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Purpose: Chronic steroid use has been found to be significantly associated with postoperative complications following total joint arthroplasty. The purpose of this study was to investigate the relationship between chronic steroid and immunosuppressant use and postoperative complications following carpometacarpal (CMC) arthroplasty., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all records of patients who underwent carpometacarpal (CMC) arthroplasty between 2015 and 2020. The initial pool of records was divided into two cohorts: chronic steroid and no chronic steroid use. Patient demographics and comorbidities were compared between cohorts using bivariate logistic regression., Results: A total of 6624 records of CMC arthroplasty were identified in NSQIP from 2015 to 2020. Of the 6432 records remaining after exclusion criteria, 223 (3.5%) were chronic steroid use and 6209 (96.5%) were without chronic steroid use. The patient demographics and comorbidities significantly associated with chronic steroid use were ASA classification ≥ 3 (p < 0.001), insulin-dependent diabetes mellitus (p = 0.032), and COPD (p < 0.001). Compared to no chronic steroid use, chronic steroid use had higher rates of any complication (2.24% vs. 2.01%), superficial incisional SSI (1.35% vs. 0.63%), urinary tract infection (0.45% vs. 0.31%), sepsis (0.45% vs. 0.05%), and mortality (0.45% vs. 0.05%). However, these differences in complication rates were not statistically significant., Conclusion: Chronic preoperative steroid use was not significantly associated with any increased postoperative complication within 30 days following CMC arthroplasty., Level of Evidence: Level III; Retrospective Cohort Comparison; Prognosis Study., Competing Interests: Declarations. Conflict of interest: The authors have no relevant financial or non-financial interests to disclose., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: A recent database study found that 15.2% of clavicle fractures underwent surgical treatment. Recent evidence accentuates the role of smoking in predicting nonunion. The purpose of this study was to further elucidate the effect of smoking on the 30-day postoperative outcomes after surgical treatment of clavicle fractures., Methods: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent open reduction and internal fixation of clavicle fracture between 2015 and 2020. Multivariate logistic regression, adjusted for notable patient demographics and comorbidities, was used to identify associations between current smoking status and postoperative complications., Results: In total, 6,132 patients were included in this study of whom 1,510 (24.6%) were current smokers and 4,622 (75.4%) were nonsmokers. Multivariate analysis found current smoking status to be significantly associated with higher rates of deep incisional surgical-site infection (OR, 7.87; 95% CI, 1.51 to 41.09; P = 0.014), revision surgery (OR, 2.74; 95% CI, 1.67 to 4.49; P < 0.001), and readmission (OR, 3.29; 95% CI, 1.84 to 5.89; P < 0.001)., Conclusion: Current smoking status is markedly associated with higher rates of deep incisional surgical-site infection, revision surgery, and readmission within 30 days after open reduction and internal fixation of clavicle fracture., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Introduction: Asymmetry in pedicle anatomy is most distinctly noted around the apex of the curve. The correlation of pedicle dysmorphia with apical vertebral rotation (AVR) and coronal Cobb angle (CCA) has not been studied., Objective: To establish whether pedicle dysmorphism is linked to curve magnitude CCA and the AVR in adolescent idiopathic scoliosis (AIS)., Methodology: Preoperative plain whole spine standing radiographs and non-contrast computed tomography (CT) scans of 25 AIS patients that were operated at a single centre from 2013 to 2019 were retrospectively reviewed by 3 independent co-investigators. CCA was noted on the standing radiograph, whereas the AVR was measured on the axial cuts of CT scan. Pedicle morphometric measurements were performed for apical and periapical pedicles. These included apical vertebra (when present), 2 vertebrae above (U1 and U2) and below (B1 and B2) the apex vertebra/disc. The pedicle morphometric measurements were performed on CT scans. We assessed the transverse pedicle diameter, transverse cancellous channel diameter, sagittal pedicle diameter, pedicle length and pedicle axis length. Correlation tests between various pedicle morphometric measurements, AVR and the curve magnitude (Cobb angle) was performed by the Pearson correlation test., Results: The apex of the major curve was in the thoracic spine in 20 patients, thoracolumbar in three patients and in the lumbar spine in two patients. The mean Cobb angle was 61.5 ± 9.3° and the mean AVR was 28.4 ± 17.8°. A positive correlation was noted with the AVR for U1 concave pedicle length (r = 0.45, p = 0.03), pedicle axis length of the U2 concave pedicle (r = 0.6, p = 0.04), transverse pedicle diameter of the convex apical vertebrae (r = 0.82, p = 0.00009) and the convex apical transverse pedicle diameter (r = 0.80, p = 0.002). A negative correlation with the AVR was noted for U2 convex pedicle length (r = - 0.51, p = 0009), transverse cancellous channel diameter of the U2 concave pedicle (r = - 0.42, p = 0.04) and apical concave pedicle (r = - 0.78, p = 0.002) and the sagittal pedicle diameter for the convex pedicle of U2 (r = - 0.45, p = 0.03) and apex(r = - 0.59, p = 0.04). The Cobb angle did not show a significant correlation with any of the pedicle measurements at any of the levels on the convex and the concave sides., Conclusion: Pedicle asymmetry and dysmorphism demonstrate a morphometric association with the apical vertebral rotation than the curve magnitude. The pedicle length and the pedicle axis length increase on the concave apical and periapical region with increase in AVR. The transverse cancellous channel diameter significantly decreases on the concave apical region with the increase in AVR. The sagittal pedicle diameter decreases on the convex side with the increase in AVR., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Objectives: Recreational swimming/diving is among the most common physical activities in US children and a significant cause of morbidity across the United States. This study updates the national epidemiology of diving-related injuries., Methods: The Consumer Product Safety Commission's National Electronic Injury Surveillance System database was queried for patients aged 0 to 19 from 2008 to 2020 who presented to any of the 100 National Electronic Injury Surveillance System-participating emergency departments for a diving-related injury. Dive characteristics such as dive height, dive skill, dive direction, and dive sequence were determined from case narratives., Results: A total of 1202 cases were identified for analysis corresponding to a total national estimate of 37,387 diving related injuries during the period from 2008 to 2020 and a national incidence of 3.6 injuries per 100,000 population. Males accounted for 64% of injuries. The average yearly incidences of injury in the 10 to 14 and 15 to 19 age groups were identical at 5.8 per 100,000. Contact with the diving board or platform was the most common cause of injury (34%). Diving backwards or attempting a flip or handstand dive were associated with increased odds of sustaining an injury resulting from contact with the diving board or platform (odds ratio, 16.0 and 6.9, respectively). In 2020, the incidence of diving-related injury fell to 1.6 per 100,000 population., Conclusions: Diving injuries are common in children and adolescents, especially in boys aged 10 to 19. There was a significant reduction in diving-related injury corresponding with the COVID-19 pandemic., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.

Background: The diagnosis of spinal tuberculosis often relies on clinical, radiological, and laboratory findings, particularly in resource-constrained settings. However, numerous noninfectious conditions exhibit similar clinical and radiological features to spinal tuberculosis, leading to potential misdiagnosis in the absence of microbiological or histopathological confirmation. This study aims to present a case series from a developing country, highlighting noninfectious conditions that mimic spinal tuberculosis., Methods: A retrospective analysis was conducted on hospital records and imaging of patients diagnosed with spinal tuberculosis, lacking microbiological or histopathological evidence, and unresponsive to empirical antitubercular treatment. Patients displaying noninfectious conditions resembling spinal tuberculosis upon further investigation were included. Clinical and radiological findings of these patients were thoroughly analyzed., Results: Among a total of 23 patients observed over a 6-year period (2015-2020), various noninfectious conditions were identified as mimickers of spinal tuberculosis. These conditions included vertebral body haemangioma, ankylosing spondylitis (with or without Andersson lesion), rheumatoid pannus, osteoid osteoma, cystic hygroma, multiple myeloma, vertebral metastasis, malignant small round-cell tumor, pancreatic pseudocyst, esophageal duplication cyst, Modic changes in degenerative disc disease, Paget's disease, and psoas hematoma., Conclusion: Noninfectious spinal conditions can masquerade as spinal tuberculosis, underscoring the importance of obtaining a definitive tissue diagnosis before initiating antitubercular treatment. Particular attention should be given to features such as central lesions and the absence of soft tissue involvement in suspected cases of spinal tuberculosis, warranting a careful reconsideration of the diagnosis., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

With a population dividend of around 1.3 billion, India is the largest democracy in the world that encompasses "unity in diversity". The kaleidoscope of the socio-cultural fabric comprises the transgender population too, which has a historical context dating back millennia and also plays a vital role as described in Hindu scriptures. The Indian transgender person's community shows a variety of gender identities and sexual orientations, which is unlikely from the West, forming a culturally unique gender group. In India, transgender persons were recognised as the 'third gender' in 2014. The third gender population of India is marginalised to a great extent in every sector. Often, transgender persons have been the subjects of sociology, psychology, and health issues. There was a dearth of data regarding their major health problems including bone health, which has not been reported in India and elsewhere before this study. Through a prospective cross-sectional study design, we aimed to determine the current health status of transgender persons with a special emphasis on bone health. Descriptive statistics were used for data analysis. The preliminary results of the study show poor bone health in the transgender population of India. The majority of transgender persons have low bone mineral density (BMD) at a much young age, even before the achievement of their peak bone mass. The health status of the transgender population in India is poor overall. Transgender persons have many impediments to optimal healthcare that requires holistic care. This study presents the current health challenges of the transgender population with a special emphasis on their bone health status as 'AIIMS initiative'. This study also shows transgender persons human rights needs to be explicitly discussed. The stakeholders of social policies require an urgent attention to unfold the major concerns encompassing transgender persons., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

3D printing (3DP) has been brought to medical use since the early part of this century- but it has been widely researched on and publicized only in the last few years. Amongst patients with spinal disorders, 3DP has been utilized in various facets of patient care. These include pre-operative aspects - such as patient education, resident training, pre-operative planning and simulations, intra-operative assistance in the form of customized jigs for pedicle screw insertion, patient specific interbody cages and vertebral body substitutes in complex malignancies and spinal infections. It has also been utilized in deformity surgeries and has opened new avenues in minimally invasive spine care. Guidelines have now been drafted by various organizations including the FDA with a prime focus on quality control measures applicable to this new technology. There has been a recent surge in publications supporting the use of 3DP in spinal disorders, reporting an improvement in various aspects of patient care. As the technology spreads out its wings further, more innovations and applications are expected to unfold in the coming years. Considering the rapid advances that 3DP has made, having a basic understanding of this technology is imperative for all spine surgeons. Despite promising preliminary results, there still exist a few pitfalls of the technology which have hindered the universal application of 3DP. Most importantly, there is a dearth of data related to long term outcomes supporting its clinical use. The prohibitive cost of 3D models, the specialized manpower it necessitates and the need for specific instrumentation are major deterrents to widespread use of this technology, particularly in small-scale healthcare setups. With further advancements in technology, the goal must be to make it more accurate and affordable to hospitals and patients so that the benefits of the technology can reach a wider patient population., (© 2022 Delhi Orthopedic Association. All rights reserved.)

Historically, osteoarticular tuberculosis (TB), including spinal TB, was treated with prolonged course of antitubercular therapy (ATT). Due to various challenges, there has been reluctance to explore the use of short-course ATT in spinal TB. However, with the success of short-course ATT being demonstrated in other forms of extrapulmonary TB, the subject is open for debate again. Therefore, we systematically reviewed various published literature to determine whether short-course treatment regimen (6 months) of ATT provides equivalent results in terms of disease healing as long-course treatment regimen (≥9 months) in the management of spinal TB. Five electronic databases (PubMed, MEDLINE, EMBASE, CENTRAL, and Web of Science) and their reference lists were searched to identify relevant randomized controlled trials with at least 1 year of follow-up that compared short-course with standard-course ATT for treatment of spinal TB. The methodological quality of included studies was assessed, and their data were extracted. A meta-analysis was used to calculate pooled effect sizes and 95% confidence interval (CI). The outcome measure was healed status of the disease at the final follow-up. Of 331 publications identified through literature search, eight publications describing six randomized studies were included. Moreover, 375 of 414 patients (90.58%) who received 6 months of ATT had healed status at their final follow-up compared to 404 of 463 patients (87.26%) who received ≥9 months of ATT. Overall, the healed status of spinal TB was equivalent in patients in both groups (pooled relative risk, 0.98; 95% CI, 0.92-1.04; p =0.439). However, there was considerable heterogeneity among the trials (I2=40.8%, p =0.149). The results suggest that the use of short-course (6 months) chemotherapy may be considered for the treatment of spinal TB in view of the similarity in the healing response achieved compared to treatment regimens of longer duration.

Purpose: To report the histopathological, electron microscopic, and immunohistochemical findings of tissue samples obtained from patients with radial longitudinal deficiency (RLD) and investigate the contribution of abnormality in soft tissues as a secondary driver of deformity in RLD., Methods: Specimens from radial-sided muscles and tendons were obtained at the time of surgery (either radialization or centralization) from 14 patients with 16 limbs affected with Bayne type 3 and type 4 RLD. The specimens were evaluated using light microscopy, electron microscopy, and immunohistochemical examination., Results: Among the 16 frozen muscle specimens, 6 (37%) showed normal muscle, while 10 (63%) showed the presence of atrophic fibers. The 6 cases with normal muscle showed no abnormality in fiber type distribution. Six patients showed predominance of type 1 muscle fibers. None of the specimens had myofibroblasts; 4 of 16 specimens had mast cells, and 9 of 16 specimens showed the presence of platelet derived growth factor-positive cells. Features of myofibroblasts (the presence of basal lamina, intercellular junctions, or pinocytic vesicles) were not identified in any specimen on electron microscopy., Conclusions: The histopathological, electron microscopic, and immunohistochemical findings, in particular the absence of myofibroblasts, in tissue samples obtained from patients with RLD, do not support the assumption of abnormality in soft tissues as a secondary driver of deformity in RLD., Clinical Relevance: This study provides a preliminary insight into a possible role of soft tissues in the development of the deformity in RLD., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK)., Methods: The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24 months., Results: Patients in Group CK (median: 13 years, range: 4-30 years) presented earlier than those in Group PTK (median: 16 years, range: 6-45 years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5 min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2 ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24 months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group., Conclusion: Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Accurate prediction of operative duration is necessary for efficient operating room scheduling, minimizing cancellations, shortening waitlists, better risk stratification, and effective preoperative counseling. Prolonged operative duration is also associated with negative patient outcomes. Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is typically a lengthy surgical procedure with variable operative duration. The purpose of this study is to identify patient-, procedure-, and surgeon-specific variables that influence the operative duration in PSF for AIS and determine its impact on early postoperative outcomes., Methods: Hospital records of 150 AIS patients who underwent PSF at a single center were retrospectively reviewed. Various patient-, procedure-, and surgeon-specific variables-deemed to be possibly affecting the operative duration-were analyzed. A multivariate regression model was used to identify independent predictors of operative duration. The association between operative duration and early postoperative outcome measures was determined., Results: The final model obtained from the multivariate regression analysis included the following factors: experience of the chief surgeon (β = -0.36), Cobb angle of the major structural curve (β = 0.35), number of screws inserted (β = 0.28), coronal deformity angular ratio (β = 0.20), and apical vertebral rotation (β = -0.21 to 0.03). The model could explain 44% of the variability in the operative duration ( R 2 = 0.44). The operative duration had a significant correlation with estimated blood loss, need for perioperative blood transfusion, and length of hospital stay., Conclusions: A set of variables that predict the variability in operative duration during PSF for AIS was identified, with the experience of the chief surgeon and the severity of the curve being the strongest predictors., Clinical Relevance: The results of this study emphasize the need for each hospital and surgical team to identify predictors of operative duration in their setup in order to better anticipate prolonged operative duration., Competing Interests: Declaration of Conflicting Interests: The authors report no conflicts of interest related to this work., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2022 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. There is no funding source for this publication/study.

»: An insight into musculoskeletal disorders through advancements in next-generation sequencing (NGS) promises to maximize benefits and improve outcomes through improved genetic diagnosis., »: The primary use of whole exome sequencing (WES) for musculoskeletal disorders is to identify functionally relevant variants., »: The current evidence has shown the superiority of NGS over conventional genotyping for identifying novel and rare genetic variants in patients with musculoskeletal disorders, due to its high throughput and low cost., »: Genes identified in patients with scoliosis, osteoporosis, osteoarthritis, and osteogenesis imperfecta using NGS technologies are listed for further reference., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A827)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Retrospective cohort., Purpose: To report the demographic characteristics, clinico-radiological presentation, laboratory findings, and outcomes of "middlepath" treatment in patients with spinal tuberculosis from a single public healthcare facility in a developing country., Overview of Literature: Tuberculosis is a global health problem that is endemic in developing countries and undergoing resurgence in developed ones. Spinal tuberculosis can cause disabling back pain, progressive deformity, and neurological involvement. However, there is a lack of large-scale epidemiological studies quantifying the size and severity of the problem of spinal tuberculosis., Methods: Hospital records of spinal tuberculosis patients treated at a single center over a period of 5 years were retrospectively reviewed. A diagnosis of spinal tuberculosis was based on standard clinical, radiological, microbiological, and histopathological evidence. Patients were treated in accordance with the "middle-path" regimen; surgery was reserved for selective indications., Results: A total of 1,652 patients were included. Their median age was 32.4 years, with 53% being male. Axial pain (98%) was the most common presenting symptom; 19% of patients had neurological deficit. Lumbar spine (37%) was the most common site of involvement, with a paradiscal pattern (82%) of involvement predominating. Multi-level involvement was seen in 19% of patients; skip lesions were noted in 2.8%. Transpedicular biopsy was performed in 667 patients; at least one tissue test was diagnostic of tuberculosis in 65% of patients. Forty-four patients had drug resistance to rifampicin. Surgery was required in 10.5% of patients. The "middle-path" regimen was associated with high compliance and significant improvements in pain (Visual Analog Scale score) and function (36-Item Short Form Health Survey)., Conclusions: Our findings confirm the widespread prevalence of spinal tuberculosis and describe various epidemiological characteristics of a large sample of spinal tuberculosis patients. Adoption of the "middle-path" regimen is associated with high compliance and favorable outcomes in spinal tuberculosis.

Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The purpose of this study was to investigate whether an elbow arthrogram after closed reduction and percutaneous fixation of lateral condyle fractures results in a change in surgical management. This is a retrospective review of lateral condyle fractures managed with closed reduction and percutaneous fixation followed by an elbow arthrogram at our institution between 2008 and 2019. Chart and radiographic review was performed and operative notes were reviewed to determine rates of subsequent intervention after arthrogram. Descriptive statistics were used to summarize the data. This study included 47 patients. The majority of patients were male (34 patients, 72%), and the mean age at time of injury was 5.5 ± 2.6 years. The mean radiographic displacement was 2.6 mm (range 0.8-6.9 mm). All fractures were managed by fellowship-trained pediatric orthopaedic surgeons with an average of 10.5 years of experience (range 0-32 years). Fractures were stabilized with percutaneous pins in 44 patients (94%) and percutaneous screws in three patients (6%). No patients had subsequent changes in management after an elbow arthrogram. There were no complications related to performance of the arthrogram. Closed reduction and percutaneous fixation is often indicated for mildly displaced lateral condyle fractures. Articular reduction after percutaneous fixation is commonly assessed using an elbow arthrogram; however, it did not change surgical management in any case reviewed over the 10-year study period. While there seems to be little risk of performing an arthrogram, the clinical utility should be further evaluated., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB., Methods: A total of 284 patients with clinically and radiologically suspected infectious spondylodiscitis were prospectively recruited into the study. Image-guided biopsy of the vertebral lesion was performed and specimens were sent for various microbiological tests and histological examinations. The final diagnosis was determined using a composite reference standard based on clinical, radiological, serological, microbiological, and histological findings. The overall diagnostic yield of the biopsy, and that for each test, was calculated in light of the final diagnosis., Results: The final diagnosis was tuberculous spondylodiscitis in 250 patients (88%) and pyogenic spondylodiscitis in 22 (7.8%). Six (2.1%) had a noninfectious condition-mimicking infectious spondylodiscitis, and six (2.1%) had no definite diagnosis and improved without specific treatment. The diagnosis was made by image-guided biopsy in 152 patients (56%) with infectious spondylodiscitis. Biopsy was contributory in identifying 132/250 patients (53%) with tuberculous spondylodiscitis, and 20/22 patients (91%) with pyogenic spondylodiscitis. Histological examination was the most sensitive diagnostic modality, followed by Xpert MTB/RIF assay., Conclusion: Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. A combination of histological examination, Xpert MTB/RIF assay, bacterial culture, and sensitivity provides high diagnostic accuracy in a country in which TB is endemic. Cite this article: Bone Joint J  2022;104-B(1):120-126.

Background Low back pain (LBP) is a healthcare problem with high global prevalence, with non-operative management being the first line of treatment in the majority of patients. This literature review summarizes the current evidence for various modalities of non-operative treatment for LBP. Methods We did a literature search to elicit high-quality evidence for non-operative treatment modalities for LBP, including Cochrane Database reviews and systematic reviews or meta-analysis of randomized controlled trials. Only when these were not available for a particular treatment modality, other level 1 studies were included. The quality of evidence was categorized in accordance with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method-a globally adopted tool for grading the quality of evidence and making treatment recommendations. Results The treatment modalities that were reviewed included: general measures, medications/pharmacotherapy, exercises, electromagnetic therapies, alternative treatment modalities and interventional therapies. We found that high-quality evidence is lacking for most non-operative treatment modalities for LBP. The majority of interventions have small benefits or are similar to placebo. Conclusion The current evidence for non-operative treatment modalities for LBP is insufficient to draw conclusions or make recommendations to clinicians. High-quality trials are required before widespread use of any treatment modality. Considering that non-operative treatment is usually the first line of therapy for most patients with LBP, it deserves to be the focus of future research in spinal disorders.

Background: The expression pattern of micro-RNAs (miRNA) has been implicated in the pathomechanism of various bone disorders, and has a role in differentiation of osteoblasts and osteoclasts. The purpose of the study was to investigate the differential miRNA profiles of osteoporotic hip fractures compared to young patients with hip fractures., Methods: Blood samples from ten osteoporosis patients and ten young, healthy patients, presenting with acute hip fractures were collected and subjected to an initial miRNA profiling to detect those miRNAs with significant variations between the two groups based on polymerase chain reactions performed in duplicate. A real-time quantitative polymerase chain reaction-based analysis was then performed for validation of specific miRNAs that were significantly different between the two groups., Results: A total of 182 miRNAs were analyzed. Thirty-nine of them showed significant differences between the two groups in the initial miRNA profiling. The validation results suggested that five miRNAs related to bone metabolism had significantly different expression among the osteoporotic hip fracture group compared to the young, healthy group: miR-23b-3p and miR-140-3p were up-regulated; miR-21-5p, miR-122-5p and miR-125b-5p were down-regulated., Conclusions: Differential expression of selected miRNAs in patients with osteoporotic hip fracture suggests a possible role of miRNAs as potential biomarkers in prevention or timely prediction of osteoporotic fractures in the elderly. Further research is required to elucidate the mechanism of their involvement in osteoporosis., Level of Evidence: Not applicable., Competing Interests: Conflict of interestDr. Bhavuk Garg has received funding from AOTrauma Asia Pacific Research Grant 2017 (AOTAP 17-27). Dr Samarth Mittal, Dr Rajesh Malhotra, Dr. Arvind Kumar, Dr Nishank Mehta, Dr Garima Malik, Dr Manish Gupta and Dr Vivek Trikha declare that they have no conflict of interest., (© Indian Orthopaedics Association 2021.)

Purpose: To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery., Methods: Pre-operative and 2-year postoperative radiographs of 82 Lenke 1 AIS patients recruited from five hospitals were analysed. Selected radiographic parameters capturing regional and global sagittal alignment were measured. Comparison was made between groups based on baseline thoracic kyphosis (TK: TK < 20°, TK ≥ 20°). Pre-operative and postoperative values were compared-the change in each radiographic parameter was correlated with the degree of sagittal and coronal correction., Results: At baseline, TK was 29.8° ± 16°, cervical lordosis (CL) was - 1° ± 14°, lumbar lordosis (LL) was - 57.1° ± 21°, C2-C7 sagittal vertical axis (SVA) was 16 ± 14 mm and C7-S1 SVA was - 15 ± 28 mm; 44% of patients had cervical kyphosis. Patients with thoracic hypokyphosis had a significantly lower LL and more kyphotic cervical spine compared to those with thoracic normohyperkyphosis. The effect of surgery on TK depended on pre-operative thoracic sagittal alignment-TK increased in patients with thoracic hypokyphosis, but decreased in patients with thoracic normohyperkyphosis. Neither CL nor C2-C7 SVA changed significantly with surgery; 46% of patients still had cervical kyphosis postoperatively., Conclusion: There is a high incidence of cervical kyphosis at baseline in AIS patients-more so in those with pre-operative thoracic hypokyphosis. Unlike TK, CL is not significantly altered with surgery-improvement in CL correlates weakly with sagittal correction of the structural curve., (© 2021. Scoliosis Research Society.)

Purpose: To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy., Methods: The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded., Results: The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient., Conclusion: Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction., (© 2021. Scoliosis Research Society.)

Aims: To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach., Methods: Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded., Results: The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient., Conclusion: Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J  2021;103-B(7):1309-1316.

Study Design: Retrospective, comparative., Objective: The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care., Summary of Background Data: Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes., Methods: Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals., Results: A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months)., Conclusion: Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

»: Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints., »: ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia., »: The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A699)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Retrospective cohort., Objective: ( a ) To compare the recommendations of Lenke and Peking Union Medical College (PUMC) classifications in choosing distal fusion levels in Lenke 1 adolescent idiopathic scoliosis (AIS) curves and ( b ) to analyze whether the variability in distal fusion levels influences treatment outcomes., Methods: Hospital records of Lenke 1 AIS patients operated for single stage, posterior-only deformity correction were analyzed. Distal fusion levels recommended by Lenke and PUMC classifications were calculated and were compared with the actual distal fusion levels. The study population was divided based on whether the actual distal fusion levels were in agreement, shorter or longer than those recommended by Lenke classification. Subgroup analysis of Lenke 1C curves was done. The groups were compared with regard to the following outcome measures: Cobb angle correction, postoperative sagittal vertical axis, postoperative C7 offset, and Scoliosis Research Society-22r (SRS-22r) score at 24 months., Results: The distal fusion levels recommended by the 2 classifications were in agreement in 92 of 104 cases. In all the cases with disparity, Lenke classification recommended shorter fusions than the PUMC classification. No statistically significant difference was observed in the outcome measures-whether the actual distal fusion levels were in agreement, shorter, or longer than those recommended by the Lenke classification or whether or not the recommendations for selective fusion of any of these classifications were adhered to., Conclusion: Lenke classification can save fusion levels without compromising on treatment outcomes when compared with PUMC classification. Variability in choice of distal fusion levels is not clinically significant at 24-month follow-up.

Background: Abnormal anatomy is a contributory factor to wrong-level surgery. Variations in the number of vertebrae in populations from different races and geographical regions have been described. A ∼10% prevalence of variations in number of thoracic and lumbar vertebrae in adolescent idiopathic scoliosis (AIS) patients has been previously reported. The objectives of present study were (i) to find out the prevalence of variations in the number of thoracic and lumbar vertebrae and the presence of lumbosacral transitional vertebrae (LSTV) in Indian AIS patients and (ii) to correlate these variations with gender and type of curve., Methods: Hospital records and imaging of 198 AIS patients were reviewed retrospectively. A standardized numbering strategy was used to identify the number of thoracic vertebrae, number of lumbar vertebrae, and presence of LSTV. Patients' gender and curve type were correlated with the presence of an abnormal number of thoracic or lumbar vertebrae. Radiology reports and operation notes were reviewed to find out instances when the radiologist or surgeon had identified an abnormal number of vertebrae., Results: Forty patients (20.2%) with abnormally numbered thoracic or lumbar vertebrae were identified. Twenty patients (10.1%) had abnormally numbered thoracic vertebrae, and 33 patients (16.7%) had abnormally numbered lumbar vertebrae. The prevalence of LSTV was 18.2%. Presence of variations did not correlate with gender or curve type. Radiology reports identified 2/40 patients with variations, whereas operation notes showed 4/40 patients had been correctly identified to have abnormally numbered vertebrae., Conclusions: There is high prevalence of variation in the number of thoracic or lumbar vertebrae in AIS patients, with most of those missed being identified by radiologists or surgeons. The patient's preoperative imaging must be scrutinized to identify these patients and take the variation into account to avoid wrong selection of fusion levels., Level of Evidence: 3., Clinical Relevance: Text. The study raises awareness about possibility of wrong selection in fusion levels due to anatomical variations in surgery for AIS., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2021 ISASS.)

Study Design: Prospective comparative study., Objective: The aim of this study was to compare the spatiotemporal, kinematic, kinetic and electromyographic (EMG) gait variables in patients with adolescent idiopathic scoliosis (AIS) and congenital scoliosis and to compare these gait variables of scoliosis patients with healthy controls., Summary of Background Data: Earlier studies have solely focussed on the possibility of altered gait patterns in AIS patients; not much light has been shed on the differences in gait patterns in congenital and adolescent scoliosis patients., Methods: Forty scoliosis patients (20 each with AIS and congenital scoliosis) and 20 healthy volunteers were prospectively recruited. After thorough clinical and radiological examination, all patients underwent gait analysis in accordance with standard protocols.The outcome measures included spatiotemporal, kinetic, kinematic and EMG activity. Composite indices for gait analysis-Gait Profile Score (GPS) and Gait Deviation Index (GDI)-were also calculated. Relevant statistical tests were applied to compare the different groups., Results: No significant difference was found between the AIS and congenital scoliosis groups with respect to baseline demographic and radiological parameters. The two subgroups of scoliosis patients (AIS and congenital) did not differ significantly with respect to any of the measured gait analysis parameters. However, when compared to the healthy age-matched control group, the scoliosis patients differed significantly with respect to gait speed, stride length, step length, GDI, GPS and peak EMG activation for erector spinae, biceps femoris, semimembranosus, rectus femoris, gastrocnemious, and tibialis anterior., Conclusion: Our findings confirm the previous findings of literature regarding the alteration in gait patterns in scoliosis patients when compared to normal individuals. However, the lack of difference in gait analysis variables between AIS and congenital scoliosis patients suggests that this alteration in gait is secondary to the existence of the deformity and does not correlate with the onset or etiology of deformity.Level of Evidence: 2., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

There are no established guidelines regarding the surgical strategy to be adopted in congenital scoliosis with multiple hemivertebrae-decision has to be guided taking into account the contribution of each hemivertebra to the deformity and its growth potential. We describe a case of a 12-year-old woman with congenital scoliosis due to unbalanced multiple hemivertebrae. Preoperative imaging revealed the presence of three hemivertebrae-at D7, D10 and L5. Our surgical strategy was guided by various factors-the morphology of the hemivertebrae, the location, the contribution of each hemivertebra to the deformity and their relationship to each other. Based on this, we performed a selective hemivertebrae resection-completely resecting L5 hemivertebra and performing 'egg-shell' decancellation of D7 hemivertebra and in situ fusion of D10 hemivertebra, yielding satisfactory results. This case report illustrates a rational thought process that can guide a paediatric spinal deformity surgeon in treating scoliosis with multiple hemivertebrae., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern 'separation' surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors., Methods: A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed., Discussion: Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment., Conclusion: The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2021.)

Purpose: AIS patients consider shoulder balance an important cosmetic outcome after surgery. We examined the impact of preoperative left shoulder elevation (LSE) and choice of upper instrumented vertebra (UIV) on postoperative shoulder imbalance (PostSI)., Methods: This was a retrospective cohort study utilizing a prospective AIS database. Patients had Lenke type 1-4 curves and preoperative shoulder height ≥ 1.0 cm. Patients with preoperative LSE and right shoulder elevation (RSE) were compared. Shoulder height difference < 1 cm was considered 'mild', 1-2 cm was 'moderate', and ≥ 2.0 cm was 'severe'., Results: 407 patients had ≥ 1.0 cm imbalance preoperatively, with 88 (21.6%) LSE. There were no differences in gender (p = 0.855) or age (p = 0.477). Patients with LSE more frequently had Lenke type 2 curves (43.2% vs 16.3%, p < 0.001), while preoperative RSE averaged 1.9 ± 0.9 cm versus 1.6 ± 0.5 cm for LSE (p < 0.001). Those with LSE more often had severe PostSI at 2 years (30.7% vs 5.0%, p < 0.001), and only 26.1% of patients with severe preoperative LSE corrected to mild. In contrast, most patients with RSE had mild PostSI regardless of initial imbalance. When examining only LSE patients, there was no difference in preoperative SH by final UIV (p = 0.101). Further, UIV choice did not impact the proportion of severely unbalanced patients postoperatively (p = 0.446). A PTC > 34.5° was predictive of PostSI ≥ 2.0 cm for patients with preoperative LSE., Conclusion: AIS patients with preoperative LSE are less likely to achieve level shoulders postoperatively. Choice of higher UIV did not affect postoperative shoulder imbalance in this cohort. A PTC > 34.5° was predictive of severe PostSI in patients with preoperative LSE., Level of Evidence: II.

Background: The use of cervical pedicle screws (CPSs) in pediatric subaxial cervical spine has been scarcely reported in the literature. The biomechanical superiority of CPS over other methods of fixation is beneficial in surgery for correcting severe, rigid cervical/cervicothoracic deformity. Our study aims to assess the safety, efficacy, and feasibility of CPS fixation in pediatric subaxial cervical spine without intraoperative navigation., Methods: Eight pediatric patients requiring rigid subaxial cervical spine fixation for complex cervical deformities were operated at a single center between 2014 and 2016. Their hospital records and imaging were retrospectively studied. The feasibility of inserting CPS was assessed by studying pedicle morphometry on preoperative computed tomography (CT) scans. Aberrant vertebral artery anatomy was ruled out using CT angiography. CPS were inserted into selected pedicles without navigation. Postoperative CT scans were studied to look for screw containment within pedicles. Complications were noted and clinicoradiologic follow-up was for a minimum of 36 months., Results: Thirty-seven CPS were inserted in 8 pediatric patients with a mean age of 9.2 years (range: 5 to 13 y). Surgery was done for complex cervical deformities due to various causes-neglected cervical spine trauma (n=3), posttubercular kyphosis (n=2), cervicothoracic scoliosis (n=2), and cervicothoracic osteoblastoma (n=1). The level-wise distribution of the inserted CPS was: C3=4, C4=6, C5=10, C6=10, and C7=7. Postoperative CT scans showed grade-1 medial cortical breach in 5/37 screws and grade-2 medial cortical breach in a single screw (16%). No perioperative complications were noted. At a mean follow-up of 3.6 years (range: 3 to 4.33 y), no patient had implant failure or deformity progression., Conclusions: CPS insertion in pediatric subaxial cervical spine without neuronavigation is safe, feasible, and effective in carefully selected cases. Biomechanical advantages of CPS can be extended to the pediatric subaxial cervical spine., Level of Evidence: Level IV-retrospective cohort., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)