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Solla F, Ilharreborde B, Blondel B, Prost S, Bauduin E, Laouissat F, Riouallon G, Wolff S, Challier V, Obeid I, Boissière L, Ferrero E, Lamas V, Le Huec JC, Bourret S, Faddoul J, Abi Lahoud GN, Fière V, Kerckhove MV, Lebhar J, Giorgi H, Faure A, Sauleau EA, Pesenti S, Charles YP. Can Lumbopelvic Parameters Be Used to Predict Thoracic Kyphosis at all Ages? A National Cross-Sectional Study. Global Spine J 2024; 14:1116-1124. [PMID: 36282728 DOI: 10.1177/21925682221134039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN National cross-sectional study. OBJECTIVE Thoracic kyphosis (TK) is related to sagittal parameters as pelvic tilt (PT), lumbar lordosis (LL) and pelvic incidence (PI). The equation TK = 2 (PT+LL-PI) was validated for adolescents. The purpose of this study was to investigate if this equation correctly predicts TK regardless of age. METHODS Sagittal alignment parameters were assessed on full spine radiographs of 2599 individuals without spine pathology (1488 females, 1111 males). Calculated TK (CTK) = 2 (PT+LL-PI) and measured TK (MTK) were compared by calculating the gap and using a linear regression between both parameters. Subgroup analyses were performed for gender, age, TK groups (≤20°, 21°-40°, 41°-60°, >60°), and PI groups (<45°, 45°-60°, >60°). RESULTS Average values in the total population were: MTK 45.0°, CTK 36.9°. Average TK gap was 8.1°, 5.2° in females (intercept 11.7, slope .61) and 11.9° in males (intercept 7.1, slope .58). The mean gap was 3.6° for 15-34 years, 5.7° under 15 years and it increased progressively after 35 years with a maximum of 19.9° over 80 years. The gap also increased with the amount of MTK: -3.5° for TK<20° up to 17.3° for TK >60°. Differences in gaps were minor between PI groups. The intercept was smallest and slopes >.6 for PI <45° and TK ≤20°. CONCLUSION The formula TK=2 (PT+LL-PI) yielded moderate accuracy for adolescents and young adults, but did not fit for over 35 years and under 15. The amount and variance in TK increased in elderly subjects, which made the formula less accurate.
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Affiliation(s)
| | - Brice Ilharreborde
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, Île-de-France, France
| | - Benjamin Blondel
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Solène Prost
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Eloïse Bauduin
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital Maison Blanche, CHU de Reims, Reims, France
| | | | - Guillaume Riouallon
- Service de Chirurgie Orthopédique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Stéphane Wolff
- Service de Chirurgie Orthopédique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | | | | | - Emmanuelle Ferrero
- Service de Chirurgie Orthopédique de la Colonne Vertébrale, AP-HP, Hôpital Européen Georges-Pompidou, Université de Paris, Paris, France
| | - Vincent Lamas
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | | | - Stéphane Bourret
- Polyclinique Bordeaux Nord Aquitaine, Université de Bordeaux, France
| | - Joe Faddoul
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Georges Naïm Abi Lahoud
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Vincent Fière
- Unité du Rachis, Centre Orthopédique Santy, Hôpital privé Jean Mermoz Ramsay Santé, Lyon, France
| | - Michiel Vande Kerckhove
- Unité du Rachis, Centre Orthopédique Santy, Hôpital privé Jean Mermoz Ramsay Santé, Lyon, France
| | - Jonathan Lebhar
- Institut Locomoteur de l'Ouest Rachis, Centre Hospitalier Privé Saint-Grégoire, France
| | | | | | - Erik A Sauleau
- Pôle Santé Publique, Hôpitaux Universitaires de Strasbourg, France
| | - Sébastien Pesenti
- Service d'Orthopédie Pédiatrique, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Yann Philippe Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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Prost S, Blondel B, Bauduin E, Pesenti S, Ilharreborde B, Laouissat F, Riouallon G, Wolff S, Challier V, Obeid I, Boissière L, Ferrero E, Solla F, Le Huec JC, Bourret S, Faddoul J, Abi Lahoud GN, Fière V, Vande Kerckhove M, Campana M, Lebhar J, Giorgi H, Faure A, Sauleau EA, Charles YP. Do Age-Related Variations Of Sagittal Alignment Rely On SpinoPelvic Organization? An Observational Study Of 1540 Subjects. Global Spine J 2023; 13:2144-2154. [PMID: 35191731 PMCID: PMC10538341 DOI: 10.1177/21925682221074660] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Descriptive radiographic analysis of a prospective multi-center database. OBJECTIVE This study aims to provide normative values of spinopelvic parameters and their correlations according to age and pelvic incidence (PI) of subjects without spinal deformity. METHODS After Institutional Review Board (IRB) approval, 1540 full spine radiographs were analyzed. Subjects were divided into 3 groups of PI: low PI < 45°, intermediate PI 45-60°, high PI > 60°, and then stratified by age (20-34, 35-49, 50-64, > 65 Y.O). Pelvic and spinal parameters were measured. Statistical analysis between parameters was performed using Bayesian inference and correlation. RESULTS Mean age was 53.5 years (845 females, 695 males, range 20-93 years).In low PI group, lumbar lordosis (LL) decrease was mainly observed in the 2 younger age groups.In medium and high PI groups, loss of lordosis was linear during aging and occurred mainly on the distal arch of lordosis. Moderate PI group had a stable lordosis apex and thoracolumbar inflection point. High PI group had a stable thoracolumbar inflection point and a more distal lordosis apex in elderly subjects.For all subjects, kyphosis and pelvic tilt (PT) increased with age.There was a constant chain of correlation between PI and age groups. Proximal lumbar lordosis (PLL) was correlated with kyphosis and sagittal vertical axis (SVA C7), while the distal lumbar lordosis (DLL) was correlated with PI and PT. CONCLUSION This study provides a detailed repository of sagittal spinopelvic parameters normative values with detailed analysis of segmental kyphosis and lordosis distribution according to gender, age, and PI.
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Affiliation(s)
- Solène Prost
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, France
| | - Benjamin Blondel
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, France
| | - Eloïse Bauduin
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital Maison Blanche, CHU de Reims, France
| | - Sébastien Pesenti
- Service d’Orthopédie Pédiatrique, CHU Timone, Aix-Marseille Université, France
| | - Brice Ilharreborde
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, France
| | | | - Guillaume Riouallon
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Stéphane Wolff
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | | | | | - Emmanuelle Ferrero
- Service de Chirurgie Orthopédique de la Colonne Vertébrale, AP-HP, Hôpital Européen Georges-Pompidou, Université de Paris, France
| | - Federico Solla
- Service d’Orthopédie Pédiatrique, Fondation Lenval, Nice, France
| | | | - Stéphane Bourret
- Polyclinique Bordeaux Nord Aquitaine, Université de Bordeaux, France
| | - Joe Faddoul
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Georges Naïm Abi Lahoud
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Vincent Fière
- Unité du Rachis, Centre Orthopédique Santy, Lyon, France
| | | | - Matthieu Campana
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, France
| | - Jonathan Lebhar
- Institut Locomoteur de l’Ouest Rachis,Centre Hospitalier Privé Saint-Grégoire, France
| | | | | | - Erik A. Sauleau
- Pôle Santé Publique, Hôpitaux Universitaires de Strasbourg, France
| | - Yann Philippe Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - The French Spine Surgery Society (SFCR)
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, France
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital Maison Blanche, CHU de Reims, France
- Service d’Orthopédie Pédiatrique, CHU Timone, Aix-Marseille Université, France
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, France
- Hôpital Privé de l’Est Lyonnais, Saint-Priest, France
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris, France
- Hôpital Privé du Dos Francheville, Périgueux, France
- Clinique du Dos Jean Villar, Bruges, France
- Service de Chirurgie Orthopédique de la Colonne Vertébrale, AP-HP, Hôpital Européen Georges-Pompidou, Université de Paris, France
- Service d’Orthopédie Pédiatrique, Fondation Lenval, Nice, France
- Polyclinique Bordeaux Nord Aquitaine, Université de Bordeaux, France
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
- Unité du Rachis, Centre Orthopédique Santy, Lyon, France
- Institut Locomoteur de l’Ouest Rachis,Centre Hospitalier Privé Saint-Grégoire, France
- Institut Méditerranéen du Dos, Marseille, France
- Pôle Santé Publique, Hôpitaux Universitaires de Strasbourg, France
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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Lefèvre E, Szadkowski M, Fière V, Vieira TD, Ould-Slimane M, d'Astorg H. Implications of cage impactions in single-level OLIF treatment of degenerative spondylolisthesis. Orthop Traumatol Surg Res 2023; 109:103385. [PMID: 35933020 DOI: 10.1016/j.otsr.2022.103385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Cage impactions (CI) of Oblique Lumbar Interbody Fusion (OLIF) appear to be a frequent mechanical complication with a potential functional impact. OBJECTIVES To determine the rate of CI occurrence, their risk factors and clinical implications in the case of combined single-level arthrodesis. METHOD A retrospective analysis of prospectively collected data was performed. All our patients with degenerative spondylolisthesis initially underwent OLIF combined with pedicle screw fixation (PSF). Intraoperative control with an image intensifier and a standard radiograph in the immediate postoperative period made it possible to assess the occurrence of CI, depending on the position of the implant. Secondary subsidence was sought on the standing radiological examination using EOS biplanar radiography during follow-up. The pelvic parameters were analyzed, as well as the occurrence of bone fusion. The clinical evaluation was made at≥1 year, by the Oswestry Disability Index (ODI), the walking distance (WD) and the Visual Analogue Scale (VAS). RESULTS In all, 130 patients out of the 131 included were analyzed. A CI occurred in 25.3% (n=33) of cases and of these, 94% (n=32) occurred intraoperatively. Postmenopausal women had more CI with an odds ratio (OR) of 5.8 (P=0.034). The "CI" group had a 9.5% lower ODI score than the "non-CI" group (P=0.0040), but both provided excellent ODI gains of 30.8±16 and 32.9±15.5% (P<0.0001). An "anterior" position of the implant allowed a greater gain in lumbar lordosis (P<0.001) but was associated with greater CI occurrence (P<0.001), with an OR of 6.75 (P=0.0018). CONCLUSION The occurrence of intraoperative cage impaction is a frequent event when performing OLIF. Postmenopausal women have an approximately 6 times greater risk of impaction than men, and patients with an "anterior" implant placement have a 7 times greater risk than with central placement. The negative impact of cage impactions on the clinical score (ODI) was significant after one year of follow-up. LEVEL OF EVIDENCE IV, non-comparative cohort study.
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Affiliation(s)
- Emeric Lefèvre
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Marc Szadkowski
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Vincent Fière
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.
| | | | - Henri d'Astorg
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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4
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Charles YP, Bauduin E, Pesenti S, Ilharreborde B, Prost S, Laouissat F, Riouallon G, Wolff S, Challier V, Obeid I, Boissière L, Ferrero E, Solla F, Le Huec JC, Bourret S, Faddoul J, Abi Lahoud GN, Fière V, Vande Kerckhove M, Campana M, Lebhar J, Giorgi H, Faure A, Sauleau EA, Blondel B. Variation of Global Sagittal Alignment Parameters According to Gender, Pelvic Incidence, and Age. Clin Spine Surg 2022; 35:E610-E620. [PMID: 35383599 DOI: 10.1097/bsd.0000000000001321] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cross-sectional study. OBJECTIVE The aim was to describe existing global sagittal alignment parameters across ages and to analyze differences according to gender and pelvic incidence (PI). SUMMARY OF BACKGROUND DATA Variability with age has been reported. It remains unclear how gender and spinopelvic morphology could additionally influence global alignment parameters. MATERIALS AND METHODS Radiographs of 2599 individuals (5-93 y) were analyzed. Translation parameters were: Sagittal Vertical Axis (SVA)-C7, SVA-C2, SVA-Center Acoustic Meatus (CAM), C7/Sacrofemoral Distance (SFD) ratio. Inclination parameters were: C7-Vertical Tilt (VT), T1-VT and T9-VT, Odontoid-Hip Axis (OD-HA), OD-CAM. Pelvic compensation parameters were: T1-Pelvic Angle (TPA), Global Tilt (GT), Spino-Sacral Angle (SSA). Global sagittal alignment (GSA) was considered among formulae. The distribution of parameters was analyzed using a Bayesian inference. Correlations with spinopelvic parameters were investigated. RESULTS SVA-C7, SVA-C2, SVA-CAM were larger in males and high PI, and increased significantly after 50 years (Pr>0.9999). C7/SFD decreased during growth and was larger in low PI (Pr=0.951). There was no correlation with spinopelvic parameters. Age-related variations of inclination parameters were nonsignificant. T1-VT and T9-VT increased with PI and were significantly larger in high PI (Pr>0.95). C7-VT was significantly larger in low PI (Pr>0.9999). OD-HA and OD-CAM were constant and increased after 80 years. TPA and GT increased with PI (Pr>0.9999) and age after 35 years (Pr>0.9999). SSA decreased nonsignificantly after 50 years. TPA correlated with PI (ρ=0.6130) and pelvic tilt (PT) (ρ=0.8375). GT correlated with PI (ρ=0.5961) and PT (ρ=0.8996). SSA correlated with sacral slope (ρ=0.9026). GSA was larger in high PI (Pr>0.9999) and increased after 35 years (Pr>0.9999). GSA correlated with PT (ρ=0.7732). CONCLUSION Translation parameters increase with age, more prominently in males and high PI. Variations of inclination parameters are smaller. Pelvic compensation parameters and GSA increase with age and are closely related to PT and spinopelvic morphology. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yann P Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg
| | - Eloïse Bauduin
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital Maison Blanche, CHU de Reims, Reims
| | - Sébastien Pesenti
- Service d'Orthopédie Pédiatrique, CHU Timone, Aix-Marseille Université, Marseille
| | - Brice Ilharreborde
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, Paris
| | - Solène Prost
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille
| | | | - Guillaume Riouallon
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris
| | - Stéphane Wolff
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris
| | | | | | | | - Emmanuelle Ferrero
- Service de Chirurgie Orthopédique de la Colonne Vertébrale, AP-HP, Hôpital Européen Georges-Pompidou, Université de Paris, Paris
| | - Federico Solla
- Service d'Orthopédie Pédiatrique, Fondation Lenval, Nice
| | | | - Stéphane Bourret
- Polyclinique Bordeaux Nord Aquitaine, Université de Bordeaux, Bordeaux
| | - Joe Faddoul
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris
| | - Georges N Abi Lahoud
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris
| | | | | | - Matthieu Campana
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, Paris
| | - Jonathan Lebhar
- Institut Locomoteur de l'Ouest Rachis, Centre Hospitalier Privé Saint-Grégoire, Saint-Grégoire
| | | | | | - Erik A Sauleau
- Pôle Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Benjamin Blondel
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille
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Szadkowski M, Bahroun S, Aleksic I, Vande Kerckhove M, Ramos-Pascual S, Saffarini M, Fière V, d'Astorg H. Bioactive glass grants equivalent fusion compared to autologous iliac crest bone for ALIF: a within-patient comparative study. J Exp Orthop 2022; 9:56. [PMID: 35713816 PMCID: PMC9206065 DOI: 10.1186/s40634-022-00496-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose To determine within-patient fusion rates of chambers filled with bioactive glass versus autologous iliac crest bone on computed tomography (CT) following anterior lumbar interbody fusion (ALIF). Methods A consecutive series of 40 patients (58 levels) that underwent single-level (L5-S1 only) or two-level (L5-S1 and L4-L5) ALIF were assessed. Indications for fusion were one or more of the following: degenerative disc disease with or without Modic changes, spondylolisthesis, and stenosis. Each intervertebral cage had a middle beam delimiting two chambers, one of which was filled with bioactive glass and the other with autologous iliac crest bone. CT scans were graded using the Bridwell classification (grade I, best; grade IV, worst). Patients were evaluated using the Oswestry Disability Index (ODI), and by rating pain in the lower back and legs on a Visual Analog Scale (pVAS); complications and reoperations were noted. Results At 15 ± 5 months follow-up, there were no significant differences in fusion across chambers filled with bioactive glass versus chambers filled with autologous bone (p = 0.416). Two patients with Bridwell grade III at both chambers of the L4-L5 cages required reoperation using posterior instrumentation. Clinical assessment of the 38 remaining patients (54 levels) at 25 ± 2 months, revealed ODI of 15 ± 12, lower back pVAS of 1.4 ± 1.5 and legs pVAS of 1.9 ± 1.6. Conclusions For ALIF at L5-S1 or L4-L5, within-patient fusion rates were equivalent for bioactive glass compared to autologous iliac crest bone; thus, bioactive glass can substitute autologous bone, avoiding increased operative time and blood loss, as well as donor site morbidity.
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Affiliation(s)
| | - Sami Bahroun
- Ramsay Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Ivan Aleksic
- Ramsay Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | | | | | - Mo Saffarini
- ReSurg SA, Rue Saint-Jean 22, 1260, Nyon, Switzerland
| | - Vincent Fière
- Ramsay Santé, Hôpital Privé Jean Mermoz, Lyon, France
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Charles YP, Prost S, Pesenti S, Ilharreborde B, Bauduin E, Laouissat F, Riouallon G, Wolff S, Challier V, Obeid I, Boissière L, Ferrero E, Solla F, Le Huec JC, Bourret S, Faddoul J, Abi Lahoud GN, Fière V, Vande Kerckhove M, Campana M, Lebhar J, Giorgi H, Faure A, Sauleau EA, Blondel B. Variation of cervical sagittal alignment parameters according to gender, pelvic incidence and age. Eur Spine J 2022; 31:1228-1240. [PMID: 34989876 DOI: 10.1007/s00586-021-07102-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/03/2021] [Accepted: 12/20/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim was to describe radiographic cervical sagittal alignment variations according to age, gender and pelvic incidence (PI) and to investigate relationships with thoracic alignment. METHODS A total of 2599 individuals (5-93 years) without spinal deformity were studied. Cranial cervical parameters were: McGregor slope, occipita-C2 angle, McGregor-C2 lordosis and C1-C2 lordosis. Caudal cervical parameters were: C2-C7, cranial arch and caudal arch lordosis and C7- and T1-slope. A Bayesian inference compared parameter distributions. Correlations with spinopelvic and global alignment parameters were investigated. RESULTS Among cranial cervical parameters, variations of McGregor slope were non-significant. McGregor-C2 lordosis and C1-C2 lordosis were smaller in males and increased significantly during growth, whereas the occipito-C2 angle decreased (Pr > 0.95). The occipito-C2 angle was larger and McGregor-C2 lordosis was smaller in low PI (Pr > 0.95). Among caudal cervical parameters, C2-C7 lordosis and C7- and T1-slope were larger in males and increased after 50 years (Pr > 0.95). Lordosis changes were non-significant in the cranial arch, whereas values increased in the caudal arch after 35 years (Pr > 0.95). Caudal parameter differences were non-significant between PI groups. Strong correlations existed between C2-C7, caudal arch lordosis, C7-slope, T1-slope and thoracic kyphosis. The sagittal vertical axis C2 correlated with caudal arch lordosis and T1-slope (ρ > 0.5; Pr > 0.95). CONCLUSION Cervical alignment parameters vary according to age, gender and PI. In the cranial cervical spine, changes occur mainly during growth. In the caudal cervical spine, lordosis increases in the caudal arch, which is related to thoracic kyphosis increase with age. The caudal cervical arch acts as a compensatory segment by progressive extension, allowing horizontal gaze.
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Affiliation(s)
- Yann Philippe Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France.
| | - Solène Prost
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Sébastien Pesenti
- Service d'Orthopédie Pédiatrique, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Brice Ilharreborde
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, Paris, France
| | - Eloïse Bauduin
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital Maison Blanche, CHU de Reims, Reims, France
| | | | - Guillaume Riouallon
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Stéphane Wolff
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | | | | | - Emmanuelle Ferrero
- Service de Chirurgie Orthopédique de la Colonne Vertébrale, AP-HP, Hôpital Européen Georges-Pompidou, Université de Paris, Paris, France
| | - Federico Solla
- Service d'Orthopédie Pédiatrique, Fondation Lenval, Nice, France
| | | | - Stéphane Bourret
- Polyclinique Bordeaux Nord Aquitaine, Université de Bordeaux, Bordeaux, France
| | - Joe Faddoul
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Georges Naïm Abi Lahoud
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Vincent Fière
- Centre Orthopédique Santy, Unité du Rachis, Lyon, France
| | | | - Matthieu Campana
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, Paris, France
| | - Jonathan Lebhar
- Institut Locomoteur de L'Ouest Rachis, Centre Hospitalier Privé Saint-Grégoire, Saint-Grégoire, France
| | | | | | - Erik André Sauleau
- Pôle Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Benjamin Blondel
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille, France
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Charles YP, Prost S, Pesenti S, Ilharreborde B, Bauduin E, Laouissat F, Riouallon G, Wolff S, Challier V, Obeid I, Boissière L, Ferrero E, Solla F, Le Huec JC, Bourret S, Faddoul J, Abi Lahoud GN, Fière V, Vande Kerckhove M, Campana M, Lebhar J, Giorgi H, Faure A, Sauleau EA, Blondel B. Correction to: Variation of cervical sagittal alignment parameters according to gender, pelvic incidence and age. Eur Spine J 2022; 31:1330. [PMID: 35301583 DOI: 10.1007/s00586-022-07170-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Yann Philippe Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France.
| | - Solène Prost
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Sébastien Pesenti
- Service d'Orthopédie Pédiatrique, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Brice Ilharreborde
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, Paris, France
| | - Eloïse Bauduin
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital Maison Blanche, CHU de Reims, Reims, France
| | | | - Guillaume Riouallon
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Stéphane Wolff
- Service de Chirurgie Orthopédique et Traumatolgique, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | | | | | - Emmanuelle Ferrero
- Service de Chirurgie Orthopédique de la Colonne Vertébrale, AP-HP, Hôpital Européen Georges-Pompidou, Université de Paris, Paris, France
| | - Federico Solla
- Service d'Orthopédie Pédiatrique, Fondation Lenval, Nice, France
| | | | - Stéphane Bourret
- Polyclinique Bordeaux Nord Aquitaine, Université de Bordeaux, Bordeaux, France
| | - Joe Faddoul
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Georges Naïm Abi Lahoud
- Institut de la Colonne Vertébrale et des Neurosciences, Centre Médico-Chirurgical Bizet, Paris, France
| | - Vincent Fière
- Centre Orthopédique Santy, Unité du Rachis, Lyon, France
| | | | - Matthieu Campana
- Service de Chirurgie Orthopédique Pédiatrique, AP-HP, CHU Robert Debré, Université de Paris, Paris, France
| | - Jonathan Lebhar
- Institut Locomoteur de L'Ouest Rachis, Centre Hospitalier Privé Saint-Grégoire, Saint-Grégoire, France
| | | | | | - Erik André Sauleau
- Pôle Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Benjamin Blondel
- Unité de Chirurgie Rachidienne, CHU Timone, Aix-Marseille Université, Marseille, France
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Solla F, Barrey CY, Rampal V, Fière V. Comments to "Utility of Patient-Specific Rod Instrumentation in Deformity Correction: Single Institution Experience" By Sadrameli et al. Spine Surg Relat Res 2021; 5:450-451. [PMID: 34966875 PMCID: PMC8668206 DOI: 10.22603/ssrr.2020-0190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Federico Solla
- Orthopaedic and Scoliosis Surgery Unit, Lenval Hospital, Nice, France
| | | | - Viriginie Rampal
- Orthopaedic and Scoliosis Surgery Unit, Lenval Hospital, Nice, France
| | - Vincent Fière
- Spinal Unit, Santy Orthopaedic Center & Mermoz Hospital Ramsay, Lyon, France
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Szadkowski M, Bahroun S, Aleksic I, Vande Kerckhove M, Ramos-Pascual S, Fière V, d'Astorg H. Clinical and radiologic outcomes of stand-alone anterior lumbar interbody fusion at L4-L5. Interdisciplinary Neurosurgery 2021. [DOI: 10.1016/j.inat.2021.101312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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d'Astorg H, Vieira TD, Gallet D, Fière V, Szadkowski M. Reply to the letter by Bhavuk Garg and Nishank Mehta. Orthop Traumatol Surg Res 2021; 107:102883. [PMID: 33689870 DOI: 10.1016/j.otsr.2021.102883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/11/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Henri d'Astorg
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, 24, avenue Paul Santy, 69008 Lyon, France.
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, 24, avenue Paul Santy, 69008 Lyon, France
| | - Denis Gallet
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, 24, avenue Paul Santy, 69008 Lyon, France
| | - Vincent Fière
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, 24, avenue Paul Santy, 69008 Lyon, France
| | - Marc Szadkowski
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, 24, avenue Paul Santy, 69008 Lyon, France
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Solla F, Fière V, Barrey CY. Comments to "Patient-specific" rods in the management of adult spinal deformity. One-year radiographic results of a prospective study about 86 patients, Prost et al. Neurochirurgie 66 (3) (2000) 162-167. Neurochirurgie 2020; 67:402-403. [PMID: 33053404 DOI: 10.1016/j.neuchi.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- F Solla
- Orthopaedic and Scoliosis Surgery unit, Lenval Hospital, 57, Av. De la Californie, 06200 Nice, France.
| | - V Fière
- Spinal Unit, Santy Orthopaedic Center & Mermoz Hospital Ramsay GDS, 24 Avenue Paul Santy, 69008 Lyon, France.
| | - C Y Barrey
- Spine Unit, P. Wertheimer Hospital, University Hospitals of Lyon, 59 Boulevard Pinel, 69677 Bron, France.
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d'Astorg H, Fière V, Dupasquier M, Vieira TD, Szadkowski M. Enhanced recovery after surgery (ERAS) protocol reduces LOS without additional adverse events in spine surgery. Orthop Traumatol Surg Res 2020; 106:1167-1173. [PMID: 32631715 DOI: 10.1016/j.otsr.2020.01.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/06/2019] [Accepted: 01/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols aim to reduce the physiological stress induced by surgery. These protocols are persistently associated with improved outcomes and reduced costs in several orthopaedic subspecialties. Recently, spine surgery has been explored in the literature as a potential and beneficial domain for ERAS protocols. The aim of this study was to compare the short-term postoperative spine surgery follow-up between patients who underwent the ERAS protocol and those who recovered conventionally. HYPOTHESIS The ERAS protocol developed in our department since 2016 is beneficial to patients undergoing spinal surgery. PATIENTS AND METHODS A retrospective analysis of data collected prospectively was performed to include all patients who underwent spinal surgery and went through the ERAS protocol in our clinic between January 2017 and January 2018. A control group was paired using a propensity score. Length of hospital stay (LOS), complications, rate of readmissions, postoperative pain, function and satisfaction were compared between the two groups. RESULTS A total of 193 patients received the ERAS protocol during the study period. After pairing, 193 couples were selected resulting in a final database of 386 patients for the analysis. There was a significant difference in mean LOS, defined as the average number of days spent in hospital, between the two groups (ERAS group, mean LOS=2.6 days [median 2 days, range 1-7], control group mean LOS=4.4 days [median 4 days, range 2-14]; p<0.0001). Complications, rate of readmissions, postoperative pain, function and satisfaction were similar in the two groups. DISCUSSION The ERAS protocol decreased hospital LOS, without resulting in additional adverse events after spinal surgery. These findings support the application of our ERAS protocol after spinal surgery. LEVEL OF EVIDENCE III, retrospective analysis.
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Affiliation(s)
- Henri d'Astorg
- Centre orthopédique Santy, Lyon, France; Hôpital privé Jean-Mermoz, Ramsay-générale de santé, Lyon, France
| | - Vincent Fière
- Centre orthopédique Santy, Lyon, France; Hôpital privé Jean-Mermoz, Ramsay-générale de santé, Lyon, France
| | - Maud Dupasquier
- Hôpital privé Jean-Mermoz, Ramsay-générale de santé, Lyon, France
| | - Thais Dutra Vieira
- Centre orthopédique Santy, Lyon, France; Hôpital privé Jean-Mermoz, Ramsay-générale de santé, Lyon, France.
| | - Marc Szadkowski
- Centre orthopédique Santy, Lyon, France; Hôpital privé Jean-Mermoz, Ramsay-générale de santé, Lyon, France
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13
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Canetti R, de Saint Vincent B, Vieira TD, Fière V, Thaunat M. Spinopelvic parameters in greater trochanteric pain syndrome: a retrospective case-control study. Skeletal Radiol 2020; 49:773-778. [PMID: 31828381 DOI: 10.1007/s00256-019-03359-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Greater trochanteric pain syndrome (GTPS) is a condition resulting in lateral hip pain, most commonly caused by tendinosis or tear of the gluteus medius and minimus tendons, and greater trochanteric bursitis. Our aim was to assess pelvic parameters and proximal femoral anatomy in patients suffering from surgical-stage GTPS compared with a control group. METHODS This retrospective, case-control study assessed 43 patients suffering from GTPS, matched according to age, gender, body mass index and level of sport and physical activity to 43 control patients, between 2013 and 2018. Pelvic parameters, including pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS), and proximal femoral anatomy, including femoral offset (FO) and neck-shaft angle (NSA), were measured using the EOS Imaging™ system. RESULTS GTPS patients had a significantly lower mean (± SD) SS than control patients (33.1 ± 10.4 vs. 39.6 ± 9.7°, respectively; p < 0.05). There was no significant difference in PT (21.3 ± 7.1 vs. 19.0 ± 7.2°), PI (53.5 ± 11.6 vs. 57.7 ± 10.5°), FO (40.4 ± 8 vs. 42.2 ± 6.8°) or NSA (125.1 ± 5.8 vs. 124.4 ± 4.7°). There was no difference in lower back pain symptoms in a subgroup analysis of GTPS patients. CONCLUSIONS Sacral slope was lower in patients with surgical-stage GTPS than in asymptomatic hip patients, using the EOS Imaging™ system.
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Affiliation(s)
- Robin Canetti
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008, Lyon, France
| | - Benoit de Saint Vincent
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008, Lyon, France
| | - Thais D Vieira
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008, Lyon, France
| | - Vincent Fière
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008, Lyon, France
| | - Mathieu Thaunat
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008, Lyon, France.
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14
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Solla F, Clément JL, Cunin V, Bertoncelli CM, Fière V, Rampal V. Patient-specific rods for thoracic kyphosis correction in adolescent idiopathic scoliosis surgery: Preliminary results. Orthop Traumatol Surg Res 2020; 106:159-165. [PMID: 31757655 DOI: 10.1016/j.otsr.2019.07.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 07/02/2019] [Accepted: 07/22/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Restoring a degree of kyphosis consistent with good sagittal alignment of the spine is a key concern when performing surgery to correct adolescent idiopathic scoliosis (AIS). The objective of this study was to assess the preliminary outcomes of posterior fusion for AIS using patient-specific rods that were pre-contoured based on pelvic incidence. The primary evaluation criterion was thoracic kyphosis at last follow-up. HYPOTHESIS The use of pre-bent patient-specific rods has a favourable effect on thoracic kyphosis at last follow-up. MATERIAL AND METHODS A total of 37 patients with AIS, including 17 with hypokyphosis, managed with patient-specific rods were included in a prospective study. The rod contouring angles were based on predefined pelvic incidence criteria (25° to 40° for the rod on the convex side and the same value plus 10° for the rod on the concave side). Thoracic kyphosis was assessed before surgery and at last follow-up, after 12-36 months (mean, 19 months). Student's t test was applied to compare means. Multivariate linear regression analysis was performed. RESULTS At last follow-up, the mean increase in kyphosis was 14° and was comparable to the planned increase (mean difference=0, p=0.85). Factors associated with kyphosis at last follow-up were the concave rod contouring angle and the pre-operative kyphotic angle of the thoracic segment to be instrumented (p<0.05). Mean differences between kyphosis of the instrumented thoracic segment at last follow-up and target kyphosis were -5° in the subgroup with hypokyphosis (<20°) before surgery and +4° in the subgroup with normal kyphosis before surgery. CONCLUSION With patient-specific rods, kyphosis at last follow-up was close to the target value. Predictors of kyphosis at last follow-up were the concave rod contouring angle and pre-operative kyphotic angle of the thoracic segment to be instrumented. Over-contouring of the concave rod seems necessary in patients with preoperative hypokyphosis but not in patients with normal kyphosis. LEVEL OF EVIDENCE III, prospective non-comparative study.
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Affiliation(s)
- Federico Solla
- Orthopédie Pédiatrique, hôpital Pédiatrique de Nice CHU-Lenval, 57, avenue Californie, 06200 Nice, France.
| | - Jean-Luc Clément
- Orthopédie Pédiatrique, hôpital Pédiatrique de Nice CHU-Lenval, 57, avenue Californie, 06200 Nice, France
| | - Vincent Cunin
- Orthopédie Pédiatrique, CHU de Lyon, 69800 Bron, France
| | - Carlo M Bertoncelli
- Orthopédie Pédiatrique, hôpital Pédiatrique de Nice CHU-Lenval, 57, avenue Californie, 06200 Nice, France
| | - Vincent Fière
- Chirurgie du rachis, centre orthopédique Santy et HPJM Lyon GDS Ramsay, Lyon, France
| | - Virginie Rampal
- Orthopédie Pédiatrique, hôpital Pédiatrique de Nice CHU-Lenval, 57, avenue Californie, 06200 Nice, France
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Ostenson CG, Fière V, Ahmed M, Lindström P, Brismar K, Brismar T, Kreicbergs A. Decreased cortical bone thickness in spontaneously non-insulin-dependent diabetic GK rats. J Diabetes Complications 1997; 11:319-22. [PMID: 9365871 DOI: 10.1016/s1056-8727(96)00079-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We studied the occurrence of osteopenia, as reflected by decreased cortical bone thickness, in a nonobese animal model of hereditary non-insulin-dependent diabetes with long duration, i.e., 8-month-old Goto-Kakizaki (GK) rats. In addition, motor nerve-conduction velocity was measured in the GK rats. Age- and weight-matched Wistar rats served as controls. The GK rats displayed marked glucose intolerance, as compared to control rats, in an intraperitoneal glucose tolerance test. Decreased cortical bone thickness by approximately 15%, was evident in X-ray analysis of metatarsal bones (p < 0.001) and humerus (p < 0.05) of the GK rats. Motor nerve-conduction velocity, measured in the sciatic nerve, was also decreased (by 10%) in the GK as compared with the age-matched control rats (p < 0.05). In conclusion, reduction of cortical bone thickness is present in 8-month-old GK rats, which simultaneously demonstrate signs of peripheral neuropathy. Thus, the GK rat appears to be a model of NIDDM suitable for studies of diabetic bone disease in the absence of obesity.
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MESH Headings
- Animals
- Blood Glucose/metabolism
- Bone Diseases, Metabolic/diagnostic imaging
- Bone Diseases, Metabolic/pathology
- Bone Diseases, Metabolic/physiopathology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/pathology
- Diabetes Mellitus, Type 2/physiopathology
- Disease Models, Animal
- Electrophysiology
- Humerus/diagnostic imaging
- Humerus/pathology
- Metatarsal Bones/diagnostic imaging
- Metatarsal Bones/pathology
- Neural Conduction
- Radiography
- Rats
- Rats, Inbred Strains
- Rats, Wistar
- Tibia/diagnostic imaging
- Tibia/pathology
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Affiliation(s)
- C G Ostenson
- Department of Endocrinology, Karolinska Hospital and Institute, Stockholm, Sweden
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