Criteria for surgical reduction in high-grade lumbosacral spondylolisthesis based on quality of life measures.

PURPOSE: Although surgical reduction in high-grade lumbosacral spondylolisthesis is often performed in young patients, criteria for defining adequate reduction leading to optimal outcomes have yet to be defined. The purpose of this study is to determine if surgical reduction in pelvic balance, slip grade, lumbosacral angle and L5 incidence are associated with quality of life after surgery, based on specific criteria proposed previously in the literature. METHODS: A prospective cohort of 61 patients (14.4 ± 2.7 years) with high-grade lumbosacral spondylolisthesis was followed for a minimum of 2 years after surgery. SRS-22 scores, slip grade, lumbosacral angle, pelvic balance and L5 incidence were assessed before surgery and at the latest follow-up. Multivariable regression analyses were performed using postoperative SRS domain and total scores as the dependent variables. Independent variables consisted of the preoperative SRS scores, and specific criteria of pelvic balance, slip grade, lumbosacral angle and L5 incidence. The influence of slip grade, lumbosacral angle and L5 incidence on pelvic balance was also assessed. RESULTS: Obtaining a balanced pelvis postoperatively was mainly predictive of improved satisfaction with surgery and self-image and also tended to be associated with higher scores for other domains. Improved mental health was associated with reduction to a low-grade slip. Reduction in lumbosacral angle was not predictive of quality of life. Postoperative pelvic balance was mainly associated with preoperative pelvic balance, but there was a tendency for achieving normal pelvic balance when the postoperative L5 incidence was 60° or smaller. CONCLUSIONS: When performing surgery in young patients with high-grade lumbosacral spondylolisthesis, achieving normal pelvic balance is the key because it is associated with improved quality of life. Reduction to a low-grade slip is predictive of improved mental health, but reduction in lumbosacral angle is not associated with postoperative quality of life. There was a tendency for obtaining normal postoperative balance in patients with postoperative L5 incidence 60° or smaller. These slides can be retrieved under Electronic Supplementary Material.

Radiographic Assessment of Shoulder Position in 619 Idiopathic Scoliosis Patients: Can T1 Tilt Be Used as an Intraoperative Proxy to Determine Postoperative Shoulder Balance?

BACKGROUND: The purpose of this study is to assess radiographic shoulder measures from the preoperative to the postoperative time period, specifically to determine whether T1 tilt could be used as an intraoperative proxy for shoulder balance determination. This study focused on radiographic shoulder measures of 619 adolescent idiopathic scoliosis patients who underwent spinal deformity surgery. METHODS: A prospective, multicenter database of adolescent idiopathic scoliosis was queried to identify all patients who had undergone spinal deformity surgery with >2 years of follow-up postoperatively. Radiographic analysis focused on measures of shoulder balance: T1 tilt, clavicle angle, and radiographic shoulder height. RESULTS: A total of 619 patients were included in this analysis. Mean age at surgery was 14.8 years with 83% female. Mean preoperative curve size was 58.0 degrees. Mean T1 tilt preoperatively was -0.10 degrees and postoperatively 2.42 degrees. Mean clavicle angle preoperatively was -1.39 degrees and postoperatively 0.79 degrees. Mean radiographic shoulder height preoperatively was -7.04 mm and postoperatively 1.63 mm. All 3 radiographic parameters demonstrated reasonable correlation preoperatively and postoperatively to each other. To assess the viability of T1 tilt as an intraoperative proxy for shoulder balance, standardized ratios between the variables were created. Analysis of these ratios demonstrated little or no relationship preoperatively to postoperatively, hence the relationship of T1 tilt to radiographic shoulder height does not remain constant. CONCLUSIONS: Analysis of the relationship of T1 tilt to radiographic shoulder height from preoperative to postoperative did not demonstrate consistency. Lenke 3 and 6 curve patterns demonstrated preoperative to postoperative correlation, both with nonstructural proximal thoracic curves; however, for the remaining curve patterns T1 tilt cannot be used as an intraoperative proxy for shoulder balance. LEVEL OF EVIDENCE: Level IV.

Pre-operative gait kinematics and kinetics do not change following surgery in adolescent patients with femoroacetabular impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is a condition where the femoral head-neck junction collides with the acetabulum. Open or arthroscopic treatment of FAI aims to increase hip motion while reducing impingement during passive or dynamic movements. RESEARCH QUESTION: What are the biomechanical characteristics of the hip and pelvis in adolescents and young adults diagnosed with FAI syndrome 1) pre-operatively compared to controls and 2) pre- to post-operatively? METHODS: 43 patients with FAI and 43 controls were included in the study. All patients with FAI had cam deformities and underwent unilateral hip preservation surgery (either open or arthroscopic). Pre- and post-operative imaging, patient-reported outcomes, and gait analysis were performed. Joint angles and internal joint moments were evaluated with an emphasis on the pelvis and hip. A comparative analysis was conducted to evaluate the gait patterns before and after surgical treatment, as well as to compare pre-operative gait patterns to a control group. RESULTS: 43 patients with FAI (28 female, 16.5 ± 1.5 yrs) and 43 controls (28 female, 16.0 ± 1.5 yrs) were included. Pre-operative patients with FAI had decreased stride length and walking speed compared to controls, with no significant change following surgery. There were no differences in sagittal and coronal plane hip and pelvis kinematics comparing pre- to post-operative and pre-operative to controls. Pre-operatively, differences in internal hip rotation angle (pre: 3.3˚, post: 3.9˚, controls: 7.7˚) and hip extensor moment (pre: 0.121, post: 0.090, controls: 0.334 Nm/kg) were observed compared to controls with no significant changes observed following surgery. SIGNIFICANCE: Compensatory movement strategies in pelvic and hip motion are evident during gait in patients with FAI, particularly in the sagittal and transverse planes. These strategies remained consistent two years post-surgery. While surgery improved radiographic measures and patient-reported outcomes, gait did not elicit biomechanical changes following surgical treatment.

Radiographic Predictors of Reoperation in Adolescents Undergoing Hip Preservation Surgery for Femoroacetabular Impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is a condition caused by repetitive abutment of a morphologically abnormal proximal femur and/or acetabulum that may result in chondral and labral pathology. An understanding of radiographic parameters associated with successful primary surgery has not been well established. PURPOSE: To determine preoperative radiographic parameters that predict reoperation for FAI and correlate radiographic measurements with outcomes in these patients. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A prospectively collected institutional registry of adolescent patients (age, <19 years) who underwent surgery for FAI (arthroscopic/open) was reviewed. Preoperative standing anteroposterior pelvic radiographs were analyzed for femoroepiphyseal acetabular roof (FEAR) index, as well as lateral center-edge angle (LCEA) and alpha, Tönnis, and Sharp angles. Patient-reported outcomes (PROs) (modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score) were analyzed preoperatively and at 1- and 2-year followup. Radiographic indication of risk for reoperation was evaluated using receiver operating characteristic (ROC) analysis. Spearman correlation was calculated between radiographic measurements and PROs at 2 years postoperatively. RESULTS: A total of 81 patients (91 hips) underwent primary surgery (57 surgical dislocations vs 34 arthroscopies) for FAI. The mean age at time of primary operation was 16.23 years (range, 10.4-19.6 years) (73.6% female). Eleven hips (12.1%) underwent reoperation at a mean of 20.6 months from primary surgery. The LCEA, FEAR index, Tönnis angle, and Sharp angle before index surgery were significantly different (P < .05) between patients who underwent reoperation and those who did not. ROC analysis indicated that LCEA <22°, FEAR index >-8.7°, Tönnis angle >6.0°, and Sharp angle >44° were predictors for increased risk of reoperation. Using the cutoff values from the ROC analysis in this series, 43% of patients with an LCEA ≤22° had a repeat procedure, while only 8% of those with an LCEA >22° had a repeat procedure. Similar trends were seen with the other aforementioned acetabular radiographic measurements (FEAR index, Tönnis angle, Sharp angle). Patients who did not require a reoperation demonstrated significant improvement in all PRO categories from their preoperative to 2-year postoperative visits (P < .0001). CONCLUSION: In patients undergoing treatment for FAI, a reoperation was associated with radiographic signs of hip dysplasia, indicating that patients with a shallower acetabulum are at risk for a repeat operation.

A Surgical Treatment Algorithm for Restoring Pelvic Balance and Health-related Quality of Life in High-grade Lumbosacral Spondylolisthesis: Prospective Multicenter Cohort of 61 Young Patients.

STUDY DESIGN: Retrospective multicenter cohort-study. OBJECTIVE: We propose an evidence-based surgical algorithm for achieving normal pelvic balance while optimizing health-related quality of life (HRQoL) in high-grade spondylolisthesis. SUMMARY OF BACKGROUND DATA: The principles of surgical treatment for young patients with high-grade L5-S1 spondylolisthesis remain unclear. There is a growing body of evidence supporting the central role of pelvic balance in the postural control and biomechanics of subjects with high-grade spondylolisthesis. METHODS: This retrospective study assessed a multicenter cohort of 61 patients with high-grade L5-S1 spondylolisthesis. Classification and regression tree analysis was used to identify objective criteria associated with pelvic balance and HRQoL after surgery. RESULTS: The most important predictor of a postoperative balanced pelvis was a postoperative L5 incidence ≤63.5 degrees. With postoperative L5 incidence ≤63.5 degrees,a residual slip percentage 9% and performing an L5-S1 posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) increased the likelihood of achieving a balanced pelvis postoperatively. When L5 incidence was 63.5 degrees,a balanced pelvis was most likely achieved with fusion limited to L5 proximally, residual slip percentage ≤40%, and residual lumbosacral angle 98 degrees. Predictors of postoperative HRQoL were the preoperative HRQoL score, L5 incidence and slip percentage. CONCLUSIONS: A surgical algorithm is proposed to achieve normal pelvic balance, while optimizing HRQoL. The first step during surgery is to assess L5 incidence and if L5 incidence is <65 degrees, the next step depends on the pelvic balance. With a preoperative balanced pelvis, it is important not to reduce completely the slip percentage by leaving a slip percentage ≥10%. When the preoperative pelvis is unbalanced, a TLIF/PLIF at L5-S1 is recommended to facilitate correcting the angular deformity at L5-S1. If L5 incidence is ≥65 degrees,a TLIF/PLIF at L5-S1 should be performed to correct the angular deformity at L5-S1, and fusion should ideally end at L5 proximally, in addition to performing gradual reduction of the slip percentage. If fusion up to L4 is required, a lumbosacral angle ≥100 degrees is key.

Acetabular Coverage May Affect Radiographic and Clinical Outcomes of Osteochondral Allograft Transplantation of Focal Femoral Head Lesions: A Case Series From a Single Institution.

Osteochondral lesions of the femoral head in young people are rare and present unique management challenges. Optimal treatment for these lesions is unclear. From 2009 to 2016, clinical and radiographic outcomes were prospectively collected within a series of symptomatic focal osteochondral lesions of the femoral head with a minimum follow-up of 2 years. A surgical hip dislocation followed by implantation of a size-matched fresh osteochondral femoral head allograft was performed. Nine hips in eight patients (6 female patients) underwent surgery at an average of 17 years (11 to 21 years). Individual allograft sizes ranged from 10 to 35 mm in diameter; with 2 of 9 hips receiving two allografts in a stacked or mosaicplasty technique at the time of treatment. The average graft implantation was 3536.5 mm2. Modified Harris hip scores improved by 13.4 (P = 0.018) from preoperative to final follow-up for all patients. Significant improvements in internal rotation (12° versus 23°, P = 0.011), external rotation (32° versus 50°, P = 0.041), and abduction (28° versus 40°, P = 0.042) were also achieved. Three patients (four hips) demonstrated poor radiographic healing (<50% incorporation at 2 years), which correlated with worse clinical outcomes and was associated with a lower preoperative lateral center edge angle (21.5° versus 30.4°, P = 0.049). Fresh osteochondral allograft treatment is a good option for focal osteochondral lesions of the femoral head with improved outcomes and motion; however, higher failure rates may be seen in those with a lower center edge angle.

Treatment Patterns and Outcomes of Stable Hips in Infants With Ultrasonic Dysplasia.

INTRODUCTION: No clear practice guideline exists for the management of stable hip with ultrasonic dysplasia (UD). This study assessed the treatment patterns for stable UD and determined the outcomes of Pavlik harness (PH) treatment or observation (OB). METHODS: This is a prospective study of 80 infants (107 hips) aged ≤12 weeks at presentation diagnosed with stable UD. RESULTS: Sixty-five hips were treated with PH, whereas 42 hips were observed. Patients who were older at the time of initial sonogram and those with lower head coverage were more likely to be treated with PH. The mean head coverage was lower in the PH group, indicating more severe UD. At a 2-year follow-up period, 93% of patients in the OB group and 87% in the PH group had a good radiographic outcome. DISCUSSION: Head coverage and age at first sonogram had a significant influence on the treatment decision for PH. A milder ultrasonic hip dysplasia can be observed because 93% of the patients who were observed had a good outcome. LEVEL OF EVIDENCE: Level II: prospective cohort study.

Immediate effects of scoliosis-specific corrective exercises on the Cobb angle after one week and after one year of practice.

BACKGROUND: We are unaware of any studies describing the immediate effects of scoliosis-specific exercises on the Cobb angle measured by radiograph. This study aimed to describe the differences between radiographs obtained with and without corrective exercises after initial training and after one year. METHODS: A female with adolescent idiopathic scoliosis was first seen at age 13 years, 0 months with a Risser 0. She had a 43o left lumbar, 15o right thoracic curve. She was seen again after 6, 18 and 30 months and performed exercises from 18 to 30 months. She performed Barcelona Scoliosis Physical Therapy School (BSPTS) exercises for a four-curve type (lumbar dominant with pelvis deviation to the lumbar concave side). At 18 and 30 months, x-rays were obtained with and without performing corrective exercises. RESULTS: At 6 months, her lumbar and thoracic curves measured 41o and 28o, respectively. At 18 months, her lumbar and thoracic curves measured 47 o and 30o, respectively. Also at 18 months, immediately after her x-ray in the relaxed standing position, she performed her corrective exercises in standing with arms lowered for a second x-ray. Her lumbar and thoracic curves remained similar and measured 43o and 32o, respectively. At 30 months, she performed unsolicited corrective exercises during the x-ray. Her lumbar and thoracic curves measured 26o and 41o, respectively. Another x-ray in the relaxed position revealed lumbar and thoracic curves measuring 39o and 35o, respectively. The immediate effect of corrective exercises after a year of training was a 33 % improvement at the lumbar spine compared to only a 9 % improvement the previous year. CONCLUSION: After initial training, corrective exercises during a standing x-ray did not significantly improve the Cobb angle for the major lumbar curve compared to the relaxed standing x-ray. However, a year after performing exercises, unsolicited corrective exercises resulted in a significantly improved Cobb angle compared to relaxed standing for the curve primarily targeted by the exercise program. Improved exercise ability and spinal flexibility may have contributed to the improved Cobb angle.