Does spinopelvic alignment affect the union status in thoracolumbar osteoporotic vertebral compression fracture?

Purpose

In the healing of osteoporotic vertebral fracture, global spinal mal-alignment might increase the load sharing at the fracture site and deteriorate the fracture healing. This study aimed to evaluate the effect of spinopelvic alignment on the union status of thoracolumbar osteoporosis-related vertebral compression fracture (OVCF).

Methods

Consecutive 48 patients with a single-level thoracolumbar fresh OVCF were treated non-operatively. Union was judged by three independent observers at 6 months, and patients were divided into union group and non-union group. Spinopelvic alignment was measured using upright whole spine radiograph before treatment as follows: pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), sagittal vertical axis (SVA), and DSVA, defined as the distance from a plumb line dropped from the center of the C7 body to the center of fractured vertebral body.

Result

Global spinal alignment was different in union group and non-union group: SVA (4.7 ± 0.7 cm in union group vs. 8.9 ± 1.3 cm in non-union group, P = 0.007), DSVA (4.2 ± 0.6 cm in union group vs. 9.5 ± 1.0 cm in non-union group, P < 0.001), and PI–LL (18.9° ± 2.2° in union group vs. 30.3° ± 3.9° in non-union group, P = 0.014). Over 5 cm of DSVA [P = 0.022, adjusted odds 7.9 (95 % CI 1.3–77.0)] and/or over 30° of PI–LL [P = 0.026, adjusted odds 6.6 (95 % CI 1.5–44.2)] showed the significant risk factors for non-union using multivariate logistic regression analysis in the other background status.

Conclusions

Global spinal mal-alignment, showing over 5 cm of DSVA and/or over 30° of PI–LL, affected the union status of OVCF.

     

Does bisphosphonate-based anti-osteoporosis medication affect osteoporotic spinal fracture healing?

Summary

Effects of bisphosphonate on fracture healing were prospectively investigated for osteoporotic spinal fracture. Although there were no significant differences in clinical outcomes, the presence of intravertebral cleft was related to the medication use. These results suggest that suspension of bisphosphonate use should be considered during the fracture healing period.

Introduction

The purpose of this prospective study is to investigate whether bisphosphonate-based anti-osteoporosis medication affects fracture healing and clinical outcomes of conservatively treated osteoporotic spinal fractures (OSFs).

Methods

A total of 105 patients who were diagnosed with acute OSFs were prospectively enrolled. According to their previous medication history, the patients were allocated into group I (n?=?39, no history of bisphosphonate use) or group II (n?=?66, history of bisphosphonate use). Clinical outcomes were assessed using visual analogue scale (VAS), and Oswestry disability index (ODI). Radiographic parameters including changes in height loss and kyphotic angle at the index vertebra were measured, and radiographic findings suggesting impaired fracture healing such as the intravertebral cleft (IVC) sign and fracture instability were evaluated. Univariate and multivariate regression analyses were used to identify related factors.

Results

There were no significant differences in the last VAS and ODI between groups. There were also no significant differences in the radiographic parameters. Although the IVC sign was seen more commonly in group II (30.3 %) than in group I (20.5 %), fracture instability combined with IVC was noted in the same number of cases. On multiple regression analysis, medication history showed no significant relationship with the clinical parameters. However, the presence of the IVC sign was related to medication history (odds ratio 4.8; 95 % confidence interval [CI] 1.02–22.69).

Conclusions

Bisphosphonate use does not significantly affect the clinical results during conservative treatment for OSFs. However, the occurrence of the IVC sign was related to medication history. Although further studies are needed to verify our findings, these results suggest that suspension of bisphosphonate use should be considered during the fracture healing period for acute OSFs.

     

What is the importance of “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture?

Summary

We investigated the importance, risk factors, and clinical course of the radiolucent “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture. Preoperative osteonecrosis and a lump cement pattern were the most important risk factors for the peri-cement halo phenomenon, and it was associated with vertebral recollapse.

Introduction

We observed a newly developed radiolucent area around the bone cement following vertebral augmentation for osteoporotic compression fractures. Here, we describe the importance of the peri-cement halo phenomenon, as well as any associated risk factors and long-term sequelae.

Methods

In total, 175 patients (202 treated vertebrae) were enrolled in this study. The treated vertebrae were subdivided into two groups: Group A (with halo, n?=?32) and Group B (without halo, n?=?170), and the groups were compared with respect to multiple preoperative (age, sex, BMD, preoperative osteonecrosis) and perioperative factors (operative approach: vertebroplasty or kyphoplasty; cement distribution pattern; cement leakage; cement volume), and postoperative results (VAS score, recollapse). Logistic regression analysis was used to evaluate the relationship between the incidence of the peri-cement halo and all of the parameters described above.

Results

Rates of osteonecrosis were also significantly higher in Group A than in Group B (62.5% vs. 31.2%, p?p?p?p?p?=?0.001), KP (OR?=?3.630; 95% CI?=?1.628–8.095; p?=?0.002), lump pattern (OR?=?13.870; 95% CI?=?2.907–66.188; p?=?0.001), and vertebral recollapse (OR?=?5.356; 95% CI?=?1.897–15.122; p?=?0.002) were significantly associated with peri-cement halo.

Conclusions

The peri-cement halo was found to be associated with vertebral recollapse, this sign likely represents a poor prognostic factor after vertebral augmentation for osteoporotic compression fractures.     

Does the type of hip fracture affect functional recovery in elderly patients undergoing inpatient rehabilitation?

BackgroundHip fractures should not be considered as a single, homogeneous condition. Various determinants of functional recovery of patients with hip fracture have been proposed, such as age or type of fracture. The aim of this study was to determine if patients with an intertrochanteric fracture (ITF) had lower functional recovery characteristics with respect to those with a femoral neck fracture (FNF).MethodsA retrospective study was carried out on 531 elderly patients with hip fracture, surgically treated, admitted to a rehabilitation institute between December 1, 2014, and December 31, 2017. Patients underwent an individualized rehabilitation program for improving their physical function. The outcome measures of this study were the length of stay (LOS) in the rehabilitation institute, the Functional Independence Measure (FIM) gain, i.e. the difference in FIM score between discharge and admission, and the FIM efficiency, which represents the daily gain. Patients were also stratified by age categories and by different levels of functional independence, as evaluated with the FIM total score at baseline.ResultsAge (p<0.05), LOS (p<0.005) and rehabilitation outcomes (FIM score and efficiency; p<0.05) differed significantly between patients with FNF and ITF. In particular, patients with ITF were older and more dependent at baseline. Moreover, they showed a lower FIM efficiency with respect to patients with FNF (p<0.05), which obtained a similar improvement in FIM total score of about 26 points but were discharged on average 3 days before. With aging, FIM efficiency decreased, while LOS increased. Patients highly dependent at baseline (FIM total score <40) had the lowest FIM gain and efficiency and the longest LOS respect to the more independent patients. Moreover, in older (85+ years) and in higher dependent patients the differences in the outcome measures between ITF and FNF were reduced.ConclusionsThe type of hip fracture could affect the LOS and FIM efficiency of younger and more independent patients with hip fracture during inpatient rehabilitation. In particular, patients with ITF require a longer rehabilitation period to achieve a similar functional gain as those with FNF.     

Does early administration of bisphosphonate affect fracture healing in patients with intertrochanteric fractures?

This prospective multicentre study was undertaken to determine whether the timing of the post-operative administration of bisphosphonate affects fracture healing and the rate of complication following an intertrochanteric fracture. Between August 2008 and December 2009, 90 patients with an intertrochanteric fracture who underwent internal fixation were randomised to three groups according to the timing of the commencement of risedronate treatment after surgery: Group A (from one week after surgery), Group B (from one month after surgery), and Group C (from three months after surgery). The radiological time to fracture healing was assessed as the primary endpoint, and the incidence of complications, including excessive displacement or any complication requiring revision surgery, as the secondary endpoint. The mean time to fracture healing post-operatively in groups A, B and C was 10.7 weeks (SD 4.4), 12.9 weeks (SD 6.2) and 12.3 weeks (SD 7.1), respectively (p = 0.420). At 24 weeks after surgery, all fractures had united, except six that had a loss of fixation. Functional outcomes at one year after surgery according to the Koval classification (p = 0.948) and the incidence of complications (p = 0.386) were similar in the three groups. This study demonstrates that the timing of the post-operative administration of bisphosphonates does not appear to affect the rate of healing of an intertrochanteric fracture or the incidence of complications.     

Does acromion anatomy affect the risk of acromion stress fracture after reverse shoulder arthroplasty?

IntroductionReverse shoulder arthroplasty (RSA) alters normal anatomic relationships and results in increased deltoid forces. Which alter physiologic stress patterns in the acromion resulting in fractures. The purpose of this study was to evaluate the effect of acromion anatomy on the stress levels and risk of acromial fracture after RSA.MethodsA lateralization onlay design of the Exactech Equinoxe RSA standard stem was used for all four different acromial sizes (ranging from −5.0 mm to +5.0 mm) and compared to standard normal shoulder model (acromial size 0). A finite element analysis (FEA) model was then constructed for each case and quasi-static analysis was carried out to determine the highest minimum principal stress (HMPS) for each case and this was used to predict fatigue life percentage (FLP) of the acromion.ResultsFor smaller acromion sizes of −5 mm and -2.5 mm, the HMPS was found to be 1.87 and 1.24 times higher than the standard, respectively. The HMPS for the +2.5 mm acromial size was 0.95 times compared to the standard and 1.04 times higher for the +5 mm acromial size. According to our model, the highest FLP was seen when the acromion size was +2.5 mm (case 4 - 178%) and the lowest FLP was seen when it was -5 mm (−0.06%).ConclusionOur results suggest that there is an optimal acromion size (+2.5 mm from normal male) that leads to the lowest fracture risk in RSA. Surgeons must be aware of acromion size as a critical factor in deltoid tensioning, acromial stress, and risk of acromial fracture when selecting optimal implant designs and sizes for RSA.Level of evidence: Basic Science Study     

Does the completeness of revascularization affect early survival after coronary artery bypass grafting in elderly patients?

OBJECTIVE: Usefulness and risks of incomplete versus complete revascularization are still matters of ongoing discussions. Because an increasing number of elderly patients are undergoing coronary artery bypass grafting (CABG), the question arises whether a less extensive surgical approach is more prudent than complete revascularization. METHODS: Of 6531 patients undergoing isolated CABG, 859 were 75 and older at the time of operation. Mean age of the 859 patients was 77+/-2.7 years (median: 76 years); 65% were men. Follow-up enquiry by questionnaire was performed at the 180th postoperative day with a completeness of 95.6%. Assessment of the impact of incomplete revascularization utilized both multivariable analysis and propensity score matching to account for selection factors. RESULTS: Incomplete revascularization was performed in 133 patients (16%). The most common reasons for incomplete revascularization were small vessels (55%) and massive calcification (32%). Mortality until 180 days after CABG was higher (n=32; 24%) after incomplete than after complete revascularization (n=105; 15%; P=0.005). By logistic multivariable regression, incomplete revascularization was identified as an independent risk factor for death (Odds ratio, 1.8; P=0.015). By time-related analysis, incomplete revascularization predominantly affected the early period after CABG (P=0.001). Aortic cross clamping time was only slightly shorter for the group with incomplete (59+/-27 min (median: 55 min) vs. 63+/-26 min (median: 58 min); P=0.1). CONCLUSIONS: Incomplete revascularization increases the early risk of death after CABG in patients aged 75 years and older. The potential compensating benefit of the shorter aortic cross clamping time does not outweigh the advantages of complete revascularization. Thus, in the era of high-volume interventional approaches and minimally invasive techniques, the advantages of complete revascularization need to be considered.     

Does the level of an intracapsular femoral fracture influence fracture healing after internal fixation? A study of 411 patients

The aim of the study was to determine if the level of an intracapsular femoral fracture influences the risk of non-union or avascular necrosis occurring after internal fixation. An observer blinded to the outcome of the treatment (fracture union, non-union or avascular necrosis) reviewed the radiographs of 411 patients with an intracapsular fracture, which had been treated by internal fixation. The level of the fracture was determined by two methods, a direct distance measurement and a ratio method. In addition, the diameter of the femoral head was measured. Results indicated that none of the methods for determining the fracture level had any relationship to the risk of non-union or avascular necrosis occurring. Undisplaced fractures were found to be more proximally located than displaced fractures. We conclude that the level of an intracapsular fracture should not be used as a method of deciding if the femoral head should be preserved or replaced. The level of an intracapsular fracture may determine if the fracture displaces at the time of injury.     

Does hip strength analysis explain the lower incidence of hip fracture in the People's Republic of China?

To explore whether there are ethnic differences in calculated hip strength that might explain the low incidence of hip fracture in China, we used Lunar DPX 'beta' version of hip strength analysis (HAS) and hip axis length (HAL) programs to compare hip geometry, calculated strength and densitometric values from Chinese subjects in Shenyang to those of Caucasian subjects in Oslo and Leuven participating in the European Prospective Osteoporosis Study (EPOS). Subjects were 210 Chinese and 403 Caucasian men and women aged 53-77 years. Parameters investigated included bone mineral density (BMD), bone mineral content (BMC), bone area (BA), cross-sectional moment of inertia (CSMI) and section modulus (both indicating strength and rigidity of the femoral neck), HAL, neck length (NL), neck diameter, tensile stress (Tstress) and compressive stress (Cstress) (indicating the stress in the femoral neck at its weakest cross section arising from walking or a standard fall, respectively), safety factor (SF, indicating the resistance to fracture for forces generated during walking) and fall index (FI, indicating the resistance to fracture from force generated during a fall in the greater trochanter). The Chinese men and women were significantly shorter and lighter than their Caucasian counterparts (P<0.01) and had significantly lower BMD, BMC and BA of the femoral neck (P<0.01). After adjusting for BA, weight and height, there was no significant ethnic difference in either gender in BMC. CSMI and section modulus were significantly lower, and HAL, NL and neck diameter were significantly shorter in the Chinese men and women (P<0.01). These differences all remained after adjusting for weight and height. There were no significant differences in Tstress, Cstress, SF and FI between ethnic groups in either gender. Most of the parameters of calculated hip strength in the Chinese subjects were similar to or poorer than those in the Caucasian subjects. There was no evidence to indicate that Shenyang Chinese have superior BMD or BMC or better calculated hip strength. The short HAL and NL of the population, however, could be an independent factor contributing to the low incidence of hip fracture.     

Does the absence of the palmaris longus affect grip and pinch strength?

The palmaris longus tendon is the most frequently harvested tendon for reconstructive plastic and hand surgical procedures. A question patients often ask is whether loss of the palmaris longus will result in any functional deficit. In order to answer this question, the presence or absence of the palmaris longus muscle was clinically determined in 418 normal Asian subjects. All subjects also had their grip and pinch strengths measured. No statistically significant difference was seen in the grip or pinch strength measurements between subjects who had a palmaris longus tendon and those who did not. This study demonstrates that absence of the palmaris longus is not associated with a decrease of grip or pinch strength.     

Stability of extracapsular hip fracture: Does it affect rehabilitation outcome of post-acute patients?

BackgroundVarious factors have been shown to affect rehabilitation outcome of hip fractured patients. The degree of extracapsular fracture stability may also affect functional recovery. The aim of our study was to assess the relationship between extracapsular hip fracture stability and rehabilitation outcome in a post-acute setting.MethodsA retrospective cohort study of 144 hip fractured patients was carried out in a post-acute geriatric rehabilitation center from 1/2014 to 6/2015. The main outcome measures were the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). The associations between patients with stable vs. unstable and clinical, demographic and comorbidity variables, were assessed by the Mann-Whitney U and chi-square tests. A multiple linear regression model was used to estimate the association between fracture stability and LOS score after controlling for sociodemographic characteristics and chronic diseases.ResultsRehabilitation outcomes (FIM and mFIM score changes, mFIM MRFS) were found independent of extracapsular hip fracture stability. Patients with an unstable fracture presented with a significantly longer LOS compared with a stable fracture (p = .008). Multiple linear regression analysis showed that fracture stability was significantly associated with LOS after adjustment for confounding demographic, clinical and functional variables (p = .009).ConclusionPatients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures.     

Does kyphoplasty affect the global sagittal alignment in patients with osteoporotic vertebral fractures? A systematic review and meta-analysis

Background

Osteoporotic vertebral compression fractures (OVCF) are common in elderly patients and may cause local kyphosis due to the vertebral collapse and wedging. Balloon kyphoplasty (BKP) with polymethyl methacrylate is widely used to relieve back pain and restore the height and kyphosis of the destroyed vertebra Johnell (Osteoporos Int 17(12):1726–33, 2006); Wasnich (Bone 18: 179S–183S, 1996); Finnern (Osteoporos Int 14:429–436, 2003). However, the influence of BKP on global sagittal alignment (GSA) in patients with OVCF remains unclear.

Objective

To systematically evaluate the relevant literature regarding the influence of BKP on the global spinal sagittal alignment using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spinosacral Angle (SSA). Visual Analogue Score (VAS) was also recorded.

Methods

A systematic review of the English language literature dating up until August 2022, was undertaken utilising the PRISMA guidelines.

Results

Of a total of 548 articles, 4 studies met the inclusion criteria (4 level III evidence) and were analyzed. Overall, 201 patients of mean age 73.8 years (69–77) had acute OVCF of one or more vertebra. The male to female ratio was 51:128. The number of fractured vertebrae was 235 (average of 1.17 fractured vertebrae per patient). Their pre-operative radiological parameters on standing x-rays showed a mean PI of 56°, PT 24.1°, LL 44.4°, TK 42.3°, PI-LL 11.7°, SVA 4.9 cm, LL/TK 1 and SSA 114.8°. The average VAS was 7.6 (2.6–10). All the patients underwent BKP and their radiological parameters on standing x-rays post operatively showed a mean PI of 55.3°, PT 23.1°, LL 45.1°, TK 41.4°, PI-LL 10.3°, SVA 4.29 cm, LL/TK 1.07 and SSA 116.8°. Their average VAS post BPK was 2.36 (0–4.8).A statistical analysis comparing the pre/post-operative GSA (111 patients, 3 studies with standard deviations) showed no statistical difference in PT (24.1° vs. 23.5°, P = 0.93), TK (42.3° vs. 42.4°, P = 0.57), PI-LL (14.4° vs.12.4°, P = 0.4), SVA (6.1 cm vs. 5.5 cm, P = 0.19) SSA (114.8° vs. 116.7° P = 0.36). VAS was significantly reduced post BKP (7.1 vs. 2.5 P = 0.004).

Conclusion

Performing BKP procedures does not significantly affect the global sagittal alignment in patients with osteoporotic vertebral compression fractures. There was however, a significant improvement in pain scores in patients undergoing BKP at 1 or more levels.

     

Does the addition of cement improve the rate of local recurrence after curettage of giant cell tumours in bone?

We retrospectively compared the outcome after the treatment of giant cell tumours of bone either with curettage alone or with adjuvant cementation. Between 1975 and 2008, 330?patients with a giant cell tumour were treated primarily by intralesional curettage, with 84 (25%) receiving adjuvant bone cement in the cavity. The local recurrence rate for curettage alone was 29.7% (73 of 246) compared with 14.3% (12 of 84) for curettage and cementation (p = 0.001). On multivariate analysis both the stage of disease and use of cement were independent significant factors associated with local recurrence. The use of cement was associated with a higher risk of the subsequent need for joint replacement. In patients without local recurrence, 18.1% (13 of 72) of those with cement needed a subsequent joint replacement compared to 2.3% (4 of 173) of those without cement (p?=?0.001). In patients who developed local recurrence, 75.0% (9 of 12) of those with previous cementation required a joint replacement, compared with 45.2% (33 of 73) of those without cement (p = 0.044).     

Does anaesthetic technique affect the outcome after transurethral resection of the prostate?

OBJECTIVE: To determine if the choice of anaesthetic (spinal or general) has any influence on outcomes after transurethral resection of the prostate (TURP). PATIENTS AND METHODS: The records of 261 patients undergoing TURP between October 1995 and July 1998 were selected for a matched-cohort study. There were 87 complete datasets for cases performed under general anaesthesia and each was matched to two patients (174) from those undergoing spinal anaesthesia. The cohorts were matched by age, physical status score and date of operation. The primary outcome measures were length of stay in the recovery room and satisfaction with postoperative analgesia. RESULTS: There were no significant differences in major outcomes. There was a higher incidence of some minor adverse events in the group having general anaesthesia. Back pain was more common after spinal anaesthesia. CONCLUSION: Spinal anaesthesia was not associated with an improved outcome after TURP. The choice of anaesthesia should be made by the patient, surgeon and anaesthetist on the basis of the known risks of particular adverse events.     

Does the anchorage form and depth influence the pull-out strength of screws from bone cement?

The pull-out strengths of cortical screws inserted into soft, unpolymerised Refobacin Palacos bone cement (procedure S) and into hardened polymerised cement into which a hole had been drilled and tapped (procedure P) were compared. Cortical screws 58 mm in length, outer diameter 4.5 mm and inner diameter 2.95 mm were used. Screws were inserted into cement cylinders at 5 mm incremental depths between 10 and 30 mm. At a screw depth of less than 25 mm, the screws pulled out, and at a depth of greater than 25 mm, the screws broke in both procedures. There was no statistically significant difference in pull-out strength leading to burst or break between the two procedures for screws inserted to comparable depths, but there was a statistically significant difference regarding the screwing depth regardless of the procedure of screw insertion chosen. The average material stability () of the cortical screws used was calculated to be 1191 N/mm², and the elasticity limit was 5137 N. This study demonstrated that the material stability and not the depth of screw insertion was the limiting parameter in screw anchorage in bone cement while static testing. To avoid screw breakage due to fatigue during continuous alternate loading, the screws should not be loaded above this value.     

Does cyclical loading affect the elution of antibiotics from articulating cement knee spacers?

Two-stage revision surgery for infected total knee replacement offers the highest rate of success for the elimination of infection. The use of articulating antibiotic-laden cement spacers during the first stage to eradicate infection also allows protection of the soft tissues against excessive scarring and stiffness. We have investigated the effect of cyclical loading of cement spacers on the elution of antibiotics. Femoral and tibial spacers containing vancomycin at a constant concentration and tobramycin of varying concentrations were studied in vitro. The specimens were immersed and loaded cyclically to 250 N, with a flexion excursion of 45°, for 35 000 cycles. The buffered solution was sampled at set intervals and the antibiotic concentration was established so that the elution could be calculated. Unloaded samples were used as a control group for statistical comparison. The elution of tobramycin increased proportionately with its concentration in cement and was significantly higher at all sampling times from five minutes to 1680 minutes in loaded components compared with the control group (p = 0.021 and p = 0.003, respectively). A similar trend was observed with elution of vancomycin, but this failed to reach statistical significance at five, 1320 and 1560 minutes (p = 0.0508, p = 0.067 and p = 0.347, respectively). However, cyclically loaded and control components showed an increased elution of vancomycin with increasing tobramycin concentration in the specimens, despite all components having the same vancomycin concentration. The concentration of tobramycin influences both tobramycin and vancomycin elution from bone cement. Cyclical loading of the cement spacers enhanced the elution of vancomycin and tobramycin.