and Its Treatment for Bone Microarchitecture Assessed by High-Resolution Peripheral Quantitative Computed Tomography.

Background: Hyperthyroidism is associated with bone mass reduction and increased fracture risk, but the effects on other important bone parameters have been sparsely examined. Therefore, we investigated bone microarchitecture and estimated bone strength by high-resolution peripheral quantitative computed tomography (HR-pQCT) in hyperthyroid patients at diagnosis and after being euthyroid for at least one year. Methods: Two approaches were used: (A) a case-control study comparing 61 hyperthyroid women with 61 euthyroid women matched for age and menopause status; (B) a follow-up study, in which 46 of the 61 women were re-examined after having been euthyroid for one year. HR-pQCT of the distal radius and tibia, and dual-energy X-ray absorptiometry (DXA) of the lumbar spine and the hip were performed. Results: In analysis A: In the radius, compared with the healthy controls, hyperthyroid patients had higher total area (16.9% ± 29.5%; p < 0.001), trabecular area (28.6% ± 45.7%; p < 0.001), and lower cortical area (-11.7% ± 23.2%; p < 0.001). Total volumetric bone mineral density (vBMD) (-13.9% ± 26.5%; p < 0.001), cortical vBMD (-5.8% ± 7.9%; p < 0.001), cortical thickness (-16.7% ± 26.0%; p < 0.001), and estimated bone strength (-6.6% ± 19.5%; p < 0.01) were lower. No significant differences were found in the tibia or in the DXA parameters. In analysis B: In the radius, significant improvements were observed in the cortical area (2.1% ± 4.6%; p < 0.01), cortical thickness (2.5% ± 5.1%; p < 0.001), and total vBMD (0.8% ± 3.0%; p < 0.05). Trabecular area decreased (-0.5% ± 1.0%; p < 0.01) and trabecular separation increased (2.0% ± 8.3%; p < 0.05). In the tibia, cortical area (3.6% ± 7.3%; p < 0.01) and cortical thickness (3.8% ± 7.6%; p < 0.01) increased, and trabecular area decreased (-0.5% ± 1.1%; p < 0.01). Areal BMD, measured by DXA, increased in the spine (1.1% ± 3.4%; p < 0.05) and in the hip (2.0% ± 3.8%; p < 0.01). Conclusions: Compared with the healthy control group, hyperthyroid women had lower vBMD, lower estimated bone strength, and compromised cortical microarchitecture in the radius. After restoration of euthyroidism, significant improvements in vBMD and cortical microarchitecture were observed, highlighting the importance of achieving and maintaining euthyroidism.

Retrospective Clinical Evaluation of Negative-Pressure Wound Therapy for Infection Prevention Following Malignant Pelvic Bone Tumor Resection Reconstruction.

OBJECTIVE: To evaluate the clinical outcomes of negative-pressure wound therapy (NPWT) for infection prevention following pelvic reconstruction after malignant bone tumor resection. METHODS: The study involved 82 patients who underwent pelvic reconstruction following en-bloc resection of malignant bone tumors between January 2003 and January 2016. Forty patients were treated with NPWT via implantation of vacuum-sealing drainage (VSD) materials into the pelvic cavity to prevent infection and wound problems (VSD group), and the remaining 42 patients underwent conventional treatment (control group). Study authors compared the inpatient length of stay, antibiotic use, drainage volume, time to wound closure, and infection rates between groups. Investigators also conducted cell cultures of the wound cavity washing fluid and hematoxylin-eosin staining for VSD materials to find recurrent tumor cells. RESULTS: In the VSD group, one patient (2.5%) had a superficial wound problem. In the control group, 18 patients (42.9%) had deep infection or wound problems. The VSD group had a significantly decreased infection rate, duration of antibiotic administration and inpatient stay, as well as increased wound healing compared with the control group (P < .05). Further, no tumor cells were observed in the VSD material or the wound cavity washing fluid. CONCLUSIONS: The application of NPWT with VSD material may be an effective and reliable method for preventing infection in patients who undergo pelvic reconstruction following malignant tumor resection.

Compensatory Mechanism of Maintaining the Sagittal Balance in Degenerative Lumbar Scoliosis Patients with Different Pelvic Incidence.

OBJECTIVE: To investigate the compensatory mechanism of maintaining the sagittal balance in degenerative lumbar scoliosis patients with different pelvic incidence (PI). METHODS: This was a retrospective imaging observation study. Patients in our department with degenerative lumbar scoliosis between 2017 and 2019 were reviewed. A total of 36 patients were eligible and included in the present study. The average age of those patients was 64.22 years, including 8 men and 28 women. The coronal and sagittal parameters were measured on full-length spine X-ray film, including globe kyphosis (GK), lumber lordosis (LL), thoracolumbar kyphosis (TLK), thoracic kyphosis (TK), sagittal vertical axis (SVA), sagittal shift angle, Cobb angle, coronal shift angle, and vertebra. The anterior pelvic plane angle (APPA) and pelvic parameters were also measured, including the pelvic tilt (PT), the PI, and the sacral slope (SS). PI-LL, LL-SS, and GK-SS were calculated. Traditional pelvic tilt was also calculated using the following formula: cPT = PI × 0.37-7. These patients were divided into two groups according to their PI values. The patients' PI value in Group 1 was smaller than 50°. The patients' PI value in Group 2 was equal to or larger than 50°. RESULTS: These patients' SS, PT, PI, LL, TLK, TK, and GK were 28.70° ± 11.36°, 23.28° ± 6.55°, 52.00° ± 11.03°, 31.66° ± 14.12°, 12.12° ± 14.9°, 17.81° ± 13.53°, and -13.17° ± 16.27°. The sagittal shift angle, the APPA, the Cobb angle, the coronal shift angle, vertebra, PI-LL, cPT, APPA-4, LL-SS, and GK-SS were 4.38° ± 5.75°, -12.55° ± 8.83°, 30.03° ± 12.59°, 2.40° ± 2.13°, 4.08 ± 0.93, 19.86° ± 10.97°, 12.35° ± 4.55°, -8.30° ± 9.07°, 3.30° ± 8.82°, and 15.53° ± 9.83°, respectively. There was no significant difference between PT and cPT + APPA-4 or between cPT and PT-APPA+4. There was significant difference between PT and cPT + APPA or between cPT and PT-APPA. This demonstrated that the APPA-4 is reliable as degree of the pelvic sagittal retroversion. There were significant differences in SS, PI, LL, TLK, GK, APPA, PT-APPA, PT-APPA+4, cPT, and APPA-4 between Group 1 and Group 2. There were no significant differences in PT, TK, sagittal shift angle, SVA, Cobb angle, coronal shift angle, vertebra number, PI-LL, cPT + APPA, cPT + APPA-4, LL-SS, and GK-SS between Group 1 and Group 2. The Pearson tests showed that PI-LL had significant correlations with TK, LL, sagittal shift angle, SVA, and LL-SS. There was no significant correlation between PI-LL and Cobb angle, GK, TLK, APPA, vertebra, Coronal Shift Angle, or GK-SS. CONCLUSION: The APPA-4 is reliable as degree of the pelvic sagittal retroversion. In degenerative lumbar scoliosis, patients with smaller PI tended to rely more on the pelvic retroversion to maintain the sagittal balance than patients with larger PI, or patients with smaller PI were likely to start up the pelvic retroversion compensatory mechanism earlier than the patients with larger PI.

Patient-reported physical functioning and quality of life after pelvic ring injury: A systematic review of the literature.

BACKGROUND: Pelvic ring injuries are one of the most serious traumatic injuries with large consequences for the patients' daily life. During recent years, the importance of the patients' perception of their functioning and quality of life following injury has increasingly received attention. This systematic review reports on self-reported physical functioning and quality of life after all types of pelvic ring injuries. METHODS: The online databases MEDLINE-PubMed and Ovid-EMBASE were searched for studies published between 2008 and 2019 to identify published evidence of patient-reported physical functioning and quality of life after which they were assessed for their methodological quality. RESULTS: Of the 2577 articles, 46 were reviewed in full-text, including 3049 patients. Most studies were heterogeneous, with small cohorts of patients, a variety of injury types, treatment methods and use of different, often non-validated, outcome measures. The overall methodological quality was moderate to poor. Nine different PROMs were used, of which the Majeed Pelvic Score (MPS), SF-36 and EQ-5D were the most widely used. Mean scores respectively ranged from 75-95 (MPS), 53-69 (SF-36, physical functioning) and 0.63-0.80 (EQ-5D). CONCLUSIONS: Physical functioning and quality of life following pelvic ring injuries seem fair and tend to improve during follow-up. However, differences in patient numbers, injury definition, treatment strategy, follow-up duration and type of PROMs used between studies hampers to elucidate the actual effects of pelvic ring injuries on a patient's life. IMPLICATIONS OF KEY FINDINGS: Physicians and researchers should use valid and reliable patient-reported outcome instruments on large cohorts of patients with properly defined injuries to truly evaluate physical functioning and quality of life after pelvic ring injuries. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO International prospective register of systematic reviews; registration number CRD42019129176.

The Effects of Pelvic Incidence in the Functional Anatomy of the Hip Joint.

BACKGROUND: The spine-pelvis-hip interaction during postural change should be considered in the functional anatomy of the hip. The component parts of this anatomy and how they influence hip function are important to know. Pelvic incidence (PI) is one of these components. We studied if PI was preoperatively predictive of impingement risk and if it postoperatively influences hip position, which could cause outliers from the functional safe zone of hip replacement. METHODS: This was a prospective radiographic study of 187 consecutive patients (200 hips) who had lateral spinopelvis-hip radiographs before and after primary total hip arthroplasty with measurements of the component factors that influence mobility and position of the functional anatomy. The predictive value of PI for risk of impingement of the hip and its postoperative relationship to functional safe-zone outliers were assessed. Forty-one dislocations from our clinical practice were also reviewed. RESULTS: Of 200 hips, the PI was normal in 145 hips (73%), low in 18 hips (9%), and high in 37 hips (19%). Eighty-two hips had spinopelvic imbalance: 12 (67%) of the 18 hips with low PI, 56 (39%) of the 145 hips with normal PI, and 14 (38%) of the 37 hips with high PI. Low-PI hips was the most predictive of the risk of impingement and postoperatively these hips had the most outliers from the functional safe zone. CONCLUSIONS: PI is an anatomical component that is predictive of both impingement risk and functional safe-zone outliers. Preoperative risk, based on factors such as the Lewinnek zones and combined anteversion, is an established guide in determining cup position in hip replacement. Low-PI hips that have the "terrible triad" of a posteriorly tilted pelvis, stiff pelvic mobility, and increased femoral flexion therefore have no functional safe zone. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Limited correction of lumbar lordosis in the treatment of degenerative scoliosis.

BACKGROUND: Patients suffering from degenerative scoliosis (DS) were commonly associated with coronal and sagittal imbalance which made deformity correction surgery necessary. The study aimed to explore the efficacy and feasibility of the limited correction of lumbar lordosis (LL) in the treatment of patients with DS. METHODS: This was a retrospective study including 58 DS patients who underwent spinal deformity correction surgery and were followed up at least 2 years between January 2013 and January 2017. According to the difference of postoperative LL, the patients were divided into 2 groups: the limited correction group: Pelvic incidence(PI)-18°≤ LL .05). In terms of surgery, the limited group had less intra-operative blood loss and operation time (P < .05). At the last follow-up, significant differences were found in terms of LL(-38.2 ±â€Š4.7° and -46.9 ±â€Š4.7°), PT (18.8 ±â€Š5.2° and 11.1 ±â€Š3.6°), sacrum slope (33.7 ±â€Š7.0° and 41.4 ±â€Š6.1°) (P < .05), while there were no significant differences in terms of lumbar Cobb angle (10.5 ±â€Š9.3°and 8.3 ±â€Š6.7°), Oswestry Disability Index scores (25.6 ±â€Š10.2 and 26.4 ±â€Š12.1), and JOA scores (23.6 ±â€Š5.2 and 22.3 ±â€Š5.7) (P > .05). CONCLUSION: Limited correction of LL in the treatment of DS patients can achieve favorable clinical outcomes including effective Cobb angle correction with less blood loss and operative time.