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Background Isolated pulmonary vasculitis (IPV) is a single-organ vasculitis of unknown etiology and may mimic chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to review our clinical experience with pulmonary endarterectomy in patients with CTEPH secondary to IPV. Methods Data were collected prospectively for consecutive patients who underwent pulmonary endarterectomy and had a diagnosis of IPV at or after surgery. Results We identified nine patients (six female, median age 48 (23–55) years) with IPV. The diagnosis was confirmed after histopathological examination of all surgical materials. The mean duration of disease before surgery was 88.0 ±70.2 months. Exercise-induced dyspnea was the presenting symptom in all patients. Pulmonary endarterectomy was bilateral in six patients and unilateral in three. No mortality was observed, however, one patient had pulmonary artery stenosis and stent implantation was performed. All patients received immunosuppressive therapies after surgery. Mean pulmonary artery pressure decreased significantly from 30(19–67) mm Hg to 21(15–49) mm Hg after surgery (p Conclusions Isolated pulmonary vasculitis can mimic CTEPH, and these patients can be diagnosed with pulmonary endarterectomy. Furthermore, surgery has not only diagnostic but also therapeutic value for IPV when stenotic and/or thrombotic lesions are surgically accessible. A multidisciplinary experienced CTEPH team is critical for management of these unique patients.

Survey among spine experts.To investigate the different views and opinions of clinically relevant spinal post-traumatic deformity (SPTD).There is no clear definition of clinically relevant SPTD. This leads to a wide variation in characteristics used for diagnosis and treatment indications of SPTD. To understand the current concepts of SPTD a survey was conducted among spine trauma surgeons.Members of the AO Spine Knowledge Forum Trauma participated in an online survey. The survey was divided in 4 domains: Demographics, criteria to define SPTD, risk factors, and management. The data were collected anonymously and analyzed using descriptive statistics, absolute, and relative frequencies. Consensus on dichotomous outcomes was set to 80% of agreement.Fifteen members with extensive experience in treatment of spinal trauma participated, representing the 5 AO Spine Regions. Back pain was the only criterion for definition of SPTD with complete agreement. Consensus (≥80%) was reached for kyphotic angulation outside normative ranges and impaired function. Eighty-seven percent and 100% agreed that a full-spine conventional radiograph was necessary in diagnosing and treating SPTD, respectively. The "missed B-type injury" was rated at most important by all but 1 participant. There was no agreement on other risk factors leading to clinically relevant SPTD. Concerning the management, all participants agreed that an asymptomatic patient should not undergo surgical treatment and that neurological deficit is an absolute surgical indication. For most of the participants the preferred surgical treatment of acute injury in all spine regions but the subaxial region is posterior fixation.Some consensus exists among leading experts in the field of spine trauma care concerning the definition, diagnosis, risk factors, and management of SPTD. This study acts as the foundation for a Delphi study among the global spine community.

ÖZETAmaç:Bu çalışmada koksartrozu mevcut olup kompleks asetabulum kırığı nedeniyle erken ve geç kalça artroplastisi yapılan hastaların klinik sonuçlarını karşılaştırmayı ve klinik sonuçları etkileyen faktörleri araştırmayı amaçladık.Yöntem:2005 ve 2017 yılları arasında asetabular kırık nedeniyle ameliyat edilen hastalar geriye dönük olarak incelendi. Letournel Sınıflamasına göre kompleks kırıklar ve Kellgren-Lawrence radyolojik kriterlerine göre artrozu olan hastalar, çalışmaya dahil edildi. Hastalar artroplasti yapılma zamanlarına göre kırık sonrası erken dönem (grup 1) ve geç dönem (grup 2) olmak üzere iki gruba ayrıldı. Her iki grup Harris kalça skoru, Visual Analogue Scale (VAS), yaş, artroz, ameliyat süresi ve günlük hayata dönme süresi açısından karşılaştırıldı.Bulgular:Çalışmaya alınan hastaların 20'sinin erken dönemde, 21'inin ise geç dönemde artroplasti geçirdiği belirlendi. Ortalama Harris skoru erken artroplasti yapılanlarda 71.60 (± 13.5), geç artroplasti yapılanlarda 61.23 (± 2.6) idi (p = 0.002). Ortalama VAS skoru erken artroplasti yapılanlarda 1.7 (1-3), geç artroplasti yapılanlarda 2.6 (1-5) idi (p = 0,102).Sonuç:Erken artroplasti, koksartroz zemininde kompleks asetabular kırığı olan hastalarda geç artroplastiye göre daha iyi fonksiyonel sonuç ve daha düşük komplikasyon oranları ile daha güvenli bir seçenektir. Koksartroz zemininde kompleks asetabular kırığı olan hastalarda, cerrahın erken veya geç artroplasti kararında arada kaldığı durumlarda, erken artroplasti tercih edilmelidir.Anahtar Kelimeler: Asetabular kırık, koksartroz, total kalça replasmanı, Purpose:We aimed to compare the clinical results of patients who underwent early and late hip arthroplasty due to complex acetabulum fracture with coxarthrosis and investigate the factors affecting the clinical results.Method: Patients who were operated on for acetabular fractures between 2005 and 2017 were retrospectively analysed. Patients with complex fractures according to the Letournel Classification and arthrosis according to the Kellgren-Lawrence radiological criteria were included in the study. Patients were divided in to two groups, post-fracture early period (group 1) and late period (group 2), based on when they underwent arthroplasty. Both groups were compared in terms of Harris hip score, Visual Analogue Scale (VAS), age, arthrosis, operation time, and time to return to daily life.Result: It was determined that 20 of the patients included in the study underwent arthroplasty in the early period and 21 in the late period. The mean average Harris score was 71.60 (± 13.5) in those who underwent early arthroplasty and 61.23 (± 2.6) in those who underwent late arthroplasty (p = 0.002). The average VAS score was 1.7 (1–3) in those who underwent early arthroplasty and 2.6 (1–5) in those who underwent late arthroplasty (p= 0.102)Conclusion:Early arthroplasty is a safer option with better functional results and lower complication rates than late arthroplasty in patients with complex acetabular fractures with coxarthrosis. In patients with complex acetabular fractures with coxarthrosis, early arthroplasty should be preferred when the surgeon is not sure about early or late arthroplasty.Keywords: Acetabular fracture, coxarthrosis, total hip replacement.

Study Design Narrative review Objectives Multiple classifications have been proposed for sacral fractures since the last century. While initial classifications focussed on vertical and transverse fractures, the recent fracture classifications encompass all injury patterns. In 1990, Isler classified unilateral vertical sacral fractures based on its potential influence on lumbo-sacral joint (LSJ) stability. Methods We re-visited the original description of Isler’s classification of sacral fractures and subsequent studies that have cited it. We will further describe basic LSJ anatomy, evolution of sacral classification systems and the use of Isler’s classification system as it relates to LSJ instability and chronic low back pain. Results Isler described a subset of unilateral vertical sacral fractures where the fracture line exited medial or through the L5-S1 facet joint, based on radiographic review of 193 sacral fractures (incidence -3.5%). He stated that such a fracture should be recognised as it can impede hemi-pelvis reduction and can result in late LSJ instability. The article has been cited in 106 studies and only a few studies have described the incidence of this variant. Nevertheless, the injury is considered as an indication for surgical fixation. Conclusion A review of various classifications indicates that sacral fractures have three important bio-mechanical implications, namely, pelvic ring continuity (vertical fractures), spino-pelvic alignment (high transverse fractures) and lumbo-sacral joint integrity (Isler’s fractures). Though there is a universal recognition of Isler’s fractures and its impact on LSJ integrity, there is a lack of clinical and bio-mechanical evidence regarding the concept of instability caused by a unilateral Isler fracture.

WOS:000730954400001 PMID: 34913804 Introduction We aimed to evaluate the impact of the resection technique (tumor enucleation (TE) or standard partial nephrectomy (SPN)) on trifecta outcomes in patients having undergone partial nephrectomy (PN). Materials and Methods We retrospectively analyzed the clinical and pathologic parameters in patients with localized renal cell carcinoma (pT1-2N0M0) who had undergone PN between January 2001-December 2018 at one of 15 different tertiary referral centers. Multivariable logistic regression analysis was applied to investigate independent predictors of trifecta failure, decreased postoperative renal functions (decreased estimated glomerular filtration rate (eGFR) > 10%), perioperative complications (Clavien-Dindo > 1), and positive surgical margins. Results A total of 1070 patients with a mean age 56.11 +/- 11.88 years were included in our study. PN was performed with TE in 848 (79.25%) and SPN in 222 (20.75%) patients. Trifecta failure rate was 56.2% for TE and 64.4% for SPN (p = 0.028). On multivariable analysis, TE was associated with less trifecta failure (p = 0.025) and eGFR decrease >10% rates (p = 0.024). On the other hand, there was no statistically significant difference between TE and SPN according to positive surgical margins (p = 0.450) and complication > Clavien-Dindo grade 1 (p = 0.888) rates. The only independent predictive factor for complications > Clavien-Dindo 1 was the Charlson comorbidity index (CCI) (p = 0.001). Conclusion TE is associated with less trifecta failure than SPN. This result is mainly due to better preservation of renal function with TE.

Supplemental Digital Content is Available in the Text., Objectives: To (1) demonstrate that the AO Spine Sacral Classification System can be reliably applied by general orthopaedic surgeons and subspecialists universally around the world and (2) delineate those injury subtypes that are most difficult to classify reliably to refine the classification before evaluating clinical outcomes. Design: Agreement study. Setting: All-level trauma centers, worldwide. Participants: One hundred seventy-two members of the AO Trauma and AO Spine community. Intervention: The AO Sacral Classification System was applied by each surgeon to 26 cases in 2 independent assessments performed 3 weeks apart. Main Outcome Measurements: Interobserver reliability and intraobserver reproducibility. Results: A total of 8097 case assessments were performed. The kappa coefficient for interobserver agreement for all cases was 0.72/0.75 (assessment 1/assessment 2), representing substantial reliability. When comparing classification grading (A/B/C) regardless of subtype, the kappa coefficient was 0.84/0.85, corresponding to excellent reliability. The kappa coefficients for interobserver reliability were 0.95/0.93 for type A fractures, 0.78/0.79 for type B fractures, and 0.80/0.83 for type C fractures. The overall kappa statistic for intraobserver reliability was 0.82 (range 0.18–1.00), representing excellent reproducibility. When only evaluating morphology type (A/B/C), the average kappa value was 0.87 (range 0.18–1.00), representing excellent reproducibility. Conclusion: The AO Spine Sacral Classification System is universally reliable among general orthopaedic surgeons and subspecialists worldwide, with substantial interobserver and excellent intraobserver reliability.

BACKGROUND CONTEXT Prior upper cervical spine injury classification systems have focused on injuries to the craniocervical junction (CCJ), atlas, and dens independently. However, no previous system has classified upper cervical spine injuries using a comprehensive system incorporating all injuries from the occiput to the C2-3 joint. PURPOSE To (1) determine the accuracy of experts at correctly classifying upper cervical spine injuries based on the recently proposed AO Spine Upper Cervical Injury Classification System (2) to determine their interobserver reliability and (3) identify the intraobserver reproducibility of the experts. STUDY DESIGN/SETTING International Multi-Center Survey PATIENT SAMPLE: A survey of international spine surgeons on 29 unique upper cervical spine injuries OUTCOME MEASURES: Classification accuracy, interobserver reliability, intraobserver reproducibility METHODS: Thirteen international AO Spine Knowledge Forum Trauma members participated in two live webinar-based classifications of 29 upper cervical spine injuries presented in random order, four weeks apart. Percent agreement with the gold-standard and kappa coefficients (ƙ) were calculated to determine the interobserver reliability and intraobserver reproducibility. RESULTS Raters demonstrated 80.8% and 82.7% accuracy with identification of the injury classification (combined location and type) on the first and second assessment, respectively. Injury classification intraobserver reproducibility was excellent (mean, [range] ƙ = 0.82 [0.58-1.00]). Excellent interobserver reliability was found for injury location (ƙ = 0.922 and ƙ= 0.912) on both assessments, while injury type was substantial (ƙ=0.689 and 0.699) on both assessments. This correlated to a substantial overall interobserver reliability (ƙ = 0.729 and 0.732). CONCLUSION Early phase validation demonstrated classification of upper cervical spine injuries using the AO Spine Upper Cervical Injury Classification System to be accurate, reliable, and reproducible. Greater than 80% accuracy was detected for injury classification. The intraobserver reproducibility was excellent, while the interobserver reliability was substantial.

Objective: Deep vein thrombosis (DVT) of the lower extremities is the most common form of vascular involvement in Behcet disease (BD), frequently leading to post-thrombotic syndrome (PTS) as a disabling complication. We have described the clinical characteristics and predictors of PTS presence among patients with BD and lower extremity DVT. We also used venous Doppler ultrasound (US) examinations in our assessment. Methods: Patients with BD (n = 205; 166 men, 39 women; age 39 6 9.5 years) and a history of DVT were investigated. The Villalta scale was used to assess the presence and severity of PTS. Doppler US examinations were performed within 1 week of the clinical evaluation. The total number of vessels with reflux, thrombi, recanalization, and collateral vessels were calculated. Results: Of the 205 patients with BD, 62% had had PTS and 18% had had severe PTS. Patients with PTS had had greater reflux (P = .054) and thrombosis (P = .02) scores compared with patients without PTS. Treatment with anticoagulation (AC), immunosuppressive (IS) therapy, or AC combined with IS drugs did not affect the occurrence of PTS. However, patients treated with IS therapy, with or without AC drugs, had a decreased incidence of severe PTS compared with the AC-only group (P = .017). Patients treated with AC plus IS agents also had increased collateral scores compared with patients treated with only IS drugs. Interferon-a use seemed to provide better recanalization scores compared with azathioprine only (1.0 [range, 0-14] vs 2.5 [range, 0-10]; P = .010). Conclusions: Patients with BD and DVT have a high risk of developing severe PTS. IS treatment decreases the development of severe PTS. AC therapy might influence the course of PTS by increasing the collateral scores, and the use of interferon-a also increased recanalization scores. Routine assessment with Doppler US examinations could be helpful in the prediction of severe PTS. (J Vasc Surg Venous Lymphat Disord 2021;9:1451-9.)

The term "early-onset scoliosis" (EOS) refers to spinal deformities that develop before the age of 10 years. The aim of surgical treatment for EOS is stopping the progression of the curvature, maintaining the correction, ensuring the maximum growth of the vertebrae, and ensuring that the vertebrae remain mobile. Using magnetically controlled growing rods (MCGRs) in the treatment of EOS is intended to protect the patient from the negative effects of repetitive surgeries, increase patient compliance and satisfaction, and increase the speed of return to normal social life. Our aim was to report the early radiological evaluation findings and detect the changes in the quality of life of patients and their parents after the diagnosis of EOS and treatment with MCGRs.We performed a retrospective clinical study (level 4 case series) of 20 patients with a surgical indication for the treatment of EOS. The 20 patients had undergone treatment with MCGRs and lengthening procedures at 3-month intervals from August 2014 to August 2016. The mean patient age at surgery was 7.9 years (range, 4-10 years), and the mean length of follow-up was 14.9 months (range, 6-30 months). The preoperative, early postoperative, and final follow-up radiographs of all patients were obtained. The Cobb angle, thoracic kyphosis, spinal height, thoracic height, sagittal balance, coronal balance, shoulder balance, and pelvic balance were measured from the radiographs. All the patients had undergone preoperative and final follow-up respiratory function tests, and all the patients completed the Early Onset Scoliosis 24-item questionnaire (EOSQ-24). The outcome measures were the Cobb angle, thoracic kyphosis, spinal height, thoracic height, sagittal balance, coronal balance, shoulder balance, and pelvic balance. All the patients had undergone preoperative and final follow-up respiratory function tests, and the parents of every patient completed the Turkish version of the EOSQ-24.The preoperative, early postoperative and final follow-up mean Cobb angles were 56.6° (range, 38°-93°), 30.5° (range, 13°-80°), and 33.5° (range, 14°-86°), respectively. These findings showed statistically significant improvement in the Cobb angle (P0.05). The thoracic height was also significantly increased. The preoperative, early postoperative, and final follow-up mean height was 181 mm (range, 123-224 mm), 200 mm (range, 164-245 mm), and 212 mm (range, 167-248 mm), respectively (P0.05). The measurements for spinal height had also increased significantly, with preoperative, early postoperative, and final follow-up values of 219 mm (range, 213-366 mm), 315 mm (range, 260-402 mm), and 338 mm (range, 261-406 mm), respectively (P0.05). The thoracic kyphosis measurement was 41° (range, 5°-65°) preoperatively, which had decreased significantly to 32.5° (range, 0°-53°) at the final follow-up (P0.05). Our measurements showed no statistically significant differences in the coronal and sagittal balance, pelvic balance, or shoulder balance. No significant differences were found between the preoperative and postoperative respiratory function test results. The assessment of the EOSQ-24 scores had demonstrated significant improvements in the mean scores at the final follow-up (P0.05). When different categories in the EOSQ-24 were evaluated separately, no statistically significant differences were found between the preoperative and final follow-up scores for general health, pain and discomfort, respiratory function, movement capability, physical function, or effects on daily life (P0.05). However, the exhaustion and energy levels, emotional state, effect of the disease on the parents and patient, and parent satisfaction scores had increased significantly from the preoperative assessment to the final follow-up (P0.05). The financial effect had decreased significantly at the final follow-up compared with the preoperative values (P0.05). Four patients had developed complications requiring further treatment, and none of the patients had developed infection that required surgical intervention.Our study showed that insertion of a MCGR is a safe procedure for treatment of EOS to correct the deformity and improve function in daily life. This method reduces the need for repetitive surgery and the likelihood of complications associated with other treatments. Thus, treatment with MCGRs increases patient satisfaction and facilitates patient compliance.

Background and purpose — Advancements in software and hardware have enabled the rise of clinical prediction models based on machine learning (ML) in orthopedic surgery. Given their growing popularity and their likely implementation in clinical practice we evaluated which outcomes these new models have focused on and what methodologies are being employed. Material and methods — We performed a systematic search in PubMed, Embase, and Cochrane Library for studies published up to June 18, 2020. Studies reporting on non-ML prediction models or non-orthopedic outcomes were excluded. After screening 7,138 studies, 59 studies reporting on 77 prediction models were included. We extracted data regarding outcome, study design, and reported performance metrics. Results — Of the 77 identified ML prediction models the most commonly reported outcome domain was medical management (17/77). Spinal surgery was the most commonly involved orthopedic subspecialty (28/77). The most frequently employed algorithm was neural networks (42/77). Median size of datasets was 5,507 (IQR 635–26,364). The median area under the curve (AUC) was 0.80 (IQR 0.73–0.86). Calibration was reported for 26 of the models and 14 provided decision-curve analysis. Interpretation — ML prediction models have been developed for a wide variety of topics in orthopedics. Topics regarding medical management were the most commonly studied. Heterogeneity between studies is based on study size, algorithm, and time-point of outcome. Calibration and decision-curve analysis were generally poorly reported.

Purpose To validate the Dutch version of AOSpine PROST (Patient Reported Outcome Spine Trauma). Methods Patients were recruited from two level-1 trauma centers from the Netherlands. Next to the AOSpine PROST, patients also filled out SF-36 for concurrent validity. Descriptive statistics were used to analyze the characteristics. Content validity was assessed by evaluating the number of inapplicable or missing questions. Also floor and ceiling effects were analyzed. Internal consistency was assessed by calculating Cronbach’s α and item-total correlation coefficients (itcc). Spearman correlation tests were performed within AOSpine PROST items and in correlation with SF-36. Test–retest reliability was analyzed using Intraclass Correlation Coefficients (ICC). Responsiveness was assessed by calculating effect sizes (ES) and standardized response mean (SRM). Factor analysis was performed to explore any dimensions within AOSpine PROST. Results Out of 179 enrolled patients, 163 (91.1%) were included. Good results were obtained for content validity. No floor or ceiling effects were seen. Internal consistency was excellent (Cronbach’s α = 0.96, itcc 0.50–0.86), with also good Spearman correlations (0.25–0.79). Compared to SF-36, the strongest correlation was seen for physical functioning (0.79; p p 1), explaining 65.4% of variance. Conclusions Very satisfactory results were obtained for reliability, validity and responsiveness of the Dutch version of AOSpine PROST. Treating surgeons are encouraged to use this novel and validated tool in clinical setting and research to contribute to evidence-based and patient-centered care.

Noninvasive assessment of osseous fusion after spinal fusion surgery is essential for timely diagnosis of patients with symptomatic pseudarthrosis and for evaluation of the performance of spinal fusion procedures. There is, however, no consensus on the definition and assessment of successful posterolateral fusion (PLF) of the lumbar spine. This systematic review aimed to (1) summarize the criteria used for imaging-based fusion assessment after instrumented PLF and (2) evaluate their diagnostic accuracy and reliability.First, a search of the literature was conducted in November 2018 to identify reproducible criteria for imaging-based fusion assessment after primary instrumented PLF between T10 and S1 in adult patients, and to determine their frequency of use. A second search in July 2021 was directed at primary studies on the diagnostic accuracy (with surgical exploration as the reference) and/or reliability (interobserver and intraobserver agreement) of these criteria. Article selection and data extraction were performed by at least 2 reviewers independently. The methodological quality of validation studies was assessed with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) and QAREL (Quality Appraisal of Reliability Studies).Of the 187 articles included from the first search, 47% used a classification system and 63% used ≥1 descriptive criterion related to osseous bridging (104 articles), absence of motion (78 articles), and/or absence of static signs of nonunion (39 articles). A great variation in terminology, cutoff values, and assessed anatomical locations was observed. While the use of computed tomography (CT) increased over time, radiographs remained predominant. The second search yielded 11 articles with considerable variation in outcomes and quality concerns. Agreement between imaging-based assessment and surgical exploration with regard to demonstration of fusion ranged between 55% and 80%, while reliability ranged from poor to excellent.None of the available criteria for noninvasive assessment of fusion status after instrumented PLF were demonstrated to have both sufficient accuracy and reliability. Further elaboration and validation of a well-defined systematic CT-based assessment method that allows grading of the intertransverse and interfacet fusion mass at each side of each fusion level and includes signs of nonunion is recommended.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The upper cervical spine accounts for the largest proportion of cervical range of motion afforded by a complex system of bony morphology and ligamentous stability. Its unique anatomy, however, also makes it particularly vulnerable during both low and high energy trauma. Trauma to this area, referred to as upper cervical spine trauma, can disrupt the stability of the upper cervical spine and result in a wide spectrum of injury. Numerous upper cervical injury classification systems have been proposed, each of which have distinct limitations and drawbacks that have prevented their universal adoption. In this article, we provide an overview of previous classifications, with an emphasis on the development of the new AO Spine Upper Cervical Classification System (AO Spine UCCS).

Background Numbness of the nasal skin is one of the most common complications following rhinoplasty. Objectives The present study investigated postoperative changes in nasal skin sensation among primary and revision rhinoplasty patients and evaluated the recovery outcomes for both groups. Methods A prospective, randomized blinded study was undertaken involving 100 primary and 34 revision open rhinoplasty patients and 50 volunteers as control group. Semmes-Weinstein monofilament testing was performed on 7 designated nasal points preoperatively and at postoperative months 1, 3, 6, and 12, and the results were evaluated. Results Among the primary rhinoplasty patients, the change in reduced sensation on pressure to the tip and infratip over time was significant (P Conclusions This study found that the sense of touch on pressure returned to normal, aside from at the tip and infratip, by the end of month 12 in primary rhinoplasty patients. The revision rhinoplasty patients, in turn, were observed to have reduced sensation on pressure by the end of month 12, with the greatest reduction at the tip, infratip, and columellar base. Level of Evidence: 3

Introduction Placental insufficiency is one of the reasons for the reduction of hormone production. Thus, if one of the suspected causes of hypospadias is placental insufficiency, then the neurodevelopmental status of boys with hypospadias may be impaired. The aim of this study was to evaluate the neurodevelopmental status of boys with hypospadias and guide the parents of those who need support to related departments for early intervention. Materials and Methods Boys were divided into two groups, those with hypospadias (group H) and healthy children undergoing traditional circumcision (group C). The parents of the boys completed the Ages and Stages Questionnaire (ASQ) and ASQ–Social Emotional (SE), both of which are screening instruments for the early identification of developmental and social–emotional problems, respectively. Results Seventy-eight boys had hypospadias and 59 were admitted for traditional circumcision. The group H had statistically significant more impaired scores than group C in communication, gross motor, and personal–social skill sections. The multivariate logistic regression analysis revealed that hypospadias was the independent predictive factor for communication and personal–social skills. Conclusion Hypospadias and neurologic impairment may share common etiologic factors. Accordingly, physicians should keep in mind that if a boy presents with hypospadias, the possibility of having neurologic impairment is higher than normal population and early intervention has crucial importance. Every boy with hypospadias should be evaluated for neurodevelopmental status.

Purpose The management of cervical facet dislocation injuries remains controversial. The main purpose of this investigation was to identify whether a surgeon’s geographic location or years in practice influences their preferred management of traumatic cervical facet dislocation injuries. Methods A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. The survey included clinical case scenarios of cervical facet dislocation injuries and asked responders to select preferences among various diagnostic and management options. Results A total of 189 complete responses were received. Over 50% of responding surgeons in each region elected to initiate management of cervical facet dislocation injuries with an MRI, with 6 case exceptions. Overall, there was considerable agreement between American and European responders regarding management of these injuries, with only 3 cases exhibiting a significant difference. Additionally, results also exhibited considerable management agreement between those with ≤ 10 and > 10 years of practice experience, with only 2 case exceptions noted. Conclusion More than half of responders, regardless of geographical location or practice experience, identified MRI as a screening imaging modality when managing cervical facet dislocation injuries, regardless of the status of the spinal cord and prior to any additional intervention. Additionally, a majority of surgeons would elect an anterior approach for the surgical management of these injuries. The study found overall agreement in management preferences of cervical facet dislocation injuries around the globe.

Study Design: Retrospective cohort study Objectives: Minimizing delays in referral, diagnosis and treatment of patients with symptomatic spinal metastases is important for optimal treatment outcomes. The primary objective of this study was to investigate several forms of delay from the onset of symptoms until surgical treatment of spinal metastases for patients with and without a known preexisting known malignancy. Methods: All patients receiving surgical treatment for spinal metastases in a single tertiary spine center were identified. Referral patterns were reconstructed and the total delay was divided into 4 categories: patient delay (onset of symptoms until medical consultation), diagnostic delay (medical consultation until diagnosis), referral delay (diagnosis until referral to spine surgeon) and treatment delay (referral spine to surgeon until treatment). These intervals were compared between patients with and without a known preexisting malignancy. Results: The median total delay was 99 days, patient delay 19 days, diagnostic delay 21,5 days, referral delay 7 days, treatment delay 8 days and diagnosis and treatment delay combined 18,5 days. No difference in total delay was observed between patients with and without a known preexisting malignancy. Total delay was not significantly associated with patient age, sex, oncological history, tumor prognosis and spinal level of the tumor. Conclusions: Patients with symptomatic spinal metastases experience considerable delays, even after metastatic spinal disease has been diagnosed, regardless of a preexisting malignancy. By identifying and eliminating the causes of these delays, diagnosis, referral and treatment may be expedited leading to improved patient outcome.

Study Design: Retrospective cohort study. Objectives: Symptoms caused by spinal metastases are often difficult to distinguish from symptoms caused by non-malignant spinal disease, complicating timely diagnosis, referral and treatment. The ensuing delays may promote the risk of neurological deficits or severe mechanical instability and consequent emergency surgery, leading to poorer prognosis. Presumably, treatment delay may subsequently lead to more health-care consumption and therefore increased average costs of treatment. Methods: All patients surgically treated for spinal metastases were included in the current study. Based on the presence of alarming symptoms and urgency of the required intervention, patients were categorized as having received timely or delayed treatment. Pre-surgical, in-hospital, aftercare and total costs were analyzed and compared between the 2 groups. Results: In total, 299 patients were included, of which 205 underwent timely and 94 delayed treatment. There was no significant difference in pre-surigcal costs (€3.229,13 in the timely treated group vs. €2.528,70 in the delayed treatment group, p = 0.849). The in-hospital costs (€16.738,49 vs. €13.108,81, p < 0.001) and the aftercare costs (€13.950,37 vs. 3.981,93, p < 0.001) were significantly higher for delayed treatment vs. timely treatment, respectively. The total costs were €33.741,71 for delayed treatment and €20.318,52 for timely treatment (p < 0.001). Conclusions: The total costs for timely treated patients with spinal metastases are significantly lower compared with patients receiving delayed treatment. Investing in the optimization of referral patterns may therefore reduce the overall pretreatment delay and subsequently increase patient outcome, leading to better clinical outcomes at lower costs.

Study Design: Systematic review. Objective: Spinal orthoses have been generally used in the management of osteoporotic vertebral fractures in the elderly population with purported positive biomechanical and functional effects. To our knowledge, this is the first systematic review of the literature examining the role of spinal orthoses in osteoporotic elderly patients who sustain low energy trauma vertebral fractures. Methods: A systematic literature review adherent to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. Methodical searches utilizing MEDLINE, EMBASE, Google Scholar, and Cochrane Databases was performed. Results: Of the 2019 articles initially retrieved, 7 published articles (4 randomized controlled trials and 3 prospective cohort studies) satisfied the inclusion criteria. Five studies reported improvement in quantitative measurements of spinal column stability when either a rigid or semirigid orthosis was used, while 1 study was equivocal. The studies also showed the translation of biomechanical benefit into significant functional improvement as manifested by improved postural stability and reduced body sway. Subjective improvement in pain scores and quality of life was also noted with bracing. Conclusion: The use of spinal orthoses in neurologically intact elderly patients aged 60 years and older with osteoporotic compression vertebral fractures results in improved biomechanical vertebral stability, reduced kyphotic deformity, enhanced postural stability, greater muscular strength and superior functional outcomes.

Study Design: Systematic Review. Objective: To systematically analyze the definitions and descriptions in literature of “Spinal Posttraumatic Deformity” (SPTD) in order to support the development of a uniform and comprehensive definition of clinically relevant SPTD. Methods: A literature search in 11 international databases was performed using “deformity” AND “posttraumatic” and its synonyms. When an original definition or a description of SPTD (Patient factors, Radiological outcomes, Patient Reported Outcome Measurements and Surgical indication) was present the article was included. The retrieved articles were assessed for methodological quality and the presented data was extracted. Results: 46 articles met the inclusion criteria. “Symptomatic SPTD” was mentioned multiple times as an entity, however any description of “symptomatic SPTD” was not found. Pain was mentioned as a key factor in SPTD. Other patient related parameters were (progression of) neurological deficit, bone quality, age, comorbidities and functional disability. Various ways were used to determine the amount of deformity on radiographs. The amount of deformity ranged from not deviant for normal to >30°. Sagittal balance and spinopelvic parameters such as the Pelvic Incidence, Pelvic Tilt and Sacral Slope were taken into account and were used as surgical indicators and preoperative planning. The Visual Analog Scale for pain and the Oswestry Disability Index were used mostly to evaluate surgical intervention. Conclusion: A clear-cut definition or consensus is not available in the literature about clinically relevant SPTD. Our research acts as the basis for international efforts for the development of a definition of SPTD.

Purpose Despite the rapid increase in instrumented spinal fusions for a variety of indications, most studies focus on short-term fusion rates. Long-term clinical outcomes are still scarce and inconclusive. This study investigated clinical outcomes > 10 years after single-level instrumented posterolateral spinal fusion for lumbar degenerative or isthmic spondylolisthesis with neurological symptoms. Methods Cross-sectional long-term follow-up among the Dutch participants of an international multicenter randomized controlled trial comparing osteogenic protein-1 with autograft. Clinical outcomes were assessed using the Oswestry Disability Index (ODI), EQ-5D-3L and visual analogue scale (VAS) for leg and back pain, as well as questions on satisfaction with treatment and additional surgery. Results The follow-up rate was 73% (41 patients). At mean 11.8 (range 10.1–13.7) years after surgery, a non-significant deterioration of clinical outcomes compared to 1-year follow-up was observed. The mean ODI was 20 ± 19, mean EQ-5D-3L index score 0.784 ± 0.251 and mean VAS for leg and back pain, respectively, 34 ± 33 and 31 ± 28. Multiple regression showed that diagnosis (degenerative vs. isthmic spondylolisthesis), graft type (OP-1 vs. autograft) and 1-year fusion status (fusion vs. no fusion) were not predictive for the ODI at long-term follow-up (p = 0.389). Satisfaction with treatment was excellent and over 70% of the patients reported lasting improvement in back and/or leg pain. No revision surgeries for non-union were reported. Conclusion This study showed favourable clinical outcomes > 10 years after instrumented posterolateral spinal fusion and supports spondylolisthesis with neurological symptoms as indication for fusion surgery.

Purpose Combined sternal and spinal fractures are rare traumatic injuries with significant risk of spinal and thoracic wall instability. Controversy remains with regard to treatment strategies and the biomechanical need for sternal fixation to achieve spinal healing. The present study aimed to assess outcomes of sternovertebral fracture treatment. Methods A systematic review of literature on the treatment of traumatic sternovertebral fractures was conducted. Original studies published after 1990, reporting sternal and spinal healing or stability were included. Studies not reporting treatment outcomes were excluded. Results Six studies were included in this review, with a total study population of 98 patients: 2 case series, 3 case reports, and 1 retrospective cohort study. 10 per cent of sternal fractures showed displacement. Most spinal fractures were located in the thoracic spine and were AOSpine type A (51%), type B (35%), or type C (14%). 14 per cent of sternal fractures and 49% of spinal fractures were surgically treated. Sternal treatment failure occurred in 5% of patients and biomechanical spinal failure in 8%. There were no differences in treatment failure between conservative and operative treatment. Conclusion Literature on traumatic sternovertebral fracture treatment is sparse. Findings indicate that in most patients, sternal fixation is not required to achieve sternal and spinal stability. However, results of the current review should be cautiously interpreted, since most included studies were of poor quality.

Purpose A major challenge in metastatic spinal disease is timely identification of patients. Left untreated, spinal metastases may lead to gross mechanical instability and/or neurological deficits, often requiring extensive invasive surgical treatment. The aim of this cohort study was to assess the correlation between delayed treatment of patients with spinal metastases and functional performance, quality of life and survival. Methods All patients surgically treated for metastatic spinal disease at a tertiary care facility were included for analysis. Patients who underwent elective surgery were considered as timely treated, whereas patients requiring emergency surgery were considered to be treated in a delayed fashion. EQ-5D scores, KPS scores and mortality rates were compared between the two groups. Results A total of 317 patients (215 timely treated, 102 delayed) had survivorship data available and 202 patients (147 timely treated, 55 delayed) had clinical data available. Multivariate analyses showed delayed treatment was associated with lower EQ-5D and KPS scores and higher mortality rates, independent of confounders such as baseline EQ-5D/KPS scores, neurological status, tumor prognosis and patient age. Conclusions The results from the present study show delayed treatment of patients with symptomatic spinal metastases has both direct and indirect adverse consequences for functional performance status, quality of life and survival. Optimization of referral pattern may accelerate the time to surgical treatment, potentially leading to better quality of life and survival.

Aims The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting. Methods A total of 421 patients from the Cohort Hip and Cohort Knee (CHECK) database, a population-based observational cohort, with hip and knee complaints < 6 months, aged between 45 and 65 years old, and with lateral lumbar, hip, and knee radiographs available, were included. Sagittal spinopelvic parameters and pathologies (spondylolisthesis and degenerative disc disease (DDD)) were measured at eight-year follow-up and characteristics of hip and knee osteoarthritis (OA) at baseline and eight-year follow-up. Epidemiology of the degenerative disorders and clinical outcome scores (hip and knee pain and Western Ontario and McMaster Universities Osteoarthritis Index) were compared between low PI (< 50°), normal PI (50° to 60°), and high PI (> 60°) using generalized estimating equations. Results Demographic details were not different between the different PI groups. L4 to L5 and L5 to S1 spondylolisthesis were more frequently present in subjects with high PI compared to low PI (L4 to L5, OR 3.717; p = 0.024 vs L5 to S1 OR 7.751; p = 0.001). L5 to S1 DDD occurred more in patients with low PI compared to high PI (OR 1.889; p = 0.010), whereas there were no differences in L4 to L5 DDD among individuals with a different PI. The incidence of hip OA was higher in participants with low PI compared to normal (OR 1.262; p = 0.414) or high PI (OR 1.337; p = 0.274), but not statistically different. The incidence of knee OA was higher in individuals with a high PI compared to low PI (OR 1.620; p = 0.034). Conclusion High PI is a risk factor for development of spondylolisthesis and knee OA. Low pelvic incidence is related to DDD, and may be linked to OA of the hip. Level of Evidence: 1b Cite this article: Bone Joint J 2020;102-B(9):1261–1267.

Background/aim The male sling operation and artificial urinary sphincter implantation are common methods for treating urinary incontinence. However, there are some drawbacks to these methods such as infection, urethral erosion, pain, inefficiency, and the technical difficulty of the operations. Here we describe a new device we have named the Turkish Continence Device (TCD) which has advantages over these other methods. The aim of this study was perform experiments with the TCD prototype in vivo and ex vivo to determine efficiency, convenience of implantation, and negative effects. Materials and methods We implanted the prototype device in male goats and sheep, compressing the posterior urethra, and then fixed it by sutures on the lateral sides of the cavernosal bodies, bilaterally. Then we recorded urodynamic findings and performed urinary imaging. Additionally we measured urethral closure pressure ex vivo. Results The balloon volume for efficient urethral closure pressure using the new device was under 1 mL. It compressed the urethra towards the corpus cavernosum perfectly, because the wings of the prototype device are fixed near the tunica of the cavernosal bodies on each side. Conclusion A smaller device with smaller arms/wings would be efficient for obtaining enough pressure on the urethra. Additionally, the technique for implanting the device is very simple and would likely be learned quickly.

PURPOSE: The aim of this study was to assess the clinical and radiological outcomes of patients with recurrent or neglected pes equinovarus (PEV), who underwent talonavicular or calcaneocuboid arthrodesis with a hexapod spider frame. METHODS: The study included 18 patients; a total of 25 feet were treated with dual arthrodesis and a hexapod spider frame. The International Club Foot Study Group (ICFSG) scoring system and visual analog scale (VAS) were used to assess preoperative status and postoperative outcomes. All functional, morphological and radiologic evaluations during the follow-up were done as described by Kling et al. RESULTS: Patients were followed up for an average of 24.1 ± 11.8 months. The mean age of our cohort was 8.84 ± 2.83 years. The mean duration of correction was 3 weeks and the mean duration treatment length was 15.3 ± 1.9 weeks. Postoperative assessment revealed eight excellent, 13 good, and four poor outcomes, according to the ICFSG scoring system. There was a significant difference between preoperative and postoperative ICFSG scores, 12 feet showed an excellent outcome, 12 feet had good outcomes, and one foot was rated as a failure in the final assessment, based on the Kling criteria. There was also a significant difference between preoperative and postoperative VAS scores. CONCLUSION: Dual arthrodesis plus a hexapod spider frame is a valuable option for patients with recurrent or neglected PEV. It can be offered safely to avoid secondary recurrences and potential complications in cases of rigid feet as well as challenging cases that are resistant to soft tissue manipulation.

This study aimed to analyse the effect of preoperative radiotherapy on survival, recurrence and necrosis rates in osteosarcoma patients treated with neoadjuvant chemotherapy and limb-salvage surgery. Osteosarcoma patients who referred to our clinic from 1998 to 2015 were investigated retrospectively. 141 patients with non-metastatic osteosarcoma of the limb who received neoadjuvant chemotherapy and underwent limb-sparing surgery with or without preoperative radiotherapy were included in the study. 73 patients had neoadjuvant chemotherapy only (CT group), while 68 patients had additional preoperative radiotherapy (CT + RT group). 5-year survival, disease-free survival, limb survival, local recurrence, metastasis, complication and necrosis rates were compared between the two groups. Overall 5-year survival, 5-year disease-free survival, 5-year limb survival rates were 68.5, 64.3, 65.7 for CT group and 72.1, 67.6, 64.7 for CT + RT group, respectively. Preoperative radiotherapy gave similar survival and disease-free survival rates. Limb survival, recurrence and metastasis rates were similar between the groups. The necrosis rate of the lesions was significantly higher in the CT + RT group compared to the CT group. Preoperative radiotherapy can provide a higher necrosis rate and may allow the resection of unresectable lesions in the treatment of osteosarcoma. CT + RT provided similar 5-year survival despite the larger tumour size compared to CT group. Due to the higher wound complication rate (8.2% in CT, 23.5% in CT + RT group, p = 0.01), CT + RT should be restricted to the lesions with large size or close proximity to neurovascular structures. Level III; Therapeutic, Retrospective comparative study.

Supplemental Digital Content is available in the text, Study Design. Two-year clinical and radiographic follow-up of a double-blind, multicenter, randomized, intra-patient controlled, non-inferiority trial comparing a bone graft substitute (AttraX® Putty) with autograft in instrumented posterolateral fusion (PLF) surgery. Objectives. The aim of this study was to compare PLF rates between 1 and 2 years of follow-up and between graft types, and to explore the role of bone grafting based on the location of the PLF mass. Summary of Background Data. There are indications that bony fusion proceeds over time, but it is unknown to what extent this can be related to bone grafting. Methods. A total of 100 adult patients underwent a primary, single- or multilevel, thoracolumbar PLF. After instrumentation and preparation for grafting, the randomized allocation side of AttraX® Putty was disclosed. The contralateral posterolateral gutters were grafted with autograft. At 1-year follow-up, and in case of no fusion at 2 years, the fusion status of both sides of each segment was blindly assessed on CT scans. Intertransverse and facet fusion were scored separately. Difference in fusion rates after 1 and 2 years and between grafts were analyzed with a Generalized Estimating Equations (GEE) model (P

The surgical procedure of lipomas is performed under local, regional, or general anaesthesia depending on the location, number, and size of the lipoma. Anaesthesia can be achieved with a superficial cervical plexus block in the short-term surgery of soft tissue lesions in the dermatome areas of the lesser occipital nerve and great auricular nerve. In this article, we presented a high-risk patient with comorbid diseases and difficult airway who underwent superficial cervical plexus block for retro-auricular lipoma excision.

The Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification hierarchically separates fractures based on their injury severity with A-type fractures representing less severe injuries and C-type fractures representing the most severe fracture types. C0 fractures represent moderately severe injuries and have historically been referred to as nondisplaced "U-type" fractures. Injury management of these fractures can be controversial. Therefore, the purpose of this narrative review is to first discuss the Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification System and describe the different fracture types and classification modifiers, with particular emphasis on C0 fracture types. The narrative review will then focus on the epidemiology and etiology of C0 fractures with subsequent discussion focused on the clinical presentation for patients with these injuries. Next, we will describe the imaging findings associated with these injuries and discuss the injury management of these injuries with particular emphasis on operative management. Finally, we will outline the outcomes and complications that can be expected during the treatment of these injuries.

Study Design Global cross-sectional survey. Objective To explore the influence of geographic region on the AO Spine Sacral Classification System. Methods A total of 158 AO Spine and AO Trauma members from 6 AO world regions (Africa, Asia, Europe, Latin and South America, Middle East, and North America) participated in a live webinar to assess the reliability, reproducibility, and accuracy of classifying sacral fractures using the AO Spine Sacral Classification System. This evaluation was performed with 26 cases presented in randomized order on 2 occasions 3 weeks apart. Results A total of 8320 case assessments were performed. All regions demonstrated excellent intraobserver reproducibility for fracture morphology. Respondents from Europe (k = .80) and North America (k = .86) achieved excellent reproducibility for fracture subtype while respondents from all other regions displayed substantial reproducibility. All regions demonstrated at minimum substantial interobserver reliability for fracture morphology and subtype. Each region demonstrated >90% accuracy in classifying fracture morphology and >80% accuracy in fracture subtype compared to the gold standard. Type C morphology (p2 = .0000) and A3 (p1 = .0280), B2 (p1 = .0015), C0 (p1 = .0085), and C2 (p1 =.0016, p2 =.0000) subtypes showed significant regional disparity in classification accuracy (p1 = Assessment 1, p2 = Assessment 2). Respondents from Asia (except in A3) and the combined group of North, Latin, and South America had accuracy percentages below the combined mean, whereas respondents from Europe consistently scored above the mean. Conclusions In a global validation study of the AO Spine Sacral Classification System, substantial reliability of both fracture morphology and subtype classification was found across all geographic regions.

Study Design: Randomized controlled trial. Objectives: Lumbar interbody fusion with cages is performed to provide vertebral stability, restore alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used. Silicon nitride (Si3N4) is an alternative material with good osteointegrative properties. This study was designed to assess if Si3N4 cages perform similar to PEEK. Methods: A non-inferiority double-blind multicenter RCT was designed. Patients presenting with chronic low-back pain with or without leg pain were included. Single- or double-level instrumented transforaminal lumbar interbody fusion (TLIF) using an oblique PEEK or Si3N4 cage was performed. The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ). The non-inferiority margin for the RMDQ was 2.6 points on a scale of 24. Secondary outcomes included the Oswestry Disability Questionnaire (ODI), Visual Analogue Scales (VAS), SF-36 Physical Function, patient and surgeon Likert scores, radiographic evaluations for subsidence, segmental motion, and fusion. Follow-up was planned at 3, 6, 12, and 24-months. Results: Ninety-two patients were randomized ( i.e. 48 to PEEK and 44 to Si3N4). Both groups showed good clinical improvements on the RMDQ scores of up to 5-8 points during follow-up. No statistically significant differences were observed in clinical and radiographic outcomes. Mean operative time and blood loss were statistically significantly higher for the Si3N4 cohort. Although not statistically significant, there was a higher incidence of complications and revisions associated with the Si3N4 cage. Conclusions: There was insufficient evidence to conclude that Si3N4 was non-inferior to PEEK.

Background: Primary hyperparathyroidism (pHPT) caused by a single benign parathyroid adenoma is a common endocrine disorder that is affected by regional differences. Living in different geographical regions reveals differences in the laboratory results and pathological findings, but studies on this subject are not sufficient. The article focuses on biochemical and pathological effects of geographical differences in parathyroid adenoma. In addition, the present study seeks to elaborate on treatment methods and effectiveness of screening in geographical area of Bulgaria and Turkey. Method: In this prospective study, 159 patients were included from 16 centres. Demographic characteristics, symptoms, biochemical markers and pathologic characteristics were analysed and compared between 8 different regions. Results: Patients from Turkish Black Sea had the highest median serum calcium (Ca) level, whereas patients from Eastern Turkey had the lowest median serum phosphorus (P) level. On the other hand, there was no significant difference between Ca, parathormone (PTH) and P levels according to regions. Patients from Eastern Turkey had the highest adenoma weight, while patients from Bulgaria had the lowest adenoma weight. The weight of adenoma showed statistically significant differences between regions (p < 0.001). There was a correlation between adenoma weight and serum PTH level (p = 0.05) and Ca level (p = 0.035). Conclusion: This study has provided a deeper insight into the effect of the regional differences upon clinicopathological changing and biochemical values of pHTP patients with adenoma. Awareness of regional differences will assist in biochemical screening and treatment of this patient group. (c) 2021 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Purpose To validate the AO Spine Subaxial Injury Classification System with participants of various experience levels, subspecialties, and geographic regions. Methods A live webinar was organized in 2020 for validation of the AO Spine Subaxial Injury Classification System. The validation consisted of 41 unique subaxial cervical spine injuries with associated computed tomography scans and key images. Intraobserver reproducibility and interobserver reliability of the AO Spine Subaxial Injury Classification System were calculated for injury morphology, injury subtype, and facet injury. The reliability and reproducibility of the classification system were categorized as slight (ƙ = 0–0.20), fair (ƙ = 0.21–0.40), moderate (ƙ = 0.41–0.60), substantial (ƙ = 0.61–0.80), or excellent (ƙ = > 0.80) as determined by the Landis and Koch classification. Results A total of 203 AO Spine members participated in the AO Spine Subaxial Injury Classification System validation. The percent of participants accurately classifying each injury was over 90% for fracture morphology and fracture subtype on both assessments. The interobserver reliability for fracture morphology was excellent (ƙ = 0.87), while fracture subtype (ƙ = 0.80) and facet injury were substantial (ƙ = 0.74). The intraobserver reproducibility for fracture morphology and subtype were excellent (ƙ = 0.85, 0.88, respectively), while reproducibility for facet injuries was substantial (ƙ = 0.76). Conclusion The AO Spine Subaxial Injury Classification System demonstrated excellent interobserver reliability and intraobserver reproducibility for fracture morphology, substantial reliability and reproducibility for facet injuries, and excellent reproducibility with substantial reliability for injury subtype.

Study Design Global cross-sectional survey Objective To develop and refine the techniques for web-based international validation of fracture classification systems. Methods A live webinar was organized in 2018 for validation of the AO Spine Subaxial Injury Classification System, consisting of 35 unique computed tomography (CT) scans and key images with subaxial spine injuries. Interobserver reliability and intraobserver reproducibility was calculated for injury morphology, subtype, and facet injury according to the classification system. Based on the experiences from this webinar and incorporating rater feedback, adjustments were made in the organization and techniques used and in 2020 a repeat validation webinar was performed, evaluating images of 41 unique subaxial spine injuries. Results In the 2018 session, the AO Spine Subaxial Injury Classification System demonstrated fair interobserver reliability for fracture subtype (κ = 0.35) and moderate reliability for fracture morphology and facet injury (κ=0.45, 0.43, respectively). However, in 2020, the interobserver reliability for fracture morphology (κ = 0.87) and fracture subtype (κ = 0.80) was excellent, while facet injury was substantial (κ = 0.74). Intraobserver reproducibility for injury morphology (κ =0.49) and injury subtype/facet injury were moderate (κ = 0.42) in 2018. In 2020, fracture morphology and subtype reproducibility were excellent (κ =0.85, 0.88, respectively) while reproducibility for facet injuries was substantial (κ = 0.76). Conclusion With optimized webinar-based validation techniques, the AO Spine Subaxial Injury Classification System demonstrated vast improvements in intraobserver reproducibility and interobserver reliability. Stringent fracture classification methodology is integral in obtaining accurate classification results.

Study Design A single-center validation study. Objective To translate and cross-culturally adapt the AO Spine PROST (Patient Reported Outcome Spine Trauma) into German, and to test its psychometric properties among German-speaking Swiss spine trauma patients. Methods Patients were recruited from a level-1 Swiss trauma center. Next to the AO Spine PROST, the EQ-5D-3L questionnaire was used for concurrent validity. Questionnaires were filled out at two-time points for test-retest reliability. Patient characteristics were analyzed using descriptive statistics. For content validity, floor, and ceiling effects, as well as any irrelevant and missing questions were analyzed. Construct validity of the AO Spine PROST questionnaire to the EQ-5D-3L was tested using Spearman correlation tests. Results The AOSpine PROST was translated and adapted into German using established guidelines. We included 179 patients. The floor effect for all items was well within the optimal range (below 15%), while the ceiling effect of seven items was within the optimal range. None of the items displayed a problematic floor or ceiling effect. The overall test-retest reliability of the total PROST score was excellent, with an ICC of .83 (95% CI .69-.91). The Spearman correlation coefficient between the total PROST summary score and EQ-5D-3 L was ρ = .63. Conclusions The German version of the AO Spine PROST questionnaire demonstrated very good validity and reliability results.