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Aubert T, Gerard P, Butnaru M, Graff W, Rigoulot G, Auberger G, Aubert O. Archetype analysis of the spine-hip relationship identifies distinct spinopelvic profiles. Orthop Traumatol Surg Res 2024:103944. [PMID: 39048457 DOI: 10.1016/j.otsr.2024.103944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/26/2024] [Accepted: 03/08/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION The position of the pelvis in the sagittal plane can vary considerably between different functional positions. Adapting the position of the acetabular cup in relation to the alignment between the spine and the hip of each individual, prior to prosthesis placement, can prevent the risk of prosthetic impingement. Taken individually, risk factors for unfavorable spinopelvic kinematics can be difficult to interpret when trying to precisely predict which patients are at risk. Furthermore, the use of classifications or algorithms can be complex, most often associated with limited values and often difficult to apply in current practices of risk assessment. HYPOTHESIS We hypothesized that the deconstruction of the data matrix including age and spinopelvic parameters (SPT, LL, PI, LF and PI-LL) correlated with the analysis of spinopelvic kinematics could be used to define an individualized hip-spine relationship. MATERIAL AND METHOD We applied archetypal analysis, which is a probabilistic, data-driven and unsupervised approach, to a complete phenotype cohort of 330 patients before total hip arthroplasty to define the spinopelvic profile of each individual using the spinopelvic parameters without threshold value. For each archetype, we analyzed the spinopelvic kinematics, not implemented in the creation of the archetypes. RESULTS An unsupervised learning method revealed seven archetypes with distinct spinopelvic kinematic profiles ranging from -8.9 ° to 13.15 ° (p = 0.0001) from standing to sitting and -5. 35 ° to -10.81 ° (p = 0.0001) from supine to standing. Archetype 1 represents the "ideal" patient (A1); young patients without spinopelvic anomaly and the least at risk of mobility anomaly. Followed by 3 archetypes without sagittal imbalance according to their lumbar lordosis and pelvic incidence, from the highest to the lowest (archetypes 2-4), archetype 4 exposing a greater risk of spinopelvic kinematic anomaly compared to others. Then 2 archetypes with sagittal imbalance: archetype 5, with an immobile pelvis in the horizontal plane from standing to sitting position in anterior tilt and archetype A6, with significant posterior pelvic tilt standing, likely compensating for the imbalance and associated with the greatest anomaly of spinopelvic kinematics. Finally, archetype 7 with the stiffest lumbar spine without sagittal imbalance and significant unfavorable kinematics from standing to sitting. CONCLUSION An archetypal approach to patients before hip replacement can refine diagnostic and prognostic features associated with the hip-spine relationship and reduced heterogeneity, thereby improving spinopelvic characterization. This risk stratification of spinopelvic kinematic abnormalities could make it possible to target patients who require adapted positioning or types of implants before prosthetic surgery. LEVEL OF EVIDENCE IV retrospective study.
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Affiliation(s)
- Thomas Aubert
- Groupe Hospitalier Diaconesses Croix Saint Simon, 125 Rue d'Avron, Paris 75020, France.
| | - Philippe Gerard
- Groupe Hospitalier Diaconesses Croix Saint Simon, 125 Rue d'Avron, Paris 75020, France
| | - Michael Butnaru
- Groupe Hospitalier Diaconesses Croix Saint Simon, 125 Rue d'Avron, Paris 75020, France
| | - Wilfrid Graff
- Groupe Hospitalier Diaconesses Croix Saint Simon, 125 Rue d'Avron, Paris 75020, France
| | | | - Guillaume Auberger
- Groupe Hospitalier Diaconesses Croix Saint Simon, 125 Rue d'Avron, Paris 75020, France
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Aubert T, Gerard P, Galanzino G, Marmor S. In silico analysis of the patient-specific acetabular cup anteversion safe zone. Orthop Traumatol Surg Res 2024:103940. [PMID: 39043498 DOI: 10.1016/j.otsr.2024.103940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Various computer-assisted surgical systems claim to improve the accuracy of cup placement in total hip arthroplasties after assessing spinopelvic mobility to prevent prosthetic impingement. However, no study has yet analyzed the extent of the patient-specific cup anteversion safe zones. HYPOTHESIS We hypothesized that most patients have a safe zone >10 °, except those with abnormal spinopelvic mobility, who have a much narrower safe zone. MATERIALS AND METHODS We simulated the risks of prosthetic impingement using the planned cup anteversion. The consecutive cohort included 341 patients who underwent total hip arthroplasty. Our primary endpoint was the patient-specific impingement-free zone for cup anteversion, which was then divided into four subgroups: 0 °, 1 ° to 5 °, 6 ° to 10 °, and >10 °. This data was then secondarily analyzed for abnormal spinopelvic mobility (the difference in the spinopelvic tilt [ΔSPT] from a standing to a flexed seated position >20 °). RESULTS The mean anteversion safe zone was 22.8 ° with 82.4% (281/341) of patients with a zone strictly >10 °. The mean safe zone was 8.9 ° (+/- 9 °) in patients with an ΔSPT ≥20 ° (18.2%), with 37.1% of these patients having a zone of 0 °, 16.13% a zone between 1 ° and 5 °, 8.06% a zone between 6 ° and 10 ° and 38.71% a zone >10 °. The mean safe zone was 25.9 ° (+/- 9 °) in patients with an ΔSPT <20 ° (81.8%), and the proportion of cases in each zone was 2.51%, 1.08%, 4.3%, and 92.11%, respectively (p < 0.001). CONCLUSION The safe zone for anteversion appears to be fairly wide in most patients. However, identifying patients at risk of abnormal spinopelvic mobility seems necessary to identify the two-thirds of patients with a narrow safe zone. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Thomas Aubert
- Orthopedic Department, Croix St Simon Hospital 125 rue d'Avron, 75020 Paris, France.
| | - Philippe Gerard
- Orthopedic Department, Croix St Simon Hospital 125 rue d'Avron, 75020 Paris, France
| | - Giacomo Galanzino
- Orthopedic Department, Croix St Simon Hospital 125 rue d'Avron, 75020 Paris, France
| | - Simon Marmor
- Orthopedic Department, Croix St Simon Hospital 125 rue d'Avron, 75020 Paris, France
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Balmaceno-Criss M, Lafage R, Alsoof D, Daher M, Hamilton DK, Smith JS, Eastlack RK, Fessler RG, Gum JL, Gupta MC, Hostin R, Kebaish KM, Klineberg EO, Lewis SJ, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Buell T, Scheer JK, Mullin JP, Soroceanu A, Ames CP, Lenke LG, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Burton DC, Diebo BG, Daniels AH. Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity. Spine (Phila Pa 1976) 2024; 49:743-751. [PMID: 38375611 DOI: 10.1097/brs.0000000000004957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To investigate the effect of lower extremity osteoarthritis on sagittal alignment and compensatory mechanisms in adult spinal deformity (ASD). BACKGROUND Spine, hip, and knee pathologies often overlap in ASD patients. Limited data exists on how lower extremity osteoarthritis impacts sagittal alignment and compensatory mechanisms in ASD. PATIENTS AND METHODS In total, 527 preoperative ASD patients with full body radiographs were included. Patients were grouped by Kellgren-Lawrence grade of bilateral hips and knees and stratified by quartile of T1-Pelvic Angle (T1PA) severity into low-, mid-, high-, and severe-T1PA. Full-body alignment and compensation were compared across quartiles. Regression analysis examined the incremental impact of hip and knee osteoarthritis severity on compensation. RESULTS The mean T1PA for low-, mid-, high-, and severe-T1PA groups was 7.3°, 19.5°, 27.8°, and 41.6°, respectively. Mid-T1PA patients with severe hip osteoarthritis had an increased sagittal vertical axis and global sagittal alignment ( P <0.001). Increasing hip osteoarthritis severity resulted in decreased pelvic tilt ( P =0.001) and sacrofemoral angle ( P <0.001), but increased knee flexion ( P =0.012). Regression analysis revealed that with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis ( r2 =0.812). Hip osteoarthritis decreased compensation through sacrofemoral angle (β-coefficient=-0.206). Knee and hip osteoarthritis contributed to greater knee flexion (β-coefficients=0.215, 0.101; respectively). For pelvic shift, only hip osteoarthritis significantly contributed to the model (β-coefficient=0.100). CONCLUSIONS For the same magnitude of spinal deformity, increased hip osteoarthritis severity was associated with worse truncal and full body alignment with posterior translation of the pelvis. Patients with severe hip and knee osteoarthritis exhibited decreased hip extension and pelvic tilt but increased knee flexion. This examines sagittal alignment and compensation in ASD patients with hip and knee arthritis and may help delineate whether hip and knee flexion is due to spinal deformity compensation or lower extremity osteoarthritis.
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Affiliation(s)
- Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell, New York, NY
| | - Daniel Alsoof
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical School, Chicago, IL
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of Texas Health, Houston, TX
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
| | | | | | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | | | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, CA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Canada
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell, New York, NY
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
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Colasanti CA, Shankar DS, Li ZI, Savage-Elliott I, Rynecki ND, Bi AS, Youm TJ. Effect of Spinopelvic Parameters on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Am J Sports Med 2024; 52:1735-1743. [PMID: 38767153 DOI: 10.1177/03635465241248447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Spinopelvic parameters, including pelvic tilt (PT), sacral slope (SS), and pelvic incidence, have been developed to characterize the relationship between lumbar spine and hip motion, but a paucity of literature is available characterizing differences in spinopelvic parameters among patients with femoroacetabular impingement syndrome (FAIS) versus patients without FAIS, as well as the effect of these parameters on outcomes of arthroscopic treatment of FAIS. PURPOSE To (1) identify differences in spinopelvic parameters between patients with FAIS versus controls without FAIS; (2) identify associations between spinopelvic parameters and preoperative patient-reported outcomes (PROs); and (3) identify differences in PROs between patients with stiff spines (standing-sitting ΔSS ≤10°) versus those without. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS The study enrolled patients ≥18 years of age who underwent primary hip arthroscopy for treatment of FAIS with cam, pincer, or mixed (cam and pincer) morphology. Participants underwent preoperative standing-sitting imaging with a low-dose 3-dimensional radiography system and were matched on age and body mass index (BMI) to controls without FAIS who also underwent EOS imaging. Spinopelvic parameters measured on EOS films were compared between the FAIS and control groups. Patients with FAIS completed the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) before surgery and at 1-year follow-up. Outcome scores were compared between patients with stiff spines versus those without. Associations between spinopelvic parameters and baseline outcome scores were assessed with Pearson correlations. Continuous variables were compared with Student t test and/or Mann-Whitney U test, and categorical variables were compared with Fisher exact test. RESULTS A total of 50 patients with FAIS (26 men; 24 women; mean age, 36.1 ± 10.7 years; mean BMI, 25.6 ± 4.2) were matched to 30 controls without FAIS (13 men; 17 women; mean age, 36.6 ± 9.5 years; mean BMI, 26.7 ± 3.6). Age, sex, and BMI were not significantly different between the FAIS and control groups (P > .05). Standing PT was not significantly different between stiff and non-stiff cohorts (P = .73), but sitting PT in the FAIS group was more than double that of the control group (36.5° vs 15.0°; P < .001). Incidence of stiff spine was significantly higher in the FAIS group (62.0% vs 3.3%; P < .001). Among FAIS patients, those with stiff spines had a significantly higher prevalence of cam impingement, whereas those with non-stiff spines had a higher prevalence of mixed impingement (P = .04). No significant differences were seen in preoperative mHHS or NAHS scores or pre- to postoperative improvement in scores between FAIS patients with stiff spines versus those without (P > .05), but a greater sitting SS was found to be positively correlated with a higher baseline mHHS (r = 0.36; P = .02). CONCLUSION Patients with FAIS were more likely to have a stiff spine (standing-sitting ΔSS ≤10°) compared with control participants without FAIS. FAIS patients with stiff spines were more likely to have isolated cam morphology than patient without stiff spines. Although sitting SS was positively correlated with baseline mHHS, no significant differences were seen in 1-year postoperative outcomes between FAIS patients with versus without stiff spine.
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Affiliation(s)
| | - Dhruv S Shankar
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Ian Savage-Elliott
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Nicole D Rynecki
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Andrew S Bi
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Thomas J Youm
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
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Khan IA, Cozzarelli NF, Sutton R, Ciesielka KA, Arshi A, Fillingham YA. Patients Requiring Both Total Hip Arthroplasty and Lumbar Spinal Fusion Have Lower Hip Functional Outcome Scores: A Matched Case-Control Study. J Arthroplasty 2024; 39:1291-1297. [PMID: 37952736 DOI: 10.1016/j.arth.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND While patients who undergo both lumbar spinal fusion (LSF) and total hip arthroplasty (THA) have increased complication rates compared to patients who have not undergone LSF, there is a paucity of literature evaluating THA functional outcomes in patients with a history of LSF. This study was conducted to determine whether patients undergoing THA with a history of LSF have inferior functional outcomes compared to patients having no history of LSF. METHODS A retrospective matched case-control study was conducted at an academic center. Patients who underwent both THA and LSF (cases) were matched with controls who underwent THA without LSF. Inclusion criteria required a minimum of 1-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS-JR]. Following propensity matching for age, sex, race, body mass index, and comorbidities, 291 cases and 1,164 controls were included, with no demographic differences. RESULTS Patients who underwent both THA and LSF had a significantly lower preoperative HOOS-JR (47 versus 50; P < .001), postoperative HOOS-JR (77 versus 85; P < .001), a significant lower rate of achieving the patient acceptable symptom state (55 versus 67%; P < .001), with no significant difference in delta HOOS-JR (34 versus 34; P = .834). When comparing patients undergoing THA before LSF or LSF before THA, no differences existed for preoperative HOOS-JR (50 versus 47; P = .304), but patients undergoing THA before LSF had lower postoperative HOOS-JR scores (74 versus 81; P = .034), a lower-delta HOOS-JR (27 versus 35; P = .022), and a lower rate of reaching the HOOS-JR minimal clinically important difference (62 versus 76%; P = .031). CONCLUSIONS Patients who have a history of LSF experience a similar improvement in hip function when undergoing THA compared to patients who do not have a history of LSF. However, due to lower preoperative function, they may have a lower postoperative functional outcome ceiling. Additionally, patients undergoing THA before LSF have worse hip functional outcomes than patients undergoing LSF before THA.
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Affiliation(s)
- Irfan A Khan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedics, LSU Health New Orleans, New Orleans, Louisiana
| | - Nicholas F Cozzarelli
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ryan Sutton
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kerri-Anne Ciesielka
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Armin Arshi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Khalifé M, Vergari C, Rebeyrat G, Ferrero E, Guigui P, Assi A, Skalli W. Femoral neck version in the spinopelvic and lower limb 3D alignment: a full-body EOS ® study in 400 healthy subjects. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1807-1815. [PMID: 37697058 DOI: 10.1007/s00586-023-07915-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/19/2023] [Accepted: 08/21/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND The goal of this study was to better understand the variation of femoral neck version according to spinopelvic and lower limb 3D alignment using biplanar X-rays in standing position. METHODS This multicentric study retrospectively included healthy subjects from previous studies who had free-standing position biplanar radiographs. Subjects were excluded if they presented spinal or any musculo-skeletal deformity, and reported pain in the spine, hip or knee. Age, sex, and the following 3D-reconstructed parameters were collected: spinal curvatures, pelvic parameters, sagittal vertical axis (SVA), T1 pelvic angle (TPA), spino-sacral angle (SSA), femoral torsion angle (FTA), sacro-femoral angle (SFA), knee flexion angle (KA), ankle angle (AA), pelvic shift (PS) and ankle distance. Femoral neck version angle (FVA) was calculated between horizontal plane projection of the bi-coxo-femoral axis and the line passing through the femoral neck barycenter and femoral head center. Analysis according to age subsets was performed. RESULTS A total of 400 subjects were included (219 females); mean age was 29 ± 18 years (range: 4-83). Subjects with high pelvic tilt values presented significantly higher FVA than average and low-PT individuals, respectively, 7.8 ± 7.1°, 2 ± 9° and 2.1 ± 9.5° (p < 0.001). These subjects also presented lower lumbar lordosis values and higher acetabulum anteversion in the horizontal plane than the two other groups. SVA correlation with FVA was weaker (r = 0.1, p = 0.03) than SSA and TPA (r = - 0.3 and r = 0.3, respectively, p < 0.001). A strong correlation was found with femoral torsion (r = 0.5, p < 0.001). SFA (r = - 0.3, p < 0.001), pelvic shift (r = 0.2, p < 0.001) and ankle distance (r = 0.3, p < 0.001) were also significantly correlated. Multivariate analysis confirmed significant association of age, pelvic tilt, lumbar lordosis, pelvic shift, ankle distance and femoral torsion with FVA. CONCLUSION Patients with lower lumbar lordosis present pelvic retroversion which induces a higher femoral neck version. This finding may help positioning implants in total hip replacement procedures. Higher pelvic shift, age, male gender and increased femoral torsion were also correlated with higher FVA. LEVEL OF EVIDENCE II (Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding).
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Affiliation(s)
- Marc Khalifé
- Orthopaedic Surgery Unit, Hôpital Européen Georges Pompidou, 20, rue Leblanc, 75015, Paris, France.
- Université Paris-Cité, Paris, France.
- Arts et Métiers Institute of Technology, Université Sorbonne Paris Nord, IBHGC - Institut de Biomécanique Humaine Georges Charpak, HESAM Université, 75013, Paris, France.
| | - Claudio Vergari
- Arts et Métiers Institute of Technology, Université Sorbonne Paris Nord, IBHGC - Institut de Biomécanique Humaine Georges Charpak, HESAM Université, 75013, Paris, France
| | - Guillaume Rebeyrat
- Arts et Métiers Institute of Technology, Université Sorbonne Paris Nord, IBHGC - Institut de Biomécanique Humaine Georges Charpak, HESAM Université, 75013, Paris, France
| | - Emmanuelle Ferrero
- Orthopaedic Surgery Unit, Hôpital Européen Georges Pompidou, 20, rue Leblanc, 75015, Paris, France
- Université Paris-Cité, Paris, France
| | - Pierre Guigui
- Orthopaedic Surgery Unit, Hôpital Européen Georges Pompidou, 20, rue Leblanc, 75015, Paris, France
- Université Paris-Cité, Paris, France
| | - Ayman Assi
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Wafa Skalli
- Arts et Métiers Institute of Technology, Université Sorbonne Paris Nord, IBHGC - Institut de Biomécanique Humaine Georges Charpak, HESAM Université, 75013, Paris, France
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Schönnagel L, Camino-Willhuber G, Braun S, Zhu J, Tani S, Guven AE, Caffard T, Chiapparelli E, Arzani A, Haffer H, Muellner M, Shue J, Duculan R, Bendersky M, Cammisa FP, Girardi FP, Sama AA, Mancuso CA, Hughes AP. Association Between Osteoarthritis Burden and Intervertebral Disk Degeneration in Patients Undergoing Lumbar Spine Surgery for Degenerative Lumbar Spondylolisthesis. Spine (Phila Pa 1976) 2024; 49:478-485. [PMID: 37796191 DOI: 10.1097/brs.0000000000004847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023]
Abstract
STUDY DESIGN A retrospective analysis of prospectively collected data. OBJECTIVE To assess the association between intervertebral disk degeneration and hip and knee osteoarthritis (OA) in patients with degenerative lumbar spondylolisthesis. BACKGROUND The co-occurrence of hip OA and degenerative spinal pathologies was first described as the "hip-spine syndrome" and has also been observed in knee OA. It remains unclear whether both pathologies share an underlying connection beyond demographic factors. MATERIALS AND METHODS Intervertebral disk degeneration was classified by the Pfirrmann Classification and intervertebral vacuum phenomenon. Intervertebral vacuum phenomenon was classified into mild (1 point), moderate (2 points), and severe (3 points) at each level and combined into a lumbar vacuum score (0-15 points). Similarly, a lumbar Pfirrmann grade was calculated (5-25 points). Patients with previous hip or knee replacement surgery were classified as having an OA burden. We used multivariable regression to assess the association between OA and disk degeneration, adjusted for age, body mass index, and sex. RESULTS A total of 246 patients (58.9% female) were included in the final analysis. Of these, 22.3% had OA burden. The multivariable linear regression showed an independent association between OA burden and lumbar vacuum (β = 2.1, P <0.001) and Pfirrmann grade (β = 2.6, P <0.001). Representing a 2.1 points higher lumbar vacuum and 2.6 points higher lumbar Pfirrmann grade after accounting for demographic differences. CONCLUSIONS Our study showed that OA burden was independently associated with the severity of the intervertebral disk degeneration of the lumbar spine. These findings give further weight to a shared pathology of OA of large joints and degenerative processes of the lumbar spine. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Sebastian Braun
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopedics (Friedrichsheim), Goethe University, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Henryk Haffer
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | | | - Mariana Bendersky
- Normal Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
- Intraoperative Monitoring, Pediatric Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY
- Weill Cornell Medical College, New York, NY
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
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Eneqvist T, Persson L, Kojer E, Gunnarsson L, Gerdhem P. Spinal surgery and the risk of reoperation after total hip arthroplasty: a cohort study based on Swedish spine and hip arthroplasty registers. Acta Orthop 2024; 95:25-31. [PMID: 38240741 PMCID: PMC10798353 DOI: 10.2340/17453674.2024.35228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/05/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND AND PURPOSE Studies suggest increased revision risk of total hip arthroplasty (THA) in individuals with lumbar spinal fusion, but studies including non-fused individuals are lacking. We aimed to investigate whether individuals undergoing lumbar spinal stenosis surgery with or without fusion are at an increased risk of reoperation before or after THA. PATIENTS AND METHODS The Swedish Spine Register and the Swedish arthroplasty register were searched from 2000 through 2021. Chi-square, Kaplan-Meier and binary multivariate logistic regression were used to compare reoperation rates up to 10 years after THA surgery. RESULTS 7,908 individuals had undergone lumbar spinal stenosis surgery (LSSS) (fusion n = 1,281) and THA. LSSS before THA compared with THA-only controls was associated with a higher risk of THA reoperations: 87 (2%) out of 3,892 vs. 123 (1%) out of 11,662 (P < 0.001). LSSS after THA compared with THA-only controls was not associated with a higher risk of reoperation, confirmed by Kaplan- Meier analyses and binary multivariate logistic regression. Mortality was lower in individuals undergoing both LSSS and THA, regardless of procedure order. There was no difference in THA reoperations in individuals who had undergone LSSS before THA without fusion or with fusion. The individuals who had undergone LSSS after THA with fusion had an increased risk of THA reoperation compared with those without fusion. CONCLUSION LSSS with or without fusion before THA is associated with an increased risk of THA reoperation. Spinal fusion increased the risk of reoperation of THA when performed after THA.
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Affiliation(s)
- Ted Eneqvist
- Department of Clinical Sciences, Södersjukhuset, Karolinska Institutet, Stockholm; Department of Orthopaedics, Södersjukhuset, Stockholm
| | - Louise Persson
- Department of Clinical Sciences, Södersjukhuset, Karolinska Institutet, Stockholm; Department of Orthopaedics, Södersjukhuset, Stockholm
| | - Emma Kojer
- Department of Clinical Sciences, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Linus Gunnarsson
- Department of Clinical Sciences, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Paul Gerdhem
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm; Department of Orthopaedics and Hand Surgery, Uppsala University Hospital; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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Tang H, Guo S, Ma Z, Wang S, Zhou Y. A patient-specific algorithm for predicting the standing sagittal pelvic tilt one year after total hip arthroplasty. Bone Joint J 2024; 106-B:19-27. [PMID: 38160697 DOI: 10.1302/0301-620x.106b1.bjj-2023-0640.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Aims The aim of this study was to evaluate the reliability and validity of a patient-specific algorithm which we developed for predicting changes in sagittal pelvic tilt after total hip arthroplasty (THA). Methods This retrospective study included 143 patients who underwent 171 THAs between April 2019 and October 2020 and had full-body lateral radiographs preoperatively and at one year postoperatively. We measured the pelvic incidence (PI), the sagittal vertical axis (SVA), pelvic tilt, sacral slope (SS), lumbar lordosis (LL), and thoracic kyphosis to classify patients into types A, B1, B2, B3, and C. The change of pelvic tilt was predicted according to the normal range of SVA (0 mm to 50 mm) for types A, B1, B2, and B3, and based on the absolute value of one-third of the PI-LL mismatch for type C patients. The reliability of the classification of the patients and the prediction of the change of pelvic tilt were assessed using kappa values and intraclass correlation coefficients (ICCs), respectively. Validity was assessed using the overall mean error and mean absolute error (MAE) for the prediction of the change of pelvic tilt. Results The kappa values were 0.927 (95% confidence interval (CI) 0.861 to 0.992) and 0.945 (95% CI 0.903 to 0.988) for the inter- and intraobserver reliabilities, respectively, and the ICCs ranged from 0.919 to 0.997. The overall mean error and MAE for the prediction of the change of pelvic tilt were -0.3° (SD 3.6°) and 2.8° (SD 2.4°), respectively. The overall absolute change of pelvic tilt was 5.0° (SD 4.1°). Pre- and postoperative values and changes in pelvic tilt, SVA, SS, and LL varied significantly among the five types of patient. Conclusion We found that the proposed algorithm was reliable and valid for predicting the standing pelvic tilt after THA.
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Affiliation(s)
- Hao Tang
- Department of Adult Joint Reconstruction, Beijing Jishuitan Hospital, Capital Medical University, Fourth Clinical College of Peking University, Beijing, China
| | - Shaoyi Guo
- Department of Adult Joint Reconstruction, Beijing Jishuitan Hospital, Capital Medical University, Fourth Clinical College of Peking University, Beijing, China
| | - Zhuyi Ma
- Department of Adult Joint Reconstruction, Beijing Jishuitan Hospital, Capital Medical University, Fourth Clinical College of Peking University, Beijing, China
| | - Siyuan Wang
- Department of Adult Joint Reconstruction, Beijing Jishuitan Hospital, Capital Medical University, Fourth Clinical College of Peking University, Beijing, China
| | - Yixin Zhou
- Department of Adult Joint Reconstruction, Beijing Jishuitan Hospital, Capital Medical University, Fourth Clinical College of Peking University, Beijing, China
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Turcotte JJ, Brennan JC, Baxter S, Lashgari A, Stock LA, Johnson AH, King PJ, Patton CM. Effect of Lower Extremity Osteoarthritis on Outcomes of Lumbar Decompression. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202310000-00009. [PMID: 37861423 PMCID: PMC10586837 DOI: 10.5435/jaaosglobal-d-23-00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND The purpose of this study is to evaluate how hip or knee osteoarthritis (OA) and total joint arthroplasty impact the outcomes of patients undergoing lumbar decompression. METHODS A retrospective review of 342 patients undergoing lumbar decompression without fusion from January 2019 and June 2021 at a single institution was performed. Univariate and multivariate analyses were used to compare outcomes between patients with and without concomitant hip or knee OA. RESULTS Forty-six percent of patients had a hip or knee OA diagnosis and were higher risk as they were older, had higher BMIs, were more likely to be former smokers, had higher ASA scores, and were more likely to undergo 3+ level surgery. Postoperatively, after adjusting for differences between groups, hip or knee OA patients were more likely to be readmitted (OR=12.45, p=0.026) or have a complication (OR=13.77, p=0.031). However, patient reported outcomes as measured by Patient Reported Outcomes Measurement Information System-physical function. were similar at 1-3 months and 3-6 months. Higher levels of physical function were observed at 3-6 months postoperatively in hip OA patients with a history of THA. CONCLUSION Patients with concomitant hip or knee OA are at higher risk for readmission and postoperative complications but may achieve similar levels of physical function as those without OA.
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Nagata K, Dimar JR, Carreon LY, Glassman SD. Preoperative Optimization: Risk Factors for Perioperative Complications and Preoperative Modification. Neurosurg Clin N Am 2023; 34:505-517. [PMID: 37718097 DOI: 10.1016/j.nec.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Adult spinal deformity (ASD) is common and the complication rate in ASD surgery is high due to its invasiveness. There are several factors that increase the risk of complications with ASD surgery. These include age, past medical history, frailty, osteoporosis, or operative invasiveness. Risk factors for perioperative complications can be categorized as modifiable and non-modifiable. The purpose of this article is to present the current available evidence on risk factors for perioperative complications, with a focus on frailty, osteoporosis, surgical site infection prevention, and hip-spine syndrome. In addition, we present the latest evidence for patient-specific surgical risk assessment and surgical planning.
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Affiliation(s)
- Kosei Nagata
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA.
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
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Aubert T, Gerard P, Auberger G, Rigoulot G, Riouallon G. Low pelvic incidence with low lordosis and distal apex of lumbar lordosis associated with higher rates of abnormal spinopelvic mobility in patients undergoing THA. Bone Jt Open 2023; 4:668-675. [PMID: 37659768 PMCID: PMC10474956 DOI: 10.1302/2633-1462.49.bjo-2023-0091.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2023] Open
Abstract
Aims The risk factors for abnormal spinopelvic mobility (SPM), defined as an anterior rotation of the spinopelvic tilt (∆SPT) ≥ 20° in a flexed-seated position, have been described. The implication of pelvic incidence (PI) is unclear, and the concept of lumbar lordosis (LL) based on anatomical limits may be erroneous. The distribution of LL, including a unusual shape in patients with a high lordosis, a low pelvic incidence, and an anteverted pelvis seems more relevant. Methods The clinical data of 311 consecutive patients who underwent total hip arthroplasty was retrospectively analyzed. We analyzed the different types of lumbar shapes that can present in patients to identify their potential associations with abnormal pelvic mobility, and we analyzed the potential risk factors associated with a ∆SPT ≥ 20° in the overall population. Results ΔSPT ≥ 20° rates were 28.3%, 11.8%, and 14.3% for patients whose spine shape was low PI/low lordosis (group 1), low PI anteverted (group 2), and high PI/high lordosis (group 3), respectively (p = 0.034). There was no association between ΔSPT ≥ 20° and PI ≤ 41° (odds ratio (OR) 2.01 (95% confidence interval (CI)0.88 to 4.62), p = 0.136). In the multivariate analysis, the following independent predictors of ΔSPT ≥ 20° were identified: SPT ≤ -10° (OR 3.49 (95% CI 1.59 to 7.66), p = 0.002), IP-LL ≥ 20 (OR 4.38 (95% CI 1.16 to 16.48), p = 0.029), and group 1 (OR 2.47 (95% CI 1.19; to 5.09), p = 0.0148). Conclusion If the PI value alone is not indicative of SPM, patients with a low PI, low lordosis and a lumbar apex at L4-L5 or below will have higher rates of abnormal SPM than patients with a low PI anteverted and high lordosis.
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Affiliation(s)
- Thomas Aubert
- Department of Orthopaedic Surgery, Deaconess Saint Simon Cross Hospital Group, Paris, Île-de-France, France
| | - Philippe Gerard
- Department of Orthopaedic Surgery, Deaconess Saint Simon Cross Hospital Group, Paris, Île-de-France, France
| | - Guillaume Auberger
- Department of Orthopaedic Surgery, Deaconess Saint Simon Cross Hospital Group, Paris, Île-de-France, France
| | | | - Guillaume Riouallon
- Orthopaedic department, Paris Saint Joseph Hospital Group, Paris, Île-de-France, France
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Cho SK. Commentary on "The Posterior Cranial Vertical Line: A Novel Radiographic Marker for Classifying Global Sagittal Alignment". Neurospine 2023; 20:798. [PMID: 37798972 PMCID: PMC10562221 DOI: 10.14245/ns.2346868.434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Affiliation(s)
- Samuel K. Cho
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Does fusion length matter? Total hip arthroplasty dislocation after extension of lumbosacral fusion: a case report. Spine Deform 2023; 11:253-257. [PMID: 35921039 DOI: 10.1007/s43390-022-00563-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/23/2022] [Indexed: 10/16/2022]
Abstract
CASE Hip-spine syndrome is a complex challenge for orthopedic surgeons. We present a 60-year-old female with a history of spinal fusion and total hip arthroplasty. The patient underwent extension of the previous fusion with sacropelvic fixation, and 5 months later she presented with left posterior prosthetic hip dislocation which required sedation and closed reduction. CONCLUSION Even with no change in lumbar lordosis or pelvic tilt and adequate acetabular cup position, extension of the fusion construct may predispose patients to dislocation. This may be the result of an increased lever arm acting at the hip joint, thereby leading to instability.
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Muellner M, Wang Z, Hu Z, Hardt S, Pumberger M, Becker L, Haffer H. Hip replacement improves lumbar flexibility and intervertebral disc height - a prospective observational investigation with standing and sitting assessment of patients undergoing total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2022; 46:2195-2203. [PMID: 35821119 PMCID: PMC9492615 DOI: 10.1007/s00264-022-05497-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/22/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE The pathogenic mechanism of the hip-spine syndrome is still poorly elucidated. Some studies have reported a reduction in low back pain after total hip arthroplasty (THA). However, the biomechanical mechanisms of THA acting on the lumbar spine are not well understood. The aim of the study is to evaluate the influence of THA on (1) the lumbar lordosis and the lumbar flexibility and (2) the lumbar intervertebral disc height. METHODS A total of 197 primary THA patients were prospectively enrolled. Pre- and post-operative biplanar stereoradiography was performed in standing and sitting positions. Spinopelvic parameters (lumbar lordosis (LL), pelvic tilt, sacral slope, pelvic incidence), sagittal spinal alignment (sagittal vertical axis, PI-LL mismatch (PI-LL)) and lumbar disc height index (DHI) for each segment (L1/2 to L5/S1) were evaluated. The difference between standing and sitting LL (∆LL = LLstanding - LLsitting) was determined as lumbar flexibility. Osteochondrosis intervertebralis was graded according to Kellgren and Lawrence (0-4), and patients were assigned to subgroups (mild: 0-2; severe: 3-4). RESULTS Lumbar flexibility increased significantly after THA (pre: 22.04 ± 12.26°; post: 25.87 ± 12.26°; p < 0.001), due to significant alterations in LL in standing (pre: 51.3 ± 14.3°; post: 52.4 ± 13.8°; p < 0.001) and sitting (pre: 29.4 ± 15.4°; post: 26.7 ± 15.4°; p = 0.01). ∆LL increased significantly in both subgroups stratified by osteochondrosis (pre/post: ΔLLmild: 25.4 (± 11.8)/29.4 ± 12.0°; p < 0.001; ΔLLsevere: 17.5 (± 11.4)/21.0 ± 10.9°; p = 0.003). The DHI increased significantly from pre-operatively to post-operatively in each lumbar segment. PI-LL mismatch decreased significantly after THA (pre: 3.5°; post: 1.4°; p < 0.001). CONCLUSION The impact of THA on the spinopelvic complex was demonstrated by significantly improved lumbar flexibility and a gain in post-operative disc height. These results illustrate the close interaction between the pelvis and the vertebral column. The investigation provides new insights into the biomechanical patterns influencing the hip-spine syndrome.
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Affiliation(s)
- Maximilian Muellner
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Zhen Wang
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Zhouyang Hu
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sebastian Hardt
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Luis Becker
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Henryk Haffer
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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