Tibia-first, gap-balanced patient-specific alignment restores bony phenotypes and joint line obliquity in a great majority of varus and straight knees and normalises valgus and severe varus deformities.

PURPOSE: The present study focuses on testing the capability of a restricted tibia-first, gap-balanced patient-specific alignment technique (PSA) to restore bony morphology and phenotypes. METHODS: Three-hundred and sixty-seven patients were treated with navigated total knee arthroplasty and tibia-first gap-balanced PSA technique. Boundaries for medial proximal tibial angle were 86°-92°, mechanical lateral distal femoral angle 86°-92°, and hip-knee-ankle angle 175°-183°. Knees were classified by coronal plane alignment of the knee (CPAK), with subsequent analyses comparing pre- and postoperative distributions. Phenotype classification within CPAK groups assessed pre- and postoperative distributions. RESULTS: Preoperatively, the largest CPAK group was type II (30.8%), followed by type I (20.5%) and type V (17.8%). Postoperatively, type II remained the largest group (39%), followed by type V (30%). All groups with varus/valgus deformities (I, III, IV and VI) became smaller. While in straight legs (II, IV), the CPAK was restored in more than 70%-75%, in varus groups (I, IV) in 40%-50% and in valgus (III and VI) in 5%-18%. The joint line obliquity remained the same in the majority of knees (straight >75%; varus 63%-80%; valgus VI 95%), with the exception of CPAK III (40%). The phenotype analysis showed for straight legs a phenotype restoration of 85%, for varus 94% and for valgus 37%. Joint line convergence angle was reduced significantly in all groups from 1.8°-4.3° preoperatively to 0.6°-1.2° postoperatively. CONCLUSION: PSA restores bony phenotypes and joint line obliquity in the majority of straight and varus knees, while most of the valgus and extreme varus knees are normalised. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Deformity in valgus knee malalignment is not only in the femur but also in tibia or both, based on demographic and morphological analysis before and after knee osteotomies.

PURPOSE: This study aims to identify the demographic and morphological features of valgus knee deformity with unilateral osteoarthritic knee in the coronal plane. A secondary aim was to identify the distinct phenotypes of valgus knees in Hirschmann's phenotype and the coronal plane alignment of the knee (CPAK) classifications before and after a knee osteotomy (KO). METHODS: A total of 107 patients (57 female and 50 male) with a mean age of 42.4 ± 17.2 years, who underwent varisation osteotomy for symptomatic unilateral knee osteoarthritis (OA) and constitutional valgus deformity, were enrolled in the study, and the mean follow-up period was 29.1 ± 7.3 months. The included cases comprised 60 cases of distal femoral osteotomy, 10 cases of double-level osteotomy and 33 cases of high tibial osteotomy. All patients underwent preoperative and postoperative clinical, functional and radiological evaluations, analysed by analysis of variance tests. RESULTS: An analysis of the location of the valgus deformities demonstrated that 56 cases (52.3%) were femoral based, 18 cases (16.8%) were both femoral and tibial based and 33 cases (30.9%) were tibial based. Twelve preosteotomy cases (11.2%) and 38 postosteotomy cases (35.5%) matched the most common eight Hirschmann's phenotypes, phenotyping the coronal lower limb alignment based on the native alignment in young patients without OA. Four (3.7%) preosteotomy cases and 89 postosteotomy cases (83.1%) matched the most common three CPAK phenotypes (Ⅰ, Ⅱ, Ⅴ) based on constitutional alignment and joint line obliquity in healthy and osteoarthritic knees. CONCLUSION: In valgus knee malalignment, the location of the deformity is not only solely femoral-based but also solely tibial-based or combined femoral and tibial-based. An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. Hirschmann's and CPAK classification would not be relevant when KO is considered. LEVEL OF EVIDENCE: Level Ⅳ, retrospective case-control study.

Reconstrucción por técnica de Chevron reverso y transferencia tendinosa con técnica no convencional en Hallux Varus Iatrogénico Severo / Reconstruction by reverse Chevron technique and tendon transfer with unconventional technique in severe iatrogenic Hallux Varus

El Hallux Varus Iatrogénico es una complicación de la cirugía correctiva del Hallux Valgus muy poco frecuente. El tratamiento incluye la intervención de los tejidos blandos, y óseos. El propósito de este trabajo es mostrar los resultados clínico-radiológicos del tratamiento quirúrgico del Hallux Varus Iatrogénico Flexible Severo empleando la combinación de técnicas de reconstrucción alternativas en una paciente femenina de 59 años de edad. Se realizó liberación medial de la capsula articular MTF y abductor, osteotomía de Chevron reverso, artrodesis interfalángica izquierda, transferencia tendinosa del extensor largo de Hallux hacia plantar con botón artesanal. De acuerdo a la Escala AOFAS aumentó de 30 a 90 puntos. Se logró la corrección estable de la deformidad en varo y la consolidación de la osteotomía. El Hallux Varus Iatrogénico es una complicación poco frecuente considerada una deformidad mal tolerada, con pocos casos reportados y pocos reportes. Se debe hacer un enfoque de tratamiento paso a paso para abordar todos los elementos involucrados en el Hallux Varus iatrogénico. La corrección quirúrgica del Hallux Varus iatrogénico severo con técnicas de reconstrucción no convencionales tipo Chevron reverso y transferencia tendinosa con botón plantar, es una excelente opción terapéutica de acuerdo a los resultados obtenidos en este caso(AU)

Iatrogenic Hallux Varus is a very rare complication of Hallux Valgus corrective surgery. The treatment includes the intervention of soft tissues and bones. The purpose of this paper is to show the clinical-radiological results of the surgical treatment of Severe Flexible Iatrogenic Hallux Varus using the combination of alternative reconstruction techniques in a 59-year-old female patient. Medial release of the MTF and abductor joint capsule, reverse Chevron osteotomy, left interphalangeal arthrodesis, tendon transfer of the long extensor of Hallux to plantar with artisanal button was performed. According to the AOFAS Scale, it increased from 30 to 90 points. Stable correction of the varus deformity and consolidation of the osteotomy were achieved. Iatrogenic Hallux Varus is a rare complication considered a poorly tolerated deformity, with few reported cases and few reports. A step-by-step treatment approach must be taken to address all the elements involved in iatrogenic Hallux Varus. Surgical correction of severe iatrogenic Hallux Varus with unconventional reconstruction techniques such as reverse Chevron and plantar button tendon transfer is an excellent therapeutic option according to the results obtained in this case(AU)

Eight-year trajectories of malalignment progression in symptomatic knee osteoarthritis.

BACKGROUND: Although various therapies have been developed to treat malalignment in osteoarthritic knees, the pattern of malalignment progression is still unclear. This study aimed to identify homogeneous subgroups with distinct trajectories of malalignment progression in subjects with symptomatic knee osteoarthritis (KOA) and to determine corresponding risk factors. METHODS: Eight-year follow-up (from 2004 to 2012) data on 1252 participants with symptomatic KOA from the Osteoarthritis Initiative were included. Varus/valgus angle progression was characterized by group-based trajectory models. Time-varying covariates were introduced into the model to investigate how they affected trajectories. Multinomial logistic regression for trajectory group membership was applied to ascertain risk factors. RESULTS: Five subgroups were identified. Participants in the varus worsening trajectory (n = 166) or valgus worsening trajectory (n = 118) proceeded to worsen malalignment over time. The neutral trajectory (n = 378), varus stable trajectory (n = 328), and valgus stable trajectory (n = 262) maintained close to the initial varus/valgus angle over 8 years. Higher baseline Kellgren and Lawrence grade (odds ratio [OR] = 4.35, P  < 0.001 for varus; OR = 3.85, P  < 0.001 for valgus) and "severe" baseline malalignment (OR = 13.57, P < 0.001 for varus; OR = 23.04, P < 0.001 for valgus) were risk factors for worsening trajectories. The cutoff point of the baseline varus/valgus angle to discriminate between stable or worsening trajectory was -4.5° for varus and 3.6° for valgus. CONCLUSIONS: This study identified the malalignment progression pattern - minor malalignment (-4.5° to +3.6°) tends to remain stable, while major baseline malalignment is likely to progress. This provides a reference for therapy to prevent malalignment from deteriorating and emphasizes the necessity of determining the trigger factors for malalignment onset.

Knee varus alters three-dimensional ankle alignment in standing- a study with upright computed tomography.

BACKGROUND: For knee osteoarthritis (OA) treatment, it is important to correct the lower limb alignment including the foot. However, in the upright position, lower limb alignment is generally assessed from the body surface or radiographs, and it is a challenge to capture the exact characteristics of three-dimensional lower limb alignment. The purpose of the study was to measure lower limb alignment in patients with knee OA using upright computed tomography (CT) and radiography, and to identify features of knee joint deformity. METHODS: A total of 45 limbs in 25 patients with knee OA were enrolled. The subjects underwent both upright CT and radiography for the whole lower limb in the standing position. The joint angles were calculated on both images. The degree of knee OA was classified according to Kellgren-Lawrence (KL) grade by referring to radiography, which is mainly based on the degree of articular cartilage loss and severity of osteophytes, and the characteristics or correlation between knee and ankle joint in each group was investigated. RESULTS: In KL-I, there was an association between varus of the knee joint and internal rotation of the talocrural joint (r = 0.76, P < 0.05). In KL-II, there was an association between varus of the knee joint and eversion of the subtalar joint (r = 0.63, P < 0.05) and talocrural joint (r = - 0.65, P < 0.05). In KL-III, there was an association between varus of the knee joint and internal rotation of the subtalar joint (r = - 0.62, P < 0.05), and in KL-IV, there was an association between varus of the knee joint and internal rotation of the subtalar joint (r = - 0.58, P < 0.05). CONCLUSIONS: The lower limb alignment of patients with knee OA in the standing position was found that as knee OA worsened, it became apparent that compensatory knee joint alignment depended on the ankle joint rather than the subtalar joint. The results may help in the rehabilitation of patients with knee OA, since the ankle joint alignment has a significant impact on the knee joint during coarse movements involving load.

Effects of preoperative sagittal spinal imbalance on pain after lateral lumbar interbody fusion.

Sagittal misalignment has been associated with negative quality of life (QOL). However, there is no report on whether differences in preoperative sagittal misalignment in patients with lumbar degenerative diseases affect postoperative results after lateral lumbar interbody fusion (LLIF). We investigated whether preoperative sagittal alignment influences the correction of alignment after surgery and whether the preoperative sagittal alignment affects the rating of low back pain, leg pain, and leg numbness. The subjects were 81 patients (48 male, 33 females, average age at surgery 70.2 years) who underwent anterior-posterior combined surgery with LLIF and percutaneous pedicle screws from May 2018 to July 2020. Cluster analysis was performed using the preoperative sagittal vertical axis (SVA) value, and patients were classified into two groups (group 1; n = 30, SVA = 129.0 ± 53.4 mm, group 2; n = 51, SVA = 30.8 ± 23.5 mm). Baseline demographics and treatment data were compared between groups. Sagittal and pelvic parameters and pain scores, such as low back pain, leg pain, and leg numbness, were also compared. Operative time, blood loss, and length of hospital stay did not differ significantly between groups. The changes (Δ) in SVA and lumbar lordosis (LL) for all patients from before to after surgery were not significant (ΔSVA; p = 0.218, ΔLL; p = 0.189, respectively). The SVA, LL, and PI - LL changed significantly after the surgery in group 1, but no marked improvement in sagittal imbalance was obtained after LLIF surgery. The improvement in each pain score from before to after the surgery did not differ significantly between groups. LLIF surgery has a limited chance of recovering sagittal imbalance. However, postoperative low back pain, leg pain, and leg numbness may be improved by LLIF surgery, regardless of the preoperative sagittal alignment.

Comparison of Efficacy between Acupuncture Therapies in Improving Sacroiliac Joint Malposition: A Systematic Review and Meta-Analysis.

AIM: To provide available quantitative evidence of efficacy and safety of acupuncture treatments for improving sacroiliac joint malposition. METHODS: Databases such as the China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (CQVIP), Wanfang Database (Wanfang), China Biology Medicine disc (CBMdisc), PubMed, Web of Science, EMBASE, and Cochrane Library were searched by computer to collect the reports on acupuncture treatment of sacroiliac joint malposition from the database creation to July 20, 2021. The selection of included studies, data extraction and coding, and bias risk assessment were conducted independently by two reviewers. RevMan5.4 software was used for meta-analysis, and the results were expressed as mean difference (MD) or standardized mean difference (SMD), with a confidence interval (CI) of 95%. RESULTS: A total of 10 randomized controlled clinical trials (RCTs) with 1019 participants were included. Their overall quality of methodology was not high, and there may be publication bias. Meta-analysis showed that the total effective rate of the treatment group was higher than that of the control group (OR = 2.74, 95% CI 2.00 to 3.74, P < 0.00001). The treatment group was better than the control group in improving VAS score (WMD = -1.56, 95% CI -2.18 to -0.94, P < 0.00001). The ODI score of the treatment group was lower than that of the control group (WMD = -6.04, 95% CI -7.05 to -5.02, P < 0.00001). With the improvement of the JOA score, the difference of iliac transverse diameter of sacroiliac joint dislocation and the index of sacroiliac joint malposition in the treatment group were better than those in the control group (P < 0.05). There was no significant heterogeneity among the studies. CONCLUSION: Acupuncture may have therapeutic advantages in improving sacroiliac joint malposition. Acupuncture and acupotomy provide a safe way to improve the related clinical symptoms and functional disorders in activity of sacroiliac joint dislocation. However, due to the low quality of the included literature, this conclusion still needs to be further verified by more high-quality and large-sample RCTs.

Impact of Internal Malrotation of the Femur Followed by Derotational Osteotomy as Demonstrated by 3D Gait Analysis: A Case Report.

CASE: An 18-year-old man with 48° of internal malrotation of the femur after nailing underwent derotational osteotomy with gait dynamics and electromyography data collected preoperatively and postoperatively. Hip abduction and internal foot progression angles were significantly deviated from normal preoperatively compared with the contralateral side. At 10 months postoperatively, the hip was abducted and externally rotated throughout the entire gait cycle. His Trendelenburg gait had resolved, and he reported no residual functional concerns. Before corrective osteotomy, walking velocity was significantly slower with shorter stride lengths. CONCLUSION: Significant internal malrotation of the femur impairs hip abduction and foot progression angles as well as gluteus medius activation during ambulation. Derotational osteotomy considerably corrected these values.

Repositional Subtalar Arthrodesis Combined With Supramalleolar Osteotomy for Late-Stage Varus Ankle Arthritis With Hindfoot Valgus.

BACKGROUND: Late-stage varus ankle arthritis is thought to be associated with varus of the tibial plafond and hindfoot. However, some late-stage varus arthritis show hindfoot valgus, which can be explained by subtalar subluxation with opposite directional motion between the talus and calcaneus. We hypothesized that late-stage varus ankle arthritis with hindfoot valgus could improve with repositional subtalar arthrodesis and supramalleolar osteotomy (SMO). The purpose of this study was to investigate the clinical and radiographic results of the repositional subtalar arthrodesis combined with SMO for late-stage varus ankle arthritis with hindfoot valgus. METHODS: This study includes 16 consecutive patients (16 ankles) with late-stage varus ankle arthritis of Takakura stage 3-b and hindfoot valgus who were treated using repositional subtalar arthrodesis combined with SMO and followed for a minimum of 2 years. Clinical results were assessed with the visual analog scale (VAS) and the Foot Function Index (FFI). Radiographic results were assessed with standard parameters measured on weightbearing foot and ankle radiographs. Clinical and radiographic results were evaluated preoperatively and at the last follow-up. RESULTS: VAS and FFI significantly improved after surgery. Mean talar tilt angle improved from 12.8 ± 2.8 degrees to 3.9 ± 3.1 degrees (P < .001). Talus center migration and Meary angle significantly improved after surgery. Medial distal tibial angle, lateral talocalcaneal angle, hindfoot moment arm, and talonavicular coverage angle significantly changed after surgery. Radiographic stage improved in 15 ankles (93.8%) after surgery. CONCLUSION: In this series with minimum 2-year follow-up, we found that late-stage (Takakura stage 3-b) varus ankle arthritis with hindfoot valgus clinically and radiographically improved with repositional subtalar arthrodesis combined with SMO. LEVEL OF EVIDENCE: Level IV, prognostic.

Enclavado endomedular en fracturas de tibia. ¿Existe una relación entre el punto de entrada para la inserción del clavo y su alineación final? / Intramedullary nailing of tibial fractures. Is there a relationship between the entry point and its final alignment?

Introducción: Las fracturas de tibia representan aproximadamente el 2% de las fracturas del adulto. El enclavado endomedular es hoy el procedimiento de elección para tratar fracturas diafisarias de tibia; sin embargo, esta técnica no está exenta de complicaciones, la desalineación en el plano coronal es una de las más frecuentes y temidas por los cirujanos. El objetivo de este estudio fue investigar la relación entre el punto de entrada del clavo y la desalineación en el plano coronal después de la cirugía. Materiales y Métodos: Se realizó un estudio retrospectivo, descriptivo, observacional, entre enero de 2015 y enero de 2019, de pacientes con fracturas diafisarias de tibia, tratadas con clavo endomedular. Se obtuvieron radiografías en el posquirúrgico inmediato y luego cada dos meses, se tuvo en cuenta la radiografía del octavo mes, en la que se observaban signos francos de consolidación ósea, para valorar la alineación tibial. Resultados:Cuando el punto de entrada del clavo fue central, hubo apenas un 0,021 de posibilidades (o 2,1%) de alguna desalineación significativa en el posquirúrgico inmediato y luego de 8 meses. En cambio, cuando fue medial, las posibilidades de una tendencia al valgo fueron >0,85 (u 85%) ya al tomar la primera imagen, i.e., poscirugía; y cuando fue lateral, esta posibilidad se modifica y profundiza según el tiempo transcurrido hasta la imagen lograda en el paciente. Conclusión: Se observó una relación marcada y continua entre el punto de entrada del clavo endomedular y la alineación de la tibia después de la consolidación ósea. Nivel de Evidencia: IV

Introduction: Tibial fractures represent approximately 2% of adult fractures. Today, intramedullary nailing is the procedure of choice to treat diaphyseal fractures of the tibia; however, this technique is not exempt from complications, misalignment in the coronal plane is one of the most frequent and feared by surgeons. The aim of this study was to investigate the relationship between nail entry point and misalignment in the coronal plane after surgery. Materials and Methods: We carried out a retrospective, descriptive, observational study between January 2015 and January 2019 of patients with diaphyseal fractures of the tibia, treated with intramedullary nailing. Radiographs were obtained in the immediate postoperative period and then every two months. The eighth-month radiograph, in which clear signs of bone consolidation could be observed, was taken into account to assess tibial alignment. Results: When the nail entry point was central, there was only a 0.021 chance (or 2.1%) of any significant misalignment in the immediate postoperative period and after 8 months. In contrast, when it was medial, the chances of a valgus tendency were >0.85 (or 85%) already at the first image, i.e., post-surgery; and when it was lateral, this possibility was modified and deepenedaccording to the time elapsed until the image achieved in the patient. Conclusion: A marked and continuous relationship wasobserved between the entry point of the intramedullary nail and the alignment of the tibia after bone consolidation..Level of Evidence: IV

Relationship of sagittal spinal alignment with low back pain and physical performance in the general population.

Studies have suggested a relationship between sagittal spinal malalignment and low back pain (LBP). The current study investigated the relationship of spinal alignment with LBP and physical performance in 1491 individuals who attended the second follow-up visit of the Wakayama Spine Study. The sagittal vertical axis at C7 (C7 SVA) was measured by a spine surgeon. The occurrence of LBP within one month, pain intensity, Oswestry Disability Index (ODI), and physical performance (grip strength, 6-m walking time, chair stand test, one-leg standing test) were also evaluated. LBP in the previous month was determined using ODI, and indicators of physical performance were measured. The mean C7 SVA was 11.0 ± 42.7 mm and was significantly greater in older participants (p < 0.001). LBP was more prevalent in participants with a greater C7 SVA (< 40 mm, 35.7%; 40-95 mm, 47.3%; ≥ 95 mm, 59.4%; p < 0.001) and those with a higher ODI score (10.0%, 17.5%, and 29.4%, respectively; p < 0.001). Physical performance significantly decreased in participants with a greater C7 SVA (p < 0.001). Multiple linear regression analysis revealed that LBP and physical performance were significantly associated with C7 SVA (p < 0.001). Thus, sagittal spinal malalignment may lead to LBP and decreased physical performance.

The Influence of Postoperative Coronal Alignment on Tibial Migration After Total Knee Arthroplasty in Preoperative Varus and Valgus Knees: A Secondary Analysis of 10 Randomized Controlled Trials Using Radiostereometric Analysis.

BACKGROUND: Orthopaedic surgeons aim for mechanical alignment when performing total knee arthroplasty (TKA) as malalignment is associated with loosening. Loosening may be predicted by migration as measured with radiostereometric analysis (RSA), but previous RSA studies on postoperative alignment have shown contradictory results and have been limited to cemented implants and small numbers of patients. Therefore, we performed a secondary analysis of 10 previously published randomized controlled trials (RCTs) to compare migration between postoperative in-range and out-of-range cemented and uncemented TKA implants among patients with a preoperative varus or valgus knee. METHODS: All RCTs involving the use of RSA that had been conducted at 2 centers were included. Alignment was classified, with use of the hip-knee-ankle angle (HKA), as in-range (0° ± 3°) or out-of-range (<-3° or >3°). The fixation methods included cemented, uncemented-coated, and uncemented-uncoated. Migration was measured at 3, 12, and 24 months. A linear mixed model was used, with adjustment for fixation method and clustering of patients within centers. RESULTS: Of 476 TKA implants that had been out-of-range preoperatively, 290 were in-range postoperatively and 186 were out-of-range in either varus (n = 143) or valgus (n = 43) postoperatively. The mean migration at 3, 12, and 24 months was 0.73 mm (95% confidence interval [CI], 0.66 to 0.79 mm), 0.92 mm (95% CI, 0.85 to 1.00 mm), and 0.97 mm (95% CI, 0.90 to 1.05 mm), respectively, for the in-range group and 0.80 mm (95% CI, 0.72 to 0.87 mm), 0.98 (95% CI, 0.90 to 1.07 mm), and 1.04 mm (95% CI, 0.95 to 1.13 mm), respectively, for the out-of-range group (p = 0.07). The fixation method significantly influenced migration, with uncemented-uncoated implants migrating more than cemented and uncemented-coated implants (p < 0.001). CONCLUSIONS: Postoperative alignment did not influence migration of TKAs in the first 2 postoperative years in patients with preoperative varus or valgus alignment of the knee. However, the fixation method significantly influenced migration, with uncemented-uncoated implants showing the greatest migration. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Spine-Pelvis-Hip Alignments in Degenerative Spinal Deformity Patients and Associated Procedure of One-Stage Long-Fusion with Multiple-Level PLIF or Apical-Vertebra Three Column Osteotomy-a Clinical and Radiographic Analysis Study.

OBJECTIVE: To explore the spine-pelvis-hip alignments in degenerative spinal deformity (DSD) patients, and compare the outcomes in the procedure of long-fusion with posterior lumbar inter-body fusion (PLIF) or single-level three-column osteotomy (STO) at lower lumbar level (LLL, L3 -S1 ) and thoracolumbar levels (TLL, T10 -L2 ) for those patients. METHODS: This is a retrospective study. Following institutional ethics approval, a total of 83 patients (Female, 67; Male, 16) with DSD underwent long-fusion with PLIF or STO surgery between March 2015 and December 2017 were reviewed. All of those patients were assigned into LLL and TLL groups. The average age at surgery was 65.2 years (SD, 8.1). Demographic (age, gender, BMI, and comorbidities), radiographs (both coronal and sagittal parameters) and health-related quality of life (HRQOL) assessments were documented. The radiographic parameters and HRQOL-related measurements at pre- and post-operation were compared with paired-samples t test, and those variables in the two groups were analyzed using an independent-sample t test. The relationships between pelvic incidence (PI) and other sagittal parameters were investigated with Pearson correlation analysis. The Pearson χ2 or Fisher's exact was carried out for comparison of gender, incidence of comorbidities and post-operative complications. RESULTS: There were 53 and 30 patients in the LLL and TLL groups respectively. Those spino-pelvic radiographic parameters had significant improvements after surgeries (P < 0.001). The patients in the two group with different pre-operative thoracolumbar kyphosis (TLK, P = 0.003), PI (P = 0.02), and mismatch of PI minus lumbar lordosis (PI-LL, P = 0.01) had comparable post-operative radiographic parameters except PI (P = 0.04) and pelvic-femur angle (PFA, P = 0.02). Comparing the changes of those spine-pelvic-hip data during surgeries, the corrections of TLK in TLL group were significant larger (P = 0.004). Pearson correlation analysis showed that there were negative relationship between PI and TLK (r = -0.302, P = 0.005), positive relationship between PI and LL (r = 0.261, P = 0.016) at pre-operation. Those patients underwent the surgical procedure that long-segment instrumentation and fusion with STO would have higher incidence of complications involving longer operative timing (P = 0.018), more blood loss (P < 0.001), revision surgery (P = 0.008), and cerebrospinal fluid leakage (P = 0.001). All the HRQOL scores significantly improved at final follow-up (P < 0.001), with no difference of intra-group. CONCLUSION: Patients suffered de-novo scoliosis or hyper-kyphosis with low PI would be vulnerable to significant thoracolumbar degeneration, and have more changes of spine-pelvis-hip data after long-fusion surgery, however, those with high PI would be closed to significant lumbar degeneration. Although spine-pelvis-hip alignments in DSD patients can be restored effectively after long-fusion with PLIF or STO, the incidence of complications in patients underwent STO was significant higher than that in patients performed multi-level PLIF.

A lifespan approach to osteoarthritis prevention.

Prevention is an attractive solution for the staggering and increasingly unmanageable burden of osteoarthritis. Despite this, the field of osteoarthritis prevention is relatively immature. To date, most of what is known about preventing osteoarthritis and risk factors for osteoarthritis is relative to the disease (underlying biology and pathophysiology) of osteoarthritis, with few studies considering risk factors for osteoarthritis illness, the force driving the personal, financial and societal burden. In this narrative review we will discuss what is known about osteoarthritis prevention, propose actionable prevention strategies related to obesity and joint injury which have emerged as important modifiable risk factors, identify where evidence is lacking, and give insight into what might be possible in terms of prevention by focussing on a lifespan approach to the illness of osteoarthritis, as opposed to a structural disease of the elderly. By targeting a non-specialist audience including scientists, clinicians, students, industry employees and others that are interested in osteoarthritis but who do not necessarily focus on osteoarthritis, the goal is to generate discourse and motivate inquiry which propel the field of osteoarthritis prevention into the mainstream.

Use of Lesser Trochanter Profile as a Rotational Alignment Guide in Intramedullary Nailing for Femoral Shaft Fracture.

BACKGROUND: Malrotation after nailing of femoral shaft fractures occurs in about 25% of cases. It can cause substantial functional problems. The lesser trochanter (LT) profile has been used to assess rotational alignment. However, the extent to which the LT profile is symmetrical between limbs, whether the LT profile varies as a function of age or sex, and the efficacy of the LT profile technique remain unknown. The purpose of this study was to determine if there was a significant side-to-side length difference in the LT profile (LTD) according to age and sex. METHODS: We attempted to determine the amount of medial prominence of the lesser trochanter relative to the medial cortex of the femoral shaft (the LT profile) using 3-dimensional computed tomography (3D-CT) images of normal femora obtained bilaterally (366 subjects) in anatomic positions. We also compared the left and right sides to determine the amount of natural asymmetry by age and sex. In addition, we compared the side-to-side difference in the LT version with the LTD to determine whether the LTD represented the difference in femoral rotation. RESULTS: The LTD was <4 mm (meaning an LT version difference of <10°) in 83% of the subjects, but was ≥4 mm (an LT version difference of ≥10°) in 17%. Subset analysis demonstrated that the differences were greatest in women >70 years of age. The largest LTD (both sexes) was observed in individuals over 70 years of age (2.62 ± 1.37 mm, compared with <55 years: 1.55 ± 1.36 mm and 55 to 70 years: 2.27 ± 1.70 mm). There was no significant difference between sexes in the under-70 age groups. However, the LTD was significantly greater in women over 70 years than in men over 70 years (3.10 ± 1.42 versus 2.41 ± 1.30 mm). CONCLUSIONS: Since the LTD demonstrated side-to-side symmetry within 4 mm, or 10° of rotation, in 83% of all subjects, we consider the LT profile to be useful as a guide to assess rotational reduction clinically. However, surgeons should recognize that, in 17% of cases, using this technique could result in malrotation of ≥10°. The rate of malrotation may be even higher in women over 70, for whom supplemental techniques to ensure correct rotation may be appropriate.

Transiency of postoperative cervical kyphosis seen after surgical correction of sagittal malalignment in adult spinal deformity patients.

OBJECTIVE: In this study, we evaluated factors affecting changes in cervical lordosis after deformity correction and during follow-up period in adult spinal deformity (ASD) patients with severe sagittal imbalance. METHODS: Seventy-nine patients, with an average age of 71.6 years, who underwent long-segment fixation from T10 to S1 with sacropelvic fixation were included. We performed a comparative analysis of the radiographic parameters after surgery (Post) and at the last follow-up (Last). We calculated the Pearson's correlation coefficient and performed multilinear regression analysis to predict independent parameters for Post and Last cervical lordosis (CL), T1 slope (T1S), and thoracic kyphosis (TK). RESULTS: Hyperlordotic changes of -23.3° in CL before surgery was reduced to -7° after surgery, and Last CL had increased to -15.3°. T1S was reduced from 27° before surgery to 14.4° after surgery and had increased to 18.8° at the last follow-up. Through multilinear regression analysis, we found that Post CL and T1S were more significantly affected by the amount of LL correction (p = .045 and .049). The effect of Last T1S was significantly associated with the Last CL; the effect of Last TK, with the Last T1S; and the effect of Post PI-LL, with the Last TK (p < .05). CONCLUSION: The postoperative kyphotic change in CL in ASD patients with preoperative cervical hyperlordosis is not permanent and is affected by drastic LL correction and SVA restoration. To achieve spinopelvic harmony proportional to the difference in LL relative to PI, TK becomes modified over time to increase T1S and CL, in an effort to achieve optimal spine curvature.

[Radiographic analysis of limb malalignment in the frontal plane]. / Radiologische Analyse von Achsfehlstellungen des Knies in der Frontalebene.

Radiographic measurement of the lower limb alignment in the frontal plane is used to assess limb deformity, to plan corrective surgery and for follow-up. It is essential that age-related normal lower limb alignment and joint orientation angles are known before planning surgical treatment. EOS (EOS™ Imaging, Paris, France) can lead to supplemental information, especially in cases of severe multidimensional joint malalignment. It allows 3D reconstruction of a bone model of the limb to assess multi-dimensional deformity.

Radiographic cortical thickness parameters as predictors of rotational alignment in proximal tibial shaft fractures: a cadaveric study.

AIM: The treatment of tibial fractures with an intramedullary nail is an established procedure. However, torsional control remains challenging using intraoperatively diagnostic tools. Radiographic tools such as the Cortical Step Sign (CSS) and the Diameter Difference Sign (DDS) may serve as tools for diagnosing a relevant malrotation. The aim of this study was to investigate the effect of torsional malalignment on CSS and DDS parameters and to construct a prognostic model to detect malalignment. METHODS: A proximal tibial shaft fracture was set in human tibiae. Torsion was set stepwise from 0° to 30° in external and internal torsion. Images were obtained with a C-arm and transferred to a PC for measuring the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD) in AP and the anterior cortical thickness (ACT) as well as the posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and the distal main fragment. RESULTS: There were significant differences between the various degrees of torsion for each of the absolute values of the examined variables. The parameters with the highest correlation were TD, LCT and ACT. A model combining ACT, LCT, PCT and TD lateral was most suitable model in identifying torsional malalignment. The best prediction of clinically relevant torsional malalignment, namely 15°, was obtained with the TD and the ACT. CONCLUSION: This study shows that the CSS and DDS are useful tools for the intraoperative detection of torsional malalignment in proximal tibial shaft fractures and should be used to prevent maltorsion.