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Purpose When revising acetabular cups, it is often necessary to provide additional stabilisation with screws. In extensive defect situations, the placement of screws caudally in the ischium and/or pubis is biomechanically advantageous. Especially after multiple revision operations, the surgeon is confronted with a reduced bone stock and unclear or altered anatomy. In addition, screw placement caudally is associated with greater risk. Therefore, the present study aims to identify and define safe zones for the placement of caudal acetabular screws. Methods Forty-three complete CT datasets were used for the evaluation. Sixty-three distinctive 3D points representing bone landmark of interests were defined. The coordinates of these points were then used to calculate all the parameters. For simplified visualisation and intra-operative reproducibility, an analogue clock was used, with 12 o’clock indicating cranial and 6 o’clock caudal. Results A consistent accumulation was found at around 4.5 ± 0.3 hours for the ischium and 7.9 ± 0.3 hours for the pubic bone. Conclusions The anatomy of the ischium and pubis is sufficiently constant to allow the positioning of screws in a standardised way. The interindividual variation is low — regardless of gender — so that the values determined can be used to position screws safely in the ischium and pubis. The values determined can provide the surgeon with additional orientation intra-operatively when placing caudal acetabular screws.

Background Sacral insufficiency fractures (SIFs) are fractures related to reduced bone strength. In a previous study, we noticed that many patients with SIF had undergone total hip arthroplasty (THA). Therefore, the purpose of the present study was to research the localization of clinically apparent SIFs in relation to unilateral THA as well as the influence of unilateral THA on bone mineral density changes in the sacrum. Methods In this retrospective study, 171 patients with SIFs were screened for unilateral THA. In the group of patients with SIF and THA, the rate of SIF ipsilateral and contralateral to the side of the THA was determined. In a second cohort of 39 THA patients with healthy bone, changes in bone mineral density at the sacral alae ipsilateral and contralateral to the THA were analyzed by use of computed tomography immediately postoperatively and at the 1-year follow-up. Results Of the 171 patients with SIF, 50 (40 female; mean age, 79 years; range, 54 to 101 years) were previously treated with THA. Of the 50, 31 patients were treated with unilateral THA. The proportion of patients with an SIF contralateral to the THA was 42% (13 of 31) and ipsilateral to the THA was 19% (6 of 31). Twelve patients had bilateral SIFs. The mean age of the THA group without SIF was 62 years (range, 49 to 79 years); 17 were female. The median bone mineral density decreased significantly (p = 0.023), from 35.0 to 13.0 HU, at the sacral ala contralateral to the THA, whereas the decrease of ipsilateral bone mineral density, from 24.0 to 17.0 HU, was not significant (p = 0.361). Conclusions The proportion of patients with an SIF contralateral to a THA was twice as high as that of patients with an SIF ipsilateral to a THA. These findings are supported by the second cohort's decrease in bone mineral density at the sacral ala contralateral to the THA at 1 year after surgery. We conclude that THA can lead to spatially different remodeling of the sacrum, possibly affecting the development of SIFs. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background For cup revision after total hip arthroplasty, sufficiently good periacetabular bone stock is a prerequisite for fixation of the revision implant. Cementless cups can lead to a relevant reduction of peri-implant bone mineral density (BMD) through stress-shielding. Methods Fifty patients were included in this prospective randomized controlled trial. Group 1 (RM group) received an isoelastic monoblock cup (RM Pressfit vitamys; Mathys). Group 2 (IT group) received a modular titanium cup (Allofit-S IT Alloclassic with a polyethylene liner; Zimmer). Periacetabular BMD was determined and subdivided into 4 regions of interest by dual x-ray absorptiometry at 1 week (baseline) and at 4 years postoperatively. Our primary outcome was reduction in periacetabular BMD. Results Periacetabular BMD was reduced by an average of 15.1% in the RM group and 16.5% in the IT group at 4 years postoperatively. No significant difference was found between the 2 groups over the periacetabular structure as a whole. However, the decrease of BMD in the polar region was significantly different in the RM group (4.9% ± 10.0%) compared with the IT group (15.9% ± 14.9%, p = 0.005). Use of the isoelastic RM cup showed significantly less bone loss than the modular IT cup. Conclusions Relevant loss of BMD at 4 years after surgery was identified in the periacetabular region in both groups. No differences between the 2 cup systems were found when looking at the overall periacetabular region. As a secondary outcome, less postoperative periacetabular bone loss occurred in the polar region when an isoelastic cup was used. Longer follow-up is required to allow for conclusions to be drawn about the long-term course of the 2 cup systems. Level of evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Aims The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS). Methods We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups. Results In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis. Conclusion Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373–381.

Purpose To present the first known pediatric utilization of cone-beam navigation system (CBNS) for hemivertebra resection and spondylodesis Case presentation A 14-year-old female with congenital scoliosis, diagnosed at 8 years of age, presenting with progressive symptoms, a Cobb angle (L3-5) of 38° at time of surgery, treated historically with conservative measures. Presence of spinal intramedullary disease was excluded prior to operation via whole spine MRI. Results Patient successfully underwent surgical correction utilizing the CBNS (O-arm™, Medtronic®). Post-operative Cobb angle (L3-5) was restored to 8°. Following four different pediatric patient’s radiation exposures (two receiving correction via the O-arm platform and two via the traditional method employing fluoroscopy), we show a reduction in radiation exposure using the CBNS system. Conclusion We present the first known pediatric case of the utilization of the CBNS system for hemivertebra correction. We demonstrate that utilizing the CBNS platform can not only increase surgical accuracy but also decrease pediatric patient’s radiation exposure as a preoperative CT scan is not needed. Future studies should continue to explore additional benefits of implementing the system into surgical practice.

Objectives The implant constructs used in scoliosis surgery are often long with a high screw density. Therefore, it is generally believed that magnetic resonance imaging (MRI) should not be carried out after scoliosis surgery, with the result that computed tomography is often preferred despite the ionizing radiation involved. The objective of this study was to evaluate the MRI compatibility of long pedicle-screw-rod constructs at 1.5 T and 3 T using standardized methods of the American Society for Testing and Materials (ASTM). Methods Constructs between 130 and 430 mm long were systematically examined according to the ASTM standards F2182 (radio frequency–induced heating), F2119 (susceptibility artifacts), F2213 (magnetically induced torque), and F2052 (magnetically induced displacement force). Results The maximum heating in the magnetic field was 1.3 K. Heating was significantly influenced by magnetic field strength (p < 0.001), implant length (p = 0.048), and presence of cross-links (p = 0.001). The maximum artifact width for different lengths of the anatomically bent titanium rods with CoCr alloy ranged between 14.77 ± 2.93 mm (TSE) and 17.49 ± 1.82 mm (GRE) for 1.5 T and between 23.67 ± 2.39 mm (TSE) and 27.77 ± 2.37 mm (GRE) for 3 T. TiCP and TiAl showed the smallest and CoCr and CoCr Plus the largest artifact widths. The magnetically induced torque and displacement force were negligible. Conclusions MRI following scoliosis surgery with long implant constructs is safe with the patient in supine position. Although susceptibility artifacts can severely limit the diagnostic value, the examination of other regions is possible. Key Points • Large spinal implants are not necessarily a contraindication for MRI; MR conditional status can be examined according to the ASTM standards F2182, F2119, F2213, and F2052. • A metallic pedicle-screw-rod system could be reliably and safely examined in all combinations of length (130 to 430 mm), configuration, and material in a B0at 1.5 T and 3 T. • According to ASTM F2503, the examined pedicle-screw-rod system is MR conditional and especially the young patients can benefit from a non-ionizing radiation MRI examination.

Acute postoperative infections after surgical interventions on the spinal column are associated with prolonged treatment duration, poor patient outcomes, and a high socioeconomic burden. In the field of joint replacement, guidelines have been established with recommendations for the diagnosis and treatment of such complications, but in spinal surgery there are no definitions permitting distinction between early and late infections and no specific instructions for their management. Various factors increase the risk of acute postoperative infection, including blood transfusions, leakage of cerebrospinal fluid, urinary tract infection, injury of the dura mater, an American Society of Anesthesiologists (ASA) score >2, obesity, diabetes mellitus, and surgical revision. We suggest defining all infections occurring within the first 4 weeks after spinal surgery as early infections. The symptoms are pain at rest, on motion, and/or pressure pain, abnormal warmth, local erythema, circumscribed swelling of the wound, and newly occurring secretion. Together with laboratory parameters such as C-reactive protein (CRP) and leukocytes, a central role is played by imaging in the form of magnetic resonance imaging (MRI), although diagnosis can be hampered by the presence of postoperative fluid collections such as edema or hematoma or by artifacts from an implant. Once an infection has been confirmed, immediate wound revision with debridement and rinsing (sodium hypochlorite) is essential. Intraoperatively it may prove advantageous to use jet lavage and administer vancomycin. We recommend leaving the implant in place in cases of acute postoperative infection. Patients who are not conditional for surgery can first receive antibiotic suppression treatment before surgery at a later date. In such cases initial computed tomography (CT)-guided aspiration or drain insertion can take place.

Introduction Very few publications have previously described spondylodiscitis as a potential complication of endovascular aortic procedures (EVAR/TEVAR). We present to our knowledge the first case series of spondylodiscitis following EVAR/TEVAR based on our data base. Particular focus was laid on the complexity of disease treatment and grave outcome perspectives from a spine surgeon’s point of view in this seriously affected patient group. Materials and methods A retrospective analysis and chart review was performed for 11 out of 284 consecutive spondylodiscitis patients who underwent EVAR/TEVAR procedure and developed destructive per continuitatem spondylodiscitis. Results All 11 patients had single or more level destructive spondylodiscitis adjacent to the thoracic/lumbar stent graft. In mean, four surgeries were performed per patient to treat this rare complication. Six out of eleven patients (55%) died within 6 months of first identification of per continuitatem spondylodiscitis. In four patients due to persisting infection of the graft and recurrence of the abscess formation, a persisting fistula from anterior approach to the skin was applied. Conclusions Destructive per continuitatem spondylodiscitis is a rare and severe complication post-EVAR/TEVAR. Clinical and imaging features of anterior paravertebral disease and anterior vertebral body involvement suggest direct continuous spread of the graft infection to the adjacent vertebral column. The mortality rate of these severe infections is extremely high and treatment with a permanent fistula may be one salvage procedure.

Purpose This retrospective cohort study investigated the efficacy of a sublingual sufentanil tablet system (SSTS) in comparison to intravenous patient-controlled analgesia (IV-PCA) with piritramide for the management of postoperative pain following lumbar spinal fusion surgery. Methods This was a retrospective analysis of patients undergoing single- or two-level lumbar spinal fusion surgery and receiving the SSTS or IV-PCA for postoperative pain relief as part of multimodal pain management that included IV paracetamol and oral metamizole. The following variables were collected: postoperative pain intensity and frequency scores using the numerical rating scale (NRS), hospital anxiety and depression scale (HADS), occurrence of nausea, postoperative mobilization, and patient satisfaction (MacNab criteria). Results Sixty-four patients were included. Those receiving the SSTS (n = 30) had significantly lower pain intensities on the operative day (NRS: 4.0, CI: 3.6–4.3 vs. 4.5, CI: 4.2–4.9; p p n = 34). No differences were observed on postoperative days 2 to 5. SSTS patients experienced more nausea than IV-PCA patients (p = 0.027). Moreover, SSTS patients had a higher percentage of early mobilization following surgery than IV-PCA patients (p = 0.040). Regarding patient satisfaction, no significant differences were seen between the groups. Conclusion The SSTS is a potentially advantageous alternative to opioid IV-PCA for use within a multimodal approach to managing postoperative pain after lumbar fusion surgery. Furthermore, the potentially higher emetic effect of SSTS should be considered, and the patient should be able to perform the application.

Study Design: Retrospective observational study. Objective: The aim of the present study was to evaluate the role of lumbar magnetic resonance imaging (MRI) in the diagnostic algorithm of sacral insufficiency fractures (SIF). The primary objective was to compare the sensitivity in fracture detection and correct fracture classification according to MRI and computed tomography (CT). The secondary objective was to identify differences of additional pathologies found in MRI of the lumbar spine and the pelvis and their rates. Methods: A total of 943 patients (from 2010 to 2017) with fracture of the pelvic ring were screened. All patients without high-energy trauma and radiologic diagnostics consisting of X-ray, CT, and MRI of the pelvis or the lumbar spine including the sacrum were included. Differences in fracture detection and description in the various radiologic procedures were evaluated. Detection rates of additional pathologies in MRI of the pelvis and lumbar spine were recorded. Results: A total of 77 subjects were included. The sensitivities for SIF were 14% in X-ray and 88% in CT, and all fractures were detected in MRI. MRI showed a more complex fracture pattern compared with CT in 65% of the cases. Additional pathologies were seen in MRI of the lumbar spine (51%) and that of the pelvis (18%). Conclusions: We suggest performing MRI of the lumbar spine including the sacrum with coronal STIR (short tau inversion recovery) sequence for elderly patients with suddenly increasing low back pain at an early stage. This procedure might improve fracture detection, classification, and recognition of concomitant pathologies.

The aim of the study was to compare decompression of bone-marrow edema or osteonecrosis of the proximal femur by means of a cone beam-based imaging and navigation system (cone beam-navigated decompression, CBND) with decompression by the conventional technique of drilling using fluoroscopy (FD). The data of patients with bone-marrow edema syndrome treated between 2016 and 2018 by drilling of the proximal femur in CBND or FD technique were compared retrospectively. Each treatment group included 20 patients. The mean operating time for CBND was 16.4 ± 5.8 min, compared with 29.1 ± 20.8 min for FD (p = 0.018). The lesion was definitely reached by CBND in 19/20 patients. Eighteen of the 20 patients in the CBND group reported that their pain decreased after the treatment, compared with 12/20 patients in the FD group (p = 0.065). The radiation dosage was significantly higher (p

Prospective cross-sectional exploratory study.To evaluate the correlation between in vivo lumbar dual-energy x-ray absorptiometry (DXA) and parameters of bone architecture in micro-computed tomography (micro-CT) in patients with osteoporosis.DXA is the current diagnostic standard for evaluating osteoporosis. However, there are various concerns regarding its validity, especially in the spine. No study has so far investigated whether in vivo DXA correlates with the actual lumbar bone architecture.Lumbar DXA scans were compared with micro-CT analysis of vertebral biopsies in patients with osteoporotic vertebral fractures (fracture group) and those without (control group). Preoperatively, all patients underwent a DXA scan (L1-L4). Intraoperative biopsies from nonfractured vertebrae (preferably L3) were analyzed by micro-CT regarding bone quantity and quality. The groups were compared regarding differences in DXA and micro-CT results. In each group, a correlation analysis was performed between DXA and micro-CT.The study included 66 patients (33 per group). Preoperative DXA results were worse in the fracture group than the control group (areal bone mineral density [aBMD] 0.95 vs. 1.31, T-score -1.97 vs. 0.92, each P 0.001). Micro-CT analysis confirmed differences regarding quantitative parameters (bone/total volume: 0.09 vs. 0.12, P 0.001) and qualitative parameters (connectivity index: 15.73 vs. 26.67, P 0.001; structure model index: 2.66 vs. 2.27, P 0.001; trabecular number: 2.11 vs. 2.28, P = 0.014) of bone architecture between both groups. The DXA results did not correlate with micro-CT parameters in the fracture group. In the control group, correlations were found for some parameters (bone/total volume vs. aBMD: r = 0.51, P = 0.005; trabecular number vs. aBMD: r = 0.56, P = 0.001).These data constitute the first comparison of DXA measurements with microstructural analysis of vertebral biopsies in patients with osteoporosis. Our results indicate that lumbar DXA neither qualitatively nor quantitatively represents microstructural bone architecture and is therefore not a reliable tool for the evaluation of bone quality in the spine.Level of Evidence: 3.

OBJECTIVE The aim of this study was to research the influence of psychosocial confounders on outpatient rehabilitation after arthroscopic shoulder surgery. DESIGN This retrospective study included patients who underwent such rehabilitation in a single center between January 2014 and October 2016. Shoulder function (Constant Shoulder Score) and pain (visual analog scale), improvements in these scores, and patient satisfaction were evaluated with regard to anxiety and depression (Hospital Anxiety and Depression Scale), self-rated return-to-work problems (Wurzburg screening), and employment status. RESULTS The analysis included 176 patients. The mean (SD) Constant Shoulder Score and visual analog scale improved from 53.9 (18) to 75.4 (16.5) and 4.6 (2.1) to 2.9 (2.4) cm, respectively. A total of 84.1% of the patients were satisfied with the outcome. Unemployed patients (P = 0.001) and Hospital Anxiety and Depression Scale-positive ones (P = 0.014) were less satisfied than their counterparts. Patients with a Wurzburg screening-positive screening showed less improvement in pain (P = 0.015), function (P = 0.016), and satisfaction (P = 0.002) than those without. Unemployed reported more pain (P = 0.008) than employed patients when starting rehabilitation. At the end of rehabilitation, all psychosocial scores (Hospital Anxiety and Depression Scale, P = 0.002; Wurzburg screening, P = 0.001; unemployment, P < 0.001) negatively influenced pain, Wurzburg screening (P = 0.007), and unemployment (P = 0.008) function. CONCLUSIONS Because we identified psychosocial factors that influence the success of outpatient shoulder rehabilitation, rehabilitation setup should be adjusted in patients with such problems.

Background Progression of scoliosis following completion of growth, and the combination of low mental retardation and the conspicuous sagittal clinical and radiographic abnormalities suggest a secondary genesis of the scoliosis according to a genetic aberration. Case Description In the outpatient department, an 18-year-old woman presents with scoliosis and mild mental retardation. Radiography findings demonstrate a sacral agenesis and then consecutively performed magnetic resonance imaging on a conus depression. Because of the symptom constellation, a genetic syndrome was suspected. Genetic diagnostics revealed a trisomy 19q and monosomy 7q. Typically, deletions of the subtelomere 7q show a phenotype with growth retardation, facial anomalies, and intellectual deficit; trisomy of the subtelomere 19q shows growth retardation, atypical ears, short neck, and intellectual deficit with delayed development. The further clinical radiologic and neurologic examination showed no evidence of a tethered cord syndrome. The correction of scoliosis was performed under intraoperative neurophysiological monitoring without neurologic complications. Conclusions In the presence of dysplastic sacral changes and accompanying elongated conus medullaris in patients with scoliosis, it is always necessary to think of rare chromosome aberrations and to initiate appropriate diagnostics before surgery. The intraoperative neurophysiological monitoring is strongly recommended, owing to a morphologically, and not fully-excludable, tethered cord syndrome.

In total joint replacement, culturing of the sonication fluid of removed implants has proven to be more sensitive than conventional periprosthetic tissue culture for the microbiological diagnosis of prosthetic joint infection. However, its role in postoperative spinal implant infection (PSII) is not well investigated. Therefore, the aim of this study was to determine the validity of sonication in detecting infection following instrumented spine surgery. In this prospective controlled consecutive cohort study, patients undergoing spinal revision between September 2016 and March 2018 were analyzed. In all patients sonication of removed spinal implants and at least one peri-implant tissue culture were performed. Demographic data, including age, gender, clinical manifestation, comorbidities, laboratory values (CRP and blood leukocytes), were recorded. Microorganisms causing PSII were documented. Sensitivity and specificity of sonication and peri-implant tissue culture were evaluated. A total of 118 patients were included. PSII was diagnosed in 35 patients, representing 29.6% of the study cohort. Sensitivities of tissue and sonication fluid culture were 65.7% (95% confidence interval (CI) 48.6–80.0) and 94.3% (95% CI 85.7–100) (p value = 0.002) and specificities 96.4% (95% CI 91.6–100) and 98.8% (95% CI 96.4–100), respectively. The most common microorganisms found in PSII were coagulase-negative Staphylococci and Propionibacterium acnes. Eleven PSIIs were detected only by sonicate fluid culture. Culture of samples obtained by spinal implant sonication was more sensitive than conventional peri-implant tissue culture for the microbiological diagnosis of PSII. Therefore, sonication should be used as a routine tool in the diagnostic workup of PSII. These slides can be retrieved under Electronic Supplementary Material.

Die Electron-Beam-Melting (EBM)-Technik ermoglicht Cage-Design-Veranderungen wie die Integration von Fuhrungsschienen auf der Cage-Oberflache oder eine 3‑D-Matrix fur die Osseointegration. Eine Anderung von Herstellungstechnik oder Design kann zu einer Verminderung der Fusionsrate fuhren und die Anwendbarkeit beeinflussen. Das Ziel der Arbeit war, die operative Handhabung, die Wiederherstellung der Lordose sowie die Fusionsrate 1 Jahr nach Implantation eines derartigen Cages zu evaluieren. In eine retrospektive Studie wurden 50 Patienten nach Implantation eines in EBM-Technik hergestellten Cages mit dem minimal-invasiven („transforaminal lumbar interbody fusion“, TLIF) oder offenen Verfahren („posterior lumbar interbody fusion“, PLIF) eingeschlossen. Die Fusion wurde anhand von routinemasig 12 Monate postoperativ erstellten CTs und Rontgenfunktionsaufnahmen evaluiert. Die lumbale und segmentale Lordose wurden praoperativ, postoperativ und nach 1 Jahr verglichen. Die postoperative Cage-Position diente der Evaluation der Handhabung. Radiologisch wurde nach 1 Jahr eine Fusionsrate von 97 % erzielt. Intraoperativ waren 2 Cages in die Deckplatte eingebrochen, jedoch ohne Einfluss auf die Fusion. Bei 31 % der Cages gelang eine Positionierung im anterioren Drittel. Die lumbale Lordose wurde durch die Operation im Mittel um 5° und die segmentale um durchschnittlich 4° verbessert, mit einem Repositionsverlust von jeweils 1° nach 1 Jahr. Implantatassoziierte Komplikationen traten nicht auf. Das Implantat ist sehr sicher und hat eine sehr gute Fusionsrate. Eine Lernkurve entsteht dadurch, dass der Cage mit Fuhrungsschienen einem vorgegebenen Radius folgt. Danach ermoglichen die Fuhrungsschienen aber ein exaktes Platzieren des Cages an der ventralen Randleiste.

Surgical treatment methods for degenerative spondylolisthesis (decompression versus decompression and fusion) have been critically debated. The medical care situation is almost unknown for either treatment. Therefore, the aim of the present study was to provide information regarding the use of parameters for decision-making and the employment of surgical techniques. A web-based survey was performed among members of the German-Spine-Society (DWG). Information regarding participant characteristics (specialty, age, DWG certification status, number of spine surgeries performed at the participant’s institution each year, institutional status), estimates of the use of both treatment options, clinical and morphological decision-making criteria for additive fusion, and the surgical technique used was queried. 305 members (45% neurosurgeons/ 55% orthopedic or trauma surgeons) participated in the present study. The participants estimated that in 41.7% of the cases, decompression only was required, while 55.6% would benefit from additional fusion. Among the participants, 74% reported that low back pain was an important indicator of the need for fusion if the numerical rating scale for back pain was at least 6/10. The most commonly used decompression technique was minimally invasive unilateral laminotomy, whereas open approach-based interbody fusion with transpedicular fixation and laminotomy was the most frequently used fusion technique. Specialty, age, certification status, and institutional status had a partial effect on the responses regarding indications, treatment and surgical technique. The present survey depicts the diversity of approaches to surgery for degenerative spondylolistheses in Germany. Considerable differences in treatment selection were observed in relation to the participants’ educational level and specialty.

STUDY DESIGN Prospective cross-sectional exploratory study. OBJECTIVE To evaluate the correlation between in vivo lumbar dual-energy x-ray absorptiometry (DXA) and parameters of bone architecture in micro-computed tomography (micro-CT) in patients with osteoporosis. SUMMARY OF BACKGROUND DATA DXA is the current diagnostic standard for evaluating osteoporosis. However, there are various concerns regarding its validity, especially in the spine. No study has so far investigated whether in vivo DXA correlates with the actual lumbar bone architecture. METHODS Lumbar DXA scans were compared with micro-CT analysis of vertebral biopsies in patients with osteoporotic vertebral fractures (fracture group) and those without (control group). Preoperatively, all patients underwent a DXA scan (L1-L4). Intraoperative biopsies from nonfractured vertebrae (preferably L3) were analyzed by micro-CT regarding bone quantity and quality. The groups were compared regarding differences in DXA and micro-CT results. In each group, a correlation analysis was performed between DXA and micro-CT. RESULTS The study included 66 patients (33 per group). Preoperative DXA results were worse in the fracture group than the control group (areal bone mineral density [aBMD] 0.95 vs. 1.31, T-score -1.97 vs. 0.92, each P

Aims To evaluate the histopathological examination of peri-implant tissue samples as a technique in the diagnosis of postoperative spinal implant infection (PSII). Methods This was a retrospective analysis. Patients who underwent revision spinal surgery at our institution were recruited for this study. PSII was diagnosed by clinical signs, histopathology, and microbiological examination of intraoperatively collected samples. Histopathology was defined as the gold standard. The sensitivity for histopathology was calculated. A total of 47 patients with PSII and at least one microbiological and histopathological sample were included in the study. Results PSII occurred in approximately 28% of the study population. Histopathology showed a sensitivity of 51.1% in the diagnosis of PSII. The most commonly found pathogens were Cutibacterium acnes and gram-positive staphylococci. Conclusion Histopathology has low sensitivity for detecting PSII. In particular, infections caused by low-virulence microorganisms are insufficiently detected by histopathology. Cite this article: Bone Joint J 2020;102-B(7):899–903.

The present paper is concerned with the investigation of the phenomenon of long-term bone remodelling on cementless hip replacements. Changes in bone density in the periprosthetic region around the stem, measured by dual X–ray absorptiometry (DXA), were used as a measure of the osseous adaptation reaction. A postoperative follow-up of the use of four different types of prostheses of varying design after on average 13.3 (11.4–14.5) years. Specifically, the prostheses assessed in this study were the CLS/Spotorno stem with the Allofit cup by Zimmer, the Vision 2000 stem with the Duraloc cup by DePuy Synthes, the AlphaFit stem with the AlphaLock cup by Corin and the Mayo stem with the Trilogy cup by Zimmer. For the DXA measurement, the femur was divided into the zones suggested by Gruen et al. On the femur, there was a significant reduction in bone mineral density (BMD) in the proximal Region Of Interest (ROI) 1 (p = 0.003) and 7 (p

STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective was to prove the association between anatomic pelvis parameters and specific types of lumbar spinal degeneration. SUMMARY OF BACKGROUND DATA Different spinopelvic sagittal profile types are suggested to be associated with specific degenerative lumbar spine pathologies. Because pelvic morphology plays a key role defining the spinal shape as well as its load and function it thereby potentially predisposes the development of spinal degeneration. MATERIALS AND METHODS Patients with symptomatic lumbar spinal degeneration who were surgically treated in 2 spine departments from March 2011 until August 2016 were included in this retrospective analysis. Single-level degenerative pathologies were classified as lumbar disc herniation (LDH), degenerative disc disease (DDD), lumbar spinal stenosis (LSS), and degenerative spondylolisthesis (DSPL). The constant anatomic pelvic parameters pelvic incidence (PI), pelvic radius (PR), and sacral table angle (STA) were assessed in lateral radiographs of the lumbar spine and compared between the pathologies. RESULTS In total, 249 patients were assigned to the LDH (n=73), DDD (n=67), LSS (n=42), and DSPL (n=67) groups. Group comparisons revealed significant differences in the anatomic pelvic parameters PR (LDH, 139.5±10.8 mm; DDD, 135.9±14.0 mm; LSS, 127.8±14.3 mm; DSPL, 135.8±12.7 mm; P

Aims During revision procedures for aseptic reasons, there remains a suspicion that failure may have been the result of an undetected subclinical infection. However, there is little evidence available in the literature about unexpected positive results in presumed aseptic revision spine surgery. The aims of our study were to estimate the prevalence of unexpected positive culture using sonication and to evaluate clinical characteristics of these patients. Patients and Methods All patients who underwent a revision surgery after instrumented spinal surgery at our institution between July 2014 and August 2016 with spinal implants submitted for sonication were retrospectively analyzed. Only revisions presumed as aseptic are included in the study. During the study period, 204 spinal revisions were performed for diagnoses other than infection. In 38 cases, sonication cultures were not obtained, leaving a study cohort of 166 cases. The mean age of the cohort was 61.5 years (sd 20.4) and there were 104 female patients Results Sonication cultures were positive in 75 cases (45.2%). Hardware failure was the most common indication for revision surgery and revealed a positive sonication culture in 26/75 cases (35%) followed by adjacent segment disease (ASD) in 23/75 cases (30%). Cutibacterium acnes and Staphylococcus epidermidis were the most commonly isolated microorganisms, observed in 45% and 31% of cases, respectively. C. acnes was isolated in 65.2% of cases when the indication for revision surgery was ASD. Conclusion Infection must always be considered as a possibility in the setting of spinal revision surgery, especially in the case of hardware failure, regardless of the lack of clinical signs. Sonication should be routinely used to isolate microorganisms adherent to implants. Cite this article: Bone Joint J 2019;101-B:621–624.

BACKGROUND AND OBJECTIVES Bone marrow oedema is a multifactorial conditioned illness. Alongside any strain relief of an affected joint, treatment with Iloprost also belongs to the choice of cures. In past studies, a modulatory effect on bone could be shown. The hypothesis of the present work is that Iloprost has a growth-stimulating effect on osteoblasts in vitro. METHODS Human osteoblasts were isolated and cultivated. Subsequently, the cells were treated with Iloprost in bioavailable concentrations. Alterations of the cell structure were examined by means of light microscopy. A regulation of the number of vital cells was carried out by using a CASY cell counter. Possible cell impairment after Iloprost treatment was analysed by means of XTT Elisa as well as FDA and PI staining via fluorescence microscopy. RESULTS Using light microscopy, no changes in cell structure could be observed. With the CASY cell counter, no increase in the numbers of osteoblasts appeared after Iloprost treatment. Also, XTT Elisas and fluorescence microscopy did not reveal any cell impairment due to Iloprost. CONCLUSION Our results could not confirm a modulatory effect in mature osteoblasts. On the basis of the present work we could not verify any growth-stimulating effect by Iloprost in mature osteoblasts in vitro. Admittedly, effects had been shown previously during osteogenesis, but we do exclude an effect on mature osteoblasts which have already differentiated.

Electron beam melting (EBM) technique enables cage design changes such as the integration of guide rails on the cage surface or a 3D matrix for osseointegration. A change in manufacturing technique or design can lead to a decreased fusion rate or impaired applicability.The aim of the present study was to evaluate cage handling, lordosis reconstruction capability, and fusion rate 1 year after surgery.In this study, 50 patients who had undergone minimally invasive transforaminal lumbar interbody fusion (TLIF) or open posterior lumbar interbody fusion (PLIF) using an EBM-manufactured cage were retrospectively included. Fusion evaluation was based on routinely performed CTs and flexion-extension radiographs 12 months postoperatively. Lumbar and segmental lordosis were compared between pre-, post, and 1‑year follow-up. Postoperative cage position was used for evaluation of cage handling.The radiological fusion rate was 97% at the 1‑year follow-up. Two cages were placed into the endplates during surgery without an effect on fusion. In 31% of the cages, placement at the anterior third of the disk space was possible. Lumbar lordosis was improved by a mean of 5° and segmental lordosis by a mean of 4°. At final follow-up, 1° was lost in both parameters. No implant-associated complications were registered.The implant is safe and leads to a very high fusion rate. A learning curve results from the fact that the cage follows a defined radius dictated by the guide rails. Addressing this, exact placement at the anterior endplate can be achieved.

Bone marrow oedema (BMO) is a multifactorial condition. Various conservative treatment options include analgesic therapy, immobilisation of the affected joint and/or systemic intravenous iloprost or bisphosphonate therapy. Many studies confirm the positive effect of iloprost therapy in larger joints, e.g. the hip and knee joint, after short-term follow up. The objective of this study was to investigate that treatment with iloprost leads to positive long-term functional and radiological outcomes for BMO of the hip joint. Nineteen patients with BMO of the hip joint, ARCO stage 1-2, were included in this study. The Harris Hip Score, the SF-36, the WOMAC score and a visual analogue pain scale (VAS) were evaluated before and 29 ± 11 months after Ilomedin therapy. All patients underwent MRI for radiological follow-up monitoring three months after treatment. Significant improvements were found in the WOMAC Index and the VAS. In 79% of patients, follow-up MRI after three months showed complete regression of the oedema. Based on the positive results of our study, we support treatment with iloprost for BMO of the hip joint at ARCO stage 1-2.

Study Design: Retrospective analysis of clinical and radiologic data of a prospective cohort study. Objective: To research the clinical differences after lumbar total disk replacement (TDR) with respect to the preoperative global and the adaptation at the local sagittal profile (SP) of the spine. Summary of Background Data: It was suggested that facet loads and degeneration are dependent on epidemiologically defined types of SP. Moreover, the success of TDR was related to segmental facet joint loads. The influences of the preoperative SP or of the changes of the local SP after TDR on the clinical outcome after TDR remain unclear. Methods: Fifty-two patients included in a prospective cohort study regarding lumbar single-level TDR L4/5 (n=22) or L5/S1 (n=30) because of degenerative disk disease (Modic ≤2 degrees) were clinically (visual analog scale for back, leg, and overall pain; Oswestry Disability Index) and radiologically (extension-flexion radiographs, plain-spine, and whole-spine lateral radiographs in upright standing position) reevaluated after a minimum follow-up of 24 (24–69) months. On the basis of preoperative plain radiographs in upright standing position, patients were retrospectively assigned to 4 groups according to the individual sagittal profile type (SPT). In patients with persistent back pain, a facet infiltration at the index level was performed. Results: For all patients, an SPT could be defined. Global SP did not change compared with the preoperative state. All groups improved clinically over follow-up. At the last follow-up, types 1 and 4 demonstrated significantly inferior scores for pain and function. TDR-induced changes at the superior adjacent segment and the posterior disk height at the index level were also correlated to inferior clinical results. Infiltration test was positive in type 1–4: 67%, 40%, 33%, and 75%, respectively, of the symptomatic patients. Conclusions: We suggest SPTs 1 and 4 to represent a contraindication for lumbar TDR of levels L4/5 or L5/S1. Local adaptation in the adjacent segment to TDR may influence the clinical outcome as well.

Usually, neuromuscular scolioses become clinically symptomatic relatively early and are rapidly progressive even after the end of growth. Without sufficient treatment they lead to a severe reduction of quality of life, to a loss of the ability of walking, standing or sitting as well as to an impairment of the cardiopulmonary system resulting in an increased mortality. Therefore, an intensive interdisciplinary treatment by physio- and ergotherapists, internists, pediatricians, orthotists, and orthopedists is indispensable. In contrast to idiopathic scoliosis the treatment of patients with neuromuscular scoliosis with orthosis is controversially discussed, whereas physiotherapy is established and essential to prevent contractures and to maintain the residual sensorimotor function.Frequently, the surgical treatment of the scoliosis is indicated. It should be noted that only long-segment posterior correction and fusion of the whole deformity leads to a significant improvement of the quality of life as well as to a prevention of a progression of the scoliosis and the development of junctional problems. The surgical intervention is usually performed before the end of growth. A prolonged delay of surgical intervention does not result in an increased height but only in a deformity progression and is therefore not justifiable. In early onset neuromuscular scolioses guided-growth implants are used to guarantee the adequat development. Because of the high complication rates, further optimization of these implant systems with regard to efficiency and safety have to be addressed in future research.

The aim of the present study was to histologically compare chondrotoxicity in surgically harvested intervertebral discs (IVDs) of patients following discoblock, discography, or no preoperative intervention. Thirty patients (IVD degeneration Modic ≥ 2°, Pfirrmann 3° or 4°) at L4/5 or L5/S1 who were planned for anterior lumbar interbody fusion were randomly assigned to three groups (open MRI: group DG - discography with gadobutrol; group DB - discoblock with bupivacaine at 4 weeks prior to surgery; group C - no intervention). The intervertebral discs were histologically evaluated and compared using ANOVA and Bonferroni tests for cell count, apoptosis, and proliferation. A reduced cell count (groups DG vs. DB vs. C: 14.9 ± 7.1, 9.2 ± 3.8, and 16.6 ± 5.2 cells/mm2, respectively; p ANOVA = 0.016), increased apoptosis (groups DG vs. DB vs. C: 34.9 ± 10.2, 47.4 ± 16.3, 32.6 ± 12.2 %, respectively; p ANOVA = 0.039) and increased cell proliferation (post hoc pDB vs. DG or C p

Prospective, randomized trial. The treatment of degenerative disc disease (DDD) with two-level fusion has been associated with a reasonable rate of complications. The aim of the present study was to compare (Hybrid) stand-alone anterior lumbar interbody fusion (ALIF) at L5/S1 with total disc replacement at L4/5 (TDR) as an alternative surgical strategy to (Fusion) 2-level circumferential fusion employing transforaminal lumbar interbody fusion (TLIF) with transpedicular stabilization at L4–S1. A total of 62 patients with symptomatic DDD of segments L5/S1 (Modic ≥2°) and L4/5 (Modic ≤2°; positive discography) were enrolled; 31 were treated with Hybrid and 31 with Fusion. Preoperatively, at 0, 12, and a mean follow-up of 37 months, clinical (ODI, VAS) and radiological evaluations (plain/extension-flexion radiographs evaluated for implant failure, fusion, global and segmental lordosis, and ROM) were performed. In 26 of 31 Hybrid and 24 of 31 Fusion patients available at the final follow-up, we found a significant clinical improvement compared to preoperatively. Hybrid patients had significantly lower VAS scores immediately postoperatively and at follow-up compared to Fusion patients. The complication rates were low and similar between the groups. Lumbar lordosis increased in both groups. The increase was mainly located at L4–S1 in the Hybrid group and at L1–L4 in the Fusion group. Hybrid patients presented with increased ROM at L4/5 and L3/4, and Fusion patients presented with increased ROM at L3/4, with significantly greater ROM at L3/4 compared to Hybrid patients at follow-up. Hybrid surgery is a viable surgical alternative for the presented indication. Approach-related inferior trauma and the balanced restoration of lumbar lordosis resulted in superior clinical outcomes compared to two-level circumferential fusion with TLIF.

STUDY DESIGN Pilot study. OBJECTIVE To develop and validate the feasibility and accuracy of a newly designed navigational spinal instrument guiding tool for patient-matched thoracic and lumbar pedicle screw placement in patients with severe scoliosis, and to identify intraoperative challenges that may be relevant. SUMMARY OF BACKGROUND DATA Pedicle screw placement is challenging in severely rotated scoliotic spine with small diameters and asymmetrical shape of the pedicles and vertebrae. Patient-specific drill/positioning guides with preplanned trajectory have been developed as a promising solution in spinal surgery for precise screw insertion. METHODS In 4 patients with severe scoliosis, navigational templates and models of all vertebrae to be instrumented were manufactured using a computed tomography (CT)-based 3-dimensional model of the thoracic and lumbar spine. The guides were designed differently for thoracic and lumbar segments according to the individual anatomy to achieve an optimal coupling to the surface of the patient's spine, to maximize the stability of the device itself, and to increase user friendliness for the complete screw positioning process. Intraoperative challenges and opportunities for device and process improvements regarding the handling of the guides during the surgery were recorded. Postoperatively, the intrapedicular screw positions were evaluated versus the preoperative plan and evaluated for cortical violation based on CT scans. RESULTS A total of 76 pedicle screws were implanted (56 thoracic, 20 lumbar). Two screws (2.6%) were assessed to be misplaced intraoperatively and repositioned. Eighty-four percent of the pedicle screws were completely intrapedicular, 96.1% within

Background: The aim of the study was to investigate psychological distress and health-related quality of life (HrQoL) in patients with bone marrow edema syndrome (BMES) of the hip or knee joint. Methods: This retrospective study included patients with the diagnosis BMES treated in the period 2016–2017. As well as analyzing the epidemiological data (age, sex, vascular disease, hypertension, etc.), we used the Hospital Anxiety and Depression Scale (HADS) to document anxiety and depression and the five-level version of the EuroQol Group’s EQ-5D instrument (EQ-5D-5L) to assess HrQoL and compared it to historical controls of the healthy population. Results: The study group comprised 56 patients (26 females, 30 males) with a mean age of 55.8 (range, 15–84) years. HADS: there was no difference between the study and control cohorts in the rates of anxiety (P=0.595) or depression (P=0.241). EQ-5D-5L: the HrQoL was significantly lower in the patients with BMES than in the healthy controls both for parameters of the EQ-5D-5L index and in the various age groups. No difference in HrQoL was seen between BMES of the hip and the knee or among the different radiological stages of BMES. Conclusions: The patients with BMES displayed a clear reduction in HrQoL, but this was not associated with psychological distress with regard to significant anxiety and depression. Patients with BMES and a high score for anxiety and depression are at great risk of chronic pain, and we recommend they should receive psychological counseling.

Objectives The aim of the present study was to intra-individually compare provocative discography and discoblock (disc analgesia) of idiopathic degenerated discs (IDD) results to each other, to clinical parameters, and to MRI findings. By this the value of both diagnostic features should be critically reevaluated. Methods 31 intervertebral IDD (Pfirrmann III°–IV°) of 26 patients were analyzed for surgery decision making by combined discoblock/discography procedure in an open MRI at 1 T. A correlation analysis was performed between the Dallas Discogram Scale, pain discrimination score (PDS: concordant/discordant/no pain), positive discoblock (Numerical Rating Scale [NRS] reduction by ≥3, 60 min after intervention), presence of Modic changes or high intensity zones (HIZ), patient sex and age, intervention level, injection pressure and discography endpoint analysis (pain/pressure/anatomic/volume). Results Concordant pain could be evoked in 35% of the IDDs whereas discoblock was positive in 64%. Patients’ age, sex, Dallas I, Dallas II, and Pfirrmann scores, as well as the presence of HIZ did not correlate to PDS or discoblock results. Discoblock correlated positively to concordant pain. Further positive correlation was found between PDS and intervention level/pressure, between discoblock and Modic changes/discography endpoint as well as between HIZ and discography endpoint. Conclusions We suggest discoblock to be an additional tool for surgery decision making in patients with IDD because it correlates to concordant pain evoked by provocative discography as well as to presence of Modic changes. Additionally, assessment of a release instead of provocation of pain can be of advantage.

After total disc replacement with a ball-and-socket joint, reduced range of motion and progression of facet joint degeneration at the index level have been described. The aim of the study was to test the hypothesis that misalignment of the vertebrae adjacent to the implant reduces range of motion and increases facet joint or capsule tensile forces.A probabilistic finite element analysis was performed using a lumbosacral spine model with an artificial disc at level L5/S1. Misalignment of the L5 vertebra, the gap size of the facet joints, the transection of the posterior longitudinal ligament, and the spinal shape were varied. The model was loaded with pure moments.Misalignment of the L5 vertebra reduced the range of motion up to 2°. A 2-mm displacement of the L5 vertebra in the anterior direction already led to facet joint forces of approximately 240 N. Extension, lateral bending, and axial rotation caused maximum facet joint forces between 280 and 380 N, while flexion caused maximum forces of approximately 200 N. A 2-mm displacement in the posterior direction led to capsule forces of approximately 80 N. Additional moments increased the maximum facet capsule forces to values between 120 and 230 N.Misalignment of the vertebrae adjacent to an artificial disc strongly increases facet joint or capsule forces. It might, therefore, be an important reason for unsatisfactory clinical results. In an associated clinical study (Part 2), these findings are validated.

The macroscopic pathomorphology in recurrent shoulder instability has been described. However, less is known regarding the histopathologic details of the affected structures. This study evaluates different histopathologic stages of shoulder instability by assessing biopsy specimens of static stabilizers for possible correlations with clinical parameters. Our hypothesis was that clinical parameters of shoulder instability correlate with histopathologic findings.Passive shoulder stabilizers (labrum, anterior bundle of the inferior glenohumeral ligament) were biopsied during arthroscopic shoulder stabilization. Samples were submitted to immunohistochemistry, in situ hybridization, and blinded evaluation. Clinical data, comprising age (30 years or ≥30 years), total number of dislocations (1, 2-3, or3), and period since initial dislocation (6 months, 6 months to 6 years, or6 years), were tested for statistical correlation with the following histopathologic parameters: inflammation, lipomatous changes, vascular proliferation, tissue fragmentation, and cellularity.Standardized biopsies were performed in 30 consecutive patients (4 women and 26 men; mean age, 32.6 years) with anterior shoulder instability. Microscopic evaluation showed only small variations in histologic changes among all samples. Only limited variations in cell density, matrix swelling, and collagen fiber disruptions were found. Immunohistochemical analysis showed a similar expression of decorin in all samples. Clinical parameters (age, total number of dislocations, and period since initial dislocation) were statistically independent from histopathologic parameters (inflammation, lipomatous changes, vascular proliferation, tissue fragmentation, and cellularity). No correlation was found in patients with 1 dislocation versus those with more than 1 dislocation.In contrast to macroscopic findings among different grades of shoulder instability, this study detected no correlation between clinical items (age, total number of dislocations, and period since initial dislocation) and histopathologic parameters. These clinical items seem to be independent from the tissue status of static stabilizers of the shoulder.

STUDY DESIGN: Single-center prospective study. OBJECTIVE: Clinical and radiological long-term evaluation of the effects of transpedicular dynamic stabilization after sequestrectomy. SUMMARY OF BACKGROUND DATA: Short- and mid-term investigations have shown that additional dynamic stabilization is appropriate to prevent progression of initial segment degeneration after sequestrectomy and associated with superior clinical outcome compared with sequestrectomy alone. Long-term data are missing. METHODS: Eighty-four patients with symptomatic disc herniation and initial osteochondrosis (Modic = I°) of the lumbar spine underwent sequestrectomy. Additional dynamic stabilization was performed in 35 subjects (group D); the remaining 49 subjects were treated with sequestrectomy alone (group S). Clinical (Oswestry Low Back Pain Disability Questionnaire, Version 2.0; visual analogue scale) and radiological (plain and extension-flexion radiographs and magnetic resonance images) parameters were collected preoperatively, at 3 months postoperatively, as well as at a mean follow-up of 2.8 and 10.2 years. RESULTS: Twenty-nine of 35 (83%, group D) and 38 of 49 (78%, group S) patients were available at the final follow-up. Reoperation rate in group D was 34% (10/29) due to implant failures or progression of degeneration at the index or the adjacent segments. In group S, 5 of 38 (13%) underwent further operation because of a reprolapse or progression of degeneration of the index level. In the remaining patients, clinical scores (Oswestry Low Back Pain Disability Questionnaire, Version 2.0; and visual analogue scale) improved significantly, with similar results in both groups at the final follow-up. The rate of progression of disc degeneration was lower when the patients were also dynamically stabilized than sequestrectomy alone, but the rate of adjacent segment degeneration superior to the operated segment was significantly higher in group D. CONCLUSION: Additional dynamic stabilization does not lead to a clinical benefit in patients with symptomatic disc herniation and initial segment degeneration compared with sequestrectomy alone after a long-term follow-up. Because of this and the high rate of necessary reoperations, we do not recommend this surgical strategy for this indication. LEVEL OF EVIDENCE: 4.

Purpose. To evaluate training induced metabolic changes noninvasively with magnetic resonance spectroscopy (-MRS) for measuring muscle fibre type adaptation.Methods. Eleven volunteers underwent a 24-week training, consisting of speed-strength, endurance, and detraining (each 8 weeks). Prior to and following each training period, needle biopsies and -MRS of the resting gastrocnemius muscle were performed. Fibre type distribution was analyzed histologically and tested for correlation with the ratios of high energy phosphates ([PCr]/[], [PCr]/[βATP] and [PCr + ]/[βATP]). The correlation between the changes of the -MRS parameters during training and the resulting changes in fibre composition were also analysed.Results. We observed an increased type-II-fibre proportion after speed-strength and detraining. After endurance training the percentage of fast-twitch fibres was reduced. The progression of the [PCr]/[]-ratio was similar to that of the fast-twitch fibres during the training. We found a correlation between the type-II-fibre proportion and [PCr]/[] (, ) or [PCr]/[βATP] (, ); the correlations between its changes (delta) and the fibre-shift were significant as well (delta[PCr]/[] , delta[PCr]/[βATP] , ).Conclusion. Shifts in fibre type composition and high energy phosphate metabolite content covary in human gastrocnemius muscle. Therefore -MRS might be a feasible method for noninvasive monitoring of exercise-induced fibre type transformation.