Preoperative X-ray Research Articles

The Clinical Application of Double Taylor Spatial Frame in Segmental Tibial Fracture.

Multi-planar external fixation has been used for the management of segmental tibial fractures with severe soft tissue injuries. However, fewer specialized studies have been reported. The primary aim of this study was to describe our experience of treating fractures of this type using the Taylor Spatial Frame and Ilizarov external fixation methods. We retrospectively analyzed 33 patients with segmental tibial fracture treated at our institution between January 2016 and December 2020. The patients were divided into double Taylor Spatial Frame (D-TSF) and Ilizarov groups based on the external fixation structure. Baseline demographic data included sex, age, injury side and cause, open or closed fracture, time from injury to surgery, complications, and external frame removal and fracture healing time. The hip-knee-ankle angle (HKA) was measured from preoperative, immediate postoperative, and final follow-up full-length X-rays of bilateral lower limbs. We determined the degree of deviation in the HKA by calculating the difference between the measured angle and the ideal value of 180°; the absolute value was used to assess recovery of the lower limb force line. At the final follow-up, Johner-Wruhs tibial fracture outcome criteria (J-W TFOC) were used to classify the postoperative function of the affected limb as excellent, good, moderate, or poor. Count data were analyzed with the chi-square test or Fisher's exact test; the Mann-Whitney U test was used for rank data. No statistically significant differences were observed between the two groups in terms of sex, age, side of injury, cause of injury, closed or open fracture, or time between injury and surgery, which indicates that the groups were comparable (p > 0.05). A statistically significant difference was observed in external frame removal and fracture healing time between the D-TSF and Ilizarov groups (36.24 ± 8.34 vs 45.42 ± 10.21 weeks, p = 0.009; 33.33 ± 8.21 vs 42.00 ± 9.78 weeks, p = 0.011). The Johner-Wruhs criteria were used to assess the function of the affected limb, the D-TSF group performed better in correcting the lower limb force line than the Ilizarov group. A statistically significant difference in terms of excellent ratings was observed between the two groups (18/2/1/0 vs 5/5/1/1, p = 0.010). Postoperative follow-up X-rays demonstrated a significant improvement in the HKA in both groups immediately after surgery and at the final follow-up compared to the angle before surgery. At the final follow-up, a statistically significant difference was observed in the degree of deviation in the HKA between the two groups (1.58° ± 0.84° vs 2.37° ± 1.00°, p = 0.023). The D-TSF treatment is associated with minimal secondary damage to soft tissue, a straightforward and minimally invasive procedure, multiplanar stable fracture fixation, and optimization of fracture alignment and lower limb force lines, therefore, it is highly effective therapeutic option for segmental tibial fracture.

Comparison of short-term radiographic outcomes of medial parapatellar, mini-midvastus, and subvastus surgical approaches in fast-track total knee arthroplasty

Purpose: Due to the difficulties in accessing the knee joint, correct prosthesis placement is of great importance during the implementation of total knee arthroplasty (TKA). This study aimed to compare short-term radiographic X-ray outcomes in patients who underwent fast-track TKA with medial parapatellar (MPP), mini-midvastus (mMV), or subvastus (SV) surgical approaches.
 Materials and methods: Between 2018 and 2020, 93 patients operated with MPP, mMV, and SV surgical approaches and who had complete data of radiographic outcomes before and sixth-week postoperative were retrospectively analyzed and patients divided into three groups: MPP (n=31), mMV (n=31), and SV (n=31). The alignments of preoperative and sixth-week postoperative X-ray images of the surgical approaches were measured. The operative time of fast-track TKA implementation with MPP, mMV, and SV surgical approaches was recorded.
 Results: The MPP group had higher preoperative lateral distal femoral angle than the mMV group and a higher preoperative lateral proximal femoral angle than SV group (p=0.018 and p=0.027, respectively). The mMV group had higher postoperative proximal medial tibial angle than SV group (p=0.011). In the postoperative sixth week, the MPP and mMV groups had a lower posterior tibial slope angle than SV group (p=0.001). The MPP approach had significantly shorter operative time than mMV and SV approaches (p=0.001).
 Conclusion: The outcomes indicate that MPP, mMV, and SV surgical approaches are preferable and feasible in obtaining a satisfactory prosthesis alignment during fast-track TKA. The MPP approach may be preferable because of its shorter operative time and potential advantage in minimizing surgical complication risks.

368 Preoperative Soft Tissue Imaging Features Elucidated by Artificial Intelligence May Best Predict Radiographic Proximal Junction Kyphosis Following Adult Spinal Deformity Surgery

INTRODUCTION: Proximal junction kyphosis (PJK) following adult spinal deformity surgery (ASD) remains difficult to predict. In a cohort of patients undergoing ASD surgery, we used artificial intelligence to compare three models of preoperatively predicting PJK using: 1) traditional radiographic measurements and demographics 2) raw preoperative scoliosis x-rays, and 3) raw preoperative thoracic T1 MRIs. METHODS: A single-institution retrospective cohort study was undertaken for patients undergoing ASD surgery from 2009-21. PJK was defined as a sagittal Cobb angle of upper-instrumented vertebra (UIV) and UIV+2>10° and a postoperative change in UIV/UIV+2>10°. For Model-1, A support vector machine was used to predict PJK within 2 years postoperatively using clinical and traditional sagittal/coronal radiographic variables and intended levels of instrumentation. Next, for Model-2, a convolutional neural network (CNN) was trained on raw preoperative lateral/posterior-anterior scoliosis x-rays. Finally, for Model-3, a CNN was trained on raw thoracic T1 MRIs. RESULTS: A total of 187 patients underwent ASD surgery with at least 2-year follow-up and 89 (47.6%) developed radiographic PJK within 2 years. Model-1: Using clinical variables and traditional radiographic measurements, the support vector machine predicted PJK with a sensitivity:57.2% and specificity:56.3%. Model-2: a CNN with raw scoliosis x-rays predicted PJK with sensitivity:68.2% and specificity:58.3%. Model-3: a CNN with raw thoracic MRIs predicted PJK with sensitivity:73.1% and specificity:79.5%. Finally, an attention map outlined the imaging features used by Model-3 to predict PJK. Soft tissue features predominated all true positive PJK predictions. CONCLUSIONS: The use of raw MRIs in an artificial intelligence model improved the accuracy of PJK prediction compared to raw scoliosis X-rays and traditional clinical/radiographic measurements. The improved predictive ability using MRI may indicate that PJK is best predicted by soft-tissue degeneration and muscle atrophy.

Traps and Tricks About A 6-Years Old Cutibacterium Endocarditis

Endocarditis of cardiac implanted electronic devices is a complex and serious disease. Commensal bacteria of the skin are commonly considered as contamination of blood culture. Herein, the authors report the case of a pacemaker endocarditis with cultures positive for Cutibacterium acnes. These were already found 3 and 6 years ago but not observed during hospitalisation. The PET-scan was of great help in guiding the diagnosis. The management was particularly difficult with 9 leads to extract. A sequential approach in the operating room from endovascular procedure to surgery under cardio-pulmonary bypass was used. A second procedure was necessary to extract a small forgotten foreign body already visible on the preoperative chest X-ray. This experience shows the importance of having a high level of suspicion in case of culture positive for Cutibacterium with intracardiac devices, and of looking for foreign bodies on the preoperative chest X-ray in case of a history of multiple rhythmological procedures.

Prediction of the Labrum Shape in Patients With Developmental Dysplasia of the Hip Based on Pelvic Radiography.

The shape of the labrum is strongly correlated with outcomes of developmental dysplasia of the hip (DDH). Magnetic resonance imaging (MRI) is the generally preferred imaging technique for observing the labrum. We aimed to find a correlation between the labrum shape and anterior-posterior (AP) pelvic measurements in children with DDH. Preoperative AP pelvic x-ray radiographs and MRI of patients with DDH from January 2019 to December 2021 were retrospectively collected and divided into three groups by labrum shape on MRI: everted, partly inverted, and inverted. The acetabular length ratio (RAL) in patients with unilateral DDH and the ratio of acetabular length to interpedicular distance (RALI) in all patients were calculated. T-tests were used to analyze differences between the groups. Receiver operating characteristic curve (ROC) analysis was performed between the everted group and the partly inverted and inverted groups. We found significant differences in RAL between the everted and partly inverted groups, everted and inverted groups, and everted and combined groups. The ROC analysis showed that the best cutoff value for RAL was 0.945 between the everted and combined groups, with an area under the curve (AUC) of 88.4%. The sensitivity at the best RAL value was 0.783, and the specificity was 0.887. Moreover, we observed a significant difference in RALI between the everted, partly inverted, and inverted groups, as well as between the everted and combined groups. The optimal cutoff value for RALI between the everted and combined groups was 0.575, with an AUC of 74.5%. The sensitivity at the best RALI value was 0.765, and the specificity was 0.674. The RAL or RALI values on pelvic AP radiographs can be used to predict the shape of the labrum. III.

Reliability of preoperative conventional X-ray diagnostics for multifragmentary midclavicular fractures - a retrospective cohort study.

The aim of this study was to evaluate the reliability of assessing preoperative conventional X-ray diagnostics in determining whether a comminuted clavicle fracture is present. A total of 326 patients with complete clinical and radiological documentation treated for a central clavicle fracture at the author's department between January 1, 2012, and June 30, 2023, were included. Among these, 73 were female, and 253 were male in a mean age of 37.5 ± 17years. On preoperative X-ray images or operation reports, 109 (33%) or 78 (24%) simple and 217 (67%) or 248 (76%) comminuted fractures were identified. Thity-one out of 248 comminuted fractures were only discovered intraoperatively, accounting for 13%. According to the AO classification on preoperative X-ray or operation reports, 109 or 78 fractures were classified as type A (33% or 24%), 51 or 45 as type B (16% or 14%), and 166 or 203 as type C (51% or 62%). For 40 patients, the discrepancy between the preoperative X-ray and the intraoperative fracture type led to a change in the surgical procedure. This represents 12% of the total cohort or 91% of the fractures that were classified differently preoperatively compared to intraoperatively. In these cases, fractures were treated with open reduction and angular stable plate osteosynthesis instead of the preoperatively planned elastic stable intramedullary nailing (ESIN). The results of this study suggest that conventional X-ray diagnostics may not always detect comminuted clavicle shaft fractures. The treating physician should be aware of this issue.

Midfoot width changes after first metatarsal osteotomy in hallux valgus surgery: A biomechanical effect?

Hallux valgus is a challenging pathology characterized by a valgus deformity in the metatarsophalangeal area of the first ray. The aim of this study was to analyze the influence of first metatarsal osteotomy on the relationship between midfoot bones in patients with hallux valgus. The sample consisted of patients from the orthopedics and traumatology outpatient clinic who underwent surgical treatment for hallux valgus. Preoperative and postoperative X-rays were compared regarding the width of the midfoot and the tarsometatarsal joint. The sample consisted of 17 women, with 22 feet assessed in each group. The distance from the medial cuneiform to the cuboid, the distance from the intermediate cuneiform to the cuboid, the distance between the first and fifth metatarsals, and the distance between the second and fifth metatarsals reduced significantly between pre- and postoperative assessments. Hallux valgus correction through osteotomy of the first metatarsal leads to a structural change in the midfoot. Further studies should determine whether these changes persist over time.

Development of End-to-End Artificial Intelligence Models for Surgical Planning in Transforaminal Lumbar Interbody Fusion.

Transforaminal lumbar interbody fusion (TLIF) is a commonly used technique for treating lumbar degenerative diseases. In this study, we developed a fully computer-supported pipeline to predict both the cage height and the degree of lumbar lordosis subtraction from the pelvic incidence (PI-LL) after TLIF surgery, utilizing preoperative X-ray images. The automated pipeline comprised two primary stages. First, the pretrained BiLuNet deep learning model was employed to extract essential features from X-ray images. Subsequently, five machine learning algorithms were trained using a five-fold cross-validation technique on a dataset of 311 patients to identify the optimal models to predict interbody cage height and postoperative PI-LL. LASSO regression and support vector regression demonstrated superior performance in predicting interbody cage height and postoperative PI-LL, respectively. For cage height prediction, the root mean square error (RMSE) was calculated as 1.01, and the model achieved the highest accuracy at a height of 12 mm, with exact prediction achieved in 54.43% (43/79) of cases. In most of the remaining cases, the prediction error of the model was within 1 mm. Additionally, the model demonstrated satisfactory performance in predicting PI-LL, with an RMSE of 5.19 and an accuracy of 0.81 for PI-LL stratification. In conclusion, our results indicate that machine learning models can reliably predict interbody cage height and postoperative PI-LL.

Pedicle Dysplasia in Proximal Thoracic Adolescent Idiopathic Scoliosis Curves: What are We Missing and What are its Possible Surgical Implications? An Observational Retrospective Study on 104 Patients.

Retrospective cohort study. To assess if pedicle dysplasia is present in proximal thoracic (PT), both structural and nonstructural, compared to main thoracic (MT) curves; and to assess if it is predictive of radiographic outcomes at minimum 2years of follow-up. A retrospective review of surgically-treated Adolescent Idiopathic Scoliosis (AIS) patients with Lenke 1-2-3-4 curves was performed. On preoperative CT-scan, at the apical vertebra, pedicle width on the concavity (PWc) and on the convexity (PWv) and Pedicle Dysplasia Index (PDI, defined as PWc/PWv) were measured. Preoperative and last follow-up (at least 2years) x-rays were reviewed. 104 patients meeting the inclusion criteria were divided into Structural-PT (S-PT) and Nonstructural-PT (NS-PT) groups based on Lenke criteria. PWc (P < .001). And PDI (P < .001 for S-PT, P = .004 for NS-PT) were significantly smaller in the PT than in MT curves for both groups. PT-PWc significantly correlated with follow-up PT Cobb for both groups (P < .001 and P = .015 respectively). PT-PDI significantly correlated with follow-up PT-Cobb (P < .001), CA (P < .040) and T1 tilt (P < .002), only for NS-PT group. NS-PT patients with PWc PT <1mm had higher RSHD (P = .021) and T1 tilt (P = .025) at follow-up. NS-PT patients with PDI PT <.3 had higher RSHD (P < .001), CA (P = .002) and T1 tilt (P = .003) at follow-up. S-PT and NS-PT curves show significant pedicle dysplasia on the concavity. Pedicle dysplasia significantly correlated with shoulder balance at follow-up, for NS-PT patterns. Patients with a PWc <1mm or PDI <.30 are at particular risk of postoperative shoulder imbalance.

Frontal Plane Correction of Hallux Valgus Deformity With a Minimally Invasive Third Generation Tecnique: Short-Term Radiographic Outcomes of a Prospective Case Series

A number of minimally invasive osteotomies have been described for the repair of hallux abducto valgus (HAV) deformities. However, there are no known published studies that evaluate the effects of minimally invasive surgery techniques on the reduction of frontal plane rotation in patients with HAV. The purpose of this study was to assess correction in the transverse and frontal planes in patients undergoing surgical repair of HAV deformity utilizing a modified percutaneous technique. One hundred and five feet in 105 patients with HAV deformity were treated with a third generation minimally invasive technique using a first metatarsal osteotomy that allowed for frontal plane correction in conjunction with an Akin osteotomy. The minimum follow-up time was 12 months. Preoperative and postoperative anteroposterior weightbearing x-ray images were assessed and four measurements were evaluated: hallux abductus angle (HAA), intermetatarsal angle (IMA), tibial sesamoid position and frontal plane rotation of the first metatarsal. There were statistically significant differences for each of the assessments between the preoperative and postoperative radiographs (p < .001). There was a mean reduction in the HAA of 23.5° ± 9.6°, in the IMA, 7.0° ± 3.5°, in the tibial sesamoid position, 2.6 ± 1.3, and an improvement in the assessment of first metatarsal pronation (1.4 ± 0.9). The overall complication rate was 18.1%, with 5.7% of the feet requiring reoperation. The minimally invasive procedure employed by the authors demonstrated suitable outcomes in reducing deformity in both the transverse and frontal planes.

Analysis of the causes of cage subsidence after oblique lateral lumbar interbody fusion

To observe the cage subsidence after oblique lateral interbody fusion (OLIF) for lumbar spondylosis, summarize the characteristics of the cage subsidence, analyze causes, and propose preventive measures. The data of 144 patients of lumbar spine lesions admitted to our hospital from October 2015 to December 2018 were retrospectively analyzed. There were 43 males and 101 females, and the age ranged from 20 to 81 years old, with an average of (60.90±10.06) years old. Disease types:17 patients of lumbar intervertebral disc degenerative disease, 12 patients of giant lumbar disc herniation, 5 patients of discogenic low back pain, 33 patients of lumbar spinal stenosis, 26 patients of lumbar degenerative spondylolisthesis, 28 patients of lumbar spondylolisthesis with spondylolisthesis, 11 patients of adjacent vertebral disease after lumbar internal fixation, 7 patients of primary spondylitis in the inflammatory outcome stage, and 5 patients of lumbar degenerative scoliosis. Preoperative dual-energy X-ray bone mineral density examination showed 57 patients of osteopenia or osteoporosis, and 87 patients of normal bone density. The number of fusion segments:124 patients of single-segment, 11 patients of two-segment, 8 patients of three-segment, four-segment 1 patient. There were 40 patients treated by stand-alone OLIF, and 104 patients by OLIF combined with posterior pedicle screw. Observed the occurrence of fusion cage settlement after operation, conducted monofactor analysis on possible risk factors, and observed the influence of fusion cage settlement on clinical results. All operations were successfully completed, the median operation time was 99 min, and the median intraoperative blood loss was 106 ml. Intraoperative endplate injury occurred in 30 patients and vertebral fracture occurred in 5 patients. The mean follow-up was (14.57±7.14) months from 6 to 30 months. During the follow-up, except for the patients of primary lumbar interstitial inflammation and some patients of lumbar spondylolisthesis with spondylolisthesis, the others all had different degrees of cage subsidence. Cage subsidence classification:119 patients were normal subsidence, and 25 patients were abnormal subsidence (23 patients were gradeⅠ, and 2 patients were gradeⅡ). There was no loosening or rupture of the pedicle screw system. The height of the intervertebral space recovered from the preoperative average (9.48±1.84) mm to the postoperative average (12.65±2.03) mm, and the average (10.51±1.81) mm at the last follow-up. There were statistical differences between postoperative and preoperative, and between the last follow-up and postoperative. The interbody fusion rate was 94.4%. The low back pain VAS decreased from the preoperative average (6.55±2.2 9) to the last follow-up (1.40±0.82), and there was statistically significant different. The leg pain VAS decreased from the preoperative average (4.72±1.49) to the final follow-up (0.60±0.03), and the difference was statistically significant (t=9.13, P<0.000 1). The ODI index recovered from the preoperative average (38.50±6.98)% to the latest follow-up (11.30±3.27)%, and there was statistically significant different. The complication rate was 31.3%(45/144), and the reoperation rate was 9.72%(14/144). Among them, 8 patients were reoperated due to fusion cage subsidence or displacement, accounting for 57.14%(8/14) of reoperation. The fusion cage subsidence in this group had obvious characteristics. The monofactor analysis showed that the number of abnormal subsidence patients in the osteopenia or osteoporosis group, Stand-alone OLIF group, 2 or more segments fusion group, and endplate injury group was higher than that in the normal bone mass group, OLIF combined with pedicle screw fixation group, single segment fusion group, and no endplate injury group, and the comparison had statistical differences. Cage subsidence is a common phenomenon after OLIF surgery. Preoperative osteopenia or osteoporosis, Stand-alone OLIF, 2 or more segments of fusion and intraoperative endplate injury may be important factors for postoperative fusion cage subsidence. Although there is no significant correlation between the degree of cage subsidence and clinical symptoms, there is a risk of cage migration, and prevention needs to be strengthened to reduce serious complications caused by fusion of cage subsidence, including reoperation.

Assessing the Correlation between the Radiological, Macroscopic and Histological Examination of Degenerative Changes of Articular Surfaces in Knee Osteoarthritis with Varus Deformity

Our study aims to compare the results of preoperative radiography and intraoperative visual assessment of the cartilage with histological assessment of joint surfaces of the medial and lateral compartments resected in patients during the total knee replacement. The cohort included 20 patients (9 men and 11 women) with the mean age of 66.6 (±7.0) years who met the inclusion criteria of the study. Degenerative changes of the knee joint seen on a preoperative weight-bearing anteroposterior X-ray were evaluated according to the Kellgren-Lawrence grading system separately for the medial and lateral compartment. Based on the visual appearance, the condition of articular surfaces was assessed using the International Cartilage Repair Society Score (ICRS Grade). The histological assessment of degenerative changes was conducted by a pathologist with the use of the Osteoarthritis Research Society International Osteoarthritis Cartilage Histopathology Assessment System based on six grades of articular cartilage degeneration. The mean degree of degenerative changes based on the radiological classification was assessed as 3.5 (±0.6) for the medial compartment and 2.1 (±0.4) for the lateral compartment. The visually assessed chondropathy according to the ICRS Grade was 3.7 (±0.6) for the medial femoral condyle and 1.8 (±1.0) for the lateral femoral condyle. The histological score obtained using the Osteoarthritis Research Society International Osteoarthritis Cartilage Histopathology Assessment was 4.9 (±1.1) for the medial femoral condyle and 2.4 (±0.7) for the lateral femoral condyle. In respect of the medial compartment, there was no statistically significant parametric correlation between the intraoperative visual assessment of the cartilage degeneration and the preoperative radiological grade r = 0.45. The histological assessment showed a statistically significant concordance both with the degree of chondropathy r = 0.76 and the radiological grade r = 0.64. In the lateral compartment, the parametric test showed a statistically significant concordance only between the radiological grade and the histological score r = 0.72. The correlation between the visual assessment of chondropathy and the radiological grade r = 0.27 as well as the histological score r = 0.24 was very low. In our cohort assessing the early degenerative changes of the lateral compartment as well as the more advanced degenerative changes of the medial compartment, the correlation between the intraoperative assessment of cartilage degeneration as a diagnostic method to examine the lateral compartment and the preoperative radiological grade was not confirmed. Our results failed to confirm a better reporting value of the visual cartilage degeneration assessment of the lateral compartment as against the preoperative X-ray. The space width without narrowing on an X-ray has no reporting value for this compartment in case of varus deformity. The results clearly indicate that the assessment of macroscopic appearance of the cartilage degeneration during arthroscopy does not necessarily guarantee good long-term clinical outcomes after high tibial osteotomy. The respective degrees of cartilage degeneration identified during the intraoperative visual assessment and the radiological grading of osteoarthritic changes did not correlate in either compartment. In the lateral compartment, the initial radiological and histological findings preceded the visually detectable cartilage changes. knee, cartilage, osteoarthritis, radiology, histology, arthroscopy, osteotomy.

A new and easy parameter to predict the requirement for permanent pacemaker implantation after transaortic valve implantation: aortic knob calcification.

One of the predictable and preventable complications that may occur after transaortic valve implantation (TAVI) is the requirement for permanent pacemaker (PPM) implantation. To evaluate the relationship between aortic knob calcification (AKC) assessed by preoperative chest X-ray and the requirement for post-procedure PPM implantation for patients who underwent TAVI. This study was conducted with 110 patients who underwent TAVI with a Myval transcatheter heart valve in our center between June 2020 and December 2022. The patients' electrocardiograms were monitored after the procedure. The patients were evaluated in two groups according to whether they required PPM. The AKC grading was performed by examining the routine posterior-anterior chest radiographs of all patients participating in the study. A PPM was placed in 17 (15.4%) patients after TAVI. The remaining 93 patients formed the control group. AKC (p = 0.002) and membranous septum (p = 0.013) statistically significantly differed between the PPM and control groups; however, no significant difference was detected in relation to the other parameters. In the univariable (p = 0.004) and multivariable (p = 0.024) regression analyses performed to identify predictors of PPM requirement after TAVI, AKC was found to be both a dependent and independent predictor. AKC can be used as a cost-effective and easily accessible parameter for predicting the post-procedure PPM requirement in patients who have undergone TAVI.

Use of Preoperative Lumbosacral Spine X-rays in Developing a Predictor Score for Facilitating Neuraxial Blocks in Patients undergoing Lower Limb Arthroplasty Surgeries: A Cross-sectional Study

Introduction: Due to bony changes and narrow lumbar interspinous spaces, performing a neuraxial block becomes difficult in older patients undergoing lower limb arthroplasties. Aim: To formulate a difficulty predictor score (MUSG score) for anticipating difficult Central Neuraxial Blocks (CNB) and to compare lumbar spine radiological findings with clinical findings. Materials and Methods: A cross-sectional study was conducted on 166 patients admitted for knee or hip arthroplasties from March 2023 to March 2024 in the main operation theatre complex of a tertiary care hospital. All patients were advised to get X-rays of the lumbosacral spine in both anteroposterior and lateral views before surgery. The total difficulty predictor score was calculated from the X-rays based on the presence or absence of scoliosis, bony osteophytes, angulation of spinous processes, calcification of the ligamentum flavum, and the ratio of inner and outer visible interspinous space. The minimum score was 5 and the maximum was 12. The individual score at each interspinous level was calculated and selected the space with the minimum score for the CNB. A comparison was also made with the clinically selected best space, which was identified using the traditional palpation technique. A block was labeled difficult if there were more than two attempts for spinal and epidural block, respectively. All collected data were entered into a Microsoft Excel sheet and analysed using Microsoft Excel software. Results: The study patients had a mean age of 59.83 years. The total difficulty predictor score (MUSG Score) of the lumbar spine was 5 in 3 patients (1.8%), 6-9 in 140 patients (84.3%), and ≥10 in 23 patients (13.9%). However, the minimum score at the best interspinous space was 5 in 15 patients (9%), 6-9 in 151 patients (91%), and none had a score of 10 or more. From radiological imaging, the spaces with minimal scores were in the order of L2-L3 (76), L3-L4 (62), and L1-L2 (28); while on clinical examination, they were – L2-L3 (96), L3-L4 (43), L1-L2 (23). The difference between the two was statistically significant (p-value &lt;0.05). The time required for the block procedure was longer in patients with a score of 6-9 (13.99 minutes) than in those with a score of 5 (11.13 minutes). Haemodynamic changes from baseline were also more pronounced in patients with a score of 6-9 compared to those with a score of 5. Conclusion: CNBs in patients undergoing hip and knee arthroplasties are easier to perform with the help of the difficulty predictor score (MUSG Score). A difficulty predictor score of 5 is associated with an easier block compared to higher scores.

Anterior radial head subluxation in primary elbow osteoarthritis.

To investigate elbows with primary osteoarthritis (OA) for the presence of anterior radial head subluxation. A total of 71 patients with elbow osteoarthritis and 45 with lateral epicondylitis were initially identified. The baseline characteristics and preoperative elbow X-rays of consecutive patients that had been clinically confirmed with elbow OA or lateral epicondylitis between March 2011 and January 2020 were then retrospectively reviewed. The radiocapitellar ratio (RCR; the ratio of the displacement of the radial head about the diameter of the capitulum) was calculated using lateral views. These RCR values were compared between the OA and lateral epicondylitis cases. A significant increase was detected in RCR values between patients in elbow OA and the control group (13.2% (± 10.6) vs -1.2% (± 6.8), P<0.001). Based on receiver operating characteristic curves, RCR values had an excellent area under the curve (0.89) for the detection of elbow OA (Youden index, 0.69; sensitivity, 89%; specificity, 80%). Based on the ROC curve, the cutoff value of RCR was 0.04. Patients with RCR ≥ 0.04 had a significantly higher proportion of cases with elbow OA (risk ratio, 31.50 [95% CI, 11.17-88.82]) than those with RCR ˂ 0.04 (P ˂ 0.001). Radial head subluxation is a radiographic finding associated with elbow OA and RCR ≥ 0.04 could be used as an aetiological factor for elbow OA diagnosis.

Transcutaneous ultrasound level check for selective dorsal rhizotomy.

Single-level selective dorsal rhizotomy (SDR) surgery requires an intra-operative level check to identifythe L1 vertebral level or the conus medullaris. Typically, this requires a pre-operative or intra-operative x-ray. We present our experience using initial transcutaneous ultrasound as an alternative to x-ray level check. A prospective SDR database was used to identify patients. The operation notes were reviewed to identify the level check method and any complications or wrong-level surgery. Data are reported for the first 160 SDR surgeries performed within our centre, mean age 6.47 years (range 2.5-19 years). The first 11 patients had combined x-ray and transcutaneous ultrasound for pre-incision level check. This allowed the neurosurgeon to assess the accuracy and feasibility of using transcutaneous ultrasound instead of x-ray. The subsequent 149 patients had ultrasound alone for transcutaneous pre-incision level check. An intra-operative ultrasound level check was performed for all patients following skin incision and dissection down to the spinal lamina. In this way, the conus level was confirmed before dural opening. For all patients at all ages, the combination of initial transcutaneous ultrasound followed by intra-operative ultrasound allowed accurate identification of the conus. There were no instances of wrong-level surgery. Learning points are presented within this paper. Combined use of transcutaneous ultrasound followed by intra-operative ultrasound can allow accurate identification of the conus, saving radiation exposure and potentially improving theatre efficiency. Appropriate training and experience are required for any neurosurgeon using these techniques.

Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies.

Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.

Preoperative radiological indicators for prediction of difficult laryngoscopy in patients with atlantoaxial dislocation

BackgroundDifficult airway remains a great challenge in patients with atlantoaxial dislocation (AAD). Preoperative evaluation and reliable prediction are required to facilitate the airway management. We aimed to screen out reliable radiological indicators for prediction of difficult laryngoscopy in patients with AAD. MethodsA retrospective nested case-control study within a single center longitudinal AAD cohort was conducted to investigate the radiological indicators. All the patients with difficult laryngoscopy from 2010 to 2021 were enrolled as the difficult laryngoscopy group. Others in the cohort without difficult laryngoscopy were randomly selected as the non-difficult laryngoscopy group by individually matching with the same gender, same surgery year, and similar age (±5 years) at a ratio of 6:1. Radiological data on preoperative lateral X-ray images between the two groups were compared. Bivariate logistic regression model was applied to screen out the independent predictive indicators and calculate the odds ratios of indicators associated with difficult laryngoscopy. Receiver operating characteristic curve and area under the curve (AUC) were used to describe the discrimination ability of indicators. ResultsA total of 154 patients were finally analyzed in this study. Twenty-two patients with difficult laryngoscopy and matched with 132 controls. Four radiological parameters showed significant difference between the two groups. Among which, ΔC1C2D (the difference of the distance between atlas and axis in the neutral and extension position), owned the largest AUC. ConclusionsΔC1C2D could be a valuable radiologic predictor for difficult laryngoscopy in patients with AAD.

Comparison of Radiographic and Patient-Reported Outcomes After Surgery in Adolescent Idiopathic Scoliosis Between Robotics and Navigation: An Analysis Using Propensity Score Matching.

Purpose This study aimed to compare the radiographic and patient-reported outcomes after surgery in adolescent idiopathic scoliosis (AIS) between robotics and navigation using propensity score matching. Methods This retrospective study involved 50 patients undergoing posterior spinal fusion for AIS between October 2016 and August 2022, utilizing navigation or robotic systems, analyzing them using propensity score matching. The evaluations included assessments using X-ray, Scoliosis Research Society 22-Item (SRS-22) Questionnaire, and CT, considering variables such as age, gender, BMI, and Lenke type. Results Post matching, 13 cases each from robotics and navigation groups were compared. No significant differences were found in the demographic variables, preoperative X-ray parameters, and preoperative SRS-22 scores between the two groups. The robotics group demonstrated a higher perfect accuracy rate (94.0% vs. 84.7%, p=0.005) and a lower deviation rate in pedicle screw placements (1.6% vs. 4.1%, p=0.223). At one year postoperatively, there were no significant differences in the X-ray parameters between both groups. Likewise, no significant differences were found in each domain of SRS-22, but function, self-image, mental health, and satisfaction scores were numerically higher in the robotics group. Conclusion The application of a spinal robotic system in AIS surgery presented enhanced screw accuracy and lower deviation rates, compared to navigation, with no significant differences observed in the X-ray parameters and each domain of SRS-22 at one year postoperatively. This suggests that, to improve patientquality of life (QOL), it is essential for robotic-assisted spine surgery to focus not only on screw accuracy but also on the development of novel robotic-assisted techniques.

BORS/BJR TRAVELLING FELLOWSHIP ABSTRACT: THE EFFECT OF INCREASING BONE LOSS ON THE PRIMARY STABILITY OF METAPHYSEAL SLEEVES IN THE PROXIMAL TIBIA. AN EXPERIMENTAL STUDY USING SAWBONE TIBIAS

AbstractApproximately 20% of primary and revision Total Knee Arthroplasty (TKA) patients require multiple revisions, which are associated with poor survivorship, with worsening outcomes for subsequent revisions. For revision surgery, either endoprosthetic replacements or metaphyseal sleeves can be used for the repair, however, in cases of severe defects that are deemed “too severe” for reconstruction, endoprosthetic replacement of the affected area is recommended. However, endoprosthetic replacements have been associated with high complication rates (high incidence rates of prosthetic joint infection), while metaphyseal sleeves have a more acceptable complication profile and are therefore preferred. Despite this, no guidance exists as to the maximal limit of bone loss, which is acceptable for the use of metaphyseal sleeves to ensure sufficient axial and rotational stability. Therefore, this study assessed the effect of increasing bone loss on the primary stability of the metaphyseal sleeve in the proximal tibia to determine the maximal bone loss that retains axial and rotational stability comparable to a no defect control.Methodsto determine the pattern of bone loss and the average defect size that corresponds to the clinically defined defect sizes of small, medium and large defects, a series of pre-operative x-rays of patients with who underwent revision TKA were retrospectively analysed. Ten tibiae sawbones were used for the experiment. To prepare the bones, the joint surface was resected the typical resection depth required during a primary TKA (10mm). Each tibia was secured distally in a metal pot with perpendicular screws to ensure rotational and axial fixation to the testing machine. Based on X-ray findings, a fine guide wire was placed 5mm below the cut joint surface in the most medial region of the plateau. Core drills (15mm, 25mm and 35mm) corresponding to small, medium and large defects were passed over the guide wire allowing to act at the centre point, before the bone defect was created. The test was carried out on a control specimen with no defect, and subsequently on a Sawbone with a small, medium or large defect. Sleeves were inserted using the published operative technique, by trained individual using standard instruments supplied by the manufacturers. Standard axial pull-out (0 – 10mm) force and torque (0 – 30°) tests were carried out, recording the force (N) vs. displacement (mm) curves.ResultsA circular defect pattern was identified across all defects, with the centre of the defect located 5mm below the medial tibial base plate, and as medial as possible. Unlike with large defects, small and medium sized defects reduced the pull-out force and torque at the bone-implant interface, however, these reductions were not statistically significant when compared to no bony defect.ConclusionsThis experimental study demonstrated that up to 35mm radial defects may be an acceptable “critical limit” for bone loss below which metaphyseal sleeve use may still be appropriate. Further clinical assessment may help to confirm the findings of this experimental study. This study is the first in the literature to aim to quantify “critical bone loss” limit in the tibia for revision knee arthroplasty.Declaration of Interest(a) fully declare any financial or other potential conflict of interest