Plain Lateral Radiographs Research Articles

Comparison of the Size of the Posterior Malleolar Fragment in Trimalleolar Ankle Fractures Measured Using Lateral Plain Radiography and Three-Dimensional Computed Tomography

Comparison of the Size of the Posterior Malleolar Fragment in Trimalleolar Ankle Fractures Measured Using Lateral Plain Radiography and Three-Dimensional Computed Tomography

The Medial Tibial Plateau Can Be Used as a Direct Anatomical Reference for the Posterior Tibial Slope in Medial Unicompartmental Knee Arthroplasty.

There has been no consensus about how to determine the individual posterior tibial slope (PTS) intraoperatively. The purpose of this study was to investigate whether the tibial plateau could be used as a reference for reproducing individual PTS during medial unicompartmental knee arthroplasty (UKA). Preoperative computed tomography (CT) data from 48 lower limbs for medial UKA were imported into a three-dimensional planning software. Digitally reconstructed radiographs were created from the CT data as the lateral knee plain radiographs and the radiographic PTS angle was measured. Then, the PTS angles on the medial one-quarter and the center of the MTP (¼ and ½ MTP, respectively), and that on the medial tibial eminence (TE) were measured on the sagittal multiplanar reconstruction image. Finally, 20 lateral knee radiographs with an arthroscopic probe placed on the ¼ and the ½ MTP were obtained intraoperatively, and the angle between the axis of the probe and the tangent line of the plateau was measured. The mean radiographic PTS angle was 7.9 ± 3.0 degrees (range: 1.7-13.6 degrees). The mean PTS angles on the ¼ MTP, the ½ MTP, and the TE were 8.1 ± 3.0 degrees (1.2-13.4 degrees), 9.1 ± 3.0 degrees (1.4-14.7 degrees), and 9.9 ± 3.1 degrees (3.1-15.7 degrees), respectively. The PTS angles on the ¼ MTP and the ½ MTP were strongly correlated with the radiographic PTS angle (r =0.87 and 0.80, respectively, p < 0.001). A statistically significant difference was observed between the mean angle of the radiographic PTS and the PTS on the TE (p < 0.01). The mean angle between the axis of the probe and the tangent line of the tibial plateau was -0.4 ± 0.9 degrees (-2.3-1.3 degrees) on the ¼ MTP and -0.1 ± 0.7 degrees (-1.5-1.2 degrees) on the ½ MTP, respectively. An area from the medial one-quarter to the center of the MTP could be used as an anatomical reference for the individual PTS.

Radiographic and clinical evaluation of single-level lateral interbody fusion in patients with severe stenosis analyzed using cluster analysis.

This study was a retrospective review of patients treated in a single institution. We performed a cluster analysis of the degree of preoperative stenosis to investigate the effect of indirect neural decompression in single-level lateral lumbar interbody fusion (LLIF). Surgery is generally indicated for patients with severe stenosis. On the other hand, severe lumbar spinal stenosis is a relative contraindication to LLIF and is excluded in most studies. If LLIF, which is less invasive to treatment, can be applied to severe stenosis patients, it may help treatment. Cluster analysis classified 80 patients into 3 groups based on preoperative central canal area (CCA), preoperative canal diameter (CD), and preoperative Schizas grade: group 1 with severe stenosis (n = 43); group 2 with moderate stenosis (n = 27); and group 3 with mild stenosis (n = 10). Preoperative and immediately postoperative CCA and CD in magnetic resonance imaging were compared between groups. Disc angle (DA) and anterior, posterior, and average disc heights (AvDH) (anterior disc height, posterior disc height, average disc height AvDH) were measured using standing lateral plain radiographs. For clinical analysis, a numeric rating scale was used to evaluate clinical outcomes. DA, anterior disc height, posterior disc height, and AvDH increased significantly after the operation in all groups, but the average changes in these factors did not differ. Mean midsagittal CD and axial CCA on MRI magnetic resonance imaging increased significantly in all groups, but as with DA and DH, the changes in axial CCA and midsagittal CD did not differ between groups. The numeric rating scale score did not differ between groups at any time. The cluster analysis results suggested that postoperative changes in indirect neural decompression for severe stenosis after LLIF similar for moderate and mild stenosis and that pain did not differ according to the severity of stenosis after surgery.

Arc center distance as a novel quantitative radiographic parameter for volar Barton fractures.

The aims of this study were to investigate conventional radiographic parameters and introduce a novel parameter (arc center distance, ACD) for volar Barton fractures. Twenty-four cases of volar Barton fracture were retrospectively analyzed. We measured volar tilt angle (VTA), anteroposterior distance (APD), teardrop angle (TDA), and capitate-to-axis-of-radius distance (CARD) on lateral plain radiographs. The ACD was measured on the sagittal images of computed tomography scans. VTAs, APDs, TDAs, and CARDs were compared between the fractured and normal contralateral wrist. The area under the receiver operating characteristic curve was calculated for each parameter. TDAs did not differ significantly between the fractured wrists and the controls. On the other hand, VTAs, APDs, and CARDs were all significantly greater in the fractured wrists (mean values were 17.25°, 20.70mm, and -3.40mm, respectively). The area under the curve value was highest (0.943) for the ACD. When a cutoff value of 1.02mm was used as a threshold, a sensitivity of 100% and specificity of 80.95% were achieved. The mean values of conventional parameters (VTA, APD, TDA and CARD) in volar Barton fractures were presented. The ACD can be useful parameter for quantitatively evaluating volar Barton fractures.

Carpometacarpal Dislocation with Third Metacarpal Fracture.

Case PresentationA 17-year-old male presented to the emergency department (ED) due to trauma to the right hand and wrist after punching a locker at school. He had significant soft tissue swelling. Radiographs demonstrated intra-articular metacarpal fractures with associated carpometacarpal dislocations. The dislocation was reduced bedside in the ED and ultimately underwent closed reduction surgical management with orthopedic surgery.DiscussionMetacarpal fractures result from high-force impact injuries and account for 30–40% of all hand injuries. The most common sites of second through fifth metacarpal fractures are at the neck and the shaft, with the majority involving the fifth metacarpal neck (commonly coined “boxer’s fractures”). Carpometacarpal (CMC) dislocations are a rare injury associated with high-force impact trauma to the wrist. These injuries account for as little as 1% of all acute hand and wrist injuries.1,2 Carpometacarpal dislocations are often difficult to diagnose on physical examination due to significant soft tissue swelling, and they can easily be missed on anterior-posterior views of the hand. Lateral and oblique plain radiograph views are essential in the diagnosis as they are more likely to show dislocations. Despite appropriate plain radiographic views, subtle CMC dislocations may be difficult to discern dependent on the level of dislocation or subluxation and overlapping of joints. These injuries are rare due to otherwise highly stable ligamentous and muscular attachments within the wrist. Because of these attachments, dislocations are often associated with concomitant metacarpal fractures.3

Ground truth generalizability affects performance of the artificial intelligence model in automated vertebral fracture detection on plain lateral radiographs of the spine

BACKGROUND CONTEXTComputer-aided diagnosis with artificial intelligence (AI) has been used clinically, and ground truth generalizability is important for AI performance in medical image analyses. The AI model was trained on one specific group of older adults (aged≧60) has not yet been shown to work equally well in a younger adult group (aged 18–59). PURPOSETo compare the performance of the developed AI model with ensemble method trained with the ground truth for those aged 60 years or older in identifying vertebral fractures (VFs) on plain lateral radiographs of spine (PLRS) between younger and older adult populations. STUDY DESIGN/SETTINGRetrospective analysis of PLRS in a single medical institution. OUTCOME MEASURESAccuracy, sensitivity, specificity, and interobserver reliability (kappa value) were used to compare diagnostic performance of the AI model and subspecialists’ consensus between the two groups. METHODSBetween January 2016 and December 2018, the ground truth of 941 patients (one PLRS per person) aged 60 years and older with 1101 VFs and 6358 normal vertebrae was used to set up the AI model. The framework of the developed AI model includes: object detection with You Only Look Once Version 3 (YOLOv3) at T0-L5 levels in the PLRS, data pre-preprocessing with image-size and quality processing, and AI ensemble model (ResNet34, DenseNet121, and DenseNet201) for identifying or grading VFs. The reported overall accuracy, sensitivity and specificity were 92%, 91% and 93%, respectively, and external validation was also performed. Thereafter, patients diagnosed as VFs and treated in our institution during October 2019 to August 2020 were the study group regardless of age. In total, 258 patients (339 VFs and 1725 normal vertebrae) in the older adult population (mean age 78±10.4; range, 60–106) were enrolled. In the younger adult population (mean age 36±9.43; range, 20–49), 106 patients (120 VFs and 728 normal vertebrae) were enrolled. After identification and grading of VFs based on the Genant method with consensus between two subspecialists’, VFs in each PLRS with human labels were defined as the testing dataset. The corresponding CT or MRI scan was used for labeling in the PLRS. The bootstrap method was applied to the testing dataset. RESULTSThe model for clinical application, Digital Imaging and Communications in Medicine (DICOM) format, is uploaded directly (available at: http://140.113.114.104/vght_demo/svf-model (grading) and http://140.113.114.104/vght demo/svf-model2 (labeling). Overall accuracy, sensitivity and specificity in the older adult population were 93.36% (95% CI 93.34%–93.38%), 88.97% (95% CI 88.59%–88.99%) and 94.26% (95% CI 94.23%–94.29%), respectively. Overall accuracy, sensitivity and specificity in the younger adult population were 93.75% (95% CI 93.7%–93.8%), 65.00% (95% CI 64.33%–65.67%) and 98.49% (95% CI 98.45%–98.52%), respectively. Accuracy reached 100% in VFs grading once the VFs were labeled accurately. The unique pattern of limbus-like VFs, 43 (35.8%) were investigated only in the younger adult population. If limbus-like VFs from the dataset were not included, the accuracy increased from 93.75% (95% CI 93.70%–93.80%) to 95.78% (95% CI 95.73%–95.82%), sensitivity increased from 65.00% (95% CI 64.33%–65.67%) to 70.13% (95% CI 68.98%–71.27%) and specificity remained unchanged at 98.49% (95% CI 98.45%–98.52%), respectively. The main causes of false negative results in older adults were patients’ lung markings, diaphragm or bowel airs (37%, n=14) followed by type I fracture (29%, n=11). The main causes of false negatives in younger adults were limbus-like VFs (45%, n=19), followed by type I fracture (26%, n=11). The overall kappa between AI discrimination and subspecialists’ consensus in the older and younger adult populations were 0.77 (95% CI, 0.733–0.805) and 0.72 (95% CI, 0.6524–0.80), respectively. CONCLUSIONSThe developed VF-identifying AI ensemble model based on ground truth of older adults achieved better performance in identifying VFs in older adults and non-fractured thoracic and lumbar vertebrae in the younger adults. Different age distribution may have potential disease diversity and implicate the effect of ground truth generalizability on the AI model performance.

Role of Supine and Standing Radiography in Vertebroplasty for Osteoporotic Compression Fractures”

Objective: To confirm the benefits of vertebroplasty (VP) in selected patients with acute vertebral compression fracture (VCF) and analyze whether the study of a weight dynamic plain lateral radiograph would help in making decisions to perform VP. Using retrospective analysis, we aimed to determine the radiological characteristics of patients benefiting from VP.Methods: Data were collected from 54 patients (age, 56-97 years) diagnosed with osteoporosis and compression fractures between December 2013 and January 2018. Each patient was hospitalized with ≥2 weeks of absolute bed rest (ABR) and treated for osteoporosis. Plain lateral supine radiography of the fractured spine was performed prior to diagnosis, and both supine and standing spinal radiographs were taken 1 and 2 weeks after ABR. Patients were categorized into the VP and non-VP groups 2 weeks after ABR.Results: Although patients with worse pain and functional progress were selected to undergo VP, patients in the VP group presented better outcomes in the fourth week of evaluation than those in the non-VP group. In a retrospective analysis of the radiographic study, changes in the compression rate between supine and standing (weight-bearing) X-rays (ΔCR), showed a statistically significant correlation with the patient’s outcome in the second week.Conclusion: VP was found to be an effective management option for patients with VCF. A weightbearing radiographic study of VCFs provided valuable information on patient selection for VP. Therefore, patient selection based on subjective surveys and radiological studies to determine the benefits of VP could be a beneficial management strategy.

Confirmation of accuracy/inaccuracy of lumbar pedicle screw placement using postoperative computed tomography.

Background: Transpedicular screws are extensively utilized in lumbar spine surgery. The placement of these screws is typically guided by anatomical landmarks and intraoperative fluoroscopy. Here, we utilized 2-week postoperative computed tomography (CT) studies to confirm the accuracy/inaccuracy of lumbar pedicle screw placement in 145 patients and correlated these findings with clinical outcomes.Methods: Over 6 months, we prospectively evaluated the location of 612 pedicle screws placed in 145 patients undergoing instrumented lumbar fusions addressing diverse pathology with instability. Routine anteroposterior and lateral plain radiographs were obtained 48 h after the surgery, while CT scans were obtained at 2 postoperative weeks (i.e., ideally these should have been performed intraoperatively or within 24–48 h of surgery).Results: Of the 612 screws, minor misplacement of screws (≤2 mm) was seen in 104 patients, moderate misplacement in 34 patients (2–4 mm), and severe misplacement in 7 patients (>4 mm). Notably, all the latter 7 (4.8% of the 145) patients required repeated operative intervention.Conclusion: Transpedicular screw insertion in the lumbar spine carries the risks of pedicle medial/lateral violation that is best confirmed on CT rather than X-rays/fluoroscopy alone. Here, we additional found 7 patients (4.8%) who with severe medial/lateral pedicle breach who warranting repeated operative intervention. In the future, CT studies should be performed intraoperatively or within 24–48 h of surgery to confirm the location of pedicle screws and rule in our out medial or lateral pedicle breaches.

Idiopathic Congenital Cervical Megaesophagus in a Goat Kid

Megaesophagus is atony and dilatation of the esophagus that is usually congenitally but acquired cases also happen. Salivation, regurgitation, aspiration pneumonia, and esophagitis are complications of the megaesophagus. Megaesophagus has been reported in various animals including horses, cows, buffaloes, goats, sheep, dogs, and cats but the occurrence is rare in ruminants. The exact etiology of the megaesophagus remains unknown. A two-day-old goat kid from a goat herd was referred to veterinary education and teaching hospital who regurgitate after milk feeding and sometimes cough. An Enlargement was felt under the throat after milk feeding. Two similar cases in this herd had died with these symptoms in the past month. All vital signs and complete blood cell count of the animal were normal. Lateral plain radiographs and contrast radiographs with barium contrast were performed for further examination. Radiographic findings confirmed the congenital cervical megaesophagus. Esophageal massage to the down direction and the forelimb raising after eating a small amount of milk was also recommended for this animal as a treatment protocol. It was recommended that the bucks should be culled to control the possible genetic origin. In our follow-up after a week, the kid was alive, but dead in the second week. This report presents the descriptions of clinical and radiographical findings of a congenital cervical megaesophagus in a kid. The complications can be relatively controlled with special care, but it is unlikely that the animal can be kept alive for long periods.

Surgical outcomes of cervical myelopathy in patients with athetoid cerebral palsy.

Surgical treatment for cervical myelopathy with athetoid cerebral palsy remains unestablished. Instrumented fusion is reported to have good clinical results; however, there are no data of decompression surgery for this pathology in recent years. This study aimed to assess the surgical outcomes of laminoplasty with or without posterior instrumented fusion for cervical myelopathy in patients with athetoid cerebral palsy. A multi-centre surgical series of patients with cervical myelopathy and athetoid cerebral palsy were enrolled in this study. All patients showed symptoms and signs suggestive of cervical myelopathy and underwent laminoplasty with or without instrumented fusion. The Japanese Orthopaedic Association (JOA) score, Barthel index (BI), and changes in the C2-C7 sagittal Cobb angle in the lateral plain radiograph were analysed. There were 25 patients (16 men and 9 women; mean age, 54.4 ± 10.8years) with cervical myelopathy and athetoid cerebral palsy who underwent surgical treatment. The mean follow-up period was 41.9 ± 35.6months. Overall, the BI significantly improved after surgery, whereas the JOA score and C2-C7 angle did not improve postoperatively. The recovery rate of the JOA score in the laminoplasty group was significantly higher than that of the fusion group (P = 0.02). Cervical laminoplasty with or without instrumented fusion for treating cervical myelopathy due to athetoid cerebral palsy is effective in improving activities of daily living. Cervical laminoplasty may be an effective and less invasive surgical method for selective patients, especially for those with small involuntary movements and no remarkable cervical kyphosis nor instability.

P40. Indirect effect on adjacent segment after minimally invasive transforaminal lumbar interbody fusion

<h3>BACKGROUND CONTEXT</h3> MIS-TLIF is an alternative treatment for degenerative spine disease, which aims to decompress and stabilize the most stenotic level correlating with clinical symptoms, while sparing the less severe adjacent segments. According to previous studies, interbody fusion was reported to not only affect the fused level, but also the adjacent segments. These effects might cause changes in canal dimensions at the adjacent segments, leading to unsatisfactory postoperative symptoms. <h3>PURPOSE</h3> The goal of this study was to compare the dural sac area and other canal dimension parameters on MRI at the adjacent segments before and after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), including the change in segmental and regional parameters measured on plain radiograph. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study King Chulalongkorn Memorial Hospital. <h3>PATIENT SAMPLE</h3> Patients who underwent MIS-TLIF at L4/5 level in King Chulalongkorn Memorial Hospital The indications for surgery were spinal canal stenosis, herniated nucleus pulposus, and spondylolisthesis grade 1-2. <h3>OUTCOME MEASURES</h3> MR image parameters: dural sac area (DSA), sagittal spinal AP diameter (SAPD), ligamentum flavum area (LFA), ligamentum flavum thickness (LFT), foraminal area (FA), foraminal height (FH), at the adjacent segments of fused level. Standing lateral plain radiograph: disc height (DH), segmental angle (SA) of adjacent segments and fused level lumbar lordosis (LL) <h3>METHODS</h3> Forty-four patients who underwent MIS-TLIF at L4/5 level were examined. The indications for surgery were spinal canal stenosis, herniated nucleus pulposus, and spondylolisthesis grade 1-2. We reviewed their standing plain radiograph and MR image parameters, including dural sac area (DSA), sagittal spinal AP diameter (SAPD), ligamentum flavum area (LFA), ligamentum flavum thickness (LFT), foraminal area (FA), foraminal height (FH), disc height (DH), segmental angle (SA), and lumbar lordosis (LL) at the adjacent segments of fused level. Disc height and segmental angle at fused level was also reviewed. All parameters were compared before, and 3 months postoperatively. <h3>RESULTS</h3> The mean (SD) pre- and postoperative DSA at upper adjacent segment was 125.12 (35.72) and 133.17 (35.07) mm2, while pre- and postoperative DSA at lower adjacent segment was 103.58 (44.32) and 117.66 (46.34) mm2 respectively. The postoperative DSA significantly increased in the upper (mean change 8.05 (95%CI 4.44-11.66) mm2, P <0.001) and lower (14.08 (95%CI 9.47 – 18.69) mm2; P <0.001) adjacent segments. Eleven (25%) and 22 (25%) patients had preoperative upper adjacent segment areas <100 mm2 and ≥100 mm2respectively. The mean change in DSA was greater in patients with preoperative DSA <100 mm2 versus ≥100 mm2, but the difference was more pronounced in the upper versus the lower adjacent segment (4.3 (95%CI -4 to 12.7) mm2; P = 0.30 versus 1.1 (95%CI -8.3 to 10.4); P = 0.82, respectively). Significant increases in SAPD were also seen in both upper (0.85 (95%CI 0.45 to 1.25 mm; P <0.001) and lower (0.66 (95%CI 0.34 to 0.97) mm; P<0.001) adjacent segments. LFT significantly decreased in the lower adjacent segment (-0.37 (95%CI -0.62 to -0.11) mm; P=0.006); a small but non-significant decrease was also observed in the upper adjacent segment (-0.1 (95%CI -0.37 to 0.17) mm; P=0.47). No other significant changes in other canal dimensions were noted. <h3>CONCLUSIONS</h3> Adjacent segment DSA increased significantly after MIS-TLIF. In addition, other parameters representing canal dimension (SAPD, LFT) also significantly changed after the operation. Further studies are needed to assess the relationship between these changes and postoperative clinical outcomes. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Paraspinal muscle fatty degeneration as a predictor of progressive vertebral collapse in osteoporotic vertebral compression fractures

BACKGROUND CONTEXTMost osteoporotic vertebral compression fractures (OVCFs) are treated conservatively; however, in some patients, progressive vertebral body collapse leads to spinal deformity and cord compression. These complications are strongly associated with impaired performance activities of daily living and a poor quality of life. PURPOSETo identify the role of the paraspinal muscle as a risk factor for progressive vertebral body collapse in patients with OVCF. STUDY DESIGNThis was a retrospective observational study. PATIENT SAMPLEFifty-five consecutive patients with OVCF who were treated conservatively from January 2018 to June 2020 in a single spine center and had a minimum follow-up of 6 months. OUTCOME MEASURESA lateral plain radiograph in a neutral posture was taken when the patient was first diagnosed and at 1, 3, and 6 months after the first diagnosis. Vertebral height was measured at the point of maximal collapse of the affected vertebral body; vertebral collapse (%) was also measured. The cross-sectional area (CSA) and fatty degeneration of the paraspinal muscle were measured using the open-source software Image J. The visual analogue scale (VAS) scores were collected at the time of initial fracture diagnosis and at 1, 3, and 6 months. METHODSThe clinical and radiological data were analyzed. In the L4–5 intervertebral disc level, axial T2-weighted magnetic resonance imaging was used to measure the CSA and fatty degeneration of the paraspinal muscles. Correlation and multiple regression analyses were performed to analyze the risk factors associated with progressive vertebral body collapse. RESULTSThe vertebral collapse difference was strongly associated with paraspinal muscle fatty degeneration (r=0.684, p=.000) and body mass index (r=0.300, p=.026). Multiple linear regression analysis demonstrated that the risk factor for progression of vertebral collapse was paraspinal muscle fatty degeneration (β=0.724, p=.000). There was a statistically significant correlation between the progression in vertebral collapse and VAS score at 3 (r=0.402, p=.002) and 6 months (r=0.604, p=.000). CONCLUSIONSIn patients with OVCF, fatty degeneration of the paraspinal muscle was a predictive factor for progressive vertebral body collapse. This study suggests that more attention should be paid to patients with paraspinal sarcopenia among those with OVCFs.

Role of preoperative cervical alignment on postoperative dysphagia after occipitocervical fusion.

Background: Dysphagia is one of the most serious complications of occipitocervical fusion (OCF). The previous studies have shown that postoperative cervical alignment, documented with occipito (O)-C2 angles, C2-C6 angles, and pharyngeal inlet angles (PIA), impacted the incidence of postoperative dysphagia in patients undergoing OCF. Here, we investigated the relationship of preoperative versus postoperative cervical alignment on the incidence of postoperative dysphagia after OCF.Methods: We retrospectively reviewed the clinical data/medical charts for 22 patients following OCF (2006– 2019). The O-C2 angles, C2-C6 angles, PIA, and narrowest pharyngeal airway spaces (nPAS) were assessed using plain lateral radiographs of the cervical spine before and after the surgery. The severity of dysphagia was assessed with the functional oral intake scale (FOIS) levels as documented in medical charts; based on this, patients were classified into the nondysphagia (FOIS: 7) versus dysphagia (FOIS: 1–6) groups.Results: Seven patients (35%) experienced dysphagia after OCF surgery. Preoperative PIA and nPAS were smaller in the dysphagia group. Spearman rank correlation showed a positive correlation between preoperative PIA and FOIS and between preoperative nPAS and FOIS.Conclusion: This study suggests that preoperative cervical alignment may best predict the incidence of postoperative dysphagia after OCF.

Use of residual neural network for the detection of ossification of the posterior longitudinal ligament on plain cervical radiography.

Ossification of the posterior longitudinal ligament (OPLL) causes serious problems, such as myelopathy and acute spinal cord injury. The early and accurate diagnosis of OPLL would hence prevent the miserable prognoses. Plain lateral radiography is an essential method for the evaluation of OPLL. Therefore, minimizing the diagnostic errors of OPLL on radiography is crucial. Image identification based on a residual neural network (RNN) has been recognized to be potentially effective as a diagnostic strategy for orthopedic diseases; however, the accuracy of detecting OPLL using RNN has remained unclear. An RNN was trained with plain lateral cervical radiography images of 2,318 images from 672 patients (535 images from 304 patients with OPLL and 1,773 images from 368 patients of Negative). The accuracy, sensitivity, specificity, false positive rate, and false negative rate of diagnosis of the RNN were calculated. The mean accuracy, sensitivity, specificity, false positive rate, and false negative rate of the model were 98.9%, 97.0%, 99.4%, 2.2%, and 1.0%, respectively. The model achieved an overall area under the curve of 0.99 (95% confidence interval, 0.97-1.00) in which AUC in each fold estimated was 0.99, 0.99, 0.98, 0.98, and 0.99, respectively. An algorithm trained by an RNN could make binary classification of OPLL on cervical lateral X-ray images. RNN may hence be useful as a screening tool to assist physicians in identifying patients with OPLL in future setting. To achieve accurate identification of OPLL patients clinically, RNN has to be trained with other cause of myelopathy.

Automated detection of cervical ossification of the posterior longitudinal ligament in plain lateral radiographs of the cervical spine using a convolutional neural network

Cervical ossification of the posterior longitudinal ligament (OPLL) is a contributing factor to spinal cord injury or trauma-induced myelopathy in the elderly. To reduce the incidence of these traumas, it is essential to diagnose OPLL at an early stage and to educate patients how to prevent falls. We thus evaluated the ability of our convolutional neural network (CNN) to differentially diagnose cervical spondylosis and cervical OPLL. We enrolled 250 patients with cervical spondylosis, 250 patients with cervical OPLL, and 180 radiographically normal controls. We evaluated the ability of our CNN model to distinguish cervical spondylosis, cervical OPLL, and controls, and the diagnostic accuracy was compared to that of 5 board-certified spine surgeons. The accuracy, average recall, precision, and F1 score of the CNN for classification of lateral cervical spine radiographs were 0.86, 0.86, 0.87, and 0.87, respectively. The accuracy was higher for CNN compared to any expert spine surgeon, and was statistically equal to 4 of the 5 experts and significantly higher than that of 1 expert. We demonstrated that the performance of the CNN was equal or superior to that of spine surgeons.

Atherosclerosis-calcification score and predictors of intra-dialytic hypotension.

Intra-dialytic hypotension episodes (ID-Hypos) cause significant reduction of dialysis efficiency and increased cardiovascular morbimortality. Atherosclerosis and vascular calcification are two closely inter-related processes that occur prematurely and progress aggressively in maintenance hemodialysis (MHD) patients. To study the predictors of ID-Hypos, particularly a novel combined atherosclerosis-calcification score (CACS) (0 to 6) obtained by adding the atherosclerosis score (AS) to a modified abdominal aortic calcification score (AACS), each ranging 0 to 3. In 60 adult MHD patients, AS was derived from ankle-brachial index and carotid ultrasound. AACS was modified from Kauppila score applied on lateral abdominal plain radiographs. The number of sessions complicated by ≥ 1 ID-Hypos over 14 weeks was recorded and correlated with CACS, ultrafiltration rate (UFR), and other hemodynamic and laboratory parameters. Patients developed a median of 10.5 ID-Hypos (IQR 5.75-14). The number of ID-Hypos had a statistically significant positive correlation with CACS (r = 0.291, p = 0.024), but not with its individual components. AACS had a statistically significant positive correlation with s. phosphorus and calcium-phosphorus product. On multivariate analysis, the most significant independent predictors of ID-Hypos were high UFR, high CACS, and low hemoglobin. Serum C-reactive protein had a positive correlation with ID-Hypos that was lost in the adjusted models. High UFR, CACS, and anemia are significant predictors of ID-Hypos. CACS may help in quantifying vascular pathology and characterizing MHD patients at highest risk for ID-Hypos, those who would be prioritized for potential preventive measures like biocompatible membranes or hemodiafiltration. A background of chronic inflammation may underlie and link patient-related ID-Hypos risk factors.

Double versus triple arthrodesis for adult-acquired flatfoot deformity due to stage III posterior tibial tendon insufficiency: a prospective comparative study of two cohorts

PurposeThe study aims to prospectively compare double and triple arthrodesis in terms of functional outcomes and deformity correction. To the best of our knowledge, this is the first prospective comparative study in the literature to date.MethodsThis is a prospective comparative cohort study carried out between May 2017 and May 2019. The study was approved by the IRB at Assiut University and done according to the Helsinki declaration. Patients with AAFD stage III aged between 15 and 40 years old were assigned to double arthrodesis or triple arthrodesis. The groups were prospectively followed for one year. Primary outcomes were union rates, AOFAS scores, and radiological parameters of deformity correction on AP and lateral plain radiographs. Secondary outcomes were operative time, time to union, and complications. The double arthrodesis was done through the medial approach, while the triple arthrodesis was done through dual medial and lateral approaches. The post-operative protocol was standardized for both groups.ResultsA total of twenty-three patients matched the inclusion criteria and provided their consent to participate in the study. Thirteen (all males) patients underwent double arthrodesis, while ten (nine males and one female) patients underwent triple arthrodesis. The mean age for double and triple arthrodesis was 20.15 ± 5.63 and 25.10 ± 8.36 years, respectively, and the mean follow-up lengths were 12.46 and 12.9 months, respectively. There were no statistically significant differences between both groups in age, gender, laterality, or duration of follow-up. There were no statistically significant differences between both groups in AOFAS hindfoot scores or radiographic parameters. All patients were available for the final follow-up evaluation. All patients in both groups achieved union by four months post-operatively. The mean time to union in the double and triple arthrodesis groups was 3.39 ± 0.65 vs. 3.31 ± 0.6 months, respectively, with no statistically significant differences (p = 0.77). The mean operative time was significantly shorter in the double arthrodesis group than the triple arthrodesis group, 55.77 ± 15.18 vs. 91.6 ± 24.14 min (p < 0.001), respectively. Both double and triple arthrodesis groups had a statistically significant improvement of the mean AOFAS hindfoot score post-operatively (71.46 ± 7.77 vs. 88.38 ± 3.66, p < 0.001) and (66.9 ± 7.69 vs. 85 ± 5.83, p < 0.001), respectively. In the double arthrodesis group, the mean calcaneal pitch angle increased from 11.46° pre-operatively to 19.34° (MD = 8.45°, p < 0.001). The mean Meary’s angle improved from − 4.19 to 2.9° (MD = 7.32°, p < 0.001). Hibbs angle had a mean reduction of 6.45° post-operatively (p = 0.069). In the triple arthrodesis group, the mean calcaneal pitch angle improved from 10.06° pre-operatively to 17.49° post-operatively (MD = 7.12°, p < 0.001). The mean Meary’s angle improved from − 4.72 to 2.29° (MD = 7.09°, p < 0.001). The mean Hibbs angle decreased from 153.07 to 142.32° (MD = 10.54°, p < 0.001). The double vs. triple arthrodesis groups had no statistically significant differences in AOFAS hindfoot score improvement (16.92 vs. 19.1, p = 0.44), respectively. The two groups had no statistically significant differences in the magnitude of correction of all the radiographic parameters.ConclusionDouble arthrodesis is an equally reliable surgical option for AAFD stage III for achieving union, improving the functional outcomes, and deformity correction as triple arthrodesis with a significantly shorter operative time in the former. The authors recommend double arthrodesis if the calcaneocuboid joint is unaffected.

The Kappa Line as a Regional Modification of the K-line: A Predictor of Neurological Outcome and Indicator of the Adequate Level of Decompression in Selective Laminoplasty.

This is a retrospective cohort study. The aim was to introduce Kappa line (modification of K-line) for the prediction of postoperative neurological recovery after selective cervical laminoplasty (LMP) and use in determining the decompression level. The K-line is a radiographic marker that can predict prognosis and aid in surgical planning for patients undergoing LMP through C3 to C7. However, its efficacy in LMP involving limited segments is unclear. Furthermore, no specific radiographic marker to predict the prognosis of selective LMP has been reported. Fifty-one consecutive patients with a minimum 2-year follow-up after selective LMP for cervical myelopathy caused by ossification of posterior longitudinal ligament were retrospectively reviewed. The Kappa line was defined as a straight line connecting the midpoints of the spinal canal made by remaining bony structure after decompression procedures on a plain lateral radiograph in the neutral position. Patients were classified as K-line (+) or (-) and Kappa line (+) or (-) based on whether the ossified mass crossed the indicator line. The Kappa line (+) group demonstrated significantly higher Japanese Orthopaedic Association (JOA) recovery rate (P=0.01), final JOA score (P<0.01), and dural sac diameter (P<0.01) postoperatively than the Kappa line (-) group. Cord compression grade was significantly lesser in the Kappa line (+) group. However, the K-line-based classification did not demonstrate significant difference in JOA recovery rate, final JOA score, and cord compression grade between the (+) and (-) groups; the dural sac diameter was significantly higher in the K-line (+) group (P<0.01). The Kappa line showed better correlation with ossification of posterior longitudinal ligament size and cervical alignment, providing better prediction of neurological recovery and remaining cord compression following selective LMP. Therefore, the Kappa line can aid in determining the level of decompression in selective LMP.

Does proximal migration of the first metacarpal correlate with remaining pain after trapeziectomy?

Proximal migration of the thumb metacarpal has been suggested as a possible cause of remaining pain after trapeziectomy for trapeziometacarpal joint osteoarthritis. The aim of this study was to investigate if proximal migration after trapeziectomy is associated with a poorer long-term outcome in terms of pain and objective physical variables. We retrospectively examined 91 thumbs in 65 patients after a mean of 10 years following trapeziectomy with or without ligament reconstruction and tendon interposition. Proximal migration of the thumb metacarpal was measured on plain lateral radiographs of the thumb and correlated to visual analogue pain scale (VAS), thumb range of motion and strength. Most thumbs had a severe proximal migration of the first metacarpal, the mean scaphoid metacarpal distance was 2.7 mm. Most patients reported no or little pain, median VAS was 0 at rest and 1 after load. There were no differences in reported VAS pain at rest or after load between patients with severe (<2 mm scaphoid metacarpal joint space) or less severe (≥2 mm metacarpal joint space) proximal migration. Patients that reported more pain (VAS >2) did not exhibit more migration than patients reporting less or no pain. Thumbs with severe migration had weaker key pinch (3.4 vs. 4.6 kg, p = 0.008) and grip strength (15 vs. 21 kg p = 0.002). We conclude that proximal migration most likely does not cause residual or recurrent pain after trapeziectomy.

The Influence of Endplate Morphology on Cage Subsidence in Patients With Stand-Alone Oblique Lateral Lumbar Interbody Fusion (OLIF).

A retrospective study of prospectively collected radiographic and clinical data. This study aims to investigate the relationship between endplate morphology parameters and the incidence of cage subsidence in patients with mini-open single-level oblique lateral lumbar interbody fusion (OLIF). We included 119 inpatients who underwent OLIF from February 2015 to December 2017. A total of 119 patients with single treatment level of OLIF were included. Plain anteroposterior and lateral radiograph were taken preoperatively, postoperatively, and during follow-up. The correlation between disc height, endplate concave angle/depth, cage position and cage subsidence were investigated. Functional rating index (Visual Analogue Scale for pain, and Roland Morris Disability Questionnaire) were employed to assess clinical outcomes. Cage subsidence was more commonly seen at the superior endplates (42/119, 35.29%) than at the inferior endplates (6/119, 5.04%) (p < 0.01). More importantly, cage subsidence was significantly less in patients with superior endplates that were without concave angle (3/20, 15%) than with concave angle (37/99, 37.37%) (p < 0.05). Cage subsidence correlated negatively with preoperative anterior disc height (r = -0.21, p < 0.05), but positively with disc distraction rate (r = 0.27, p < 0.01). Lastly, the distance of cage to the anterior edges of the vertebral body showed a positive correlation (r = 0.26, p < 0.01). This study for the first time demonstrated that endplate morphology correlates with cage subsidence after OLIF. Since relatively flat endplates with smaller concave angle significantly diminish the incidence of subsidence, the morphology of cage surface should be taken into consideration when designing the next generation of cage. In addition, precise measurement of the disc height to avoid over-distraction, and more anteriorly placement of the cage is suggested to reduce subsidence.