Dysphagia, health-related quality of life, and return to work after occipitocervical fixation

PURPOSE

The purpose of this study was to evaluate patient-reported outcome measures (PROMS) on dysphagia, health-related quality of life (HRQoL) and return to work after occipitocervical fixation (OCF). Postoperative radiographic measurements were evaluated to identify possible predictors of dysphagia.

METHODS

All individuals (≥ 18 years) who underwent an OCF at the study center or were registered in the Swedish spine registry (Swespine) between 2005 and 2019, and were still alive when the study was conducted, were eligible for inclusion. There was no overlap between the cohorts. Prospectively collected data on dysphagia (Dysphagia Short Questionnaire DSQ), HRQoL (EQ5D-3L) and return to work were used. Radiological and baseline patient data were retrospectively collected. In addition, HRQoL data of a matched sample of individuals was elicited from the Stockholm Public Health Survey 2006.

RESULTS

In total, 54 individuals were included. At long-term follow-up, 26 individuals (51%) had no dysphagia, and 25 (49%) reported some degree of dysphagia: 11 (22%) had mild dysphagia, and 14 (27%) had moderate to severe dysphagia. On a group level, the OCF sample scored significantly lower EQVAS and EQ-5Dindex values compared to the general population (60.0 vs. 80.0, p = 0.016; 0.43 vs. 0.80, p < 0.001). Individuals working preoperatively returned to work after surgery. Of those responding, 88% stated that they would undergo the OCF operation if it was offered today. No predictors of dysphagia based on radiographic measurements were identified.

CONCLUSION

Occipitocervical fixation results in a high frequency of long-term dysphagia. The HRQoL of OCF patients is significantly reduced compared to matched controls. However, most patients are satisfied with their surgery. No radiographic predictors of long-term dysphagia could be identified. Future prospective and systematic studies with larger samples and more objective outcome measures are needed to elucidate the causes of dysphagia in OCF.

Unstable pelvic fractures in women: implications on obstetric outcome

PURPOSE

Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery.

METHOD

A retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16-45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared.

RESULTS

Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate.

CONCLUSION

Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies.

Development and validation of a clinical tool to semi-automatic measure three-dimensional TAR alignment on two-dimensional radiographs

BACKGROUND

Malalignment is often postulated as an important reason for the high failure rate of total ankle replacements (TARs). The correlation between TAR malalignment and clinical outcome, however, is not fully understood. Improving and expanding radiographic TAR alignment measurements in the clinic might lead to a better insight into the correlation between malalignment and the clinical outcome. This study aims to develop and validate a tool to semi-automatic measure TAR alignment, and to improve alignment measurements on radiographs in the clinic.

METHODS

A tool to semi-automatically measure TAR alignment on anteroposterior and lateral radiographs was developed in MATLAB. Using the principle of edge contouring and the perpendicular relationship between the anteroposterior and lateral radiographs, the exact configuration of the TAR components can be found. Two observers validated the tool by measuring TAR alignment of ten patients using the tool. The Intraclass Coefficient (ICC) was calculated to assess the reliability of the developed method. The results obtained by the tool were compared to clinical results during radiographic follow-up in the past, and the accuracy of both methods was calculated using three-dimensional CT data.

RESULTS

The tool showed an accuracy of 76% compared to 71% for the method used during follow-up. ICC values were 0.94 (p < 0.01) and higher for both inter-and intra-observer reliability.

CONCLUSIONS

The tool presents a reproducible method to measure TAR alignment parameters. Three-dimensional alignment parameters are obtained from two-dimensional radiographs, and as the tool can be applied to most TAR designs, it offers a valuable addition in the clinic and for research purposes.

Relationship between radiographic measurements and knee adduction moment using 3D gait analysis

BACKGROUND

Radiographic factors estimate the state of the static knee joint, and it is questionable how well these parameters reflect the dynamic knee condition. The external knee adduction moment (KAM) during gait is known to be a kinetic variable contributing to osteoarthritis progression. This study aims to investigate the effects of static radiographic parameters on the dynamic KAM during gait.

METHODS

Overall, 123 patients (mean age, 65.7 years; standard deviation, 8.1 years; 34 men and 89 women) were included. Seven radiographic parameters including the mechanical tibiofemoral angle (mTFA), Kellgren-Lawrence grade, and ankle joint line orientation (AJLO) were measured on radiographs, and the maximum KAM and KAM-time integral in the stance phase were obtained using three-dimensional gait analysis. The correlation and multiple regression analyses were performed for identifying significant radiographic measurements associated with the KAM.

RESULTS

Most of the radiographic measurements correlated with the maximum KAM and KAM-time integral. As a result of multiple regression analysis, the mTFA (p < 0.001) and AJLO (p = 0.003) were identified as significant factors associated with the KAM-time integral (R² = 0.450); the mTFA (p < 0.001) and AJLO (p = 0.003) were identified as a significant factor associated with the maximum KAM (R² = 0.352) in multiple regression analysis. The discriminant validity of KAM was highest at varus 5.7 degree of the mTFA and 7.5 degree of the AJLO.

SIGNIFICANCE

The mTFA and AJLO were significantly associated with the KAM. However, to be used as a surgical indication for corrective osteotomy, a longitudinal study is needed to validate whether the mTFA and AJLO values directly cause osteoarthritis progression as we have suggested.

LEVEL OF EVIDENCE

III.

Radiographic and plantar pressure assessment of pes planovalgus severity in children with cerebral palsy

BACKGROUND

Pes planovalgus is common in children with cerebral palsy. Although severity influences treatment, there still lacks standard clinical measurements to objectively quantify pes planovalgus in this population. The comparison of pedobarographic data and radiographic measurements to clinical evaluation has not been reported in this population.

METHODS

395  feet were identified from a population of ambulatory pediatric patients with cerebral palsy. Each patient initially underwent clinical evaluation by an experienced physical therapist who classified feet as: 136 controls, 116 mild, 100 moderate, and 43 severe pes planovalgus. Quantitative measurements were then calculated from antero-posterior and lateral radiographs of the foot. Pedobarographic analysis included the arch index, center of pressure index, and a newly defined medial index.

FINDINGS

A multivariate analysis was performed on the radiographic and pedobarographic measurements collected. It identified seven variables that improved objective classification of pes planovalgus severity when utilized together. These include the foot progression angle, initial contact force, arch index, medial index, antero-posterior talonavicular coverage, lateral calcaneal pitch and lateral Meary's angle. While the lateral calcaneal pitch angle statistically differed amongst all severity classes, no pedobarographic value statistically differed between all severity classes.

INTERPRETATION

Overall, the combination of radiographic and pedobarographic measurements provides valuable information for objectively classifying severity of pes planovalgus in children with cerebral palsy by utilizing these values together rather than independently. In a clinical setting, radiographs and pedobarographic data may be obtained to enhance assessment of severity and guide treatment.

Is it possible to define reference values for radiographic parameters evaluating juvenile flatfoot deformity? A case-control study

Background

Numerous radiographic parameters are described to evaluate juvenile flexible flatfeet. Reference values for these measurements are based on few studies. The purpose of this study was to determine boundary values among the most widely used radiographic measurements to evaluate juvenile flatfeet.

Methods

Twenty-two patients with normal hind-, midfoot configuration (group A: control group; 22 ft, mean age: 12,1 years) and 19 patients with flatfoot deformity (group B: study group; 22 ft, mean age: 12,4 years) were retrospectively analyzed. Nine radiographic parameters were measured (Talocalcaneal-angles, Calcaneal-pitch-angle, Costa-Bartani-angle, Talo-metatarsal-I-angles, Talo-first-metatarsal-base-angle, Talo-navicular-coverage, Calcaneus-fifth-metatarsal-angle). ROC curve analysis was used to calculate optimal differentiating thresholds of each parameter.

Results

Four out of nine parameters (TC-dp, TC-lat, Calc-MTV, Calc-P) were not statistically different between the groups and their ability to distinct between normal foot and flatfoot was low (AUC values = 0,660 - 0,819). Calculation of reference values for these parameters was not performed due to threshold ranges between the groups of > 10°. Reference values could be defined only for three parameters: TMTInd >(−)31°, TMTIB >(−)7,5°, TMT-lat > (−)13,5°. The TMTInd was shown to be a very reliable and valid combination of two measurements (TMTIB and TMT-lat) in the differentiation of normal feet and flatfeet (AUC = 0,998).

Conclusion

The calculation of reference values for established radiographic parameters used to evaluate juvenile flatfeet is difficult for most parameters. The TMTInd as a combination of TMTIB and TMT-lat has been shown to be reliable and valuable to distinct normal feet from flatfeet.

Intervertebral Displacement of the Thoracic Spine with and without Loading: Radiographic and in Vitro Measurements

BACKGROUND

We are developing an intradural approach to spinal cord stimulation, where the thin electrode array is affixed stably to the underside of the thoracic spinal dura mater without leakage of cerebrospinal fluid. As part of the design and testing process, we sought to evaluate the potential risk of inadvertent contact of the array with the pial surface of the spinal cord during variations in spinal loading.

METHODS

As part of the risk assessment process, a 2-part study was undertaken. First, a retrospective review of the imaging studies of 25 patients was done in the supine, 45- and 90-degree positions to measure the positional shift between the T9 and T10 vertebral bodies as a function of spinal angulation. Second, similar measurements were made on a cadaveric model, with and without a prototype intradural stimulator implanted at the T9-T10 position and with and without 13.8 kg (30 lb) of axial spinal loading at the 90-degree orientation.

RESULTS

In all cases, the measured relative displacement of the dura mater towards the spinal cord in both the imaging and the cadaveric arms of the study was less than 1 mm.

CONCLUSIONS

The implantation method for the thin intradural array of the prototype device will ensure that the anatomic separation between it and the pial surface of the spinal cord will be the same as that of the dura mater. Therefore the risk of inadvertent contact will be no greater than that due to the mass effects of standard epidural stimulator implants.

Essentials of Deformity Planning

Learning the essentials of deformity planning is the basis for the treatment of simple and complex deformities. Understanding the planes of deformity, radiographic correlation, and clinical correlations allows the surgeon to treat the condition with deeper knowledge of deformity, leading to improved deformity correction.

The inter- and intra-rater reliability of the Maestro and Barroco metatarsal length measurement techniques

Background

The relationship between metatarsal length and various forefoot pathologies is a topic of contention in Orthopaedics. The results of such investigations have been shown to depend on the method of metatarsal length measurement used. The aim of this study was to assess the inter- and intra-rater reliability of the Maestro and Barroco metatarsal length measurement techniques.

Methods

A retrospective and quantitative study was performed on 15 randomly selected radiographs to determine the reliability of the two measurement techniques across all five metatarsals (M1 to M5). This was done at one week apart for three weeks by three raters. The intraclass correlation coefficient (ICC), and the 95% lower confidence limit (95% LCL) were calculated.

Results

The Maestro and Barroco techniques produced high to very high ICC vlaues for length measurements across all metatarsals. The 95% lower confidence limit for inter-rater measurements ranged between 0.92–0.98 for Maestro’s and 0.86–0.99 for Barroco’s technique. For intra-rater measurements the 95% LCL ranged between 0.83–0.99 for Maestro’s and 0.75–0.99 for Barroco’s technique.

Conclusions

Our study found that both the Maestro and Barroco methods of measurements produced high to very high inter- and intra-rater reliability. Both methods may be suitable for the use of peri-operative planning and clinical research relating metatarsal length and forefoot pathology. Besides having a more simplistic method of application, the novel Barroco technique is comparable to the more established Maestro method in both repeatability and reproducibility.

Pelvic incidence: a fixed value or can you change it?

BACKGROUND CONTEXT

There has been renewed interest in the pelvic vertebrae by spinal surgeons recently. Those involved in working with patients with adult spinal deformity focus on the position of the fused spine as it relates to the pelvis, and determine success or failure by specific numbers for given pelvic parameters. The pelvic parameters that are commonly measured for these patients are pelvic tilt, sacral slope, and pelvic incidence (PI). Out of the three, PI has always been considered to be the fixed measurement, whereas pelvic tilt and sacral slope have the capacity to change in relation to external forces. The assumption that the PI does not change has not been proven in a healthy, asymptomatic population.

PURPOSE

This study aimed to investigate the differences in PI between three pelvic positions used in common functional activities: resting baseline pelvic posture, maximal anterior pelvic rotation, and maximal posterior pelvic rotation.

STUDY DESIGN/SETTING

This was a randomized, prospective study of 50 healthy, asymptomatic, individuals who were recruited from the vicinity of our institution.

PATIENT SAMPLE

Fifty patients (16 men with a mean age of 26.5±12.1 years; 34 women with a mean age of 27.2±10.8 years) were recruited for this study. Initial screening occurred by telephone. The inclusion criteria consisted of participants being between 18 and 79 years of age, no previous history of spine, pelvic, or lower extremity pain which had lasted longer than 48 hours, or history of any disorder in the spine, pelvis, or lower extremity that had required medical care. Female patients could not be pregnant at the time of participation.

OUTCOME MEASURES

Changes in PI were assessed by examining the differences between the values of the PI with each change in pelvic position: resting to maximal anterior pelvic rotation and resting to maximal posterior pelvic rotation. Inter-rater reliability was assessed using Cronbach's alpha.

METHODS

This study was funded by a Small Exploratory Grant from the Scoliosis Research Society. All subjects had an initial posterior-anterior and lateral radiograph taken in their resting pelvic position. If no spinal deformity was noted, each subject was instructed to maximally rotate their pelvis anteriorly and an immediate lateral radiograph was taken. The subject was then instructed to maximally rotate their pelvis posteriorly and an immediate lateral radiograph was again taken. Radiographic measurements of PI were independently measured by a board-certified, fellowship trained orthopedic spine surgeon and a board-certified musculoskeletal radiologist after defining and agreeing to the specific manner of measurement.

RESULTS

Pelvic incidence values changed in 44 of 50 subjects (88%) when they maximally anteriorly rotated their pelvis from the resting pelvic position. The mean change was 2.9°, with 23 of 50 subjects (46%) changing ≥3°. Pelvic incidence values changed in 40 of 50 subjects (80%) when they maximally posteriorly rotated their pelvis from the resting position. The mean change was 2.82° with 27 of 50 subjects (54%) changing by ≥3°.

CONCLUSIONS

This study demonstrated that for a high percentage of the healthy subjects who participated, the PI changed when the subjects varied their pelvic position. This questions the assumption that PI is a fixed parameter and suggests a potential functional motion at the sacroiliac joint. It also supports the idea that intentionally changing one's posture could lead to a change in PI, an idea that could have ramifications in surgical cases.

Radiographs Versus Radiographic Measurements in Distal Radius Fractures

Surgeons use radiographic measures of deformity to help make treatment decisions in distal radius fractures. Precise threshold values are sometimes offered as a guide to treatment. The purpose was to evaluate if agreement on treatment recommendations would improve if surgeons were provided with radiographs rather than precise numeric radiographic measurements. We randomized 259 surgeons to review the scenarios of 30 consecutive adult patients with a distal radius fracture treated at our emergency department either with radiographs (135 surgeons) or with radiographic measurements (124 surgeons). Interrater reliability was measured with the Fleiss' generalized Kappa. Factors associated with a recommendation for operative treatment were sought in bivariate and multivariable analyses. Surgeons that received measurements only recommended operative treatment significantly more often, but were less likely to agree than surgeons evaluating actual radiographs. Patient factors - radiographic factors in particular - had a greater influence on treatment recommendation than surgeon factors. Agreement on treatment recommendations improved if surgeons were provided with radiographs instead of just measurements. There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery.

Hip joint center localisation: A biomechanical application to hip arthroplasty population

AIM: To determine hip joint center (HJC) location on hip arthroplasty population comparing predictive and functional approaches with radiographic measurements.

METHODS: The distance between the HJC and the mid-pelvis was calculated and compared between the three approaches. The localisation error between the predictive and functional approach was compared using the radiographic measurements as the reference. The operated leg was compared to the non-operated leg.

RESULTS: A significant difference was found for the distance between the HJC and the mid-pelvis when comparing the predictive and functional method. The functional method leads to fewer errors. A statistical difference was found for the localization error between the predictive and functional method. The functional method is twice more precise.

CONCLUSION: Although being more individualized, the functional method improves HJC localization and should be used in three-dimensional gait analysis.