Planning of surgical treatment requires determination of whether osteoarthritis of the spine with lumbar pain should be treated as spinal canal stenosis with or without deformity or as lumbar ...degenerative scoliosis and clarification of whether treatment should be provided for both. When sagittal spinal alignment is not appropriate, symptoms of adult spinal deformity may be observed. To correct this deformity, appropriate pelvic tilt should be obtained similar to that in healthy adults, and, especially, the retroversion of the pelvis should be corrected.
Abstract
Osteoarthritis (OA) is a common disease of joints that is more common in females than in males. It is characterized by severe knee degeneration, damaged cartilage and appearance of ...osteophytes. Hip geometry and morphometric parameters in the knee joint vary between the sexes and depend on the severity of OA and the presence of osteophytes. Very few studies have assessed this phenomenon; therefore in this study, we assessed the difference in hip geometry and morphometric parameters in the lower limbs of males and females and evaluated the association of the differences with the presence or absence of osteophytes. Three hundred and six knees volunteers (104 male knees and 202 female knees) from the Toei region were included in the study between 2012 and 2018. The parameters measured were from the anteroposterior and lateral views of the hip and anteroposterior view of the knee. The participants were divided into 4 groups based on the assessment for osteophytes: Group 1 had no osteophytes, Group 2 had lateral compartment osteophytes, Group 3 had medial compartment osteophytes, and Group 4 had osteophytes in both compartments. Males had an increased femoral neck-shaft angle, femoral-tibial angle, and plateau angle, and a decreased femoral offset, femoral neck length, fibular-tibial angle, and knee rotation index than females. Group 2 had a greater height of the hip center, the angle between the femoral mechanical axis and the femoral shaft axis, condylar-hip angle, and plateau angle than Group 1. Group 3 showed an increased abductor angle, the angle between the femoral mechanical axis and the femoral shaft axis. Group 4 showed an increased angle between the femoral mechanical axis and the femoral shaft axis, femoral-tibial angle, and a decreased patellar shift index and knee rotation index. The angle between the femoral mechanical axis and the femoral shaft axis, condylar-hip angle, femoral-tibial angle, plateau angle, patellar shift index, and knee rotation index were different in both sexes and may be dependent on the presence or absence of osteophytes.
Purpose
Malnutrition is reported as one of the risk factors for surgical site infection (SSI). The prognostic nutritional index (PNI) is a simple method for nutritional evaluation. However, little is ...known about the relationship between SSI and the PNI in patients after spine surgery. We aimed to determine independent predictors of SSI after spine surgery.
Methods
We analyzed 1115 patients who underwent spine surgery (369 males, 746 females, mean age 56 years, follow-up period: at least 1 year). Patients were divided into SSI and non-SSI groups. Preoperative risk factors, including PNI (10 × serum albumin g/dL + 0.005 × total lymphocyte count /μL), were assessed.
Results
Postoperatively, 43 patients (3.9%) experienced SSI. Univariate analysis showed that preoperative PNI (48.5 vs 51.7;
p
< 0.01), revision status (
p
< 0.05), male sex (
p
< 0.01), body mass index (BMI) (
p
< 0.05), and usage of anticoagulant agents (
p
< 0.05) differed significantly between the SSI and non-SSI groups. Multivariate logistic regression analysis showed that preoperative PNI (odds ratio OR, 0.94; 95% confidence interval CI: 0.90–0.98;
p
< 0.01), male sex (OR, 2.64; 95% CI: 1.40–4.99;
p
< 0.01), length of surgery ≥ 180 min (OR, 2.78; 95% CI: 1.30–5.96;
p
< 0.01), BMI ≥ 30 kg/m
2
(OR, 2.89; 95% CI: 1.20–6.97;
p
< 0.05), and revision status (OR, 2.30; 95% CI: 1.07–4.98;
p
< 0.05) were independently associated with SSI postoperatively.
Conclusion
Lower preoperative PNI was found to be a risk factor for SSI after spine surgery. Patients with lower preoperative PNI values should be cautioned about the risk of SSI and provide adequate informed consent.
STUDY DESIGN.Large cohort study of volunteers aged over 50.
OBJECTIVE.To investigate influence of age and sex on cervical sagittal alignment among volunteers aged over 50.
SUMMARY OF BACKGROUND ...DATA.Few large-scale studies have described normative values in cervical spine alignment regarding age and sex among volunteers aged over 50.
METHODS.The study cohort included 656 volunteers aged 50 to 89 years. Pelvic tilt, sacral slope, pelvic incidence, lumbar lordosis, pelvic incidence−lumbar lordosis, thoracic kyphosis, T1 slope (T1S), cervical lordosis (CL), C7 sagittal vertical axis (C7 SVA), C2−C7 SVA, and T1S−CL were measured using whole spine and pelvic radiographs taken in the standing position. Health-related quality of life was assessed using the EuroQOL (EQ-5D) standardized instrument for measurement of health outcome and Oswestry Disability Index.
RESULTS.There were 36 subjects aged 50 to 59 years, 174 aged 60 to 69 years, 311 aged 70 to 79 years, and 135 aged 80 to 89 years. Average T1S for each decade was 32°, 31°, 33°, and 36° for males, and 28°, 29°, 32°, and 37° for females, respectively. Average C2–C7 SVA was 25, 28, 34, and 35 mm for males, and 20, 21, 22, and 28 mm for females, respectively. C2–C7 SVA 40 mm or more, T1S 40° or more, and T1S–CL 20° or more pertaining to EQ-5D were significantly worse in other cases.
CONCLUSION.C2–C7 SVA was significantly greater in males among all age groups, particularly among those with C2–C7 SVA of 40 mm or more males, 69% (82/118) vs. females, 33% (36/118). Sagittal parameters of cervical spine were significantly worse in males than females. C2–C7 SVA, T1S, and T1S–CL negatively influenced EQ-5D. These results help to explain the greater prevalence of cervical spondylotic myelopathy among elderly males.Level of Evidence3
Ligamentum flavum hypertrophy (HLF) is the most important component of lumbar spinal canal stenosis (LSCS). Analysis of hypertrophied ligamentum flavum (HLF) samples from patients with LSCS can be an ...important que. The current study analyzed the surgical samples of HLF samples in patients with LCSC using quantitative and qualitative high performance-liquid chromatography and mass spectrometry. We collected ligamentum flavum (LF) tissue from twelve patients with LSCS and from four patients with lumbar disk herniation (LDH). We defined LF from LSCS patients as HLF and that from LDH patients as non-hypertrophied ligamentum flavum (NHLF). Total lipids were extracted from the LF samples and evaluated for quantity and quality using liquid chromatography and mass spectrometry. The total lipid amount of the HLF group was 3.6 times higher than that of the NHLF group. Phosphatidylcholines (PCs), ceramides (Cers), O-acyl-ω-hydroxy fatty acids (OAHFAs), and triglycerides (TGs) in the HLF group were more than 32 times higher than those of the NHLF group. PC(26:0)+H+, PC(25:0)+H+, and PC(23:0)+H+ increased in all patients in the HLF group compared to the NHLF group. The thickness of the LF correlated significantly with PC(26:0)+H+ in HLF. We identified the enriched specific PCs, Cers, OAHFAs, and TGs in HLF.
STUDY DESIGN.A retrospective study.
OBJECTIVE.We investigated the prevalence of iliac screw loosening and determined risk factors after adult spinal deformity surgery.
SUMMARY OF BACKGROUND ...DATA.Lumbosacral fixation is crucial to maintain optimal sagittal alignment. Iliac screws are commonly placed to provide protection for sacral pedicle screws. Radiolucent areas around the screws indicate fixation loss and pseudarthrosis.
METHODS.Seventy-two patients with adult spinal deformity (13 men, 59 women; mean age, 69.0 yr) who underwent spinal deformity surgeries using bilateral iliac screws with at least 2 years follow-up were studied. Iliac and S1 screw loosening were assessed by postoperative radiograph. The period of loosening appearance and the relations between loosening and the following items were investigated(1) upper instrumented vertebra, (2) L5/S interbody fusion, (3) iliac screw placement, (4) spinopelvic parameters (T1 pelvic angle, sagittal vertical axis, pelvic tilt, pelvic incidence-lumbar lordosis LL). Oswestry Disability Index scores were obtained preoperatively and 2 years postoperatively.
RESULTS.Iliac and S1 screw loosening was found in 20 (27.8%) and 7 patients (9.7%), respectively. Iliac screw loosening appeared at 5.2 months (range, 3–12) on average. Compared with nonloosening, loosening had significantly higher upper thoracic fusion rates (above T6), lower L5/S interbody fusion rate, higher misplacement rate, and higher insufficient correction rate (PI-LL >10°). Oswestry Disability Index significantly improved in nonloosening, whereas no significant difference was observed in loosening. Multiple regression analysis showed that misplacement (odds ratio = 10.8) and insufficient correction (odds ratio = 7.5) affected loosening.
CONCLUSION.Iliac screw loosening indicated instability of the lumbosacral junction, resulting in sagittal malalignment and poor outcomes. Accurate screw insertion and restoration of optimal LL were necessary to prevent complications.Level of Evidence4
With aging of society, clarification of the relationship between QOL and abnormal posture in the elderly may allow improvement of QOL through any preventive methods and training. However, sagittal ...balance has not been studied widely and most studies have focused on postmenopausal patients with osteoporosis. In this report, we provide the first evaluation of the simultaneous effects of degenerative changes on radiograph, spinal range of motion (ROM), sagittal balance, and back muscle strength, and examine the influence of these effects on QOL of the middle-aged and elderly male subjects. The subjects were 100 Japanese males who underwent a basic health checkup. Lumbar lateral radiograph, sagittal balance and spinal mobility determined with SpinalMouse
®
and back muscle strength were measured. The thoracic/lumbar angle ratio (
T
/
L
ratio) was used as an index of sagittal balance. SF-36 physical component summary (PCS) scores showed a significant negative correlation with age (
r
= −0.377), osteophyte score (
r
= −0.246) and
T
/
L
ratio (
r
= −0.214), and a significant positive correlation with lumbar lordosis angle (
r
= 0.271), thoracic ROM (
r
= 0.282), and back muscle strength (
r
= 0.549). Multiple regression analysis indicated that thoracic spinal ROM (
r
= 0.254,
p
< 0.01) and back muscle strength (
r
= 0.488,
p
< 0.0001) were significantly associated with SF-36 PCS (
R
2
= 0.403). In conclusion, QOL of the middle-aged and elderly male subjects was related to sagittal balance, lumbar lordosis angle, spinal ROM, and back muscle strength. Exercise including muscle strength and spinal ROM may be able to influence these primary factors related to QOL. Back muscle strength and thoracic ROM impact on improvement of QOL in the middle-aged and the elderly.
Intradiscal condoliase injection is an alternative therapeutic option for lumbar disc herniation (LDH). However, it is often associated with disc degeneration. Several in vivo studies have ...demonstrated the regenerative potential of platelet-rich plasma (PRP) in disc degeneration. Thus, we hypothesized that the intradiscal injection of PRP releasate (PRPr), a soluble releasate isolated from PRP, has the potential to regenerate degenerated intervertebral discs (IVDs) induced by condoliase. This study examined the regenerative effects of PRPr on rabbit IVDs degenerated following condoliase injection.
Eleven New Zealand white rabbits were used in this study. Condoliase (12.5 mU/10 μl) was injected into two non-contiguous discs (L2-L3 and L4-L5), and L3-L4 disc was left intact as a non-injection control. Saline (20 μl) or PRPr (20 μl) was randomly injected into L2-L3 and L4-L5 discs 4 weeks after the condoliase injection. Disc height (DH) was radiographically monitored biweekly from the day of condoliase injection to 16 weeks post-injection. Changes in DH were expressed as percentage DH (%DH) normalized to the baseline DH. Sixteen weeks after condoliase injection, all rabbits were euthanized, and subjected to MRI and histological analyses.
Intradiscal injection of condoliase induced a significant decrease in %DH (L2-L3 and L4-L5) to 52.0% at week 4. However, the %DH began to return to normal after saline injection and reached 76.3% at week 16. In the PRPr group, %DH began to recover to normal after the PRPr injection and was restored to 95.5% at week 16. The MRI-modified Pfirrmann grade of the PRPr group was significantly lower than that of the saline group (P < 0.01). Histological analyses showed progressive degenerative changes, including reduction of the NP area and condensation of the matrix in the saline and PRPr groups. The histological score of the PRPr group was significantly lower than that of the saline group (P < 0.01).
PRPr has great potential to enhance the regeneration of degenerated rabbit IVDs induced by condoliase. The results of this preclinical study suggest that PRPr injection therapy may be indicated for patients with LDH who have poor recovery from disc degeneration after chemonucleolysis treatment with condoliase.
Although Oxford unicompartmental knee arthroplasty is often used to successfully treat patients with knee osteoarthritis isolated at the medial compartment, we present a case of fracture just below ...the tibial keel caused by either a shift in medial loading position or an increased amount of tibial osteotomy. Finite element analysis was used to determine which factor was more important. First, a 3D-surface model of the patient’s tibia and the implant shape were created using computed tomography-Digital Imaging and Communications in Medicine (CT-DICOM) data taken preoperatively. The finite element analysis found that following unicompartmental knee arthroplasty, the cortical stress (normal, 5.8 MPa) on the medial tibial metaphyseal cortex increased as the load point moved medially (3 and 12 mm medially: 7.0 and 10.7 MPa, respectively) but was mild with increased tibial bone resection (2 and 6 mm lower: 6.1 and 6.5 MPa, respectively). Implanting the femoral component more medially than the preoperative plan increases stresses in the medial cortex of the tibia and may cause fractures.
Delirium has been reported to cause delayed functional recovery, prolonged hospitalization, future institutionalization, increased mortality, and increased healthcare costs. However, there are no ...reports on how prognostic nutritional index (PNI), Controlling Nutritional Status (CONUT) score, and geriatric nutritional risk index (GNRI) are related to delirium after total knee arthroplasty (TKA). This study aimed to identify risk factors for post-operative delirium after TKA using various pre-operative nutritional assessments (PNI, CONUT score, and GNRI).
In total, 289 patients who underwent primary TKA between September 2011 and April 2022 in our institute (Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan) were enrolled. Patients were divided into two groups: those who developed post-operative delirium (Group D), and those who did not (Group ND). Pre-operative risk factors, including nutritional indices, for post-operative delirium were evaluated.
Group D comprised 16 participants, while Group ND comprised 273 participants. Comparisons between the two groups revealed significant differences in age, PNI, CONUT score, GNRI, and history of cerebrovascular disease. Multiple logistic regression analysis revealed that significant risk factors for delirium after TKA were age, PNI, and history of cerebrovascular disease. A receiver operating characteristic curve indicated that the cutoff values for delirium were 47.4 for PNI (sensitivity, 0.810; specificity, 0.875) and 78.5 years for age (sensitivity, 0.813; specificity, 0.722).
Risk factors for post-operative delirium after TKA were PNI <47.4, age >78.5 years, and history of cerebrovascular disease. Patients exceeding these pre-operative cutoff values or with a history of cerebrovascular disease should receive counseling about delirium before surgery.
•Pre-operative risk factors for post-operative delirium after total knee arthroplasty were evaluated.•Age, prognostic nutritional index (PNI), and cerebrovascular disease were significant risk factors for delirium.•Cutoff values for delirium were 47.4 for PNI and 78.5 years for age.
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