Scientific Productivity of University Orthopaedics and Trauma Surgery in Germany, Austria, and Switzerland

BACKGROUND

Despite major achievements, such as the development of hip prostheses, scientific productivity in orthopaedics and trauma surgery has hardly been investigated. Our study's aim therefore was to analyse the correlation between the leading physicians' h-index and their academic rang, in order to determine whether this objective measure of scientific accomplishments correlates with clinical position.

METHODS

All physicians in leading positions at university hospitals' orthopaedics or trauma surgery departments in Germany, Austria, and Switzerland were included. Year of habilitation, number of publications and citations as well as h-index were collected from September to November 2020.

RESULTS

A total of 844 leading physicians at 46 university hospitals were included. Professors had the highest number of total publications (117.4 ± 124.8, p < 0.001) and highest h-index (20.1 ± 10.1, p < 0.001). We found significant differences in the total number of publications (p = 0.001), publications in the last three years (p < 0.001), and h-index (p < 0.001) between the three investigated nations, with all parameters being highest in Switzerland.

CONCLUSION

Our study shows that increasing scientific productivity is correlated with academic success. The country-specific differences indicate significant differences in the value of scientific activity in daily clinical routine.

Does Total Hip Arthroplasty Affect Spinopelvic and Spinal Alignment?: A Prospective Observational Investigation

STUDY DESIGN

A prospective observational study, level of evidence 3.

OBJECTIVES

The study with patients undergoing unilateral total hip arthroplasty (THA) aimed to evaluate the following hypotheses: (1) the spinal sagittal and coronal alignment alters due to THA, (2) the spinopelvic parameter changes after THA, (3) the spinopelvic alignment differs between sagittal balanced and imbalanced patients.

SUMMARY OF BACKGROUND DATA

Surgical correction of spinal sagittal misalignment affects the spinopelvic alignment and pelvic tilt. It is not yet known to what extent THA affects spinopelvic, spinal sagittal, and coronal alignment.

MATERIALS AND METHODS

A total of 153 patients undergoing THA were assessed with biplanar stereoradiography in standing position preoperatively and postoperatively. Two independent investigators examined C7-sagittal vertical axis (C7-SVA), pelvic incidence-lumbar lordosis (PI-LL) mismatch, lumbar lordosis (LL), C7-central sacral vertical line, pelvic oblique angle lumbosacral, intra-pelvic oblique angle, pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), anterior plane pelvic tilt (APPT), and pelvic femoral angle (PFA). An analysis of the sagittal misaligned subgroups of C7-SVA and PI-LL on the influence of the spinopelvic alignment was performed.

RESULTS

A significant difference in spinopelvic parameters was detected in the preoperative to postoperative comparison (SS, PT, APPT, and PFA; P <0.000) ( d =-0.394; d =0.609; d =-0.481; d =0.431). The coronal alignment and pelvic obliquity revealed no significant differences. The misaligned groups (C7-SVA; PI-LL) demonstrated significant increases in PI and PT and decreased in LL compared with the groups with normal sagittal alignment. Preoperatively, 66/153 (C7-SVA) and 46/153 (PI-LL) of the THA patients presented sagittal misalignment, respectively.

CONCLUSIONS

The results suggest an effect of THA on sagittal spinal and spinopelvic alignment, with a significant reduction of PT postoperatively and no effect on coronal alignment. Particularly striking are the significant differences in the misaligned groups, which may be classified as risk population and potentially can contribute biomechanically to a higher risk of posterior impingement and anterior THA dislocation. The substantial proportion of sagittal misaligned patients in the THA collective illustrates the crucial need for interdisciplinary collaboration.

Optimising both disease control and glucocorticoid dosing is essential for bone protection in patients with rheumatic disease

OBJECTIVES

Inflammatory rheumatic and musculoskeletal diseases (iRMDs) are associated with increased systemic bone loss that is mediated by chronic inflammation, treatment with glucocorticoids (GCs) and other factors. Our objective was to analyse the impact of variables that influence osteoporosis (OP) in patients with iRMD treated with GC.

METHODS

Rh-GIOP (acronyme) is a prospective observational cohort study investigating bone health in consecutive patients with iRMD and current or prior GC treatment. We present an analysis of the patients' baseline data here. Bone mineral density (BMD) measured by dual X-ray absorptiometry was the primary outcome. Multivariable linear regression models were performed to identify variables associated with BMD.

RESULTS

Data from 1066 patients with iRMD were analysed. GC doses of <5 mg prednisone equivalent per day, cumulative dose and duration of GC therapy were not associated with negative effects on BMD. Dosages of ≥5 mg/day lost their negative association with BMD after adjustment for confounders. When subanalysing patients with exactly 5 mg/day, no negative effect was seen. For patients with rheumatoid arthritis (RA), GC doses of >7.5 mg/day showed a negative association with BMD overall, but this effect seemed to be specific only to patients with moderate or high disease activity (Disease Activity Score 28-C reactive protein >3.2).

CONCLUSIONS

GCs of ≤5 mg/day did not seem to be associated with a reduction of BMD in patients with iRMD and current or prior exposure to GC. This is most likely due to the dampening of inflammation by GC, which exerts a mitigating effect on the risk of OP. In RA, current GC doses of >7.5 mg/day were negatively associated with BMD, but only in patients with moderate to high disease activity.

TRIAL REGISTRATION NUMBER

NCT02719314.

Relationship Between the OF Classification and Radiological Outcome of Osteoporotic Vertebral Fractures After Kyphoplasty

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The OF classification is a new classification for osteoporotic vertebral fractures. The aim of this study was to clarify the relationship between preoperative OF subgroups and the postoperative outcome after kyphoplasty in patients with such fractures.

METHODS

Patients who underwent kyphoplasty of a single osteoporotic vertebral fracture were included and divided into groups according to the OF subgroups. Pre- and postoperative plain radiographs were analyzed in regard to the restoration of vertebral body height and local kyphotic angle (LKA). Additionally, clinical data including pre- and postoperative Visual Analogue Scale pain scores was documented. The clinical and radiological results were compared pre- and postoperatively within groups and between groups.

RESULTS

A total of 156 patients from OF subgroups 2 to 4 were included (OF 2: n = 58; OF 3: n = 36; OF 4: n = 62). Patients from all groups experienced significant pain relief postoperatively (P < .001). Patients with OF 2 fractures showed a repositioning of the vertebral body height in the anterior and middle portions (both P < .001), but no significant improvement in LKA. For OF 3 and 4 fractures, there was a significant restoration of vertebral body height (P < .001 for both) and a significant improvement of LKA (P < .001 for both). The highest average restoration was noted in the OF 4 group.

CONCLUSIONS

A higher OF subgroup is related to a higher radiological benefit from kyphoplasty. This confirms that the OF classification is an appropriate tool for the preoperative assessment of osteoporotic fractures.

[Influence of the COVID-19 pandemic on the physiotherapeutic and medical follow-up care after reconstructions of the anterior cruciate ligament]

BACKGROUND

The aim of this study was to examine the influence of the COVID-19(coronavirus disease 2019) pandemic on the medical and physiotherapeutic follow-up care after reconstructions of the anterior cruciate ligament.

METHODS

116 patients (72 men and 44 women) who had received a reconstruction of the anterior cruciate ligament between September 2019 and December 2020 were included in this study. These patients were divided into two groups depending on the date of surgery: one group that had received surgery in 2019 before the COVID-19 pandemic and one group that had undergone surgery in 2020 and was directly affected by the COVID-19 pandemic. All patients were interviewed using a standardized questionnaire regarding the influence of the coronavirus pandemic on the medical and physiotherapeutic follow-up care, as well as the moment of return to work. In addition, the range of motion of the respective knee 3 months postoperatively was analysed based on physical examination.

RESULTS

At 3 months postoperatively, patients who had undergone surgery in 2020 showed a clear trend towards a higher frequency of extension deficits of ≥ 5° (18.8% vs. 4.3%, p = 0.097) or an inability to bend the knee ≥ 120° (23.3% vs. 10%, p = 0.197) compared to those who had received surgery in 2019. Patients who had undergone surgery in 2020 reported significantly longer delays for appointments, a higher number of futile attempts to get an appointment and a higher number of cancelled appointments, regarding both medical and physiotherapeutic follow-up care. 34.9% of the patients who received surgery in 2020 indicated that they were able to reduce the duration of their sick leave due to the increased possibilities of working in a home-office situation during the pandemic. Alternative treatment options due to the pandemic were offered by 13.3% of the physiotherapists and 12.2% of the physicians.

CONCLUSION

Although the physiotherapeutic and medical follow-up care was not directly affected by a "lockdown", the pandemic led to significant restrictions, which are also reflected in a clear trend towards worse clinical outcomes. Consequently, a further expansion of alternative treatment options, which were only offered by 12-13% of practices and that are presumably of comparable relevance for various other diseases, is needed.

Does obesity affect acetabular cup position, spinopelvic function and sagittal spinal alignment? A prospective investigation with standing and sitting assessment of primary hip arthroplasty patients

Background

Total hip arthroplasty (THA) instability is influenced by acetabular component positioning, spinopelvic function and sagittal spinal alignment. Obesity is considered as a risk factor of THA instability, but the causal relationship remains unknown. This study aimed to investigate the influence of BMI on (1) spinopelvic function (lumbar flexibility, pelvic mobility and hip motion), (2) sagittal spinal alignment pre- and postoperatively and (3) acetabular cup position postoperatively in primary THA patients in a prospective setting.

Methods

One hundred ninety patients receiving primary total hip arthroplasty were enrolled in a prospective cohort study and retrospectively analysed. All patients received stereoradiography (EOS) in standing and relaxed sitting position pre-and postoperatively. C7-sagittal vertical axis (C7-SVA), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), anterior plane pelvic tilt (APPT), and pelvic femoral angle (PFA) were assessed. Key parameters of the spinopelvic function were defined as lumbar flexibility (∆ LL = LL_standing − LL_sitting), pelvic mobility (∆ PT = PT_standing − PT_sitting) and hip motion (∆ PFA = PFA_standing − PFA_sitting). Pelvic mobility was further defined based on ∆ PT as stiff, normal and hypermobile (∆ PT < 10°; 10°–30°; > 30°). The patients were stratified to BMI according to WHO definition: normal BMI ≥ 18.5–24.9 kg/m² (n = 68), overweight ≥ 25.0–29.9 kg/m² (n = 81) and obese ≥ 30–39.9 kg/m² (n = 41). Post-hoc analysis according to Hochberg's GT2 was applied to determine differences between BMI groups.

Results

Standing cup inclination was significant higher in the obese group compared to the normal BMI group (45.3° vs. 40.1°; p = 0.015) whereas standing cup anteversion was significantly decreased (22.0° vs. 25.3°; p = 0.011). There were no significant differences for spinopelvic function key parameter lumbar flexibility (∆ LL), pelvic mobility (∆ PT) and hip motion (∆ PFA) in relation to BMI stratified groups. The obese group demonstrated significant enhanced pelvic retroversion compared to the normal BMI group (APPT − 1.8° vs. 2.4°; p = 0.028). The preoperative proportion of stiff pelvic mobility was decreased in the obese group (12.2%) compared to normal (25.0%) and overweight (27.2%) groups. Spinal sagittal alignment in C7-SVA and PI-LL mismatch demonstrated significantly greater imbalance in the obese group compared to the normal BMI group (68.6 mm vs. 42.6 mm, p = 0.002 and 7.7° vs. 1.2°, p = 0.032, respectively) The proportion of patients with imbalanced C7-SVA was higher in the obese (58.5%) than in the normal BMI group (44.1%).

Conclusions

The significantly increased spinal sagittal imbalance with altered pelvic mechanics is a potential cause for the reported increased risk of THA dislocations in obese patients. Consequently, the increased spinal sagittal imbalance in combination with normal pelvic mobility need to be taken into account when performing THA in obese patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02716-8.

Analysis of cartilage injury patterns and risk factors for knee joint damage in patients with primary lateral patella dislocations

BACKGROUND

Lateral patellar dislocation (LPD) frequently causes damage to the knee. Injury patterns and risk factors contributing to such injuries have not yet been examined in detail.

METHODS

We retrospectively analyzed 50 consecutive patients with primary LPD. Two reviewers evaluated the MRI images regarding risk factors for LPD (Dejours classification; Caton-Deschamps Index, CDI; distance from the tibial tuberosity to trochlear groove, TT-TG; trochlear depth, TD) as well as joint damages according to the Whole-Organ Magnetic Resonance Imaging Score (WORMS).

RESULTS

33 male and 17 female patients with a mean age of 23.2 (±9.6) years were included in this study. 52% were classified Dejours ≥ B, 34% had a CDI ≥ 1.3, 22% a TT-TG ≥ 20mm and 52% a TD < 3mm. 49 out of 50 patients (98%) showed abnormalities according to WORMS. The most frequently observed abnormalities were synovitis/effusion (49/50, 98%), bone marrow oedema (44/50, 88%) and cartilage damage (42/50, 84%). Most frequently affected subregions were medial (41/50, 82%) and lateral (31/50, 62%) patella as well as the anterior (43/50, 86%), central (42/50, 84%) and posterior (11/50, 22%) portion of the lateral femoral condyle. There was no significant correlation between any of the examined risk factors and joint damages according to WORMS. Male patients had higher scores regarding total cartilage damage (5.11 vs. 2.56, p = 0.029), total score for the lateral femorotibial joint (3.15 vs. 1.65, p = 0.026) and overall total WORMS score (12.15 vs. 8.29, p = 0.038).

CONCLUSION

Risk factors for LPD do not influence the risk of damages to the knee joint after primary LPD. Although LPD is generally known to affect more female than male patients, male patients suffered more severe injuries after primary LPD, particularly of the lateral femorotibial joint. Overall, our results underline the importance of MRI imaging after primary LPD.

In vivo analysis of hip joint loading on Nordic walking novices

Objective

To evaluate the influence of Nordic walking (NW) on hip joint loads in order to determine whether it can be safely performed during postoperative physiotherapy in patients after orthopeadic surgery of the hip.

Methods

Internal hip joint loads were directly measured in vivo in 6 patients using instrumented hip prostheses during NW and ordinary walking (OW). All patients received training in two different NW techniques (double-poling and the diagonal technique) by a certified NW instructor. Measurements were conducted on a treadmill at a speed of 4 km/h on level ground, at 10% inclination and at 10% slope as well as on a level lawn at a self chosen comfortable speed. Resultant contact force (F_res), bending moment (M_bend) and torsional torque (M_tors) were compared between NW and OW as well as between both NW techniques.

Results

Joint loads showed a double peak pattern during all setups. Neither NW technique significantly influenced hip joint loads at the time of the first load peak during contralateral toe-off (CTO), which was also the absolute load peak, in comparison to OW. Compared to OW, double-poling significantly reduced F_res and M_bend at the time of the second load peak during the contralateral heel strike (CHS) on level ground both on the treadmill (− 6% and − 7%, respectively) and on the lawn (− 7% and − 9%). At 10% inclination, the diagonal technique increased F_res and M_bend at CHS (by + 6% and + 7%), but did not increase the absolute load peak at CTO.

Conclusion

Joint loads during NW are comparable to those of OW. Therefore, NW can be considered a low-impact activity and seems to be safe for patients that are allowed full weight bearing, e.g. during postoperative rehabilitation after THA.

Is implant sonication useful when screening for infection in conversion of prior hip fracture fixation to total hip arthroplasty?

Objective

To examine sonication results in presumed aseptic conversion total hip arthroplasty (THA) after hip fracture fixation and to evaluate its implications on the treatment outcome.

Methods

This retrospective cohort study reviewed the data from presumed aseptic patients that underwent conversion of prior internal fixation of proximal femoral fractures to THA between 2012 and 2018. Microbiological analysis was performed using sonication of osteosynthesis material and tissue samples. Treatment outcome including the occurrence of periprosthetic joint infection (PJI) was recorded.

Results

A total of 32 patients were included in the study. Of these, five patients (15.6%) had positive intraoperative cultures. The mean follow-up following conversion THA was 43.0 months (range, 19.0–91.5 months). Sonication was positive in three patients (9.4%), all of whom were deemed contaminated and did not develop PJI. Tissue cultures were positive in two patients (6.3%). One patient with Enterococcus faecalis received antibiotic treatment and did not develop PJI. Another patient with growth of Cutibacterium acnes that was initially classified as a contaminant later developed acute PJI caused by the same pathogen. Overall, PJI occurred in two patients (6.3%) after conversion THA.

Conclusion

Sonication of internal fixation devices did not add diagnostic value in clinically aseptic conversion THA. Further studies are needed to better understand the relevance of unexpected positive cultures, and to develop diagnostic criteria for the management of these patients.

Vertebral disk morphology of the lumbar spine: a retrospective analysis of collagen-sensitive mapping using dual-energy computed tomography

OBJECTIVES

To investigate the diagnostic accuracy of collagen-sensitive maps derived from dual-energy computed tomography (DECT) for the detection of lumbar disk pathologies in a feasibility setting.

MATERIALS AND METHODS

We retrospectively reviewed magnetic resonance imaging (MRI), computed tomography (CT), and DECT datasets acquired in patients who underwent periradicular therapy of the lumbar spine from June to December 2019. Three readers scored DECT collagen maps, conventional CT, and MRI for presence, type, and extent of disk pathology. Contingency table analyses were performed to determine diagnostic accuracy using MRI as standard of reference. Interrater agreement within and between imaging modalities was evaluated by computing intraclass correlation coefficients (ICCs) and Cohen's kappa. Correlation between sum scores of anteroposterior disk displacement was determined by calculation of a paired t test.

RESULTS

In 21 disks in 13 patients, DECT had a sensitivity of 0.87 (0.60-0.98) and specificity of 1.00 (0.54-1.00) for the detection of disk pathology. Intermodality agreement for anteroposterior disk displacement was excellent for DECT (ICC 0.963 [0.909-0.985]) and superior to CT (ICC 0.876 [0.691-0.95]). For anteroposterior disk displacement, DECT also showed greater within-modality interrater agreement (ICC 0.820 [0.666-0.916]) compared with CT (ICC 0.624 [0.39-0.808]).

CONCLUSION

Our data suggest that collagen-sensitive imaging has an added benefit, allowing more accurate evaluation of the extent of disk displacement with higher interrater reliability. Thus, DECT could provide useful diagnostic information in patients undergoing CT for other indications or with contraindications to MRI.

Musculature adaption in patients with lumbosacral transitional vertebrae: a matched-pair analysis of 46 patients

OBJECTIVE

Even though lumbosacral transitional vertebrae (LSTV) are one of the most common congenital anomalies of the spine, their effect on surrounding soft tissues is not well-studied. We therefore aimed at analyzing the association between LSTV and changes in volume, mass, symmetry, and degeneration of lumbar and trunk muscles.

MATERIALS AND METHODS

Abdomen-pelvis CT scans were analyzed in patients with LSTV and a matched control group. LSTV were classified according to the Castellvi classification. Muscles were segmented from the remaining soft tissue and their cross-sectional area and volume were examined at five defined levels. Threshold segmentation was used to differentiate between muscle fibers and fat tissue. Matched pairs were compared using Wilcoxon rank sum tests. For comparison of categorical data, chi-squared tests were performed and for associations between the degree of fusion and muscle size and degeneration, Spearman's correlation coefficients were calculated. Inter- and intrarater reliabilities were evaluated by computing intraclass correlation coefficients.

RESULTS

Forty-six patients with LSTV and 46 controls were included. Muscle volume of the paraspinal and trunk muscles was significantly lower (707.0 cm³ vs. 809.7 cm³, p < 0.001) and fatty muscle changes were significantly increased in all but the caudal paravertebral muscles of LSTV patients (M. psoas p < 0.04, M. quadratus lumborum p < 0.001, paravertebral muscles p = 0.011, M. rectus abdominis p < 0.001, M. obliquus abdominis p < 0.001). Correlations between the degree of Castellvi classification and muscle volume were significant (p = 0.001).

CONCLUSION

LSTV are associated with a reduction in muscle volume and an increase in muscle degeneration of both lumbar and trunk muscles.

Antibiotic treatment of postoperative spinal implant infections

Postoperative spinal implant infection (PSII) is a serious complication after spinal surgery. It is associated with increased morbidity and mortality for affected patients as well as significant costs for the healthcare system. Due to the formation of biofilm on foreign material, both diagnosis and treatment of PSII can pose a considerable challenge. Modern treatment protocols allow efficient eradication and good clinical outcomes in the majority of patients. In this article, we review the current antibiotic treatment concepts for PSII including the correct choice of antibiotics and their combination. In cases of late-onset PSII where the implants can be removed, two weeks of intravenous (IV) antibiotics followed by 4 weeks of oral antibiotics seem appropriate. If the implant needs to be retained, a 2-week IV antibiotic treatment should be followed by 10 weeks of oral antibiotic therapy with biofilm activity or, in case of problematic pathogens, a long-term suppression therapy. Initial empiric antibiotic therapy should cover staphylococci, streptococci, enterococci and Gram-negative bacilli as the most common pathogens. Antibiotic adjustments according to the type of pathogen and its antimicrobial susceptibility are essential for successful eradication of infection.

Comprehensive treatment algorithm of postoperative spinal implant infection

Postoperative spinal implant infection (PSII) is a commonly found and serious complication after instrumented spinal surgery. Whereas early-onset PSII usually can be diagnosed by clinical symptoms, the diagnosis of late-onset PSII can be often made only by examination of intraoperatively collected samples. The treatment of PSII consists of surgical and antibiotic therapy schemes. In case of early PSII, the retention of spinal implants is a feasible option, whereas late PSII is usually treated by one-staged exchange of the spinal implants. Radical debridement of surrounding tissue should be performed in any case of PSII. The antibiotic treatment depends on either the implants can be removed or need to be retained or exchanged, respectively. If the causative pathogens are sensitive for biofilm-active antibiotic agents, the duration of antibiotic treatment amounts to 12 weeks with retention of spinal implants. In case of problematic pathogens, the application of antibiotics needs to be prolonged for an individual duration. Antibiotic treatment should always be initiated with an intravenous application for at least 2 weeks.

Burst fractures lead to a fracture-associated intervertebral vacuum phenomenon: a case series of 305 traumatic fractures of the thoracolumbar spine

PURPOSE

Intervertebral vacuum phenomenon (IVP) is mainly seen as a sign of degenerative disc diseases. Although studies have shown that IVP also occurs after traumatic injuries to the spine, its clinical relevance in spinal fractures remains unknown. Therefore, the aim of this study was to analyse the prevalence, demographic parameters and fracture morphology in patients with fracture-associated IVP (FAVP) of the thoracolumbar spine.

METHODS

In this retrospective cohort study, patients with traumatic fractures of the thoracolumbar spine who were admitted between January 2014 and December 2015 were included. CT scans were assessed for the presence of intervertebral areas of gaseous radiolucency, which were defined as IVP. Fractures were classified according to the AOSpine Thoracolumbar Spine Injury Classification System. Demographic and anamnestic data, including age, sex and trauma mechanism, were documented.

RESULTS

A total of 201 patients with 305 fractures were included. Seventy-three patients with 98 fractures had follow-up CTs. Sixty-eight patients had IVP, of whom 46 patients had FAVP. On the follow-up CT, a significant correlation was found between A3 fractures and FAVP, while initial FAVP was significantly correlated with age and low-velocity trauma mechanisms. Initial degenerative IVP also showed a significant correlation with age.

CONCLUSIONS

FAVP occurred significantly more often in burst fractures and therefore may lead to disc degeneration due to nutritional supply disturbances via the vertebral endplate. As surgical management strategies for burst fractures are intensively discussed, the appearance of FAVP should be taken in consideration.

Bone structure determined by HR-MDCT does not correlate with micro-CT of lumbar vertebral biopsies: a prospective cross-sectional human in vivo study

Background

Osteoporosis is characterized by a deterioration of bone structure and quantity that leads to an increased risk of fractures. The primary diagnostic tool for the assessment of the bone quality is currently the dual-energy X-ray absorptiometry (DXA), which however only measures bone quantity. High-resolution multidetector computed tomography (HR-MDCT) offers an alternative approach to assess bone structure, but still lacks evidence for its validity in vivo. The objective of this study was to assess the validity of HR-MDCT for the evaluation of bone architecture in the lumbar spine.

Methods

We conducted a prospective cross-sectional study to compare the results of preoperative lumbar HR-MDCT scans with those from microcomputed tomography (μCT) analysis of transpedicular vertebral body biopsies. For this purpose, we included patients undergoing spinal surgery in our orthopedic department. Each patient underwent preoperative HR-MDCT scanning (L1-L4). Intraoperatively, transpedicular biopsies were obtained from intact vertebrae. Micro-CT analysis of these biopsies was used as a reference method to assess the actual bone architecture. HR-MDCT results were statistically analyzed regarding the correlation with results from μCT.

Results

Thirty-four patients with a mean age of 69.09 years (± 10.07) were included in the study. There was no significant correlation for any of the parameters (bone volume/total volume, trabecular separation, trabecular thickness) between μCT and HR-MDCT (bone volume/total volume: r = − 0.026 and p = 0.872; trabecular thickness: r = 0.074 and r = 6.42; and trabecular separation: r = − 0.18 and p = 0.254).

Conclusion

To our knowledge, this is the first study comparing in vivo HR-MDCT with μCT analysis of vertebral biopsies in human patients. Our findings suggest that lumbar HR-MDCT is not valid for the in vivo evaluation of bone architecture in the lumbar spine. New diagnostic tools for the evaluation of osteoporosis and preoperative orthopedic planning are urgently needed.

Low sensitivity of histopathological examination of peri-implant tissue samples in diagnosing postoperative spinal implant infection

AIMS

To evaluate the histopathological examination of peri-implant tissue samples as a technique in the diagnosis of postoperative spinal implant infection (PSII).

METHODS

This was a retrospective analysis. Patients who underwent revision spinal surgery at our institution were recruited for this study. PSII was diagnosed by clinical signs, histopathology, and microbiological examination of intraoperatively collected samples. Histopathology was defined as the gold standard. The sensitivity for histopathology was calculated. A total of 47 patients with PSII and at least one microbiological and histopathological sample were included in the study.

RESULTS

PSII occurred in approximately 28% of the study population. Histopathology showed a sensitivity of 51.1% in the diagnosis of PSII. The most commonly found pathogens were Cutibacterium acnes and gram-positive staphylococci.

CONCLUSION

Histopathology has low sensitivity for detecting PSII. In particular, infections caused by low-virulence microorganisms are insufficiently detected by histopathology. Cite this article: Bone Joint J 2020;102-B(7):899-903.

Influence of operative timing on the early post-operative radiological and clinical outcome after kyphoplasty

PURPOSE

To clarify the relationship between operative timing and the early post-operative radiological and clinical outcome after kyphoplasty.

METHODS

We conducted a retrospective cohort study including patients who underwent kyphoplasty of a single vertebra. Patients were divided into three groups (acute [< 2 weeks], subacute [2-6 weeks] or chronic [6-51 weeks]) based on the interval between fracture and surgery. The relative vertebral body height (VBH) and local kyphotic angle (LKA) of the fractured vertebra (measured on plain radiographs) as well as pain and use of analgesics were compared pre- and post-operatively (day 2) and between the groups.

RESULTS

A total of 230 patients (100 with acute, 91 with subacute and 39 with chronic fractures) with fractures from T4 to L5 were included. In all groups, there was a significant post-operative improvement in the anterior (8.9-12.9%) and middle (10.7-13.4%) VBH (all groups: p < 0.001), LKA (acute: 3.8°, p < 0.001; subacute: 4.3°, p < 0.001; chronic: 1.7°, p = 0.046) and pain. The use of analgesics significantly decreased post-operatively in the acute and subacute groups, but did not significantly change in the chronic group. Patients from acute (p = 0.042) and subacute (p = 0.027) groups showed significantly better post-operative correction of the LKA than the chronic group.

CONCLUSION

Kyphoplasty is effective for vertebral height restoration as well as pain relief for both acute, subacute and chronic fractures. However, the achievable correction of the fracture-related local kyphosis decreases significantly after 6 weeks. Therefore, we recommend making a final decision about conservative vs. operative treatment within 6 weeks to ensure better height restoration in surgically treated patients.

AB1223 RHEUMATOID ARTHRITIS PATIENTS INCLUDED IN GLUCOCORTICOID TRIALS MOSTLY RESEMBLE THOSE SEEN IN OBSERVATIONAL COHORTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Randomised controlled trials (RCTs) are considered the gold standard in clinical research. Their results, however, may not be generalizable to patients in routine care.1Together with methotrexate, glucocorticoids (GCs) constitute the mainstay of therapy for many patients with rheumatoid arthritis (RA), but it is unclear whether trial evidence is actually generalizable to real-world patients.

Objectives:

This review assesses to what extent RA patients participating in GC-RCTs differ from RA patients taking GCs in routine care.

Methods:

This study was registered with PROSPERO (CRD42019134675). MEDLINE was searched for RCTs and, as comparators, cohort studies in RA evaluating systemic GC therapy. Cohorts were not allowed to exhibit apparent selection mechanisms concerning gender or age. Random-effects meta-analyses combined descriptive baseline characteristics that may modify the benefit-risk-ratio of various RA therapeutics. Meta-analyses were stratified by study type (RCT and CS). Stratified estimates were subsequently compared.

Results:

55 RCTs and ten cohort studies (21,657 participants overall) were included. Twelve characteristics (related to general demographics and disease activity) were reported frequently enough to allow for comparative analysis. Compared to cohorts, RCT participants were younger (-4.7 [-7.2 to -2.1] years) and had somewhat higher erythrocyte sedimentation rates (12 [6 to 18] mm/h) (Table 1). In the other ten characteristics, estimates did not differ significantly. Numerically, cohort patients had more longstanding disease and slightly more favourable disease levels in core set variables. Comorbidities could not be assessed.

Table 1.

Pooled estimates

OutcomeRCTkCohortkContrast(95% CI)pGeneral demographics Age (years)54.25058.910–4.7(–7.2 to –2.1)<0.001 Female (proportion)0.70520.73100.89(0.68 to 1.16)0.38 Current or previous smokers (proportion)0.5930.5121.38(0.61 to 3.14)0.44 BMI (kg/m2)25.9525.930.0(–1.9 to 1.9)0.98 Disease duration (months)56.54385.17–28.6(–85.6 to 28.4)0.33Disease activity ESR (mm/h)40.13128.2311.8(5.7 to 18.0)<0.001 DAS5.3244.950.4(–0.1 to 0.9)0.12 RF+, (proportion)0.67320.6361.19(0.80 to 1.78)0.39 ACPA+, (proportion)0.6470.5631.38(0.64 to 3.00)0.41 HAQ1.3311.140.2(–0.1 to 0.5)0.15 Pain (0-10)5.2264.820.4(–0.8 to 1.6)0.52 Patient global assessment (0-10)5.2174.930.3(–0.9 to 1.5)0.58

Conclusion:

The results of our study suggest that evidence from RA GC-RCTs can be generalized to most patients in routine practice. We note that comorbidities – a frequent exclusion criterion for trial participation – could not be evaluated due to insufficient reporting. Our findings contrast with a similar study on RCTs investigating biologics in RA: There, trial participants were found to differ significantly in 4 out of 8 investigated baseline characteristics.2

References:

1]Palmowski A et al. Applicability of trials in rheumatoid arthritis and osteoarthritis: A systematic review and meta-analysis of trial populations showing adequate proportion of women, but underrepresentation of elderly people.Semin Arthritis Rheum2018 doi: 10.1016/j.semarthrit.2018.10.017 and

[2]Kilcher G et al. Rheumatoid arthritis patients treated in trial and real world settings: comparison of randomized trials with registries.Rheumatology (Oxford) 2017 doi: 10.1093/rheumatology/kex394

Acknowledgments:

Part of the GLORIA project and trial, funded by the EU (Horizon 2020, Grant No 634886)

Disclosure of Interests:

Andriko Palmowski: None declared, Sabrina Mai Nielsen: None declared, Thomas Buttgereit: None declared, Yannick Palmowski: None declared, Maarten Boers: None declared, Robin Christensen: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

Glucocorticoid-trials in rheumatoid arthritis mostly study representative real-world patients: A systematic review and meta-analysis

OBJECTIVE

Randomized controlled trials (RCTs) are considered the gold standard in clinical research due to credible causality. Their results, however, may not be generalizable to real-world populations. While glucocorticoids (GCs) remain a mainstay of rheumatoid arthritis (RA) treatment, it is unclear whether the results of GC-RCTs are generalizable to current real-world RA patients.

METHODS

MEDLINE was searched for RCTs and, as comparators, cohort studies (CSs) in RA evaluating systemic GCs. Random-effects meta-analyses were performed for descriptive baseline characteristics (including general demographics, comorbidities, and disease activity) that have been shown to be able to modify the benefit-risk-ratio of various RA therapeutics. These meta-analyses were stratified by study type (RCT and CS). Stratified estimates were subsequently compared. Further sensitivity analyses were performed stratifying by disease duration.

RESULTS

56 RCTs (7053 participants) and 10 CSs (14,688 participants) were included. 12 characteristics were reported frequently enough to allow for comparative analysis. In 10/12 characteristics (83%), RCT estimates did not appear to differ from CS estimates. However, RCT participants were younger (-4.7 years [95% CI -7.2 to -2.1]; p < 0.001) and had higher erythrocyte sedimentation rates (11.8 mm/h [5.7 to 17.8]; p < 0.001) than CS participants. Comorbidities could not be assessed due to insufficient reporting.

CONCLUSION

Our findings suggest that evidence from GC trials in RA is of acceptable generalizability to current real-world patients - especially compared to findings from biologic agents in RA. However, RCT participants were younger than real-world patients, potentially limiting the generalizability of trial results to elderly patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42019134675).

Association Between Participant Retention and the Proportion of Included Elderly People in Rheumatology Trials: Results From a Series of Exploratory Meta-Regression Analyses

OBJECTIVE

The elderly, a population defined by an age of ≥65 years, are underrepresented in rheumatology trials, possibly due to investigators' concerns of increased premature discontinuations in higher age groups. The present study was undertaken to evaluate whether the proportion of included elderly individuals (PE) is independently associated with participant retention in rheumatology trials.

METHODS

Medline was searched for randomized controlled trials (RCTs) in rheumatoid arthritis (RA) and osteoarthritis (OA) of any intervention (years 2016 and 2017). PE was either extracted from the research manuscript or estimated from an assumed (truncated) normal distribution. We used mixed-effects meta-regression models including several covariates to assess whether there is an independent association between PE and participant retention. Using sensitivity analyses, we evaluated whether associations were connected to attrition due to lack of efficacy (LoE) or adverse events (AE).

RESULTS

In total, 243 RCTs comprising >48,000 participants were included. Pooled participant retention was 88%. PE was not associated with retention in the unadjusted (P = 0.97) or adjusted (all: P ≥ 0.14) models. Of all covariates, only study duration and type of intervention were associated with retention (both: P < 0.001). Post hoc analyses allowing for interaction revealed a small but statistically significant positive association between PE and retention in pharmacologic interventions and a negative association in physical/physiotherapeutic interventions (overall P for interaction = 0.05). No associations were found for PE and attrition due to LoE or AE.

CONCLUSION

Participant retention in RA and OA trials is high and not associated with PE. These findings should motivate investigators to include more elderly participants in rheumatology trials.

The 70th anniversary of glucocorticoids in rheumatic diseases: the second youth of an old friend

Seventy years ago, the first administration of cortisone in a patient with RA marked a milestone in the treatment of inflammatory diseases. However, the initial enthusiasm rapidly vanished as the administration of high doses for lengthy periods revealed worrisome adverse effects. It has taken several decades to overcome the (sometimes excessive) mistrust and to achieve a more differentiated evaluation of the benefit–risk profile and the adequate usage of glucocorticoids (GCs). Today, GCs remain indispensable for the treatment of many inflammatory conditions and their usefulness in RA as a disease-modifying low-dose co-medication is widely acknowledged. Recent studies show promising results concerning both traditional GCs and new formulations. Still, decades of relatively little scientific attention have resulted in a continuing lack of detailed evidence. Hence there is an ongoing need for further research regarding mechanisms of GC actions, the further optimization of treatment parameters for traditional GCs and new formulations.

"Official View" on Glucocorticoids in Rheumatoid Arthritis: A Systematic Review of International Guidelines and Consensus Statements

OBJECTIVE

To describe the perception of the current role of systemic glucocorticoids in the management of rheumatoid arthritis (RA) by examining their importance and the current level of evidence in recent guidelines, and to identify open questions to be addressed in future guidelines and research projects.

METHODS

We conducted a systematic literature review using the databases Ovid Embase, PubMed Medline, and Cochrane Library for guidelines on the pharmacologic treatment of RA. Retrieved articles were evaluated regarding their quality using the Appraisal of Guidelines for Research and Evaluation II tool and scrutinized for all relevant information concerning the use of glucocorticoids.

RESULTS

All guidelines agree that glucocorticoids, especially if given at low doses and for a short duration, are an appropriate option in the treatment of RA. However, many recommendations remain vague, as reliable and detailed evidence is scarce. Important aspects of glucocorticoid therapy are partially or completely neglected, and the existing nomenclature is not used uniformly. Quality evaluation revealed flaws in many articles, concerning not only glucocorticoid-specific recommendations but also guideline quality in general.

CONCLUSION

Current recommendations for use of glucocorticoids in the management of RA are suboptimal. More rigorous evaluation of doses, timing, and duration of their use is needed. Existing nomenclature on glucocorticoid therapy should be used uniformly.