L1-pelvic angle: a convenient measurement to attain optimal deformity correction

PURPOSE

(1) Evaluate the associations between L1-pelvic angle (L1PA) and both sagittal vertical axis (SVA) and T1-pelvic angle (T1PA), and (2) assess the clinical impact of L1PA.

METHODS

A single-institution retrospective cohort study was undertaken for patients undergoing adult spinal deformity (ASD) surgery from 2013 to 2017. Ideal L1PA was defined as (0.5xPelvic Incidence)-21. Pearson correlation was performed to compare L1PA, SVA, and T1PA. Univariate/multivariate regression was performed to assess the effect of L1PA on mechanical complications, controlling for age, BMI, and postoperative pelvic incidence-lumbar lordosis mismatch (PI/LL). Due to the overlapping nature of patients with pseudarthrosis and rod fracture, these patients were analyzed together.

RESULTS

A total of 145 patients were included. Mean preoperative L1PA, SVA, and T1PA were 15.5 ± 8.9°, 90.7 ± 66.8 mm, and 27.1 ± 13.0°, respectively. Mean postoperative L1PA, SVA, and T1PA were 15.0 ± 8.9°, 66.7 ± 52.8 mm, and 22.3 ± 11.1°, respectively. Thirty-six (24.8%) patients achieved ideal L1PA. Though the correlation was modest, preoperative L1PA was linearly correlated with preoperative SVA (r2 = 0.16, r = 0.40, 95%CI = 0.22-0.60, p < 0.001) and T1PA (r2 = 0.41, r = 0.62, 95%CI = 0.46-0.76, p < 0.001). Postoperative L1PA was linearly correlated with postoperative SVA (r2 = 0.12, r = 0.37, 95%CI = 0.18-0.56, p < 0.001) and T1PA (r2 = 0.40, r = 0.62, 95%CI = 0.45-0.74, p < 0.001). Achieving ideal L1PA ± 5° was associated with a decreased risk of rod fracture/pseudarthrosis on univariate and multivariate regression (OR = 0.33, 95%CI = 0.12-0.86, p = 0.024). No association between achieving ideal L1PA and patient-reported outcomes was observed.

CONCLUSION

L1PA was modestly correlated with SVA and T1PA, and achieving ideal L1PA was associated with lower rates of rod fracture/pseudarthrosis. Future studies are warranted to better define the clinical implications of achieving a normal L1PA.

LEVEL OF EVIDENCE

III.

Clinical and radiographic outcomes following correction of idiopathic scoliosis in adolescence vs young adulthood

PURPOSE

The natural history of adolescent idiopathic scoliosis (AIS) has been well documented, but the impact of age at the time of surgical correction is relatively understudied. In this study, we matched patients undergoing surgical correction of adult idiopathic scoliosis (AdIS) with a cohort of AIS patients to compare: (1) coronal and sagittal radiographic correction, (2) operative variables, and (3) postoperative complications.

METHODS

A single-institution scoliosis registry was queried for patients undergoing idiopathic scoliosis surgery from 2000-2017.

INCLUSION CRITERIA

patients with idiopathic scoliosis, no previous spine surgery, and 2-year follow-up. AdIS patients were matched 1:2 with AIS patients based on Lenke classification and curve characteristics. Independent sample t-test and Chi-square test was used to analyze the data.

RESULTS

31 adults underwent surgical correction of idiopathic scoliosis and were matched with 62 adolescents. Mean age of adults was 26.2 ± 11.05, mean BMI was 25.6 ± 6.0, and 22 (71.0%) were female. Mean age of adolescents was 14.2 ± 1.8, mean BMI was 22.7 ± 5.7, and 41(66.7%) were female. AdIS had significantly less postoperative major Cobb correction (63.9% vs 71.3%, p = 0.006) and final major Cobb correction (60.6% vs 67.9%, p = 0.025). AdIS also had significantly greater postoperative T1PA (11.8 vs 5.8, p = 0.002). AdIS had longer operative times (p = 0.003), higher amounts of pRBCs transfused (p = 0.005), longer LOS (p = 0.016), more ICU requirement (p = 0.013), higher overall complications (p < 0.001), higher rate of pseudarthrosis (p = 0.026), and more neurologic complications (p = 0.013).

CONCLUSION

Adult patients undergoing surgical correction of idiopathic scoliosis had significantly worse postoperative coronal and sagittal alignment when compared with adolescent patients. Adult patients also had higher rates of complications, longer operative times, and longer hospital stays.

LEVEL OF EVIDENCE

III.

The importance of Hounsfield units in adult spinal deformity surgery: finding an optimal threshold to minimize the risk of mechanical complications

Background

Low bone mineral density (BMD) is a well-established risk factor for mechanical complications following adult spinal deformity (ASD) surgery. Hounsfield units (HU) measured on computed tomography (CT) scans are a proxy of BMD. In ASD surgery, we sought to: (I) evaluate the association of HU with mechanical complications and reoperation, and (II) identify optimal HU threshold to predict the occurrence of mechanical complications.

Methods

A single-institution retrospective cohort study was undertaken for patients undergoing ASD surgery from 2013-2017. Inclusion criteria were: ≥5-level fusion, sagittal/coronal deformity, and 2-year follow-up. HU were measured on 3 axial slices of one vertebra, either at the upper instrumented vertebra (UIV) itself or UIV ±4 from CT scans. Multivariable regression controlled for age, body mass index (BMI), postoperative sagittal vertical axis (SVA), and postoperative pelvic-incidence lumbar-lordosis mismatch.

Results

Of 145 patients undergoing ASD surgery, 121 (83.4%) had a preoperative CT from which HU were measured. Mean age was 64.4±10.7 years, mean total instrumented levels was 9.8±2.6, and mean HU was 153.5±52.8. Mean preoperative SVA and T1PA were 95.5±71.1 mm and 28.8°±12.8°, respectively. Postoperative SVA and T1PA significantly improved to 61.2±61.6 mm (P<0.001) and 23.0°±11.0° (P<0.001). Mechanical complications occurred in 74 (61.2%) patients, including 42 (34.7%) proximal junctional kyphosis (PJK), 3 (2.5%) distal junctional kyphosis (DJK), 9 (7.4%) implant failure, 48 (39.7%) rod fracture/pseudarthrosis, and 61 (52.2%) reoperations within 2 years. Univariate logistic regression showed a significant association between low HU and PJK [odds ratio (OR) =0.99; 95% confidence interval (CI): 0.98-0.99; P=0.023], but not on multivariable analysis. No association was found regarding other mechanical complications, overall reoperations, and reoperations due to PJK. HU below 163 were associated with increased PJK on receiver operating characteristic (ROC) curve analysis [area under the curve (AUC) =0.63; 95% CI: 0.53-0.73; P<0.001].

Conclusions

Though several factors contribute to PJK, it appears that 163 HU may serve as a preliminary threshold when planning ASD surgery to mitigate the risk of PJK.

Sex-related Anthropometrics in a Lower-Body Mobility Assessment Among Professional Soccer Athletes

Background

The functional movement screen (FMS™) and Y-balance test (YBT) are commonly used to evaluate mobility in athletes.

Purpose

The primary aim of this investigation was to determine the relationship between demographic and anthropometric factors such as sex, body composition, and skeletal dimension and scoring on YBT and FMS™ in male and female professional soccer athletes.

Study Design

Cross Sectional.

Methods

During pre-season assessments, athletes from two professional soccer clubs were recruited and underwent body composition and skeletal dimension analysis via dual-energy X-ray absorptiometry (DEXA) scans. Balance and mobility were assessed using the YBT and FMS™. A two-tailed t-test was used to compare YBT between sexes. Chi-square was used for sex comparisons of FMS™ scores. Correlation analysis was used to determine if body composition and/or skeletal dimensions correlated with YBT or FMS™ measures. Type-I error; α=0.05.

Results

40 Participants were successfully recruited: (24 males: 27±5yr, 79±9kg; |16 females: 25±3yr, 63±4kg). YBT: Correlations were found between anterior reach and height (r=-0.36), total lean mass (LM)(r=-0.39), and trunk LM(r=-0.39) as well as between posterolateral reach and pelvic width (PW)(r=0.42), femur length (r=0.44), and tibia length (r=0.51)(all p<0.05). FMS™: The deep squat score was correlated with height(r=-0.40), PW(r=0.40), LM(r=-0.43), and trunk LM (r =-0.40)(p<0.05). Inline lunge scores were correlated with height(r=-0.63), PW(r=0.60), LM(r=-0.77), trunk LM(r=-0.73), and leg LM(r=0.70)(all p<0.05). Straight leg raise scores were correlated with PW (r=0.45, p<0.05). Females scored higher for the three lower body FMS™ measures where correlations were observed (p<0.05).

Conclusions

Lower body FMS™ scores differ between male and female professional soccer athletes and are related to anthropometric factors that may influence screening and outcomes for the FMS™ and YBT, respectively. Thus, these anatomical factors likely need to be taken into account when assessing baseline performance and risk of injury to improve screening efficacy.

Level of Evidence

Level 3b.

Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

Performance and Return to Sport After Hip Arthroscopy in the National Basketball Association

PURPOSE

To determine: (1) return to sport (RTS) rate in National Basketball Association (NBA) players following hip arthroscopy, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players.

METHODS

NBA athletes who underwent hip arthroscopy and matched controls were identified. RTS was defined as playing in at least 1 game after surgery. Player efficiency ratings were used for performance evaluation. Continuous variables of each group were compared using a 2-tailed paired samples Student t test for normally distributed data. χ² was used to analyze categorical data. RTS was used as the primary outcome with statistical significance defined by a P value < .05. A Bonferroni correction was used to control for the remaining multiple comparisons with statistical significance defined by a P value ≤.008.

RESULTS

Twenty-three players (24 hips) were analyzed (mean age 27.5 ± 3.1 years; mean experience in the NBA 5.8 ± 2.8 years at time of surgery). Small forwards (n = 8, 33.3%) represented the largest proportion of players that underwent hip arthroscopy. Twenty players (21 surgeries, 87.5%) were able to RTS in NBA at an average of 5.7 ± 2.6 months. The overall 1-year NBA career survival rate of players undergoing hip arthroscopy was 79.2%. Players in the control group (5.2 ± 3.5 years) had a similar career length as (P = .068) players who underwent surgery (4.4 ± 3.0 years). There was no significant (P = .045) decrease in games per season following surgery. There was no significant difference in performance postoperatively compared with preoperatively (P = .017) and compared with matched controls following surgery (P = .570).

CONCLUSIONS

The RTS rate for NBA athletes after hip arthroscopy is high. There was no decrease in games played, career lengths, or performance following hip arthroscopy in NBA players versus preoperatively and matched controls.

LEVEL OF EVIDENCE

Level III case-control study.

Performance and Return to Sport After Femoroacetabular Impingement Surgery in National Football League Players

The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls. [Orthopedics. 2019; 42(5):e423-e429.].

Performance and Return to Sport After Hip Arthroscopic Surgery in Major League Baseball Players

Background

Femoroacetabular impingement (FAI) is a common cause of hip pain that may lead to decreased performance in Major League Baseball (MLB) players.

Purpose

To determine the (1) return-to-sport (RTS) rate in MLB players after hip arthroscopic surgery for FAI; (2) postoperative career length, innings pitched (IP) (pitchers), and plate appearances (PA) (position players); (3) preoperative and postoperative performance; and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance.

Study Design

Cohort study; Level of evidence, 3.

Methods

MLB athletes who underwent hip arthroscopic surgery for FAI and matched controls were identified. Demographic and performance data were collected. RTS was defined as playing in at least 1 MLB game after surgery. Continuous variables of each group were compared using a 2-tailed paired-samples Student t test for normally distributed data. The chi-square test was used to analyze categorical data. The Bonferroni correction was used to control for multiple comparisons, with statistical significance defined by a P value of ≤.007.

Results

A total of 50 players (57 surgeries) were analyzed (mean age, 30.4 ± 3.9 years; mean MLB experience at the time of surgery, 7.0 ± 4.6 years). Pitchers (31 surgeries; 54.4%) represented the largest proportion of players analyzed. Of these players, 42 (47 surgeries; 82.5%) were able to RTS at a mean of 8.3 ± 4.1 months. The overall 1-year MLB career survival rate of players undergoing FAI surgery was 78.9%. Players in the control group were in MLB a similar number of years (4.0 ± 2.9 years) to players who underwent surgery (3.3 ± 2.4 years) (P > .007). There was no significant decrease in IP or PA per season after surgery (P > .007). There was no significant difference in performance for pitchers and nonpitchers compared with matched controls after surgery (P > .007).

Conclusion

The RTS rate for MLB athletes after hip arthroscopic surgery for FAI was high. There were similar IP, PA, and career lengths postoperatively compared with preoperatively and with matched controls. There was no significant difference in performance for pitchers and nonpitchers compared with matched controls after surgery.

Balance Right in Multiple Sclerosis (BRiMS): a guided self-management programme to reduce falls and improve quality of life, balance and mobility in people with secondary progressive multiple sclerosis: a protocol for a feasibility randomised controlled trial

BACKGROUND

Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed 'Balance Right in MS' (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial.

METHODS/DESIGN

This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include:Feasibility outcomes, including trial recruitment, retention and completionAssessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level)Measures of adherence to the BRiMS programmeData to inform the economic evaluation in a future trialProcess evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience).

DISCUSSION

The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial.

TRIAL REGISTRATION

ISRCTN13587999.

Study protocol for a double blind, randomised, placebo-controlled trial of continuous subpectoral local anaesthetic infusion for pain and shoulder function following mastectomy: SUB-pectoral Local anaesthetic Infusion following MastEctomy (SUBLIME) study

INTRODUCTION

Over 16 000 mastectomies are performed in England and Wales annually. Acute postoperative pain and nausea are common. The most frequently occurring long-term complications are chronic pain (up to 50%) and reduced shoulder function (reported at 35%). Regional techniques that improve acute postoperative pain relief may reduce the incidence of these complications. This study assesses the effectiveness of a 24-hour continuous local anaesthetic in the subpectoral plane in improving postoperative pain and quality of life in patients undergoing mastectomy.

METHODS AND ANALYSIS

This is a randomised, double blind, placebo-controlled, two-centre, parallel group trial in women undergoing mastectomy with or without axillary involvement. One hundred and sixty participants will be randomised in a 1:1 ratio to receive either 0.25% levobupivacaine or 0.9% saline by subpectoral infusion postoperatively for 24 h. All participants will be provided with an intravenous morphine patient-controlled analgesia (PCA) system. Participants will be followed-up for 24 h in hospital and at approximately 14 days and 6 months postoperatively. Joint primary outcome measures are total morphine consumption and total pain score (captured via patient-recorded visual analogue scale (VAS) 4 hourly) during the first 24 h postoperatively. Primary statistical analysis of total pain is based on the area under the curve of pain versus time graph. Secondary outcomes include PCA attempts in first 24 h; VAS pain scores and shoulder function by goniometry at 24 h, 14 days (approximately) and 6 months; Verbal Rating Scale pain scores in first 24 h; Brief Pain Inventory and Oxford Shoulder Score at 6 months; duration of hospital stay; incidence of postoperative nausea and vomiting; cost-effectiveness.

ETHICS AND DISSEMINATION

The study is approved by the South West England Research Ethics Committee (12/SW/0149).

RESULTS

will be published in a peer-reviewed journal and presented at local, national and international scientific meetings.

TRIAL REGISTRATION

ISRCTN46621916. EudraCT 2011-005775-16.

Multipolar plasmonic resonances in silver nanowire antennas imaged with a subnanometer electron probe

We detect short-range surface plasmon-polariton (SR-SPP) resonances setup in individual silver nanoantenna structures at high-spatial resolution with a scanning, subnanometer electron probe. Both even and odd multipolar resonant modes are resolved up to sixth order, and we measure their spatial distribution in relation to nanoantenna structures at energies down to 0.55 eV. Fabry-Perot type SR-SPP reflection phase shifts are calculated from direct measurements of antinode spacings in high-resolution plasmonic field maps. We observe resonant SR-SPP antinode bunching at nanoantenna terminals in high-order resonant modes, and antinode shifts in nonhomogeneous local environments. Finally, we achieve good agreement of our experimental SR-SPP maps with numerical calculations of photon excited near fields, using a novel integrated photon excitation geometry.

The impact of a temporary ice rink on a local emergency department service

Ice skating is becoming more popular throughout the UK, with temporary ice rinks opening in many city centres during holiday periods, especially during Christmas. Data were collected from patients who presented to the local emergency department with injuries sustained on a nearby city-centre temporary ice rink. Injuries related to ice rinks accounted for 0.76% of all emergency department attendances and represented 0.29% of ice rink participants (2.9 per 1000). Women in the older age range sustained the most significant injuries. Our study has shown that the rate of injuries per 1000 ice rink participants is comparable with data recorded when a new ice rink is opened.

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children

OBJECTIVE

To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury.

DESIGN

Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care.

SETTING

Five emergency departments in southwest England.

PARTICIPANTS

2127 adults and children presenting to the emergency department with acute elbow injury.

INTERVENTION

Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children.

MAIN OUTCOME MEASURES

Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days.

RESULTS

Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children.

CONCLUSION

The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

In vivo disintegration of luting cements

The in vivo disintegration of luting cements was determined at 6- and 12-month intervals in two test series of 20 participants each. Four cements were inserted in the wells located in the mesial and distal surfaces of cast crowns. Glass ionomer, silicophosphate, polycarboxylate, and zinc phosphate cements prepared with recommended powder/liquid ratios are discussed, and are ranked with respect to disintegration at 6 and 12 months.