Validation of the Subaxial Cervical Spine Injury Classification score in children: a single-institution experience at a level 1 pediatric trauma center.

OBJECTIVE: The Subaxial Cervical Spine Injury Classification (SLIC) score has not been previously validated for a pediatric population. The authors compared the SLIC treatment recommendations for pediatric subaxial cervical spine trauma with real-world pediatric spine surgery practice. METHODS: A retrospective cohort study at a pediatric level 1 trauma center was conducted in patients < 18 years of age evaluated for trauma from 2012 to 2021. An SLIC score was calculated for each patient, and the subsequent recommendations were compared with actual treatment delivered. Percentage misclassification, sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated. RESULTS: Two hundred forty-three pediatric patients with trauma were included. Twenty-five patients (10.3%) underwent surgery and 218 were managed conservatively. The median SLIC score was 2 (interquartile range = 2). Sixteen patients (6.6%) had an SLIC score of 4, for which either conservative or surgical treatment is recommended; 27 children had an SLIC score ≥ 5, indicating a recommendation for surgical treatment; and 200 children had an SLIC score ≤ 3, indicating a recommendation for conservative treatment. Of the 243 patients, 227 received treatment consistent with SLIC score recommendations (p < 0.001). SLIC sensitivity in determining surgically treated patients was 79.2% and the specificity for accurately determining who underwent conservative treatment was 96.1%. The PPV was 70.3% and the NPV was 97.5%. There was a 5.7% misclassification rate (n = 13) using SLIC. Among patients for whom surgical treatment would be recommended by the SLIC, 29.6% (n = 8) did not undergo surgery; similarly, 2.5% (n = 5) of patients for whom conservative management would be recommended by the SLIC had surgery. The ROC curve for determining treatment received demonstrated excellent discriminative ability, with an AUC of 0.96 (OR 3.12, p < 0.001). Sensitivity decreased when the cohort was split by age (< 10 and ≥ 10 years old) to 0.5 and 0.82, respectively; specificity remained high at 0.98 and 0.94. CONCLUSIONS: The SLIC scoring system recommended similar treatment when compared with the actual treatment delivered for traumatic subaxial cervical spine injuries in children, with a low misclassification rate and a specificity of 96%. These findings demonstrate that the SLIC can be useful in guiding treatment for pediatric patients with subaxial cervical spine injuries. Further investigation into the score in young children (< 10 years) using a multicenter cohort is warranted.

Can conservative treatment be effective for thoracolumbar injuries patients with TLICS scores of 4 or 5? An analysis of initial radiological findings and clinical risk factors for treatment failure.

BACKGROUND: This study aimed to assess the outcomes of conservative management in patients with thoracolumbar fractures classified with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4 or 5, and to analyze initial imaging findings and clinical risk factors associated with treatment failure. METHODS: In this retrospective analysis, patients with thoracolumbar fractures and a TLICS score of 4 or 5, determined through MRI from January 2017 to December 2020, were included. Patients undergoing conservative treatment were categorized into two groups: Group 1 (treatment success) and Group 2 (treatment failure), based on initial and 6-month follow-up outcomes. Clinical data were compared between the two groups. Initial radiological assessments included three kyphosis measurements (Cobb angle, Gardner angle, and sagittal index [SI]), anterior and posterior wall height, and central canal compromise (CC). Additionally, risk factors contributing to treatment failure were analyzed. RESULTS: The conservative treatment group comprised 84 patients (mean age, 60.25 ± 15.53; range 22-85; 42 men), with 57 in Group 1 and 27 in Group 2. Group 2 exhibited a higher proportion of women, older age, and lower bone mass density (p = 0.001-0.005). Initial imaging findings in Group 2 revealed significantly greater values for Cobb angle, SI, and CC (p = 0.001-0.045 or < 0.001; with cutoff values of 18.2, 12.8, and 7.8%, respectively), and lower anterior wall height (p = 0.001), demonstrating good to excellent interobserver agreement (0.72-0.99, p < 0.001). Furthermore, osteoporosis was identified as a significant risk factor (odds ratio = 5.64, p = 0.008). CONCLUSION: Among patients with TLICS scores of 4 or 5, those experiencing conservative treatment failure exhibited unfavorable initial radiological findings, a higher proportion of women, advanced age, and osteoporosis. Additionally, osteoporosis emerged as a significant risk factor for treatment failure.

Refined Detection and Classification of Knee Ligament Injury Based on ResNet Convolutional Neural Networks.

Currently, medical imaging has largely supplanted traditional methods in the realm of diagnosis and treatment planning. This shift is primarily attributable to the non-invasive nature, rapidity, and user-friendliness of medical-imaging techniques. The widespread adoption of medical imaging, however, has shifted the bottleneck to healthcare professionals who must analyze each case post-image acquisition. This process is characterized by its sluggishness and subjectivity, making it susceptible to errors. The anterior cruciate ligament (ACL), a frequently injured knee ligament, predominantly affects a youthful and sports-active demographic. ACL injuries often leave patients with substantial disabilities and alter knee mechanics. Since some of these cases necessitate surgery, it is crucial to accurately classify and detect ACL injury. This paper investigates the utilization of pre-trained convolutional neural networks featuring residual connections (ResNet) along with image-processing methods to identify ACL injury and differentiate between various tear levels. The ResNet employed in this study is not the standard ResNet but rather an adapted version capable of processing 3D volumes constructed from 2D image slices. Achieving a peak accuracy of 97.15% with a custom split, 96.32% through Monte-Carlo cross-validation, and 93.22% via five-fold cross-validation, our approach enhances the performance of three-class classifiers by over 7% in terms of raw accuracy. Moreover, we achieved an improvement of more than 1% across all types of evaluation. It is quite clear that the model's output can effectively serve as an initial diagnostic baseline for radiologists with minimal effort and nearly instantaneous results. This advancement underscores the paper's focus on harnessing deep learning for the nuanced detection and classification of ACL tears, demonstrating a significant leap toward automating and refining diagnostic accuracy in sports medicine and orthopedics.

Orchard Sports Injury and Illness Classification System (OSIICS) Version 15.

BACKGROUND: Sports medicine (injury and illnesses) requires distinct coding systems because the International Classification of Diseases is insufficient for sports medicine coding. The Orchard Sports Injury and Illness Classification System (OSIICS) is one of two sports medicine coding systems recommended by the International Olympic Committee. Regular updates of coding systems are required. METHODS: For Version 15, updates for mental health conditions in athletes, sports cardiology, concussion sub-types, infectious diseases, and skin and eye conditions were considered particularly important. RESULTS: Recommended codes were added from a recent International Olympic Committee consensus statement on mental health conditions in athletes. Two landmark sports cardiology papers were used to update a more comprehensive list of sports cardiology codes. Rugby union protocols on head injury assessment were used to create additional concussion codes. CONCLUSION: It is planned that OSIICS Version 15 will be translated into multiple new languages in a timely fashion to facilitate international accessibility. The large number of recently published sport-specific and discipline-specific consensus statements on athlete surveillance warrant regular updating of OSIICS.

Using Equipoise to Determine the Radiographic Characteristics Leading to Agreement on Best Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficits.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVES: Our goal was to assess radiographic characteristics associated with agreement and disagreement in treatment recommendation in thoracolumbar (TL) burst fractures. METHODS: A panel of 22 AO Spine Knowledge Forum Trauma experts reviewed 183 cases and were asked to: (1) classify the fracture; (2) assess degree of certainty of PLC disruption; (3) assess degree of comminution; and (4) make a treatment recommendation. Equipoise threshold used was 77% (77:23 distribution of uncertainty or 17 vs 5 experts). Two groups were created: consensus vs equipoise. RESULTS: Of the 183 cases reviewed, the experts reached full consensus in only 8 cases (4.4%). Eighty-one cases (44.3%) were included in the agreement group and 102 cases (55.7%) in the equipoise group. A3/A4 fractures were more common in the equipoise group (92.0% vs 83.7%, P < .001). The agreement group had higher degree of certainty of PLC disruption [35.8% (SD 34.2) vs 27.6 (SD 27.3), P < .001] and more common use of the M1 modifier (44.3% vs 38.3%, P < .001). Overall, the degree of comminution was slightly higher in the equipoise group [47.8 (SD 20.5) vs 45.7 (SD 23.4), P < .001]. CONCLUSIONS: The agreement group had a higher degree of certainty of PLC injury and more common use of M1 modifier (more type B fractures). The equipoise group had more A3/A4 type fractures. Future studies are required to identify the role of comminution in decision making as degree of comminution was slightly higher in the equipoise group.

Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care.

STUDY DESIGN: Reliability study utilizing 183 injury CT scans by 22 spine trauma experts with assessment of radiographic features, classification of injuries and treatment recommendations. OBJECTIVES: To assess the reliability of the AOSpine TL Injury Classification System (TLICS) including the categories within the classification and the M1 modifier. METHODS: Kappa and Intraclass correlation coefficients were produced. Associations of various imaging characteristics (comminution, PLC status) and treatment recommendations were analyzed through regression analysis. Multivariable logistic regression modeling was used for making predictive algorithms. RESULTS: Reliability of the AO Spine TLICS at differentiating A3 and A4 injuries (N = 71) (K = .466; 95% CI .458 - .474; P < .001) demonstrated moderate agreement. Similarly, the average intraclass correlation coefficient (ICC) amongst A3 and A4 injuries was excellent (ICC = .934; 95% CI .919 - .947; P < .001) and the ICC between individual measures was moderate (ICC = .403; 95% CI .351 - .461; P < .001). The overall agreement on the utilization of the M1 modifier amongst A3 and A4 injuries was fair (K = .161; 95% CI .151 - .171; P < .001). The ICC for PLC status in A3 and A4 injuries averaged across all measures was excellent (ICC = .936; 95% CI .922 - .949; P < .001). The M1 modifier suggests respondents are nearly 40% more confident that the PLC is injured amongst all injuries. The M1 modifier was employed at a higher frequency as injuries were classified higher in the classification system. CONCLUSIONS: The reliability of surgeons differentiating between A3 and A4 injuries in the AOSpine TLICS is substantial and the utilization of the M1 modifier occurs more frequently with higher grades in the system.

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

STUDY DESIGN: A prospective study. OBJECTIVE: to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons. METHODS: A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively. RESULTS: ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]). CONCLUSION: The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit.

STUDY DESIGN: Prospective Observational Study. OBJECTIVE: To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making. METHODS: 183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected. RESULTS: There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01). CONCLUSIONS: The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

Is it true that treatment in patients with Subaxial Cervical Spine Injury Classification System (SLICS) 4 is the surgeon's choice?

BACKGROUND: The Subaxial Cervical Spine Injury Classification System (SLICS) is a commonly used algorithm for diagnosing and managing subaxial cervical spine trauma. A SLIC score 4 suggests either surgery or non-surgically treatment depending on the surgeon's experience and patient's conditions. OBJECTIVE: Prognosis and treatment results were analyzed in patients with SLIC score 4. METHODS: The patients with SLIC score 4 were retrospectively reviewed from 2012 to 2019. Forty-one patients were included and divided into two groups: non-surgically treated and surgically treated. Demographic data and radiographs were analyzed. Statistical analysis was performed to determine the difference between the two clinical groups. RESULTS: Twenty-two patients were non-surgically treated, and nineteen patients were surgically treated. There was no neurological deterioration in both groups. However, there was no statistically significant difference in the last follow-up AISA and Nurick grade (p> 0.05). There was no significant difference in the number of patients who showed improvement when comparing the initial and the last follow-up neurological status (p> 0.05). CONCLUSION: Regardless of the treatment method, the spinal cord injury patients with SLICS point 4 showed a relatively good prognosis. Patients with SLIC score 4 could be treated non-surgically or surgically based on the surgeon's experience and factors associated with the patient's acute health status and chronic comorbidities.

[Research progress of pubic symphysis diastasis].

Objective: To review the research progress of pubic symphysis diastasis and provide effective reference for orthopedic surgeons in the diagnosis and treatment of pubic symphysis diastasis. Methods: The anatomy, injury mechanism, treatment, and other aspects of pubic symphysis diastasis were summarized and analyzed by reviewing the relevant research literature at domestically and internationally in recent years. Results: The incidence of pubic symphysis diastasis is high in pelvic fractures, which is caused by the injury of the ligaments and fibrocartilage disc around the pubic symphysis by external force. The treatment plan should be individualized according to the pelvic stability and the needs of patients, aiming to restore the stability and integrity of the pelvis and improve the quality of life of patients after surgery. Conclusion: At present, the research on pubic symphysis diastasis still needs to be improved. In the future, high-quality, multi-center, and large-sample studies are of great significance for the selection of treatment methods and the evaluation of effectiveness for patients with pubic symphysis diastasis.

Imaging of acute lower limb muscle injury and potential gender differences.

OBJECTIVES: To assess the most common lower limb acute muscle injuries on MRI imaging in a national specialist centre for orthopaedics and sports medicine and to explore potential gender differences. METHODS: Over a 3-year time period, all MRI lower limb studies with acute muscle injury (AMI) were reviewed. A British Athletics muscle injury classification (BAMIC) was given and a statistical analysis was performed. RESULTS: A total of 195 AMIs were diagnosed: 177 (91%) male and 18 (9%) female injuries (M to F = 9.8:1). The most common lower limb AMIs were BAMIC grade 1a injuries (n = 48, 25%). The most commonly injured muscle was biceps femoris (n = 87, 45%), specifically grade 1b and grade 2b injuries. There was no significant difference in age between men and women with acute lower limb muscle injuries (p = 0.19). Females were 1.5 times more likely to have a lower grade AMI than males, although this did not reach statistical significance (p = 0.7) owing to a striking lower number of female patients. There was no significant difference between genders in the likelihood of sustaining a hamstring or quadricep AMI (hamstrings OR = 2.47, p = 0.14 and quadriceps OR = 0.926, p 0.99). CONCLUSIONS: Grade 1a is the most common lower limb AMI grade in our institution, accounting for 25%. Biceps femoris is the most commonly injured muscle (45%) with grade 1b and grade 2b being the most frequently encountered grades of biceps femoris injuries. Lower-grade injuries are more common in females compared to males, although not significantly so. Further studies are required to explore possible reasons for this gender gap.

Outcomes of Activity-Related Lower Extremity Muscle Tears After Application of the British Athletics Muscle Injury Classification: A Systematic Review.

CONTEXT: Muscle injury classification and grading systems have been reported for >100 years; yet it offer limited evidence relating the clinical or radiological qualities of a muscle injury to the pathology or clinical outcome. The British Athletics Muscle Injury Classification (BAMIC) incorporates recent predictive features of muscle injuries and provides a precise radiographic framework for clinical prediction and management. OBJECTIVE: To investigate clinical outcomes, particularly time to return to play (RTP), reinjury rate (RIR), and prognostic value of specific magnetic resonance imaging (MRI) findings, of activity-related muscle injuries (tears) in athletes after application of the BAMIC. DATA SOURCES: A search of PubMed (NLM), EMBASE (Ovid), Web of Science (Clarivate), Cochrane Library (Wiley), and ClinicalTrials.gov from the inception date of each database through August 31, 2022, was conducted. Keywords included the BAMIC. STUDY SELECTION: All English language studies evaluating clinical outcomes of RTP and RIR after activity-related muscle injuries and where BAMIC was applied were included. A total of 136 articles were identified, and 11 studies met inclusion criteria. STUDY DESIGN: Systematic review (PROSPERO: CRD42022353801). LEVEL OF EVIDENCE: Level 2. DATA EXTRACTION: Two reviewers independently screened studies for eligibility and extracted data. Methodological quality of included study was assessed independently by 2 reviewers with the Newcastle-Ottawa Quality Scale (NOS); 11 good quality studies (4 prospective cohort studies, 7 retrospective cohort studies) with 468 athletes (57 female) and 574 muscle injuries were included. RESULTS: All studies reported a statistically significant relationship between BAMIC grade, BAMIC injury site, and/or combined BAMIC grade and injury site with RTP. A statistically significant increased RIR was reported by BAMIC grade and BAMIC injury site in 2 of 4 and 3 of 4 studies, respectively. The prognostic value of individual MRI criteria was limited. CONCLUSION: Consistent evidence suggests that BAMIC offers prognostic and therapeutic guidance for clinical outcomes, particularly RTP and RIR, after activity-related muscle injuries in athletes that may be superior to previous muscle injury classification and grading systems.

Evaluation of the Thoracolumbar Injury Classification and Severity (TLICS) Score Over a Two-Year Period at a Level One Trauma Center.

Introduction The use of the Thoracolumbar Injury Classification and Severity Score (TLICS) and other classification systems for guiding the management of traumatic spinal injuries remains controversial. TLICS is one of the few classifications that provides treatment recommendations.We sought to analyze intervention modality selection based on the TLICS scoring system. Methods A retrospective review of patients presenting with traumatic thoracolumbar fractures at a level 1 trauma center over a two-year period was performed. Primary endpoints for comparison analysis included visual analog scale (VAS) scores and Cobb angles during follow-up. Results There were 272 patients with thoracolumbar fractures, of whom 212 had TLICS of ≤3, six with TLICS of 4, and 54 with TLICS of ≥5. Of the 272 total patients, 59 were treated via surgery and 213 via non-surgical conservative methods. The VAS scores significantly decreased from presentation to last follow-up in both surgically treated and conservative groups (p<0.0001). This remained consistent in subgroup analyses of TLICS ≤ 3, TLICS = 4, and TLICS ≥ 5 (p<0.0001). Burst fractures treated conservatively had larger fracture Cobb angles versus those treated via surgery at the last follow-up, although this was not significantly associated (p=0.07). The only significant relationship with Cobb angles was in distraction fractures of the TLICS > 4 conservative group, who had significantly lower Cobb angles at the last follow-up than the TLICS > 4 surgical group (p<0.04). The "surgeon's choice" for TLICS = 4 was surgical intervention (4/6 patients, 66.7%). Conclusion Using the TLICS score, thoracolumbar injuries in a level 1 trauma center are more commonly TLICS ≤ 3. For patients with TLICS = 4, the surgeon's choice was most commonly surgical repair. VAS scores decreased over time from presentation between surgically and conservatively managed patients (as well as within-group analyses). The data concerning Cobb angles were more ambiguous, as larger Cobb angles in burst fractures treated conservatively did not show statistically significant differences with surgery.

A new metric for characterizing limb loading dynamics in post anterior cruciate ligament reconstruction individuals.

BACKGROUND: Unresolved neuromuscular deficits often persist in post-anterior cruciate ligament reconstruction (ACLR) individuals manifesting as altered impact and active peak force production during running that can contribute to detrimental limb loading. Elevated impact and active peaks are common in pathological populations indicating a stiffer limb loading strategy. Although impact and active peaks are sensitive to changes in limb loading, to our knowledge, there are no established, standardized measures or cutoff criteria to differentiate between healthy and pathological limb loading. However, prior studies have demonstrated that the ratio between traditional biomechanical measures can be used to successfully establish quantifiable and graphical ranges to delineate between healthy and pathological movement. RESEARCH QUESTION: Therefore, this study sought to exploit the impact-to-active peak ratio to generate a new, standardized metric to quantify and characterize limb loading dynamics in healthy controls and post-ACLR individuals during running. METHODS: Twenty-eight post-ACLR individuals and 18 healthy controls performed a running protocol. Impact peak and active peak data were extracted from their strides as they ran at a self-selected speed. A linear regression model was fit to the healthy control data and the models 95 % prediction intervals were used to define a boundary region of healthy limb loading dynamics. RESULTS: The post-ACLR individuals produced a higher impact-to-active peak ratio than the healthy controls indicating that they adopted a stiffer limb loading strategy. The boundary regions derived from the impact and active peak model successfully classified the healthy controls and post-ACLR individual's limb loading dynamics with an accuracy, sensitivity, and specificity of 89 %, 100 %, and 75 %, respectively. SIGNIFICANCE: The ability to effectively evaluate limb loading dynamics using impact and active peaks can provide clinicians with a new, non-invasive metric to quantify and characterize healthy and pathological movement in a clinical setting.

The classification of freezing cold injuries - a NATO research task group position paper.

INTRODUCTION: Freezing cold injuries (FCI) are a common risk in extreme cold weather operations. Although the risks have long been recognised, injury occurrences tend to be sparse and geographically distributed, with relatively few cases to study in a systematic way. The first challenge to improve FCI medical management is to develop a common nomenclature for FCI classification. This is critical for the development of meaningful epidemiological reports on the magnitude and severity of FCI, for the standardisation of patient inclusion criteria for treatment studies, and for the development of clinical diagnosis and treatment algorithms. METHODOLOGY: A scoping review of the literature using PubMed and cross-checked with Google Scholar, using search terms related to freezing cold injury and frostbite, highlighted a paucity of published clinical papers and little agreement on classification schemes. RESULTS: A total of 74 papers were identified, and 28 were included in the review. Published reports and studies can be generally grouped into four different classification schemes that are based on (1) injury morphology; (2) signs and symptoms; (3) pathophysiology; and (4) clinical outcome. The nomenclature in the different classification systems is not coherent and the discrete classification limits are not evidence based. CONCLUSIONS: All the classification systems are necessary and relevant to FCI medical management for sustainment of soldier health and performance in cold weather operations and winter warfare. Future FCI reports should clearly characterise the nature of the FCI into existing classification schemes for surveillance (morphology, symptoms, and appearance), identifying risk-factors, clinical guidelines, and agreed inclusion/exclusion criteria for a future treatment trial.

Research progress of pubic symphysis diastasis / 中国修复重建外科杂志

OBJECTIVE@#To review the research progress of pubic symphysis diastasis and provide effective reference for orthopedic surgeons in the diagnosis and treatment of pubic symphysis diastasis.@*METHODS@#The anatomy, injury mechanism, treatment, and other aspects of pubic symphysis diastasis were summarized and analyzed by reviewing the relevant research literature at domestically and internationally in recent years.@*RESULTS@#The incidence of pubic symphysis diastasis is high in pelvic fractures, which is caused by the injury of the ligaments and fibrocartilage disc around the pubic symphysis by external force. The treatment plan should be individualized according to the pelvic stability and the needs of patients, aiming to restore the stability and integrity of the pelvis and improve the quality of life of patients after surgery.@*CONCLUSION@#At present, the research on pubic symphysis diastasis still needs to be improved. In the future, high-quality, multi-center, and large-sample studies are of great significance for the selection of treatment methods and the evaluation of effectiveness for patients with pubic symphysis diastasis.

Nonoperative Management in Intact Burst Fracture Patient With Thoracolumbar Injury Classification and Severity Score of 5: A Case Report.

Thoracolumbar fractures are a common consequence of trauma, often a result of motor vehicle accidents or falls. Burst fractures are a morphology of thoracolumbar fracture in which compressive force causes retropulsion of the posterior elements of the vertebral body, potentially leading to neurological deficits. The Thoracolumbar Injury Classification and Severity (TLICS) score is a decision-making tool to help surgeons decide between nonoperative and operative management. For assigned scores of 4, management is at the discretion of the surgeon, and for scores ≥ 5, operative treatment is recommended. Burst fracture patients that are neurologically intact are given a score of 5 if there is a posterior ligamentous complex (PLC) injury and are recommended to undergo operative management. Here we present a neurologically intact patient with an L4 burst fracture with PLC injury that was managed conservatively and demonstrated successful clinical, functional, and radiographic recovery.

Global Validation of the AO Spine Upper Cervical Injury Classification: Geographic Region Affects Reliability and Reproducibility.

STUDY DESIGN: Global Survey. OBJECTIVE: To determine the accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeons' AO Spine region of practice (Africa, Asia, Central/South America, Europe, Middle East, and North America). METHODS: A total of 275 AO Spine members assessed 25 upper cervical spine injuries and classified them according to the AO Spine Upper Cervical Injury Classification System. Reliability, reproducibility, and accuracy scores were obtained over two assessments administered at three-week intervals. Kappa coefficients (ƙ) determined the interobserver reliability and intraobserver reproducibility. RESULTS: On both assessments, participants from Europe and North America had the highest classification accuracy, while participants from Africa and Central/South America had the lowest accuracy (P < .0001). Participants from Africa (assessment 1 (AS1):ƙ = .487; AS2:0.491), Central/South America (AS1:ƙ = .513; AS2:0.511), and the Middle East (AS1:0.591; AS2: .599) achieved moderate reliability, while participants from North America (AS1:ƙ = .673; AS2:0.648) and Europe (AS1:ƙ = .682; AS2:0.681) achieved substantial reliability. Asian participants obtained substantial reliability on AS1 (ƙ = .632), but moderate reliability on AS2 (ƙ = .566). Although there was a large effect size, the low number of participants in certain regions did not provide adequate certainty that AO regions affected the likelihood of participants having excellent reproducibility (P = .342). CONCLUSIONS: The AO Spine Upper Cervical Injury Classification System can be applied with high accuracy, interobserver reliability, and intraobserver reproducibility. However, lower classification accuracy and reliability were found in regions of Africa and Central/South America, especially for severe atlas injuries (IIB and IIC) and atypical hangman's type fractures (IIIB injuries).

Thoracic and lumbar spine trauma classification systems fail to predict post-traumatic kyphotic deformity.

Background: Post-traumatic kyphosis of the thoracic and lumbar spine can lead to pain and decreased function. MRI has been advocated to assess ligament integrity and risk of kyphosis. Methods: All thoracic and lumbar spine MRI performed for evaluation of trauma over a 3-year period at a single institution were reviewed. Patients were included if there was an MRI showing a vertebral body fracture and follow-up radiographs. Two observers retrospectively reviewed all radiographs, CT and MRI scans, and classified injuries based on the Denis, TLICS, AO and load sharing classification systems. Change in kyphosis between injury and follow-up studies was measured. The initial radiology reports made at time of patient injury were compared to the retrospective interpretations. Results: There were 67 separate injuries in 62 patients. Kyphosis measuring ≥ 10° developed despite an intact PLC in 6/14 nonoperative cases, and 3/7 surgically treated cases; when PLC was partially injured, it developed in 6/10 cases (8 treated nonoperatively, 2 treated operatively. Thirty injuries had complete disruption of PLC by MRI, 24 treated with fusion. Kyphosis ≥ 10° developed in 3/6 treated nonoperatively, and 8/24 treated with fusion. Development of kyphosis was independent of degree of vertebral body comminution. It developed equally in patients with Grade 2 and Grade 3 Denis injuries. It developed in patients with intact PLC when multiple vertebrae were involved and/or there was compressive injury to anterior longitudinal ligament (ALL). There was high interobserver variability in assessment of severity of ligamentous injury on MRI. Conclusions: Classification systems of thoracic and lumbar spine injury and integrity of the PLC failed to predict the risk of development of post-traumatic kyphotic deformity.

Impact of Recent Acute Kidney Injury on Creatinine Clearance Estimation in Critically Ill Patients Undergoing Cardiac Surgery.

Acute kidney injury (AKI), often present in critically ill patients and patients with cardiac dysfunction, may alter estimates of renal function. The impact of recent AKI on the accuracy of the Cockcroft-Gault creatinine clearance equation (CG-CrCl) before cardiac surgery is unknown. This single-center, retrospective study included patients who underwent cardiac surgery from 1 January 2006 through 30 June 2012 and whose 24-hour urine creatinine clearance (24hr-CrCl) was measured in the intensive care unit before surgery. We evaluated CG-CrCl accuracy by calculating absolute differences between 24hr-CrCl and CG-CrCl estimates. Clinical impact was signified by discrepancies in United States Food and Drug Administration (FDA) renal impairment stage indicated by 24hr-CrCl versus CG-CrCl estimates. Acute kidney injury was evaluated by using Kidney Disease: Improving Global Outcomes criteria. Of 161 patients, 93 (58%) had recent AKI: stage 1, 31 (33%); stage 2, 39 (42%); and stage 3, 23 (25%). In mL/min, the CG-CrCl overestimated 24hr-CrCl (absolute difference: total, -10 ± 25; no AKI, -7 ± 26; stage 1, -8 ± 17; stage 2, -16 ± 28; and stage 3, -10 ± 26; P=0.29). Renal impairment stages assigned by CG-CrCl did not match 24hr-CrCl in 70 (43%) of the 161 patients, especially those with recent AKI: no AKI, 24/68 (35%); stage 1, 13/31 (42%); stage 2, 23/39 (59%); and stage 3, 10/23 (43%). The CG-CrCl consistently overestimated 24hr-CrCl in critically ill patients before cardiac surgery. Clinicians should use the CG-CrCl cautiously when estimating renal function and medication dosages in this population.