Is ankle fracture related to low bone mineral density and subsequent fracture? A systematic review.

OBJECTIVES: Ankle fractures are common in the elderly. However, their association with osteoporosis remains controversial. This systematic review aims to determine the relationship between ankle fracture and bone mineral density (BMD), and to investigate the risk of subsequent fractures after ankle fracture. METHODS: MEDLINE and Scopus publications were searched from inception to March and April 2019, respectively. Articles were selected by 2 independent reviewers for cross-sectional, cohort, or case-control studies comparing BMD or subsequent fracture risk in low-energy ankle fractures patients with that of the normal population. Data extraction was performed by 2 investigators. Discrepancies were resolved with the third reviewer. Quality assessment was conducted using the modified Newcastle-Ottawa Scale. RESULTS: Overall, 19 articles were included. The quality assessment showed a generally low-to-moderate risk of bias among studies, mainly due to potential confounders and inadequate follow-up. Of 13 studies exploring BMD in ankle fractured-patients, lower central and peripheral BMD was found in 3 and 2 studies, respectively. The risk of subsequent fracture was examined in 11 studies with relative risks ranging from 0.7 to 4.59. An increased risk of any subsequent fractures in women, both genders, and men was found in 5, 2, and 1 articles, respectively. CONCLUSIONS: Despite the lack of clear association with BMD, the contribution of ankle fracture to increased subsequent fracture risk and its associated microarchitectural changes cannot be overlooked. Moreover, its potential role as an early predictor of future fracture may promote secondary prevention. Further studies with longer follow-up and stricter confounder control are recommended.

Prevalence of High-Riding Vertebral Artery and Morphometry of C2 Pedicles Using a Novel Computed Tomography Reconstruction Technique.

STUDY DESIGN: Cross-sectional, matched-pair comparative study. PURPOSE: To determine whether a thin-sliced pedicular-oriented computed tomography (TPCT) scan reconstructed from an existing conventional computed tomography (CCT) scan is more accurate for identifying vertebral artery groove (VAG) anomalies than CCT. OVERVIEW OF LITERATURE: Posterior atlantoaxial transarticular screw fixation and C2 pedicle screws can cause vertebral artery (VA) injury. Two anatomic variations of VAG anomalies are associated with VA injury: a high-riding VA (HRVA) and a narrow pedicle of the C2 vertebra. CCT scan is a reliable method used to evaluate VAG anomalies; however, its accuracy level remains debatable. Literature comparing the prevalence of C2 VAG anomalies between CCT and TPCT is limited. METHODS: A total of 200 computed tomography scans of the upper cervical spine obtained between January 2008 and December 2011 were evaluated for C2 VAG anomalies (HRVA and narrow pedicular width) using CCT and TPCT. The prevalence of C2 VAG anomalies was compared using these two different measurement methods via a McNemar's test. RESULTS: Of the 200 patients studied, 23 HRVA (6.01%; 95% confidence interval [CI], 3.61%-8.39%) were detected with CCT, whereas 66 HRVA (16.54%; 95% CI, 12.85%-20.23%) were detected with TPCT (p<0.001). Sixty-two narrow pedicles (15.58%; 95% CI, 11.99%-19.15%) were detected with CCT, whereas 90 narrow pedicles (22.83%; 95% CI, 18.58%-26.87%) were detected with TPCT (p<0.001). CONCLUSIONS: VAG anomalies are commonly observed. A preoperative evaluation using TPCT reconstructed from an existing CCT revealed a significantly higher prevalence of C2 VAG anomalies than did CCT and showed comparable prevalence to previously published studies using more sophisticated and higher risk techniques. Therefore, we propose TPCT as an alternative preoperative evaluation for C2 screw placement and trajectory planning.

Anatomic Considerations of Intervertebral Disc Perspective in Lumbar Posterolateral Approach via Kambin's Triangle: Cadaveric Study.

STUDY DESIGN: Anatomical study. PURPOSE: To evaluate the anatomy of intervertebral disc (IVD) area in the triangular working zone of the lumbar spine based on cadaveric measurements. OVERVIEW OF LITERATURE: The posterolateral percutaneous approach to the lumbar spine has been widely used as a minimally invasive spinal surgery. However, to our knowledge, the actual perspective of disc boundaries and areas through posterolateral endoscopic approach are not well defined. METHODS: Ninety-six measurements for areas and dimensions of IVD in Kambin's triangle on bilateral sides of L1-S1 in 5 fresh human cadavers were studied. RESULTS: The trapezoidal IVD area (mean±standard deviation) for true working space was 63.65±14.70 mm2 at L1-2, 70.79±21.88 mm2 at L2-3, 99.03±15.83 mm2 at L3-4, 116.22±20.93 mm2 at L4-5, and 92.18±23.63 mm2 at L5-S1. The average dimension of calculated largest ellipsoidal cannula that could be placed in IVD area was 5.83×11.02 mm at L1-2, 6.97×10.78 mm at L2-3, 9.30×10.67 mm at L3-4, 8.84×13.15 mm at L4-5, and 6.61×14.07 mm at L5-S1. CONCLUSIONS: The trapezoidal perspective of working zone of IVD in Kambin's triangle is important and limited. This should be taken into consideration when developing the tools and instruments for posterolateral endoscopic lumbar spine surgery.

Demineralized Bone Matrix Add-On for Acceleration of Bone Healing in Atypical Subtrochanteric Femoral Fracture: A Consecutive Case-Control Study.

BACKGROUND: Delayed union and nonunion are common complications in atypical femoral fractures (AFFs) despite having good fracture fixation. Demineralized bone matrix (DBM) is a successfully proven method for enhancing fracture healing of the long bone fracture and nonunion and should be used in AFFs. This study aimed to compare the outcome after subtrochanteric AFFs (ST-AFFs) fixation with and without DBM. MATERIALS AND METHODS: A prospective study was conducted on 9 ST-AFFs patients using DBM (DBM group) during 2013-2014 and compared with a retrospective consecutive case series of ST-AFFs patients treated without DBM (2010-2012) (NDBM group, 9 patients). All patients were treated with the same standard guideline and followed up until fractures completely united. Postoperative outcomes were then compared. RESULTS: DBM group showed a significant shorter healing time than NDBM group (28.1 ± 14.4 versus 57.9 ± 36.8 weeks, p = 0.04). Delayed union was found in 4 patients (44%) in DBM group compared with 7 patients (78%) in NDBM group (p > 0.05). No statistical difference of nonunion was demonstrated between both groups (DBM = 1 and NDBM = 2, p > 0.05). Neither postoperative infection nor severe local tissue reaction was found. CONCLUSIONS: DBM is safe and effective for accelerating the fracture healing in ST-AFFx and possibly reduces nonunion after fracture fixation. Trial registration number is TCTR20151021001.

Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents.

AIM: To investigate the effect of early surgical intervention on the high surgical risk elderly patients who sustained femoral neck fracture (FNF) and taking concomitant antiplatelet agents. METHODS: Between 2010 and 2012, a prospective study was conducted on 49 geriatric patients, who took antiplatelet agents, sustained FNF and underwent surgery within 72 h [early surgery (ES) group], and these were compared with a retrospective consecutive case series of patients with similar characteristics (45 cases) who had delayed surgery (DS group) after 72 h during an earlier 3-year period. Postoperative outcomes were followed for one year and compared. RESULTS: There were non-significant differences in perioperative blood loss, blood transfusion, intensive care unit requirement and postoperative mortality (P > 0.05 all). There were 2 patients (4%) in the DS group who died after surgery (P = 0.23). However, the ES group showed a significantly better postoperative outcome in terms of postoperative complications, length of hospital stay, and functional outcome (P < 0.05 all). CONCLUSION: Early hip surgery in geriatric hip fracture patients with ongoing antiplatelet treatment was not associated with a significant increase of perioperative blood loss and postoperative mortality. Moreover, ES resulted in a better postoperative surgical outcome. In early hip surgery protocol, the antiplatelet agents are discontinued and the patient is operated on within 72 h after admission, which is safe and effective for the medically fit patients.

Cost-Utility Analysis of Osteoporotic Hip Fractures in Thais.

A prospective study was conducted among osteoporotic hip fracture in 2008. It was aimed to assess cost per quality adjusted life year (QALY) of hip fracture in the context of a developing country. The patients who were diagnosed as hip fracture and admitted to the orthopedic wards were included. Any pathological fractures or missing data were discarded from the analysis. Median cost was evaluated from a societal perspective. EQ-5D was used to assess health utility state and then converted into a time trade off Cost per QALYwas estimated at one year of follow-up. Forty-two patients completed a quality of life assessment. The average age was 75.6 years old and 71% were female. Most of them were undergone either hemiarthroplasty or internal fixation. The median total cost per year was US$ 4,210.60. The median QALY was 0.636 and cost per QALY was US$ 6,620.52. Cost utility of a hip fracture in Thai setting was lower than other developed countries due to strong family support and insufficient rehabilitation. However it has high impact on 78.8% of the Thai Gross National Product. Prevention of hip fracture is needed in underdeveloped countries as much as others, worldwide.

The Impacts of Early Hip Surgery in High-Risk Elderly Taking Antithrombotic Agents and Afflicted with Intertrochanteric Fracture.

OBJECTIVE: To compare the outcome of early hip surgery in intertrochanteric fracture between high surgical risk patients receiving antiplatelet and anticoagulant drugs and those who did not. DESIGN: Retrospective study. MATERIAL AND METHOD: One hundred and four elderly patients with intertrochanteric fracture and having American Society of Anesthesiologist grade III-IV who underwent early hip surgery (within 72 hours after admission) with proximalfemoral nail anti-rotation (PFNA), were recruited and allocated into two group: antiplatelet and anticoagulant (AA-AC) group (n = 65), and no drug group (n = 39). Perioperative and postoperative outcomes were recorded and analyzed. RESULTS: The mean age was 81?8 years. The overall 1-year mortality was 6.7% (7 patients: 5 AA-AC group, and 2 no drug group, p = 0.7). Intra-operative blood loss in AA-AC group and No drug group were 87 ± 70 and 91 ± 65 ml, respectively (p = 0.74). There was no significant difference in blood transfusion, postoperative complications, and 1-year ambulatory status between both groups (p > 0.05 all). However, AA-AC group showed significant longer in duration of hospital stay compared with no drug group (p = 0.02). CONCLUSION: Early hip fracture surgery with PFNA in patients who received antiplatelet and anticoagulant medications is safe and does not significantly increase perioperative blood loss, blood transfusion, and postoperative mortality and morbidity.

The Association of Bone Mineral Density and G2014A Polymorphism in the Estrogen Receptor Alpha Gene in Osteoporotic Hip Fracture in Thai Population.

OBJECTIVE: This study aimed to determine the association of a recent identified G2014A single nucleotide polymorphism (SNP) genotype distribution in exon 8 of the estrogen receptor in postmenopausal Thai women. MATERIAL AND METHOD: A prospective study was conducted at Ramathibodi Hospital between July 2005 and July 2006. Postmenopausal Thai women, aged more than 55 years and had sustained osteoporotic hipfracture, were included. Exclusion criteria were renal and metabolic bone diseases. Age, body mass index (BMI), blood tests for metabolic bone disease, and G2014A SNP genotype, bone mineral density (BMD) were collected. The relationship between the degree of osteoporosis (normal, osteopenia, and osteoporosis) and SNP genotype was analyzed by Fisher's exact test. RESULTS: Sixty-five postmenopausal women with osteoporosis were included. The average age was 76.2 ± 10.9 years old, and the average BMI was 21.3 ± 3.5 kg/m2. The data expressing the genotype distribution of gene G2014A SNP were G/G 23.1%, G/A 29.2% and A/A 47.7%. There was no statistical difference between age and BMI in each genotype. Gene G2014A was associated with osteoporosis of lumbar spine, femoral neck, ward triangle, and femoral neck. CONCLUSION: It could be concluded that a G2014A SNP genotype in exon 8 of the estrogen receptor was associated with postmenopausal women who had osteoporotic hip fracture.

Outcomes of fluoroscopically guided lumbar transforaminal epidural steroid injections in degenerative lumbar spondylolisthesis patients.

STUDY DESIGN: A prospective cohort. PURPOSE: To report the short and long term outcomes of fluoroscopically guided lumbar transforaminal epidural steroid injection (TFESI) in degenerative lumbar spondylolisthesis (DLS) patients. OVERVIEW OF LITERATURE: TFESI has been widely used for the treatment of lumbosacral radicular pains. However, to our knowledge, there has been no study which has evaluated the outcomes of TFESI in patients with DLS. METHODS: The DLS patients received fluoroscopically guided lumbar TFESI with 80 mg of methylprednisolone and 2 mL of 1% lidocaine hydrochloride. Patients were evaluated by an independent observer before the initial injection, at 2 weeks, at 6 weeks, at 3 months, and at 12 months after the injections. Visual analog scale (VAS), Roland 5-point pain scale, standing tolerance, walking tolerance, and patient satisfaction scale were evaluated for outcomes. RESULTS: Thirty three DLS patients treated with TFESI, who were completely followed up, were included in this study. The average number of injections per patient was 1.9 (range from 1 to 3 injections per patient). Significant improvements in VAS and Roland 5-point pain scale were observed over the follow up period from 2 weeks to 12 months. However, the standing and walking tolerance were not significantly improved after 2 weeks. At 2 weeks, the patient satisfaction scale was highest, although, these outcomes declined with time. The DLS patients with one level of spinal stenosis showed significantly better outcome than the DLS patients with two levels of spinal stenosis. Five patients (13%) underwent surgical treatment during the 3 to 12 months follow up. CONCLUSIONS: TFESI provides short term improvements in VAS and Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale in DLS patients. In the long term, it improves VAS but limits the improvements in Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale.

Morphometric evaluation of subaxial cervical spine using multi-detector computerized tomography (MD-CT) scan: the consideration for cervical pedicle screws fixation.

BACKGROUND: Cervical pedicle screw (CPS) insertion is a technically demanding procedure. The quantitative understanding of cervical pedicle morphology, especially the narrowest part of cervical pedicle or isthmus, would minimize the risk of catastrophic damage to surrounding neurovascular structures and improve surgical outcome. The aim of this study was to investigate morphology and quantify cortical thickness of the cervical isthmus by using Multi-detector Computerized Tomography (MD-CT) scan. METHODS: The cervical CT scans were performed in 74 patients (37 males and 37 females) with 1-mm slice thickness and then retro-reconstructed into sagittal and coronal planes to measure various cervical parameters as follows: outer pedicle width (OPW), inner pedicle width (IPW), outer pedicle height (OPH), inner pedicle height (IPH), pedicle cortical thickness, pedicle sagittal angle (PSA), and pedicle transverse angle (PTA). RESULTS: Total numbers of 740 pedicles were measured in this present study. The mean OPW and IPW significantly increased from C3 to C7 while the mean OPH and IPH of those showed non-significant difference between any measured levels. The medial-lateral cortical thickness was significantly smaller than the superior-inferior one. PTA in the upper cervical spine was significantly wider than the lower ones. The PSA changed from upward inclination at upper cervical spine to the downward inclination at lower cervical spine. CONCLUSIONS: This study has demonstrated that cervical vertebra has relatively small and narrow inner pedicle canal with thick outer pedicle cortex and also shows a variable in pedicle width and inconsistent transverse angle. To enhance the safety of CPS insertion, the entry point and trajectories should be determined individually by using preoperative MD-CT scan and the inner pedicle width should be a key parameter to determine the screw dimensions.

Using a reconstruction locking compression plate as external fixator in infected open clavicle fracture.

Open clavicle fracture is an uncommon injury mostly caused by severe direct trauma. It is often associated with multiple organ injuries. Generally, surgical intervention with debridement and fracture repair is always indicated in order to prevent infection, non-union, and malalignment. In situations of bony exposure and significant contamination concomitant with severe soft tissue damage, the external fixation is the treatment of choice because of the possibility it offers of providing stable fixation with minimal local tissue damage resulting in excellent union rates and better soft tissue outcome. Nevertheless, traditional external fixation encountered some potential problems as its bulkiness and sharp edges caused discomfort to the patient. In this study, we present an interesting case of a polytraumatized patient with a gunshot injury with complex open clavicle fracture that was successfully treated with external fixation using reconstruction with a locking compression plate as definitive treatment.

Anteromedial Marginal Fracture of Medial Tibial Plateau without Significant Knee Ligamentous Injury in Hypermobility Patient: a Case Report and Review of Literature.

Anteromedial rim fracture of medial tibial plateau is a rare fracture pattern with only a small number of case reports in the literature. However, it is highly likely that is associated with specific significant soft tissue injuries, especially posterior and posterolateral corner structure, and medial meniscus injury. It is thought this fracture is caused by hyperextension and varus rotation mechanism. The previous reports highlight the typical pattern of severe concomitant knee ligament injury associated with this fracture that always require surgical repair to restore knee stability and function. In this report, we present an unusual case with a history of generalized joint laxity and acute anteromedial marginal fracture of medial tibial plateau without associated significant ligament damage, together with a literature review of this condition. We believe this case report introduces new insights into this unique fracture pattern.

The correlation between the sagittal lumbopelvic alignments in standing position and the risk factors influencing low back pain.

Low back pain (LBP) is the most common health problem. Many factors have been demonstrated to be fundamental risk factors of LBP such as body mass index (BMI), age and sex. However, so far there have been few studies demonstrating the association between lumbo-pelvic alignment (LPA) and these factors. This present study was aimed to clarify the correlation between the LPA and the risk factors contributing to LBP. Standing lateral X-rays were taken from 100 healthy volunteers (70 males and 30 females) with no history of low back pain before their participation. Average age of subjects was 33.3±6.8 years (rang 21-50). Mean body weight was 59.1±7.9kg (range 40-82), mean body height was 163.6±7.2 cm (range 145-178) and mean BMI was 22.1±2.4 kg/m(2) (range 18.0-29.3). The LPA was classified into 3 types according to the recently proposed pelvic orientation guidelines. No direct correlation was found between the pelvic orientation and age or BMI. Each LPA type was associated with sex but not BMI and age (P=0.00, 0.71, and 0.36, respectively). The results from this study demonstrated the differences in LPA between male and female, and also confirmed that the sagittal orientation of the pelvis remained constant in adults. The high prevalence of LPA type 1 in males may reduce the occurrence of LBP in obese male individuals.

Non-union and avascular necrosis of delayed reduction and screw fixation in displaced femoral neck fracture in young adults.

OBJECTIVE: Management of displaced femoral neck fracture is crucial and vulnerable to develop complications. The present study was performed to evaluate the clinical outcome of delayed reduction with multiple screw fixations in young patients who had displaced femoral neck fracture. MATERIAL AND METHOD: The authors conducted a retrospective study in young patients, aged less than 50 years old, who underwent delayed fixation for traumatic displaced femoral neck fracture (Garden classification III or IV) at Phetchabun Hospital between 1997 and 2002. Either closed or open reduction was performed to achieve an acceptable alignment and fixed with 2 or 3 cancellous screws. Study factors were age, gender Garden classification, time to reduction, type of reduction, number of screw fixation and Garden alignment index. Non-union and avascular necrosis was assessed by clinical and radiographic findings. RESULTS: There were 26 eligible patients. The average duration of delayed surgery was 13 days (range 2 to 30 days). Twenty-three patients had completed followed-up at average 28.4 months (range 14-52 months). All patients revealed complete union and independently ambulated within 10-16 months postoperatively. Clinical and radiographic avascular necroses of the femoral head developed in 2 patients (8.7%) at 20 and 24 months after surgery. Three patients who had early fixation failure underwent hemiarthroplasty except one patient refused to re-operate. CONCLUSION: Within 30-day delayed reduction and screw fixation for the treatment of displaced femoral neck fracture in the young is still good alternative treatment to preserve the femoral head with low rate of avascular necrosis.

Treatment of acute tuberculous spondylitis by the spinal shortening osteotomy: a technical notes and case illustrations.

Surgical treatment for spinal tuberculosis is necessary in particular cases that a large amount of necrotic tissue is encountered and there is spinal cord compression. A spinal shortening osteotomy procedure has previously been described for the correction of the sagittal balance in a late kyphotic deformity, but there have been no reports on this as a surgical treatment in the acute stage. Thus, the aim of this report is to present the surgical techniques and clinical results of 3 patients who were treated with this procedure. Three patients with tuberculous spondylitis at the thoracic spine were surgically treated with this procedure. All the patients presented with severe progressive back pain, kyphotic deformity and neurological deficit. The patients recovered uneventfully from surgery without further neurological deterioration. Their pain was improved and the patients remained free of pain during the follow-up period. In conclusion, posterior spinal shortening osteotomy is an alternative method for the management of tuberculous spondylitis.

A genetic association study between growth differentiation factor 5 (GDF 5) polymorphism and knee osteoarthritis in Thai population.

OBJECTIVE: Osteoarthritis (OA) is a multi-factorial disease and genetic factor is one of the important etiologic risk factors. Various genetic polymorphisms have been elucidated that they might be associated with OA. Recently, several studies have shown an association between Growth Differentiation Factor 5(GDF5) polymorphism and knee OA. However, the role of genetic predisposing factor in each ethnic group cannot be replicated to all, with conflicting data in the literatures. Therefore, the aim of this study was to investigate the association between GDF5 polymorphism and knee OA in Thai population. MATERIALS AND METHODS: One hundred and ninety three patients aged 54-88 years who attended Ramathibodi Hospital were enrolled. Ninety cases with knee OA according to American College of Rheumatology criteria and one hundred and three cases in control group gave informed consent. Blood sample (5 ml) were collected for identification of GDF5 (rs143383) single nucleotide polymorphism by PCR/RFLP according to a standard protocol. This study protocol was approved by the Ethics Committee on human experimentation of Ramathibodi Hospital Faculty of Medicine, Mahidol University. Odds ratios (OR) and 95% confidence intervals were calculated for the risk of knee OA by genotype (TT, TC and CC) and allele (T/C) analyses. RESULTS: The baseline characteristics between two groups including job, smoking and activity were not different, except age and BMI. The entire cases and controls were in Hardy-Weinberg equilibrium (p > 0.05). The OA knee group (n = 90) had genotypic figure which has shown by TT 42.2% (n = 38), TC 45.6% (n = 41) and CC 12% (n = 11), whereas the control group (n = 103) revealed TT 32% (n = 33), TC 45.6% (n = 47), and CC 22.3% (n = 23), respectively. Genotypic TT increased risk of knee OA as compared to CC [OR = 2.41 (P = 0.04, 95%CI = 1.02-5.67)]. In the allele analysis, the T allele was found to be significantly associated with knee OA [OR = 1.53 (P = 0.043, 95%CI = 1.01-2.30)]. CONCLUSION: These data suggested that GDF5 polymorphism has an association with knee OA in Thai ethnic. This finding also supports the hypothesis that OA has an important genetic component in its etiology, and GDF5 protein might play important role in the pathophysiology of the disease.

Reliability and validity of an adapted Thai version of the Scoliosis Research Society-22 questionnaire.

PURPOSE: The Scoliosis Research Society-22 (SRS-22) questionnaire is a widely accepted questionnaire used to assess the health-related quality of life for scoliosis patients in the United States. However, its adaptation in other languages is necessary for its multinational use. A cross-sectional study was performed to evaluate the validity and reliability of an adapted Thai version of the SRS-22 questionnaire. METHODS: An expert committee performed translation/retranslation of the English version of the SRS-22 questionnaire, as well as a cross-cultural adaptation process. Later, SRS-22 questionnaires and previously validated Short Form-36 version 2 (SF-36v2) outcome instruments were given to patients treated for idiopathic scoliosis with a minimum of 1 year of follow-up. Internal consistency and reproducibility were determined by Cronbach's alpha statistics and the intraclass correlation coefficient, respectively. Concurrent validity was measured by comparing SRS-22 results with a previously validated questionnaire (SF-36v2). Measurement was made using the Pearson correlation coefficient (r). RESULTS: The study showed satisfactory internal consistency with Cronbach's alpha values for all of the corresponding domains (pain, 0.72; self-image/appearance, 0.87; mental health, 0.83; satisfaction with management, 0.63; and function/activity, 0.83). The test-retest reproducibility was also excellent or good for all domains (pain, 0.72; self-image/appearance, 0.85; mental health, 0.82; satisfaction, 0.62; and function/activity, 0.81). For concurrent validity, excellent correlation was found in two domains, good in six domains, moderate in five domains, and poor in five domains of the 18 relevant domains. CONCLUSIONS: The Thai version of the SRS-22 outcome instrument has satisfactory internal consistency, excellent reproducibility, and acceptable validity.

Lumbopelvic alignment on standing lateral radiograph of adult volunteers and the classification in the sagittal alignment of lumbar spine.

The analysis of the sagittal balance is important for the understanding of the lumbopelvic biomechanics. Results from previous studies documented the correlation between sacro-pelvic orientation and lumbar lordosis and a uniqueness of spino-pelvic alignment in an individual person. This study was subjected to determine the lumbopelvic orientation using pelvic radius measurement technique. The standing lateral radiographs in a standardized standing position were taken from 100 healthy volunteers. The measurements which included hip axis (HA), pelvic radius (PR), pelvic angle (PA), pelvic morphology (PR-S1), sacral translation distance (HA-S1), total lumbosacral lordosis (T12-S1), total lumbopelvic lordosis (PR-T12) and regional lumbopelvic lordosis angles (PR-L2, PR-L4 and PR-L5) were carried out with two independent observers. The relationships between the parameters were as follows. PR-S1 demonstrated positive correlation to regional lumbopelvic lordosis and revealed negative correlation to T12-S1. PA showed negative correlation to PR-S1 and regional lumbopelvic lordosis, but revealed positive correlation to HA-S1. T12-S1 was significantly increased when PR-S1 was lesser than average (35°-45°) and was significantly decreased when PR-S1 was above the average. PR-L4 and PR-L5 were significantly reduced when PR-S1 was smaller than average and only PR-L5 was significantly increased when PR-S1 was above the average. In conclusion, this present study supports that lumbar spine and pelvis work together in order to maintain lumbopelvic balance.

Functional outcome after decompression and instrumented arthrodesis in degenerative lumbar spinal stenosis: factors influencing unsuccessful outcome change.

OBJECTIVE: To determine functional outcome after decompressive laminectomy and instrumented arthrodesis in patients with degenerative lumbar spinal stenosis and identify predictors of failed clinical outcome in these patients. MATERIAL AND METHOD: A retrospective cohort data were collected from January 1999 to February 2004. Degenerative lumbar spinal stenosis patients who had decompressive laminectomy and instrumented fusion with pedicular screw system and completed at least 2 years follow-up were enrolled in the present study. Outcomes included Oswestry Disability Index (ODI), Roland Morris score and patient satisfaction. Factors evaluated as outcome variables were age, gender onset, patient income, associated diseases, smoking, diagnosis of spondylolisthesis or scoliosis, number of levels of instrumentation and presence of S1 fusion. Univariate analysis for factors influencing failed clinical outcome used Chi-square and Fisher exact test and multivariate analysis used the logistic regression. RESULTS: One-hundred and fifty-eight patients were included in the present study. Mean follow-up was 2.64 years (range, 2-5 years). The mean age of the patients at the time of surgery was 60.3 years (range, 34-87 years) and 129 cases (81.7%) were female. According to the US FDA, the criteria of significant successful clinical outcome change is reduction of ODI at least 15%, the proportion of patients reporting significant successful clinical outcome change was 63.9%. Multivariate analysis identified age > 65 years, onset > 24 months and number of levels of instrumentation > 4 as the factors of failed clinical outcome change (p < 0.05). CONCLUSION: Decompression and instrumented arthrodesis in degenerative lumbar spinal stenosis gained satisfactory functional outcome. Older age, prolonged onset and long level of instrumentation were the factors of failed clinical outcome change.