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Nick Spindler, Philipp Pieroh, Ulrich Spiegl, Sergey Arakelyan, Johannes Karl Maria Fakler, Christoph-Eckhard Heyde, Stefan Langer Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, GermanyCorrespondence: Nick SpindlerDepartment of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, Leipzig, 04103, GermanyTel +49-341-9717140Fax +49-341-9717139Email nick.spindler@medizin.uni-leipzig.dePurpose: Demographic changes are leading to population aging, and free flap reconstructions for various indications are expected to become increasingly common among older patients. Therefore, this study evaluated free flap reconstruction of the extremities in older patients and compared the outcomes to those from younger patients who underwent similar procedures during the same period.Patients and Methods: This single-center retrospective study used a case-control design to compare older and younger patients who underwent free flap reconstruction of soft tissue defects in the extremities. One-to-one matching was performed for older patients (≥ 65 years) and younger patients (≤ 64 years) according to indication, flap recipient site, and flap type. The parameters of interest were clinico-demographic characteristics, flap type, defect location, indication for free flap reconstruction, number of venous anastomoses, and postoperative complications (flap loss, infection, and wound healing disorders).Results: The study included 48 older patients and 133 younger patients, with a mean follow-up of 12 months after discharge. The free flap reconstruction was performed at a mean interval of 19.8± 22.8 days (range: 0– 88 days). The 1:1 matching created 38 pairs of patients, which revealed no significant differences in the rates of flap necrosis and flap failure.Conclusion: This study failed to detect a significant age-related difference in the flap necrosis rate after free flap reconstruction of extremity defects. Therefore, with careful perioperative management and patient selection, microsurgical free flap reconstruction is a feasible option for older patients.Keywords: older patients, microsurgery, free flap, limb reconstruction

A 35-year-old female patient sustained three contiguous vertebral fractures at the thoracolumbar junction while jumping off the third floor in a suicide attempt. Initial fracture treatment occurred in the setting of a multiple injury scenario. While the Th12 and the L1 vertebral fractures were considered stable, the L2 fracture exhibited a complete burst configuration with 80% canal compromise due to a posterior wall fragment causing paraplegia. A posterior pedicle screw stabilisation with indirect fracture reduction was carried out initially from T12 to L3. At 1 year follow-up the patient presented to us for new onset radiculopathy L2, and loss of correction. A circumferential revision surgery with an expandable cage was carried out to restore the anterior and posterior columns. Unfortunately again loss of reduction with kyphosis occurred, this time at the upper instrumented vertebra, which made another revision necessary. In this situation a longer construct was chosen using a combined approach and a Mesh cage. This later procedure was complicated by a postoperative paraparesis believed to be vascular in origin. Six months later a further complication involving MSSA deep wound infection required a series of irrigation debridement for healing. At the 2.5 years follow up the spine was stable and the patient had a neurologic recovery allowing her to ambulate with crutches. This Grand Round Case raises the question on the initial management of multiply injured patients with spine fracture, the classification of these fractures, the optimal initial internal fixation, the need for complementary anterior column reconstruction and the strategy when all these fails. [ABSTRACT FROM AUTHOR]

Study design:Case report.Objective:To present an unusual traumatic neurologic pathology caused by gunshot injury.Setting:Spine unit of Department of Trauma and Orthopaedic Surgery, University Medical School, Charité - Campus Benjamin Franklin, Berlin, Germany.Method and result:A 35-year-old male sustained a gunshot injury from a machine gun. The projectile caused a fracture of the left pedicle of Th10. The spinal cord was indirectly damaged by cavitation that caused a Brown-Séquard syndrome (BSS). After a microscopically assisted posterior revision at T9/10 with removal of bullet and bone fragments from the spinal canal and debridement of the bullet cavity via extended fenestrectomy the patient gained his motor function back. The sensory deficit remained unchanged.Conclusion:BSS can be caused by bullet-related injury of the spinal canal with no direct damage of neural structures. The initial treatment is always based on the total injury pattern. Possible spinal cord injuries are only clarified after restitution of vital functions. Decompression of neural structures in shotgun injury is indicated in incomplete paraplegia, injury of intra-abdominal hollow organs or high velocity bullet wounds. Through debridement and decompression of neural structures and chronic damage caused by foreign body granulomas can be prevented. Secondary destabilization of the spine should be avoided.Spinal Cord (2007) 45, 579-582; doi:10.1038/sj.sc.3101986; published online 14 November 2006. [ABSTRACT FROM AUTHOR]

Background: Managing degenerative lumbar diseases is challenging due to the complexity of identifying symptom causes, especially when multiple pathologies coexist. This study evaluated the impact of patient-specific lumbar spine infiltrations on therapeutic strategies in patients with multiple spinal pathologies (MSP) or specific spinal pathologies (SSP)., Methods: A retrospective cohort of 176 patients treated for subacute or chronic lumbar pain with targeted spinal infiltrations was analyzed. Patients were categorized based on the presence of MSP or SSP. The primary endpoint was the relief of lumbar spine-specific symptoms following each infiltration. Secondary endpoints included epidemiological factors and comorbidities, while tertiary endpoints focused on post-treatment recommendations and performed treatments., Results: High rates of spinal pain (97.1% in both groups) and radiating symptoms (88.2% in SSP and 92.3% in MSP) were reported. Psychological conditions were significantly more prevalent in female patients (19.4% vs. 7.7%, p = 0.0307), whereas hip osteoarthritis was more common in male patients (20.5% vs. 9.2%, p = 0.0490). Among all infiltration types, lumbar transforaminal injections were the most effective, leading to pain reduction in 80.1% of SSP patients and 72.2% of MSP patients. Facet joint and sacroiliac joint infiltrations also frequently resulted in pain reduction in both groups. Overall, conservative treatment was recommended for most patients (73.3%), while only 22.7% of all evaluated patients were recommended for surgical intervention. Additionally, seven patients received a hip prosthesis., Conclusions: Patient-specific lumbar spine infiltrations effectively relieve pain, support therapeutic decision-making, and tend to favor conservative treatment approaches. These findings highlight the role of infiltration therapies in managing both mixed and specific lumbar spine pathologies, suggesting their potential to reduce the need for surgical interventions., (© 2024. The Author(s).)

The guideline of the Federal Joint Committee (G-BA) on quality assessment measures for the care of patients with hip fracture makes it mandatory for hospitals to use an appropriate geriatric screening instrument in the context of acute inpatient care. After systematic application of GeriNOT and data collection in the admission process with integration into the Hospital Information System (HIS), it is possible to identify potential risks in geriatric patients with other diagnoses as well.With the integration of GeriNOT into the acute inpatient admission process, it was examined whether vulnerable geriatric patients with other diagnoses could benefit from the early initiation of risk identification.The data base for the present study was a retrospective bicentric collection of electronic case records (May 2014 to April 2015, n = 3,443). From this primary data set, the subgroup of inpatient acute admissions (n = 821) in the orthopaedic/trauma surgery of a study centre was analysed and evaluated with respect to the endpoints "utilisation of needs-based post-inpatient care services" and "new admission to inpatient permanent/short-term care". The predictive power and classification accuracy of GeriNOT of these patients who were 70 years and older to the endpoints were assessed for several groups: total acute admissions, total fractures, hip fracture, and spinal disorders including spinal fractures.A total of 821 patients were admitted as acute inpatients during the study period. The mean age of the patients was 81.4 ± 6.8 years (n = 821; 68.1% women, 31.9% men). The following subgroups were formed and analysed: total fractures (n = 490), spinal disorders (n = 265) including spinal fractures (n = 174), and hip fracture (n = 108). Both in the overall group (n = 821; M = 4.279; SD = 2.180) and in the subgroups, the mean GeriNOT score was above the threshold ≥ 4. The highest score was found in the hip fracture group (M = 4.852; SD = 2.022), and the lowest in the spine fracture group (M = 4.177; SD = 2.171). At admission, if the terms of variables for requiring treatment were "polypharmacy" and "nursing services already used as needed", there were only slight differences in the diagnostic groups. Admissions from short-term and long-term care occurred in the total group in 16.44% of cases, most frequently with 31.48% in the group of hip fractures, compared to spinal diseases with 6.79%. For this group, GeriNOT detected an elevated risk with respect to the defined endpoints. However, only 4.26% of all patients with identified geriatric risk potential received further geriatric care.The results showed increased geriatric risk in all analysed groups, but most pronouncedly within the group of spinal diseases. The HIS-supported use of GeriNOT offers the possibility of systematic risk identification in acute inpatient admission management. The continuous visualisation of results at HIS workstations throughout the workflow could be used as a starting point for the subsequent application of standardized assessment tools and risk-adjusted treatment pathways. These findings could potentially improve outcomes., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

This study aimed to develop a graph neural network (GNN) for automated three-dimensional (3D) magnetic resonance imaging (MRI) visualization and Pfirrmann grading of intervertebral discs (IVDs), and benchmark it against manual classifications. Lumbar IVD MRI data from 300 patients were retrospectively analyzed. Two clinicians assessed the manual segmentation and grading for inter-rater reliability using Cohen's kappa. The IVDs were then processed and classified using an automated convolutional neural network (CNN)-GNN pipeline, and their performance was evaluated using F1 scores. Manual Pfirrmann grading exhibited moderate agreement (κ = 0.455-0.565) among the clinicians, with higher exact match frequencies at lower lumbar levels. Single-grade discrepancies were prevalent except at L5/S1. Automated segmentation of IVDs using a pretrained U-Net model achieved an F1 score of 0.85, with a precision and recall of 0.83 and 0.88, respectively. Following 3D reconstruction of the automatically segmented IVD into a 3D point-cloud representation of the target intervertebral disc, the GNN model demonstrated moderate performance in Pfirrmann classification. The highest precision (0.81) and F1 score (0.71) were observed at L2/3, whereas the overall metrics indicated moderate performance (precision: 0.46, recall: 0.47, and F1 score: 0.46), with variability across spinal levels. The integration of CNN and GNN offers a new perspective for automating IVD analysis in MRI. Although the current performance highlights the need for further refinement, the moderate accuracy of the model, combined with its 3D visualization capabilities, establishes a promising foundation for more advanced grading systems., (© 2024. The Author(s).)

Background: There is a gap in evidence about medical outcomes in oldest-old patients (aged 85 and older) with vertebral fractures (VFs). The aim of this study was to evaluate the impact of patient and fracture characteristics on "short-term" hospital outcomes., Methods: All patients aged ≥ 85 presenting an acute or subsequent VF at our single level I spine center between 2019 and 2021 requiring hospital treatment were included. The data collection was conducted retrospectively. The primary parameters of interest were length of stay (LOS) and in-hospital mortality. Further outcome parameters were the occurrence of general (non-operative) complications and Intensive Care Unit (ICU) admission. For statistical analysis, linear and binary logistic regression modeling were performed., Results: A total of 153 patients with an average age of 88.5 (range 85 to 99) met the inclusion criteria. Our patients were mostly female (68.6%) and moderately comorbid according to a Charlson Comorbidity Index (CCI) of 2.9. 58.8% had diagnosed osteoporosis. Fracture morphologies represented as "Osteoporotic Fracture" (OF) classification types were of central importance for undergoing operative treatment (OP) (p < 0.001), necessity for intensive care (p = 0.023), LOS (p = 0.014), and mortality (p = 0.018). 38.6% had OP. We recorded a complication rate of 59.5%, which highly influenced (p < 0.001) both primary outcome parameters. Overall, patients stayed 14.6 days with a mortality of 11.1%., Conclusion: VFs are a severe event in oldest-old patients with a crucial risk of poor medical outcomes during hospitalization. The fracture morphologies are of central importance. However, little is known about the hospital stay of oldest-old inpatients with VFs. Considering an aging population, further investigations would be recommended., Competing Interests: Declarations. Conflict of interest: There is no conflict of interest on behalf of all authors., (© 2024. The Author(s).)

The revision of ceramic inlays of acetabular cups is a challenging surgical procedure. The mechanical impact during the inlay extraction process can damage the ceramic or metal cup rim. To avoid these risks, a concept for a new revision procedure was developed. It is based on an actuator system, which allows a non-destructive release of the ceramic inlay. To integrate the actuator system, different design concepts of acetabular cup components were investigated, and an actuator based on shape-memory alloy (SMA) wires was developed. The process chain for the actuator, starting from nickel-titanium wires manufactured into the actuator geometry by laser welding and thermo-mechanical treatment for the shape setting process up to the functionality evaluation of the actuator system, was implemented on a laboratory scale. The new revision procedure is based on a phase transformation of the SMA wire actuator, which was obtained through two methods-applying an electrical current by an instrument and rinsing the wire with heated water. The phase transformation of the actuator resulted in a contraction between 3.2% and 4.3% compared to its length after pre-stretching and was able to release the ceramic inlay from the cup. Therefore, the developed actuator design and process chain is a proof of concept towards a new revision procedure for modular acetabular cups.

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Study Design: Systematic review., Purpose: Osteoporotic vertebral fractures (OVFs) and degenerative spine conditions are age-related and associated with higher morbidity and mortality and greater health care costs. The relationship between OVFs and prevalent spine degeneration is rarely reported. The aim of this study was to systematically review current literature on the influence of preexisting degenerative spine conditions in patients with OVFs on the occurrence of complications during and after treatment., Methods: A systematic literature review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed using Web of Science and MEDLINE. We considered English and German articles published from January 1990 to December 2022. The inclusion criteria were patients with OVFs and preexisting spinal degeneration with complications such as subsequent fractures, deformity, implant failure and surgical and general complications. The included studies were controlled trials, cohort studies, and case series., Results: Ten articles met the inclusion criteria (two prospective studies, seven retrospective studies and one case series). These were divided into two groups: studies on OVFs in patients with coexisting degenerative spine conditions (n = 5) and studies on OVFs following surgical treatment for degenerative spine conditions (n = 5). Three studies reported more complications in patients with OVFs and severe degeneration. One study stated the opposite. One study did not find any correlation. The remaining studies described complications narratively. Subsequent fractures were the most frequent complications., Conclusion: OVFs in patients with preexisting spinal degeneration seem to cause more complications. In addition to subsequent fractures, other complications have rarely been examined. The presence of degenerative changes or undergoing surgical correction may increase the risk of subsequent fractures., (© 2024. The Author(s).)

Background: Gold standard for determining bone density as a surrogate parameter of bone quality is measurement of bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA), most commonly performed on the lumbar spine (L1-L4). Computed tomography (CT) data are often available for surgical planning prior to spine procedures, but currently this information is not standardized for bone quality assessment. Besides, measuring the Hounsfield-Units (HU) is also of great importance in the context of biomechanical studies. This in vitro study aims in comparing BMD from DXA and HU based on diagnostic CT scans. In addition, methods are presented to quantify local density variations within bones., Methods: One hundred and seventy-six vertebrae (L1-L4) from 44 body donors (age 84.0±8.7 years) were studied. DXA measurements were obtained on the complete vertebrae to determine BMD, as well as axial CT scans with a slice thickness of 1 mm. Using Mimics Innovation Suite image processing software (Materialise NV, Leuven, Belgium), two volumes (whole vertebra vs. spongious bone) were formed for each vertebra, which in turn were divided in their left and right sides. From these total of six volumes, the respective mean HU was determined. HU of the whole vertebra and just spongious HU were compared with the BMD of the corresponding vertebrae. Side specific differences were calculated as relative values., Results: Whole bone and spongious HU correlated significantly (P>0.001; α=0.01) with BMD. A positive linear correlation was found, which was more pronounced for whole bone HU (R=0.72) than for spongious HU (R=0.62). When comparing the left and right sides within each vertebra, the HU was found to be 10% larger on average on one side compared to the opposite side. In some cases, the difference of left and right spongious bone can be up to 170%. There is a tendency for the side comparison to be larger for the spongious HU than for the whole vertebra., Conclusions: Determination of HU from clinical CT scans is an important tool for assessing bone quality, primarily by including the cortical portion in the calculation of HU. Unlike BMD, HU can be used to distinguish precisely between individual regions. Some of the very large side-specific gradients of the HU indicate an enormous application potential for preoperative patient-specific planning., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-23-121/coif). The authors have no conflicts of interest to declare., (2024 Journal of Spine Surgery. All rights reserved.)

Background: Idiopathic scoliosis is common in adolescence. Due to the rapid growth of the spine, it must be monitored closely with radiographs to ensure timely intervention when therapy is needed. As these radiographs continue into young adulthood, patients are repeatedly exposed to ionizing radiation., Objective: This study aimed to investigate whether real-time magnetic resonance imaging (MRI) is equivalent to conventional radiography in juvenile idiopathic scoliosis for determining curvature, rotation and the Risser stage. Additionally, the time requirement should be quantified., Materials and Methods: Children with idiopathic scoliosis who had postero-anterior whole-spine radiography for clinical indications were included in this prospective study. A real-time spine MRI was performed at 3 tesla in the supine position, capturing images in both the coronal and sagittal planes. The scoliosis was assessed using Cobb angle, rotation was evaluated based on Nash and Moe criteria, and the Risser stage was determined for each modality. The correlations between modalities and a correction factor for the Cobb angle between the standing and supine position were calculated., Results: A total of 33 children (aged 5-17 years), who met the inclusion criteria, were recruited. The Cobb angle (R 2  = 0.972; P < 0.01) was positively correlated with a correction factor of 1.07 between modalities. Additionally, the degree of rotation (R 2  = 0.92; P < 0.01) and the Risser stage (R 2  = 0.93; P < 0.01) demonstrated a strong correlation., Conclusion: Real-time MRI is equivalent to conventional radiography in determining baseline parameters. Furthermore, it is radiation-free and less time-consuming., (© 2024. The Author(s).)

BackgroundThe amendment to the medical licensing regulations (ÄApprO) was decided at the federal level in the version of the "Master Plan for Medical Studies 2020" passed in 2017. In addition to the organizational effort involved in redesigning the curricular teaching, the expected costs associated with the implementation of the new licensing regulations due to the necessary additional time and, therefore, personnel expenditure are of particular importance. Taking into account the different forms of study and the 20% scope for study-design provided to the individual faculties, the process of transferring the teaching content to the new modules confronts us with an enormous organizational challenge.Significance of O&UDiseases of the musculoskeletal system are of particular medical, social and economic importance. Therefore, the training of future physicians in the field of orthopedics and traumatology must be taken into account. The visibility of the field of orthopedics and traumatology must not be lost with the introduction of the new medical licensing regulations (ÄApprO).ImplementationThe implementation of the new medical licensing regulations at German universities will be costly and necessitates an increased number of staff. However, there is a great opportunity to position orthopedics and traumatology as a "central player" in the modular, interdisciplinary and interprofessional course landscape. It is, therefore, important to take on concrete responsibility for the design of the new teaching programs and to bring in our specialist and interdisciplinary skills wherever sensible and possible., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Mortality of patients with a femoral neck fracture is high, especially within the first year after surgery, but also remains elevated thereafter. The aim of this study was to identify factors potentially associated with long-term mortality in patients homogeneously treated with hemiarthroplasty for femoral neck fracture., Methods: This retrospective cohort study was performed at a single level 1 national trauma center at the university hospital of Leipzig (Saxony, Germany). The study time-window was January 1, 2010 to December 31, 2020. Primary outcome measure was mortality depending on individual patient-related characteristics and perioperative risk factors. Inclusion criteria was a low-energy femoral neck fracture (Garden I-IV) in geriatric patients 60 years of age or older that were primarily treated with bipolar hemiarthroplasty. Date of death or actual residence of patients alive was obtained from the population register of the eastern German state of Saxony, Germany. The outcome was tested using the log-rank test and plotted using Kaplan-Meier curves. Unadjusted and adjusted for other risk factors such as sex and age, hazard ratios were calculated using Cox proportional hazards models and presented with 95% confidence intervals (CI)., Results: The 458 included patients had a median age of 83 (IQR 77-89) years, 346 (75%) were female and 113 (25%) male patients. Mortality rates after 30 days, 1, 5 and 10 years were 13%, 25%, 60% and 80%, respectively. Multivariate regression analysis revealed age (HR = 1.1; p < 0.001), male gender (HR = 1.6; p < 0.001), ASA-Score 3-4 vs. 1-2 (HR = 1.3; p < 0.001), dementia (HR = 1.9; p < 0.001) and a history of malignancy (HR = 1.6; p = 0.002) as independent predictors for a higher long-term mortality risk. Perioperative factors such as preoperative waiting time, early surgical complications, or experience of the surgeon were not associated with a higher overall mortality., Conclusions: In the present study based on data from the population registry from Saxony, Germany the 10-year mortality of older patients above 60 years of age managed with hemiarthroplasty for femoral neck fracture was 80%. Independent risk factors for increased long-term mortality were higher patient age, male gender, severe comorbidity, a history of cancer and in particular dementia. Perioperative factors did not affect long-term mortality., (© 2024. The Author(s).)

Background: Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking., Objectives: The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients., Materials and Methods: A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years)., Results: A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%)., Conclusions: The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed., (© 2023. The Author(s).)

In revision operations, ceramic heads of modular hip implants can be replaced. As the surface of the stem taper can be damaged, additional adapter sleeves are applied. The components are usually connected manually by the surgeon in a one-step procedure by hammer impacts. In this study, we investigated a two-step joining procedure with reproducible impaction force. First, the adapter sleeve and head were joined quasi-statically with a force of 2 kN using an assembly device. In the second step, these components were applied to the stem taper using a pulse-controlled instrument. For reference, the joints were assembled according to standard conditions using a tensile testing machine. An average pull-off force of 1309 ± 201 N was achieved for the components joined by the instrument, and the average measured values for the components joined by the testing machine were 1290 ± 140 N. All specimens achieved a force >350 N when released and therefore met the acceptance criterion defined for this study. This study showed that a modified procedure in two steps with a defined force has a positive effect on the reproducibility of the measured joining forces compared to previous studies.

Objective: Correction of a pathological kyphosis to restore a balanced, low-pain or pain-free and load-bearing spine., Indications: Pronounced sagittal imbalance, progressive kyphosis despite conservative therapy, and neurological deficits are indications for surgery. Further surgical indications are severe therapy-resistant complaints and/or psychologically burdening cosmetic impairment. The guidelines for surgical indications are kyphosis angles of 75-80° thoracic and 30-50° lumbar., Contraindications: No specific, but general contraindications for surgical treatment., Surgical Technique: Depending on the characteristics of the kyphosis, different surgical techniques are used. Rod-screw systems are mainly used, and surgery is primarily performed by shortening the spinal column from posterior using a wide variety of techniques. In individual cases, this can be combined with ventrally mobilizing, resecting, or straightening techniques., Postoperative Management: The aim of surgical treatment is to achieve a primarily stable and weight-bearing spine. Regular wound control as well as stabilizing physiotherapy during follow-up are essential. Postoperatively, initially abstaining from sports; later physical activity is encouraged under professional guidance., Results: The literature shows very good corrective results in children and adolescents. The technical procedures are associated with a low and acceptable complication rate. Over the course of time, these patients must be monitored in order to detect possible long-term complications such as junctional kyphosis or pseudarthrosis., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Hip implants have a modular structure which enables patient-specific adaptation but also revision of worn or damaged friction partners without compromising the implant-bone connection. To reduce complications during the extraction of ceramic inlays, this work presents a new approach of a shape-memory-alloy-actuator which enables the loosening of ceramic inlays from acetabular hip cups without ceramic chipping or damaging the metal cup. This technical in vitro study exam-ines two principles of heating currents and hot water for thermal activation of the shape-memory-alloy-actuator to generate a force between the metal cup and the ceramic inlay. Mechanical tests concerning push-in and push-out forces, deformation of the acetabular cup according to international test standards, and force generated by the actuator were generated to prove the feasibility of this new approach to ceramic inlay revision. The required disassembly force for a modular acetabular device achieved an average value of 602 N after static and 713 N after cyclic loading. The actuator can provide a push-out force up to 1951 N. In addition, it is shown that the necessary modifications to the implant modules for the implementation of the shape-memory-actuator-system do not result in any change in the mechanical properties compared to conventional systems.

In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors' hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery., (© 2023. Springer Nature Limited.)

Modern hip implants have a modular design. In case of wear or other damage it allows surgeons to change the tribological partners, i.e., the acetabular liner and femoral ball. In both revision and primary surgery, the secure joining of the implant components is important for the success of the operation. The two components, namely the ceramic liner and hip cup, are connected via a conical press connection and should be concentrically aligned to avoid chipping. Malseated liners can reduce the life span in situ. The amount of the joining force, which is usually applied via a hammer, depends on the surgeon. In this study, an alternative joining method for acetabular ceramic liners in hip cups was investigated, which intends to make the process more reproducible and thus safer. For this purpose, a handpiece was used to apply a defined force impulse of 4 kN. For the concentric alignment of a ceramic liner in the hip cup, an adapter was developed based on findings via a qualitative finite element (FE) analysis. Insertion and pushout tests of the acetabular cup-liner connection were performed in the laboratory with the new instrument (handpiece with the connected adapter) to evaluate the functionality of the instrument and the reproducibility of the new insertion method. For comparison, liners and acetabular cups were joined using a testing machine according to the standard. The presented results demonstrate the technical proof-of-concept of the new joining method under laboratory conditions. They meet the acceptance criteria of established manufacturers, which proves the equivalency to proven methods for joining modular implant components. To verify the improvement of the new joining method compared to the conventionally used joining method, an application-oriented study with different surgeons and the new joining instrument under clinical conditions is necessary.

The number of osteoporotic fractures of the spine is increasing. These fractures are associated with elevated morbidity and mortality. This article provides an overview of the special features of these fractures, the diagnostic procedure, their classification, and the conservative and surgical treatment options. For the mostly elderly patients, it is important to treat the underlying disease and to address associated problems such as frailty and sarcopenia. To meet this growing medical and socio-economic challenge, a holistic interdisciplinary and interprofessional treatment approach is required., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background: Conservative scoliosis therapy in the form of assisted physiotherapeutic scoliosis exercises is supplemented by self-contained training at home, depending on the approach (eg, Schroth, the Scientific Exercises Approach to Scoliosis). Complex exercises, lack of awareness of the importance of training, and missing supervision by therapists often lead to uncertainty and reduced motivation, which in turn reduces the success of home-based therapy. Increasing digitalization in the health care sector offers opportunities to close this gap. However, research is needed to analyze the requirements and translate the potential of digital tools into concrete solution concepts., Objective: The aim of this study is to evaluate the potential for optimizing home-based scoliosis therapy in terms of motivation, assistive devices, and digital tools., Methods: In collaboration with the Institute of Physiotherapy at the Jena University Hospital, a survey was initiated to address patients with scoliosis and physical therapists. A digital questionnaire was created for each target group and distributed via physiotherapies, scoliosis forums, the Bundesverband für Skoliose Selbsthilfe e. V. newsletter via a link, and a quick response code. The survey collected data on demographics, therapy, exercise habits, motivation, assistive devices, and digital tools. Descriptive statistics were used for evaluation., Results: Of 141 survey participants, 72 (51.1%; n=62, 86.1%, female; n=10, 13.9%, male) patients with scoliosis with an average age of 40 (SD 17.08) years and 30 scoliosis therapists completed the respective questionnaires. The analysis of home-based therapy showed that patients with scoliosis exercise less per week (2 times or less; 45/72, 62.5%) than they are recommended to do by therapists (at least 3 times; 53/72, 73.6%). Patients indicated that their motivation could be increased by practicing together with friends and acquaintances (54/72, 75%), a supporting therapy device (48/72, 66.7%), or a digital profile (46/72, 63.9%). The most important assistive devices, which are comparatively rarely used in home-based therapy, included balance boards (20/72, 27.8%), wall bars (23/72, 31.9%), mirrors (36/72, 50%), and long bars (40/72, 55.6%). Therapists saw the greatest benefit of digital tools for scoliosis therapy in increasing motivation (26/30, 87%), improving home therapy (25/30, 83%), monitoring therapy progress (25/30, 83%), and demonstrating exercise instructions (24/30, 80%)., Conclusions: In this study, we investigated whether there is any potential for improvement in home-based scoliosis therapy. For this purpose, using online questionnaires, we asked patients with scoliosis and therapists questions about the following topics: exercise habits, outpatient and home-based therapy, motivation, supportive devices, and digital tools. The results showed that a lack of motivation, suitable training equipment, and tools for self-control leads to a low training workload. From the perspective of the patients surveyed, this problem can be addressed through community training with friends or acquaintances, a supportive therapy device, and digital elements, such as apps, with training instructions and user profiles., (©Florian Günther, Fabian Schober, Sandra Hunger, Julia Schellnock, Steffen Derlien, Stefan Schleifenbaum, Welf-Guntram Drossel, Christoph-Eckhard Heyde. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 04.08.2023.)

The complexity of the osseo-ligamentous lumbopelvic system has made it difficult to perform both, the overall preparation as well as specimen harvesting and material testing with a reasonable amount of time and personnel. The logistics of such studies present a hurdle for reproducibility. A structured procedure was developed and proved, which allows all necessary steps to be carried out reproducibly and in a reasonable time. This enables the extraction of 26 soft tissue, 33 trabecular and 32 cortical bone specimens from this anatomical region per cadaver. The integrity of the specimens remains maintained while keeping requirements within manageable limits. The practicability of the intended five-day specimen harvesting and testing procedure could be demonstrated on five test and two pre-test sequences. The intended minimization of physical, biological, and chemical external influences on specimens could be achieved. All protocols, instructions and models of preparation and storage devices are included in the supporting information. The high grade of applicability and reproducibility will lead to better comparability between different biomechanical investigations. This procedure proven on the human pelvis is transferable to other anatomical regions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Kurz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The soft tissues of residual limb amputees are subject to large volume fluctuations over the course of a day. Volume fluctuations in residual limbs can lead to local pressure marks, causing discomfort, pain and rejection of prostheses. Existing methods for measuring interface stress encounter several limitations. A major problem is that the measurement instrumentation is applied in the sensitive interface between the prosthesis and residual limb. This paper presents the principle investigation of a non-intrusive technique to evaluate the fit of orthopaedic prosthesis sockets in transfemoral amputees based on experimentally obtained vibrational data. The proposed approach is based on changes in the dynamical behaviour detectable at the outer surface of prostheses; thus, the described interface is not affected. Based on the experimental investigations shown and the derived results, it can be concluded that structural dynamic measurements are a promising non-intrusive technique to evaluate the fit of orthopaedic prosthesis sockets in transfemoral amputee patients. The obtained resonance frequency changes of 2% are a good indicator of successful applicabilityas these changes can be detected without the need for complex measurement devices.

Introduction: Multidisciplinary tumor conferences are a fundamental component in the treatment of oncological patients. The COVID-19 pandemic and its resulting social distancing restrictions offered the opportunity to compare in-person to virtual multidisciplinary tumor conferences., Methods: Retrospective analysis of first-time presentations in tumor conferences at a university musculoskeletal tumor center in the time periods from September 2019 to February 2020 (in-person) and May 2020 to October 2020 (virtual)., Results: A total of 209 patients were first-time discussed in one of 52 analyzed musculoskeletal multidisciplinary tumor conferences (105 patients in 25 in-person, and 104 patients 27 virtual meetings). The total number of participants was slightly lower with virtual meetings ( p  < .001) and more disciplines were represented in virtual tumor conferences ( p  < .001). With median six consultants present in either, the level of available expertise did not differ between the conference formats ( p   =  .606). Compared to in-person tumor meetings, the patients were discussed earlier in the virtual conferences ( p   =  .028). The interval between first presentation to biopsy was significantly shorter after virtual tumor conferences (median 4 vs. 7 days, p  < .001). There was no significant difference in the interval between initial presentation and resection ( p   =  .544) among the two conference formats., Conclusions: The implementation of virtual tumor conferences appears to have had a positive effect on timely diagnosis and multidisciplinarity during tumor conferences. This may result in better decision-making and treatment of patients with musculoskeletal tumors and could be routinely implemented into cancer care., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Purpose: In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures., Methods: A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12 months., Results: One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10 years. The mean time between trauma and surgery was 49 ± 42 days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7. Positioning and preparing of the patients on the operation table took a mean of 57 ± 28 min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels. Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18 months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively)., Conclusion: High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: In lumbar spinal stabilization pedicle screws are used as standard. However, especially in osteoporosis, screw anchorage is a problem. Cortical bone trajectory (CBT) is an alternative technique designed to increase stability without the use of cement. In this regard, comparative studies showed biomechanical superiority of the MC (midline cortical bone trajectory) technique with longer cortical progression over the CBT technique. The aim of this biomechanical study was to comparatively investigate the MC technique against the not cemented pedicle screws (TT) in terms of their pullout forces and anchorage properties during sagittal cyclic loading according to the ASTM F1717 test., Methods: Five cadavers (L1 to L5), whose mean age was 83.3 ± 9.9 years and mean T Score of -3.92 ± 0.38, were dissected and the vertebral bodies embedded in polyurethane casting resin. Then, one screw was randomly inserted into each vertebra using a template according to the MC technique and a second one was inserted by freehand technique with traditional trajectory (TT). The screws were quasi-static extracted from vertebrae L1 and L3, while for L2, L4 and L5 they were first tested dynamically according to ASTM standard F1717 (10,000 cycles at 1 Hz between 10 and 110 N) and then quasi-static extracted. In order to determine possible screw loosening, there movements were recorded during the dynamic tests using an optical measurement system., Results: The pull-out tests show a higher pull-out strength for the MC technique of 555.4 ± 237.0 N compared to the TT technique 448.8 ± 303.2 N. During the dynamic tests (L2, L4, L5), 8 out of the 15 TT screws became loose before completing 10,000 cycles. In contrast, all 15 MC screws did not exceed the termination criterion and were thus able to complete the full test procedure. For the runners, the optical measurement showed greater relative movement of the TT variant compared to the MC variant. The pull-out tests also revealed that the MC variant had a higher pull-out strength, measuring at766.7 ± 385.4 N, while the TT variant measured 637.4 ± 435.6 N., Conclusion: The highest pullout forces were achieved by the MC technique. The main difference between the techniques was observed in the dynamic measurements, where the MC technique exhibited superior primary stability compared to the conventional technique in terms of primary stability. Overall, the MC technique in combination with template-guided insertion represents the best alternative for anchoring screws in osteoporotic bone without cement., (© 2023. The Author(s).)

Background: Visits to an outpatient cancer clinic represent a challenging situation for patients, which can trigger anxiety and helplessness in those affected. It is important to identify patients with high psychological distress as early as possible in order to provide them with supportive psychological interventions. The aim of this study was to validate the Distress Thermometer (DT), a widely used screening for distress, in a cohort of patients with musculoskeletal tumors and to explore associations between distress, treatment satisfaction and health literacy., Methods: All patients presenting to a University outpatient clinic for musculoskeletal cancers were asked to complete a set of questionnaires including the DT), the Hospital Anxiety and Depression Scale (HADS) as a comparison scale, the Patient Satisfaction with Comprehensive Cancer Care (SCCC) and European Health Literacy Survey Questionnaire (HLS-EU-Q16).To assess the sensitivity and specificity of the DT in a cohort of patients with musculoskeletal tumors, we compare the performance of the DT in relation to an established screener for anxiety and depression using receiver operating characteristics (ROC) analyses., Results: A total of 120 patients (age 58 ± 18, 51% female) were analyzed. Patients reported a mean DT of 5.0 (SD 2.3, range, 0 to 10). Eighty-six patients (71.7 %) had a DT score ≥ 5 indicating moderate or severe psychological distress.The mean total HADS score (scale 0 to42 points) was 11.7 (SD 7.6, range, 0 to 32) with a HADS score of ≥ 15 in 29.2% of patients. The DT correlated moderately with anxiety and depression (HADS total r = 0.48, p < 0.001), while the correlation with depression (HADS-D, r = 0.47, p < 0.001) was stronger than with anxiety (HADS-A, r = 0.38, p < 0.001).For a DT score ≥ 5, ROC analysis yielded a sensitivity of 71.4% and a specificity of 75.3% for detecting moderate or severe psychological distress (HADS ≥ 15, AUC 0.782).The REPERES-G, collected from a subgroup (n = 49), showed high treatment satisfaction with a median score of 132 (min 90, max 163). Especially the "satisfaction with medical aspects of treatment" (REPERES-G medical aspects) showed a moderate correlation with the DT (r = 0.51, p < 0.001) a strong correlation with anxiety and depression (HADS total, r = 0.69, p < 0.001)., Conclusion: About three in four patients with musculoskeletal tumors have relevant psychological distress. A visual analogue scale can only be a rough guide for identifying patients in need of psychological support, with a sensitivity of 71.4 % and a specificity of 75.3 %. A strong relationship between patient and care team was associated with lower patient psychological distress.Consequently, screening tools cannot replace detailed discussion and personal contact, especially in the treatment of malignant diseases., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Study Design: Systematic review., Objectives: Spinal orthoses are frequently used to non-operatively treat osteoporotic vertebral fractures (OVF), despite the available evidence is rare. Previously systematic reviews were carried out, presenting controversial recommendations. The present study aimed to systematic review the recent and current literature on available evidence for the use of orthoses in OVF., Methods: A systematic review was conducted using PubMed, Medline, EMBASE and CENTRAL databases. Identified articles including previous systematic reviews were screened and selected by three authors. The results of retrieved articles were presented in a narrative form, quality assessment was performed by two authors using scores according to the study type., Results: Thirteen studies (n = 5 randomized controlled trials, n = 3 non- randomized controlled trials and n = 5 prospective studies without control group) and eight systematic reviews were analyzed. Studies without comparison group reported improvements in pain, function and quality of life during the follow-up. Studies comparing different types of orthoses favor non-rigid orthoses. In comparison to patients not wearing an orthosis three studies were unable to detect beneficial effects and two studies reported about a significant improvement using an orthosis. In the obtained quality assessment, three studies yielded good to excellent results. Previous reviews detected the low evidence for spinal orthoses but recommended them., Conclusion: Based on the study quality and the affection of included studies in previous systematic reviews a general recommendation for the use of a spinal orthosis when treating OVF is not possible. Currently, no superiority for spinal orthoses in OVF treatment was found.

Objectives: The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy., Materials and Methods: Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years)., Results: A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92)., Conclusions: The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically., (© 2023. The Author(s).)

Virtual Reality (VR) is applied in various areas were a high User Experience is essential. The sense of Presence while being in VR and its relation to User Experience therefore form crucial aspects, which are yet to be understood. This study aims at quantifying age and gender effects on this connection, involving 57 participants in VR, and performing a geocaching game using a mobile phone as experimental task to answer questionnaires measuring Presence (ITC-SOPI), User Experience (UEQ) and Usability (SUS). A higher Presence was found for the older participants, but there was no gender difference nor any interaction effects of age and gender. These findings are contractionary to preexisting limited work which has shown higher Presence for males and decreases of Presence with age. Four aspects discriminating this study from literature are discussed as explanations and as a starting point for future investigations into the topic. The results further showed higher ratings in favor of User Experience and lower ratings towards Usability for the older participants., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lorenz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: This study aimed to investigate the effect of epicutaneous vacuum therapy on the rate of unplanned spinal wound revisions compared with conventional wound dressing., Methods: This retrospective study included patients who underwent unplanned revision spine surgery after primary aseptic spine surgery who were treated at a level I spine centre between December 2011 and December 2019. Patients with revision surgery who required a further unplanned revision surgery during the inpatient stay were considered a treatment failure. The epicutaneous vacuum-assisted closure (Epi-VAC) therapy was the standard treatment method beginning in 2017 (the epi-VAC group). Before, conventional wound dressing was used (the control group (CG)). In addition, a one-to-one matched-pair comparison analysis was performed between both groups., Results: Of 218 patients, 48 were in the epi-VAC group. The mean age was 65.1 years (epi-VAC 68.2 to CG 64.3 years (P = 0.085)), and the mean body mass index (BMI) was 28.2 kg/m 2 (epi-VAC 29.4 to CG 27.9 kg/m 2 (P = 0.16)). No significant differences in the treatment failure rate could be detected between the two groups (epi-VAC 25% to CG 22.4% (P = 0.7)). There was also no significant difference for the matched-pair analysis (epi-VAC 26.1% to CG 15.2% (P = 0.3)). An elevated CRP level (C-reactive protein) immediately before the first wound revision was a significant risk factor for further revision surgery (treatment failure: 135.2 ± 128.6; no treatment failure: 79.7 ± 86.1 mg/l (P < 0.05))., Conclusion: Concerning repeat unplanned wound revision after spinal revision surgery, we cannot demonstrate an advantage of the epicutaneous vacuum therapy over conventional wound dressing., (© 2023. The Author(s).)

Background: The aim of this study was to evaluate the applicability and advantages of intraoperative imaging using a 3D flat panel in the treatment of C1/2 instabilities., Materials: Prospective single-centered study including surgeries at the upper cervical spine between 06/2016 and 12/2018. Intraoperatively thin K-wires were placed under 2D fluoroscopic control. Then an intraoperative 3D-scan was carried out. The image quality was assessed based on a numeric analogue scale (NAS) from 0 to 10 (0 = worst quality, 10 = perfect quality) and the time for the 3D-scan was measured. Additionally, the wire positions were evaluated regarding malpositions., Results: A total of 58 patients were included (33f, 25 m, average age 75.2 years, r.:18-95) with pathologies of C2: 45 type II fractures according to Anderson/D'Alonzo with or without arthrosis of C1/2, 2 Unhappy triad of C1/2 (Odontoid fracture Type II, anterior or posterior C1 arch-fracture, Arthrosis C1/2) 4 pathological fractures, 3 pseudarthroses, 3 instabilities of C1/2 because of rheumatoid arthritis, 1 C2 arch fracture). 36 patients were treated from anterior [29 AOTAF (combined anterior odontoid and transarticular C1/2 screw fixation), 6 lag screws, 1 cement augmented lag screw] and 22 patients from posterior (regarding to Goel/Harms). The median image quality was 8.2 (r.: 6-10). In 41 patients (70.7%) the image quality was 8 or higher and in none of the patients below 6. All of those 17 patients the image quality below 8 (NAS 7 = 16; 27.6%, NAS 6 = 1, 1.7%), had dental implants. A total of 148 wires were analyzed. 133 (89.9%) showed a correct positioning. In the other 15 (10.1%) cases a repositioning had to be done (n = 8; 5.4%) or it had to be drawn back (n = 7; 4.7%). A repositioning was possible in all cases. The implementation of an intraoperative 3D-Scan took an average of 267 s (r.: 232-310 s). No technical problems occurred., Conclusion: Intraoperative 3D imaging in the upper cervical spine is fast and easy to perform with sufficient image quality in all patients. Potential malposition of the primary screw canal can be detected by initial wire positioning before the Scan. The intraoperative correction was possible in all patients. Trial registration German Trials Register (Registered 10 August 2021, DRKS00026644-Trial registration: German Trials Register (Registered 10 August 2021, DRKS00026644- https://www.drks.de/drks&#95;web/navigate.do?navigationId=trial.HTML&TRIAL&#95;ID=DRKS00026644 )., (© 2023. The Author(s).)

Background: End artefacts play a major role in uniaxial compression tests with cancellous bone specimens. They lead to misinterpretation of mechanical parameters of bones due to uncontrolled introduction of bending moments into the free ends of trabeculae. This work aims to simplify current methods preventing end-artefacts and furthermore to investigate the influence of end artefacts on plateau stress., Methods: 176 cylindrical cancellous bone specimens were taken from human femoral condyles and tested in uniaxial compression. The specimens were divided into 2 groups (direct, end-cap) and compressive modulus, maximum stress, plateau stress, energy absorbtion as well as apparent density were evaluated. Density values are from separate specimens which are immediately adjacent to the mechanical specimen., Findings: All mechanical parameters were significantly higher in the end-cap specimens than in the direct ones by about 30 - 40 %, thus reaching similar differences as the previous studies. Greatest differences between groups were determined for compressive modulus (45 %) and plateau stress (35 %). Energy absorbtion can be explained with great accuracy by plateau stress (P < 0.001; R 2  = 0.95). Among all parameters plateau stress can be best explained by apparent density using an exponential function (P < 0.001; R 2  = 0.38)., Interpretation: The end-cap method used here to prevent end artefacts showed variations consistent with the literature when compared to the direct method. Additionally it was shown that the way in which the force is applied to the specimen has a major influence on the failure progression behavior, which was characterized using the plateau stress., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The prevalence of nonspecific pyogenic spondylodiskitis, associated with both a high morbidity and a high mortality, has increased in the last few decades. The diagnosis is often delayed because of the nonspecific clinical manifestation at the early stage. The reliability of radiographs is limited, particularly in early stage after the onset of infection. Computed tomography (CT) can reliably assess the bony condition with the possibility of spatial visualization. Contrast enhancement supports the detection of affected soft tissue. Magnetic resonance imaging (MRI) continues to be the gold standard in the diagnosis of spondylodiskitis. Sophisticated investigation protocols supported by gadolinium enhancement secure the diagnosis. MRI has a high resolution without radiation exposure. Different nuclear investigation techniques extend the diagnostic options. Reports of 18F-fluorodeoxyglucose-positron emission tomography (18-FDG-PET) are particularly promising to confirm the diagnosis. The drawback of the reduced image quality with respect to detailed anatomical information can be overcome by a combined simultaneous acquisition of CT or MRI. With respect to one of the greatest challenges, the differentiation between degenerative changes (Modic type 1) and infection at an early stage using differentiated MRI protocols and FDG-PET is promising. This overview presents a concise state-of-the-art look at radiologic investigations in case of suspected nonspecific pyogenic spondylodiskitis with the focus on a pragmatic approach., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: The purpose of this study was analyzing the effect of subsequent vertebral body fractures on the clinical outcome in geriatric patients with thoracolumbar fractures treated operatively., Methods: Retrospectively, all patients aged ≥ 60 with a fracture of the thoracolumbar spine included. Further inclusion parameters were acute and unstable fractures that were treated by posterior stabilization with a low to moderate loss of reduction of less than 10°. The minimal follow-up period was 18 months. Demographic data including the trauma mechanism, ASA score, and the treatment strategy were recorded. The following outcome parameters were analyzed: the ODI score, pain level, satisfaction level, SF 36 score as well as the radiologic outcome parameters., Results: Altogether, 73 patients were included (mean age: 72 years; 45 women). The majority of fractures consisted of incomplete or complete burst fractures (OF 3 + 4). The mean follow-up period was 46.6 months. Fourteen patients suffered from subsequent vertebral body fractures (19.2%). No trauma was recordable in 5 out of 6 patients; 42.8% of patients experienced a low-energy trauma (significant association: p < 0.01). There was a significant correlation between subsequent vertebral body fracture and female gender (p = 0.01) as well as the amount of loss of reduction (p = 0.02). Thereby, patients with subsequent vertebral fractures had significant worse clinical outcomes (ODI: 49.8 vs 16.6, p < 0.01; VAS pain: 5.0 vs 2.6, p < 0.01)., Conclusion: Patient with subsequent vertebral body fractures had significantly inferior clinical midterm outcome. The trauma mechanism correlated significantly with both the rate of subsequent vertebral body fractures and the outcome. Another risk factor is female gender., (© 2022. The Author(s).)

Background: Spinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction., Methods: Prospective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated., Results: Forty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4-73.5%), radiating pain (9.4-34.7%), and nerve root irritation (2-18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (p < 0.001), but relapse occurred at the 12-week follow-up., Conclusions: Various consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient., (© 2022. The Author(s).)

Purpose: To investigate the innervation pattern of the sacroiliac region, especially with regard to the sacroiliac joint (SIJ). Dorsal SIJ innervation was analyzed and described. Our main hypothesis was that nerves reach the SIJ dorsally, passing ligamental compartments, as this would explain dorsal SIJ pain., Methods: To examine sacroiliac innervation, we followed the nerves in over 50 specimens over several years. Plastinated slices were evaluated, nerves in the region were stained histologically, and the data were summarized as 3D models., Results: The Rami communicans and posterior branches of the spinal nerves and their branches that form a dorsal sacral plexus and communicating branches, together with corresponding vessels, were observed to form neurovascular bundles embedded by tiny fatty connectives in gaps and tunnels. Branches of L5-S1 pass the inner sacroiliac ligaments (the interosseous sacroiliac ligament and axial interosseous ligament). The outer sacroiliac ligaments (posterior sacroiliac ligaments, long posterior sacroiliac ligament, sacrotuberal ligament, thoracolumbar fascia) are passed by the S1-S4 branches. However, although the paths of these nerves are in the direction of the SIJ, they do not reach it. It is possible that impingement of the neurovascular bundles may result in pain. Moreover, the gaps and tunnels connect to the open dorsal SIJ., Conclusion: Our findings suggest that Bogduk's term "sacroiliac pain" correlates to "sacroiliac innervation", which consists of "inner-" and "outer sacroiliac ligament innervation", and to ventral "SIJ pain". The watery gaps and tunnels observed could play a significant role in innervation and thus in the origins of SIJ pain., Level of Evidence: Individual cross-sectional studies with consistently applied reference standard and blinding., (© 2022. The Author(s).)

Objective: Convolutional neural networks (CNNs) are being increasingly used in the medical field, especially for image recognition in high-resolution, large-volume data sets. The study represents the current state of research on the application of CNNs in image segmentation and pathology detection in spine magnetic resonance imaging., Methods: For this systematic literature review, the authors performed a systematic initial search of the PubMed/Medline and Web of Science (Core collection) databases for eligible investigations. The authors limited the search to observational studies. Outcome parameters were analyzed according to the inclusion criteria and assigned to 3 groups: 1) segmentation of anatomical structures, 2) segmentation and evaluation of pathologic structures, and 3) specific implementation of CNNs., Results: Twenty-four retrospectively designed articles met the inclusion criteria. Publication dates ranged from 2017 to 2021. In total, 14,065 patients with 113,110 analyzed images were included. Most authors trained their network with a training-to-testing ratio of 80/20, while all but 2 articles used 5- to 10-fold cross-validation. Nine articles compared their performance results with other neural networks and algorithms, and all 24 articles described outcomes as positive., Conclusions: State-of-the-art CNNs can detect and segment-specific anatomical landmarks and pathologies across a wide range, comparable to the skills of radiologists and experienced clinicians. With rapidly evolving network architectures and growing medical image databases, the future is likely to show growth in the development and refinement of these capable networks. However, the aid of automated segmentation and classification by neural networks cannot and should not be expected to replace clinical experts., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The objective of this study was to evaluate the intrinsic preload of the sacrotuberous ligament. Preload measurements and anatomical experiments were performed on 20 specimens from 10 human cadavers and assessed to consider the thesis of the ligamentous tension band system as a possible load distribution. The result was an unexpectedly high preload force with an overall average of 118 N ± 74 N. Age has been significantly different between females and males in the cohort (median 94 vs. 77 years). Nevertheless, there is preliminary evidence of the sex-dependent sacrotuberous ligament preload force with an average value of approximately 65 N for the 10 female cadaver specimens and 172 N for the 10 male cadaver specimens. The assessment of further influencing factors and their statistical evaluation also showed a dependence of the sacrotuberous ligament preload force on body height, age and elastin content. Thus, the sacrotuberous ligament is more preloaded in the cadaver than previously assumed in the literature. Therefore, and contrary to most assumptions, it could possibly also be more preloaded in a living person in an upright position under a muscular load. This leads to the hypothesis that pelvic stability is more dependent on ligamentous preload than previously thought. These considerations should be taken more into account in numerical simulations of sacroiliac joint function., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: In recent years, the sacroiliac joint has become increasingly important as a generator of low back pain with and without pseudo-radicular pain in the legs. Up to 27% of reported back pain is generated by disorders in the sacroiliac joint., Method: This review is based on a selective literature search of the sacroiliac joint (SIJ) as a possible pain generator. It also considers the anatomical structures and innervation of the sacroiliac joint., Results: The SIJ is a complex joint in the region of the posterior pelvis and is formed by the sacrum and the ilium bones. The SIJ is very limited in movement in all three planes. Joint stability is ensured by the shape and especially by strong interosseous and extraosseous ligaments. Different anatomical variants of the sacroiliac joint, such as additional extra-articular secondary joints or ossification centres, can be regularly observed in CT scans. There is still controversy in the literature regarding innervation. However, there is agreement on dorsal innervation of the sacroiliac joint from lateral branches of the dorsal rami of the spinal nerves S I-S III with proportions of L III and L IV as well S IV. Nerve fibres and mechanoreceptors can also be detected in the surrounding ligaments., Conclusion: A closer look at the anatomy and innervation of the SIJ shows that the SIJ is more than a simple joint. The complex interaction of the SIJ with its surrounding structures opens the possibility that pain arises from this area. The SIJ and its surrounding structures should be included in the diagnosis and treatment of back and leg pain. Published literature include a number of plausible models for the sacroiliac joint as pain generator. The knowledge of the special anatomy, the complex innervation as well as the special and sometimes very individual functionality of this joint, enhance our understanding of associated pathologies and complaints., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: Acetabular fractures pose high demands on the surgeon and in the case of osteosynthetic treatment, anatomical reconstruction has the highest priority to achieve a good outcome. However, especially in older patients with poor bone quality, even anatomical reconstruction is no guarantee for a good clinical outcome and may nevertheless end in early osteoarthritis. Primary arthroplasty therefore has an increasing importance in the treatment of these patients. The aim of this study was to biomechanically compare fracture gap displacement and failure load as an assessment measure of the primary stability of conventional plate osteosynthesis with the treatment using a sole multi-hole cup for acetabular fractures., Methods: Six hemi-pelvises each with anterior column and posterior hemi-transverse (ACPHT) fracture were treated with either plate osteosynthesis or a multi-hole cup. The tests were carried out in a standardised test set-up with cyclic loading in various stages between 150 N and 2500 N. The fracture gap displacement was recorded with optical 3D measuring and the failure load was determined after the cyclic measurement., Results: With increasing force, the fracture gap displacement increased in both procedures. In each group there was one treatment which failed at the cyclic loading test and a bone fragment was broken out. The primary stability in arthroplasty was comparable to that of the standard osteosynthesis., Conclusions: The results found seem promising that the primary arthroplasty with a sole multi-hole cup and corresponding screw fixation achieves an initial stability comparable to osteosynthesis for typical ACPHT fractures. However, further clinical studies are needed to prove that the cups heal solidly into the bone., Competing Interests: The authors have declared that no competing interests exist.

Background: No comparison of a single hypervascular tumor entity in terms of major complications in different spinal regions has been performed. We aimed to evaluate post-embolic and post-operative outcomes in anatomic regions with renal cell carcinoma (RCC) metastases to the spine., Methods: We retrospectively evaluated data from patients with confirmed, embolized, and surgically treated RCC spine metastases at a single-spine center between 2010 and 2020. Patients were divided into thoracic (TSM) and lumbar (LSM) spine metastasis groups., Results: Seventeen patients had TSM and 14 had LSM. In all cases, embolization was performed preoperatively. The ΔHb value did not differ between the two groups pre- and postoperatively (p=0.3934). There was no significant difference in intraoperative blood loss between both groups either within 1 day or 2 days after embolization. Neurological deficits occurred in eight patients after embolization or surgery, with no significant difference between TSM (n=5) and LSM (n=3)., Conclusions: Embolization is the standard procedure for the preoperative treatment of hypervascular spinal metastases, possible up to 48 h before surgery, without the risk of higher intraoperative blood loss. Regardless of intraoperative complications, major complications can occur up to several hours after embolization. We recommend surgery the day after embolization to reliably detect neurologic complications from this procedure., (© 2022. The Author(s).)

Wear-induced complications after cervical disc replacement (CDR) are rare. A literature review on this topic found only a few case reports. We present a case of late complications after implantation of two cervical disc replacements, which resulted in infectious/abrasion-induced mixed-type inflammation with extensive osteolysis. The diagnostic workup, surgical therapy and outcome are presented and discussed with a review of the recent literature., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: Revision arthroplasty involving mega-implants is associated with a high complication rate. In particular, infection is a serious complication of revision arthroplasty of hip and knee joints and has been reported to have an average rate of 18%, and for mega-implants, the range is from 3 to 36%. This study was designed to analyze the strategy of treatment of infection of mega-endoprostheses of the lower extremities in our patient cohort, particularly the management of chronic infection., Material and Methods: This was a retrospective study that focused on the results of the treatment of periprosthetic infections of mega-implants of the lower extremities. We identified 26 cases with periprosthetic infections out of 212 patients with 220 modular mega-endoprostheses of the lower extremities who were treated in our department between September 2013 and September 2019. As a reinfection or recurrence, we defined clinical and microbiological recurrences of local periprosthetic joint infections after an antibiotic-free period., Results: In this study, 200 cases out of 220 were investigated. The average follow-up period was approximately 18 months (6 months to 6 years). Endoprosthesis infections after implantation of mega-implants occurred in 26 cases (13%). This group comprised 2 early infections (within the first 4 weeks) and 24 chronic infections (between 10 weeks and 6 years after implantation). Nineteen cases out of the identified 26 cases with infection (73.1%) belong to the group of patients who were operated on due to major bone loss following explantation of endoprosthetic components due to previous periprosthetic joint infection. The remaining seven cases with infection comprised four cases following management of periprosthetic fracture, two cases following treatment of aseptic loosening, and one case following tumor resection. All infections were treated surgically. In all cases, the duration of continuous antibiotic treatment did not exceed 6 weeks. Both cases with early infection were treated by exchanging polyethylene inlays and performing debridement with lavage (two cases). In two (7.7%) cases with chronic infection, one-stage surgery was performed. In all remaining cases with chronic infection (22 cases; 84.6%), explantation of all components and temporary implantation of cement spacers were carried out prior to reimplantation., Conclusion: There is still no gold standard therapeutic regimen for the management of periprosthetic infection of mega-implants, though radical surgical debridement and lavage accompanied by systemic antibiotic therapy are the most important therapeutic tools in all cases of periprosthetic infections, regardless of the time of onset. Further studies are needed to standardize management strategies of such infections. Nevertheless, it is not uncommon for compromises to be made based on the particular condition of the individual., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)