Management decisions for adolescent idiopathic scoliosis significantly affect patient radiation exposure

Background contextAdolescent idiopathic scoliosis (AIS) patients treated before the 1990s have a 1% to 2% increased lifetime risk of developing breast and thyroid cancer as a result of ionizing radiation from plain radiographs. Although present plain radiographic techniques have been able to reduce some of the radiation exposure, modern treatment algorithms for scoliosis often include computed tomography (CT) and intraoperative fluoroscopy. The exact magnitude of exposure to ionizing radiation in adolescents during modern scoliosis treatment is therefore unclear.PurposeTo determine the difference in radiation exposures in patients undergoing various forms of treatment for AIS.Study designRetrospective cohort.Patient samplePatients aged 9 to 18 years with a diagnosis of AIS, followed and/or treated with nonoperative or operative management for a minimum of 2 years.Outcome measuresNumber of radiographs and total radiation exposure calculated.MethodsThe charts and radiographs of patients managed for AIS at a single institution between September 2007 and January 2012 were reviewed. Patients were divided into three groups: operative group, braced group, and observation group. Patient demographics, Cobb angles, and curve types were recorded. The number of radiographs per year that each patient received and the total radiation dose were recorded. The plain radiographic radiation exposure was then combined with the direct exposure recording from ancillary tests, such as fluoroscopy and CT, and a radiation exposure rate was calculated (mrad/y). A single-factor analysis of variance (α=0.01) with a Tukey honest significant difference post hoc analysis was used to test significance between groups.ResultsTwo hundred sixty-seven patients were evaluated: 86 operative, 80 brace, and 101 observation. All groups had similar demographics and curve type distribution. The mean initial Cobb angle at presentation was significantly different between the groups: operative (57°±11°), brace (24°±7.9°), and observation (18°±9.4°) (p<.01). There was a significant difference among the groups in terms of the mean number of radiographs received per year; operative group, 12.2 (95% confidence interval [CI]: 10.8–13.5; p<.001); braced group, 5.7 (95% CI: 5.2–6.2; p<.001), and observed group, 3.5 (95% CI: 3.160–3.864; p<.001). The operative group received 1,400 mrad per year (95% CI: 1,350–1,844; p<.001), braced group received 700 mrad per year (95% CI: 598–716; p<.001), and observed group received 400 mrad per year (95% CI: 363–444; p<.001). Importantly, 78% of radiation in the operative group was attributable to the operative fluoroscopy exposure.ConclusionsSignificant differences exist in the total radiation exposure in scoliosis patients with different treatment regimens, with operative patients receiving approximately 8 to 14 times more radiation than braced patients or those undergoing observation alone, respectively. Operative patients also receive more than twice the radiation per year than braced or observed patients. Almost 78% of the annual radiation exposure for operative patients occurs intraoperatively. Because children are notably more sensitive to the carcinogenic effects of ionizing radiation, judicious use of present imaging methods and a search for newer imaging methods with limited ionizing radiation should be undertaken.     

Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial

Background contextThoracolumbar burst fractures have good outcomes when treated with early ambulation and orthosis (TLSO). If equally good outcomes could be achieved with early ambulation and no brace, resource utilization would be decreased, especially in developing countries where prolonged bed rest is the default option because bracing is not available or affordable.PurposeTo determine whether TLSO is equivalent to no orthosis (NO) in the treatment of acute AO Type A3 thoracolumbar burst fractures with respect to their functional outcome at 3 months.Study designA multicentre, randomized, nonblinded equivalence trial involving three Canadian tertiary spine centers. Enrollment began in 2002 and 2-year follow-up was completed in 2011.Patient sampleInclusion criteria included AO-A3 burst fractures between T11 and L3, skeletally mature and older than 60 years, 72 hours from their injury, kyphotic deformity lower than 35°, no neurologic deficit. One hundred ten patients were assessed for eligibility for the study; 14 patients were not recruited because they resided outside the country (3), refused participation (8), or were not consented before independent ambulation (3).Outcome measuresRoland Morris Disability Questionnaire score (RMDQ) assessed at 3 months postinjury. The equivalence margin was set at δ=5 points.MethodsThe NO group was encouraged to ambulate immediately with bending restrictions for 8 weeks. The TLSO group ambulated when the brace was available and weaned from the brace after 8 to 10 weeks. The following competitive grants supported this work: VHHSC Interdisciplinary Research Grant, Zimmer/University of British Columbia Research Fund, and Hip Hip Hooray Research Grant. Aspen Medical provided the TLSOs used in this study. The authors have no financial or personal relationships that could inappropriately influence this work.ResultsForty-seven patients were enrolled into the TLSO group and 49 patients into the NO group. Forty-six participants per group were available for the primary outcome. The RMDQ score at 3 months postinjury was 6.8±5.4 (standard deviation [SD]) for the TLSO group and 7.7±6.0 (SD) in the NO group. The 95% confidence interval (?1.5 to 3.2) was within the predetermined margin of equivalence. Six patients required surgical stabilization, five of them before initial discharge.ConclusionsTreating these fractures using early ambulation without a brace avoids the cost and patient deconditioning associated with a brace and complications and costs associated with long-term bed rest if a TLSO or body cast is not available.     

针刀治疗腕管综合征的病例对照研究

目的:研究针刀治疗腕管综合征的疗效。方法:2014年7月至2016年12月,60例门诊收治的腕管综合征患者分为两组,针刀治疗组(治疗组)和支具药物组(对照组),每组30例。治疗组男8例,女22例;平均年龄(49.38±7.43)岁。对照组男7例,女23例;平均年龄(50.23±8.71)岁。治疗前两组患者的年龄、性别、病程、感觉神经传导速度(SCV)、感觉神经动作电位波幅(SNAP)、运动传导末端潜伏期(DML)差异无统计学意义。治疗组患者采用针刀治疗1~2次;对照组患者口服塞来昔布、维生素B1、维生素B12,并采用支具固定;疗程结束后观察两组患者SCV、SNAP、DML变化。结果:两组患者治疗后,SCV分别为(48.63±7.33)、(41.24±6.15)m/s,SNAP分别为(9.89±3.71)、(8.22±2.19)m/s,DML分别为(5.11±2.28)、(6.13±2.23)m/s,均较治疗前改善,且治疗组优于对照组。结论:针刀疗法可以减轻患者症状,具有可行性,适合在临床中推广使用。     

Effect of wearing a knee brace or sleeve on the knee joint and anterior cruciate ligament force during drop jumps: A clinical intervention study

Background

Knee braces are considered to be extremely useful tools in reducing the shear force of knee joints for non-contact anterior cruciate ligament (ACL) injury prevention. However, the effectiveness of sports knee braces and sleeves remains to be identified. Therefore, the purpose of this study was to evaluate the effectiveness of wearing commercialized sports knee braces and sleeves on knee kinematics, kinetics, and ACL force during drop jumps using musculoskeletal modeling analysis.

Very short-term effect of brace wearing on gait in adolescent idiopathic scoliosis girls

Purpose

Adolescent idiopathic scoliotic (AIS) deformity induces excessive oxygen consumption correlated to a bilateral increase of lumbo-pelvic muscles timing activity (EMG) during gait. Wearing a brace, the usual treatment for AIS, by supporting the spine and the pelvis, would generate lumbo-pelvic muscular relaxation and consequently reduce excessive oxygen consumption. The purpose of this study was to evaluate the short-term effect of bracing on gait biomechanics in scoliotic spine when compared with normal braced spine.

Methods

Thirteen healthy volunteers were compared to 13 AIS girls. In both samples, gait analysis was assessed using a three-dimensional motion analysis, including synchronous kinematic, electromyographic, mechanical and energy measurements, first without brace, then wearing a brace.

Results

For scoliotic patients, comparison of in-brace and out-brace situations revealed a significant decrease of frontal pelvis (p < 0.001), hip (p < 0.001) and shoulder (p = 0.004) motion in brace associated with a significant reduction of pelvis rotation (p = 0.003). However, the brace did not change significantly the lumbo-pelvic muscle activity duration (EMG) or the mechanical and energetic parameters. Transversal pelvis motion was reduced by 39 % (p = 0.04), frontal hip and shoulder motions by 23 % (p = 0.004) and 30 % (p = 0.01) respectively, and energy cost of walking remained increased by 37 % in braced AIS girls relatively to braced healthy subjects. Mechanical and electromyographic variables were not significantly different between the two braced populations during gait except for the gluteus medius muscle that showed bilaterally an increase of duration of electrical activity in healthy subjects and contrarily a decrease in AIS patients (healthy: −3.5 ± 9.6 % of gait cycle vs. scoliotic: 3.7 ± 7.7 % of gait cycle; p = 0.04).

Conclusions

Bracing changed neither the oxygen consumption nor the timing of the lumbo-pelvic muscles activity in both groups during gait. However, in brace the timing activity of bilateral gluteus medius muscles tended to decrease in AIS patients and increase in healthy subjects. Moreover, braced AIS patients had more restricted frontal hips and shoulder motion as well as pelvis rotation than braced healthy subjects.     

术前支具治疗对女性青少年特发性脊柱侧凸患者手术矫形效果的影响

目的:分析术前支具治疗对女性青少年特发性脊柱侧凸(AIS)患者手术矫形效果的影响。方法 :筛选2001年7月~2009年12月在我院接受单一后路矫形内固定手术治疗的女性青少年特发性主胸弯脊柱侧凸患者70例,其中术前接受支具治疗组(A组)26例;未接受支具治疗组(B组)44例。两组发现畸形年龄、术时年龄、术前主胸弯冠状面Cobb角、凸侧Bending像Cobb角、侧凸柔韧性、手术融合椎体数比较均无统计学差异(P>0.05),A、B组随访时间超过1年者分别为23例和34例,随访时间分别为12~101个月(平均37.7个月)、12~87个月(平均28.7个月),两组比较无统计学差异(P>0.05)。比较两组患者的手术矫形效果。结果:A组与B组患者术前主胸弯冠状面Cobb角分别为52.8°±8.3°和54.0°±10.7°,术后分别矫正到12.3°±7.3°和11.5°±8.1°,术后较术前均明显改善(P<0.01),主胸弯矫形率分别为(77.0±12.6)%和(79.3±11.9)%,两组比较无统计学差异(P>0.05);末次随访时主胸弯冠状面Cobb角分别为16.7°±8.4°和15.4°±7.2°,两组比较无统计学差异(P>0.05),主胸弯矫形率分别为(68.8±14.5)%和(70.5±13.0)%,两组比较无统计学差异(P>0.05)。A、B组患者术前主胸弯顶椎偏距分别为41.4±14.3mm和36.8±13.7mm,两组比较无统计学差异(P>0.05),术后分别被矫正到10.4±5.4mm和7.2±5.6mm,B组优于A组(P<0.05);末次随访时分别为14.4±11.3mm和12.1±8.5mm,两组比较无统计学差异(P>0.05)。A、B组患者术前、术后、末次随访时冠状面失平衡的发生比例分别为15.4%(4/26)和9.1%(4/44),15.4%(4/26)和15.9%(7/44),4.3%(1/23)和8.8%(3/34),两组比较均无统计学差异(P>0.05)。A、B组患者术前主胸弯矢状面Cobb角分别为12.9°±11.1°和18.7°±11.3°,A组胸后凸更小(P<0.05),术后主胸弯矢状面Cobb角分别被矫正到18.0°±6.3°和22.3°±7.8°,矫正度分别为5.0°±9.8°和3.6°±12.6°,两组矫正度比较无统计学差异(P>0.05);末次随访时A、B组患者主胸弯矢状面Cobb角分别为20.0°±6.7°和22.4°±7.7°,两组比较无统计学差异(P>0.05)。结论:术前支具治疗对女性青少年特发性主胸弯脊柱侧凸患者手术矫形效果未产生明显影响。     

Active non-operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization

The objective of our study was to investigate the outcome of an active non-operative treatment of the acute isolated posterior cruciate ligament (PCL) injury using cylinder cast immobilization and brace with tibial supporter. This study included 17 acute and isolated PCL injuries with two years or more of follow-up for each patient. We applied a cylinder cast immobilization with tibial supporter with full extension of the knee for 6 weeks, and then another 6 weeks of PCL brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. There was improved anteroposterior stability with some residual laxity and improved clinical results at the last follow-up. The conservative treatment utilizing cylinder cast immobilization and brace may be one of the recommendable treatment methods in an isolated and acute PCL injury.     

压力保护支具在老年股骨粗隆间骨折术后康复训练中的应用

目的 观察带有压力传感保护装置(自主研发)的康复训练支具在骨折早期进行康复训练对骨折愈合的效果.方法 选取40例资料完整、符合条件的老年股骨粗隆间骨折行动力髋螺钉内固定术后患者,随机分为实验组和对照组各20例.实验组患者应用带压力传感器保护装置(自2008年5月开始研制带有压力传感保护装置的康复训练支具,2009年1月至2010年6月临床推广应用)的下肢康复训练支具,在术后不同时期,根据患者具体情况,由医师通过计算机调控支具应力阈值,按照预定的个性化康复计划,指导患者借助双拐进行负重行走康复训练.对照组采用传统的康复治疗方法.按照统一的标准评价骨折临床愈合和骨性愈合时间.结果 随访13.0～24.0周,平均17.6周.实验组临床愈合时间7.0～12.0周,平均9.1周;骨性愈合时间12.0～16.0周,平均13.7周.对照组临床愈合时间9.0～13.0周,平均11.3周;骨性愈合时间14.0～20.0周,平均16.6周.2组间骨折临床愈合时间和骨性愈合时间经独立样本t检验,结果显示2组间骨折临床愈合时间和骨性愈合时间差异均有统计学意义(t值分别为5.174、5.846,P均＜0.01).最终2组骨折均愈合,无骨折移位,无内固定物折断、松脱、失效等不良并发症.结论 应用带有压力传感保护装置的康复训练支具,在骨折早期由医师根据患者体重调控间断纵向应力刺激阈值,指导患者进行有效的量化的个性化康复训练,可以达到促进骨折愈合、缩短疗程、减少并发症目的.进一步证明在一定范围内间断的压应力刺激对骨折愈合有促进作用.

Abstract：

Objective To observe the effect of pressure-protective brace with pressure-sensitive device in the early stage rehabilitation training enhance bone healing, shorten the treatment course and reduce complications,a kind of independently developed pressure-protective brace with pressure-sensitive device was utilized with quantified discontinuous longitudinal stress stimulation under doctors' regulation according to procedure. Methods The pressure-protective brace with pressure sensitive device for rehabilitation training was developed in May 2008 ,and was applied in clinics during January 2009 to June 2010. Forty elder patients,with complete clinical data, underwent Dynamic Hip Screw (DHS) internal fixation of femoral intertrochanteric fracture were were enrolled into this study. These cases were assigned into experimental group and control group with 20 patients respectively. The patients of experimental group performed lower extremity rehabilitation training wearing the pressure-protective brace. The load training of lower extremities with double crutches was modulated by doctors through regulating the threshold value of pressure in different time and different condition after operation according to the prearranged rehabilitative plan of individuation. The controls were instructed to performed lower extremity rehabilitation training in traditional way. Both the clinical healing and bone union time in all cases were evaluated according to the uniform standard. Results Total 40 patients were followed up for 13.0 - 24. 0 weeks ( average, 17.6 weeks ). Clinical healing time was 7.0 - 12. 0 weeks ( average,9. 1 weeks ) and bone healing time was 12. 0 - 16.0 weeks(average,13. 7 weeks)in experimental group. While in control group,the clinic healing time and bone union time was 9. 0 - 13.0 weeks( average, 11.3 weeks) and 14. 0 -20. 0 weeks (average, 16. 6 weeks)respectively. The Independent T-test results showed that whether clinic healing time or bone healing time presented significant differences between experimental group and the controls( P＜0. 01 ). All of the fractures in these two groups were healed at the end time of follow up without adverse complications,including fracture displacement, implant break, implant loose and failure. Conclusion The pressure-protective brace with pressure sensitive device used for quantifying rehabilitation training can enhance bone union, shorten the treatment course and reduce complications. This method further proves that discontinuous compressive stress in a certain range can stimulate fracture healing.     

支具治疗对女性青少年特发性脊柱侧凸患者肺功能的影响

目的:观察支具治疗对女性青少年特发性脊柱侧凸(AIS)患者肺功能的影响。方法:2001年2月~2009年12月283例女性AIS患者在我院接受矫形手术治疗,术前检测患者用力肺活量(FVC)、第1秒用力呼气容积(FEV1),记录预计值、实测值及实测值占预计值百分比。根据术前是否曾接受支具治疗分为2组,支具治疗组80例(A组),未接受支具治疗组203例(B组)。分析2组患者术前肺功能参数的差异,同时对A组患者肺功能FVC及FEV1的实测值占预计值百分比(FVC%、FEV1%)与术时年龄、身高、主弯冠状面Cobb角、主侧凸累及节段数、主胸弯矢状面Cobb角、每日支具治疗时间、支具治疗总时长进行多元线性回归分析。结果:A、B组患者FVC预计值分别为3.23±0.40L和3.20±0.40L,FEV1预计值分别为2.76±0.40L和2.73±0.30L,A组与B组比较均无统计学差异(P>0.05);A、B组FVC实测值分别为2.58±0.60L和2.72±0.60L,FEV1实测值分别为2.34±0.50L和2.49±0.50L,A、B组FVC%分别为(80.3±16.5)%和(85.4±16.5)%、FEV1%分别为(85.6±18.4)%和(91.3±16.9)%,A组FEV1实测值、FVC%及FEV1%较B组均明显降低(P<0.05),其中主弯为胸弯患者(173例)明显(P<0.05),而主弯为胸腰弯/腰弯患者(110例)不明显(P>0.05)。A组患者中,胸段侧凸矢状面Cobb角与FVC%、FEV1%呈正相关(P<0.05),支具治疗总时长与FEV1%呈负相关(P<0.05);而术时年龄、身高、主弯冠状面Cobb角、主侧凸累及节段数、每日支具治疗时间(8~23h,平均18.7h)与FVC%及FEV1%均无显著相关性(P>0.05)。结论:支具治疗可使女性青少年特发性胸段脊柱侧凸患者肺功能FVC%及FEV1%下降,支具治疗总时长和胸段侧凸矢状面Cobb角可能是影响患者肺功能FVC%及FEV1%的相关因素。     

Comparison of the biomechanical 3D efficiency of different brace designs for the treatment of scoliosis using a finite element model

The biomechanical influence of thoraco-lumbo-sacral bracing, a commonly employed treatment in scoliosis, is still not fully understood. The aim of this study was to compare the immediate corrections generated by different virtual braces using a patient-specific finite element model (FEM) and to analyze the most influential design factors. The 3D geometry of three patients presenting different types of curves was acquired with a multi-view X-ray technique and surface topography. A personalized FEM of the patients’ trunk and a parametric model of a virtual custom-fit brace were then created. The installation of the braces on the patients was simulated. The influence of 15 design factors on the 3D correction generated by the brace was evaluated following a design of experiments simulation protocol allowing computing the main and two-way interaction effects of the design factors. A total of 12,288 different braces were tested. Results showed a great variability of the braces effectiveness. Of the 15 design factors investigated, according to the 2 modalities chosen for each one, the 5 most influential design factors were the position of the brace opening (posterior vs. anterior), the strap tension, the trochanter extension side, the lordosis design and the rigid shell shape. The position of the brace opening modified the correction mechanism. The trochanter extension position influenced the efficiency of the thoracic and lumbar pads by modifying their lever arm. Increasing the strap tension improved corrections of coronal curves. The lordosis design had an influence in the sagittal plane but not in the coronal plane. This study could help to better understand the brace biomechanics and to rationalize and optimize their design.