Classification Grading System Research Articles

Automated Association for Osteosynthesis Foundation and Orthopedic Trauma Association classification of pelvic fractures on pelvic radiographs using deep learning

High-energy impacts, like vehicle crashes or falls, can lead to pelvic ring injuries. Rapid diagnosis and treatment are crucial due to the risks of severe bleeding and organ damage. Pelvic radiography promptly assesses fracture extent and location, but struggles to diagnose bleeding. The AO/OTA classification system grades pelvic instability, but its complexity limits its use in emergency settings. This study develops and evaluates a deep learning algorithm to classify pelvic fractures on radiographs per the AO/OTA system. Pelvic radiographs of 773 patients with pelvic fractures and 167 patients without pelvic fractures were retrospectively analyzed at a single center. Pelvic fractures were classified into types A, B, and C using medical records categorized by an orthopedic surgeon according to the AO/OTA classification system. Accuracy, Dice Similarity Coefficient (DSC), and F1 score were measured to evaluate the diagnostic performance of the deep learning algorithms. The segmentation model showed high performance with 0.98 accuracy and 0.96–0.97 DSC. The AO/OTA classification model demonstrated effective performance with a 0.47–0.80 F1 score and 0.69–0.88 accuracy. Additionally, the classification model had a macro average of 0.77–0.94. Performance evaluation of the models showed relatively favorable results, which can aid in early classification of pelvic fractures.

An effective ensemble learning approach for classification of glioma grades based on novel MRI features

The preoperative diagnosis of brain tumors is important for therapeutic planning as it contributes to the tumors’ prognosis. In the last few years, the development in the field of artificial intelligence and machine learning has contributed greatly to the medical area, especially the diagnosis of the grades of brain tumors through radiological images and magnetic resonance images. Due to the complexity of tumor descriptors in medical images, assessing the accurate grade of glioma is a major challenge for physicians. We have proposed a new classification system for glioma grading by integrating novel MRI features with an ensemble learning method, called Ensemble Learning based on Adaptive Power Mean Combiner (EL-APMC). We evaluate and compare the performance of the EL-APMC algorithm with twenty-one classifier models that represent state-of-the-art machine learning algorithms. Results show that the EL-APMC algorithm achieved the best performance in terms of classification accuracy (88.73%) and F1-score (93.12%) over the MRI Brain Tumor dataset called BRATS2015. In addition, we showed that the differences in classification results among twenty-two classifier models have statistical significance. We believe that the EL-APMC algorithm is an effective method for the classification in case of small-size datasets, which are common cases in medical fields. The proposed method provides an effective system for the classification of glioma with high reliability and accurate clinical findings.

Bending Strength Evaluation of Japanese Wooden Cultural Heritage Building Columns Based on a Non-Destructive Testing Method

ABSTRACT Column failure assessment is essential for seismic diagnosis of Japanese wooden cultural heritage buildings. Achieving accurate column failure assessment depends on accurately estimating the bending Young’s modulus (E b ) and characteristic bending strength (F b ) of columns. This study extends the application of a non-destructive testing (NDT) method to estimate E b and F b of Japanese cedar columns generally used in wooden cultural heritage buildings. For this purpose, a correlation between the dynamic bending Young’s modulus (E p ) and E b of Japanese cedar columns is established and the variations in the E p –E b relationship across different wood provenances and species are clarified. Using the proposed method, a statistical analysis of the estimated E b of Japanese wooden cultural heritage buildings is provided. Furthermore, estimated E b is used to determine F b of the columns using the mechanical grade classification system. The results show that most Japanese cypress and Japanese cedar columns feature higher F b than those used in conventional seismic diagnosis. Conversely, two-thirds of the Japanese red pine columns feature a lower F b than that used in conventional seismic diagnosis. The proposed F b evaluation method offers an NDT method that can be widely applied to Japanese wooden cultural heritage buildings to assess column failure more accurately.

284 CT-Based Assessment of Prone Versus Lateral Pedicle Screw Placement Accuracy: A Retrospective Single-surgeon Study

INTRODUCTION: Lateral lumbar interbody fusion (LLIF) including the anterior-to-psoas oblique lumbar interbody fusion (OLIF) has conventionally relied on pedicle screw placement (PSP) for construct stabilization. Single-position surgery with lumbar interbody fusion (LIF) in the lateral decubitus position with concomitant PSP has been associated with increased operative efficiency. What remains unclear is the accuracy of PSP with robotic guidance when compared to the more familiar prone patient positioning. METHODS: We identified all consecutive patients treated with interbody fusion and PSP in the prone or lateral position by a single surgeon between January 2019 and October 2022. All pedicle screws placed were analyzed using CT imaging to determine appropriate positioning according to the Gertzbein-Robbins Classification Grading System. Multivariate logistic regression models were constructed to identify risk factors for the occurrence of a radiographically significant breach. RESULTS: 89 consecutive patients were included (n = 690 screws), of whom 46 were treated in the prone position (n = 477 screws) and 43 in the lateral decubitus position (n = 213 screws). There were fewer breaches in the prone (n = 13; 2.7%) versus lateral decubitus group (n = 15; 7.0%; p = 0.012). Nine (1.9%) radiographically significant breaches occurred in the prone group compared to 10 (4.7%) in the lateral decubitus group (p = 0.019), for a prone vs. lateral decubitus pedicle screw accuracy rate of 98.1% vs. 95.3%. There were no significant differences in BMI between prone vs. lateral decubitus cohorts (30.1 vs. 29.6) or breached patients vs. non-breached patients (31.2 vs. 29.5). In multivariate models, prone position was the only significant protective factor for screw accuracy; we did not identify any other significant risk factors for screw breach. CONCLUSIONS: The present data suggest pedicle screws placed with robotic assistance have higher placement accuracy in the prone position.

External validation of a four-tiered grading system for chromophobe renal cell carcinoma

This study aimed to validate the prognostic value of a four-tiered grading system recently proposed by Avulova et al. and to explore the prognostic ability of another four-tiered classification grading system in which there is a separate Grade 3 for tumor necrosis. Grading of chromophobe renal cell carcinoma (ChRCC) by the Fuhrman system is not feasible because of the inherent nuclear atypia in ChRCC. We collected relevant data of 263 patients with ChRCC who had undergone surgery in our hospital from 2008 to 2020. The Kaplan–Meier method was used to calculate the survival rate and Cox proportional hazard regression models to assess associations with cancer-specific survival and distant metastasis-free survival by hazard ratios (HRs) and 95% confidence intervals (CIs). Ten patients died from ChRCC, and 12 developed metastases. The 5 year CSS rates were 95.9%. Grades 2 (HR = 10.9; CI 1.11–106.4; P = 0.04), 3 (HR = 33.6, CI 3.32–339.1; P = 0.003), and 4 (HR = 417.4, CI 35.0–4976.2; P < 0.001) in a four-tiered grading system were significantly associated with CSS in a multivariate setting. However, the difference in CSS between Grades 2 and 3 was not significant (HR = 2.14, 95% CI 0.43–10.63; P = 0.35). The HRs of the associations between an exploratory grading system that includes a separate Grade 3 for tumor necrosis and CSS were as follows: Grade 2, 10.2 (CI 1.06–97.9, P = 0.045); Grade 3, 11.4 (CI 1.18–109.6, P = 0.04); and Grade 4, 267.9 (CI 27.6–2603.3, P < 0.001). Similarly, Grades 2 and 3 did not differ significantly. The four-tiered grading system studied is useful for predicting death from ChRCC and metastasis. However, Grade 3 did not more accurately predict risk of death and metastasis than did Grade 2. This was also true for the novel exploratory grading system that classifies tumors with necrosis into a separate Grade 3.

Efficacy and influencing factors of cervical perivascular sympathectomy in children with cerebral palsy

BackgroundThere is a lack of research to determine the efficacy of cervical perivascular sympathectomy (CPVS) in children with cerebral palsy (CP).ObjectiveThis study aimed to evaluate the efficacy of CPVS in children with CP and analyze the associated influential factors.MethodsUsing the method of retrospective cohort studies, children who underwent CPVS were included in the CPVS group, whereas those who underwent selective posterior rhizotomy (SPR) were included in the SPR group. The Communication Function Classification System (CFCS) and Teacher Drooling Scale (TDS) were used to evaluate the communication function and salivation in the two groups before and 12 months after surgery and compare the surgical efficiency between the two groups, and the factors affecting the efficacy were screened by binary logistic regression.ResultsThe study included 406 patients, 202 in the CPVS group and 204 in the SPR group. No significant differences were observed in the baseline characteristics (p > 0.05). The surgical efficacy of the CPVS group (47.01%) was significantly higher than that in the SPR group (9.81%) (χ2 = 71.08, p < 0.001). Binary logic regression analysis showed that preterm birth and Gross Motor Function Classification System (GMFCS) grade were influencing factors of surgical efficacy. Eighteen patients developed postoperative complications.ConclusionCPVS is a safe and effective surgery for cerebral palsy. Preterm birth and GMFCS grade are independent factors affecting the efficacy of surgery.

Characteristics and risk factors of UCS fracture subtypes in periprosthetic fractures around the hip.

Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade. Using a multicentre collaborative study design, independent of registry data, we identified adults from 29 centres with PPFs around the hip between January 2010 and December 2019. Radiographs were assessed for the Unified Classification System (UCS) grade. Patient and injury characteristics, management, and outcomes were compared between UCS grades. A multinomial logistic regression was performed to estimate relative risk ratios (RRR) of variables on UCS grade. A total of 1,104 patients were included. The majority were female (57.9%; n = 639), ethnically white (88.5%; n = 977), used mobility aids (67%; n = 743), and had a median age of 82 years (interquartile range (IQR) 74 to 87). A total of 77 (7%) had pain prior to the PPF. The most common UCS grade was B2 (33%; n = 368). UCS type D fractures had the longest length of stay (median 19 days (IQR 11 to 26)), highest readmission to hospital (21%; n = 9), and highest rate of discharge to step-down care (52%; n = 23). Multinomial regression suggests that uncemented femoral stems are associated with a reduced risk of UCS C (RRR 0.36 (95% confidence interval (CI) 0.2 to 0.7); p = 0.002) and increased risk of UCS A (RRR 3.3 (95% CI 1.9 to 5.7); p < 0.001), compared to UCS B fracture. The most common PPF type in elderly frail patients is UCS B2. Uncemented stems have a lower risk of UCS C fractures compared to cemented stems. A national PPF database is needed to further identify correlation between implants and fracture subtypes.

Retrospective single-surgeon study of prone versus lateral robotic pedicle screw placement: a CT-based assessment of accuracy.

Lateral lumbar interbody fusion including anterior-to-psoas oblique lumbar interbody fusion has conventionally relied on pedicle screw placement (PSP) for construct stabilization. Single-position surgery with lumbar interbody fusion in the lateral decubitus position with concomitant PSP has been associated with increased operative efficiency. What remains unclear is the accuracy of PSP with robotic guidance when compared with the more familiar prone patient positioning. The present study aimed to compare robot-assisted screw placement accuracy between patients with instrumentation placed in the prone and lateral positions. The authors identified all consecutive patients treated with interbody fusion and PSP in the prone or lateral position by a single surgeon between January 2019 and October 2022. All pedicle screws placed were analyzed using CT scans to determine appropriate positioning according to the Gertzbein-Robbins classification grading system (grade C or worse was considered as a radiographically significant breach). Multivariate logistic regression models were constructed to identify risk factors for the occurrence of a radiographically significant breach. Eighty-nine consecutive patients (690 screws) were included, of whom 46 (477 screws) were treated in the prone position and 43 (213 screws) in the lateral decubitus position. There were fewer breaches in the prone (n = 13, 2.7%) than the lateral decubitus (n = 15, 7.0%) group (p = 0.012). Nine (1.9%) radiographically significant breaches occurred in the prone group compared with 10 (4.7%) in the lateral decubitus group (p = 0.019), for a prone versus lateral decubitus PSP accuracy rate of 98.1% versus 95.3%. There were no significant differences in BMI between prone versus lateral decubitus cohorts (30.1 vs 29.6) or patients with screw breach versus those without (31.2 vs 29.5). In multivariate models, the prone position was the only significant protective factor for screw accuracy; no other significant risk factors for screw breach were identified. The present data suggest that pedicle screws placed with robotic assistance have higher placement accuracy in the prone position. Further studies will be needed to validate the accuracy of PSP in the lateral position as single-position surgery becomes more commonplace in the treatment of spinal disorders.

Prediction of survival of preoperative colorectal patients: A new tool to assess the interaction of nutritional status and inflammation

Colorectal cancer (CRC) is responsible for the second leading cause of cancer death worldwide. Thus, the aim of this study was to investigate the application of a new nutritional status and inflammatory tool to predict overall survival (OS) in patients with CRC in the preoperative period. Retrospective cohort study with CRC patients of both sexes treated at a hospital unit, aged ≥20 years. Data were extracted between 2007 and 2015. Multivariate Cox's models were employed to predict OS utilizing a new grade classification system (body mass index vs. percentage weight loss - BMI/%WL), inflammatory markers and clinical data. We evaluated 361 patients. BMI/%WL grade 3-4 (HR: 2.01; p=0.001; 95% CI: 1.34-3.02) were independent predictors of poor OS. Moreover, BMI/%WL grade 3-4+neutrophil-to-lymphocyte ratio (NLR) ≥2.4 (HR: 2.79; p=0.001; 95% CI: 1.54-5.03) increased the death risk in 5-years. However, low NLR (<2.4) altered the OS prognostic ability of the BMI/%WL (HR: 1.72; p=0.099; 95% CI: 0.90-3.28). BMI/%WL was independent predictors of poor OS and the interaction with NLR produced an adjustment effect. These associated tools may be useful in the clinical management of preoperative patients with CRC.

Intelligent Mango Fruit Grade Classification Using AlexNet-SPP With Mask R-CNN-Based Segmentation Algorithm

In this article, the grades of mangoes were classified using an AlexNet–spatial pyramid pooling network (SPP-Net) with a segmentation algorithm based on a Mask region-based convolutional neural network (R-CNN). Computer vision technologies have begun to be used for fruit grade classification, and this is a major topic of interest in agricultural automation. However, because insufficient fruit grade classification accuracy is achieved with these technologies, manual processing must be performed. The accuracy of fruit grade classification can be enhanced using a Mask R-CNN, SPP-Net, and specific background processing. The designed mango grade classification system contains four modules: 1) a user interface module, 2) an object detection module, 3) an image preprocessing module, and 4) a fruit grade classification module. A camera is used to capture images of mangoes for display on the user interface. The object segmentation module generates a mango shape mask and bounding box by using a Mask R-CNN. The image preprocessing module uses the generated bounding box and mango shape mask to crop the mango and color the background blue. Finally, AlexNet–SPP-Net outputs the fruit grade. We validated the proposed approach by implementing it in mango grade classification and comparing its accuracy with that of relevant existing methods from the literature. According to the experimental results, the proposed approach outperforms the traditional AlexNet-based approach.

Added value of dynamic MRI in assessment of cervical spondylodegenerative diseases

BackgroundMagnetic resonance imaging (MRI) is an effective imaging tool for diagnosing spinal disorders. With a high degree of sensitivity and specificity, it gives vital information on the spinal cord, nerve roots, intervertebral discs, and ligamentous structures inside the spine. Dynamic MRI may image patients in flexed and extended postures, showing abnormalities undetected by static MRI studies. It allows for a more complete investigation of each patient and a better knowledge of the real nature of the pathology. Imaging the spine in extension and flexion, or putting the spine in pain, may help spine surgeons improve their diagnostic accuracy. We aimed to assess the diagnostic value of flexion–extension sagittal T2 (Dynamic MRI) for patients with cervical spondylodegenerative diseases.ResultsWe found that more spinal canal stenosis levels were detected on extension position MRI compared to a neutral position (128 vs. 133 MUHLE classification system grade 0, 38 vs. 63 MUHLE grade 1, 31 vs. 13 MUHLE grade 2, 13 vs. 1 MUHLE grade 3), which was statistically significant according to MUHLE among total disc levels, with p value < 0.05. While more spinal canal stenosis levels were detected on flexion position MRI than in neutral position (134 vs. 133 MUHLE grade 0, 49 vs. 63 MUHLE grade 1, 23 vs. 13 MUHLE grade 2, 4 vs. 1 MUHLE grade 3), which was statistically insignificant according to MUHLE among total disc levels (p value > 0.05).ConclusionsFlexion and extension MR imaging demonstrates additional information using a non-invasive technique concerning the dynamic factors in the pathogenesis of cervical spondylodegenerative diseases. DMRI identifies a significant percentage of increased spinal stenosis especially at extension position more than at neutral and flexion positions. So, we recommend to include extension DMRI in investigations for diagnosis and management plans of cervical spondylodegenerative diseases.

Topical Esmolol Hydrochloride as a Novel Treatment Modality for Diabetic Foot Ulcers

Preclinical and phase 1/2 studies with esmolol hydrochloride suggest its potential role in treatment of diabetic foot ulcers (DFUs). To study the efficacy of topical esmolol for healing of uninfected DFUs. A randomized, double-blind, multicenter, phase 3 clinical trial was conducted from December 26, 2018, to August 19, 2020, at 27 referral centers across India. Participants included adults with DFUs. Participants were randomized after a run-in phase (1 week) to receive esmolol, 14%, gel with standard of care (SoC), SoC only, or vehicle with SoC (3:3:1 proportion) for 12 weeks (treatment phase) and followed up subsequently until week 24. The primary outcome was the proportion of wound closure within the 12-week treatment phase in the esmolol with SoC and SoC only groups. Analysis was conducted using an intention-to-treat safety evaluable population, full analysis set or efficacy-evaluable population, and per-protocol population comparing the esmolol plus SoC and SoC only treatment groups. In the study, 176 participants (122 men [69.3%]; mean [SD] age, 56.4 [9.0] years; mean [SD] hemoglobin A1c level, 8.6% [1.6%]) with DFUs classified as University of Texas Diabetic Wound Classification system grade IA and IC (mean [SD] ulcer area, 4.7 [2.9] cm2) were randomized to the 3 groups. A total of 140 participants were analyzed for efficacy. The proportion of participants in the esmolol with SoC group who achieved target ulcer closure within 12 weeks was 41 of 68 (60.3%) compared with 30 of 72 (41.7%) participants in the SoC only group (odds ratio [OR], 2.13; 95% CI, 1.08-4.17; P = .03). A total of 120 participants completed the end of study visit which were analyzed. Target ulcer closure by the end of the study (week 24) was achieved in 44 of 57 (77.2%) participants in the esmolol with SoC group and 35 of 63 (55.6%) participants in the SoC only group (OR, 2.71; 95% CI, 1.22-5.99; P = .01). The median time for ulcer closure was 85 days for the esmolol with SoC group and was not estimable for SoC only group. Significant benefits of Esmolol with SoC were seen in patients with factors that impede the healing of DFU. Treatment-emergent adverse events were noted in 18.8% of the participants, but most (87.3%) of these events were not attributable to the study drug. In this multicenter, randomized, double-blind clinical trial, the addition of esmolol to SoC was shown to significantly improve the healing of DFUs. With these results, topical esmolol may be an appropriate addition to SoC for treating DFUs. ClinicalTrials.gov Identifier: NCT03998436; Clinical Trial Registry, India CRI Number: CTRI/2018/11/016295.

Elevated HbA1c level associated with disease severity and surgical extension in diabetic foot patients.

Diabetic foot is a complex syndrome that is associated with other diabetic complications, such as peripheral arte-rial disease and peripheral neuropathy. Optimization of plasma glucose and glycated hemoglobin (HbA1c) is one of the main principles of standard care and treatment approaches in individuals with diabetes mellitus (DM). In this study, the relationship of HbA1c level at the time of diagnosis was evaluated with diabetic foot disease severity score and surgical extension in patients with Type 2 DM. This study included 301 consecutive patients who were diagnosed with diabetic foot in the general surgery diabetic foot clinic and were hospitalized for surgery. The relationships between the HbA1c levels of the patients with the Wagner and PEDIS (Perfusion, Extent, Dept, Infection, Sensation) classification system grades, and the surgical procedures performed were analyzed and the treatment outcomes were evaluated. It was determined that there was a 90% statistically significant relationship between HbA1c values of ≥10.1% and the de-velopment of Wagner Grade 4 diabetic foot ulcer (DFU) (P=0.037). A strong statistically significant relationship at the rate of 85% was determined between HbA1c values of ≥10.1% and the development of PEDIS Grade 3 ulcers. As the HbA1c values increased, so there was determined to be a statistically significant relationship with the development of PEDIS Grade 3 ulcer (P=0.003). In the comparison of the HbA1c values according to the type of surgery performed, a weak relationship was determined at the rate of 26%, and it was determined that as the HbA1c values increased, so there could be an increase in the amputation level. The results of this study showed that as HbA1c values at diagnosis increased in patients with diabetic foot; Wagner/PEDIS grades, disease severity, surgical extension, amputation level, and tissue loss increased. To reduce the severity of diabetic foot disease and prevent amputation, compliance with diabetic treatment and glycemic control should be increased.

The ligamentum mucosum’s potential as a preventative structure in the development of knee osteoarthritis

PurposeThis paper aimed to identify whether the presence, type, and/or morphology of the ligamentum mucosum could play a role in the development of knee osteoarthritis. Since its microscopic structure is alike that of other knee ligaments, it was hypothesized that its presence could facilitate knee motion and stability, thus preventing or reducing the extent of knee osteoarthritis.MethodsThirty three cadavers (a total of 51 knees) were dissected. The ligamentum mucosum, if present, was measured with a digital caliber and a measuring tape in terms of length, width, and thickness. Knee osteoarthritis was assessed in six regions of the knee. The OuterBridge Classification System (Grades 0–4) was used to visually assess the extent, in addition to probing the area. Osteoarthritis was deemed present if the grade was 2 or greater.ResultsThe presence of the ligament was associated with a lower mean osteoarthritis level in the trochlear groove and lateral tibial plateau regions (p < 0.001 and p = 0.013, respectively). Overall osteoarthritis of the knee was also present at varying levels for each type of the ligamentum mucosum (p < 0.001). The patella and the medial condyle had the greatest levels of osteoarthritis, while the medial and lateral tibial plateaus had the lowest levels.ConclusionThe presence of the ligamentum mucosum is linked with decreased osteoarthritis in the trochlear groove region. In addition, both the absent ligament and its classification as a vertical septum are associated with increased knee osteoarthritis.Level of evidenceFive.

Automated classification of breast cancer histologic grade using multiphoton microscopy and generative adversarial networks

Histological grade is one of the most powerful prognostic factors for breast cancer and impacts treatment decisions. However, a label-free and automated classification system for histological grading of breast tumors has not yet been developed. In this study, we employed label-free multiphoton microscopy (MPM) to acquire subcellular-resolution images of unstained breast cancer tissues. Subsequently, a deep-learning algorithm based on the generative adversarial network (GAN) was introduced to learn a representation using only MPM images without the histological grade information. Furthermore, to obtain abundant image information and determine the detailed differences between MPM images of different grades, a multiple-feature discriminator network based on the GAN was leveraged to learn the multi-scale spatial features of MPM images through unlabeled data. The experimental results showed that the classification accuracies for tumors of grades 1, 2, and 3 were 92.4%, 88.6%, and 89.0%, respectively. Our results suggest that the fusion of multiphoton microscopy and the GAN-based deep learning algorithm can be used as a fast and powerful clinical tool for the computer-aided intelligent pathological diagnosis of breast cancer.

Performance analysis of seven Convolutional Neural Networks (CNNs) with transfer learning for Invasive Ductal Carcinoma (IDC) grading in breast histopathological images

Computer-aided Invasive Ductal Carcinoma (IDC) grading classification systems based on deep learning have shown that deep learning may achieve reliable accuracy in IDC grade classification using histopathology images. However, there is a dearth of comprehensive performance comparisons of Convolutional Neural Network (CNN) designs on IDC in the literature. As such, we would like to conduct a comparison analysis of the performance of seven selected CNN models: EfficientNetB0, EfficientNetV2B0, EfficientNetV2B0-21k, ResNetV1-50, ResNetV2-50, MobileNetV1, and MobileNetV2 with transfer learning. To implement each pre-trained CNN architecture, we deployed the corresponded feature vector available from the TensorFlowHub, integrating it with dropout and dense layers to form a complete CNN model. Our findings indicated that the EfficientNetV2B0-21k (0.72B Floating-Point Operations and 7.1 M parameters) outperformed other CNN models in the IDC grading task. Nevertheless, we discovered that practically all selected CNN models perform well in the IDC grading task, with an average balanced accuracy of 0.936 ± 0.0189 on the cross-validation set and 0.9308 ± 0.0211on the test set.

PSAT157 Efficacy of Bisphosphanate Treatment in Pediatric Patients with Osteoporosis Due to Immobilization

Abstract Introduction Osteoporosis is medical condition commonly associated with immobilization in children, which can lead to a vicious cycle of disability, worsening osteoporosis, and recurrent fractures. Currently, bisphosphonates are widely used as a standard therapy in children with osteoporosis, but there are limited data on efficacy according to its dosage and duration. We aimed to evaluate efficacy of bisphosphonate treatment according to the dosage and duration in pediatric patients with osteoporosis due to immobilization.METHOD: We reviewed medical records of pediatric patients who were diagnosed with osteoporosis due to immobilization rated as Gross Motor Function Classification System (GMFCS) grade V, and who received bisphosphonate therapy with regular check-up for at least 1 year. The dosage and duration of the treatment, biochemical laboratory measurements, data of bone densitometry, and the occurrence of side effects were collected. Results Subjects were 21 children. The average duration of bisphosphonate treatment was 2.0 ± 0.9 years, and mean cumulative dose per body weight of bisphosphonate was 7.7 ± 2.5 (mg/kg/year). After the treatment, mean lumbar spine bone mineral contents (BMC) significantly increased from 14.20 ± 8.58 (g) to 19.38 ± 9.89 (g) (p&amp;lt;0.05), lumbar spine bone mineral density (BMD) significantly increased from 0.40 ± 0.14 (g/cm2) to 0.49 ± 0.14 (g/cm2) (p&amp;lt;0.05), and height-adjusted lumbar spine BMD Z-score also showed improvement from -2.66 ± 1.66 to -1.66 ± 1.38 with statistical significance (p&amp;lt;0.05). The cumulative dose and the duration of treatment were not related to its efficacy, but increasing average dose per body weight in each cycle (mg/kg/cycle) showed significant effects on increasing change in height-adjusted lumbar spine BMD z-score (β = 1.065, p &amp;lt;0.05). Discussion BMC, BMD, and height-adjusted BMD z-score significantly increased after bisphosphonate treatment in pediatric patient with osteoporosis due to immobilization. Independent of cumulative dosage and duration, the efficacy of bisphosphonate treatment increased significantly as average dose per body weight in each cycle increased. Further studies with sufficient number of subjects and long term follow-up observation are needed. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Long-term outcome of hamstring lengthening versus transfer and the role of biceps femoris lengthening in patients with spastic diplegia and dynamic knee flexion in gait.

Orthopedic treatment of flexed-knee gait consists of hamstring lengthening along with surgery at other levels. Transfer of the semitendinosus (hamstring transfer) was introduced to avoid increase of anterior pelvic tilt as well as reduce risk of recurrence. We retrospectively assessed children with spastic cerebral palsy and flexed-knee gait pre-operatively, 1 year post-operatively, and at a minimum of 7 years post-operatively. The 39 patients were a mean 9.4 ± 3.4 years at the time of surgery, 20 subjects underwent hamstring transfer, and 19 subjects had hamstring lengthening with mean follow-up 9.1 years. Passive range of motion improved initially, but regressed at long term. Dynamic minimum knee flexion in stance decreased in both groups at the first post-operative study, and was maintained at final follow-up in 64-67% of patients. There was a small increase in anterior pelvic tilt at the 1-year follow-up which subsequently decreased to less than pre-operative in the hamstring lengthening group but remained mildly increased (5°) in the hamstring transfer group at final follow-up. Success in correcting stance knee flexion of the entire group was 69% of the Gross Motor Function Classification System grades I and II and 60% of the Gross Motor Function Classification System grade III subjects. Gait profile Score and sagittal knee Gait Variable Score both showed clinically important improvement after surgery and was mostly maintained long term for both groups. Lateral hamstring lengthening was beneficial in more severe patients, with minimal risk of adverse effects. Hamstring surgery as part of single event multi-level surgery (SEMLS) is effective in correcting flexed-knee gait in 60%-70% of patients with minimal effect on anterior pelvic tilt. There was no added advantage to hamstring transfer. Biceps Femoris lengthening may be beneficial and without significant additional risk. level III.

The British Athletics Muscle Injury Classification grading system as a predictor of return to play following hamstrings injury in professional football players

ObjectivesInvestigate the British Athletics Muscle Injury Classification (BAMIC) grading system as a predictor of return to play (RTP) following primary hamstring strain injury (HSI) and its agreement with the Peetron's classification system in professional footballers. MethodsA retrospective cohort study of 39 hamstrings strains in a professional English football club were identified. Two musculoskeletal radiologists reviewed historical MRI's and classified them against the BAMIC and Peetron's grading system. Classification, oedema length and cross-sectional area were compared against RTP. ResultsPearson's correlation coefficient demonstrated a weak but statistically significant correlation between BAMIC and RTP (r = 0.32; 95%CI 0.01 to 0.58; p = 0.05). Maximum length of intramuscular oedema demonstrated weak correlations with RTP (r = 0.3; 95%CI -0.02 to 0.56; p = 0.06). Percentage cross sectional demonstrated a weak correlation with RTP (r = 0.02; 95%CI -0.3 to 0.33; p = 0.91). Multiple regression demonstrated that 16% of the variance in RTP was explained by the model. Kappa for the agreement between BAMIC and Peetron's was 0.21 (95%CI 0 to 0.42). ConclusionsA significant association between the grade of HSI on the BAMIC system and RTP was found. Findings suggest BAMIC could provide valuable prognostic information on the RTP.

Evaluation of prognostic preoperative factors in patients undergoing surgery for spinal metastases: Results in a consecutive series of 81 cases.

Background: Surgical treatment of spinal metastases should be tailored to provide pain control, neurological deficit improvement, and vertebral stability with low operative morbidity and mortality. The aim of this study was to analyze the predictive value of some preoperative factors on overall survival in patients undergoing surgery for spinal metastases.Methods: We retrospectively analyzed a consecutive series of 81 patients who underwent surgery for spinal metastases from 2015 and 2021 in the Clinic of Neurosurgery of Ancona (Italy). Data regarding patients’ baseline characteristics, preoperative Karnofsky Performance Status Score (KPS), and Frankel classification grading system, histology of primary tumor, Tokuhashi revised and Tomita scores, Spine Instability Neoplastic Score, and Epidural Spinal Cord Compression Classification were collected. We also evaluated the interval time between the diagnosis of the primary tumor and the onset of spinal metastasis, the type of surgery, the administration of adjuvant therapy, postoperative pain and Frankel grade, and complications after surgery. The relationship between patients’ overall survival and predictive preoperative factors was analyzed by the Kaplan–Meier method. For the univariate and multivariate analysis, the log-rank test and Cox regression model were used. P ≤ 0.05 was considered as statistically significant.Results: After surgery, the median survival time was 13 months. In our series, the histology of the primary tumor (P < 0.001), the Tomita (P < 0.001) and the Tokuhashi revised scores (P < 0.001), the preoperative KPS (P < 0.001), the adjuvant therapy (P < 0.001), the postoperative Frankel grade (P < 0.001), and the postoperative pain improvement (P < 0.001) were significantly related to overall survival in the univariate analysis. In the multivariate analysis, the Tomita (P < 0.001), Tokuhashi revised scores (P < 0.001), and the adjuvant therapy were confirmed as independent prognostic factors.Conclusion: These data suggest that patients with limited extension of primitive tumor and responsive to the adjuvant therapy are the best candidates for surgery with better outcome.