Sagittal Profile Research Articles

Unplanned return to OR (UPROR) for children with early onset scoliosis (EOS): a comprehensive evaluation of all diagnoses and instrumentation strategies.

Retrospective analysis of a prospectively collected multicenter database. Our goal was to study unplanned return to the OR (UPROR, a postoperative complication that could not be treated without an additional anesthetic) as a function of C-EOS diagnosis and implant type. Growing concerns over the impact of multiple anesthetic events on the young brain have focused attention on limiting UPROR in early onset scoliosis (EOS). We studied all patients with a diagnosis of EOS who had surgical implantation of growing instrumentation from October 4, 2010, to September 27, 2015, with a minimum 2-year follow-up. Among the complications requiring surgical treatment (revision for implant or anchor failure, infection, or implant removal), we analyzed all UPROR events-those that required a separate anesthetic (could not be treated as part of a planned surgical lengthening) within the first 2years after initial implantation. UPROR was analyzed by diagnosis, deformity type, and implant strategy using the C-EOS classification. A total of 369 patients met inclusion criteria. Eighty-five of the 369 (23%) required unplanned trips to the operating room for various reasons. The C-EOS group at highest risk of an unplanned trip to the operating room is the hyperkyphotic neuromuscular (M3+, 14/85) cohort, followed closely by the congenital (C3N, 9/85) and neuromuscular (M3N, 8/85) groups with normal sagittal profiles and Cobb angles between 50° and 90°. Implant strategy was significantly related to risk of UPROR (p = .009; Table1), with traditional implants (vertically expandable prosthetic titanium rib/traditional growing rod) being less likely to have an UPROR event. Growing instrumentation to treat EOS, when considered comprehensively, results in a true unplanned reoperation rate within 2years of implantation of 23% (85/369). UPROR events are more common with certain C-EOS groups (hyperkyphotic neuromuscular deformities) and implant strategies. Families should be counseled that unplanned anesthetics are common with any implant strategy available today. Level III, therapeutic.

Spine deformities in patients with cerebral palsy; the role of the pelvis.

IntroductionProgressive neuromuscular spinal deformities with pelvic obliquity and loss of sitting balance are typical features of severely affected patients with cerebral palsy. The pelvis represents the key bone between the spine and the lower extremity when it comes to deciding whether and when to operate and if spine or hip surgery first is beneficial. The pelvis can be looked at as the lowest vertebra and as the rooftop of the lower extremities.Biomechanical considerationsTo allow for a normal spinal shape, the pelvis needs to be horizontal in the frontal plane and mildly anterior tilted in the sagittal plane, less for sitting and more for standing. Any abnormal pelvic position requires spinal compensation and challenges the equilibrium control of the individual. Both anatomical neighbourhoods – the spine and the hip joints — have to be considered when spinal deformities, hip instability and contractures evolve, in conservative therapy (bracing, physiotherapy, seating in the wheelchair) and when surgical interventions are weighed out against each other.Surgical considerationsMultiple anatomical factors such as sagittal profile and pelvic orientiation, pelvic transverse plane asymmetries and lumbosacral malformations have to be considered in case the pelvis is instrumented with sacral and iliac screws. Rotational deformities and asymmetries of the pelvic bones make the safe insertion of long screws challenging. Advantages of primary pelvic fixation include correction of pelvic obliquity, especially considering the lever arm of the whole spinal construct. The risk of revision surgery due to progression of distal curves is also reduced. Disadvantages of pelvic fixation include the complexity of the additional intervention, which may result in longer operating times, increased risk of blood loss, infection and hardware malpositioning.

The Reverse Oblique Supracondylar Humerus Fracture: Description of a Novel Fracture Pattern.

Sagittal profile descriptions of supracondylar humerus fractures are limited. We describe a reverse oblique (RO) pattern in which the distal fragment has a prominent anterior spike that is displaced posterior to the proximal fragment. This pattern presents a challenge during closed manipulation utilizing traditional reduction maneuvers. The purpose of this study is to compare the clinical and radiographic characteristics of the RO and non-RO patterns of supracondylar humerus fractures. We hypothesized that the RO pattern would be associated with greater soft tissue trauma. Retrospective evaluation of operative supracondylar humerus fractures treated at a tertiary pediatric hospital from 2014 to 2016. Patients were categorized into RO and non-RO groups for analysis. Associated neurovascular injuries were compared between groups. Two hundred ninety-nine consecutive patients were reviewed. The RO fracture pattern was seen in 12 patients. All displaced RO fractures were able to be closed reduced with a modification to the traditional reduction sequence. Overall cohort rates of preoperative soft tissue injury included antecubital ecchymosis 16.8%, nerve palsies 15%, and vascular compromise 6.4%. Compared with non-RO fractures, the RO fracture group had significantly higher rates of anterior interosseous nerve (AIN) palsies (P=0.013), antecubital ecchymosis (P=0.018), and compartment syndrome (P=0.043). When comparing RO with non-RO type II fractures, there were no differences in soft tissue injury (P=0.439). Compared with non-RO type III fractures, RO type III fractures had higher rates of AIN injury (P=0.047), antecubital ecchymosis (P=0.007), and overall soft tissue injury (P=0.009). This study introduces a previously undescribed supracondylar humerus fracture subtype: the RO fracture. We found increased rates of soft tissue compromise including antecubital ecchymosis and AIN palsy in this fracture type. Further, traditional reduction methods proved to be ineffectual for this fracture pattern. We utilized a simple modification that allowed for closed reduction and percutaneous pinning of displaced RO fractures. Level III-prognostic.

Coronal Balance vs. Sagittal Profile in Adolescent Idiopathic Scoliosis, Are They Correlated?

Background: Clinical evaluation of the postural balance in adolescent idiopathic scoliosis has been evaluated by coronal and sagittal parameters. The relationship between coronal and sagittal parameters has not been fully studied in adolescent idiopathic scoliosis.Objective: This study aimed to evaluate the relationship between coronal and sagittal parameters in idiopathic scoliosis.Methods: One hundred and three patients of Adolescent Idiopathic Scoliosis (AIS) were recruited. Radiographs were evaluated for the following spine and pelvic measurements. Coronal parameters including thoracic Cobb angle (TC), lumbar Cobb angle (LC), global coronal balance (GCB), apical translation of the major curve (AT), and coronal pelvic tilt (CPT) were analyzed. Sagittal parameters including thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were analyzed. A canonical correlation analysis was performed between all of the coronal parameters and sagittal parameters.Results: One hundred and three patients were recruited (male 15, female 88; aged 12.5 ± 1.5 years). Compared with the published age-matched normal population, TK, PI, LL, and SS were not statistically different in the normal group. However, PT was significantly increased in patent groups (P = 0.003). Canonical correlation analysis showed strong correlation between coronal parameters and sagittal parameters, F(20, 313) = 2.44, p = 0.001. SVA was not correlated with any coronal parameter.Conclusions: Children with AIS showed an increased pelvic tilt sign. In this study, TC, LC, GCB, AT, CPT, TK, LL, SVA, PI, PT, and SS contributed to the postural balance. In AIS, coronal balance is contributed to sagittal balance.

Ideal sagittal profile restoration and ideal lumbar apex positioning play an important role in postoperative mechanical complications after a lumbar PSO.

Retrospective analysis of prospectively collected data. To determine the influence of postoperative ideal lordosis distribution and ideal sagittal harmony on mechanical complications in patients undergoing one-level lumbar pedicle subtraction osteotomy (L-PSO). Many variables have been associated with mechanical complications after L-PSO. However, the impact of restoring the ideal inflexion point, lumbar apex, and sagittal shape is still underexplored. Analyzed risk factors were: age and patient-related variables, PSO level, interbody cages, rod material/diameter, number of rods, upper instrumented vertebra, lower instrumented vertebra, PI-LL mismatch, global tilt (GT), postoperative level of lumbar apex (LApex), postoperative level of inflexion point (InfxP), and postoperative type of Roussouly sagittal profile (R-type). These last variables were compared to ideal (based on pelvic incidence). Univariate and multivariate analyses were performed to identify risks for mechanical complications with a minimum 2-year follow-up. A total of 87 patients were included. Mean follow-up was 4.5 ± 1.7years. 40.2% of the patients suffered postoperative mechanical complications (7 PJK, 4 PJF, 18 pseudoarthrosis/rod breakage, 6 screw pullout). Mean time for complications was 584 ± 416days from surgery. Univariate analysis showed that age (63 vs 57years; P = 0.04), BMI (28.1 vs 25.9; P = 0.024), preoperative-GT (50.7° vs 38.7°; P < 0.001), postoperative-GT (28.9° vs 23.4°; P = 0.018), postoperative LApex location mismatched from ideal (77.8% vs 22.2%; P = 0.036), and postoperative R-type mismatched from ideal (67.6% vs 22.6%; P < 0.001) were significantly related to mechanical complications. The independent factorsselected bymultivariate analysis were: postoperative R-type mismatched from ideal OR 11.3 (95% CI 3.9-32.6; P < 0.001), age OR 1.05 (95% CI 1-1.1; P = 0.03), and LApex matching OR 0.5 (95% CI 0.27-0.97; P = 0.04). The further the LApex was from its ideal position, the higher the risk of mechanical complications (P = 0.036). Over other multiple suspected risk factors, proper lumbar apex position and ideal sagittal shape restoration played an important role in postoperative mechanical complications after L-PSO. III.

The relationship between the posterior tibial slope and the sagittal femoral condylar shape: Two circles and ellipses.

Whether the posterior tibial slope (PTS) is associated with the femoral condylar shape has remained unclear. Classical anatomical studies considered the sagittal profiles of femoral condyles to consist of two circles. Recently, an elliptical method was described to simplify the "two circles" model. Our purpose was to analyze the relationship between the PTS and the shape of the sagittal femoral condyle, that is, two circles and two ellipses, using magnetic resonance imaging (MRI) scans. Eighty right knees of healthy subjects were scanned by MRI at full extension. The medial and lateral PTS were measured (mPTS and lPTS). On the distal-most medial and lateral slices, the femoral condylar articular surfaces were best fitted by circles or ellipses, respectively. The radii of the medial and lateral posterior circles and inferior circles (rm and rl , Rm and Rl , respectively), the semi-major axes and the semi-minor axes of the medial and lateral ellipses (am and al , bm and bl , respectively), and the rm /Rm , bm /am , rl /Rl , bl /al ratios were measured and calculated. mPTS correlated significantly with the parameters of the medial condyle (all p < .05) and the ratios bm /am and rm /Rm (p = .017 and p = .027, respectively). However, the lPTS did not correlate with the parameters of the lateral condyle (all p > .05) or the ratios bl /al and rl /Rl (p = .461 and p = .241, respectively). The mPTS is associated with the sagittal shape of the medial femoral condyle but the lPTS is not. Both two circles and two ellipses are feasible ways to represent the sagittal femoral condylar shape.

Chin Augmentation and Reshaping: Using Calcium Hydroxylapatite With Lidocaine (CaHA+) Filler

Adequate chin projection is associated with strength in the male jawline, youth in a female face, and a harmonious balance with the nose. Calcium hydroxylapatite plus integral lidocaine (CaHA+; Merz North America, Inc.) is a filler that has demonstrated immediate volume improvement for midface augmentation and for filling facial folds. There is a paucity of reports of the use of CaHA+ in the chin. The objective of this study was to assess the use of moldable CaHA+ injections to improve the chin profile. Twelve patients with microgenia were treated with CaHA+ chin injections for improvement of the chin profile. Deep, pre-periosteal, serial injections of CaHA+ were performed on the chin. Efficacy was assessed by the treating physician using sagittal profile views at 1-week, 1-month and 6-month follow-ups. Patients were monitored for complications. In total, 5 male and 7 female patients were treated to optimal enhancement of their chin profile. Average age was 47 years (range of 22-64 years). Patients received a mean total volume of 4.8 mL CaHA+. All patients were satisfied, and results persisted at the 6-month assessment. No complications were noted. CaHA+ can be used to augment the chin to enhance a recessed chin profile. This procedure is quick and effective, providing immediate results. Patients seeking a less-invasive alternative to surgery without the associated downtime may be ideal candidates for CaHA+ injections into the chin.

Anterior instrumented fusion for adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a complex three-dimensional deformity of the spine consisting of a lateral curvature, apical vertebral rotation, and an impairment of the sagittal profile. Surgical options include anterior and posterior approaches. Anterior instrumented fusion is suitable in Lenke type 1 and 5 curves. It supplies excellent results in coronal plane correction and is superior in the restoration of the sagittal profile and apical derotation. Fusion is shorter compared to posterior correction, and the complication rate is low. Pulmonary function is impaired postoperatively but recovers within a few years.

Posterior techniques for correcting deformity in adolescent idiopathic scoliosis––How much correction is optimal?

The optimal surgical treatment of adolescent idiopathic scoliosis is heavily debated in the literature. This study aimed to review posterior surgical techniques in the treatment of adolescent idiopathic scoliosis. Literature review was performed. In treating adolescent idiopathic scoliosis with posterior spine fusion, there are many factors to consider when determining where to start and end the fusion construct: skeletal maturity, stress/bending radiographs, and assessment of vertebral rotation and translation. When considering selective thoracic fusion, the relative magnitudes of the main thoracic (MT) and thoracolumbar/lumbar (TL/L) curves and the overall sagittal profile of the thoracolumbar junction are assessed. Selective thoracic fusion can be appropriate if two of the three are found to be true: the MT-to-TL/L Cobb angle ratio is >1.2, the MT-to-TL/L apical vertebral translation (AVT) ratio is >1.2, and/or the MT-to-TL/L apical vertebral rotation (AVR) ratio is >1.2. Moreover, selective thoracic fusion can be an option in the presence of a nonstructural lumbar curve (bending Cobb angle <25°) with thoracolumbar (T10-L2) kyphosis <20°. When choosing the uppermost and lowest instrumented vertebra, one must consider standing coronal balance and regional kyphosis to lessen risk of postoperative complication. The uppermost instrumented vertebra should be a stable, neutral vertebra with <5° of junctional kyphosis; and the lowest instrument vertebra should be touched by the central sacral vertical line and within two vertebrae proximal to the neutral vertebra. To aid in correction, the addition of posterior surgical releases improves the mobility of spine, especially in more rigid curves, but may increase intraoperative blood loss and operative time. Rod derotation and vertebral translation appear to have similar results in correcting coronal and sagittal deformities. The addition of direct vertebral rotation and segmental rotation plays a role in surgical correction as well.

Rehabilitation of patients with early scoliosis after stage corrections of spine deformations by growing systems

Idiopathic scoliosis is a large etiological group in the structure of early scoliosis which requires the use of modern effective surgical methods for correction of deformity, in particular, using various structures with possible staged distraction (growing structures). Dysplastic changes in the musculoskeletal tissue are very important in the pathogenesis of scoliosis. Active correction of the tone of the muscular-ligamentous system of the spine in the postoperative period is of great importance in the recovery of such patients. Individual rehabilitation programs are aimed at consolidating the result of the operation (correction of the sagittal profile and normalization of the body balance), improving respiratory function, fast recovery of motor activity (in order to prevent hypostatic and thromboembolic complications), increasing self-esteem and patient satisfaction with the results of the operation. The purpose of the study is to assess the effectiveness of an integrated approach to the rehabilitation of patients with early scoliosis after correction of spinal deformities by growing systems. Materials and methods. A retrospective analysis of the results of a comprehensive rehabilitation of patients (n = 15) with idiopathic infantile scoliosis (mean age 8.6 ± 1.0 years) was performed. This group of patients was operated using a growing system with stepwise corrections using the Growing Rods, VEPTER technique. The algorithm of rehabilitation of the studied group of patients using the parameters of activity, participation, degree of dysfunction in accordance with the International classification of functioning (ICF) is presented. Evaluation of the effectiveness of the results carried out taking into account the criteria of the pain scale (VAS), verticalization time, indicators of walking, coordination, support capacity, balance of body and strength (on the CSBS platform), self-perception, psychological comfort, functions, satisfaction with the treatment. Results and discussion. In all patients, a normal sagittal profile was formed, satisfactory correction was achieved, and body balance was normalized. After a comprehensive rehabilitation course, we observed statistically significant improvements in balance, balance and load distribution, and postoperative pain was stopped. Early verticalization was successfully carried out, walking indicators reached values exceeding the conditional "norm". Assessment of coordination, support ability, balance of the body and strength on the CSBS platform showed a uniform improvement in the index of symmetry, the average value of the load on the limbs. Patients' self-perception and the level of psychological comfort before discharge were rated at 3 points, patients evaluated spinal function after surgery at 2.7 points, satisfaction with treatment was 3.5 points. Characteristics of signs of activity and participation, the degree of dysfunction within 6 months after surgery went from a score of 3-4 to a score of 0-2 (dynamic improvement). Conclusions. Correction of scoliotic spinal deformity with the help of growing systems due to improved respiration function, correction of the sagittal profile and body balance, restoration of motor activity and increased self-esteem and satisfaction with the results of the operation improves the quality of life of the patient. Due to the lack of clinical recommendations for rehabilitation in the postoperative period of patients with scoliosis (with early development), taking into account the age characteristics of this group of patients, the algorithm for their rehabilitation used in the Center shows good results in the restoration of functions and satisfaction with the treatment.

Reciprocal Change in Sagittal Profiles After Adolescent Idiopathic Scoliosis Surgery With Segmental Pedicle Screw Construct: A Full-body X-ray Analysis.

Retrospective cohort. This radiographic analysis using a full-body x-ray evaluated the ways in which the sagittal profiles of the unfused spinal segments, pelvic, and lower extremities spontaneously change after adolescent idiopathic scoliosis (AIS) surgery with segmental pedicle screw constructs. Reciprocal lordotic changes in unfused spinal segments after corrective surgery for AIS have been reported. However, a full-body analysis has not been studied. The sagittal profiles of 51 (age ≤18) patients with AIS undergoing corrective surgery with segmental pedicle screw constructs were investigated. Patients were divided into two groups: group T; selective thoracic fusion and group L; fusion to the low lumbar spine. They were further subcategorized according to preoperative thoracic kyphosis (TK: T5-12): hypokyphotic (TK <20°) and normohyperkyphotic (TK >20°) groups. The postoperative change in the sagittal parameters and the correlation between the instrumented thoracic alignment change (ΔT2-12) and reciprocal changes of unfused segments were analyzed. At baseline, the entire cohort had a relatively hypokyphotic thoracic spine (TK: 25.5° ± 13.7°), low T1 slope (13.6° ± 7.7°), and kyphotic cervical spine (C2-7 lordosis: 7.7° ± 13.1°). The lower extremities were in neutral alignment overall. Postoperatively, the cervical alignment changed significantly lordotic (average -13.4° increased lordosis) after the adequate preservation of TK (average 17.8° increased kyphosis) in the hypokyphotic group T. Linear correlations were observed between ΔT2-12 and spontaneous reciprocal changes in C2-7 lordosis, lumbar lordosis, and knee flexion angle in group T. The sagittal profiles of patients with AIS can significantly change after adequate restoration of TK which averaged 17.8°, particularly in the cervical spine. Lordotic reciprocal change in the cervical spine as well as increase in lumbar lordosis can occur in a linear correlation after adequate restoration of TK. There were no significant changes that occurred in the pelvis or lower extremities after AIS corrective surgery. 4.

3D Deformation Patterns of S Shaped Elastic Rods as a Pathogenesis Model for Spinal Deformity in Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a three-dimensional (3D) deformity of the spinal column in pediatric population. The primary cause of scoliosis remains unknown. The lack of such understanding has hampered development of effective preventive methods for management of this disease. A long-held assumption in pathogenesis of AIS is that the upright spine in human plays an important role in induction of scoliosis. Here, the variations in the sagittal curve of the scoliotic and non-scoliotic pediatric spines were used to study whether specific sagittal curves, under physiological loadings, are prone to 3D deformation leading to scoliosis. To this end, finite element models of the S shaped elastic rods, which their curves were derived from the radiographs of 129 sagittal spinal curves of adolescents with and without scoliosis, were generated. Using the mechanics of deformation in elastic rods, this study showed that the 3D deformation patterns of the two-dimensional S shaped slender elastic rods mimics the 3D patterns of the spinal deformity in AIS patients with the same S shaped sagittal spinal curve. On the other hand, the rods representing the non-scoliotic sagittal spinal curves, under the same mechanical loading, did not twist thus did not lead to a 3D deformation. This study provided strong evidence that the shape of the sagittal profile in individuals can be a leading cause of the 3D spinal deformity as is observed in the AIS population.

Micrognathia

Micrognathia

Three-Dimensional Analysis of Initial Brace Correction in the Setting of Adolescent Idiopathic Scoliosis.

The three-dimensional nature of adolescent idiopathic scoliosis (AIS) necessitates a tridimensional assessment and management. Bracing constitutes the mainstay conservative treatment for mild adolescent idiopathic scoliosis. In the literature hitherto, there has been uncertainty regarding the behavior of the spine, pelvis, and vertebral orientations in the context of bracing, especially in the transverse plane. This poses a challenge to healthcare providers, patients, and their families, as brace treatment, although not as invasive as surgery, is laden with medical and psychological complications and could be considered traumatizing. Hence, a thorough understanding of initial three-dimensional spinal behavior in the context of bracing is important. The purpose of this retrospective study was to investigate the immediate 3D impact of Chêneau-type brace. Thirty-eight patients with AIS undergoing Chêneau-type bracing were included. Patients were stratified according to their structural curve topography into thoracic, thoracolumbar, and lumbar groups. 3D reconstruction of the spine using a dedicated biplanar stereoradiography software with and without the brace was performed. The examined anthropometric radiographic measures were pre- to in-brace variations and differences of spinopelvic parameters and vertebral orientations in the coronal, sagittal, and transverse planes. The complex impact of the Chêneau-type brace on different curves in three planes was delineated. In the coronal plane, the Cobb angle was significantly decreased in all types of curves, and the coronal tilt correction was concentrated in specific segments. The impact of the brace in this study on the sagittal profile was variable, including the loss of thoracic kyphosis and lumbar lordosis. In the transverse plane, an axial vertebral rotation change and detorsion above the apex occurred in the thoracolumbar curves. The results from this exploratory study could shed some light on the initial 3D spinal behavior in the context of bracing and may be of beneficial for treating physicians and brace makers.

Excessive correction impacts postoperative shoulder imbalance in lenke type 5C adolescent idiopathic scoliosis

BackgroundPostoperative shoulder imbalance (PSI) has a negative impact on the surgical outcomes of patients with adolescent idiopathic scoliosis. This study aimed to evaluate the risk factors of PSI in patients with Lenke type 5C curves. MethodsThis study included 100 patients who underwent posterior correction surgery using pedicle screw constructs for Lenke type 5C curves. The mean age of the patients at surgery was 15.5 ± 2.3 years, and the mean follow-up period was 36.6 ± 15.0 months. The subjects were classified into the following two groups: PSI and non-PSI. Radiographic parameters, including the preoperative and 2-year postoperative coronal and sagittal profiles, were compared between the two groups. ResultPSI was found in eight patients (8.0%). The preoperative Cobb angles were 47.3° ± 8.7° and 48.0° ± 3.9° in the non-PSI and PSI groups, respectively. The correction rate in the PSI group was significantly higher than that in the non-PSI group (81.0% ± 17.7% vs. 67.7% ± 14.7%; p = 0.018). The preoperative T1 tilt angle in the PSI group was significantly larger than that in the non-PSI group (6.1° ± 3.3° vs. 3.1° ± 2.8°; p = 0.005). Receiver operating characteristic (ROC) analysis showed that the area under the ROC curve was 0.769 (p = 0.012, 95% confidence interval [CI], 0.556–0.982) and 0.763 (p = 0.014, 95% CI, 0.598–0.928) for the correction rate and preoperative T1 tilt, respectively. The cut-off value was 73% and 4° for the correction rate and preoperative T1, respectively. ConclusionPSI was found in 8.0% of Lenke type 5C curves. Excessive correction of the lumbar curve of >73% and preoperative T1 tilt of >4° can be risk factors for PSI in patients with Lenke type 5C curve.

Restoring the ideal Roussouly sagittal profile in adult scoliosis surgery decreases the risk of mechanical complications.

There are still no data proving whether restoring the ideal sagittal profile (according to Roussouly classification) in adult scoliosis (AS) patients leads to any additional benefit, especially regarding mechanical complications. Retrospective analysis of operated AS patients recorded in a prospective multicenter database. Demographic and radiographic (preoperative and 6-week postoperative) data were analyzed. Patients with and without mechanical complications were compared looking especially at the surgical restoration of the ideal (based on Pelvic Incidence) sagittal profile. Univariate and multivariate analysis was performed to identify causes of mechanical complications at 2-year minimum follow-up. Ninty-six AS patients were analyzed. Thirty-nine patients suffered a mechanical complication (18 PJK, 11 pseudoarthrosis, 10 screw pull-out), and 57 patients had no mechanical complications. Postoperatively, 72% of patients not matching the ideal Roussouly-type suffered mechanical complications compared to 15% of matched patients (P < 0.001). Univariate analysis showed that older patients 64.9 ± 13 versus 40.7 ± 15.6years (P < 0.001), higher postoperative Global Tilt (27° vs. 14.7°) and Pelvic Tilt (25° vs. 16°) (P < 0.001), upper instrumented vertebra at the thoracolumbar junction (62% vs. 21%) (P < 0.001), fixation to the Iliac (76% vs. 6%) (P < 0.001), and postoperative Roussouly-type mismatch (72% vs. 15%) (P < 0.001) significantly increased the rate of mechanical complications. Multivariate logistic regression analysis selected: postoperative Roussouly-type mismatch (OR = 41.9; 95%CI = 5.5-315.7; P < 0.001), iliac instrumentation (OR = 19.4; 95%CI = 2.6-142.5; P = 0.004), and age (OR = 1.1; 95%CI = 1.02-1.16; P = 0.004), as the most important variables. Adult scoliosis surgery should restore the ideal Roussouly sagittal profile to decrease the rate of mechanical complications, especially in patients older than 65, instrumented to the pelvis. These slides can be retrieved under Electronic Supplementary Material.

Safety and effectiveness of minimally invasive scoliosis surgery for adolescent idiopathic scoliosis: a retrospective case series of 84 patients.

The aim of this study was to retrospectively evaluate a prospective series of patients with adolescent idiopathic scoliosis (AIS) who were treated with minimally invasive scoliosis surgery (MISS) technique with a minimum follow-up more than 1year. We retrospectively analyzed the prospectively collected data of 84 patients with AIS treated with MIS technique using two or three coin hole size incisions and a muscle-splitting approach. The clinical and radiological data such as the correction of deformity, coronal and sagittal profile and record of the perioperative morbidity of the patients were analyzed. The mean primary Cobb angle was corrected from 59.8° preoperatively to 18.6° postoperatively with a mean correction of 68.9% (p < 0.001). The mean kyphosis at T2 to T12 was maintained within normal range with an increase from 31.2° preoperatively to 35.3° postoperatively (p < 0.001). The 30-day perioperative complication rate was 7.14% with one deep infection and five cases of hemothorax. The mean operation time was 312.8min; mean estimated blood loss was 846.6ml (range 420-2800); and mean length of stay was 8.5days (range 5 to 14). All data of postoperative SRS-22 questionnaire were significantly improved (p < 0.001). MISS used for AIS provides adequate correction in both planes and acceptable rate of perioperative complications, with a low estimated blood loss and short length of stay. Considering all the positives, the application of MISS technique for AIS seems meaningful and can become a valid alternative to posterior approach in the routine use. These slides can be retrieved under Electronic Supplementary Material.

Sagittal Reconstruction and Clinical Outcome Using Traditional ACDF, Versus Stand-alone ACDF Versus TDR: A Systematic Review and Quantitative Analysis.

Systematic review. To determine the difference in postoperative sagittal alignment when single level cervical radiculopathy or myelopathy is treated with an anterior cervical discectomy and fusion (ACDF) using a structural graft and plate, a stand-alone ACDF, or a total disc arthroplasty (TDR). We also wanted to determine if postoperative sagittal alignment impacted clinical outcomes in this patient population. Although there are several accepted techniques for interbody reconstruction during single level anterior cervical surgery, little is known on the impact of any of them on segmental and regional sagittal alignment. A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines of the PubMed, Embase, and Cochrane databases. Only studies which contained pre and postoperative C2-7 Cobb angles as well as Neck Disability Index (NDI) scores following single level traditional ACDF with plate and cage, stand-alone ACDF, or TDR with at least 1 year follow up were included. There were 12 publications that fulfilled the inclusion criteria with a total of 658 patients. Cluster regression analysis showed no difference between treatment arms at each respective time-point or in the overall change in NDI from preoperative to postoperative (P = 0.88). Cluster regression analysis showed no difference between treatment arms at each respective time point or in the overall change in lordosis from pre-op to post-op (P = 0.93). This review provides evidence that while NDI scores improved across all devices, there was no significant difference in NDI improvement or C2-7 Cobb angle change between single level traditional ACDF, stand-alone ACDF, or TDR. Although TDR has not been considered a lordosis producing operation, our investigation shows it does not differ significantly in sagittal profile from other cervical fusion techniques. Moreover, we show that the NDI score improved, regardless of device implanted. 1.

Intramedullary nailing of abnormally bowed atypical femoral shaft fractures: surgical technique.

The treatment of atypical femoral shaft fractures with abnormal bowing provides a unique challenge for surgeons. Whilst intramedullary fixation of atypical femoral shaft fractures affords both mechanical and biological benefits, the mismatch between standard intramedullary devices and the abnormal femoral bowing in these patients makes this method of fixation challenging for the surgeon. The purpose of this manuscript is to illustrate the evolution of our surgical technique through a series of four patients. The critical factors we identified include lateral positioning of the patient for reduction, the use of a piriformis-start nail, and an entry point that was anterior in the sagittal profile and lateral in the coronal profile. This technique was easily replicable, facilitated more anatomical reduction and aided in avoiding complications.

Predicting spinal profile using 3D non-contact surface scanning: Changes in surface topography as a predictor of internal spinal alignment.

Introduction3D non-contact surface scanners capture highly accurate, calibrated images of surface topography for 3D structures. This study sought to establish the efficacy and accuracy of using 3D surface scanning to characterise spinal curvature and sagittal plane contour.Methods10 healthy female adults with a mean age of 25 years, (standard deviation: 3.6 years) underwent both MRI and 3D surface scanning (3DSS) (Artec Eva, Artec Group Inc., Luxembourg) while lying in the lateral decubitus position on a rigid substrate. Prior to 3DSS, anatomical landmarks on the spinous processes of each participant were demarcated using stickers attached to the skin surface. Following 3DSS, oil capsules (fiducial markers) were overlaid on the stickers and the subject underwent MRI. MRI stacks were processed to measure the thoracolumbar spinous process locations, providing an anatomical reference. 3D coordinates for the markers (surface stickers and MRI oil capsules) and for the spinous processes mapped the spinal column profiles and were compared to assess the quality of fit between the 3DSS and MRI marker positions.ResultsThe RMSE for the polynomials fit to the spinous process, fiducial and surface marker profiles ranged from 0.17–1.15mm for all subjects. The MRI fiducial marker location was well aligned with the spinous process profile in the thoracic and upper lumbar spine for nine of the subjects. Over the 10 subjects, the mean RMSE between the MRI and 3D scan sagittal profiles for all surface markers was 9.8mm (SD 4.2mm). Curvature was well matched for seven of the subjects, with two showing differing curvatures across the lumbar spine due to inconsistent subject positioning.ConclusionComparison of the observed trends for vertebral position measured from MRI and 3DSS, suggested the surface markers may provide a useful method for measuring internal changes in sagittal curvature or skeletal changes.