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To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK).The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24 months.Patients in Group CK (median: 13 years, range: 4-30 years) presented earlier than those in Group PTK (median: 16 years, range: 6-45 years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5 min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2 ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24 months (p 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group.Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies.

Aims The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB. Methods A total of 284 patients with clinically and radiologically suspected infectious spondylodiscitis were prospectively recruited into the study. Image-guided biopsy of the vertebral lesion was performed and specimens were sent for various microbiological tests and histological examinations. The final diagnosis was determined using a composite reference standard based on clinical, radiological, serological, microbiological, and histological findings. The overall diagnostic yield of the biopsy, and that for each test, was calculated in light of the final diagnosis. Results The final diagnosis was tuberculous spondylodiscitis in 250 patients (88%) and pyogenic spondylodiscitis in 22 (7.8%). Six (2.1%) had a noninfectious condition-mimicking infectious spondylodiscitis, and six (2.1%) had no definite diagnosis and improved without specific treatment. The diagnosis was made by image-guided biopsy in 152 patients (56%) with infectious spondylodiscitis. Biopsy was contributory in identifying 132/250 patients (53%) with tuberculous spondylodiscitis, and 20/22 patients (91%) with pyogenic spondylodiscitis. Histological examination was the most sensitive diagnostic modality, followed by Xpert MTB/RIF assay. Conclusion Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. A combination of histological examination, Xpert MTB/RIF assay, bacterial culture, and sensitivity provides high diagnostic accuracy in a country in which TB is endemic. Cite this article: Bone Joint J 2022;104-B(1):120–126.

BACKGROUND: The expression pattern of micro-RNAs (miRNA) has been implicated in the pathomechanism of various bone disorders, and has a role in differentiation of osteoblasts and osteoclasts. The purpose of the study was to investigate the differential miRNA profiles of osteoporotic hip fractures compared to young patients with hip fractures. METHODS: Blood samples from ten osteoporosis patients and ten young, healthy patients, presenting with acute hip fractures were collected and subjected to an initial miRNA profiling to detect those miRNAs with significant variations between the two groups based on polymerase chain reactions performed in duplicate. A real-time quantitative polymerase chain reaction-based analysis was then performed for validation of specific miRNAs that were significantly different between the two groups. RESULTS: A total of 182 miRNAs were analyzed. Thirty-nine of them showed significant differences between the two groups in the initial miRNA profiling. The validation results suggested that five miRNAs related to bone metabolism had significantly different expression among the osteoporotic hip fracture group compared to the young, healthy group: miR-23b-3p and miR-140-3p were up-regulated; miR-21-5p, miR-122-5p and miR-125b-5p were down-regulated. CONCLUSIONS: Differential expression of selected miRNAs in patients with osteoporotic hip fracture suggests a possible role of miRNAs as potential biomarkers in prevention or timely prediction of osteoporotic fractures in the elderly. Further research is required to elucidate the mechanism of their involvement in osteoporosis. LEVEL OF EVIDENCE: Not applicable.

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy. The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded. The median age of the study population was 16 years (6–45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value

Background: Abnormal anatomy is a contributory factor to wrong-level surgery. Variations in the number of vertebrae in populations from different races and geographical regions have been described. A ∼10% prevalence of variations in number of thoracic and lumbar vertebrae in adolescent idiopathic scoliosis (AIS) patients has been previously reported. The objectives of present study were (i) to find out the prevalence of variations in the number of thoracic and lumbar vertebrae and the presence of lumbosacral transitional vertebrae (LSTV) in Indian AIS patients and (ii) to correlate these variations with gender and type of curve. Methods: Hospital records and imaging of 198 AIS patients were reviewed retrospectively. A standardized numbering strategy was used to identify the number of thoracic vertebrae, number of lumbar vertebrae, and presence of LSTV. Patients9 gender and curve type were correlated with the presence of an abnormal number of thoracic or lumbar vertebrae. Radiology reports and operation notes were reviewed to find out instances when the radiologist or surgeon had identified an abnormal number of vertebrae. Results: Forty patients (20.2%) with abnormally numbered thoracic or lumbar vertebrae were identified. Twenty patients (10.1%) had abnormally numbered thoracic vertebrae, and 33 patients (16.7%) had abnormally numbered lumbar vertebrae. The prevalence of LSTV was 18.2%. Presence of variations did not correlate with gender or curve type. Radiology reports identified 2/40 patients with variations, whereas operation notes showed 4/40 patients had been correctly identified to have abnormally numbered vertebrae. Conclusions: There is high prevalence of variation in the number of thoracic or lumbar vertebrae in AIS patients, with most of those missed being identified by radiologists or surgeons. The patient9s preoperative imaging must be scrutinized to identify these patients and take the variation into account to avoid wrong selection of fusion levels. Level of Evidence: 3. Clinical Relevance: Text. The study raises awareness about possibility of wrong selection in fusion levels due to anatomical variations in surgery for AIS.

BACKGROUND: Accurate prediction of operative duration is necessary for efficient operating room scheduling, minimizing cancellations, shortening waitlists, better risk stratification, and effective preoperative counseling. Prolonged operative duration is also associated with negative patient outcomes. Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is typically a lengthy surgical procedure with variable operative duration. The purpose of this study is to identify patient-, procedure-, and surgeon-specific variables that influence the operative duration in PSF for AIS and determine its impact on early postoperative outcomes. METHODS: Hospital records of 150 AIS patients who underwent PSF at a single center were retrospectively reviewed. Various patient-, procedure-, and surgeon-specific variables—deemed to be possibly affecting the operative duration—were analyzed. A multivariate regression model was used to identify independent predictors of operative duration. The association between operative duration and early postoperative outcome measures was determined. RESULTS: The final model obtained from the multivariate regression analysis included the following factors: experience of the chief surgeon (β = −0.36), Cobb angle of the major structural curve (β = 0.35), number of screws inserted (β = 0.28), coronal deformity angular ratio (β = 0.20), and apical vertebral rotation (β = −0.21 to 0.03). The model could explain 44% of the variability in the operative duration (R (2) = 0.44). The operative duration had a significant correlation with estimated blood loss, need for perioperative blood transfusion, and length of hospital stay. CONCLUSIONS: A set of variables that predict the variability in operative duration during PSF for AIS was identified, with the experience of the chief surgeon and the severity of the curve being the strongest predictors. CLINICAL RELEVANCE: The results of this study emphasize the need for each hospital and surgical team to identify predictors of operative duration in their setup in order to better anticipate prolonged operative duration. LEVEL OF EVIDENCE: 3.

An insight into musculoskeletal disorders through advancements in next-generation sequencing (NGS) promises to maximize benefits and improve outcomes through improved genetic diagnosis.The primary use of whole exome sequencing (WES) for musculoskeletal disorders is to identify functionally relevant variants.The current evidence has shown the superiority of NGS over conventional genotyping for identifying novel and rare genetic variants in patients with musculoskeletal disorders, due to its high throughput and low cost.Genes identified in patients with scoliosis, osteoporosis, osteoarthritis, and osteogenesis imperfecta using NGS technologies are listed for further reference.

Retrospective analysis of a prospectively collected multi-center database. UPROR (Unplanned Return to the Operating Room) is an inclusive metric for unexpected surgery after the index procedure. Given the many quality and safety improvements in AIS surgery over the past 20 years, it is useful for spine deformity surgeons to understand the current rate of UPROR, the etiologies, and trends over time. A report from a very large data set, including multiple surgeons and centers, with longer follow-up, would provide the clearest picture. We performed a retrospective review of a prospective multi-center database of patients who had AIS deformity correction surgery to analyze all cases of UPROR, using linear regression models, survival analysis, and descriptive statistics. Among 3464 patients who had surgery (ASF, PSF, or ASF + PSF) for AIS from 1995 to 2017, 4.8% had an UPROR event in one of the following categories: surgical-site-related (43.3%), instrument failures (34.3%), revisions (8.4%), neurologic (5.1%), pulmonary (5.1%), medical (0.6%), and other (3.4%). The average time from initial surgery to UPROR was 734.4 days. 45.5% of UPRORs occurred within 1 year, 12.4% between 1 and 2 years, 30.9% between 2 and 5 years, and 11.2% between 5 and 10 years. In patients with at least 2-year, 5-year, and 10-year follow-up, the UPROR rates were 6.6, 7.3, and 9.2%, respectively. Between 1997 and 2013, the UPROR rate decreased by 0.46% per year (95% CI 0.25–0.68, p

AIS patients consider shoulder balance an important cosmetic outcome after surgery. We examined the impact of preoperative left shoulder elevation (LSE) and choice of upper instrumented vertebra (UIV) on postoperative shoulder imbalance (PostSI). This was a retrospective cohort study utilizing a prospective AIS database. Patients had Lenke type 1–4 curves and preoperative shoulder height ≥ 1.0 cm. Patients with preoperative LSE and right shoulder elevation (RSE) were compared. Shoulder height difference 34.5° was predictive of PostSI ≥ 2.0 cm for patients with preoperative LSE. AIS patients with preoperative LSE are less likely to achieve level shoulders postoperatively. Choice of higher UIV did not affect postoperative shoulder imbalance in this cohort. A PTC > 34.5° was predictive of severe PostSI in patients with preoperative LSE. II.

Background: The incidence of anterior cruciate ligament (ACL) injuries among adolescent athletes is steadily increasing. Identification of the highest risk sports for ACL injuries by sex and competitive setting (ie, practice vs match) is important for targeting injury prevention programs. Purpose: To identify the risk of ACL injuries in adolescent athletes by sport, sex, and setting across a variety of common US and international sports. Study Design: Meta-analysis. Methods: Essentially, 3 online databases (PubMed, Embase, and Cochrane Library) were searched for all studies of ACL injuries per athlete-exposure (AE) or hours of exposure in adolescent athletes. Injuries were then pooled and incidence rates (IRs) reported per 1000 AEs or hours of exposure, with the relative risk (RR) of injuries calculated for sex-comparable sports. IRs per competitive setting (match vs practice) were also calculated. Results: A total of 1235 ACL injuries over 17,824,251 AEs were identified (IR, 0.069 [95% CI, 0.065-0.074]), with 586 of these injuries in girls across 6,986,683 AEs (IR, 0.084 [95% CI, 0.077-0.091]) versus 649 injuries in boys over 10,837,568 AEs (IR, 0.060 [95% CI, 0.055-0.065]). Girls had a higher overall rate of ACL injuries (RR, 1.40 [95% CI, 1.25-1.57]), with the most disproportionate risk observed in basketball (RR, 4.14 [95% CI, 2.98-5.76]). The risk of ACL injuries by sex was highest in girls’ soccer (IR, 0.166 [95% CI, 0.146-0.189]) and boys’ football (IR, 0.101 [95% CI, 0.092-0.111]). ACL injuries were over 8 (RR, 8.54 [95% CI, 6.46-11.30]) and 6 (RR, 6.85 [95% CI, 5.52-8.49]) times more likely to occur in a match versus a practice setting for female and male athletes, respectively. Conclusion: The risk of ACL injuries overall approached nearly 1 per 10,000 AEs for female athletes, who were almost 1.5 times as likely as male athletes to suffer an ACL injury across all adolescent sports. A multisport female athlete was estimated to have a nearly 10% risk of ACL injuries over her entire high school or secondary school career. Specifically, male and female adolescents playing soccer, basketball, lacrosse, and football appeared at particular risk of injuries, a finding that can be used to target an injury intervention.

Posterior vertebral column resection (PVCR) has several advantages over a combined anterior-posterior procedure for management of severe, rigid spinal deformities. The technique, described by Suk et al., has a high complication rate. Modifications of the technique which can reduce this complication rate might make this challenging procedure safer.To report the results of PVCR in severe, rigid spinal deformity; to describe a modified technique for PVCR and compare its results with the conventional technique.Retrospective cohort.A total of 38 patients who underwent PVCR for severe, rigid spinal deformities.Mean correction of deformity (sagittal and/or coronal), estimated blood loss, operation time, neurological and non-neurological complications, patient-reported outcome score (SRS-22r).Thirty-eight patients underwent PVCR for severe, rigid spinal deformities. These patients had a deformity in excess of 90° and a flexibility index20%. Twenty-one of 38 patients (Group 1) underwent PVCR by the technique reported by Suk et al.; 17 patients (Group 2) underwent a modified PVCR technique. Our technique involves retaining the posterior elements until the other steps of PVCR are completed, which prevents ventral settling and allows for less handling of an already tight spinal cord. The results and complications were compared between the two groups.The mean operating time was 251 minutes and the mean blood loss was 1,251 mL. Mean coronal correction of 50% and a mean sagittal correction of 52.4% were achieved. Intraoperative loss of motor evoked potentials was seen in eight patients while there were two instances of permanent postoperative deficit, both occurring with the conventional PVCR technique. The average operating time, mean correction and blood loss did not differ between the two techniques. There was, however, a reduction in the occurrence of neurological complications with the authors' modified technique.Our retrospective study with a small cohort suggests that the authors' modified technique of PVCR, wherein the posterior elements are preserved until just prior to attempting to correct the deformity, may be safer in terms of neurological complications when compared with the conventional technique. However, larger studies are warranted to conclusively establish this.

EOS® imaging is a proprietary imaging technology that was launched in 2007. Based on a gaseous particle detector with a multi-wire proportional chamber, it offers several advantages over other imaging modalities: low dose of radiation, ability to create 3D reconstructions, ability to conduct whole body imaging, high reproducibility in measuring various parameters of alignment and faster imaging time. EOS® imaging is slowly gaining widespread acceptance as its applications in various disorders continue to evolve. It has been found to be particularly useful and has opened up new avenues of research in the field of spinal deformities. This narrative review seeks to provide an overview of the proprietary technology behind EOS® imaging, compare it to existing imaging modalities, summarize its current applications in various spinal disorders and outline its limitations.

To investigate whether intraoperative neuromonitoring (IONM) may be avoided in growing rod lengthening procedures in early onset scoliosis (EOS). A total of 636 primary growing rod surgeries and lengthening procedures were performed in 112 patients with EOS. Traditional growing rods (TGR) or magnetically controlled growing rods (MCGR) were implanted and subsequent lengthening procedures were done at stipulated intervals. Combined multi-modality IONM was used in all index surgeries—but was only used in lengthening procedures in patients with existing spinal cord abnormality or a history of neurosurgical procedure for the same, patients with prior history of a neuromonitoring alert in their index surgery and when lengthening was accompanied by an implant exchange/revision. All the remaining growing rod lengthening procedures were carried out without IONM. Hospital records and operation notes were retrospectively reviewed with focus on details of neurological events/complications. In 112 primary growing rod applications (TGR = 96, MCGR = 16) and 524 lengthening procedures (TGR = 444, MCGR = 80), intraoperative neuromonitoring ‘alerts’ were encountered in 6/112 index surgeries and temporary postoperative neurological deficits were seen in 2/112 index surgeries. No intraoperative neuromonitoring event or postoperative neurological complication was encountered in 524 lengthening procedures—irrespective of whether they were carried out along with implant exchange, or in patients with spinal cord abnormality or prior neuromonitoring event during index surgery. While IONM should be used in primary growing rod application surgeries, its use may be avoided in lengthening and implant exchange procedures in a resource-limited setting. Level 3.

BACKGROUND: During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of school and organized sports. A resulting change in pediatric fracture epidemiology is expected. This study examines the impact of the COVID-19 pandemic on fracture incidence and characteristics. METHODS: This is a retrospective cohort study comparing acute fractures presenting to a single level I pediatric trauma hospital during the COVID-19 pandemic with fractures during a prepandemic period at the same institution. The "pandemic" cohort was gathered from March 15 to April 15, 2020 and compared with a "prepandemic" cohort from the same time window in 2018 and 2019. RESULTS: In total, 1745 patients presenting with acute fractures were included. There was a significant decrease in the incidence of fractures presenting to our practice during the pandemic (22.5±9.1/d vs. 9.6±5.1/d, P

Study Design: Prospective, comparative.Purpose: To compare the histopathological and electron microscopic changes in the ligamentum flavum (LF) between degenerative lumbar canal stenosis (LCS) and lumbar disk herniation (LDH).Overview of Literature: The LF has been implicated as a key structure in the pathogenesis of LCS. With aging, the LF undergoes morphological changes–a decrease in the elastic component and an increase in the collagen component, in addition to other focal changes. By comparing the histopathological and electron microscopic picture of the LF in elderly patients with LCS with that in young patients with LDH, the role of this ligament in the pathogenesis of LCS may be clarified.Methods: Forty patients were prospectively recruited and divided into two groups: group 1 included 20 patients with degenerative LCS aged >55 years and group 2 included patients with LDH aged

Case series. To describe a novel surgical strategy for severe, rigid post-tubercular cervical kyphosis with treatment outcomes in two patients. Spinal tuberculosis is a common cause of kyphotic deformity in the developing world with 3–5% of non-operatively managed patients ending up with kyphosis exceeding 60°. Ventral, dorsal and combined approaches have been described for cervical kyphosis, but there is no established surgical strategy for severe, rigid post-tubercular cervical kyphosis. We operated on two girls with severe, rigid cervical kyphosis with preoperative kyphosis measuring 98° and 62°. Our surgical strategy included a three-step approach in the same sitting—(1) An anterior approach to osteotomize the fused vertebral body mass, decompress the spinal cord ventrally and place a temporary cage to stabilize the spine, (2) A posterior approach to osteotomize the fused facets and decompress the cord dorsally. With the completion of the osteotomy, a combination of pedicle screws and lateral mass screws was used to correct the deformity via an anterior opening, posterior closing type of osteotomy. This was followed by, (3) An anterior approach to replace the corpectomy cage with a larger one supplemented with an anterior cervical plate. Our 540° approach achieved a substantial improvement in each of the clinical and radiological parameters we measured, viz. C2–C7 lordosis angle, C2–C7 sagittal vertical axis, neck tilt and Neck Disability Index. For severe, rigid post-tubercular cervical spine kyphosis, a three-step, anterior–posterior–anterior procedure can be used for achieving acceptable correction, improving symptoms and avoiding further progression. IV.

Study Design: Retrospective cohort. Objective: ( a) To compare the recommendations of Lenke and Peking Union Medical College (PUMC) classifications in choosing distal fusion levels in Lenke 1 adolescent idiopathic scoliosis (AIS) curves and ( b) to analyze whether the variability in distal fusion levels influences treatment outcomes. Methods: Hospital records of Lenke 1 AIS patients operated for single stage, posterior-only deformity correction were analyzed. Distal fusion levels recommended by Lenke and PUMC classifications were calculated and were compared with the actual distal fusion levels. The study population was divided based on whether the actual distal fusion levels were in agreement, shorter or longer than those recommended by Lenke classification. Subgroup analysis of Lenke 1C curves was done. The groups were compared with regard to the following outcome measures: Cobb angle correction, postoperative sagittal vertical axis, postoperative C7 offset, and Scoliosis Research Society–22r (SRS-22r) score at 24 months. Results: The distal fusion levels recommended by the 2 classifications were in agreement in 92 of 104 cases. In all the cases with disparity, Lenke classification recommended shorter fusions than the PUMC classification. No statistically significant difference was observed in the outcome measures—whether the actual distal fusion levels were in agreement, shorter, or longer than those recommended by the Lenke classification or whether or not the recommendations for selective fusion of any of these classifications were adhered to. Conclusion: Lenke classification can save fusion levels without compromising on treatment outcomes when compared with PUMC classification. Variability in choice of distal fusion levels is not clinically significant at 24-month follow-up.

Pedicle screw instrumentation is currently the “gold standard” in scoliosis surgery. However, placement of pedicle screws in thoracic spine is considered challenging. Previous studies have described morphometric changes in the pedicle when a larger screw is inserted, with pedicle expansion preceding screw cutout and pedicle fracture. We report an unusual case of neurological deficit due to cord compression by an expanded pedicle following pedicle screw insertion on the concave side of the apical vertebra in a 14-year-old patient with Lenke Type 3C(-) adolescent idiopathic scoliosis. Identification of the expanded pedicle as the cause of neurological symptoms, prompt action, and deferring the corrective surgery while accepting less correction helped us in negotiating the problem without causing permanent neurological deficit. Pedicle expansion in an immature spine can cause neurological complications. The screw diameter at the apical vertebrae on the concave side should be carefully selected.

Minimal access surgery has revolutionized most surgical disciplines and spine surgery is no exception. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) was devised to reduce the approach-related morbidity of open TLIF and has flourished in the last decade. With expanding indications, standardization of technique and equipment, publication of more studies on its results and complications being brought to light – an update of the existing knowledge on MI-TLIF is imminent. We provide a review of the indications, technique, results and complications of MI-TLIF while also highlighting its variations and utility in special situations.

The purpose of this study was to investigate whether an elbow arthrogram after closed reduction and percutaneous fixation of lateral condyle fractures results in a change in surgical management. This is a retrospective review of lateral condyle fractures managed with closed reduction and percutaneous fixation followed by an elbow arthrogram at our institution between 2008 and 2019. Chart and radiographic review was performed and operative notes were reviewed to determine rates of subsequent intervention after arthrogram. Descriptive statistics were used to summarize the data. This study included 47 patients. The majority of patients were male (34 patients, 72%), and the mean age at time of injury was 5.5 ± 2.6 years. The mean radiographic displacement was 2.6 mm (range 0.8-6.9 mm). All fractures were managed by fellowship-trained pediatric orthopaedic surgeons with an average of 10.5 years of experience (range 0-32 years). Fractures were stabilized with percutaneous pins in 44 patients (94%) and percutaneous screws in three patients (6%). No patients had subsequent changes in management after an elbow arthrogram. There were no complications related to performance of the arthrogram. Closed reduction and percutaneous fixation is often indicated for mildly displaced lateral condyle fractures. Articular reduction after percutaneous fixation is commonly assessed using an elbow arthrogram; however, it did not change surgical management in any case reviewed over the 10-year study period. While there seems to be little risk of performing an arthrogram, the clinical utility should be further evaluated.

Aims To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach. Methods Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded. Results The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient. Conclusion Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J 2021;103-B(7):1309–1316.

» Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints. » ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia. » The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

Study Design: Retrospective cohort.Purpose: To report the demographic characteristics, clinico-radiological presentation, laboratory findings, and outcomes of “middlepath” treatment in patients with spinal tuberculosis from a single public healthcare facility in a developing country.Overview of Literature: Tuberculosis is a global health problem that is endemic in developing countries and undergoing resurgence in developed ones. Spinal tuberculosis can cause disabling back pain, progressive deformity, and neurological involvement. However, there is a lack of large-scale epidemiological studies quantifying the size and severity of the problem of spinal tuberculosis.Methods: Hospital records of spinal tuberculosis patients treated at a single center over a period of 5 years were retrospectively reviewed. A diagnosis of spinal tuberculosis was based on standard clinical, radiological, microbiological, and histopathological evidence. Patients were treated in accordance with the “middle-path” regimen; surgery was reserved for selective indications.Results: A total of 1,652 patients were included. Their median age was 32.4 years, with 53% being male. Axial pain (98%) was the most common presenting symptom; 19% of patients had neurological deficit. Lumbar spine (37%) was the most common site of involvement, with a paradiscal pattern (82%) of involvement predominating. Multi-level involvement was seen in 19% of patients; skip lesions were noted in 2.8%. Transpedicular biopsy was performed in 667 patients; at least one tissue test was diagnostic of tuberculosis in 65% of patients. Forty-four patients had drug resistance to rifampicin. Surgery was required in 10.5% of patients. The “middle-path” regimen was associated with high compliance and significant improvements in pain (Visual Analog Scale score) and function (36-Item Short Form Health Survey).Conclusions: Our findings confirm the widespread prevalence of spinal tuberculosis and describe various epidemiological characteristics of a large sample of spinal tuberculosis patients. Adoption of the “middle-path” regimen is associated with high compliance and favorable outcomes in spinal tuberculosis.

Osteoporosis and fragility fractures have become a major healthcare challenge globally in the recent years. However, this problem has only recently been accorded its due importance in developing countries such as India. India is a model case study for the management of osteoporosis and fragility fractures in a resource-limited setting, as it harbors a large geriatric population and has the highest prevalence of osteopenia globally. It is imperative to identify the myriad factors contributing to poor bone health and understand the many hurdles encountered to tackle this healthcare problem in a developing country. Innovative methods for managing fragility fractures are commonly seen. Collaborative multidisciplinary care and structured, evidence-based management has finally found its place in India with the establishment of a regional fragility fracture network. This chapter outlines the current status of management of fragility fractures in India by focusing on the disease burden, hurdles, innovative treatment methods, and the challenges lying ahead.

Historically, osteoarticular tuberculosis (TB), including spinal TB, was treated with prolonged course of antitubercular therapy (ATT). Due to various challenges, there has been reluctance to explore the use of short-course ATT in spinal TB. However, with the success of short-course ATT being demonstrated in other forms of extrapulmonary TB, the subject is open for debate again. Therefore, we systematically reviewed various published literature to determine whether short-course treatment regimen (6 months) of ATT provides equivalent results in terms of disease healing as long-course treatment regimen (≥9 months) in the management of spinal TB. Five electronic databases (PubMed, MEDLINE, EMBASE, CENTRAL, and Web of Science) and their reference lists were searched to identify relevant randomized controlled trials with at least 1 year of follow-up that compared short-course with standard-course ATT for treatment of spinal TB. The methodological quality of included studies was assessed, and their data were extracted. A meta-analysis was used to calculate pooled effect sizes and 95% confidence interval (CI). The outcome measure was healed status of the disease at the final follow-up. Of 331 publications identified through literature search, eight publications describing six randomized studies were included. Moreover, 375 of 414 patients (90.58%) who received 6 months of ATT had healed status at their final follow-up compared to 404 of 463 patients (87.26%) who received ≥9 months of ATT. Overall, the healed status of spinal TB was equivalent in patients in both groups (pooled relative risk, 0.98; 95% CI, 0.92–1.04; p =0.439). However, there was considerable heterogeneity among the trials (I2=40.8%, p =0.149). The results suggest that the use of short-course (6 months) chemotherapy may be considered for the treatment of spinal TB in view of the similarity in the healing response achieved compared to treatment regimens of longer duration.

There are no established guidelines regarding the surgical strategy to be adopted in congenital scoliosis with multiple hemivertebrae—decision has to be guided taking into account the contribution of each hemivertebra to the deformity and its growth potential. We describe a case of a 12-year-old woman with congenital scoliosis due to unbalanced multiple hemivertebrae. Preoperative imaging revealed the presence of three hemivertebrae—at D7, D10 and L5. Our surgical strategy was guided by various factors—the morphology of the hemivertebrae, the location, the contribution of each hemivertebra to the deformity and their relationship to each other. Based on this, we performed a selective hemivertebrae resection—completely resecting L5 hemivertebra and performing ‘egg-shell’ decancellation of D7 hemivertebra and in situ fusion of D10 hemivertebra, yielding satisfactory results. This case report illustrates a rational thought process that can guide a paediatric spinal deformity surgeon in treating scoliosis with multiple hemivertebrae.

Study design Prospective comparative study. Objective The aim of this study was to compare the spatiotemporal, kinematic, kinetic and electromyographic (EMG) gait variables in patients with adolescent idiopathic scoliosis (AIS) and congenital scoliosis and to compare these gait variables of scoliosis patients with healthy controls. Summary of background data Earlier studies have solely focussed on the possibility of altered gait patterns in AIS patients; not much light has been shed on the differences in gait patterns in congenital and adolescent scoliosis patients. Methods Forty scoliosis patients (20 each with AIS and congenital scoliosis) and 20 healthy volunteers were prospectively recruited. After thorough clinical and radiological examination, all patients underwent gait analysis in accordance with standard protocols.The outcome measures included spatiotemporal, kinetic, kinematic and EMG activity. Composite indices for gait analysis-Gait Profile Score (GPS) and Gait Deviation Index (GDI)-were also calculated. Relevant statistical tests were applied to compare the different groups. Results No significant difference was found between the AIS and congenital scoliosis groups with respect to baseline demographic and radiological parameters. The two subgroups of scoliosis patients (AIS and congenital) did not differ significantly with respect to any of the measured gait analysis parameters. However, when compared to the healthy age-matched control group, the scoliosis patients differed significantly with respect to gait speed, stride length, step length, GDI, GPS and peak EMG activation for erector spinae, biceps femoris, semimembranosus, rectus femoris, gastrocnemious, and tibialis anterior. Conclusion Our findings confirm the previous findings of literature regarding the alteration in gait patterns in scoliosis patients when compared to normal individuals. However, the lack of difference in gait analysis variables between AIS and congenital scoliosis patients suggests that this alteration in gait is secondary to the existence of the deformity and does not correlate with the onset or etiology of deformity.Level of Evidence: 2.

Oncogenic osteomalacia (OO) is an uncommon paraneoplastic syndrome occurring due to the presence of a tumour that oversecretes fibroblast growth factor-23, which impairs renal phosphate handling. In most cases, the tumour is a morphologically distinct entity called ‘phosphaturic mesenchymal tumour’ (PMT). Spinal tumours causing OO are exceedingly rare. A 55-year-old man presented with multiple bone pain and proximal muscle weakness in the lower limbs. The constellation of biochemical findings (hypophosphataemia, normocalcaemia, increased alkaline phosphatase, low–normal serum vitamin D and hyperphosphaturia) with radiographical rarefaction of the skeleton and pseudofractures led us to consider OO as a possibility. Functional imaging (68Ga DOTA-NOC positron emission tomography/CT scan) localised the tumour to the D2 vertebra. Complete surgical resection led to resolution of symptoms, improved ambulatory status, normalisation of biochemical parameters and healing of pseudofractures. PMT should be considered in the differential diagnosis of hypophosphataemic osteomalacia with hyperphosphaturia. Tumour localisation with functional imaging and complete surgical resection produces satisfactory outcome.

To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery. Pre-operative and 2-year postoperative radiographs of 82 Lenke 1 AIS patients recruited from five hospitals were analysed. Selected radiographic parameters capturing regional and global sagittal alignment were measured. Comparison was made between groups based on baseline thoracic kyphosis (TK: TK

Retrospective, comparative.The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care.Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months).Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3.

Study design Retrospective, comparative. Objective The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care. Summary of background data Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes. Methods Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals. Results A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months). Conclusion Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3.