Incidence and clinical results of tendinous injuries in calcaneus and pilon fractures.

PURPOSE: The aims of this study were: (1) to define the incidence of tendinous injuries in calcaneus and pilon fractures with different fracture severity and (2) to determine the clinical impact of such injuries. STUDY DESIGN AND METHODS: CT-scans of 121 patients with calcaneus and pilon fractures were retrospectively analyzed over a 4-year period. The tendinous injuries were identified and correlated with the type of fracture (location and classification). Clinical analysis was performed using the American Orthopedic Foot and Ankle Society (AOFAS) and SF-36 (Short Form-36 Health Survey) scores. RESULTS: Tendinous injuries were observed in 36% of all CT-scans analyzed, with the most common injury being incarceration (n = 20) and dislocation (n = 24). Calcaneus fractures sanders type 3/4 were 9 times more prone to tendon injury (p < 0.001; OR 8.67; 95% CI 2.49-30.24). Pilon fractures Ruedi-Allgower type 2/3 were 8 times more prone to tendon injury (p = 0.005; OR 7.5; 95% CI 1.72-32.80). No significant differences (p > 0.05) were found in AOFAS and SF-36 scores between patients with/without tendon injuries for fractures with the same severity. CONCLUSION: The incidence of tendon injuries in calcaneus/pilon fractures is high and may be underreported. Calcaneus fractures are prone to peroneal tendon injury. In pilon fractures, it is important to look for tibialis posterior tendon injury, especially entrapment. The presence of tendinous injuries does not affect function and pain for the same type of calcaneus and pilon fractures at the long term. LEVEL OF EVIDENCE: Level 3 retrospective study.

Is preoperative fat infiltration in lumbar spine muscles associated with worse clinical outcomes after lumbar interbody fusion?

PURPOSE: Lumbar musculature has a fundamental role in spine stability and spinal balance. Muscle atrophy and fat infiltration play an important role in pain pathophysiology. Accordingly, the preoperative condition of lumbar muscles may influence clinical outcomes after surgical treatment. In this context, the aim of this study was to evaluate the association between preoperative lumbar paravertebral muscle fat infiltration and clinical outcomes after lumbar interbody fusion. METHODS: A retrospective study of patients with lumbar pathology submitted to lumbar transforaminal (TLIF) or posterior interbody fusion (PLIF) was performed, with a minimum of two years of follow-up. Preoperative lumbar magnetic resonance imaging (MRI) images were classified for fat infiltration in lumbar multifidus muscle and correlated with clinical outcomes. RESULTS: Seventy-five patients were included: 24 submitted to PLIF and 51 to TLIF. Most patients underwent surgery for spondylolisthesis (67%). Higher degrees of fat infiltration were associated with more advanced age (54.8 vs. 49.1 years old, p = 0.04) and more leg pain after surgery (p = 0.04). No statistically significant differences in other clinical outcomes such as Oswestry Disability Index, visual analogue scale for back and leg pain, self-reported back pain relief, return to work and overall satisfaction were found between different groups of fat infiltration. The improvement in leg pain was associated with improvement in self-reported lumbar pain (p < 0.001). CONCLUSION: Age and preoperative degree of fat infiltration may be important to predict improvement in leg pain after lumbar interbody fusion. The absence of solid literature on this topic and universal assessment methodologies reinforce the need for further studies.

Lumbosacral transitional vertebrae: prevalence in a southern European population and its association with low back pain.

PURPOSE: Lumbosacral transitional vertebra (LSTV) is a congenital anomaly of the lumbosacral junction. Its prevalence is variable in the literature such as its association with low back pain. The aim of this study was to identify the prevalence of LSTV in a southern European population, and its correlation with low back pain. METHODS: A retrospective review of 639 thoraco-abdomino-pelvic consecutive CT-scans between January 2019 and November 2020 was performed. The presence of LSTV was classified into type II, III, IV based on Castellvi's classification. To investigate the association with low back pain, Oswestry Low Back Disability Questionnaire (ODI) and the EuroQol-5D-3L questionnaire was applied. RESULTS: The prevalence of LSTV was 24.9% (142 of 571). 37,3% were type IIb, 31,0% were type IIa, 13,4% were type IIIa, 9.9% were type IIIb and 8.5% were type IV. Individuals with LSTV were more likely to report low back pain and have a higher ODI score (OR:0.392, 95% CI:0.192-0.802, p = 0.010), (OR: 1050, 95% CI: 1029-1072, p < 0.01). Castellvi's type IV showed a significantly higher ODI when compared to type II (OR:1059, 95% CI:1019-1100, p = 0,04). There was no statistical difference in the EuroQol-5D-3L score between two groups (OR:1085, 95% CI: 0.459-2.560, p = 0.852). CONCLUSION: This population-based study adds to the literature the prevalence of LSTV in a southern European population. LSTV was associated with low back pain. However, this difference did not translate into a loss of quality life. Type IV was associated with higher functional disability when compared with type II.

Risk factors for cage subsidence and clinical outcomes after transforaminal and posterior lumbar interbody fusion.

BACKGROUND: Cage subsidence is a very common complication after lumbar interbody fusion. It may compromise vertebral interbody fusion through progressive spinal deformity and consequently cause compression of neural elements. Clinical relevance remains, however, unclear, with few studies on this subject and even less information regarding its correlation with clinical findings. The aim of this study was to identify risk factors for cage subsidence and clinical evaluation after transforaminal (TLIF) and posterior (PLIF) lumbar interbody fusion. METHODS: A retrospective study in patients submitted to TLIF and PLIF between 2008 and 2017 was conducted. RESULTS: A total of 165 patients were included (123 TLIF and 42 PLIF). Univariate analysis showed an increased risk of cage subsidence in spondylolisthesis comparing with degenerative disk disease (p = 0.007). A higher preoperative lumbar lordosis angle (p = 0.014) and cage placement in L2-L3 (p = 0.012) were associated with higher risk of subsidence. The posterior cage positioning on vertebral endplate was associated with a higher risk of subsidence (p = 0.028) and significant subsidence (p = 0.005), defined as cage migration > 50% of cage height. PLIF presented a higher risk when comparing with TLIF (p = 0.024). Hounsfield unit (HU) values < 135 (OR6; 95% CI [1.95-34]) and posterior positioning (OR7; 95% CI [1.7-27.3]) were independent risk factors for cage subsidence and significant subsidence, respectively, in multivariate analysis. There was a tendency for significant subsidence in degrees ≥ 2 of Meyerding spondylolisthesis (OR4; 95% CI [0.85-21.5]). Significant cage subsidence was not associated with worse clinical results. Other analyzed factors, such as age (p = 0.008), low bone mineral density (BMD) (p = 0.029) and type of surgery (TLIF) (p = 0.004), were associated with worse results. CONCLUSION: The present study shows that lower BMD and posterior cage positioning are relevant risk factors for lumbar cage subsidence. Low BMD is also a predictor of poor clinical results, so it must be properly evaluated and considered, through HU values measurement in CT scan, a feasible and reliable tool in perioperative planning.

Can Denosumab cure giant cell tumors of the spine? A case report and literature review.

BACKGROUND: Bone giant cell tumors, although benign, may be locally aggressive and cause severe morbidity; in some cases, they can also disseminate at distance and cause death. Denosumab has been approved to treat unresectable bone giant cell tumors or when surgery is likely to result in severe morbidity. Furthermore, its curative potential has been recently suggested. CASE: An 18-year-old girl presented with a spinal giant cell tumor at T9. Neo-adjuvant denosumab was administered for 9 months with great clinical and analytical tolerance. A posterior left T9 costo-transversectomy and vertebral body curettage was performed and the spine stabilized. Interestingly, histopathology examination of the surgical specimens found no evidence of tumoral cells. Denosumab was reinstated until completion of 12 months of treatment. CONCLUSION: Denosumab has an important but still limited role in the treatment of spinal giant cell tumors. Here, it resulted in complete histological resolution of the tumor, potentially widening its applicability from a strictly neo-adjuvant to a curative role.

Septic arthritis of the lumbar facet joint presenting as spontaneous bacterial peritonitis: a rare case requiring surgical intervention.

PURPOSE: To report and discuss a rare case of septic arthritis of a lumbar facet joint presenting as septic bacterial peritonitis and requiring surgical debridement. METHODS: A 55-year-old man, with a history of intravenous drug usage and hepatitis C, presented to the emergency department with fever, abdominal and lumbar pain. Examination showed ascites. Erythrocyte sedimentation rate and C-reactive protein were elevated. A paracentesis was performed, and a diagnosis of spontaneous bacterial peritonitis was assumed as acute on chronic liver failure. The patient was admitted for antibiotic treatment with cefotaxime. Staphylococcus aureus was isolated in blood cultures. Despite directed treatment, there were persistent fever, back pain and continuous elevation of serum inflammatory markers. An MRI of the lumbar spine was performed 14 days after presentation and identified septic arthritis of the left L4-L5 facet joint. In the absence of a response to the medical treatment, surgical debridement of the facet joint was performed. After surgery, back pain resolved and inflammatory markers started to decline. One year after surgery, the patient is asymptomatic and has normalization of the inflammatory markers of infection. Follow-up MRI shows complete resolution of the infection. CONCLUSIONS: Septic arthritis of the lumbar facet joints is a rare condition with no more than 50 cases reported in the literature. This infection, which can cause significant morbidity, can result from local or systemic inoculation. MRI is the diagnostic method of choice. While antibiotic therapy is the first line of treatment, when it fails, surgical debridement may be necessary.

Comparison of fine needle aspiration and core needle biopsy in the diagnosis of bone tumours.

Much literature exists regarding the diagnostic yield and accuracy of core needle biopsy (CNB) and fine needle aspiration (FNA) but none compares both in the same tumour. Ninety-four patients were prospectively studied using a FNA and CNB. With FNA 70 diagnoses were possible (74,5%). Accurate diagnosis rate was 97,1%. In 92 patients (97,9%) a diagnosis was obtained with CNB and 91 (98,9%) were accurate.. The diagnostic yield was 74,5% for FNA and 97,9% for CNB (p < 0.0001). The diagnostic accuracy was 97,1% for FNA and 98,9% for CNB (p = 0.5787). Regarding determining malignancy FNA and CNB had 98,3% and 98,5% sensibility, 100% and 100% specificity, 100% and 100% positive predictive value and 95,2% and 96,2% negative predictive value, respectively. In conclusion FNA is as accurate as CNB on all accounts. Despite the reliability of FNA, the number of inconclusive cases makes it an inferior technique when compared with CNB.

Posterior Arthroscopic Subtalar Arthrodesis: Clinical and Radiologic Review of 19 Cases.

Arthroscopic subtalar arthrodesis has recently gained popularity in the treatment of primary subtalar or post-traumatic arthritis, coalition, or inflammatory diseases with subtalar arthritis. The present study reports the clinical and radiologic results of 19 patients (19 feet) who underwent posterior arthroscopic subtalar arthrodesis using 2 posterior portals. A total of 19 posterior arthroscopic subtalar arthrodeses (minimum follow-up of 24 months) performed without a bone graft and with 2 parallel screws were prospectively evaluated. The fusion rate was 94% (mean time to fusion 9.8 weeks). Modified American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score (maximum 94 points) improved significantly from 43 to 80 points and the visual analog scale for pain score improved from 7.6 to 1.2. The 12-item short-form physical and mental scores at the last follow-up point were 52.5 and 56.4, respectively. One (5.3%) patient underwent open repeat fusion for nonunion, 2 (10.5%) patients required a second procedure for implant removal, and 1 (5.3%) experienced reversible neuropraxia. In conclusion, posterior arthroscopic subtalar arthrodesis is a safe technique with a good union rate and a small number of complications in patients with no or very little hindfoot deformity.

EGR1 controls divergent cellular responses of distinctive nucleus pulposus cell types.

BACKGROUND: Immediate early genes (IEGs) encode transcription factors which serve as first line response modules to altered conditions and mediate appropriate cell responses. The immediate early response gene EGR1 is involved in physiological adaptation of numerous different cell types. We have previously shown a role for EGR1 in controlling processes supporting chondrogenic differentiation. We recently established a unique set of phenotypically distinct cell lines from the human nucleus pulposus (NP). Extensive characterization showed that these NP cellular subtypes represented progenitor-like cell types and more functionally mature cells. METHODS: To further understanding of cellular heterogeneity in the NP, we analyzed the response of these cell subtypes to anabolic and catabolic factors. Here, we test the hypothesis that physiological responses of distinct NP cell types are mediated by EGR1 and reflect specification of cell function using an RNA interference-based experimental approach. RESULTS: We show that distinct NP cell types rapidly induce EGR1 exposure to either growth factors or inflammatory cytokines. In addition, we show that mRNA profiles induced in response to anabolic or catabolic conditions are cell type specific: the more mature NP cell type produced a strong and more specialized transcriptional response to IL-1ß than the NP progenitor cells and aspects of this response were controlled by EGR1. CONCLUSIONS: Our current findings provide important substantiation of differential functionality among NP cellular subtypes. Additionally, the data shows that early transcriptional programming initiated by EGR1 is essentially restrained by the cells' epigenome as it was determined during development and differentiation. These studies begin to define functional distinctions among cells of the NP and will ultimately contribute to defining functional phenotypes within the adult intervertebral disc.

Anatomical relations of anterior and posterior ankle arthroscopy portals: a cadaveric study.

BACKGROUND: Ankle arthroscopy is an increasingly used technique. Knowledge of the anatomical structures in relation to its portals is paramount to avoid complications. METHODS: Twenty cadaveric ankles were analysed to assess the distance between relevant neurovascular structures to the anteromedial, anterolateral, posteromedial, and posterolateral arthroscopy portals. RESULTS: The intermediate dorsal branch of the superficial peroneal nerve was the closest structure to any of the portals (4.8 mm from the anterolateral portal), followed by the posterior tibial nerve (7.3 mm from the posteromedial portal). All structures analysed but one (posterior tibial artery) were, at least in one specimen, <5 mm distant from one of the portals. DISCUSSION: This study provides information on the anatomical relations of ankle arthroscopy portals and relevant neurovascular structures, confirming previous studies identifying the superficial peroneal nerve as the structure at highest risk of injury, but also highlighting some important variations. Techniques to minimise the injury to these structures are discussed.

An understanding of intervertebral disc development, maturation and cell phenotype provides clues to direct cell-based tissue regeneration therapies for disc degeneration.

Cell-based regenerative medicine therapies have been proposed for repairing the degenerated intervertebral disc (a major cause of back pain). However, for this approach to be successful, it is essential to characterise the phenotype of its native cells to guarantee that implanted cells differentiate and maintain the correct phenotype to ensure appropriate cell and tissue function. While recent studies have increased our knowledge of the human nucleus pulposus (NP) cell phenotype, their ontogeny is still unclear. The expression of notochordal markers by a subpopulation of adult NP cells suggests that, contrary to previous reports, notochord-derived cells are retained in the adult NP, possibly coexisting with a second population of cells originating from the annulus fibrosus or endplate. It is not known, however, how these two cell populations interact and their specific role(s) in disc homeostasis and disease. In particular, notochordal cells are proposed to display both anabolic and protective roles; therefore, they may be the ideal cells to repair the degenerate disc. Thus, understanding the ontogeny of the adult NP cells is paramount, as it will inform the medical and scientific communities as to the ideal phenotype to implant into the degenerate disc and the specific pathways involved in stem cell differentiation towards such a phenotype.

Analysis of Complications in Multilevel Anterior Cervical Discectomy and Fusion Using Osteobiologics Other than Bone Morphogenetic Protein: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: The aim of this study is to analyze the complications related to multilevel anterior cervical discectomy and fusion (ACDF) using osteobiologics other than bone morphogenetic protein (BMP). METHODS: A systematic review of the literature was conducted using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases. The search to identify studies reporting complications in multilevel ACDF surgery using osteobiologics other than bone morphogenetic protein was performed in August 2020. The study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). RESULTS: A total of 584 articles were found after searching the databases and removing duplicates. Next, screening was performed in a double reviewer process, and 153 eligible articles-with 4 retrospective studies-in full-text were selected; these met all inclusion criteria. A total of 197 patients received 3-level ACDF, while 72 patients received 4-level ACDF. Osteobiologics were used in all selected articles, allograft was used in 4 studies, autologous bone graft was utilized in 3 articles, and hydroxyapatite was used in 1 article. The main complications reported were dysphagia, adjacent segment disease, and pseudarthrosis. CONCLUSIONS: Given the limited evidence, no conclusions on complications in multilevel ACDF using osteobiologics other than BMP could be made. However, descriptively, the most common complications found were dysphagia, adjacent segment disease, and pseudoarthrosis. Further prospective studies separately analyzing complications in multilevel ACDF by osteobiologics and a number of treated levels are needed.

Complications of the Use Allograft in 1- or 2-Level Anterior Cervical Discectomy and Fusion: A Systematic Review.

Study Design: Systematic literature reviewObjective: To critically analyze the literature and describe the complications associated with the use of allograft in 1- or 2- level anterior cervical discectomy and fusion (ACDF)Methods: A systematic search of PubMed/MEDLINE, EMBASE, and ClinicalTrials.gov databases was conducted for literature published between January 2000 and August 2020 reporting complications associated with the use of allograft in 1- or 2- level ACDF.Results: From 584 potentially relevant citations, 21 met the inclusion criteria (4 randomized controlled trials (RCT), 4 prospective, and 13 retrospective studies). The patient number varied between 26 and 463 in comparative studies (RCT and non-RCT) and between 29 and 345 in non-comparative studies. Fusion rate was reported in 14 studies and ranged between 68.5-100%. The most frequently reported complication was post-operative dysphagia or dysphonia, with incidences ranging between .5% and 14.4%. Revision surgery was the second most reported complication (14 studies) and ranged between 0% and 10.3%. Wound-related complications were reported in 6 studies and ranged between 0% and 22.8%.Conclusion: The overall reporting of complications was low with very few comparative studies. Reported complications with allografts are within the range of other osteobiologics and autografts and in most cases may not attributable to the use of osteobiologics and may be complications of the procedure itself. Comparative studies with a more robust methodology analyzing complications with allograft and other osteobiologics are needed to inform current practice with strong recommendations.

Comparison of Different Osteobiologics in Terms of Imaging Modalities and Time Frames for Fusion Assessment in Anterior Cervical Discectomy and Fusion: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: The study's primary objective was to determine how osteobiologic choice affects fusion rates in patients undergoing anterior cervical discectomy and fusion (ACDF). The study's secondary objectives were to 1) determine the optimal timing of fusion assessment following ACDF and 2) determine if osteobiologic type affects the timing and optimal modality of fusion assessment. METHODS: A systematic search of PubMed/MEDLINE was conducted for literature published from 2000 through October 2020 comparing anterior fusion in the cervical spine with various osteobiologics. Both comparative studies and case series of ≥10 patients were included. RESULTS: A total of 74 studies met the inclusion criteria. Seventeen studies evaluated the efficacy of autograft on fusion outcomes, and 23 studies assessed the efficacy of allograft on fusion outcomes. 3 studies evaluated the efficacy of demineralized bone matrix, and seven assessed the efficacy of rhBMP-2 on fusion outcomes. Other limited studies evaluated the efficacy of ceramics and bioactive glasses on fusion outcomes, and 4 assessed the efficacy of stem cell products. Most studies utilized dynamic radiographs for the assessment of fusion. Overall, there was a general lack of supportive data to determine the optimal timing of fusion assessment meaningfully or if osteobiologic type influenced fusion timing. CONCLUSIONS: Achieving fusion following ACDF appears to remain an intricate interplay between host biology and various surgical factors, including the selection of osteobiologics. While alternative osteobiologics to autograft exist and may produce acceptable fusion rates, limitations in study methodology prevent any definitive conclusions from existing literature.

Do the Choice of Fusion Construct With and Without Autograft Influence the Fusion and Complication Rates in Patients Undergoing 1 or 2-Level Anterior Cervical Discectomy and Fusion Surgery? A PRISMA-Compliant Network Meta-Analysis.

STUDY DESIGN: Network meta-analysis. OBJECTIVES: To compare the fusion outcome and complications of different 1 or 2-level anterior cervical decompression and fusion (ACDF) constructs performed with and without the application of autografts. METHODS: We performed an independent and duplicate search in electronic databases including PubMed, Embase, Web of Science, Cochrane, and Scopus for relevant articles published between 2000 and 2020. We included comparative studies reporting fusion rate and complications with and without the use of autografts in ACDF across 5 different fusion constructs. A network meta-analysis was performed in Stata, categorized based on the type of fusion constructs utilized. Fusion constructs were ranked based on p-score approach and surface under cumulative ranking curve (SUCRA) scores. The confidence of results from the analysis was appraised with Cochrane's CINeMA approach. RESULTS: A total of 2216 patients from 22-studies including 6 Randomized Controlled Trials (RCTs) and 16 non-RCTs were included in network analysis. The mean age of included patients was 49.3 (±3.62) years. Based on our meta-analysis, we could conclude that use of autograft in 1- or 2-level ACDF did not affect the fusion and mechanical implant-related complications. The final fusion and mechanical complication rates were also not significantly different across the different fusion constructs. The use of plated constructs was associated with a significant increase in post-ACDF dysphagia rates [OR 3.42; 95%CI (.01,2.45)], as compared to stand-alone constructs analysed. CONCLUSION: The choice of fusion constructs and use of autografts does not significantly affect the fusion and overall complication rates following 1 or 2-level ACDF surgery.

What Is the Evidence Supporting Osteobiologic Use in Revision Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: Systematic literature review. OBJECTIVE: To analyze the literature and describe the evidence supporting osteobiologic use in revision anterior cervical discectomy and fusion (ACDF) surgery. METHODS: A systematic search of PubMed/MEDLINE, EMBASE, Cochrane library, and ClinicalTrials.gov databases was conducted for literature reporting the use of osteobiologics in revision ACDF. We searched for studies reporting outcomes of using any osteobiologic use in revision ACDF surgeries (independently of the number of levels) in the above databases. RESULTS: There are currently no studies in the literature describing the outcome and comparative efficacy of diverse osteobiologic agents in the context of revision ACDF surgery. A majority of the current evidence is based only upon studies involving primary ACDF surgery. CONCLUSION: The current study highlights the paucity of literature evidence on the role of diverse osteobiologics in revision ACDF, and foregrounds the need for high-quality evidence on this subject.

Complications With Demineralized Bone Matrix, Hydroxyapatite and Beta-Tricalcium Phosphate in Single and Two-Level Anterior Cervical Discectomy and Fusion Surgery.

STUDY DESIGN: Systematic literature review. OBJECTIVES: To analyze the evidence available reporting complications in single or two-level anterior cervical discectomy and fusion (ACDF) using a demineralized bone matrix (DBM), hydroxyapatite (HA), or beta-tricalcium phosphate (ß-TCP). METHODS: A systematic review of the literature using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases was performed in August 2020 to identify studies reporting complications in one or two-level ACDF surgery using DBM, HA, or ß-TCP. The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. RESULTS: A total of 1857 patients were included, 981 male and 876 female, across 17 articles; 5 prospective, and 12 retrospectives. We noted heterogeneity among the included studies concerning the study design and combination of graft materials utilized in them. However, we noted a higher incidence of adjacent segment disease (17.7%) and pseudoarthrosis (9.3%) in fusion constructs using DBM. Studies using ß-TCP reported a higher incidence of pseudoarthrosis (28.2%) and implant failures (17.9%). CONCLUSIONS: Degenerative cervical conditions treated with one or two-level ACDF surgery using DBM, HA, or ß-TCP with or without cervical plating are associated with complications such as adjacent segment disease, dysphagia, and pseudarthrosis. However, consequent to the study designs and clinical heterogeneity of the studies, it is not possible to correlate these complications accurately with any specific graft material employed. Further well-designed prospective studies are needed to correctly know the related morbidity of each graft used for achieving fusion in ACDF.

AO Spine Guideline for the Use of Osteobiologics (AOGO) in Anterior Cervical Discectomy and Fusion for Spinal Degenerative Cases.

STUDY DESIGN: Guideline. OBJECTIVES: To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions. METHODS: The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus. RESULTS: Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. CONCLUSION: This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery.

STUDY DESIGN: Clinical practice guideline development. OBJECTIVES: Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). METHODS: A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. CONCLUSIONS: It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Functional results and complication analysis after total ankle replacement: early to medium-term results from a Portuguese and Spanish prospective multicentric study.

BACKGROUND: Ankle arthroplasty is increasingly being used to treat end-stage ankle osteoarthritis. METHODS: Between January 2005 and January 2011, 159 patients have been included in an ongoing prospective multicentric study analysing the results of total ankle arthroplasty in Portugal and Spain. 119 patients (119 replacements) were available for review and were evaluated for range of motion (ROM), clinical status (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score), complications and survivorship rate. RESULTS: Mean follow-up was 39 months. A total of 17 complications were reported, with 7 leading to subsequent surgery (94.1% survivorship rate). Of these, there were two infections (98.3% survivorship rate), two painful subtalar arthritis, one instability, one malalignment and one tibial bone cyst. Complications not requiring further surgery were 6 intra-operative malleolar fractures and 4 cases of skin necrosis. CONCLUSIONS: Adequate patient selection and a thorough knowledge of the surgical technique are mandatory to reduce the number of complications and increase ankle arthroplasty survivorship.