Standard Radiographic Parameters Research Articles

Importance of modifiable non-radiographic functional parameters for adult spinal deformity

We clarified non-radiographic physical parameters associated with the severity of adult spinal deformity (ASD) using community-dwelling adult volunteers. They were subjected to upright entire spine radiographs for standard radiographic parameters and the number of sagittal modifiers of SRS-Schwab ASD classification (Schwab-SM). Clinical evaluations included isometric muscle strength of trunk extensor (TEX), trunk flexor (TFL), quadriceps femoris (QF), gluteus maximus, and iliopsoas; range of motion (ROM) of hip, knee, ankle, and active back extension (BET); SF36 physical component score (PCS), VAS for back and knee pain, and the degree of ambulatory kyphosis (dTIA). Each muscle strength was calibrated by body weight (BW) and expressed as BW ratio. According to our previous study, dTIA ≥ 7.6° was defined as pathological and dTIA ≤ 3.5° as normal. A final total of 409 female volunteers were included, and their demographics were; age 67.0 ± 5.5 years, Schwab-SM 2.1 ± 1.8, TEX 0.90 ± 0.33BW, TFL 0.48 ± 0.15BW, QF 0.45 ± 0.19BW, PCS 33.5 ± 6.5. Subjects were classified as clinical ASD group (cASD, n = 10) with PCS ≤ 27(mean-1SD) and pathological dTIA, robust group (n = 19) with PCS ≥ 40 (mean + 1SD) and normal dTIA, and the rest (non-cASD, n = 338). Statistical analyses showed significant differences in TEX, TFL, QF, knee extension (KEX), and BET between robust and cASD, and the mean values of robust group (TEX ≥ 1.1BW, TFL ≥ 0.5BW, QF ≥ 0.5BW, KEX ≥ 0° and BET ≥ 14 cm) were used as ‘ASD-MJ’ index. Subjects with fully achieving ASD-MJ goals showed significantly better radiographic and clinical outcomes than those with unmet goals. In conclusion, upon prescribing conservative or physical therapies for ASD patients, modifiable clinical goals should be clarified, and ASD-MJ could be a benchmark.

Poster 276: Assessment of Trochlear Cartilage Thickness and Volume Using Sagittal Magnetic Resonance Images to Quantify Trochlear Dysplasia: A Matched-Cohort Study

Objectives: Trochlear dysplasia is considered a major contributing factor for patellar instability. More recently, trochleoplasty procedures have become popularized to address this morphological abnormality. Both thick and thin flap trochleoplasty techniques exist, with the goal to deepen the trochlea while avoiding perforation of the trochlear cartilage during the procedure. However, the relative cartilage thickness in the dysplastic trochlea has not been well described. This study aimed to assess trochlear cartilage thickness and volume in knees with and without patellar instability and the relationship to measurements of trochlear dysplasia. Methods: 25 knees with symptomatic patellar instability were compared with 25 gender-matched knees. Retrospective chart review was performed to obtain demographic data. On sagittal images, trochlear cartilage thickness (TCT) and trochlear cartilage volume (TCV) were analyzed at the center, medial border, and lateral border of the trochlea. TCT was defined as the cartilage thickness halfway along the trochlear length at its maximum dimension. TCV was defined by total area of cartilage proximal to the plane of the intercondylar midpoint. Symptomatic and control values were compared using paired sample t-test. Stepwise multivariate linear regression was performed to assess for associations with standard radiographic parameters of trochlear dysplasia. Results: TCT was significantly different between the medial, central and lateral trochlea in both the symptomatic and control groups (p<0.001). Only lateral TCT demonstrated a significant difference between groups, which was 20.3% (p=0.035) thicker in the symptomatic cohort compared to controls. No significant differences existed in TCV between symptomatic and control groups. In females, central TCT was 28.3% thicker in the symptomatic cohort (p=0.024), while medial TCV was 2.3x greater (p = 0.019). Males failed to demonstrate gender specific differences. Regression analysis demonstrated that patient height showed a significant relationship with all measurements except for medial TCV. Central TCT demonstrated a significant, independent relationship with trochlear depth (Coefficient 0.38, p = 0.011), while central TCV demonstrated a significant, independent relationship with trochlear depth (Coefficient 9.9, p <0.001), sulcus angle (Coefficient 1.1, p <0.001), and lateral trochlear inclination (Coefficient -1.1, p <0.001). Conclusions: While trochlear dysplasia typically refers to abnormal bony morphology, this study demonstrates the role of differential contributions of chondral thickness and volume between knees with and without patellar instability, and that these measurements correlated with severity of dysplasia. Future studies should further investigate the relationship between TCT and TCV with other dysplasia parameters to better inform the surgical considerations of performing trochleoplasty in the treatment of patellar instability. [Table: see text]

Outcomes of vertebral body tethering in the lumbar spine.

The use of vertebral body tethering (VBT) for the treatment of main thoracic deformities in adolescent idiopathic scoliosis patients is becoming increasingly more common, but limited data exist on its safety and efficacy in thoracolumbar deformities. We aimed to evaluate the postoperative outcomes of patients with thoracolumbar (TL) deformities that were treated with VBT. We assessed clinical and radiographic data from twenty-eight consecutive patients that were surgically managed with VBT, all of whom exhibited a TL deformity with at least two years (mean: 44.7 ± 14.5months) of postoperative follow-up. Standard radiographic parameters were extracted from left hand wrist and standing posterior-anterior and lateral spine radiographs at various timepoints. Outcome variables were assessed based on preoperative Lenke Classification and included: deformity measures, complications, surgical revisions, and postoperative success. The mean age at the time of instrumentation was 13.4 ± 1.3years, with an average preoperative Sanders Stage of 4.6 ± 1.4. A significant reduction in preoperative deformities was observed at most postoperative timepoints. A perioperative complication was observed in three patients and surgical revision was required in another four patients. A suspected broken tether was observed in sixteen patients, most of which occurred at the apex of the lumbar deformity. Only one patient required surgical revision due to a suspected broken tether. We observed an overall success rate of 57%, regardless of Lenke Classification. These data indicate that VBT can successfully correct TL deformity patterns in 57% of patients without an increase in the rate of perioperative complications, suspected broken tethers, or surgical revisions.

Accuracy of pelvic measurements on virtual radiographic projections based on computed tomography scans compared to conventional radiographs pre- and postoperatively

BackgroundThe anteroposterior (ap) radiograph of the pelvis is decisive in the diagnosis of different pathologies of the hip joint. Technical advantages have reduced the radiation dose of pelvic CT to levels comparable to radiographs. The purpose of this study was to validate if standard radiographic parameters (lateral center edge angle, medial center edge angle, acetabular index, acetabular arc, extrusion index, crossover sign and posterior wall sign) can accurately be determined on radiograph-like projections reconstructed from the CT dataset pre- and postoperatively.MethodsA consecutive series of patient with symptomatic dysplasia of the hip and a full radiologic workup (radiographs and CT scan pre- and postoperatively) who underwent periacetabular osteotomy were included. Standard radiographic parameters were compared between radiographs and radiograph-like projections by two authors pre- and postoperatively.ResultsA total of 16 hips (32 radiographs/32 radiograph-like projections) were included in the study. No significant difference was found between the radiographs and radiograph-like images for all parameter for both examiners. ICC between radiograph and radiograph-like projections for all investigated parameters showed good to excellent reliability (0.78–0.99) pre- and postoperatively.ConclusionRadiograph-like projections show comparable results to radiographs with regard to the important investigated parameters (lateral center edge angle, medial center edge angle, acetabular index, acetabular arc, extrusion index, crossover sign and posterior wall sign). Thus, ultra-low-dose CT scans may reduce the need for conventional radiographs in pre- and postoperative analyses of 3-dimensional hip pathologies in the future, as the advantages increasingly outweigh the disadvantages.

The crescent sign-a predictor of hip instability in magnetic resonance arthrography.

ABSTRACTCurrently, much is debated on the optimal treatment of borderline hips, being in the continuum between stable and unstable hips. The diagnosis of stability is often difficult but is a prerequisite for further treatment. Analysis includes a variety of radiographic parameters. We observed that unstable hips often had a crescent-like gadolinium collection in the postero-inferior joint space. We therefore questioned if the ‘crescent sign’ could be an indicator for hip instability? A retrospective comparative study was conducted including 56 hips in the instability group (treated with PAO) and 70 hips with femoroacetabular impingement (FAI) as control group. Based on standard radiographic parameters and magnetic resonance imaging (MRI), the association between hip instability and the ‘crescent sign’ was analyzed. For univariate group comparisons, the non-parametric Wilcoxon two sample test was used. Association between discrete variables was examined by means of chi-square tests. To examine predictive variables, logistic regression models were carried out. Most hips with a crescent sign belong to the instability group. A crescent sign has a sensitivity of 73.3% and specificity of 93% for instability. Based on our results, the crescent sign is a factor that is more prevalent in unstable hips. However, its absence does not exclude instability of the hip. If present, the specificity speaks strongly in favor for instability of the hip.

BASILAR INVAGINATION: IMPORTANCE OF CRANIOMETRIC MEASUREMENT

<h3>BACKGROUND</h3> Basilar invagination (BI) is a congenital or degenerative craniovertebral junction abnormality that results from the odontoid process prolapsing into the foramen magnum. Even though the acquired form is frequently seen with rheumatoid arthritis, BI commonly presents in many congenital conditions such as in people with Chiari malformation. In another type, it has been classified as those in which the odontoid process invaginates into the foramen magnum, resulting in cranio-cervical instability (Type 1) and those with flattened base of cranium that is not associated with instability (Type 2). Clinical presentations include chronic headaches, limited neck motion, and acute neurologic deterioration. <h3>CASE REPORT</h3> A 31-year-old male patient presented for treatment of a sleep-related breathing disorder. Cone beam computed tomography (CBCT) was completed for airway evaluation. Standard radiographic parameters described by Chamberlain were used to assess the craniovertebral junction. Osseous fusion of the C1/C2 joint and extension of the odontoid process approximately 10.5 mm above the Chamberlain line were noted. BI is diagnosed once the tip of the odontoid is 5 mm or more above this line. <h3>DISCUSSION/CONCLUSIONS</h3> The diagnosis of BI relies on radiographic evaluation and various radiographic reference lines such as the Chamberlain line, McGregor line, or McRae line. However, the radiographic interpretation of the cervical vertebrae is often challenging and results in missing important findings. This case report aimed to demonstrate the characteristic radiographic features of BI as seen on CBCT and the use of craniometric measurements to assist health care providers in diagnosing and managing this condition. It is important for oral and maxillofacial radiologists to pay attention to this anatomically critical junction on every study that captures it and perform an assessment so they do not miss BI-related anomalies in asymptomatic patients.

A Prospective Randomized Comparison of Variable-Angle and Fixed-Angle Volar Locking Plating for Intra-Articular Distal Radius Fractures

To compare clinical and radiographic outcomes of using a variable-angle volar locking plate (VAVLP) with those of using a fixed-angle volar locking plate (FAVLP) for treating unstable intra-articular fractures of the distal radius. One hundred twenty patients with unstable intra-articular fractures of the distal radius were randomized to open reduction and internal fixation with a VAVLP (n= 60) or an FAVLP (n= 60). Supplementary methods (eg., Kirschner wire fixation) were required in 4 patients with a VAVLP and 9 with an FAVLP. Clinical outcomes were evaluated at 6 weeks, 3 months, 6 months, and 1 year after surgery. Posteroanterior and lateral radiographs were used to measure standard radiographic parameters before surgery, in the immediate postoperative period, and at 1 year. Plate prominence and articular congruity were quantified using computed tomography at 6 months. There were no significant differences in any clinical outcome between the groups at any follow-up time. Volar tilt was significantly greater in patients treated with a FAVLP in the immediate postoperative period (8° vs 6°) and at 1 year (8° vs 5°). Although significant differences were not found in articular gap or stepoff between the 2 plates, the distal and volar prominence of the VAVLP was significantly greater than that of the FAVLP at 6 months. Significantly more patients treated with a VAVLP had a complication (38% vs 19%). However, most secondary surgeries were performed for hardware removal, and no patients from either group had complex regional pain syndrome or tendon rupture. Patients with intra-articular distal radius fractures can expect good functional and radiographic outcomes with VAVLP or FAVLP fixation. The VAVLP may be more prone to technical errors, leading to complications, whereas the FAVLP is more likely to require supplementary fixation. Therapeutic I.

A cone beam CT based 3D-assessment of bony forefoot geometry after modified Lapidus arthrodesis

BackgroundModified Lapidus arthrodesis (MLA) is a well-established treatment modality for hallux valgus deformities (HVD) associated with instability of the first ray. Although the three-dimensional (3D) nature of HVD has long been recognized, diagnostics still focus on plain radiographs. The objective of this study was to validate 3D Cone Beam CT (CBCT) in the perioperative assessment of HVD with focus on the alignment of the forefoot. MethodsIn a prospective clinical study, MLA was performed on 30 patients (25 females, 5 males; mean age: 63.2 years). Pre- and postoperatively standard radiographs and CBCT with full weight-bearing were acquired. For the CBCT based assessment, reproducible criteria have been defined, measured, and correlated with established radiological indicators. ResultsEvaluation of standard radiographic parameters (hallux-valgus angle [HVA], intermetatarsal angle 1-2 [IMA 1-2], distal metatarsal articular angle [DMAA], tibial sesamoid position [TSP]) showed significant improvement postoperatively. Comparison of measurements obtained from plain radiographs and CBCT were significantly correlated between both measuring techniques, indicating high reliability. Pronation of the first metatarsal and the sesamoids were significantly reduced by the procedure. Due to this repositioning effect, the second metatarsal head was elevated by 3.1mm, and the lateral sesamoid was lowered by 3.8mm. However, there was no correlation between the amount of pronation and conventional radiographic measures. ConclusionsCompared to plain radiographs, CBCT allows a more detailed view of the forefoot alignment in the coronal plain after MLA. MLA was able to recenter the sesamoids under der first metatarsal head and conversely led to elevation of the second metatarsal head.

Correlations linking static quantitative gait analysis parameters to radiographic parameters in adolescent idiopathic scoliosis

BackgroundRadiography is the main tool used to assess spinal deformities in patients with adolescent idiopathic scoliosis (AIS) but requires repeated exposure to ionising radiation, potentially raising safety concerns. Consequently, new methods are needed. Among them, the acquisition of static parameters during quantitative gait analysis (QGA) has received attention in recent years. However, no data on correlations linking static QGA parameters to standard radiographic parameters are available. The objective of this study was to assess correlations between static QGA parameters and standard radiographic parameters in patients with AIS. HypothesisSpinal deformities in patients with AIS can be evaluated based on static QGA parameters. Patients and methodsWe studied patients scheduled for surgery to treat AIS. On the day before surgery, QGA was performed and antero-posterior and lateral radiographs obtained. QGA involved analysing the positions of 32 reflective markers, including 6 used to assess the spine. The coronal vertical axis (CVA), thoracic and lumbar Cobb angles, sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis, and pelvic tilt were recorded and compared to the corresponding radiographic parameters. ResultsThe study included 57 patients, including 48 (84%) females, with a mean age of 15.2 years. Among them, 45 had Lenke 1 and 12 Lenke 5 scoliosis. The mean main Cobb angle was 51.9°. In the coronal plane, significant correlations with the corresponding radiographic parameters were found for the CVA (R=0.524, p<0.01) and thoracic Cobb angle (R=0.599, p<0.01). All the sagittal parameters correlated significantly with the corresponding radiographic parameters: SVA, R=0.313; pelvic tilt, R=0.342; thoracic kyphosis, R=0.575; and lumbar lordosis, R=0.360 (p<0.05 for all four parameters). ConclusionsIn this study, static QGA parameters accurately reflected the spinal deformities visualised radiographically. The lumbar deformity was more difficult to characterise, probably because it was mild in our population. Research efforts should focus on improving the performance of QGA, notably for detecting curve progression. Thus, QGA may allow a decrease in radiation exposure of patients with AIS. Level of evidenceIII.

Treatment of extra-articular and simple articular distal radial fractures with intramedullary nail versus volar locking plate

The purpose of this prospective, randomized and blinded study was to compare the clinical outcomes of distal radial fractures treated with either an intramedullary nail or a volar locking plate. Sixty two patients were enrolled in the study and randomized to treatment with a MICRONAILTM (Group 1, 31 patients) or an adaptive plate (Group 2, 31 patients). Fracture types included were unstable extra-articular metaphyseal distal radial fractures and simple or multifragmentary sagittal articular distal radial fractures (AO classification types A2, A3, B1.1 and B1.2). All patients were evaluated at 6 weeks, 3 months and 12 months after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, the disabilities of the arm, shoulder and hand (DASH) and Mayo wrist scores. We concluded that treatment of this subset of distal radius fractures with minimally invasive intramedullary nailing gives better clinical outcomes at 6 weeks after surgery than treatment with a volar locking plate. By 3 and 12 months following surgery, there are no significant differences in outcome between the two treatment methods. Disadvantages of the MICRONAIL™ fixation system include risk of injury to the superficial branch of the radial nerve and a narrower spectrum of indications than volar locking plates.

Prospective Study of Distal Radial Fractures Treated with an Intramedullary Nail

Intramedullary nailing for the treatment of unstable distal radial fractures is reported to provide stable fixation with minimal soft-tissue complications, but there is a paucity of data documenting the results of this technique. The purpose of this study was to prospectively determine the functional outcomes of treatment of unstable distal radial fractures with an intramedullary nail. Patients aged fifty years and older with a dorsally displaced unstable distal radial fracture--an extra-articular or simple intra-articular fracture--that was amenable to closed or percutaneous reduction were offered treatment with intramedullary nail fixation (MICRONAIL). Thirty-one patients were enrolled in the study, and twenty-nine patients with a mean age of sixty-seven years (range, fifty-one to eighty-five years) were available for one-year follow-up. According to the AO classification, there was one type-A2, twenty-four type-A3, and four type-C2 distal radial fractures. The patients were evaluated at six weeks, three months, six months, and one year after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, grip strength, a modified Mayo wrist score, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. At the final one-year follow-up evaluation, the active range of motion of the injured wrist relative to that on the uninjured side averaged 95% of flexion, 95% of extension, 93% of ulnar deviation, 91% of radial deviation, 99% of pronation, and 99% of supination. The mean grip strength was 96% of that on the uninjured side. According to the modified Mayo wrist score, there were twenty excellent and nine good results. The mean DASH score was 4.8 points. The final radiographic measurements demonstrated, on average, 25° of radial inclination, 11° of volar tilt, 10 mm of radial length, and +1 mm of ulnar variance. Loss of reduction occurred in two patients. One patient developed transient superficial radial sensory neuritis, which resolved within two months. Intramedullary nailing can be a safe and effective treatment with minimal complications for dorsally displaced unstable extra-articular or simple intra-articular distal radial fractures.

Gait, Hip Strength and Functional Outcomes After a Ganz Periacetabular Osteotomy for Adolescent Hip Dysplasia

The Ganz (Bernese) periacetabular osteotomy was first described for the treatment of adult patients with hip dysplasia; however, it has also been used for adolescent patients. Its effectiveness in improving patients in the short term has not been fully established and no studies, to our knowledge, have analyzed gait and functional outcome in patients with adolescent hip dysplasia. An Institutional Review Board-approved prospective study of a consecutive series of patients undergoing a Ganz (Bernese) periacetabular osteotomy for adolescent hip dysplasia was carried out. Standard radiographic parameters were analyzed. Harris hip scores, gait analysis, hip abductor, and flexion strength testing preoperatively and at 6 months and 1 year postoperatively were performed. Statistical analysis compared the 6-month and 1-year data to the preoperative values and a second analysis was performed comparing the patients with hip dysplasia to normative data of similarly aged patients. Twenty-one patients (24 hips) underwent a Ganz periacetabular osteotomy at an average age of 16.1 years for a primary diagnosis of hip dysplasia and pain. There was a significant improvement in all radiographic parameters from preoperation to 1 year in lateral center edge angle (5.5 to 33.0 degrees) (P<0.05), acetabular index of the weight-bearing zone (29.0 to 10.5 degrees) (P<0.05), ventral center edge angle (-1.1 to 32.5 degrees) (P<0.05), and medialization of the joint center relative to the contralateral side (1.12 to 1.05) (P<0.05). Isokinetic abductor strength decreased initially from 62 Nm/kg preoperatively to 58 Nm/kg at 6 months but was improved to 64 Nm/kg at 1 year. Flexion strength decreased from 92 Nm/kg preoperatively to 58 Nm/kg at 6 months but improved to 69 Nm/kg at 1 year. Abductor impulse decreased from 0.26 Nm/kg-s preoperatively to 0.23 Nm/kg-s at 6 months but improved to 0.29 Nm/kg-s at 1 year. Flexion pull-off power decreased from 1.35 Watts/kg to 1.27 Watts/kg and then improved to 1.29 Watts/kg. The Harris hip scores improved from 64.6 at the preoperative evaluation to 74.5 at the 1-year evaluation (Max 89). The Bernese periacetabular osteotomy is effective in significantly improving radiographic parameters for adolescent hip dysplasia with improvement in functional outcome. Because the osteotomy allows for medialization of the hip joint center and limited abductor muscle dissection the abductor strength improved at follow-up, however, the hip flexion pull-off was decreased. Strategies to improve hip flexion power preoperatively and postoperatively in the future are necessary. Level IV.

Delayed Gadolinium-enhanced Magnetic Resonance Imaging of Cartilage in the Long-term Follow-up After Perthes Disease

Aim of this study was to assess the glycosaminoglycan content in hip joint cartilage in mature hips with a history of Legg-Calvé-Perthes (LCPD) disease using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC). Thirty one hips in 27 adults (mean age: 30.5+/-10.9 y) with LCPD in childhood were included. Mean follow-up after diagnosis was 24.5+/-11.4 years. Clinical symptoms and standard radiographic parameters were evaluated. dGEMRIC indices were calculated as T1(Gd) mean values in four coronal MRI slices medially, centrally, and laterally. For comparison, the morphologically normal appearing contra-lateral hips (21 hips) were assessed. The following T1(Gd) values for the LCPD group were noted: medial (507+/-100 ms), central (543+/-104 ms), and lateral (553+/-105 ms). The total T1(Gd) mean value was 534+/-104 ms. The difference between LCPD and normal hips was statistically significant only for the medial compartment (P=0.018). Hip joint cartilage after LCPD shows a significant glycosaminoglycan loss in the medial compartment while this decrease is less apparent centrally and laterally. dGEMRIC allows direct assessment of cartilage matrix biochemistry and may depict the complex damage pattern of hip joint cartilage after LCPD spatially and qualitatively better than other radiographic methods. Prognostic study, Level II-1 (retrospective study).

Radiographic Evaluation of the Hip has Limited Reliability

Radiographic evaluation provides essential information regarding the diagnosis and treatment of musculoskeletal disorders. We evaluated the ability of hip specialists to reliably identify important radiographic features and to make a diagnosis based on plain radiographs alone. Five hip specialists and one fellow performed a blinded radiographic review of 25 control hips, 25 hips with developmental dysplasia (DDH), and 27 with femoroacetabular impingement (FAI). On two separate occasions, readers assessed acetabular version, inclination and depth, position of the femoral head center, head sphericity, head-neck offset, Tönnis grade, and joint congruency. Observers made a diagnosis categorizing each hip as normal, dysplastic, FAI, or combined DDH and FAI (features of both). Reliability was determined using Cohen's kappa coefficient. Intraobserver values were highest for acetabular inclination (kappa = 0.72) and determination of femoral head center position (kappa = 0.77). Interobserver reliability values were highest for acetabular inclination (kappa = 0.61) and Tönnis osteoarthritis grade (kappa = 0.59). All other measurements, including diagnosis, had kappa values less than 0.55. We concluded many of the standard radiographic parameters used to diagnose DDH and/or FAI are not reproducible. Accordingly, a more clear set of definitions and measurements must be developed to allow for more reliable diagnosis of early hip disease.

The Success of Thoracoscopic Anterior Fusion in a Consecutive Series of 112 Pediatric Spinal Deformity Cases

A retrospective review of a single surgeon consecutive series of video-assisted thoracoscopic anterior release and fusion. To examine radiographic fusion rates and standard radiographic parameters of spinal deformity correction, as well as to identify possible complications of thoracoscopic anterior release and fusion in patients with a minimum of 2-year follow-up treated for spinal deformity. Anterior release and fusion of the thoracic spine is indicated in the treatment of rigid scoliosis and kyphosis, the treatment or prevention of crankshaft growth, and in patients at increased risk for pseudarthrosis. Although early postoperative outcomes of video-assisted thoracoscopic anterior release/fusion exist in the literature, few data are available with follow-up greater than 2 years. A retrospective chart and radiograph review of 112 consecutive cases of thoracoscopic anterior release/fusion with open posterior instrumentation/fusion was performed. The diagnosis, indications, perioperative data, as well as early and delayed complications, were evaluated. Deformity correction and intervertebral fusion rates were assessed at latest follow-up (> or =2 years). The diagnoses included 50 patients with neuromuscular deformity, 42 with idiopathic deformity, 10 congenital, and 10 miscellaneous etiologies. The average operative time was 160 +/- 41 minutes to excise and bone graft an average of 7 +/- 2 discs, with an average blood loss of 285 +/- 303 cc. The average hospital stay was 9 +/- 5 days. Fourteen percent of the patients had perioperative respiratory complications that varied from atelectasis to chylothorax. There were no long-term complications associated with the anterior surgery. Scoliosis improved from 80 +/- 12 degrees to 36 +/- 17 degrees, and kyphosis from 88 +/- 15 degrees to 60 +/- 20 degrees at latest evaluation (P < or = 0.001). Evidence of a "solid" anterior arthrodesis (with >50% filling of the disc space) was present radiographically in 75% of the disc spaces with moderate interobserver reliability of the grading system (kappa = 0.49). Thoracoscopic anterior release and fusion of the thoracic spine is a safe and effective procedure when combined with posterior instrumentation and fusion. The primary goal of increasing the flexibility of a rigid spine and achieving a solid arthrodesis occurred in the vast majority of cases.

Alterations in talar morphology associated with adult flatfoot.

To gain a better understanding on the anatomy of the factors contributing to symptomatic flatfoot, we compared the shape of the talus in feet that were flat to that in control tali from feet with a normal arch. Computed tomographic (CT) scans were performed on 9 adult patients with 10 symptomatic flatfoot deformities. CT scans of 10 feet being evaluated for acute trauma not involving the talus were randomly selected as controls. Flatfoot tali tended to be of greater overall length than the control tali, and this difference was not statistically significant. Statistically significant differences were found when comparing ratios of talar length with talar width (P = 0.011), talar length with talar height (P = 0.001) (they were long relative to their height and width), and head length with head width (P = 0.001) for individual tali from the two groups. The tali from the flatfoot group were narrower in width and shorter in height when compared with overall length and had heads that were more elongated in the transverse plane than tali in feet with a normal appearance. CLINICAL CORRELATION: When performing surgical correction of a flatfoot in an adult, appearance of the foot rather than standard radiographic parameters should be used to judge the reduction. The altered shape of the bone may alter the standard radiographic parameters.