Nonoperatively treated type A spinal fractures:mid-term versus long-term functional outcome

This study focuses on the mid-term (four years) and long-term (ten years) functional outcome of patients treated nonoperatively for a type A spinal fracture without primary neurological deficit. Functional outcome was measured using the visual analogue scale spine score (VAS) and the Roland–Morris disability questionnaire (RMDQ). The 50 patients included were on average 41.2 years old at the time of injury. Four years post injury, a mean VAS score of 74.5 and a mean RMDQ score of 4.9 were found. Ten years after the accident, the mean VAS and RMDQ scores were 72.6 and 4.7, respectively (NS). No significant relationships were found between the difference scores of the VAS and RMDQ compared with age, gender, fracture sub-classification, and time between measurements. Three (6%) patients had a poor long-term outcome. None of the patients required surgery for late onset pain or progressive neurological deficit. Functional outcome after a nonoperatively treated type A spinal fracture is good, both four and ten years post injury. For the group as a whole, four years after the fracture a steady state exists in functional outcome, which does not change for ten years at least after the fracture

Engagement of the rat hindlimb motor cortex across natural locomotor behaviors

Contrary to cats and primates, cortical contribution to hindlimb locomotor movements is not critical in rats. However, the importance of the motor cortex to regain locomotion after neurological disorders in rats suggests that cortical engagement in hindlimb motor control may depend on the behavioral context. To investigate this possibility, we recorded whole-body kinematics, muscle synergies, and hindlimb motor cortex modulation in freely moving rats performing a range of natural locomotor procedures. We found that the activation of hindlimb motor cortex preceded gait initiation. During overground locomotion, the motor cortex exhibited consistent neuronal population responses that were synchronized with the spatiotemporal activation of hindlimb motoneurons. Behaviors requiring enhanced muscle activity or skilled paw placement correlated with substantial adjustment in neuronal population responses. In contrast, all rats exhibited a reduction of cortical activity during more automated behavior, such as stepping on a treadmill. Despite the facultative role of the motor cortex in the production of locomotion in rats, these results show that the encoding of hindlimb features in motor cortex dynamics is comparable in rats and cats. However, the extent of motor cortex modulations appears linked to the degree of volitional engagement and complexity of the task, reemphasizing the importance of goal-directed behaviors for motor control studies, rehabilitation, and neuroprosthetics. © 2016 the authors

Are sarcopenia and myosteatosis in elderly patients with pelvic ring injury related to mortality, physical functioning and quality of life?

The purpose of this study was to evaluate the prevalence of sarcopenia and/or myosteatosis in elderly patients with pelvic ring injuries and their influence on mortality, patient-perceived physical functioning and quality of life (QoL). A multicenter retrospective cohort study was conducted including elderly patients aged ≥ 65 treated for a pelvic ring injury. Cross-sectional computed tomography (CT) muscle measurements were obtained to determine the presence of sarcopenia and/or myosteatosis. Kaplan–Meier analysis was used for survival analysis, and Cox proportional hazards regression analysis was used to determine risk factors for mortality. Patient-reported outcome measures for physical functioning (SMFA) and QoL (EQ-5D) were used. Multivariable linear regression analyses were used to determine the effect of sarcopenia and myosteatosis on patient-perceived physical functioning and QoL. Data to determine sarcopenia and myosteatosis were available for 199 patients, with a mean follow-up of 2.4 ± 2.2 years: 66 patients (33%) were diagnosed with sarcopenia and 65 (32%) with myosteatosis, while 30 of them (15%) had both. Mortality rates in patients at 1 and 3 years without sarcopenia and myosteatosis were 13% and 21%, compared to 11% and 36% in patients with sarcopenia, 17% and 31% in patients with myosteatosis and 27% and 43% in patients with both. Higher age at the time of injury and a higher Charlson Comorbidity Index (CCI) were independent risk factors for mortality. Patient-reported mental and emotional problems were significantly increased in patients with sarcopenia

What Are the Interobserver and Intraobserver Variability of Gap and Stepoff Measurements in Acetabular Fractures?

BACKGROUND: Gap and stepoff values in the treatment of acetabular fractures are correlated with clinical outcomes. However, the interobserver and intraobserver variability of gap and stepoff measurements for all imaging modalities in the preoperative, intraoperative, and postoperative phase of treatment is unknown. Recently, a standardized CT-based measurement method was introduced, which provided the opportunity to assess the level of variability. QUESTIONS/PURPOSES: (1) In patients with acetabular fractures, what is the interobserver variability in the measurement of the fracture gaps and articular stepoffs determined by each observer to be the maximum one in the weightbearing dome, as measured on pre- and postoperative pelvic radiographs, intraoperative fluoroscopy, and pre- and postoperative CT scans? (2) What is the intraobserver variability in these measurements? METHODS: Sixty patients with a complete subset of pre-, intra- and postoperative high-quality images (CT slices of < 2 mm), representing a variety of fracture types with small and large gaps and/or stepoffs, were included. A total of 196 patients with nonoperative treatment (n = 117), inadequate available imaging (n = 60), skeletal immaturity (n = 16), bilateral fractures (n = 2) or a primary THA (n = 1) were excluded. The maximum gap and stepoff values in the weightbearing dome were digitally measured on pelvic radiographs and CT images by five independent observers. Observers were free to decide which gap and/or stepoff they considered the maximum and then measure these before and after surgery. The observers were two trauma surgeons with more than 5 years of experience in pelvic surgery, two trauma surgeons with less than 5 years of experience in pelvic surgery, and one surgical resident. Additionally, the final intraoperative fluoroscopy images were assessed for the presence of a gap or stepoff in the weightbearing dome. All observers used the same standardized measurement technique and each observer measured the first five patients together with the responsible researcher. For 10 randomly selected patients, all measurements were repeated by all observers, at least 2 weeks after the initial measurements. The intraclass correlation coefficient (ICC) for pelvic radiographs and CT images and the kappa value for intraoperative fluoroscopy measurements were calculated to determine the inter- and intraobserver variability. Interobserver variability was defined as the difference in the measurements between observers. Intraobserver variability was defined as the difference in repeated measurements by the same observer. RESULTS: Preoperatively, the interobserver ICC was 0.4 (gap and stepoff) on radiographs and 0.4 (gap) and 0.3 (stepoff) on CT images. The observers agreed on the indication for surgery in 40% (gap) and 30% (stepoff) on pelvic radiographs. For CT scans the observers agreed in 95% (gap) and 70% (stepoff) of images. Postoperatively, the interobserver ICC was 0.4 (gap) and 0.2 (stepoff) on radiographs. The observers agreed on whether the reduction was acceptable or not in 60% (gap) and 40% (stepoff). On CT images the ICC was 0.3 (gap) and 0.4 (stepoff). The observers agreed on whether the reduction was acceptable in 35% (gap) and 38% (stepoff). The preoperative intraobserver ICC was 0.6 (gap and stepoff) on pelvic radiographs and 0.4 (gap) and 0.6 (stepoff) for CT scans. Postoperatively, the intraobserver ICC was 0.7 (gap) and 0.1 (stepoff) on pelvic radiographs. On CT the intraobserver ICC was 0.5 (gap) and 0.3 (stepoff). There was no agreement between the observers on the presence of a gap or stepoff on intraoperative fluoroscopy images (kappa -0.1 to 0.2). CONCLUSIONS: We found an insufficient interobserver and intraobserver agreement on measuring gaps and stepoffs for supporting clinical decisions in acetabular fracture surgery. If observers cannot agree on the size of the gap and stepoff, it will be challenging to decide when to perform surgery and study the results of acetabular fracture surgery. LEVEL OF EVIDENCE: Level III, diagnostic study

Feasibility of Imaging-Based 3-Dimensional Models to Design Patient-Specific Osteosynthesis Plates and Drilling Guides

Importance: In acetabular fracture surgery, achieving an optimal reconstruction of the articular surface decreases the risk of osteoarthritis and the subsequent need for total hip arthroplasty. However, no one-size-fits-all osteosynthesis plate is available owing to differences in fracture patterns and variations in pelvic anatomy. Currently, osteosynthesis plates need to be manually contoured intraoperatively, often resulting in inadequate reduction and fixation of the fractured segments. Objective: To determine the feasibility and accuracy of a novel concept of fast-track 3-dimensional (3-D) virtual surgical planning and patient-specific osteosynthesis for complex acetabular fracture surgery. Design, Setting, and Participants: This case series study examines the use of patient-specific osteosynthesis plates for patients needing operative treatment for displaced associated-type acetabular fractures at a tertiary university-affiliated referral center and level 1 trauma center between January 1, 2017, and December 31, 2018. Models were created in 3-D based on computed tomography (CT) data, fractures were virtually reduced, and implant positions were discussed in a multidisciplinary team of clinicians and engineers. Patient-specific osteosynthesis plates with drilling guides were designed, produced, sterilized and clinically applied within 4 days. Data were analyzed at the 1-year follow-up. Exposures: Development and clinical implementation of personalized fracture surgery. Main Outcomes and Measures: The primary outcome was the quality of the reduction as determined by the postoperative CT scan. The secondary outcomes were accuracy of the screw placement and clinical outcome using patient-reported outcome measures. Results: Ten patients with a median (range) age of 63 (46-79) years with an acetabular fracture were included. The median (interquartile range [IQR]) preoperative gap was 20 (15-22) mm, and the median (IQR) step-off was 5 (3-11) mm. Postoperatively, the median (IQR) gap was reduced to 3 (2-5) mm (P = .005), and the median (IQR) step-off was reduced to 0 (0-2) mm (P = .01), indicating good fracture reduction, indicating good fracture reduction. The mean difference between the preoperative and postoperative gap was 14.6 (95% CI, 10-19) mm, and the mean difference in step-off was 5.7 (95% CI, 2-9) mm. The median (IQR) difference in screw direction between the planning and actual surgery was only 7.1° (7°-8°). All patients retained their native hip and reported good physical functioning at follow-up. Conclusions and Relevance: These findings suggest that 3-D virtual surgical planning, manufacturing, and clinical application of patient-specific osteosynthesis plates and drilling guides was feasible and yielded good clinical outcomes. Fast-track personalized surgical treatment could open a new era for the treatment of complex injuries

Does 3D-assisted surgery of tibial plateau fractures improve surgical and patient outcome?:A systematic review of 1074 patients

PURPOSE: The aim of this systematic review was to provide an overview of current applications of 3D technologies in surgical management of tibial plateau fractures and to assess whether 3D-assisted surgery results in improved clinical outcome as compared to surgery based on conventional imaging modalities. METHODS: A literature search was performed in Pubmed and Embase for articles reporting on the use of 3D techniques in operative management of tibial plateau fractures. This systematic review was performed in concordance with the PRISMA-guidelines. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal. Differences in terms of operation time, blood loss, fluoroscopy frequency, intra-operative revision rates and patient-reported outcomes between 3D-assisted and conventional surgery were assessed. Data were pooled using the inverse variance weighting method in RevMan. RESULTS: Twenty articles evaluating 948 patients treated with 3D-assisted surgery and 126 patients with conventional surgery were included. Five different concepts of 3D-assisted surgery were identified: '3D virtual visualization', '3D printed hand-held fracture models', 'Pre-contouring of osteosynthesis plates', '3D printed surgical guides', and 'Intra-operative 3D imaging'. 3D-assisted surgery resulted in reduced operation time (104.7 vs. 126.4 min; P < 0.01), less blood loss (241 ml vs. 306 ml; P < 0.01), decreased frequency of fluoroscopy (5.8 vs. 9.1 times; P < 0.01). No differences in functional outcome was found (Hospital for Special Surgery Knee-Rating Scale: 88.6 vs. 82.8; P = 0.23). CONCLUSIONS: Five concepts of 3D-assisted surgical management of tibial plateau fractures emerged over the last decade. These include 3D virtual fracture visualization, 3D-printed hand-held fracture models for surgical planning, 3D-printed models for pre-contouring of osteosynthesis plates, 3D-printed surgical guides, and intra-operative 3D imaging. 3D-assisted surgery may have a positive effect on operation time, blood loss, and fluoroscopy frequency