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Study Design Systematic review. Objectives Review the surgical techniques and construct options aimed at improving the biomechanical strength of cervical constructs. Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the MEDLINE, Embase, and Cochrane Library databases was performed to identify all studies examining biomechanical strategies utilized in the osteoporotic cervical spine. Screening was performed in duplicate for all stages of the review process. Results An initial search returned 3887 articles. After deletion of duplications and review of abstracts and full text, 39 articles met inclusion criteria. Overall, the surgical techniques reviewed aimed at obtaining rigid fixation in the setting of poor bone quality, or dispersing the forces at the bone-implant interface. We identified 6 key techniques to improve biomechanical fixation. These include bicortical fixation, appropriate screw selection (size and trajectory), PMMA augmentation, load sharing techniques, consideration of ancillary fixation around the occipitocervical junction, and supplementing the construct with post-operative collar or halo. Conclusion The summation of the literature highlights a framework of modalities available to surgeons to improve biomechanical fixation in the cervical spine. While these may improve construct strength in the setting of osteoporosis, there is a paucity of evidence available to make recommendations in this patient population.

Acromial and scapular spine fractures are common complications after reverse total shoulder arthroplasty (RTSA). There is limited information on the treatment outcome of these fractures. Therefore, the purpose of this study was to compare the clinical outcome of operative and conservative treatment of patients with acromial or scapular spine fractures.A total of 1146 RTSAs were performed in our institution between 1999 and 2016. In 23 patients (2%), we identified an acromial fracture, and in 7 cases (0.6%), a scapular spine fracture in the postoperative course. Of those patients, 7 patients (23%) were treated with open reduction and internal fixation and 23 (77%) were treated conservatively. We compared the outcome of operative vs. conservative treatment assessing the Constant score (CS), range of motion, and subjective shoulder value (SSV). Fractures were classified by the system of Crosby. Radiographic assessment consisted of measuring the healing rate, time to heal, and the displacement of the acromion before and immediately after the fracture as well as after treatment.There were no statistically significant differences between operative and conservative treatment. The mean preoperative CS in the operative group was 32 points and improved to 45 points after surgery, whereas it was 35 points in the conservative group and improved to 61 points at the final follow-up. The mean SSV improved from 20 to 50 points in the operative group and from 22 to 58 points in the conservative group. Mean active flexion changed from 59° to 75°, mean abduction from 68° to 67°, and external rotation from 25° to 13° in the operative group and from 75° to 91°, 67° to 92°, and 28° to 24° in the conservative group.In our study, operative treatment was not superior to conservative treatment, neither for CS, SSV, or range of motion. Both treatment forms, however, resulted in inferior results to those previously reported for RTSA without postoperative acromion fractures. Before better surgical methods have been developed, conservative treatment of acromial fractures may be the better treatment option for acromial fractures after RTSA.

The purpose was to study if (1) diurnal changes occur in the entire spine and if (2) intervertebral discs (IVDs) of weightlifters (WL) have decreased baseline T2-values in the morning as well as (3) increased diurnal changes throughout the day. This prospective cohort study investigated healthy volunteers between 2015 and 2017. WL were required to have participated in weightlifting ≥ 4×/week for ≥ 5 years, while non-weightlifters (NWL) were limited to

We report on outcomes of surgically versus (vs) non-surgically treated patients with moderate adolescent idiopathic scoliosis (AIS) after minimum of 29 years. AIS patients with a follow-up of ≥ 41 years in the surgical group and ≥ 29 years in the non-surgical group were included. Patients were treated surgically for primary curves ≥ 45° vs non-surgically for curves

Anterior knee pain (AKP) is common following total knee arthroplasty. The tibial tuberosity trochlear groove distance (TTTG) influences patellofemoral joint loading in the native knee. Increased TTTG may lead to maltracking of the patella and anterior knee pain. The purpose of this study was to investigate potential changes in TTTG following total knee arthroplasty (TKA).TTTG was measured on preoperative CT data on a consecutive series of patients scheduled to receive TKA with patient-specific instrumentation, and compared to a computer simulation of the postoperative TTTG. Preoperative TTTG was measured with a 3D planning software in 250 knees. The postoperative result was simulated and TTTG measured within the software. Three different groups were analysed: neutral (180° ± 3) (n = 50), valgus ( 190°) (n = 100), and varus ( 170°) (n = 100).Median preoperative to simulated postoperative TTTG decreased from 15.0 [interquartile range (IQR) 6.0] mm to 6.5 (IQR 5.0) mm for all axes combined. A significant postoperative reduction of TTTG was found in each group (p 0.001). The mean change in TTTG did not differ significantly between the groups [- 8.8 (IQR 5.5) mm neutral, - 8.3 (IQR 7.0) mm valgus, - 7.5 (IQR 5.8) mm varus, p = 0.223].This computer-based study suggests that mechanically aligned TKA significantly decreases TTTG distance in neutral, valgus and varus knees, assuming that the postoperative result coincides with the preoperative planning. Further study is warranted to evaluate the clinical relevance of this finding.

STUDY DESIGN Prospective cross-sectional blinded-assessor cohort study. OBJECTIVE The aim of this study was to determine the inter-rater reliability of the modified Japanese Orthopaedic Association (mJOA) score in a large cohort of degenerative cervical myelopathy (DCM) patients. SUMMARY OF BACKGROUND DATA The mJOA score is widely accepted as the primary outcome measure in DCM; it has been utilized in clinical practice guidelines and directly influences treatment recommendations, but its reliability has not been established. METHODS A refined version of the mJOA was administered to DCM patients by two or more blinded clinicians. Inter-rater reliability was measured using intraclass correlation coefficient (ICC), agreement, and mean difference for mJOA total score and subscores. Data were also analyzed with analysis of variance for differences by mJOA severity (mild: 15-17, moderate: 12-14, severe

Surgical site infection (SSI) may cause a substantial burden for patients and healthcare systems. A potential risk of different architectures of the operating room for SSI is yet unknown and was subject of this study. This observational cohort study was performed in a university hospital and evaluated patients, who underwent a broad spectrum of orthopedic surgeries in 2016 (open-plan operating room architecture) versus (vs) 2017 (closed-plan operating room architecture). Patients, who underwent surgery in the transition time period from the open-plan to the closed-plan operating room architecture and those, who were treated e.g. for osteomyelitis as index procedure were excluded. The primary outcome was revision surgery for early SSI within 30 (superficial) or 90 (deep or organ/space) days of surgery. Age, gender, American society of anesthesiologists (ASA) classification, and the body mass index (BMI) were considered as potential interacting factors in a logistic regression analysis. The incidence of revisions for SSI was 0.6 percent (%) (n = 45) in the 7'740 included surgical cases (mean age of 52 (standard deviation (SD) 19) years; n = 3'835 (50%) females). There was no difference in incidences of revision for SSI in the open- vs closed-plan operating room architecture (0.5% vs 0.7%; adjusted odds ratio (OR) = 1.34 (95% confidence interval (CI) 0.72–2.49, P = 0.35)). Age and gender were not a risk factor for revision for SSI. However, ASA classification and BMI were identified as risk factors for the incidence of revision for SSI (OR = 1.92 (95% CI 1.16- 3.18, P = 0.01) and OR = 1.05 (95% CI 1.00–1.11, P = 0.05)). The overall incidence of revisions for early SSI after a broad spectrum of orthopedic surgeries was relatively low (0.6%) and independent from the operating room architecture. An increase in ASA classification and possibly BMI, however, were identified as independent risk factors for revision for SSI.

The objective was to report radiological and clinical outcomes after reversed L-shaped osteotomy (ReveL) for hallux valgus (HV). A retrospective cohort study was performed between January 2004 and December 2013. The primary outcome was radiological recurrence of HV (HV angle [HVA] >15°). There were various exposure and secondary outcome variables. The results showed a median follow-up of 12.0 months (N = 827). Radiological recurrence, limited patient satisfaction, complication, revision surgery, and elective hardware removal were found in 25.0%, 15.3%, 4.6%, 2.5%, and 26.7%. Median pre- to postoperative changes were highest for HVA (delta = –16.7°). Recurrence was more likely in cases with preoperative HVA ≥40° (adjusted odds ratio [ORadjusted]) 3.63, p

Background Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN. Methods A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development. Results Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2–11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations. Conclusions With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking. Level of Evidence III, long-term retrospective cohort study

Background Anterior scoliosis correction is a powerful technique with the disadvantage of a kyphotic effect on lumbar and thoracolumbar curves. We aimed to investigate whether a cognizant interposition of a rib graft anteriorly and at the concave side of the scoliotic curve causes significant fulcrum effect to enforce scoliosis correction and to reduce interfusional kyphosis in anterior scoliosis corrections. Methods Twenty otherwise comparable patients with lumbar and thoracolumbar adolescent idiopathic scoliosis (AIS) curves undergoing anterior short scoliosis correction with (n = 10) or without (n = 10, matched for age, gender and degree of deformity) fulcrum effect were retrospectively compared by means of radiographic measurements (sagittal and coronal profile, Cobb angles and intersegmental deformity correction angles) to evaluate the effect of this modified surgical technique. Results The overall amount of scoliosis correction was similar with 74 and 60% of initial curves of 57° and 53° in the case and control group respectively with a mean of 3 fused segments (4 screws). Statistically relevant differences were found for intersegmental coronal cobb angles at the apex of 20° to 3° and 17° to 9° with and without fulcrum, respectively (p, BMC Musculoskeletal Disorders, 22 (1), ISSN:1471-2474

Purpose The purpose of this study was to outline an indirect sign of advanced Achilles tendinopathy on magnetic resonance imaging (MRI), based on the hypothesis that these patients would present with secondary hypertrophy of the flexor hallucis longus muscle (FHL). Methods MRI scans of Achilles tendon were analyzed retrospectively in two cohorts. The study group consisted of consecutive patients presenting with clinical signs of Achilles tendinopathy and no previous surgeries, while the control group were patients that had an MRI due to other reasons and no signs of tendinopathy. Two parameters from two muscle bellies were measured and compared on axial MRI scans 4–5 cm above the ankle joint line at the level of greatest thickness: area and diameter of the triceps surae (TS) and of the FHL muscle. Ratios (FHL/TS) were calculated for area (Ar) and diameter (Dm) measurements. Interobserver agreement was analyzed. A receiver operating characteristic (ROC) curve was created for both ratios to assess potential cutoff points to differentiate between the groups. Results A total of 60 patients for each study group were included. Both ratios Ar(FHL/TS) and Dm(FHL/TS) showed significant higher values in the tendinopathy group (p Conclusion In our patient cohort, FHL hypertrophy was observed in patients with Achilles tendinopathy as a possible compensatory mechanism. Measuring a diameter ratio Dm(FHL/TS) of 2.0 or higher on an axial MRI, may be indicative as an indirect sign of functional deterioration of the Achilles tendon.

Patients with adult spinal deformity suffer from disease related disability as measured by the Oswestry Disability Index (ODI) for which surgery can result in significant improvements.The purpose of this study was to show the change in overall and individual components of the ODI in patients aged 60 years or older following multi-level spinal deformity surgery.Prospective, multicenter, multi-continental, observational longitudinal cohort study PATIENT SAMPLE: Patients ≥60 years undergoing primary spinal fusion surgery of ≥5 levels for coronal, sagittal or combined deformity.Oswestry Disability Index (ODI) METHODS: : Patients completed the ODI pre-operatively for baseline, then at 10 weeks, 12 months and 24 months post-operatively. ODI scores were grouped into deciles, and change was calculated with numerical score and improvement or worsening was further categorized from baseline as substantial (≥20%), marginal (≥10-20%) or no change (within 10%).Two-hundred nineteen patients met inclusion criteria for the study. The median number of spinal levels fused was 9 [Q1=5.0, Q3=12.0]. Two-year mean (95% CI) ODI improvement was 19.3% (16.7%; 21.9%; p.001) for all age groups, with mean scores improved from a baseline of 46.3% (44.1%; 48.4%) to 41.1% (38.5%; 43.6%) at 10 weeks (p.001), 28.1% (25.6%; 30.6%) at 12 months (p.001), and 27.0% (24.4%; 29.5%) at 24 months (p.001). At 2 years, 45.5% of patients showed 20% or greater improvement in ODI, 23.7% improved between 10% and 20%, 26.3% reported no change (defined as±10% from baseline), 4.5% of patients reported a worsening between 10% to 20%, and none reported worsening greater than 20%. 59.0% of patients were severely disabled (ODI40%) pre-operatively, which decreased to 20.2% at 2 years. Significant improvement was observed across all 10 ODI items at 12 and 24 months. The largest improvements were seen in pain, walking, standing, sex life, social life and traveling.In this prospective, multicenter, multi-continental study of patients 60 years or older undergoing multi-level spinal deformity surgery, almost 70% of patients reported significant improvements in ODI without taking into account surgical indications, techniques or complications. Clear data is presented demonstrating the particular change from baseline for each decile of pre-operative ODI score, for each sub-score, and for each age group.

Purpose To report and analyse factors affecting the outcome of streptococcal periprosthetic joint infections (PJIs). Methods A retrospective analysis of consecutive streptococcal PJIs was performed. Musculoskeletal Infection Society 2013 criteria were used. Outcome was compared with a prospective PJI cohort from the same institution. Results The most common isolated streptococcal species was Streptococcus dysgalactiae (9/22, 41%) among 22 patients included. Surgical treatment consisted of DAIR (debridement, antibiotics, irrigation and retention) in 12 (55%), one-stage revision arthroplasty in one (4%), two-stage revision arthroplasty in eight (37%) and implant removal in one (4%) patient. An infection free-outcome was achieved in 15 cases (68%), whilst seven (32%) patients failed initial revision and relapsed with the same pathogen, from which six were treated with DAIR and one with one-stage revision arthroplasty. No failures were observed in patients who received a two-stage revision. Failure rates did not differ in the cases treated with rifampin (1/5) from those without 6/17 (p = 0.55). There was no correlation between the length of antibiotic treatment and relapse (p = 0.723). In all failures, a persistent distant infection focus was identified at the time of relapse. Compared with our prospective PJI cohort, relapse rates were significantly higher 32% vs 12% (p Conclusion No correlation with the use of rifampin or length of antibiotic treatment was found. No failures were observed in patients who received a two-stage revision, which may be the surgical treatment of choice. A distant persisting infection focus could be the reason for PJI relapse with recurrent hematogenous seeding in the joint.

Background context Spinal sarcomas are a rare, heterogeneous group of mesenchymal tumors. Current literature reporting demographic variables and survival information is limited to small case series, and a single registry with variable treatment modalities and time periods. Purpose We report on population-level data regarding all spinal sarcomas diagnosed over a 23-year period in Ontario, Canada, for the purposes of calculating incidence and prevalence of these tumors. Secondarily, survival is assessed by tumor type as well as adjuvant therapies during this time period. Study design Retrospective Cohort Study Patient sample Population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015. Outcome measures Outcome measures include incidence and prevalence of spinal osteosarcoma, Ewing's sarcoma, and chondrosarcoma of the spine, as well as 2-, 5-, 10- and 15-year survival and prevalence of adjuvant therapies. Methods Utilizing population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015, ICD codes were searched and available data extracted for the purposes of reporting basic demographic information and calculation of Kaplan Meyer survival curves. Databases include the Ontario Cancer Registry, Discharge Abstract Database, Ontario Health Insurance Plan, National Ambulatory Care Reporting System, Registered Persons DataBase (death) were analyzed. Results One hundred and seven spinal sarcomas were identified, with a mean incidence was 0.38 sarcomas per million population per year, that was stable over time. The mean prevalence was 8.1 sarcomas per million population. The most common diagnosis was Ewing's sarcoma (48 [44.9%] patients), followed by chondrosarcoma (33 [30.8%] patients), and osteosarcoma (26 [24.3%] patients). Chondrosarcoma had the highest survival rates with 77.2% and 64.2% 5- and 10-year survival rates, respectively, followed by Ewing's sarcoma with 48.1% and 44.9% 5 and 10-year survival and osteosarcoma with 36.0% and 30.9% 5- and 10-year survival. Conclusions Spinal sarcoma is a rare disease with variable survival depending on the histologic diagnosis. This population-level study involves a heterogeneous group of patients with variable stages of disease at presentation and variable treatments. Our data fit with the published literature for survival for those treated conservatively and surgically. Our data show considerable improvement in 5- and 10-year mortality when compared with previous population level studies on earlier patient cohorts, likely reflecting improvements in systemic and surgical treatments.

The mechanical conflict in symptomatic femoroacetabular impingement can lead to early osteoarthritis. However, radiographic impingement morphology is often seen in asymptomatic individuals. Long-term observation regarding the risk of developing osteoarthritis in these individuals is lacking. Our study addressed the following questions: Does femoroacetabular impingement morphology increase the risk for development of osteoarthritis after at least 25 years? If yes, which radiographic parameter is the most predictive? Does the level of activity influence the risk for development of osteoarthritis? Are PROM influenced by the grade of osteoarthritis in this population? We investigated 51 (32 male, 19 female) patients for whom AP pelvis and Dunn view radiographs were available with a minimum follow-up of 25 years. Alpha angle in AP pelvis and Dunn view radiographs, femoral torsion in Dunn view, lateral center edge angle, cross-over sign, posterior wall sign and prominence of ischial spine sign in AP pelvis radiographs were determined. On the follow-up radiographs, osteoarthritis was graded. Tegner Score for the time of the index radiograph was evaluated. Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index were assessed at latest follow-up. The mean follow-up was 43 years (range 25–58). Cam impingement morphology showed to increase the risk for development of osteoarthritis: Alpha angles of ≥ 55° on AP pelvis and Dunn view radiographs were associated risk factors and showed an OR of 1.05 (p = 0.002) and 1.10 (p = 0.001), respectively. Abnormal femoral torsion and acetabular retroversion were not risk factors for osteoarthritis. Tegner Score at index presentation, HHS and WOMAC Score did not correlate with the grade of osteoarthritis. This study showed that cam impingement morphology in young patients raises the risk for development of hip osteoarthritis by 5–10% in a long-term follow-up with a minimum of 25 years, thus its contribution was small.

The aim of this work is to evaluate the effectiveness of training with the low-fidelity ArthroBox® regarding performance of different basic arthroscopy tasks using a validated high-fidelity virtual reality simulator of the knee. Nineteen volunteers (14 females and 5 males) without any previous experience in arthroscopy were randomly assigned either to the ArthroBox® training group (n =10) or the non-training group (n =9). The training group underwent a supervised ArthroBox ® training consisting of a daily 60-min session for three consecutive days. Both groups completed the basic and the final assessment using a validated virtual reality-based passive haptic knee arthroscopy simulator (ArthroS, VirtaMed™). The following three factors were measured in different exercises (explained in “Materials and methods”): amount of time to finish the task, length of camera and scope path within the joint. Furthermore, the volunteers’ demographics (age, sex, dexterity, video game experience, sport activities and profession) was assessed but showed no differences between the groups. There were no significant differences between the training and non-training group regarding the above-mentioned demographic factors. However, the training group showed significant improvement from baseline to follow-up in most activities (e.g. task performance time in seconds, intra-articular camera and grasp distance in centimetres; see Table 1) in comparison to the non-training group. The results from this study demonstrate that training for three consecutive days using a portable and versatile low-fidelity simulator significantly improves arthroscopy performance when using a validated high-fidelity virtual knee simulator. Arthroscopic triangulation training outside the operating theatre with a portable, low-cost simulator has proven to be a valuable educational tool to improve the arthroscopic skills of trainee surgeons. Diagnostic study, Level II.

Background Leg length discrepancy (LLD) is common after total hip arthroplasty (THA) with a plethora of clinical consequences. The associations between symptomatic (sLLD; disturbing perception of anatomical leg length discrepancy), anatomical (aLLD; side difference in leg length between the center of rotation of the hip and the center of the ankle joint) and intraarticular (iLLD; side difference between the tear drop figure and the most prominent point of the trochanter minor) LLD and lower back have not yet been reported in the literature. We performed a retrospective study to answer if postoperative (1) symptomatic LLD, (2) anatomic LLD, and (3) a change in intraarticular leg length are associated with lower back pain in patients undergoing THA. Further, we aimed to answer (4) whether symptomatic LLD is associated with the magnitude of anatomical LLD and the change in intraarticular leg length. Hypothesis LLD after THA is associated with lower back pain. Materials and methods Seventy-nine consecutive patients were retrospectively analyzed for the presence of aLLD and iLLD using EOS™ and X-rays, and were interviewed for the presence of sLLD and lower back pain using a questionnaire 5 years after primary THA. Results Postoperative new onset of lower back pain was reported by 9 (11%) patients. Twenty (25%) patients reported sLLD. Anatomical LLD > 5 mm was present in 44 (56%) (median 8.0 (IQR −3.0 to 12.0; range −22 to 22) mm) and > 10 mm in 17 (22%) (median 12.0 (IQR 11.0 to 16.5; range −22 to 22) mm) patients. iLLD changed > 5 mm in 44 (56%) (median 8.5 (IQR 7.0 to 10.0; range −8 to 18) mm) and > 10 mm in 10 (13%) (median 14.0 (IQR 12.5 to 14.5; range 11 to 18) mm). New onset lower back pain was associated with sLLD (p = 0.002) but not with aLLD or iLLD. Patients without preoperative lower back pain had a statistically significant association between presence of sLLD and an aLLD of > 10 mm (p = 0.01). Conclusions Symptomatic LLD after primary THA is associated with postoperative new onset of lower back pain irrespective of the magnitude of LLD. In patients without lower back pain prior to THA, symptomatic LLD is associated with anatomical LLD of more than 10 mm. Level of evidence IV.

Background Portal placement is a key factor for the success of arthroscopic procedures, particularly in rotator cuff repair. We hypothesize that the acromial anatomy may strongly determine the position of the shoulder bony landmarks and limit the surgeon’s freedom to position the arthroscopic approaches in direction towards the acromion. The purpose of this study was to analyze the relation between different acromial shapes and the freedom of movement of arthroscopic instruments relative to the rotator cuff from standardized arthroscopic portals in a laboratory study on 3D shoulder models. Methods 3D models of shoulders with a broad range of different acromial shapes were printed using CT and MRI scans. Angles from the portals to defined points on the rotator cuff and the supraglenoid tubercle were measured. In conventional radiographs, the critical shoulder angle, the scapular body acromial angle, and the glenoid acromial angle were measured and compared with the measured angles to the rotator cuff. Results There was a large variation of angles of approach of instruments to the rotator cuff between the seven shoulders for each portal. From the joint line portal and the posterior edge portal, the biggest angles were measured to the posterior cuff. From the intermediate portal, the angles were largest to the intermediate rotator cuff and from the anterior portals to the anterior cuff. To the supraglenoid tubercle, best access was from anterior. For all portals, there was a big correlation between the glenoid acromial angle and the scapular body acromial angle with the angles of approach to the tendon and especially to the supraglenoid tubercle. Conclusion The access to the rotator cuff from almost every portal is influenced by the acromial shape. As hypothesized, a small (small GAA) and flat (big SBAA) acromion provide an easier approach to the rotator cuff from almost every portal. Therefore, it may severely influence the instruments maneuverability.

Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.

Prognostic factors for clinical outcome after spinal cord (SC) injury (SCI) are limited but important in patient management and education. There is a lack of evidence regarding magnetic resonance imaging (MRI) and clinical outcomes in SCI patients. Therefore, we aimed to investigate whether baseline MRI features predicted the clinical course of the disease. This study is an ancillary to the prospective North American Clinical Trials Network (NACTN) registry. Patients were enrolled from 2005–2017. MRI within 72 h of injury and a minimum follow-up of one year were available for 459 patients. Patients with American Spinal Injury Association impairment scale (AIS) E were excluded. Patients were grouped into those with (n = 354) versus without (n = 105) SC signal change on MRI T2-weighted images. Logistic regression analysis adjusted for commonly known a priori confounders (age and baseline AIS). Main outcomes and measures: The primary outcome was any adverse event. Secondary outcomes were AIS at the baseline and final follow-up, length of hospital stay (LOS), and mortality. A regression model adjusted for age and baseline AIS. Patients with intrinsic SC signal change were younger (46.0 (interquartile range (IQR) 29.0 vs. 50.0 (IQR 20.5) years, p = 0.039). There were no significant differences in the other baseline variables, gender, body mass index, comorbidities, and injury location. There were more adverse events in patients with SC signal change (230 (65.0%) vs. 47 (44.8%), p &lt, 0.001, odds ratio (OR) = 2.09 (95% confidence interval (CI) 1.31–3.35), p = 0.002). The most common adverse event was cardiopulmonary (186 (40.5%)). Patients were less likely to be in the AIS D category with SC signal change at baseline (OR = 0.45 (95% CI 0.28–0.72), p = 0.001) and in the AIS D or E category at the final follow-up (OR = 0.36 (95% CI 0.16–0.82), p = 0.015). The length of stay was longer in patients with SC signal change (13.0 (IQR 17.0) vs. 11.0 (IQR 14.0), p = 0.049). There was no difference between the groups in mortality (11 (3.2%) vs. 4 (3.9%)). MRI SC signal change may predict adverse events and overall LOS in the SCI population. If present, patients are more likely to have a worse baseline clinical presentation (i.e., AIS) and in- or outpatient clinical outcome after one year. Patients with SC signal change may benefit from earlier, more aggressive treatment strategies and need to be educated about an unfavorable prognosis.

BACKGROUND A fascial dehiscence after spinal instrumentation is usually located at the mechanically stressed interscapular thoracic spine and often causes cosmetic impairment and pain. However, therapy options remain barely discussed. Synthetic meshes have been successfully used in the treatment of abdominal hernias. OBJECTIVE It was hypothesized that synthetic meshes are a successful treatment option for spinal fascial dehiscence. METHODS This retrospective study of a prospective database investigated all consecutive patients who received a synthetic mesh for a fascial dehiscence of the spine between 2010 and 2014 after prior spinal instrumentation. Primary outcomes were healing of the fascial dehiscence, recurrence, infection, revision, subjective satisfaction on a visual analog scale (VAS), and the Oswestry Disability Index (ODI). Among others, secondary outcomes consisted of seroma formation and return to work. The evaluated risk factors consisted of the body mass index (BMI), outer abdominal fat (OAF), back tissue, smoking, immunomodulatory therapy, preoperative radiation dose, and instrumented levels. RESULTS Sixteen patients with a mean follow up of 24 months were included. Every fascial dehiscence successfully healed with the synthetic mesh and there were no recurrences, infections or revisions. The mean subjective satisfaction level was VAS 7.3 and the mean ODI was 26%. Five (31%) patients had a seroma postoperatively, but did not show any differences in the outcome (e.g. ODI of 28%). In the patient group < 65 years (n = 12), all but two patients, who had work restrictions due to other diseases, regained at least some capacity to work. Worse ODI scores were found for patients with increased BMI, OAF, back tissue, cortisone therapy, instrumented levels, preoperative radiation dose, and for smokers. CONCLUSION Synthetic meshes are a successful treatment option for spinal fascial dehiscence, even seemingly in patients with a higher risk profile such as obese and immunocompromised patients as well as in revision procedures. They are associated with respectable cosmetic results, pain relief and clinical outcome. Postoperatively, it is recommended to leave drains for more than five to seven days in order to avoid seroma formation and to avoid weight training for six weeks. Further prospective, comparative studies are recommended.

Background Hallux valgus deformity (HV) affects around every fourth individual, and surgical treatment is performed in every thousandth person. There is an ongoing quest for the best surgical management and reduction of undesirable outcomes. The aim was to explore associations of obesity and gender with radiological and clinical outcome after reversed L-shaped osteotomy (ReveL) for HV. Materials and methods This study was carried out in a retrospective cohort design at a single University Hospital in Switzerland between January 2004 and December 2013. It included adult patients treated with ReveL for HV. The primary exposure was body mass index (BMI) at the time of ReveL. The secondary exposure was gender. The primary outcome was radiological relapse of HV (HV angle [HVA] > 15 degrees [°]) at the last follow-up. Secondary outcomes were improvable patient satisfaction, complication, redo surgery, and optional hardware removal. Logistic regression analysis adjusted for confounders. Results The median weight, height, and BMI were 66.0 (interquartile range [IQR] 57.0–76.0) kilograms (kg), 1.65 (IQR 1.60–1.71) metres (m), and 24.0 (IQR 21.3–27.8) kg/m2. Logistic regression analysis did not show associations of relapse with BMI, independent of age, gender, additional technique, and preoperative HVA (adjusted odds ratio [ORadjusted] = 1.10 [95% (%) confidence interval (CI) = 0.70–1.45], p = 0.675). Relapse was 91% more likely in males (ORadjusted = 1.91 [95% CI = 1.19–3.06], p = 0.007). Improvable satisfaction was 79% more likely in males (ORadjusted = 1.79 [CI = 1.04–3.06], p = 0.035). Hardware removal was 47% less likely in males (ORadjusted = 0.53 [95% CI 0.30–0.94], p = 0.029). Conclusions In this study, obesity was not associated with unsatisfactory outcomes after ReveL for HV. This challenges the previous recommendation that preoperative weight loss may be necessary for a successful surgical treatment outcome. Males may be informed about potentially higher associations with unfavourable outcomes. Due to the risk of selection bias and lack of causality, findings may need to be confirmed with clinical trials.

Introduction Frozen shoulder (adhesive capsulitis) is a common painful and functionally-limiting disease affecting around 2% of the population. So far, therapeutic options are limited and often unsatisfactory. Platelet-rich plasma (PRP) has been used as a treatment option in other orthopedic diseases since it contains growth factors that stimulate tissue repair. So far, the effect of PRP on frozen shoulder lacks evidence. We hypothesized that PRP may be valuable in the prophylaxis and treatment of secondary frozen shoulder due to capsular remodeling. Materials and methods An experimental study of an in vivo frozen shoulder model was conducted. Twenty Sprague–Dawley rats underwent surgery in which the body of the scapula was connected to the humerus with a high-strength suture. Two groups of 8 weeks survival time were allocated; a treatment group with one intraoperative injection of PRP into the glenohumeral joint (n = 10) and a control group without PRP (n = 10). The primary outcome was the structural change in the posterior synovial membrane of the posterior and inferior part of the glenohumeral joint using a semi-quantitative grading from 0 (lowest) to 3 (highest). Results The posterior synovial membrane structural changes were significantly lower in the PRP group (median = 1 [interquartile range (IQR) = 0–1]) compared to controls (median = 2 [IQR = 1–3]) (p = 0.028). There were no differences for the remaining synovial membrane changes and fibrous capsule responses between groups. Conclusions In this in vivo shoulder contracture model, PRP injections seem to reduce the histological severity grade of some parts (i.e., posterior synovial membrane changes) of the secondary frozen shoulder without causing any side effects. It may be considered to investigate this effect further in future studies as a potential prophylaxis of secondary frozen shoulder (e.g., in operated or immobilized shoulders) or as a treatment option for patients with frozen shoulder in the early stage.

BACKGROUND Anatomic factors associated with static posterior translation of the humeral head with or without glenohumeral osteoarthritis are unknown. We tested the hypothesis that there is an association between glenoid wear, glenoid version, and/or anteroposterior acromial tilt. METHODS Ninety-nine patients with glenohumeral joint degeneration involving advanced glenoid cartilage wear and/or rotator cuff disease scheduled for anatomic or reverse total shoulder replacement underwent standardized conventional radiographic and computed tomographic shoulder imaging. Measurements included glenoid version, humeral torsion, posterior acromial slope, and critical shoulder angle. The glenoid shape was classified according to Walch et al, and the integrity of the rotator cuff was assessed. RESULTS Patients with glenoid type B2 or C had a median of 4° more glenoid retroversion (P = .022), a 5° less steep acromion (posterior acromial slope, 61° vs 56°; P = .004), and a higher combined score (glenoid version minus slope; odds ratio, 0.93 [95% confidence interval, 0.89-0.97]; P

Background Leg length discrepancy (LLD) is common after total hip arthroplasty (THA) with a plethora of clinical consequences. The associations between symptomatic (sLLD; disturbing perception of anatomical leg length discrepancy), anatomical (aLLD; side difference in leg length between the center of rotation of the hip and the center of the ankle joint) and intraarticular (iLLD; side difference between the tear drop figure and the most prominent point of the trochanter minor) LLD and lower back have not yet been reported in the literature. We performed a retrospective study to answer if postoperative (1) symptomatic LLD, (2) anatomic LLD, and (3) a change in intraarticular leg length are associated with lower back pain in patients undergoing THA. Further, we aimed to answer (4) whether symptomatic LLD is associated with the magnitude of anatomical LLD and the change in intraarticular leg length. Hypothesis LLD after THA is associated with lower back pain. Materials and methods Seventy-nine consecutive patients were retrospectively analyzed for the presence of aLLD and iLLD using EOS™ and X-rays, and were interviewed for the presence of sLLD and lower back pain using a questionnaire 5 years after primary THA. Results Postoperative new onset of lower back pain was reported by 9 (11%) patients. Twenty (25%) patients reported sLLD. Anatomical LLD > 5 mm was present in 44 (56%) (median 8.0 (IQR -3.0 to 12.0; range -22 to 22) mm) and > 10 mm in 17 (22%) (median 12.0 (IQR 11.0 to 16.5; range -22 to 22) mm) patients. iLLD changed > 5 mm in 44 (56%) (median 8.5 (IQR 7.0 to 10.0; range -8 to 18) mm) and > 10 mm in 10 (13%) (median 14.0 (IQR 12.5 to 14.5; range 11 to 18) mm). New onset lower back pain was associated with sLLD (p = 0.002) but not with aLLD or iLLD. Patients without preoperative lower back pain had a statistically significant association between presence of sLLD and an aLLD of > 10 mm (p = 0.01). Conclusions Symptomatic LLD after primary THA is associated with postoperative new onset of lower back pain irrespective of the magnitude of LLD. In patients without lower back pain prior to THA, symptomatic LLD is associated with anatomical LLD of more than 10 mm. Level of evidence IV.

To investigate the association between arthroscopy simulator performance and video game skills.This study compared the performances of 30 volunteers without experience performing arthroscopies in 3 different tasks of a validated virtual reality knee arthroscopy simulator with the video game experience using a questionnaire and actual performances in 5 different 2- and 3-dimensional (D) video games of varying genres on 2 different platforms.Positive correlations between knee arthroscopy simulator and video game performances (ρ = 0.63, P .001) as well as experiences (ρ = 0.50, P = .005) were found. The strongest correlations were found for the task of catching (hooking) 6 foreign bodies (virtual rings; "triangulation") and the dribbling performance in a sports game and a first-person shooter game, as well as the meniscus resection and a tile-matching puzzle game (all ρ ≥ 0.60, P.001). No correlations were found for any of the knee arthroscopy simulator tasks and a strategy game.Although knee arthroscopy performances do not correlate with 2-D strategy video game skills, they show a correlation with 2-D tile-matching puzzle games only for easier tasks with a rather limited focus, and highly correlate with 3-D sports and first-person shooter video games. These findings show that experienced and good 3-D gamers are better arthroscopists than nonexperienced and poor 3-D gamers.Level II, observational cross-sectional study.

Wearing high heels is associated with chronic pain of the neck, lower back and knees. The mechanisms behind this have not been fully understood. The purpose of this study was to investigate the influence of high-heeled shoes on the sagittal balance of the spine and the whole body in non-habitual wearers of high heels. Lateral standing whole body low-dose radiographs were obtained from 23 female participants (age 29 ± 6 years) with and without high heels and radiological parameters describing the sagittal balance were quantified. These were analyzed for differences between both conditions in the total sample and in subgroups. Standing in high heels was associated with an increased femoral obliquity angle [difference (Δ) 3.0° ± 1.7°, p

The prevalence of cardiac implantable electronic devices (CIEDs), pacemakers and implantable cardioverter defibrillators (ICDs) is increasing. However, postmortem analysis of CIEDs is not performed routinely. Fourteen consecutive CIEDs were analyzed. The indication for and date of implantation, technical data, CIED reprogramming, heart rhythm disturbances, patient demographics and medical consultations were investigated. Death during the first year after implantation was seen in 54%, whereof 71% consulted a physician within 10 days before death. The time of death was attributed to a particular day in 29%. There was a relationship between CIEDs and cause/manner of death in 50%. Although limited by a small sample size, this study advocates the routine postmortem CIED analysis for forensic and clinical purposes in selected cases. Patients with CIEDs seem to show an increased risk of death during the first year after implantation. The analysis of CIEDs can be helpful in evaluating the time/cause/manner of death.