Rising within the leadership of an orthopaedic society: learning from the presidents.

Orthopaedic societies, with their diverse membership from across the world, serve a mission to endorse the progress and innovation in the field of orthopaedics and traumatology with a focus on improving patient care, as well as to encourage and develop education, teaching and research. Such organizations, whether small or large, have been successful in meeting the professional, educational and training needs of its members. The past and future presidents of these societies share insights addressing their professional experiences, lessons learnt and their vision for future leaders of the field. The objective of this article is to summarize the thoughts of presidents of orthopaedic societies from around the globe and to inspire younger and aspiring members of the global orthopaedic fraternity

Does the Spine Surgeon’s Experience Affect Fracture Classification, Assessment of Stability, and Treatment Plan in Thoracolumbar Injuries?

Study Design: Prospective survey-based study. Objectives: The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons’ clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied. Methods: Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as \u3c10 years (n = 12) and \u3e10 years (n = 29). Results: There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience hadmore correct diagnosis in classifyingA3 (47.2% vs 38.5%in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0%in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries. Conclusion: Surgeons’ experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups. © The Author(s) 2017

Morphometric Evaluation of Occipital Condyles: Defining Optimal Trajectories and Safe Screw Lengths for Occipital Condyle-Based Occipitocervical Fixation in Indian Population

Study DesignComputed tomographic (CT) morphometric analysis.PurposeTo assess the feasibility and safety of occipital condyle (OC)-based occipitocervical fixation (OCF) in Indians and to define anatomical zones and screw lengths for safe screw placement.Overview of LiteratureLimitations of occipital squama-based OCF has led to development of two novel OC-based OCF techniques.MethodsMorphometric analysis was performed on the OCs of 70 Indian adults. The feasibility of placing a 3.5-mm-diameter screw into OCs was investigated. Safe trajectories and screw lengths for OC screws and C0–C1 transarticular screws without hypoglossal canal or atlantooccipital joint compromise were estimated.ResultsThe average screw length and safe sagittal and medial angulations for OC screws were 19.9±2.3 mm, ≤6.4°±2.4° cranially, and 31.1°±3° medially, respectively. An OC screw could not be accommodated by 27% of the population. The safe sagittal angles and screw lengths for C0–C1 transarticular screw insertion (48.9°±5.7° cranial, 26.7±2.9 mm for junctional entry technique; 36.7°±4.6° cranial, 31.6±2.7 mm for caudal C1 arch entry technique, respectively) were significantly different than those in other populations. The risk of vertebral artery injury was high for the caudal C1 arch entry technique. Screw placement was uncertain in 48% of Indians due to the presence of aberrant anatomy.ConclusionsThere were significant differences in the metrics of OC-based OCF between Indian and other populations. Because of the smaller occipital squama dimensions in Indians, OC-based OCF techniques may have a higher application rate and could be a viable alternative/salvage option in selected cases. Preoperative CT, including three-dimensional-CT-angiography (to delineate vertebral artery course), is imperative to avoid complications resulting from aberrant bony and vascular anatomy. Our data can serve as a valuable reference guide in placing these screws safely under fluoroscopic guidance

Factors Affecting Early and 1-Year Motor Recovery Following Lumbar Microdiscectomy in Patients with Lumbar Disc Herniation: A Prospective Cohort Review

Study Design Prospective cohort study. Purpose The study was aimed at evaluating clinicoradiological factors affecting recovery of neurological deficits in cases of lumbar disc herniation (LDH) treated by lumbar microdiscectomy. Overview of Literature The majority of the available literature on neurological recovery following neurodeficit is limited to retrospective series. The literature is currently limited regarding variables that can help predict the recovery of neurodeficits following LDH. Methods A prospective analysis was performed on 70 consecutive patients who underwent lumbar microdiscectomy (L1–2 to L5–S1) owing to neurological deficits due to LDH. Patients with motor power ≤3/5 in L2–S1 myotomes were considered for analysis. Follow-up was performed at 2, 6, and 12 months to note recovery of motor deficits. Clinicoradiological parameters were compared between the recovered and nonrecovered groups. Results A total of 65 patients were available at the final follow-up: 41 (63%) had completely recovered by 2 months; four showed delayed recovery at the 6-month follow-up; and 20 (30.7%) showed no recovery at 1 year. Clinicoradiological factors, including diabetes, complete initial deficit, areflexia, multilevel disc prolapse, longer duration since initial symptoms, and ≥2 previous symptomatic episodes were associated with a significant risk of poorer recovery (p0.05 for all). Diabetes mellitus (p=0.033) and complete initial motor deficit (p=0.028) were significantly associated with delayed recovery in the multivariate analysis. Conclusions The overall neurological recovery rate in our study was 69%. Diabetes mellitus (p=0.033) and complete initial motor deficit were associated with delayed motor recovery

Analysis of Spinopelvic Parameters with L5 as the New Sacrum after Fusion in High-Grade Spondylolisthesis: A Possible Explanation for Satisfactory Results with Fusion

Study DesignRetrospective case series.PurposeTo correlate functional outcomes with spinopelvic parameters in patients with high-grade spondylolisthesis (HGS) treated with instrumented in-situ surgery or reduction and fusion.Overview of LiteratureSatisfactory functional outcomes are reported with reduction and in-situ fusion strategies in HGS. However, reasons for this are unclear. We hypothesize that following lumbosacral fusion, the L5 becomes part of the sacrum, which improves spinopelvic parameters, resulting in equivalent functional outcomes in both surgical methods.MethodsTwenty-six patients undergoing HGS (reduction group A, 13; in-situ group B, 13) were clinically evaluated using the Oswestry Disability Index (ODI), short form-12 (SF-12), and Visual Analogue Scale (VAS) scores. Spinopelvic parameters, including pelvic incidence, pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), lumbosacral kyphosis (LSK) angle, and sacrofemoral distance (SFD) were measured preoperatively from S1 and postoperatively from L5 as the new sacrum at 1 year follow-up. Sagittal alignment was assessed using the sagittal vertical axis.ResultsBoth groups were comparable in terms of age, sex, severity of slip, and preoperative spinopelvic parameters (p>0.05). Postoperative VAS, SF-12, and ODI scores significantly improved in both groups (p0.05).ConclusionsAfter fusion, the L5 becomes the new sacrum and influences spinopelvic parameters to change favorably. This possibly explains why reduction and in-situ fusion achieve equivalent functional outcomes in HGS

Analysis of Postoperative Clinical Outcomes in Cervical Myelopathy due to Ossification of Posterior Longitudinal Ligament Involving C2

Study Design Retrospective study. Purpose To investigate the radiological phenotype, patient and surgery-related risk factors influencing postoperative clinical outcome for cervical myelopathy caused by ossification of the posterior longitudinal ligament involving C2 following posterior instrumented laminectomy and fusion. Overview of Literature Ossified posterior longitudinal ligament (OPLL) is caused by ectopic ossification of the posterior longitudinal ligament. It can cause neurological impairment and severe disability. For multilevel cervical OPLL, studies have shown good neurological recovery following cord decompression via either an anterior or posterior approach. There is, however, a lacunae in the literature regarding the outcomes of patients with OPLL extending to C2 and above (C2 [+]). Methods We retrospectively studied 61 patients with C2 (+) OPLL who had posterior instrumented laminectomy and fusion at Ganga Hospital, Coimbatore between July 2011 and January 2021, with a minimum follow-up of 2 years. Data on demographics, clinical outcomes, radiology, and post-surgical outcomes were gathered. Results Among 61 patients, 56 were males and five were females. The OPLL pattern was mixed in 32 cases (52.5%), continuous in 26 cases (42.6%), segmental in two cases (3.3%), and circumscribed in one patient (1.6%). All of our patients showed signs of neurological improvement after a 24-month follow-up. The mean preoperative modified Japanese Orthopaedic Association (mJOA) score was 10.6 (range, 5–11) and the postoperative mJOA score was 15.8 (range, 12–18). The recovery rate was >75% in 27 patients (44.6%), >50% in 32 patients (52.5%), and >25% in two patients (3.3%). The average recovery rate was 71% (range, 33%–100%). The independent risk factor for predicting recovery rate is the preoperative mJOA score. Conclusions In C2 (+) OPLL, posterior instrumented decompression and fusion provide a relatively safe approach and satisfactory results

Impact of Patient Counseling and Socioeconomic Factors on Initiation of Rehabilitation Program in Spinal Cord Injury Patients Presenting to a Tertiary Spine Unit in India

Study Design Prospective case series. Purpose This study aimed to investigate the impact of education, financial income, occupation, and patient counseling on the timing of enrolment in a spinal cord injury (SCI) rehabilitation program. Overview of Literature A rehabilitation program following SCI is essential to improve functional outcomes. Socioeconomic factors can affect the timing of enrolment to a rehabilitation program. Literature on the effects of socioeconomic factors among patients with SCI in the Indian scenario is limited. Methods A prospective, consecutive analysis of patients with SCI was performed with 1-year follow-up. Assessment of the timing of enrolment to a rehabilitation program was performed using the modified Kuppuswamy socioeconomic scores (MKSS). Patients admitted to the SCI unit (group A), underwent intensive individual, group, and family counseling sessions to encourage early enrolment into a rehabilitation program. Patients presenting directly for rehabilitation (group B) were analyzed for comparison. Results A total of 153 patients were recruited. Group A was composed of 122 patients who started the rehabilitation program after a mean of 28 days, compared with a mean of 149 days for 31 patients in group B. In group A, 104 patients (85%; mean MKSS, 14.02) and 18 patients (15%; mean MKSS, 15.61) enrolled for rehabilitation 0.05). Conclusions Early patient counseling in the acute care unit helps in the early enrolment of patients with poor socioeconomic demographic profile to a rehabilitation program

Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic review.

OBJECTIVE The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems. METHODS A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems. RESULTS A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable "U-type" fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date. CONCLUSIONS The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries

A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders

OBJECTIVE: The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders. METHODS: A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities. RESULTS: Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers\u27 compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders. CONCLUSION: Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature

Variation in global treatment for subaxial cervical spine isolated unilateral facet fractures.

PURPOSE To determine the variation in the global treatment practices for subaxial unilateral cervical spine facet fractures based on surgeon experience, practice setting, and surgical subspecialty. METHODS A survey was sent to 272 members of the AO Spine Subaxial Injury Classification System Validation Group worldwide. Questions surveyed surgeon preferences with regard to diagnostic work-up and treatment of fracture types F1-F3, according to the AO Spine Subaxial Cervical Spine Injury Classification System, with various associated neurologic injuries. RESULTS A total of 161 responses were received. Academic surgeons use the facet portion of the AO Spine classification system less frequently (61.6%) compared to hospital-employed and private practice surgeons (81.1% and 81.8%, respectively) (p = 0.029). The overall consensus was in favor of operative treatment for any facet fracture with radicular symptoms (N2) and for any fractures categorized as F2N2 and above. For F3N0 fractures, significantly less surgeons from Africa/Asia/Middle East (49%) and Europe (59.2%) chose operative treatment than from North/Latin/South America (74.1%) (p = 0.025). For F3N1 fractures, significantly less surgeons from Africa/Asia/Middle East (52%) and Europe (63.3%) recommended operative treatment than from North/Latin/South America (84.5%) (p = 0.001). More than 95% of surgeons included CT in their work-up of facet fractures, regardless of the type. No statistically significant differences were seen in the need for MRI to decide treatment. CONCLUSION Considerable agreement exists between surgeon preferences with regard to unilateral facet fracture management with few exceptions. F2N2 fracture subtypes and subtypes with radiculopathy (N2) appear to be the threshold for operative treatment