Assessment of Quality of Life for Scheuermann’s Kyphosis Patients with Cobb’s Angle 50°–65° Treated Conservatively or Surgically in North Jordan: A Prospective Comparative Study

BackgroundScheuermann’s disease is the most common cause of hyperkyphosis of the thoracic spine during the adolescence period. It causes neck and lower back pain, restriction of lung expansion, traction of the spinal cord, increased vulnerability to vertebral fracture, and a hump. Patients with curves < 60° are treated conservatively, while surgery is used for patients with curves > 60°. The purpose of this prospective cohort study was to assess the quality of life and functional changes in conservatively or surgically treated Scheuermann’s disease patients with a curve size of 50°–65° in north Jordan.MethodsSixty-three adolescent patients with Scheuermann’s kyphosis (aged between 10 and 18 years) were treated at our hospital between January 2014 and August 2018. All patients were investigated clinically, radiologically (Cobb’s angle), and functionally (Oswestry Disability Index [ODI], Scoliosis Research Society 22 revision [SRS-22r] questionnaire, and pulmonary function test [PFT]) pre- and post-treatment (final follow-up). Patients were randomly selected for treatment method (conservative versus surgical).ResultsThere were 31 patients (mean age, 15.48 ± 2.50 years) and 32 patients (mean age, 16.19 ± 1.51 years) treated conservatively and surgically, respectively. Mean ± standard deviation of ODI, SRS-22r, and Cobb’s angle of the surgical group improved from 16.8% ± 14.3%, 3.5 ± 0.5, and 58.75° ± 3.59°, respectively, pre-surgery to 13.4% ± 10.8%, 4.2 ± 0.5, and 41.53° ± 3.94°, respectively, post-surgery, while those of the conservative group became worse from 12.6% ± 13.4%, 3.9 ± 0.7, and 56.1° ± 3.3°, respectively, to 20.1% ± 13.6%, 3.5 ± 0.7, and 58.8° ± 5.8°, respectively. The surgical group showed better improvement in all scores than the conservative group (p < 0.05), as well as in PFT.ConclusionsSurgical treatment of Scheuermann’s kyphosis with curves of 50°–65° resulted in better QOL, Cobb’s angle, and PFT than conservative treatment. This was because of lower patient cooperation in the conservative management group, which made the curve less flexible for exercises and bracing.     

Outcomes for patients with infantile idiopathic scoliosis by casting table type

Purpose:Serial casting is an effective treatment for infantile idiopathic scoliosis. The most common casting table types are Mehta, Risser, and spica tables. We compared major curve correction between patients with infantile idiopathic scoliosis treated using pediatric hip spica tables versus Risser or Mehta tables.Methods:In this multicenter retrospective study, we included 52 children younger than 3 years (mean ± standard deviation age, 1.6 ± 0.68 years) treated with ≥2 consecutive casts for infantile idiopathic scoliosis between September 2011 and July 2018. We compared major curve angle (measured using the Cobb method) before and after treatment and improvement in curve angle between the spica tables group (n = 12) and the Risser or Mehta tables group (n = 40). The primary outcome was the difference in percentage correction of the major curve according to radiographs taken after first casting and at final follow-up.Results:The mean major curve was 47° ± 18° before casting. A median of six casts (range: 2–14) were applied. Mean follow-up after treatment initiation was 22 months (range: 7–86 months). At baseline, the major curve was significantly larger in the spica tables group (58°) than in the Risser or Mehta tables group (43°) (p = 0.01). We found no differences in the percentage curve correction in the spica tables group versus Risser or Mehta tables group after first casting or at final follow-up.Conclusion:Serial casting was associated with substantial major curve correction in patients with infantile idiopathic scoliosis. Curve correction did not differ between patients treated with a spica table versus a Risser or Mehta table.Level of Evidence:Level III, retrospective cohort study     

A Novel Method of Making Hinges Using a Newly Designed Sharp Rongeur to Enhance Radiological and Clinical Outcomes in French‐Door Cervical Expansive Laminoplasty

ObjectiveAlthough the lamina open angle of making hinges is closely related to the outcomes of French‐door laminoplasty (FDL) for treatment of cervical spondylosis, there have been no methods to predict the lamina open angle preoperatively as yet. The aim of this study was to investigate the accuracy of predicting the laminal open angle using our newly designed sharp rongeur, and to compare the postoperative outcomes and complications between the methods of making hinges using the newly designed sharp rongeur and the traditional high‐speed micro‐drill during the FDL.MethodsThis was a single‐center retrospective study. Following the approval of the institutional ethics committee, a total of 39 patients (Male: 28; Female: 11) diagnosed with cervical spondylos who underwent FDL in our institution between January 2018 and May 2019 were enrolled. Patients were divided into two groups based on the method of making hinges (sharp rongeur: 22 cases; high‐speed micro‐drill: 17 cases). The average age at surgery was 59.1 years (range: 16–85 years). The radiological parameters, clinical outcomes, modified Japanese Orthopaedic Association (mJOA) scale score, and the recovery rate of mJOA were recorded and compared between the groups, respectively. The radiological parameters and clinical measurements at pre‐ and post‐operation stages were compared using the paired‐sample t‐test, the Wilcoxon signed‐rank test, and the Friedman''s test, and variables in the two groups were analyzed using an unpaired Student''s t‐test or a Mann–Whitney U test.ResultsThe average follow‐up period was 20.4 months (range: 14.0–25.9 months), the postoperative open angle was 60.13° ± 3.69° in the rongeur group with 22.78° ± 4.34° of angular enlargement, which was significantly lower than that of 68.96° ± 1.00° in the micro‐drill group with 32.75° ± 4.22° of angular enlargement (U = 19.000, p < 0.001). The rongeur group showed a higher fusion rate (34.1% vs 14.7%, χ ² = 11.340, p = 0.001), and a lower fracture rate of the lamina (7.8% vs 25.5%, χ ² = 14.185, p < 0.001) at 1‐month post‐surgery, compared to the micro‐drill group. There were no significant differences in the clinical outcomes and postoperative complications between the two groups (p > 0.05), except in the recovery rate of mJOA scores (0.836 ± 0.138 vs 0.724 ± 0.180, U = 115.000, p = 0.042) and neck disability index (NDI) at the final follow‐up (7.55 ± 10.65 vs 14.71 ± 8.72, U = 94.000, p = 0.008).ConclusionsThe special sharp rongeur with a tip angle of 20° could be a preferred method to make hinges during FDL, which can predict the laminal open angle accurately and enlarge it to about 23°, thus reducing the fracture rate and accelerating the bony fusion of hinges compared with the outcomes of the traditional micro‐drill method.     

Reliability of handgrip strength test in elderly subjects with unilateral thumb carpometacarpal osteoarthritis

BackgroundThe grip strength test is widely used; however, little has been investigated about its reliability when used in elderly with subjects thumb carpometacarpal (CMC) osteoarthritis (OA). The purpose of this study was to examine the test–retest reliability of the grip strength test in elderly subjects with thumb CMC OA.MethodsA total of 78 patients with unilateral thumb CMC OA, 84.6 % female (mean ± SD age 83 ± 5 years), were recruited. Each patient performed three pain free maximal isometric contractions on each hand in two occasions, 1 week apart. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and 95 % limits of agreement (LOA) were calculated.ResultsTest–retest reliability was excellent for side affected (ICC = 0.947; p = 0.001) and contralateral (ICC = 0.96; p = 0.001) thumb CMC OA.ConclusionsThe present results indicate that maximum handgrip strength can be measured reliably, using the Jamar hand dynamometer, in patients with thumb CMC OA, which enables its use in research and in the clinic to determine the effect of interventions on improving grip.     

The mid-term clinical outcomes of total knee arthroplasty in the management of end-stage hemophilic arthropathy

Objective:This study aimed to evaluate the mid-term clinical outcomes of total knee arthroplasty (TKA) in the management of end-stage hemophilic arthropathy.Methods:Eleven patients (15 knees) undergoing TKA with stiff knees were retrospectively evaluated. TKA was performed in all patients without additional surgical interventions such as posterior capsular release, hamstring release, synovectomy, VY quadricepsplasty, or tibial tubercle osteotomy. All patients were evaluated for clinical and radiological results at follow-ups. Functional evaluation and pain status were assessed using the Knee Society Score and Visual Analogue Scale.Results:The mean age at the time of operation was 40.8 ± 11.8 years (range = 30–64 years). The mean follow-up was 51.2 ± 20.6 months (range = 24–95). The mean flexion contracture significantly decreased from 17.6 ± 11.3 to 1.7 ± 2.8 degrees, and the mean maximum flexion increased dramatically from 55.6 ± 20.5 to 109.2 ± 16.2 degrees (P < 0.001). Statistical significant improvement in flexion and flexion contracture degrees continued up to the postoperatively 18 months. The mean Knee Society Score increased from 22.7 ± 2.4 points preoperatively to 87.8 ± 3.8 points at the last follow-up (P < 0.001). The mean cost of coagulation factor consumption and blood transfusion accounted for 78% of the total cost. Conclusion:This study has shown that TKA is an effective treatment for relieving pain and improving both ranges of motion and quality of life in managing end-stage hemophilic arthropathy of the knee joint.Level of Evidence: Level IV, Therapeutic Study     

One‐Stage Arthroscopic Multiple Ligament Reconstruction for Schenck IV Knee Dislocation

PurposeSchenck IV knee dislocation patients have dissatisfactory knee function and return‐to‐sport rate with the existing treatment methods. The purpose of this study was to illustrate a one‐stage arthroscopic multiple ligament reconstruction method for treating Schenck IV knee dislocations.MethodsA retrospective case series study was performed. All patients with a history of Schenck IV knee dislocation who underwent one‐stage arthroscopic multi‐ligament reconstruction from 2010 to 2018 were followed for 24 months. The outcomes, including general patient data, Lysholm scores, International Knee Documentation Committee (IKDC) scores, visual analog scale (VAS) pain scores, knee active range of motion, and complications, were reviewed. The data was analyzed with paired‐samples t‐test.ResultsA total of 12 patients, comprising nine males and three females, were followed up and reviewed. The mean age at the time of the surgical procedure was 40.3 ± 9.0 (22–57) years. The mean body mass index (BMI) was 24.6 ± 4.9 (15.2–32.5) kg/m². The mean IKDC score and Lysholm score before surgery were 30.4 ± 6.1 (21–42) and 28.2 ± 6.2 (22–39), respectively. The average operation time was 121.8 minutes. The mean IKDC score and Lysholm score at the 24‐month follow‐up were 80.6 ± 6.5 (68–92) and 82.0 ± 7.5 (72–95), respectively. There were significant differences in the IKDC and Lysholm scores between the preoperative and 24‐month postoperative time points (p < 0.01). The mean knee range of motion was 124.6° ± 6.6° (115°–135°) at the 24‐month follow‐up. No major complications occurred.ConclusionsThe results of this retrospective study suggest that the new arthroscopic one‐stage multi‐ligament reconstruction technique is an effective way to treat Schenck IV knee dislocation with satisfactory postoperative knee function.     

Total Hip Replacement in Sickle Cell Disease Patients with Avascular Necrosis of Head of Femur: A Retrospective Observational Study

BackgroundFemoral head avascular necrosis leads to osteoarthritis of the hip joint and affects its functional capacity in sickle cell disease patients. The functional outcomes of total hip replacement (THR) on patients with congruous joints who underwent hip replacement after having a failed joint preservation surgery are unknown. This study aimed to compare the functional outcomes of THR in patients with sickle cell disease having avascular necrosis with and without loss of hip joint congruency.MethodsThis retrospective study included 35 patients (age, 20–52 years; 18 males and 17 females) who underwent uncemented THR. Patients were divided into Group-A (n = 18, good hip joint congruency) and Group-B (n = 17, obliterated hip joint congruency). The Harris Hip Score (HHS) was used to assess functional outcomes. All patients were followed up at 6-weekly intervals then 6-monthly intervals.ResultsThe mean follow-up period was 8.26 ± 3.01 years. The mean preoperative HHSs of Group-A and Group-B were 45.22 ± 3.021 and 25.94 ± 4.437, respectively. Postoperatively, a subsequent increase in HHS was found in both groups, and a significant difference between the groups was observed at 6 weeks (p < 0.0001*) and 1 year (p < 0.0006*). Interestingly, HHS was not significantly different (p = 0.0688) at 5-year follow-up between the groups. The differences in HHS within the group at each subsequent follow-up were also statistically significant (ANOVA, p < 0.0001*).ConclusionA significant improvement was observed with THR in both groups. Nevertheless, the flattened hip joint congruency group showed significantly better HHS improvements than the normal congruency groups. These findings may aid in the decision-making capabilities of the surgeons.     

Novel Three‐Holed Titanium Plate Fixation during Open Door Laminoplasty for Cervical Spondylotic Myelopathy: Comparison with Conventional Titanium Plate

ObjectiveFor reconstructing the posterior cervical muscular–ligament complex, attachment points and various modified techniques were designed and applied in clinical practice. This study investigated the clinical and radiographic outcomes of open door laminoplasty with modified centerpiece mini‐plate fixation and extensor attachment point reconstruction in the treatment of cervical spondylotic myelopathy (CSM).MethodsSixty‐nine patients with CSM who underwent C3–C7 open door laminoplasty at our hospital from January 2016 to May 2018 were divided into two groups: 37 and 32 patients underwent laminoplasty with modified and conventional centerpiece titanium plate fixation (MPF and CPF groups), respectively. Changes in cervical spinal angle (CSA), cervical range of motion (ROM), posterior cervical muscle atrophy, neurological function (Japanese Orthopaedic Association [JOA] score), Neck Disability Index (NDI), and axial symptom severity were compared between the two groups.ResultsThere were no significant differences in operative duration (136.7 ± 23.9 vs 128.3 ± 21.5 min, t = 1.525, p > 0.05), volume of intraoperative blood loss (275.9 ± 33.1 vs 268.2 ± 31.6 ml, t = 0.984, p > 0.05), lamina open angle (41.2° ± 4.5° vs 39.4° ± 4.1°, t = 1.726, p > 0.05), and spinal cord drift distance (2.4 ± 0.3 vs 2.3 ± 0.4 mm, t = 1.184, p > 0.05) between the two groups. After surgery, JOA score significantly increased (p < 0.05), and neurological recovery rates were similar (62.7% vs 63.4%, t = 0.208, p > 0.05). The NDI score was significantly decreased in both the groups (p < 0.05); however, the MPF group recovered to a greater degree than the CPF group (8.3 ± 1.2 vs 9.8 ± 1.4) (t = 4.793, p < 0.05). There was no significant change in cervical ROM postoperatively compared with preoperatively in either group (p > 0.05). CSA decreased from 21.7° ± 2.8° to 18.3° ± 2.1°, and posterior cervical muscle cross‐sectional area decreased from 35.2 ± 4.9 cm² to 31.0 ± 4.1 cm² in the CPF group (p < 0.05), but no significant change was observed in the MPF group (20.6° ± 2.5° to 20.4° ± 2.6°and 35.9 ± 5.1 to 34.1 ± 4.6 cm², respectively) (p > 0.05). Postoperative axial symptom severity was significantly worse in the CPF group than in the MPF group (Z = −2.357, p < 0.05).ConclusionsAs an improvement to the conventional titanium plate, the modified centerpiece titanium plate effectively provides an attachment point for the posterior muscle–ligament complex, reducing posterior cervical muscle atrophy and improving neck function, without inflicting additional surgical trauma.     

A Comparative Study of Clinical and Radiological Outcomes of Open Reduction Using the Anterior and Medial Approaches for the Management of Developmental Dysplasia of the Hip

BackgroundThe literature is scanty on reports directly comparing the outcomes of anterior open reduction (AOR) and medial open reduction (MOR) in the management of developmental dysplasia of the hip (DDH).Purpose of the StudyTo compare clinical and radiographic outcomes of surgical treatment using either AOR or MOR in children with DDH aged < 24 months and to evaluate the procedure-inherent risks of avascular necrosis of the femoral head (AVN) and need for further corrective surgery (FCS).Methods61 children who underwent surgical treatment for DDH were categorized into two groups: AOR (31 hips of 28 patients) and MOR (39 hips of 33 patients). The mean age was 17 ± 5.85 (range 7–24) months in group AOR and 13 ± 5.31 (range 6–24) months in group MOR. The mean follow-up was 118 ± 41.2 (range 24–192) months and 132 ± 36.7 (range 24–209) months in group AOR and MOR. At the final follow-up, mid- to long-term clinical and radiographic outcomes were assessed. FCS was recorded.ResultsRegarding McKay’s clinical criteria, both groups exhibited similar results (p = 0.761). No significant differences were observed between the groups in both the center–edge–angle (p = 0.112) and the Severin score (p = 0.275). The AVN rate was 32% in the AOR group and 20% in the MOR group (p = 0.264). The FCS rate was 22% in the AOR group and 12% in the MOR group (p = 0.464).ConclusionsThis study showed similar clinical and radiological outcomes with AOR and MOR with no significant relation to AVN and FCS.Level of EvidenceLevel III.     

Mid‐ to Long‐Term Clinical Outcomes of Cartilage Restoration of Knee Joint with Allogenic Next‐Generation Matrix‐Induced Autologous Chondrocyte Implantation (MACI)

ObjectiveCartilage defect is a common pathology still lacking a unified treating option. The purpose of this retrospective study is to evaluate the safety, efficacy, and clinical and radiological outcome of cartilage restoration of knee joint with allogenic next‐generation Matrix‐Induced Autologous Chondrocyte Implantation (MACI) for the first time, as well as the correlation between postoperative clinical and radiological outcomes and preoperative patient history and demographics.MethodsFrom July 2014 to August 2020, 15 patients who went through cartilage restoration with allogenic next‐generation MACI were included in this study. Patient demographics and PROM including the International Knee Documentation Committee (IKDC) subjective knee score, Lysholm score, Tegner Activity Scale (TAS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were obtained preoperatively, at 3, 6, 12 months postoperatively and the last follow‐up using an online questionnaire platform. MOCART 2.0 score was calculated at the last follow‐up. Analysis of variance (ANOVA) was used to compare PROM pre‐ and post‐operation, with two‐tailed p < 0.05 defined as statistical significant. Pearson correlation coefficient was used to evaluate correlation between the PROM and MOCART 2.0 score at the last follow‐up with patients demorgraphics.ResultsAll patients were followed for an average of 66.47 ± 24.15 months (range, 21–93). All patients were satisfied with the outcome of the surgery and no complication was reported at the end of the study. No significant improvement was observed until 1 year after the implantation, except for IKDC score at 6 months. All PROM showed significant improvement 1 year post‐op except for Lysholm score and TAS, which also increased significantly at the time of the last follow‐up. Pearson correlation coefficient showed that the size of the defect, before or after debridement, was significantly negatively correlated with final KOOS‐Pain (before debridement: r = −0.57, p < 0.05; after debridement: r = −0.54, p < 0.05) and KOOS‐Symptoms score (before debridement: r = −0.66, p < 0.05; after debridement: r = −0.67, p < 0.05). The MOCART 2.0 score was found significantly and negatively correlated with BMI (r = −0.60, p < 0.05), and significantly and positively correlated with Lysholm score (r = 0.70, p < 0.05).ConclusionThe next generation MACI with autologous chondrocyte and allogenic chondrocyte ECM scaffold could be used to treat focal articular cartilage defect in the knee joint safely and efficiently with lasting promising outcomes for more than 5 years. The size of the defects should be considered the most negatively correlated parameters influencing the postoperative clinical outcomes.     

Is Plating Fixation Through the Kocher–Langenbeck Approach for Associated Posterior Wall Fragment Indispensable in Both‐Column Acetabular Fractures?

ObjectiveThe treatment methods for posterior wall (PW) in both‐column acetabular fractures are controversial. The purpose of this study was to compare reduction quality, clinical outcomes, and complications of nonfixation for posterior wall fragment and plating via the Kocher–Langenbeck (KL) approach after anterior surgical procedures in both‐column acetabular fractures.MethodsForty‐nine patients with both‐column acetabular fractures associated with PW fixed via iliac fossa and Stoppa approaches from October 2012 to October 2017 were recruited into this study and were divided into two groups: Nonfix group (nonfixation for PW) and KL group (PW plating through the KL approach). Operation duration, intraoperative blood loss, reduction quality, fracture healing, and relevant complications of patients were reviewed. Merle d''Aubigné scores were used for assessing functional outcome.ResultsThe mean blood loss and operation durations were lower in Nonfix group than in KL group (both p < 0.05). The mean hospital stay durations were (18.54 ± 6.42) days and (21.17 ± 7.32) days in groups Nonfix and KL, respectively (p = 0.186). All fractures healed well with no significant difference in union time between the two groups (p = 0.210). The rates of satisfactory reduction were 84.62% (22/26) in Nonfix group and 86.96% (20/23) in KL group (p = 1.000). The mean Merle d''Aubigné scores were 15.62 ± 2.28 in Nonfix group and 16.17 ± 2.19 in KL group (p = 0.388). The complication rates were 7.69% (2/26) in Nonfix group and 34.78% (8/23) in KL group (p = 0.046).ConclusionsFor both‐column acetabular fractures associated with PW fragment, although fixation of PW was not performed after anterior surgical procedures, satisfactory outcomes could also be obtained. However, nonfixation was a less invasive choice with a lower complication rate.     

The Impact of Spinal Fusion on Hip Displacement in Cerebral Palsy

Background and study aimsThe aims of this study were to determine the risk of progressive hip subluxation in children with CP after spinal fusion for scoliosis and how frequent the hips follow-up should be scheduled.Patients and methodsPelvis radiography [migration index (MI) and pelvic obliquity (PO)] of Gross Motor Function Classification System (GMFCS) levels IV and V children with CP who received spinal fusion and pelvic fixation were reviewed retrospectively. This population was categorized into three groups based on the MI at spinal fusion: G1 = 0–29%; G2 = 30–59%; and G3 = 60–100%.ResultsFifty children (age 7.5–15.0 years) and categorized into 3 groups (G1 = 19, G2 = 23, G3 = 8; 100 hips in total). Preoperative and last follow-up MI were 22 ± 7% and 30 ± 20% (G1), 41 ± 9% and 43 ± 22% (G2), 92 ± 15% and 97 ± 10% (G3). The MIs at spinal fusion between groups were statistically different (p < 0.001). In G1, the mean MI progression was 5% and 25% at 12 months and 62 months, respectively. In G2, the mean MI progression was 9% and 25% at 12 months and 32 months, respectively. The progression more than 10% occurred within 2 years in G1 and within 1 year in G2. There was no difference between groups based on preoperative degree of PO (p = 0.653) and correction rate in PO (p = 0.421).ConclusionsIn GMFCS IV and V children with the highest risk for progression occurred with increasing preoperative MI, especially over 50%. Hips should be monitored continuously after spinal fusion until hip stability is documented.     

Total Hip Arthroplasty with Robotic Arm Assistance for Precise Cup Positioning: A Case‐Control Study

ObjectiveTo determine whether more precise cup positioning can be achieved with robot‐assisted total hip arthroplasty (THA) as compared to conventional THA.MethodsIn this study, between July 2019 and May 2021, 93 patients aged 23–75 years with osteonecrosis of the femoral head (ONFH) and adult developmental dysplasia of hip who underwent first hip surgery were included in the study. They were randomly assigned to either the robotic‐assisted THA group (n = 45) or the conventional THA group (n = 48). After the operation, all patients were given routine rapid rehabilitation guidance. The duration of operation was recorded to estimate the learning curve through cumulative summation analysis. We compared the demographics, duration of operation, cup positioning, leg length discrepancy, hip offset, and Harris Hip Score between robot‐assisted THA and manual THA. Precision in the positioning of the acetabular prosthesis using the MAKO system was also compared between the two groups.ResultsThe mean duration of operation for the robot‐assisted THA group was 91.37 ± 17.34 min (range: 63 to 135 min), which was significantly higher than that for the conventional THA group. When the number of procedures was increased to 13, the duration of operation in the robot‐assisted group decreased significantly and gradually became stable. In terms of duration of operation, robot‐assisted THA was associated with a learning curve of 13 cases. The mean amount of bleeding in the robot‐assisted THA group was not significantly different from that in conventional THA group (328 ± 210 ml vs 315 ± 205 ml) (p = 0.741). There was no significant difference in the proportion of prostheses located within Lewinnek''s safe zone between robot‐assisted THA group and conventional THA group (69.81% vs 64.41%). The leg length discrepancy (LLD) was significantly smaller in the robot‐assisted THA group than in the conventional THA group (p < 0.001), but both were within acceptable limits (10 mm). The inclination and anteversion angles of the acetabular prosthesis planned before operations were correlated with the actual measurement (r = 0.857 p < 0.001, r = 0.830, p < 0.001). After surgery, none of the patients experienced hip dislocation, aseptic loosening, or periprosthetic infection during the 3 months of follow‐up.ConclusionThe proportion of acetabular prostheses in the Lewinnek''s safety zone was higher and the extent of LLD was significantly lower in the robot‐assisted THA group, as compared to the same metrics in the conventional THA group. The MAKO robot improved the accuracy of implant placement in THA.     

The Development of Leg Length Difference and Influence on Persistent Dysplasia in Patients with Developmental Dysplasia of the Hip

IntroductionLeg-length difference (LLD) is common in patients with developmental dysplasia of the hip (DDH). LLD of > 1 cm at skeletal maturity is reported in > 40% of patients, with the majority related to ipsilateral overgrowth. A longer DDH leg might lead to excessive mechanical loading at the acetabular margin, resulting in compromised acetabular development. We hypothesised that the LLD would negatively influence acetabular development. If so, it would be advantageous to identify such patients early in the course of follow-up, and address this if necessary.MethodsA retrospective study was conducted on a consecutive series of DDH patients managed surgically at the Royal National Orthopaedic Hospital, Stanmore, United Kingdom. We included patients with adequate long-leg radiographs at the age of 4–8 years (early-FU) and skeletal maturity (final-FU). Bilateral cases and those who underwent surgical procedures for hip dysplasia during the follow-up period were excluded. Measurements including leg length and centre-edge-angle (CE-angle) were obtained at the 2 time points.ResultsTwenty-seven patients were included, mean age at early-FU 5.7 (± 0.9) years, and 13.9 (± 1.0) years at final-FU. Mean LLD at early-FU was 9.5 (± 7.6) mm and 10.9 (± 9.4) mm at final-FU, p = 0.337. Correlation between early- and final-FU LLD was 0.68 (p < 0.001). The mean CE-angle at early follow-up was 14.6° (± 9.8), this improved to 23.2° (± 8.2) at skeletal maturity (p = 0.003, paired samples t-test). Linear regression analysis showed a non-significant trend towards less CE-angle improvement in patients with more initial residual dysplasia and more initial LLD.ConclusionMost leg-length differences can be identified early in the follow-up period, nevertheless, considerable individual changes in LLD are observed on continued follow-up. Furthermore, a trend was observed towards impaired acetabular improvement in patients with more LLD. These findings justify careful clinical and radiological monitoring of LLD from an early stage in the follow-up period.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00492-5.     

Denosumab Can Prevent Collapse in Patients with Early‐Stage Steroid‐Induced Osteonecrosis of the Femoral Head by Inhibiting Osteoclasts and Autophagy

ObjectiveThe osteoclastic bone resorption inhibitors might have positive effect in preventing femoral head collapse in patients with osteonecrosis of the femoral head (ONFH). However, as a novel osteoclastic inhibitor, whether denosumab can prevent collapse in steroid‐induced ONFH remains unknown. This study aims to evaluate the treatment effect of denosumab and the potential protective mechanism.MethodsThis was a retrospective study. A total of 161 patients with steroid‐induced ONFH who underwent denosumab treatment were reviewed, and 209 untreated patients were selected as controls. Their clinical characteristics and radiological exam results were obtained. Patients were treated with 60 mg denosumab every 6 months for 2 years. The primary outcome was the incidence of femoral head collapse at 2 years after the initial diagnosis of ONFH. Secondary outcomes included the Harris hip score, progression of osteosclerosis, increase in necrotic area, bone marrow oedema relief, and bone mineral density increase in the femoral head. The Mann–Whitney U test and chi‐square tests were performed to identify the differences between the continuous and categorical variables, respectively. A multivariate logistic regression model was built to identify the factors associated with the treatment effect of denosumab.ResultsThe incidence of femoral head collapse was 42.24% (68/161) in the denosumab group and 54.07% (113/209) in the control group (χ ² = 5.094, p = 0.024; relative risk = 0.787, 95% CI = 0.627–0.973). The excellent‐good rates of the Harris hip score were 63.98% (103/161) in the denosumab group and 44.98% (94/209) in the control group (χ ² = 13.186, p < 0.001). The incidence of osteosclerosis progression in the denosumab group was 55.28% (89/161), which was significantly higher than that in the control group (43.54%, 91/209, χ ² = 5.016, p = 0.025). Meanwhile, a significant increase in bone mineral density was identified in 29.19% (47/161) and 7.18% (15/209) of patients in the denosumab and control groups, respectively (χ ² = 31.600, p < 0.001). The osteoclastic cytoplasm expression of LC3‐II was more positive in the control group than in the denosumab group (immunohistochemistry scoring: 3.58 ± 2.27 vs 6.33 ± 2.64, Z = −2.684, p = 0.007). A total of three independent factors were considered to be associated with the positive treatment effect of denosumab, the time of first denosumab administration (OR = 2.010, 95% CI = 1.272–3.177), osteosclerosis (OR = 1.583, 95% CI = 1.024–2.445), and the necrotic area before denosumab administration (medium necrotic area: OR = 2.084, 95% CI = 1.245–3.487; large necrotic area: OR = 2.211, 95% CI = 1.255–3.893).ConclusionsThe current study demonstrated that denosumab had a positive effect on preventing femoral head collapse in patients with steroid ONFH. This effect might be closely associated with the inhibition of osteoclasts and their autophagy.     

The Utilization of Dual Second Sacral Alar‐Iliac Screws for Spinopelvic Fixation in Patients with Severe Kyphoscoliosis

ObjectivesAs a new pelvic fixation technique, the dual S2AI screws fixation technique could provide highly stable distal strength, and have wide clinical prospect in the correction of severe kyphoscoliosis. However, the ideal trajectory parameters, indications and clinical outcomes of this technique have not been reported so far. This study aimed to determine the anatomical parameters of dual S2AI screws in the normal Chinese adult population, investigating the indications of this technique and evaluating the feasibility and clinical outcomes.MethodsFifteen males and 15 females with normal pelvis underwent a pelvic CT scan to determine ideal dual S2AI screws trajectories. Sagittal angle (SA), transverse angle (TA), maximal length (ML), sacral length, and skin distance were measured. Subsequently, we retrospectively reviewed the data of 16 patients (seven males and nine females) who underwent dual S2AI screw fixation and 23 patients who underwent single S2AI screw fixation between January 2014 and December 2019. Preoperative, postoperative, and latest follow‐up measurements of Cobb angle, coronal balance (CB), spinal pelvic obliquity (SPO), and regional kyphosis (RK) were obtained. The mean follow‐up time was 16.7 ± 7.1 months (range: 12–30 months). Independent t‐test was used to determine the difference in the analysis of the trajectories. The paired sample non‐parametric Wilcoxon test was performed to assess the changes in radiographic parameters between different time points and different groups.ResultsFor both male and females, the proximal S2AI screws had significantly higher TA and ML, but a lower SA than distal screws. Females showed significantly more caudal (SA: 25.03° ± 2.32° vs. 29.82° ± 2.47°, t = 7.742, P < 0.001) trajectories of distal screw. Additionally, ML in the females were significantly shorter than that in males (106.81 mm ± 6.79 mm vs. 101.63 mm ± 6.55 mm, t = 3.007, P = 0.003, 124.41 mm ± 7.57 mm vs. 116.23 mm ± 7.03 mm, t = 4.337, P < 0.001). Eight had unilateral and eight had bilateral dual S2AI screw placement. Respectively, both the single S2AI and dual S2AI groups showed significant postoperative improvement of Cobb angle, RK angle and SPO angle. In patients with dual S2AI screws fixation, two patients found that screws loosening occurred in one of dual screws at 1‐year follow‐up, and in patients with single S2AI screws fixation, six patients found screw loosing as well as two patients found screw breakage at 1‐year follow‐up. None of all patients had any prominent loss of correction.ConclusionThe ideal trajectory of dual S2AI screw could be well established. The dual S2AI screw fixation technique is feasible in patients with severe kyphoscoliosis, and provides satisfactory correction of deformity with few postoperative complications.     

Is the Revision Rate Higher After Hip Arthroplasty in Teenage Patients? A Prospective Study with Long-Term Follow-Up of More Than 10 Years

BackgroundTotal hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) are already proven good for end-stage arthritis in the older populations but it is challenging in young teenage patients. The primary aim was to assess Hip Disability and Osteoarthritis Outcome Score (HOSS), Harris Hip Score (HHS) and secondary aim for implant survival rate.Materials and MethodsThe details of 33 teenage patients (forty hips) who underwent HRA (21) and THA (19) at our institution (January 2002 to December 2013) with a mean follow-up period of 11.00 years (range 7.00–18.40) were included. The study group had 25 males and eight females.ResultsThe overall median HOOSs with interquartile range were 89.00 (87.63–0.00). The median HOOSs at follow-up were as follows: 95.00 (90.00–95.00) for symptoms, 92.00 (90.00–95.00) pain, 87.00 (85.00–90.00) for functions, 81.00 (75.00–85.00) for sports and 94.00 (88.00–95.00) for QOL. HHS improved significantly from 36.88 ± 6.14 to 90.12 ± 6.56 (p < 0.001). The HHS of HRA group improved from 36.29 ± 5.83 to 89.38 ± 5.23 and THA group improved from 37.26 ± 6.22 to 90.94 ± 7.84. The 5-year radiological follow-up X-rays did not show any radiolucent line wider than 2 mm in all three zones of the acetabulum and no progressive subsidence or migration of > 1 mm and divergent radiopaque line in femur. The Implant survival rate for HRA was 100% at 5 years, 100% at 10 years, 92% at 15 years and THA group was 100% at 5 years and 90% at 10 years.ConclusionOur study showed a disability rate of zero with improved HOSS and HHS. The overall implant survival rate was good with 100% at 5 years, 97% at 10 years and 89.9% at 15 years in contrast to the previous studies with the use of modern implants and newer standard surgical techniques.Level of EvidenceA Level II study http://www.spine.org/Documents/LevelsofEvidenceFinal.pdf.     

Comparison of three different treatment methods for traumatic and Iatrogenic peripheral artery pseudoaneurysms

ObjectiveTo compare the efficacy of open surgery (OS), endovascular interventions (EIs), and ultrasound‐guided thrombin injection (UGTI) for the treatment of peripheral arterial pseudoaneurysms (PAs).MethodsFrom January 1, 2001, to February 10, 2021, 38 patients diagnosed with traumatic and iatrogenic PAs treated with OS, EI, and UGTI were retrospectively analyzed. There were 18 females and 20 males, with an age of 56.47 ± 14.08 years (range,17–87 years). Anesthesia modality, operation duration, blood transfusion, duration of hospital stay, primary and secondary success rates, and complication rate were used to evaluate the surgical outcomes.ResultsThere were 11 cases under regional anesthesia and 4 under general anesthesia in OS group, 9 under regional anesthesia and 1 under general anesthesia in EI group, and no regional or general anesthesia was required in UGTI group. There was no significant differences between any two groups (χ ²  = 39.80, p < 0.05). The blood tranfusion amount (units) were 3.6 ± 6.0, 0.8 ± 2.5, 0.0 ± 0.0 for OS, EI, and UGTI groups, respectively, with significant difference between OS and UGTI groups (F = 3.03, p < 0.05). The operation duration (minutes) of OS, EI, and UGTI groups were 80.0 ± 41.9, 56.0 ± 8.4, and 22.7 ± 5.3, respectively, with significant difference between any two groups (F = 15.69, p < 0.05). The duration of hospital stay (days) were 47.7 ± 39.0, 31.5 ± 17.6, and 16.3 ± 9.5, repectively, with significant difference between any two groups (F = 47.73, p < 0.05). The primary clinical success rates were 80% (12/15), 90% (9/10), and 92.3% (12/13) in OS,EI, and UGTI groups, respectively, with no significant difference between any two groups (χ ²  = 0.34, p > 0.05). The secondary clinical success rates were 100% for all three groups. The overall complication rates of OS, EI, and UGTI groups were 20% (3/15), 10% (1/10), and 7.7% (1/13), respectively, with no significant difference between any two groups (χ ²  = 1.00, p > 0.05). The infection rates were 13.3% (2/15), 10% (1/10), and 0% (0/13) in OS, EI, and UGTI groups respectively, with no significant difference between any two groups (χ ²  = 1.80, p > 0.05). The reintervention rates were 6.7% (1/15), 0% (0/10), 7.7% (1/13) in OS, EI, and UGTI groups, respectively, with no significant difference between two groups (χ ²  = 0.95, p > 0.05). Neuralgia was relieved in all patients.ConclusionsOS, EI, and UGTI are efficacious and safe options for the treatment of appropriate patients with traumatic and iatrogenic PAs. UGTI would be considered as a first‐line therapy for this condotion.     

Comparison of Inguinal Hernia Repairs Performed with Lichtenstein,Rutkow–Robbins,and Gilbert Double Layer Graft Methods

Tension-free repairs are performed commonly in inguinal hernia operations. The objective of the present study is to compare the outcomes of three different tension-free repair methods known as Lichtenstein, Rutkow–Robbins, and Gilbert double layer. One-hundred and fifty patients diagnosed with inguinal hernia were randomly split into three groups. The comparisons across groups were carried out in terms of operation length, postoperative pain, femoral vein flow velocity, early and late complications, recurrence rates, length of hospital stay, time required to return to work, and cost analysis. No difference was found between the groups regarding age, gender, type and classification of hernia, postoperative pain, and late complications (p > 0.05). Operation length was 53.70 ± 12.32 min in the Lichtenstein group, 44.29 ± 12.37 min in the Rutkow–Robbins group, and 45.21 ± 14.36 min in the Gilbert group (p < 0.05). Mean preoperative and postoperative femoral vein flow velocity values were 13.88 ± 2.237 and 13.42 ± 2.239 cm/s for Lichtenstein group, 12.64 ± 2.98 and 12.16 ± 2.736 cm/s for Rutkow–Robbins group, and 16.02 ± 3.19 and 15.52 ± 3.358 cm/s for the Gilbert group, respectively. Statistical difference was found between all the groups (p < 0.001). However, no difference was determined between the groups regarding the decrease rates (p = 0.977). Among early complications, hematoma was observed in one (2 %) patient of Lichtenstein group, five (10 %) patients of Rutkow–Robbins group, and three (6 %) patients of Gilbert group (p = 0.033). Cost analysis produced the following results for Lichtenstein, Rutkow–Robbins, and Gilbert groups: US $157.94 ± 50.05, $481.57 ± 11.32, and $501.51 ± 73.59, respectively (p < 0.001). Lichtenstein operation was found to be more advantageous compared with the other techniques in terms of cost analysis as well as having unaffected femoral blood flow. Therefore, we believe that Lichtenstein repair is still the most appropriate surgical option in patients diagnosed with inguinal hernia.     

The Standing and Sitting Spino‐Pelvic Sagittal Alignment in Patients with Instrumented Lumbar Fusion Might Correlate with Adjacent Segment Degeneration

ObjectivesSitting is a common weight‐bearing posture, like standing, but there still lacks enough understanding of sagittal alignment in sitting position for patients after lumbar fusion. This study aimed to investigate the accommodation of fixed spine from standing to sitting position and its influence on unfused segments.MethodsSixty‐two patients after lumbar fusion (test group) and 40 healthy volunteers (control group) were recruited in this research. All subjects underwent lateral radiographs of entire spine in the standing and sitting positions. The spinopelvic parameters including sagittal vertical axis (SVA), T1 pelvic angle (TPA), lumbar lordosis (LL), thoracic kyphosis (TK), and pelvic tilt (PT) were measured. The changes in parameters of patients between two positions were compared with control group, and patients were divided in different groups based on fusion level and their parameters were compared.ResultsWhen changing from standing to sitting positions, a forward‐moving SVA and TPA were observed in both patients and control groups, accompanied by the decrease in LL, TK and increase in PT, but the changes of patients were smaller in TPA, LL, and TK (6.5° ± 7.2° vs 9.7° ± 6.0°, 7.7° ± 8.3° vs 13.6° ± 8.5°, 2.2° ± 6.5° vs 5.4° ± 5.1°, respectively, p < 0.05). Increase of PT in the lumbosacral fixation group was lower than that in the control group (4.4° ± 9.1° vs 8.3° ± 7.1°, p < 0.05). Patients who had adjacent segments degeneration (ASD) showed more kyphosis in unfused lumbar segments than the other patients (16.4° ± 10.7° vs −1.0° ± 4.8°, p < 0.05) from standing to sitting.ConclusionsThe spine straightens in lumbar and thoracic curve, combined with forward‐moving axis and pelvic retroversion when changing to the sitting position. However, these changes are relatively limited in patients after lumbar fusion, so the adjacent unfused lumbar segments compensate to stress during sitting and this may be related to ASD.