Percutaneous dilational tracheostomy following anterior cervical spine fixation - a retrospective propensity-matched cohort study.

PURPOSE: In patients with traumatic, infectious, degenerative, and neoplastic surgical indications in the cervical spine, commonly the anterior approach is used. Often these patients require a tracheostomy necessary due to prolonged mechanical ventilation. The limited spinal mobility and proximity to the surgical site of anterior cervical spine fixation (ACSF) could pose an increased risk for complications of percutaneous dilational tracheostomy (PDT.) Importantly, PDT might raise wound infection rates of the cervical spine approach. The aim of this study is to prove safety of PDT after ACSF. METHODS: We performed a retrospective, single-center study comparing patients with and without ACSF who underwent Ciaglia-single step PDT. After propensity score matching using logistic regression, we compared intra- and postprocedural complication rates. Furthermore, surgical site infections were evaluated. Putensen's definitions of complications and Clavien-Dindo's classification were used. RESULTS: A total of 1175 patients underwent PDT between 2009 and 2021. Fifty-seven patients underwent PDT following ACSF and were matched to fifty-seven patients without ACSF. The mean interval between ACSF and PDT was 11.3 days. The overall complication rate was 19.3% in the ACSF group and 21.1% in the non-ACSF group. The mean follow-up was 388 days (± 791) in the ACSF group and 424 days (± 819) in the non-ACSF group. Life-threatening complications (Clavien-Dindo IV to V) were found in 1.8% of ACSF patients and 3.5% of non-ACSF patients. There were no significant differences in complication rates. No surgical site infection of the anterior spine access was detected. CONCLUSION: PDT is a feasible and safe procedure in patients after ACSF. Complication rates are comparable to patients without ACSF. Surgical site infections of ACSF are very rare.

Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study.

BACKGROUND: Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking. OBJECTIVES: The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients. MATERIALS AND METHODS: A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years). RESULTS: A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%). CONCLUSIONS: The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed.

A Statistical and AI Analysis of the Frequency Spectrum in the Measurement of the Center of Pressure Track in the Seated Position in Healthy Subjects and Subjects with Low Back Pain.

Measuring postural control in an upright standing position is the standard method. However, this diagnostic method has floor or ceiling effects and its implementation is only possible to a limited extent. Assessing postural control directly on the trunk in a sitting position and consideration of the results in the spectrum in conjunction with an AI-supported evaluation could represent an alternative diagnostic method quantifying neuromuscular control. In a prospective cross-sectional study, 188 subjects aged between 18 and 60 years were recruited and divided into two groups: "LowBackPain" vs. "Healthy". Subsequently, measurements of postural control in a seated position were carried out for 60 s using a modified balance board. A spectrum per trail was calculated using the measured CoP tracks in the range from 0.01 to 10 Hz. Various algorithms for data classification and prediction of these classes were tested for the parameter combination with the highest proven static influence on the parameter pain. The best results were found in a frequency spectrum of 0.001 Hz and greater than 1 Hz. After transforming the track from the time domain to the image domain for representation as power density, the influence of pain was highly significant (effect size 0.9). The link between pain and gender (p = 0.015) and pain and height (p = 0.012) also demonstrated significant results. The assessment of postural control in a seated position allows differentiation between "LowBackPain" and "Healthy" subjects. Using the AI algorithm of neural networks, the data set can be correctly differentiated into "LowBackPain" and "Healthy" with a probability of 81%.

Evaluating User Perceptions of a Vibrotactile Feedback System in Trunk Stabilization Exercises: A Feasibility Study.

Low back pain patients often have deficits in trunk stability. For this reason, many patients receive physiotherapy treatment, which represents an enormous socio-economic burden. Training at home could reduce these costs. The problem here is the lack of correction of the exercise execution. Therefore, this feasibility study investigates the applicability of a vibrotactile-controlled feedback system for trunk stabilisation exercises. A sample of 13 healthy adults performed three trunk stabilisation exercises. Exercise performance was corrected by physiotherapists using vibrotactile feedback. The NASA TLX questionnaire was used to assess the practicability of the vibrotactile feedback. The NASA TLX questionnaire shows a very low global workload 40.2 [29.3; 46.5]. The quality of feedback perception was perceived as good by the subjects, varying between 69.2% (anterior hip) and 92.3% (lower back). 80.8% rated the feedback as helpful for their training. On the expert side, the results show a high rating of movement quality. The positive evaluations of the physiotherapists and the participants on using the vibrotactile feedback system indicate that such a system can reduce the trainees fear of independent training and support the users in their training. This could increase training adherence and long-term success.

Evaluation of the ankle function after Achilles tendon resection: a retrospective clinical study.

INTRODUCTION: The Achilles tendon is the strongest tendon in the human body and has the function of plantar ankle flexion. When the tendon is exposed, the peritendineum has been breached and the thick avascular tendon colonized with bacteria, a complete resection of the tendon may be indicated to achieve infection control and facilitate wound closure. The Achilles tendon reconstruction is not mandatory, as the plantar flexion of the ankle joint is assumed by the remaining flexor hallucis longus, flexor digitorum longus and tibialis posterior muscles. Our study aimed to evaluate the impact of Achilles tendon resection without reconstruction on leg function and quality of life. MATERIAL AND METHODS: We retrospectively evaluated all patients who were treated with an Achilles tendon resection between January 2017 and June 2022 in our quaternary institution. After evaluating the data, the patients who survived and were not amputated were contacted for re-evaluation, which included isokinetic strength measurement of both ankle joints, evaluation of the ankle range of motion and collection of several functional scores. RESULTS: Thirty patients were included in the retrospective study, with a mean age of 70.3 years, including 11 women and 19 men. The most frequent cause of the infection was leg ulcer (43.3%), followed by open tendon suture (23.3%). No tendon reconstruction was performed. Fifteen patients could be gained for reevaluation. The average difference in ankle flexion torque on the injured side compared to the healthy side at 30 degrees/second was 57.49% (p = 0.003) and at 120 degrees/second was 53.13% (p = 0.050) while the difference in power was 45.77% (p = 0.025) at 30 degrees/second and 38.08% (p = 0.423) at 120 degrees/second. The follow-up time was between 4 and 49 months and a positive correlation could be determined between the time elapsed from surgery and the ankle joint strength. There was a significant loss of range of motion on the operated side compared to the healthy side: 37.30% for plantar flexion, 24.56% for dorsal extension, 27.79% for pronation and 24.99% for supination. The average Lepillhati Score was 68.33, while the average American Orthopedic Foot and Ankle Score was 74.53. CONCLUSION: The complete Achilles tendon resection leaves the patient with satisfactory leg function and an almost normal gait. Especially in elderly, multimorbid patients, straightforward tendon resection and wound closure provide fast infection control with acceptable long-term results. Further prospective studies should compare the ankle function and gait in patients with and without Achilles tendon reconstruction after complete resection.

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study.

OBJECTIVES: The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy. MATERIALS AND METHODS: Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years). RESULTS: A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92). CONCLUSIONS: The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

Injuries and Illnesses During the 53rd FIS Nordic World Ski Championships 2021 in Oberstdorf: A Prospective Cohort Study.

OBJECTIVE: For the 3 Nordic ski disciplines of cross-country skiing, Nordic combined, and ski jumping, data on injuries and illnesses during major sporting events only exist from the Winter Olympics of 2010 to 2018. So far, an investigation has not been conducted during the Nordic World Ski Championships. DESIGN: Prospective cohort study. SETTING: Fédération Internationale de Ski (FIS) Nordic World Ski Championships 2021 in Oberstdorf, Germany. PARTICIPANTS: Overall, 663 athletes from 65 nations participated in the FIS Nordic World Ski Championships 2021. The study population included 344 athletes from 32 nations. INTERVENTIONS: National medical teams were invited to report daily all newly incurred or exacerbated injuries and illnesses. MAIN OUTCOME MEASURES: All reported injuries and illnesses that occurred during the championships from February 23 until March 7, 2021, were analyzed. Injury and illness rates were calculated with 95% confidence intervals (95% CIs). RESULTS: The 32 reporting nations returned 88.4% of the daily report forms. The incidence of injuries was 4.7 (95% CI, 2.4-6.9) per 100 athletes in the 3 Nordic ski disciplines. The incidence of illness was also 4.7 (95% CI, 2.4-6.9) per 100 athletes with a relative proportion of infection-related illnesses of 31.3%. CONCLUSIONS: Although the incidence of injuries of the Nordic disciplines was comparable with those of the 2010 to 2018 Winter Olympics, the incidence of illnesses was lower than during the previous 3 Winter Olympic Games with a lower rate of infection-related illnesses. This might be caused by the high hygiene measures due to the coronavirus disease 2019 pandemic.

The Influence of Anthropometric Variables and Filtering Frequency on Center of Pressure Data.

Good postural control is considered to be a key component of an active lifestyle, and numerous studies have investigated the Center of Pressure (CoP) as a way of identifying motor deficits. However, the optimal frequency range for assessing CoP variables and the effect of filtering on the relationships between anthropometric variables and CoP are unclear. The aim of this work is to show the relationship between anthropometric variables and different ways of filtering the CoP data. CoP was measured in 221 healthy volunteers using a KISTLER force plate in four different test conditions, both mono and bipedal. The results show no significant changes in the existing correlations of the anthropometric variable values over different filter frequencies between 10 Hz and 13 Hz. Therefore, the findings with regard to anthropometric influences on CoP, with a reasonable but less than ideal filtering of the data, can be applied to other study settings.

Accelerate postoperative management after scoliosis surgery in healthy and impaired children: intravenous opioid therapy versus epidural therapy.

PURPOSE: Postoperative pain is a major concern following scoliosis surgery. CEA (continuous epidural analgesia) is established in postoperative pain therapy as well as intravenous patient-controlled analgesia (IV-PCA). The purpose of this study was to compare the clinical outcomes of both methods. METHODS: We retrospectively studied 175 children between 8 and 18 years who were subject to posterior scoliosis correction and fusion. Two main cohorts were formed: CEA with local anesthetic and opioids, and IV-PCA with opioids. Both groups further comprised two sub-cohorts: those who were mentally and/or physically healthy (H; n = 93 vs. n = 30) and those who were impaired (I; n = 26 vs. n = 26). The outcome parameters were the demand for pain medication, parameters of mobilization, and the presence of adverse reactions. RESULTS: Healthy children who received CEA started mobilization 1 day earlier than children with IV-PCA (p = 0.002). First postsurgical defecation was seen earlier in all children who received CEA in both groups (H; Day 4 vs. Day 5, p = 0.011, I; Day 3 vs. Day 5, p = 0.044). Healthy children who received CEA were discharged from hospital 4 days earlier than their IV-PCA counterparts (p < 0.001). No statistically significant difference in postoperative nausea nor in vomiting was identified between groups. Transient neurological irritations were seen in 9.7% of the patients in the CEA group. CONCLUSIONS: CEA provides appropriate pain management after scoliosis surgery, regardless of the patient's mental status. It allows earlier postoperative defecation for all patients , as well as shorter hospitalization and an earlier mobilization for healthy patients.

Feasibility of achieving planned surgical margins in primary spine tumor: a PTRON study.

OBJECTIVE: Oncological resection of primary spine tumors is associated with lower recurrence rates. However, even in the most experienced hands, the execution of a meticulously drafted plan sometimes fails. The objectives of this study were to determine how successful surgical teams are at achieving planned surgical margins and how successful surgeons are in intraoperatively assessing tumor margins. The secondary objective was to identify factors associated with successful execution of planned resection. METHODS: The Primary Tumor Research and Outcomes Network (PTRON) is a multicenter international prospective registry for the management of primary tumors of the spine. Using this registry, the authors compared 1) the planned surgical margin and 2) the intraoperative assessment of the margin by the surgeon with the postoperative assessment of the margin by the pathologist. Univariate analysis was used to assess whether factors such as histology, size, location, previous radiotherapy, and revision surgery were associated with successful execution of the planned margins. RESULTS: Three hundred patients were included. The surgical plan was successfully achieved in 224 (74.7%) patients. The surgeon correctly assessed the intraoperative margins, as reported in the final assessment by the pathologist, in 239 (79.7%) patients. On univariate analysis, no factor had a statistically significant influence on successful achievement of planned margins. CONCLUSIONS: In high-volume cancer centers around the world, planned surgical margins can be achieved in approximately 75% of cases. The morbidity of the proposed intervention must be balanced with the expected success rate in order to optimize patient management and surgical decision-making.

[Diagnostics and treatment of cervical spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Halswirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Severe cervical spine injuries in children under the age of 17 years are rare. Recommendations or even guidelines for the diagnostics and treatment of such injuries in children are currently not available. OBJECTIVE: The aim of the study was to formulate recommendations for diagnostics and treatment of injuries of the cervical spine in pediatric patients. MATERIAL AND METHODS: First, a search of primary and secondary literature on the topic complex of diagnostics and treatment of cervical spine injuries in children was carried out. An appropriate internal literature database was defined and maintained. Second, within the framework of 9 meetings from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) systematically formulated recommendations for the diagnostics and treatment of injuries of the cervical spine in pediatric patients by a consensus process. RESULTS: Recommendation for the diagnostics and treatment for injuries of the cervical spine could be formulated for three age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). The diagnostic and therapeutic principles known from adult patients suffering from injuries to the cervical spine cannot be easily transferred to pediatric patients. CONCLUSION: Injuries to the pediatric spine are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. Classification systems and therapeutic recommendations for injuries to the cervical spine known from adult patients could also be used for adolescent patients. This is not possible for children under the age of 10 years. Only few classification systems exist for this age group. Basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical relationships as well as the protection of all neural structures.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist. OBJECTIVE: The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients. MATERIAL AND METHODS: Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process. RESULTS: Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients. CONCLUSION: Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

[Pediatric spine trauma-Results of a German national multicenter study including 367 patients]. / Wirbelsäulenverletzungen im Kindesalter ­ Ergebnisse einer nationalen Multizenterstudie mit 367 Patienten.

BACKGROUND: In general, pediatric spinal injuries are rare. No reliable data on the epidemiology of spinal injuries in pediatric patients in Germany are available. Especially in pediatric patients, for whom the medical history, clinical examination and the performance of imaging diagnostics are difficult to obtain, all available information on a spinal injury must be taken into account. OBJECTIVE: The aim of this study was to provide epidemiological data for pediatric patients with spinal trauma in Germany in order to enhance future decision-making for the diagnostics and treatment of these patients. MATERIAL AND METHODS: Within the framework of a national multicenter study, data were retrospectively obtained from 6 German spine centers for 7 years between January 2010 and December 2016. In addition to the demographic data, the clinical databases were screened for specific trauma mechanisms, level of injury as well as accompanying injuries. Furthermore, diagnostic imaging and the treatment selected were also analyzed. RESULTS: A total of 367 children (female: male = 1:1.2) with a total of 610 spinal injuries were included in this study. The mean age was 12 years (±3.5 years). The most frequent trauma mechanisms were falls from <3 m and traffic accidents. The imaging diagnostics were only rarely carried out with the child under anesthesia. Younger children (0-9 years old) suffered more injuries to the cervical spine, whereas injuries to the thoracic and lumbar spine were more frequently found in older children (>10 years old). The children frequently showed accompanying injuries to the head and the extremities. Accompanying spinal injuries mostly occurred in adjacent regions and only rarely in other regions. Around 75% of the children were treated conservatively. CONCLUSION: The results were different from the knowledge obtained from adult patients with spinal trauma and describe the special circumstances for pediatric patients with spinal trauma. Despite certain limitations these facts may help to enhance future decision-making for the diagnostics and treatment of these patients.

Quantitative in vivo fusion assessment by (18)F-fluoride PET/CT following en bloc spondylectomy.

PURPOSE: The purpose of this retrospective analyses was to evaluate the bone viability in the ventral column of the spine following large segmental defect reconstructions. Osseous integration of implants following spinal fusion procedures is an essential precondition to provide adequate mechanical strength to any applied forces and subsequently satisfying patient outcomes. Although CT scan is the non-invasive gold standard for fusion assessment, it lacks the ability to visualize bone viability and, therefore, discrepancy remains about sensitivity and specificity of CT as evaluation tool of spinal fusion. METHODS: A novel modality, (18)F Fluoride PET/CT, specifically allows quantitative in vivo evaluation of metabolic activity of the osseous integration. Bone viability following large segmental reconstructions in patients after mono- and multi-level en bloc spondylectomies (EBS) was analyzed. Spinal fusion was assessed on plain radiographs and CT scans according to the FDA fusion criteria as well as (18)F PET/CT. RESULTS: A total of eight patients underwent (18)F PET/CT were included (one 4-level-, one 3-level, two 2-level and four 1-level EBS). The average follow-up between EBS and radiographic studies was 24.8 months. On plain radiographs and CT scans, successful fusion was confirmed in all patients. However, (18)F PET/CT showed non-union in all cases. The metabolic bone activity within the cage was fourfold decreased compared to the reference vertebra, whereas the metabolic activity of the adjacent endplates was 1.6-fold increased compared to the reference vertebra. CONCLUSION: This study suggests a discrepancy between fusion rates assessed by plain radiographs and CT scan compared to (18)F PET/CT.

Transposition of the vertebral artery after a unilateral c1 lateral mass fracture: a case report and review of the literature.

In any cervical spine trauma involving dislocation of the facet joints or transverse foramen, a concomitant injury of the vertebral arteries must be excluded. Early diagnosis of an arterial occlusion is important because therapeutic intervention can prevent further complications, such as irreversible vertebrobasilar ischemia. Conservative and surgical treatment strategies are chosen depending on patient symptoms, fracture morphology, and grade of vascular injury. The benefit of anticoagulant medication after blunt injuries of the vertebral arteries in preventing thromboembolic events remains a matter of debate in the current literature. We present a case report of a professional biathlete with a unilateral vertebral artery injury. Adequate interpretation of both initial clinical and radiological findings is essential to detect this injury and to determine appropriate therapeutic intervention to optimize clinical outcome.

Long-term functional outcome and quality of life after successful surgical treatment of tibial nonunions.

PURPOSE: Our aim was to evaluate quality of life (QoL) and functional outcome of patients with tibial nonunions after completion of surgical treatment with an average follow-up of five years. METHODS: The following data of 64 patients were retrospectively evaluated: fracture type, type and duration of surgical therapy, range of motion of the knee and ankle and American Orthopaedic Foot and Ankle Society (AOFAS) score. QoL was evaluated with the Short-Form Health Survey (SF-36) questionnaire; pain intensity, patient satisfaction and impairments of daily, professional and sport activities with a ten point visual analogue scale. RESULTS: QoL, even in cases with successfully completed treatment, was significantly reduced compared with the normal general population. Pain intensity and limited ankle dorsal extension, despite the absence of intra-articular fractures, were significantly correlated with inferior QoL. CONCLUSIONS: This study emphasises the long-term negative impact of tibial nonunions on patient QoL, even after successful surgical treatment.

Measurement of the number of lumbar spinal movements in the sagittal plane in a 24-hour period.

PURPOSE: Little is known about the number of spinal movements in the sagittal plane in daily life, mainly due to the lack of adequate techniques to assess these movements. Our aim was to measure these movements in asymptomatic volunteers. METHODS: Two sensor strips based on strain gauge technology (Epionics SPINE system) were fixed on the skin surface of the back parallel to the spine on a total of 208 volunteers without back pain. First, the lordosis angle was determined during relaxed standing. The volunteers were then released to daily life. The increases and decreases in the back lumbar lordosis angle over a period of 24 h were determined and classified into 5° increments. Changes in the lordosis angle greater than 5° were considered. RESULTS: The median number of spinal movements performed within 24 h was approximately 4,400. Of these movements, 66 % were between 5° and 10°. The proportions of higher-magnitude lordosis angle changes were much lower (e.g., 3 % for the 20-25° movement bin). Surprisingly, the median total number of movements was significantly higher (29 %) in women than in men. Large inter-individual differences were observed in the number of movements performed. The volunteers spent a median of 4.9 h with the lumbar spine flexed between 20° and 30° and only 24 min with the spine extended relative to the reference standing position. A median of 50 movements reached or exceeded full-flexion angle and zero movements full-extension angle. CONCLUSIONS: These data illustrate the predominantly small range of movement of the spine during daily activities and the small amount of time spent in extension. These unique data strongly contribute to the understanding of patients' everyday behavior, which might affect the development and testing of spinal implants and the evaluation of surgical and nonsurgical treatments.

Co-delivery of rhBMP-2 and zoledronic acid using calcium sulfate/hydroxyapatite carrier as a bioactive bone substitute to enhance and accelerate spinal fusion.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been FDA-approved for lumbar fusion, but supraphysiologic initial burst release due to suboptimal carrier and late excess bone resorption caused by osteoclast activation have limited its clinical usage. One strategy to mitigate the pro-osteoclast side effect of rhBMP-2 is to give systemic bisphosphonates, but it presents challenges with systemic side effects and low local bioavailability. The aim of this in vivo study was to analyze if posterolateral spinal fusion (PLF) could be improved by utilizing a calcium sulfate/hydroxyapatite (CaS/HA) carrier co-delivering rhBMP-2 and zoledronic acid (ZA). Six groups were allocated (CaS/HA, CaS/HA + BMP-2, CaS/HA + systemic ZA, CaS/HA + local ZA, CaS/HA + BMP-2 + systemic ZA, and CaS/HA + BMP-2 + local ZA). 10-week-old male Wistar rats, were randomly assigned to undergo L4-L5 PLF with implantation of group-dependent scaffolds. At 3 and 6 weeks, the animals were euthanized for radiography, µCT, histological staining, or biomechanical testing to evaluate spinal fusion. The results demonstrated that the CaS/HA biomaterial alone or in combination with local or systemic ZA didn't support PLF. However, the delivery of rhBMP-2 significantly promoted PLF. Combining systemic ZA with BMP-2 didn't enhance spinal fusion. Notably, the co-delivery of rhBMP-2 and ZA using the CaS/HA carrier significantly enhanced and accelerated PLF, without inhibiting systemic bone turnover, and potentially reduced the dose of rhBMP-2. Together, the treatment regimen of CaS/HA biomaterial co-delivering rhBMP-2 and ZA could potentially be a safe and cost-effective off-the-shelf bioactive bone substitute to enhance spinal fusion.

Surgical and Oncologic Outcome following Sacrectomy for Primary Malignant Bone Tumors and Locally Recurrent Rectal Cancer.

INTRODUCTION: Bone sarcoma or direct pelvic carcinoma invasion of the sacrum represent indications for partial or total sacrectomy. The aim was to describe the oncosurgical management and complication profile and to analyze our own outcome results following sacrectomy. METHODS: In a retrospective analysis, 27 patients (n = 8/10/9 sarcoma/chordoma/locally recurrent rectal cancer (LRRC)) were included. There was total sacrectomy in 9 (incl. combined L5 en bloc spondylectomy in 2), partial in 10 and hemisacrectomy in 8 patients. In 12 patients, resection was navigation-assisted. For reconstruction, an omentoplasty, VRAM-flap or spinopelvic fixation was performed in 20, 10 and 13 patients, respectively. RESULTS: With a median follow-up (FU) of 15 months, the FU rate was 93%. R0-resection was seen in 81.5% (no significant difference using navigation), and 81.5% of patients suffered from one or more minor-to-moderate complications (especially wound-healing disorders/infection). The median overall survival was 70 months. Local recurrence occurred in 20%, while 44% developed metastases and five patients died of disease. CONCLUSIONS: Resection of sacral tumors is challenging and associated with a high complication profile. Interdisciplinary cooperation with visceral/vascular and plastic surgery is essential. In chordoma patients, systemic tumor control is favorable compared to LRRC and sarcomas. Navigation offers gain in intraoperative orientation, even if there currently seems to be no oncological benefit. Complete surgical resection offers long-term survival to patients undergoing sacrectomy for a variety of complex diseases.

Impact of customized add-on nighttime bracing in full-time brace treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Bracing is an accepted standard therapy for idiopathic scoliosis at Cobb angle ranges between 25° and 40°. However, it is unclear, if a specifically tailored regimen of daytime and nighttime braces (= double brace) yields superior results compared to the standard treatment (single brace for day and night). METHODS: One-hundred-fifteen patients with adolescent idiopathic scoliosis (AIS) were assessed before initiation of bracing treatment and at the final follow-up 2 years after deposition of the brace. They were divided into two groups: double-brace group (n = 66, 4 male, 62 female, age 13.1 ± 1.9 (mean ± SD), primary curvature thoracic n = 35, lumbar n = 31) and single-brace group (n = 49, 8 male, 41 female, age 14.1 ± 1.9, primary curvature thoracic n = 18, lumbar n = 31). Each patient underwent clinical and radiological examinations and Cobb angles were measured. RESULTS: Both therapy regimens succeeded to either stop progression or improve scoliosis in over 85% of cases. The nighttime brace showed a significantly higher primary correction than the daytime brace. Nevertheless, there was no significant difference in treatment success in the 2-year follow-up (p = 0.58). CONCLUSION: It seems to be sufficient to treat idiopathic scoliosis with one well-tailored brace for day- and nighttime.