Preoperative Radiographic Parameters Research Articles

Preoperative difference between 2D and 3D planning correlates with difference between planned and achieved surgical correction in patient‐specific instrumented total knee arthroplasty

AbstractPurposeThe goals of this study were (1) to assess whether the preoperative difference between modalities and extent of deformity are associated with a higher difference between planned and achieved surgical correction and (2) if they yield a higher probability of intraoperative adjustments.MethodsRetrospective single‐centre analysis of patients undergoing patient‐specific instrumented (PSI) total knee arthroplasty (TKA). Preoperative radiographic parameters were analysed on weightbearing (WB) long‐leg radiographs (LLR) and nonweightbearing (NWB) computed tomography (CT). The 2D/3D difference was calculated as the difference between preoperative WB‐LLR (2D) hip–knee–ankle angle (HKA), and NWB CT (3D) HKA. Surgical records were screened to retrieve intraoperative adjustments to the preoperative plan. Postoperative assessment was performed on WB LLR.ResultsTwo‐hundred‐eighty‐two knees of 263 patients were analysed. The difference of postoperative achieved to planned HKA (HKADifference) was 2.2° ± 1.7°. The preoperative 2D HKA showed the highest correlation with HKADifference (r = −0.37, 95% confidence interval [CI]: −0.48 to −0.26, p < 0.001). Intraoperative adjustments were performed in 60% (n = 170) of all knees. Patients with a preoperative coronal deformity of >7.8° had 10.55 higher odds for an intraoperative coronal adjustment (95% CI: 4.60–24.20, p < 0.001).ConclusionThe extent of deformity is associated with residual coronal deformity following PSI‐TKA. Patients with extensive coronal malalignment may benefit from an adaptation of the preoperative surgical plan to avoid unintended postoperative coronal malalignment. Despite the advancements with 3D preoperative planning, intraoperative adjustments in PSI‐TKA are frequently performed, in particular in patients with a higher preoperative varus/valgus deformity.Level of EvidenceLevel III.

Comparative Analysis of Outcomes and Kyphotic Risk Factors After Cervical Laminoplasty in 2 Different Ossification of the Posterior Longitudinal Ligament Groups and Cervical Spondylotic Myelopathy.

Cervical laminoplasty is commonly used to treat cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL). Postoperative kyphotic changes can restrict spinal cord dorsal shift, leading to poor neurological outcomes. This study analyzes risk factors for loss of cervical lordosis (LCL) after laminoplasty in 3 groups: CSM, continuous OPLL, and other OPLL. It also evaluates postoperative changes in cervical spine parameters: C2-7 sagittal vertical axis, C2-7 Cobb angle (CA), T1 slope, and C2 slope. This retrospective study included 154 patients who underwent cervical laminoplasty from January 2018 to January 2023. Patients were categorized into 3 groups: CSM (Group 1), continuous OPLL group (Group 2), and noncontinuous OPLL group (Group 3). Preoperative and postoperative radiographic parameters were measured. Analysis of variance and Tukey HSD post hoc tests identified significant differences among the groups. Receiver operating characteristic analysis determined the cutoff value of K-line tilt. Kyphotic changes (>10°) were observed in 18.2% of patients postoperatively: 23.8% in Group 1, 1.7% in Group 2, and 28.3% in Group 3. Significant differences were found among the groups in preoperative K-line, C2-7 CA, extension C2-7 CA, and C2 slope (P < .05). Univariate and multivariate analyses revealed that greater age, higher K-line tilt, lower preoperative CA-extensor CA, and lower extensor muscle volume were significant risk factors of LCL in Groups 1 and 3. In Group 2, higher preoperative K-line tilt and K-line negative status were associated with greater LCL. Receiver operating characteristic analysis showed that K-line tilt is a strong predictive parameter with a threshold of 15.15°. The continuous OPLL group had a lower likelihood of postoperative kyphosis due to structural support. K-line tilt, dynamic extension reserve, and extensor muscle volume were significant predictors of LCL in CSM and segmental OPLL groups. K-line tilt is a valuable radiographic parameter for predicting outcomes and guiding surgical decisions in cervical laminoplasty patients.

Development of Modic Changes After Percutaneous Endoscopic Transforaminal Lumbar Discectomy: From Risk Analysis to Prediction Modeling.

This study examines the occurrence of Modic changes (MC) within the first year following percutaneous endoscopic transforaminal lumbar discectomy (PETD) and investigates associated risk factors. This study adopted a retrospective cohort design. Between January 2019 and June 2023, 538 patients diagnosed with single-level lumbar disc herniation and treated with PETD were included. The patients were divided into a training set and a validation set based on their surgery dates. Preoperative radiographic parameters and perioperative indicators were evaluated. Univariate analysis examined risk factors for postoperative MC. Gender-specific subgroups were analyzed. Binary logistic regression developed a predictive model for postoperative MC, assessed using ROC, calibration, and decision curves. The incidence of MC at one year after PETD was 24.8%. Logistic regression identified 8 significant risk factors for MC after PELD: longer symptom duration, proximity of herniated segment to sacrum, severe disc degeneration, reduced disc height, greater vertebral endplate concavity angle, segmental instability, and lumbar-sacral fusion. Menopause and herniation type were identified as female-specific risk factors. In males, total cholesterol levels were additionally found to be a risk factor for postoperative MC. The male and female subgroup models exhibited satisfactory performance across ROC analysis, calibration plots, and decision curve analysis. Specifically, for male patients, the area under the curve (AUC) was 0.831 for the training set and 0.820 for the validation set; for female patients, the AUC was 0.911 for the training set and 0.868 for the validation set. A nomogram was developed to visualize the model. This study explored the relevant risk factors of MC after PETD and visualized the prediction model by nomogram, which is beneficial to optimize the surgical scheme of PETD to improve the clinical efficacy.

Fractures in Oxford unicompartmental knee arthroplasty are associated with a decreased medial keel-cortex distance of the tibial implant

PurposeThis retrospective single-center study aimed to investigate incidence and risk factors influencing tibial periprosthetic fractures (TPF) in Oxford unicompartmental knee arthroplasty (UKA), with a specific focus on tibial component positioning and sizing.MethodsA total of 2063 patients with medial UKA using the Oxford® mobile partial knee implant were analyzed between July 2014 and September 2022. Various preoperative and postoperative radiographic parameters determining pre- and postoperative alignment and implant positioning, incidence and characteristics of periprosthetic fractures, and patient demographics were assessed. Statistical analyses, including Mann–Whitney U test and logistic regression, were conducted to identify significant associations and predictors of tibial fractures.ResultsOf the 1853 cases that were finally included in the study, 19 (1%) patients experienced TPF. The fracture group presented with a significantly shorter relative mediolateral and posteroanterior distance between the keel and cortex [mediolateral: 23.3% (23.2–24.8%) versus 27.1% (25.7–28.3%), p < 0.001; posteroanterior: 8.4% (6.3–10.3%) versus 10.0% (9.8–10.1%), p = 0.004]. Additionally, an increased posterior tibial slope in pre- and postoperative radiographs [preoperative: 10.4° (8.6–11.1°) versus 7.7° (5.4–10.0°), p < 0.001; postoperative 9.1° ± 3.1° versus 7.5° (5.9–9.0°), p = 0.030] was observed in the fracture group. Furthermore, the use of smaller-sized implants (AA) was associated with higher fracture rates (p < 0.001). Anatomical variants, such as a medial overhanging tibial plateau, were not observed.ConclusionsIn UKA, type Oxford TPF are linked to shorter mediolateral and posteroanterior keel-cortex distances, increased pre- and postoperative PTS, and small implant sizes (AA). Fracture lines often extend from the distal keel to the medial tibial cortex. These findings emphasize the importance of precise implant positioning and sizing to minimize fracture risk.Level of evidence Retrospective single-center study, III.

The Effect of L5 Morphology on Prevention of L5-S1 Degeneration Following Floating Fusion for Degenerative Spine Disorders.

Retrospective Study. The selection of floating fusion or lumbosacral fusion arises when treating patients with instability or stenosis of the lower lumbar spine concomitantly radiographic degeneration of L5-S1. This study aimed to investigate the preoperative anatomical or morphological factors affecting the survivorship of the L5-S1 after floating fusion. This study included 77 patients who had undergone floating fusion surgery through the TLIF approach. Preoperative radiographic parameters were evaluated using anteroposterior and lateral lumbar spine radiographs. The patients were divided into two groups according to the Modified Pfirrmann Grading and total endplate score. Multivariable regression analysis was performed to explore the relationships between the anatomical or morphological characteristics of L5 and the degeneration of L5-S1. The disc degeneration group exhibited a smaller height ratio of the iliac crest (Hi) and a less L5 deep position. Furthermore, the right/left height of L4 (Hr/Hl) and the right/left width of transverse process of L5 (CRt/CLt) were significantly higher in the disc and endplate degeneration groups. Multiple logistic regression analysis revealed that Hi and CRt were independently associated with L5-S1 disc degeneration, whereas Hr was a significant risk factor for L5-S1 endplate degeneration. Anatomical and morphological characteristics of L5, such as smaller Hi, higher CRt and Hr, were associated with an increased risk of L5-S1 degeneration in patients after floating fusion. These findings may indicate the fusion level when addressing lower lumbar degenerative diseases and the concurrent radiographic degeneration of L5-S1.

Improved clinical and radiographic outcomes with expandable cages in transforaminal lumbar interbody fusion: a propensity-matched cohort analysis.

The restoration of sufficient overall lumbar lordosis (LL) and segmental LL (SL) is associated with achieving optimal sagittal balance, decreasing back pain, and enhancing functional outcomes for patients. Expandable cages were developed in hopes of improving radiographic parameters and clinical outcomes, although current clinical evidence is inconclusive. Here, the authors aimed to evaluate the clinical and radiographic outcomes in patients undergoing one- or two-level open transforaminal lumbar interbody fusion (TLIF) with expandable versus static cage placement, using propensity-matched cohorts. An institutional retrospective cohort of patients who underwent one- or two-level open TLIF with either expandable cage or static cage placement was identified. Using relevant preoperative covariates, including age, primary versus revision operation, number of cages implanted, and surgical level implanted, the authors built propensity-matched cohorts. They identified clinical outcomes in both cohorts, including operative characteristics and complication rates, along with pain, weakness, and sensory deficits over follow-up. Furthermore, they extracted and examined preoperative, postoperative, and last follow-up radiographic parameters. A total of 148 patients were included, and they were followed for a mean of 1.7 years (range 0.5-4.3 years). Propensity matching was used to create cohorts of patients who were similar with respect to age, surgical indication, revision status, number of cages implanted, surgical level implanted, and length of follow-up. Patients in both groups had similar preoperative radiographic parameters. Patients with expandable cages saw larger increases in SL, both postoperatively (5.3° ± 7.5° vs 1.6° ± 5.6°, p = 0.006) and at last follow-up (5.7° ± 7.4° vs 1.0° ± 6.1°, p = 0.003). They also saw significant improvements in pelvic incidence minus LL mismatch at last follow-up (-4.4° ± 13.2° vs 5.8° ± 13.8°, p = 0.009). No differences in intraoperative or perioperative complications were found, but patients with expandable cages were less likely to require readmission, develop adjacent-segment disease, or require revision surgery. They were also more likely to be symptom free at 1 month after surgery and at last follow-up. Expandable cages lead to better restoration of radiographic features, including SL and improvements in clinical outcomes, compared with static cages in propensity-matched cohorts in patients undergoing one- or two-level open TLIFs.

Radiographic Measurements of Pes Planovalgus Do Not Predict Clinical Outcomes in Tarsal Coalition Excision.

Many patients who undergo tarsal coalition excision have persistent postoperative pain. Most studies have utilized cat scan (CT) scan parameters of pes planovalgus and heel valgus but have found this to be an inconsistent predictor of outcomes. Plain radiographic parameters have been less utilized in trying to predict outcomes after coalition excision. Radiographic talonavicular coverage angle correlates with pain in patients with flexible pes planovalgus (PPV) but has not been studied in tarsal coalition population. Furthermore, foot alignment is not understood to change after simple coalition excision. The purpose of this study was to compare plain radiographic parameters, including talonavicular coverage angle, with pain after tarsal coalition excision, as well as compare preoperative and postoperative weight-bearing radiographs. Seventy-seven feet that underwent excision of the tarsal coalition had clinical outcomes and radiographic data collected >1 year postoperatively. Measures of PPV on preoperative and postoperative weight-bearing radiographs and CT scans were evaluated. Patients were an average of 13 years old at excision. Of the total, 65% had calcaneonavicular (CN) coalitions, whereas the remainder had talocalcaneal coalitions. All patients had significant postoperative improvement in clinical outcomes but 34% (13/38) had continued pain at the most recent follow-up, more so in talocalcaneal than CN coalitions (55% vs 26%, P < 0.001). The subset with CN coalitions had more severe preoperative PPV but greater postoperative PPV improvement. Except for a weak correlation between radiographic weight-bearing (anterior-posterior) talus-first metatarsal angle and pain with activity (r = -0.54), there were no other correlations between preoperative radiographic parameters and clinical outcomes. Heel valgus on CT did not correlate with radiographic measurements of PPV or pain. We did not find a correlation of radiographic PPV with persistent pain after tarsal coalition excision. We did find improvement in radiographic PPV in CN coalitions after treatment with simple excision. Heel valgus on CT was not a useful metric for evaluating PPV in the setting of a tarsal coalition. Level III-prognostic study.

Increased Change in Cervical Lordosis is Associated With Decreased Rate of Recovery in Patients With C5 Palsy.

A retrospective chart review. The authors aim to investigate the role of clinical and radiographic parameters in patients who underwent posterior cervical surgery, and their association with C5 palsy severity and time to recovery. Postoperative C5 palsy affects 1%-30% of patients undergoing posterior decompression, with or without fusion. Causation and avoidance of this complication remain widely debated. A single institution review of patients who underwent posterior cervical spine surgery was focused on using specific Common Procedural Technology codes associated with the patient population of interest. Patients were excluded if they had inadequate pre and postoperative imaging, as well as a history of prior cervical spine surgery, concurrent anterior surgery, intradural pathology, spinal tumor, or spinal trauma. Radiographic measurements of the pre and postoperative images were completed with subsequent intraclass correlation coefficient analysis to confirm the precision of measurements. Out of 105 total patients, 35 (33%) patients developed a C5 palsy. Twenty-four (69%) of those palsies completely resolved, with a median time to recovery of 8 months. Preoperative demographics and radiographic parameters demonstrated heterogeneity among those patients who did and did not have a resolution of palsy. Patients with increased change in C2-C7 lordosis (P = 0.011) after surgery were associated with decreased likelihood of recovery. Patients without a smoking history (P = 0.009) had an increased likelihood of recovering from C5 palsy. The degree of increased lordosis in the treatment of degenerative cervical disease plays a role in the rate of recovery from C5 palsy. This should be considered during preoperative planning in determining the amount of lordosis desired. In addition, patients without a smoking history were associated with a higher rate of recovery. Level IV.

Predicting Immediate Lordosis Restoration After Anterior Lumbar Interbody Fusion and the Effect of Posterior Column Osteotomies

Anterior lumbar interbody fusion (ALIF) can be combined with posterior column osteotomies (PCOs) to maximize lordotic correction. This study compares radiographic changes in regional and segmental lordosis in patients undergoing ALIF with and without PCOs. Patients >18 years old who underwent ALIF at 1 or 2 segments at a single institution (January 2014-July 2020) were included. Preoperative and postoperative radiographic parameters were determined, and a propensity-matched analysis was performed. Ninety-nine patients (53 [54%] men) underwent ALIF at 129 levels (mean [SD], 1.3 [0.46] levels; median [range] age, 61 [32-83] years). PCOs were performed in 13 (13%) patients at 19 (15%) segments. PCOs included 13 Schwab grade 1 and 6 grade 2 osteotomies. All measures, including lumbar lordosis, segmental lordosis, disc angle, and neural foramen height, increased significantly after surgery (p≤0.003). In the propensity-matched analysis, PCO was associated with greater increases in lumbar lordosis (14.9° vs. 8.2°, p=0.02), segmental lordosis (14.0° vs. 9.6°, p=0.03), and disc angle (15.0° vs. 10.2°, p=0.046). The change in disc angle more closely approximated the inherent lordosis of the cage when PCO was performed (94% vs. 62%, p=0.004). Performing PCOs and ALIFs significantly increased the radiographic correction of overall and segmental lordosis in the selected patient cohort. The disc angle achieved with ALIF without PCOs was approximately 60% of the cage lordosis. The addition of PCO allowed for greater segmental compression, enabling the disc angle to reach nearly 100% of the inherent interbody cage lordosis.

Focal Dome Osteotomy Combined with Ilizarov Technique for Treating Femoral Multiplanar Deformity.

The management of femoral multiplanar deformity remains a great challenge for orthopaedic surgeons. The focal dome osteotomy (FDO) combined with Ilizarov technique is a theoretically ideal method for treating femoral multiplanar deformity, but the clinical evidence is limited. The aim of this study is to assess the clinical and radiological outcomes of this combined strategy for correcting femoral multiplanar deformities. A retrospective analysis was conducted to analyze 20 patients (29 limbs) with femoral multiplanar deformities treated by FDO combined with Ilizarov external fixation in our limb deformity center between 2017 and 2022. Preoperative and postoperative radiographical parameters were measured, including lateral proximal femoral angle (LPFA), mechanical lateral distal femoral angle (mLDFA), middle diaphysis angle (MDA), anatomic posterior distal femoral angle (aPDFA), mechanical axis deviation (MAD), and limb length discrepancy (LLD). Clinical assessments included a self-made questionnaire for exercise capacity score (ECS), visual analog scale (VAS), and the 36-Item Short-Form Health Survey (SF-36) score. There were eight males and 12 females, with a mean age of 32.8 years (14-61 years). All patients completed follow-up with a mean follow-up duration of 41.5 (27-81) months. The mean EFT was 8.9 (1.4-20.2) months. At final follow-up, significantly improvement was noted regarding mean LLD (from 1.8 to 0.4 cm, p < 0.05), MDA (from 31.8° to 10.4°, p < 0.05), aPDFA (from 97.6° to 91.8°, p < 0.05), MAD (from 22.4 to 5.3 mm, p < 0.05), CORA on the true deformity plane (from 32.4° to 6.8°, p < 0.05). The mean VAS was decreased from 4.03 (2.0-6.0) preoperatively to 1.38 (0-3.0) at final follow-up (p < 0.05). The mean score of each item of SF-36 was significantly improved at final follow-up (p < 0.05). The mean ECS was improved from 8.2 (5-12) preoperatively to 11.4 (8-13) at final follow-up (p < 0.05). During the follow-up, one patient underwent pin exchange. One patient underwent internal fixation to replace the Ilizarov fixation 1.4 months after the first surgery. Residual LLD (>0.5 cm) was noted in four patients but without significant symptoms. No serious complications occurred. The strategy of FDO combined with Ilizarov fixation could provide powerful ability and good flexibility for correcting femoral multiplanar deformities without significant complications.

Predictors of Postoperative Persistent Low Back Pain Following Lumbar Fusion in Patients Older than 75 Years: An Analysis of a Minimum 2-Year Follow-Up

PurposeThis study aimed to evaluate pre- and perioperative predictors associated with persistent low back pain (LBP) following lumbar fusion in patients aged > 75 years. MethodsThis single-center retrospective study examined 310 patients aged > 75 years who underwent lumbar fusion for lumbar degenerative disease (104 males, 206 females; mean age, 79 [75–90] years). The visual analog scale (VAS) score for LBP was examined preoperatively and 2-year postoperatively. The persistent LBP group comprised patients with a 2-year postoperative LBP-VAS score ≥ 3. The demographic and preoperative radiographic parameters were also reviewed. A multivariate stepwise logistic regression analysis was performed of variables with values of P < 0.2 on the univariate analysis. ResultsNinety-nine patients (32%) experienced persistent postoperative LBP. Multivariate logistic regression analysis revealed that age < 82 years, history of previous lumbar decompression, and greater preoperative VAS score for LBP were associated with greater postoperative persistent LBP after lumbar fusion, whereas other factors, such as gender, body mass index, osteoporosis, diabetes mellitus, depression, symptom duration, operative time, estimated blood loss, and spinopelvic sagittal parameters, were not. ConclusionsThis study showed that a relatively younger age, history of preoperative lumbar decompression, and greater preoperative VAS score for LBP were preoperative predictors of postoperative persistent LBP following lumbar fusion in elderly patients. In contrast, preoperative spinopelvic sagittal parameters were not associated with persistent postoperative LBP. Although lumbar fusion is expected to improve LBP, surgeons should pay attention to age, surgical history, and preoperative back pain intensity.

Efficacy of a Multimodal Surgical Site Injection for Postoperative Pain Control in Pediatric Patients With Cerebral Palsy Undergoing Hip Reconstruction: A Randomized Controlled Trial.

One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP. After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3mg/kg), epinephrine (0.5mg), and ketorolac (0.5mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables. Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P =0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P <0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group. In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects. Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries. Level I-therapeutic.

High Preoperative Pain Score is a Predictor of Cheilectomy Failure in Hallux Rigidus

Hallux rigidus (HR) is a prevalent arthritic condition in the foot. Cheilectomy is a common joint-preserving procedure for HR, involving the removal of prominent osteophytes to relieve impingement of the 1st MTPJ. This study aims to identify factors associated with the failure of cheilectomy in the treatment of HR. A retrospective review of a prospectively collected database from 2007 to 2021 identified all cheilectomy cases. The minimum follow-up was 2 years. Preoperative demographic data, patient-reported outcome measures (PROMs) and foot radiographs were collected. PROMs were reassessed in post-operative reviews, and cases were categorized as successes or failures. Failure was defined by meeting at least one of the following criteria at the latest review: 1) Visual analog pain score (VAS) more than or equal to 4, 2) undergoing subsequent revision procedures, or 3) reporting poor or terrible satisfaction with the surgery. The analysis involved 66 patients, with 19 failure and 47 success cases. Both groups showed similar age, BMI, and gender profiles. Preoperative radiographic parameters were comparable between groups. However, preoperative VAS was significantly higher in the failure group: 7.16 vs. 5.23 (P = 0.0029). Logistic regression confirmed preoperative VAS as a predictor of non-response (P = 0.023). Receiver Operating Characteristic analysis established an optimal cut-off VAS score of 7.0. Patients with a preoperative VAS score of more than 7 had an odds ratio of 5.11 (P = 0.0055) for failure. A higher preoperative VAS score is significantly associated with cheilectomy failure in HR treatment, suggesting a cutoff score of 7.0.

Osteotomies for genu varum: Should we always correct at the tibia? A multicenter analysis of practices in France

IntroductionTibial correction is often performed during a valgus-producing osteotomy for genu varum. However, overcorrection and the creation of a joint line obliquity (JLO) have been associated with unfavorable functional outcomes after high tibial osteotomy (HTO). The aims of this study were to analyze: 1) the corrections obtained after HTO; 2) the rationale behind the indication per the European Society for Sports Traumatology Surgery and Arthroscopy (ESSKA) recommendations; and 3) the correlation between the postoperative corrections obtained and functional outcomes. HypothesisA significant number of patients who underwent an isolated HTO did not present an “ideal” theoretical indication based on the preoperative angles and correction targets to be performed. Materials and methodsThis multicenter study included 289 isolated HTOs. Demographic and morphometric data were anonymized and compiled in a database. Preoperative radiographic parameters were compared with the ESSKA consensus recommendations on osteotomies for genu varum. The consensus defined the “ideal” indication for performing an HTO as medial tibiofemoral compartment pain with significant tibial varus deformity (medial proximal tibial angle [MPTA]<85°), no significant femoral varus deformity (lateral distal femoral angle [LDFA]<90°), an expected postoperative obliquity of less than 5°, and a correction resulting in moderate tibial valgus (postoperative MPTA<94°). The incidence of patients with an “ideal” theoretical indication for isolated HTO and those with a theoretical indication not perfectly justified by the radiographic data and preoperative planning were recorded. ResultsUnder the ESSKA consensus criteria, 25.3% (n=73) of isolated HTOs, 15.6% (n=45) of isolated femoral osteotomies, 9.3% (n=27) of double-level osteotomies, and 49.9% (n=144) of cases where no osteotomy was performed due to the lack of significant extra-articular tibial and/or femoral deformity were deemed justified. The presence of a preoperative femoral deformity and the absence of an “ideal” indication for HTO did not affect the postoperative Tegner Activity Scale or the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (p>0.05). A high preoperative hip-knee-ankle (HKA) angle and MPTA, which indicated less varus, were associated with a greater risk of there being no “ideal” theoretical indication for an HTO (coefficient of determination [R2]=0.19 and R2=1, respectively; p<0.001). ConclusionThis study showed that isolated HTOs in current practice were not justified in a significant number of patients, even though they could lead to tibial overcorrection and excessive JLO. This did not impact the functional results of this series, but it might complicate the performance of a secondary knee arthroplasty. Nevertheless, some young patients in this series underwent a salvage osteotomy outside the “ideal” indications of the European recommendations. Level of evidenceIV; case series.

Examining autocorrection of concurrent cervical malalignment following thoracolumbar deformity surgery.

The aim of the study was to assess preoperative radiographic parameters predictive of cervical deformity (CD) autocorrection in patients undergoing thoracolumbar deformity (ASD) surgery. This was a retrospective cohort study. Inclusion criteria were operative ASD patients with complete baseline (BL) and 2-year radiographic data. Patients with cervical fusion during index surgery, revision involving cervical fusion, and those who developed proximal junctional kyphosis by 2-year postoperative were excluded from the study. If patients met CD criteria at BL but not at 6 weeks or 2 years postoperatively, they were considered autocorrected (AC). Descriptive and univariate analysis, binominal logistic regression, and multivariable backward stepwise regression. Two hundred and twenty ASD patients were included. 51.4% of patients had preoperative CD. By 6-week postoperative, 32.7% achieved AC. At 2 years, 24.8% of preoperative CD patients obtained AC. 2-year AC patients had lower BL sacral slope, lumbar lordosis (LL), T1 slope, cervical lordosis (CL), and C2-T3, and T2-T12 kyphosis (all P < 0.05). Patients with BL-unmatched Roussouly types are corrected postoperatively and are more likely to experience autocorrection at 1 year (45.2% vs. 19.0%; P = 0.042) and at 2 years (31% vs. 4.8%; P = 0.018). Multivariable analysis revealed that patients with BL-mismatched Roussouly types were corrected postoperatively and showed a significant increase in likelihood of AC at 1 year (odds ratio [OR]: 18.72; P = 0.029) and 2 years (OR: 8.5; P = 0.047). Similarly, BL LL (OR: 0.772; P = 0.003) and CL (OR: 0.829; P = 0.005) exhibited significant predictive value for autocorrection at 1 year and 2 years (OR: 0.927; P = 0.004 | OR: 0.942; P = 0.039; respectively). Autocorrection is more likely in patients with postoperatively corrected Roussouly types, those with lower BL cervical, and LL. Given these findings, it may not be necessary to routinely extend reconstruction into the cervical spine for ASD patients with similar characteristics to those in this study.

Does global spinal alignment affect the use of walking aids after multi-segment spinal fixation for patients with ASD? A multicenter retrospective study.

This study aimed to clarify the relation between global spinal alignment and the necessity of walking aid use in patients with adult spinal deformity (ASD) and to investigate the impact of spinal fixation on mobility status after surgery. In total, 456 older patients with ASD who had multi-segment spinal fixation surgery and were registered in a multi-center database were investigated. Patients under 60years of age and those unable to walk preoperatively were excluded. Patients were classified by their mobility status into the independent, cane, and walker groups. Comparison analysis was conducted using radiographic spinopelvic parameters and the previously reported global spine balance (GSB) classification. In addition, preoperative and 2years postoperative mobility statuses were investigated. Of 261 patients analyzed, 66 used walking aids (canes, 46; walkers, 20). Analysis of preoperative radiographical parameters showed increased pelvic incidence and pelvic incidence-lumbar lordosis mismatch in the walker group and increased sagittal vertebral axis in the cane and walker groups versus the independent group. Analysis of GSB classification showed a higher percentage of walker use in those with severe imbalance (grade 3) in the sagittal classification but not in the coronal classification. While postoperative radiographical improvements were noted, there was no significant difference in the use of walking aids before and 2years after surgery (P = 0.085). A significant correlation was found between "sagittal" spinal imbalance and increased reliance on walking aids, particularly walkers. However, the limitation of improvement in postoperative mobility status suggested that multiple factors influence the mobility ability of elderly patients with ASD.

Radiographic and complication evaluation of 2 different bioresorbable pins in hallux valgus corrective surgery.

Osteotomies to correct hallux valgus are usually secured using metal implants. Their main disadvantage is the need for a repeat surgery for removal of implanted material. Bioresorbable implants would make it possible to overcome this complication. Few studies analyse the results of using bioresorbable pins. The primary objective of this study is to compare hallux valgus correction radiographic results with the use of two types of bioresorbable pins. The secondary objectives are to screen for possible complications related to the use of these bioresorbable pins. This is a descriptive, retrospective, single-centre study carried out between May 2018 and May 2022 in the orthopaedic surgery department of the Centre Chirurgical Emile Gallé at the CHRU in Nancy (France). The study involved 105 hallux valgus (98 patients) operated on by open double metatarsal and phalangeal osteotomy. Osteotomies were stabilised with resorbable polylactic acid (PLLA) pins (Arthrex® TRIM-IT® drill pin) in 57 cases (53 patients), and with resorbable polylactic acid-polyglycolic acid copolymer (PGLA) pins (Bioretec® ActivaPins®) in 48 cases (45 patients). The efficacy of hallux valgus correction was analysed in terms of changes in preoperative and postoperative radiographic parameters at 1 and 6 months on a weight-bearing foot. Descriptive statistics were used to describe the demographic and radiological parameters of each group. The mean age was 59.7 years (range 25-81 years) in the PLLA group and 56 years (range 23-78 years) in the PGLA group. The mean preoperative HVA was 30° (range 15-63°) in the PLLA group and 30.8° (range 15-57°) in the PGLA group. The mean preoperative IMA was 14.4° (range 7-30°) in the PLLA group and 13.8° (range 7-20°) in the PGLA group. There was a statistically significant correction of hallux valgus in the PLLA (p=5.24 X 10-15 ) and PGLA (p=3.56 X 10-13 ) groups. The mean correction for the hallux valgus angle was 13° in the PLLA group and 12° in the PGLA group. There was no statistically significant difference in hallux valgus correction between the PLLA and PGLA groups, particularly in terms of hallux valgus severity. There was no radiological or clinical complication in the groups related to bioresorbable pins. The use of bioresorbable pins allows effective stabilisation of osteotomies to correct hallux valgus. There was no significant difference in correction between PLLA and PGLA implants, regardless of the severity of the hallux valgus. We did not observe any obvious clinical or radiological complications related to their use. The use of bioresorbable osteosynthesis material in forefoot surgery seems to offer interesting advantages, providing patients with safer and less invasive treatment solutions.

Postoperative patient-reported outcome measures after medial open-wedge high tibial osteotomy was improved by decreased joint line convergence angle.

To evaluate the relationship between pre- and postoperative joint line convergence angle (JLCA) changes and patient-reported outcome measures related to medial open-wedge high tibial osteotomy (MOWHTO). Sixty-one patients (71 knees) who underwent MOWHTO were examined. Preoperative and 2-year postoperative radiographic parameters (hip-knee-ankle angle, weight-bearing line ratio, medial proximal tibial angle and JLCA) were measured, and knee injury and osteoarthritis outcome scores (KOOS) were assessed. Patients were divided into two groups: group D (decreased JLCA compared with preoperative status) included 44 knees with a ΔJLCA < 0° and group I (increased JLCA and no-change JLCA compared with preoperative status) included 27 knees with a ΔJLCA ≥ 0°. KOOS sub-scores and the proportion of patients whose improvement exceeded the minimum clinically important difference (MCID) were compared between both groups using Student's t tests, Mann-Whitney U tests and chi-square tests. Multiple regression analysis was performed to determine the factor that had an influential effect on the postoperative KOOS total. Significant differences in 2-year postoperative KOOS were observed between the two groups, including total, symptom, pain and activities of daily living scores. Group D had significantly more patients who achieved MCID for both KOOS symptoms and pain scores than group I did. Multivariate analysis indicated that JLCA change and body mass index were significantly associated with the postoperative KOOS total. Patients with decreased JLCA had better 2-year post-MOWHTO KOOS and better symptom and pain improvements. Therefore, strategies that reduce JLCA are crucial to improving clinical outcomes, and efforts should be made to improve JLCA in surgical techniques. Level Ⅳ, Case series.

Assessment of Surgical Outcomes in Patients with Degenerative Cervical Myelopathy Using the 25-Question Geriatric Locomotive Function Scale: A Longitudinal Observational Study.

Locomotive syndrome caused by degenerative musculoskeletal diseases is reported to improve with surgical treatment. However, it is unclear whether surgical treatment is effective for the locomotive syndrome developing in patients with degenerative cervical myelopathy (DCM). Thus, this study primarily aimed to longitudinally assess the change in locomotive syndrome stage before and after cervical spinal surgery for patients with DCM using the 25-question geriatric locomotive function scale (GLFS-25). A secondary objective was to identify factors associated with the postoperative improvement in the locomotive syndrome stage. We retrospectively reviewed clinical data of patients undergoing cervical spine surgery at our institution from April 2020 to May 2022 who had answered the Japanese Orthopaedic Association Cervical Myelopathy Assessment Questionnaire, visual analog scale, and GLFS-25 preoperatively and at 6 months and 1 year postoperatively. We collected demographic data, medical history, preoperative radiographic parameters, presence or absence of posterior longitudinal ligament ossification, and surgical data. We enrolled 115 patients (78 men and 37 women) in the present study. Preoperatively, using the GLFS-25, 73.9% of patients had stage 3, 10.4% had stage 2, 9.6% had stage 1, 6.1% had no locomotive syndrome. The stage distribution of locomotive syndrome improved significantly at 6-months and 1-year postoperatively. The multivariable Poisson regression analysis revealed that better preoperative lower extremity function (relative risk: 3.0; 95% confidence interval: 1.01-8.8) was significantly associated with postoperative improvement in the locomotive syndrome stage. This is the first study to longitudinally assess the locomotive syndrome stage in patients with DCM using GLFS-25. Our results indicated that patients with DCM experienced significant improvement in the locomotive syndrome stage following cervical spine surgery. Particularly, the preoperative lower extremity function was significant in postoperative improvement in the locomotive syndrome stage.

Staged Versus Same-Day Surgery in Circumferential Minimally Invasive Deformity Correction.

We sought to compare long-term clinical and radiographic outcomes in patients who underwent staged vs same-day circumferential minimally invasive surgery (cMIS) for adult spinal deformity (ASD). We reviewed staged and same-day cMIS ASD cases in a prospective multi-institution database to compare preoperative and 2-year clinical and radiographic parameters between cohorts. A total of 85 patients with a 2-year follow-up were identified (27 staged, 58 same-day). Staged patients had more extensive surgeries and greater hospital length of stay (all P < .001). There were no significant differences in preoperative or 2-year postoperative clinical metrics between cohorts. Patients in the staged cohort also had greater preoperative coronal deformity and thus experienced greater reduction in coronal deformity at 2 years (all P < .01). Patients undergoing staged or same-day cMIS correction had similar outcomes at 2 years postoperatively. Staged cMIS ASD correction may be more appropriate in patients with greater deformity, higher frailty, and who require longer, more extensive surgeries.