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Åkerstedt J, Wänman J, Banitalebi H, Myklebust TÅ, Weber C, Storheim K, Hellum C, Indrekvam K, Hermansen E, Brisby H. Change in Lumbar Lordosis after Decompressive Surgery in Lumbar Spinal Stenosis Patients and Associations with Patient Related Outcomes 2 Years after Surgery. Radiological and Clinical Results from the NORDSTEN Spinal Stenosis Trial. Spine (Phila Pa 1976) 2024:00007632-990000000-00667. [PMID: 38736326 DOI: 10.1097/brs.0000000000005037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Abstract
STUDY DESIGN A prospective cohort study. OBJECTIVE The aim was to investigate changes in lumbar lordosis (LL) and its association to changes in patient reported outcome measures (PROMs) after decompressive surgery for lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND Few studies have addressed change in LL after decompression surgery for LSS in relation to outcomes. METHOD Pre- and postoperative data from 310 patients having standing x-ray both before and 2 years after surgery were included. The patients were grouped based on the change in LL preoperatively to 2 years after surgery; group 1: <5 degrees (n=196), group 2: ≥5 <10 degrees (n=55) or group 3: ≥10 degrees (n=59) of change in LL. The changes in function, disability and pain were assessed by the Oswestry Disability Index (ODI), Numeric Rating Scale (NRS), and the Zurich claudication questionnaire (ZCQ). The three groups were compared regarding baseline variables using the ANOVA test for continuous variables and the chi-square test for categorical variables. The groups were further compared with a likelihood ratio test in relation to changes in PROMs 2 year after surgery and outcomes were adjusted for respective baseline PROMs, age, sex, smoking, BMI, Schizas and Pfirrmann scores. RESULTS LL was significantly changed at group level 2 years after surgery with a mean difference of 2.2 (SD 9.4) degrees ( P =0.001). The three LL change groups did not show any significant differences in patient characteristics, function, disability, and pain at baseline. The two groups with a change of more than 5 degrees in LL 2 year after surgery (group 2 and 3) had significantly greater improvements in ODI ( P =0.022) and ZCQ function ( P =0.016) in the adjusted analyses, but was not significant for back and leg pain. CONCLUSION Changed LL after decompressive surgery for LSS was associated with improved ODI and physical function.
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Affiliation(s)
- Josefin Åkerstedt
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - Johan Wänman
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Akershus, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital
- Department of Quality and Health Technology, University of Stavanger
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Oslo, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erland Hermansen
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Institute of Health Science, Norwegian Uniiversity for Technology and Science, Norway
| | - Helena Brisby
- Dept of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dept. of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Hermansen E, Myklebust TÅ, Austevoll IM, Hellum C, Storheim K, Banitalebi H, Indrekvam K, Brisby H. Dural Sac Cross-sectional area change from preoperatively and up to 2 years after decompressive surgery for central lumbar spinal stenosis: investigation of operated levels, data from the NORDSTEN study. Eur Spine J 2024:10.1007/s00586-024-08251-4. [PMID: 38587545 DOI: 10.1007/s00586-024-08251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/31/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE The aim of the present study was to investigate how canal area size changed from before surgery and up to 2 years after decompressive lumbar surgery lumbar spinal stenosis. Further, to investigate if an area change postoperatively (between 3 months to 2 years) was associated with any preoperative demographic, clinical or MRI variables or surgical method used. METHODS The present study is analysis of data from the NORDSTEN- SST trial where 437 patients were randomized to one of three mini-invasive surgical methods for lumbar spinal stenosis. The patients underwent MRI examination of the lumbar spine before surgery, and 3 and 24 months after surgery. For all operated segments the dural sac cross-sectional area (DSCA) was measured in mm2. Baseline factors collected included age, gender, BMI and smoking habits. Furthermore, surgical method, index level, number of levels operated, all levels operated on and baseline Schizas grade were also included in the analysis. RESULTS 437 patients were enrolled in the NORDSTEN-SST trial, whereof 310 (71%) had MRI at 3 months and 2 years. Mean DSCA at index level was 52.0 mm2 (SD 21.2) at baseline, at 3 months it increased to 117.2 mm2 (SD 43.0) and after 2 years the area was 127.7 mm2 (SD 52.5). Surgical method, level operated on or Schizas did not influence change in DSCA from 3 to 24 months follow-up. CONCLUSION The spinal canal area after lumbar decompressive surgery for lumbar spinal stenosis increased from baseline to 3 months after surgery and remained thereafter unchanged 2 years postoperatively.
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Affiliation(s)
- Erland Hermansen
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.
- Institute of Health Sciences, Norwegian University of Technology and Science, Ålesund, Norway.
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Oslo, Oslo, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Banitalebi H, Hermansen E, Hellum C, Espeland A, Storheim K, Myklebust TÅ, Indrekvam K, Brisby H, Weber C, Anvar M, Aaen J, Negård A. Preoperative fatty infiltration of paraspinal muscles assessed by MRI is associated with less improvement of leg pain 2 years after surgery for lumbar spinal stenosis. Eur Spine J 2024:10.1007/s00586-024-08210-z. [PMID: 38528161 DOI: 10.1007/s00586-024-08210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/08/2024] [Accepted: 03/01/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE Fatty infiltration (FI) of the paraspinal muscles may associate with pain and surgical complications in patients with lumbar spinal stenosis (LSS). We evaluated the prognostic influence of MRI-assessed paraspinal muscles' FI on pain or disability 2 years after surgery for LSS. METHODS A muscle fat index (MFI) was calculated (by dividing signal intensity of psoas to multifidus and erector spinae) on preoperative axial T2-weighted MRI of patients with LSS. Pain and disability 2 years after surgery were assessed using the Oswestry disability index, the Zurich claudication questionnaire and numeric rating scales for leg and back pain. Multivariate linear and logistic regression analyses (adjusted for preoperative outcome scores, age, body mass index, sex, smoking status, grade of spinal stenosis, disc degeneration and facet joint osteoarthritis) were used to assess the associations between MFI and patient-reported clinical outcomes. In the logistic regression models, odds ratios (OR) and 95% confidence intervals (CI) were calculated for associations between the MFI and ≥ 30% improvement of the outcomes (dichotomised into yes/no). RESULTS A total of 243 patients were evaluated (mean age 66.6 ± 8.5 years), 49% females (119). Preoperative MFI and postoperative leg pain were significantly associated, both with leg pain as continuous (coefficient - 3.20, 95% CI - 5.61, - 0.80) and dichotomised (OR 1.51, 95% CI 1.17, 1.95) scores. Associations between the MFI and the other outcome measures were not statistically significant. CONCLUSION Preoperative FI of the paraspinal muscles on MRI showed statistically significant association with postoperative NRS leg pain but not with ODI or ZCQ.
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Affiliation(s)
- Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Erland Hermansen
- Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | | | - Jørn Aaen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Negård
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Rognsvåg T, Bergvad IB, Furnes O, Indrekvam K, Lerdal A, Lindberg MF, Skou ST, Stubberud J, Badawy M. Exercise therapy, education, and cognitive behavioral therapy alone, or in combination with total knee arthroplasty, in patients with knee osteoarthritis: a randomized feasibility study. Pilot Feasibility Stud 2024; 10:43. [PMID: 38419024 PMCID: PMC10900652 DOI: 10.1186/s40814-024-01470-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/16/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND One in five patients experience chronic pain 1 year after total knee arthroplasty (TKA), highlighting the need for enhanced treatment strategies to improve outcomes. This feasibility trial aimed to optimize the content and delivery of a complex intervention tailored to osteoarthritis (OA) patients at risk of poor outcome after TKA and assess the feasibility of initiating a full-scale multicenter randomized controlled trial (RCT). METHODS Patients scheduled for TKA were included between August 2019 and June 2020 and block-randomized into one of three groups: (a) 12-week exercise therapy and education (ExE) and 10-module internet-delivered cognitive behavioral therapy (iCBT), (b) TKA followed by ExE and iCBT and (c) TKA and standard postoperative care. Outcomes were (i) recruitment and retention rate, (ii) compliance to the intervention and follow-up, (iii) crossover, and (iv) adverse events, reported by descriptive statistics. RESULTS Fifteen patients were included in the study. Only 1 out of 146 patients screened for eligibility was included during the first 4 months. During the next 3 months, 117 patients were not included since they lived too far from the hospital. To increase the recruitment rate, we made three amendments to the inclusion criteria; (1) at-risk screening of poor TKA outcome was removed as an eligibility criterion, (2) patients across the country could be included in the study and (3) physiotherapists without specific certification were included, receiving thorough information and support. No patients withdrew from the study or crossed over to surgery during the first year. Nine out of 10 patients completed the ExE program and six out of 10 completed the iCBT program. Fourteen out of 15 patients completed the 1-year follow-up. One minor adverse event was registered. CONCLUSIONS Except for recruitment and compliance to iCBT, feasibility was demonstrated. The initial recruitment process was challenging, and necessary changes were made to increase the recruitment rate. The findings informed how a definitive RCT should be undertaken to test the effectiveness of the complex intervention. TRIAL REGISTRATION The MultiKnee RCT, including the feasibility study, is pre-registered at ClinicalTrials.gov: NCT03771430 11/12/2018.
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Affiliation(s)
- Turid Rognsvåg
- Department of Orthopedic Surgery, Haukeland University Hospital, Coastal Hospital in Hagevik, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ingvild Buset Bergvad
- Department of Surgery, Lovisenberg Diaconal Hospital, Oslo, Norway
- Department of Interdisciplinary Health Sciences, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kari Indrekvam
- Department of Orthopedic Surgery, Haukeland University Hospital, Coastal Hospital in Hagevik, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Anners Lerdal
- Department of Interdisciplinary Health Sciences, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Research, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Maren Falch Lindberg
- Department of Surgery, Lovisenberg Diaconal Hospital, Oslo, Norway
- Department of Public Health Science, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Jan Stubberud
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Mona Badawy
- Department of Orthopedic Surgery, Haukeland University Hospital, Coastal Hospital in Hagevik, Bergen, Norway
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Hagerup S, Brox JI, Banitalebi H, Indrekvam K, Myklebust TÅ, Hermansen E. The Influence of Spinous Process Union on Clinical Outcomes After Spinous Process Osteotomy for Lumbar Spinal Stenosis After 2 Years: A Secondary Analysis From the NORDSTEN-Study. Int J Spine Surg 2024:8576. [PMID: 38413237 DOI: 10.14444/8576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Lumbar spinal stenosis is a prevalent and increasingly important cause of low back pain, leg pain, and walking impairment. Minimally invasive decompressive techniques such as spinous process (SP) osteotomy have become more common in recent years. The main aim of this study was to investigate the proportion of complete SP union and whether complete radiological healing after the osteotomy is associated with superior clinical outcome after 2 years. METHODS In this retrospective cohort study, 149 patients were included from the Spinal Stenosis Trial, a part of the NORwegian Degenerative spondylolisthesis and spinal STENosis study. Computed tomography imaging was performed 2 years postoperatively. The number of osteotomies and the number of SP unions were recorded. Patients were divided into groups based on the degree of union: nonunion, partial union, and complete union. Rate of success (>30% improvement in Oswestry Disability Index [ODI]) and mean change in ODI were the primary outcome measures. We compared the differences between baseline and follow-up between the Degree of Union groups. RESULTS The study included 102 of 149 eligible patients. Ten patients (9.8%) were classified as having nonunion, 15 (14.7%) as having partial union, and 77 (75.5%) as having complete union. Of the 155 osteotomies, there were 122 classified as union (77%). The success rate was 74%, with no influence of SP union. The mean change in the ODI was -20.1 (95% CI -37.0, 14.2) with no influence of SP union. CONCLUSIONS We found no influence of SP union, classified by computed tomography, on clinical outcome 2 years after SP osteotomy in patients with lumbar spinal stenosis. CLINICAL RELEVANCE Supplying useful information about SPO to assist surgeons in the choice of decompressive technique. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Sondre Hagerup
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Norway, Europe
| | - Jens Ivar Brox
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway, Europe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Norway, Europe
| | - Hasan Banitalebi
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway, Europe
- Department of Diagnostic Imaging, Akershus University Hospital, Norway, Europe
| | - Kari Indrekvam
- Kysthospitalet i Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway, Europe
- Department of Clinical Medicine, University of Bergen, Bergen, Norway, Europe
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway, Europe
- Department of Registration, Cancer Registry of Norway, Oslo, Norway, Europe
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Norway, Europe
- Kysthospitalet i Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway, Europe
- Department of Clinical Medicine, University of Bergen, Bergen, Norway, Europe
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Wänman J, Åkerstedt J, Banitalebi H, Myklebust TÅ, Weber C, Storheim K, Austevoll IM, Hellum C, Indrekvam K, Brisby H, Hermansen E. The association between lumbar lordosis preoperatively and changes in PROMs for lumbar spinal stenosis patients 2 years after spinal surgery: radiological and clinical results from the NORDSTEN-spinal stenosis trial. Eur Spine J 2024:10.1007/s00586-024-08137-5. [PMID: 38386059 DOI: 10.1007/s00586-024-08137-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/21/2023] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Patients with lumbar spinal stenosis (LSS) sometimes have lower lumbar lordosis (LL), and the incidence of LSS correlates closely with the loss of LL. The few studies that have evaluated the association between LL and clinical outcomes after non-instrumented surgery for LSS show conflicting results. This study investigates the association between preoperative LL and changes in PROMs 2 years after decompressive surgery. METHOD This prospective cohort study obtained preoperative and postoperative data for 401 patients from the multicenter randomized controlled spinal stenosis trial as part of the NORwegian degenerative spondylolisthesis and spinal STENosis (NORDSTEN) study. Before surgery, the radiological sagittal alignment parameter LL was measured using standing X-rays. The association between LL and 2-year postoperative changes was analyzed using the oswestry disability index (ODI), a numeric rating scale (NRS) for low back and leg pain, the Zurich claudication questionnaire (ZCQ), and the global perceived effect (GPE) score. The changes in PROMs 2 years after surgery for quintiles of lumbar lordosis were adjusted for the respective baseline PROMs: age, sex, smoking, and BMI. The Schizas index and the Pfirrmann index were used to analyze multiple regressions for changes in PROMs. RESULTS There were no associations in the adjusted and unadjusted analyses between preoperative LL and changes in ODI, ZCQ, GPE, and NRS for back and leg pain 2 years after surgery. CONCLUSION LL before surgery was not associated with changes in PROMs 2 years after surgery. Lumbar lordosis should not be a factor when considering decompressive surgery for LSS.
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Affiliation(s)
- Johan Wänman
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden.
| | - Josefin Åkerstedt
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Akershus, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
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Tronstad S, Haug KJ, Myklebust TÅ, Weber C, Brisby H, Austevoll IM, Hellum C, Storheim K, Aaen J, Banitalebi H, Brox JI, Grundnes O, Franssen E, Indrekvam K, Solberg T, Hermansen E. Do patients with lumbar spinal stenosis benefit from decompression of levels with adjacent moderate stenosis? A prospective cohort study from the NORDSTEN study. Spine J 2024:S1529-9430(24)00017-2. [PMID: 38266826 DOI: 10.1016/j.spinee.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/03/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) is characterized by pain that radiates to the buttocks and/or legs, aggravated by walking and relieved by forward flexion. There is poor correlation between clinical symptoms and severity of stenosis on MRI, and multi-level stenosis has not been described to present worse symptoms or treatment outcomes, compared with patients with single-level stenosis. In patients with one level with severe stenosis combined with an adjacent level with moderate stenosis, the surgeon must decide whether to decompress only the narrowest level or both, to achieve the best possible outcome. The potential benefits of performing surgery on an adjacent moderate stenosis is debated, and the scientific evidence in scarce. PURPOSE The aim of the present study was to investigate whether patients with a level of adjacent moderate stenosis, along with an index stenosis, benefitted from a dual-level decompression (DLD) compared with a single-level decompression (SLD). Furthermore, to investigate whether DLD patients had longer duration of surgery and hospital stay, higher rates of complications and/or lower rate of reoperations compared with SLD patients. STUDY DESIGN Prospective cohort study. PATIENT SAMPLE We analyzed data from the Norwegian Degenerative Spondylisthesis and Spinal Stenosis study- Spinal Stenosis Trial (NORDSTEN-SST). In this randomized multicenter study, 437 patients were included, evaluating clinical outcomes of three different surgical treatment options for LSS. Patients with degenerative spondylolisthesis were excluded. METHOD Based on preoperative MRI, the present analysis included all patients who had a moderate stenosis (defined as Schizas B or C) in addition to a predefined index stenosis (the level with the smallest cross-sectional area). We compared patients who, based on the surgeons` choice, received a dual-level decompression, with those receiving a single-level decompression. OUTCOME MEASURES The primary outcome was mean change in the Oswestry Disability Index (ODI) score from baseline to 2-year follow up. Secondary outcomes were proportion of success (30% reduction in ODI score), the Numeric Rating Scales for back and leg pain (NRS), the EuroQol 5-dimensional questionnaire utility index (EQ-5D), the Zurich Claudication Questionnaire (ZCQ), the Global Perceived Effect (GPE)-scale, duration of surgery, duration of hospital stay, perioperative complications and reoperation rates. RESULTS Among the 222 patients, included in the analysis, 108 underwent DLD and 114 underwent SLD. There was no difference in change scores for any of the investigated patient-reported outcomes between the groups after 2 years. However, the DLD group had longer duration of surgery and longer length of hospital stay. There was no difference in reoperation rates or perioperative complications. CONCLUSION This study, alongside the NORDSTEN-LSS trial on patients with adjacent moderate stenosis as well as an index stenosis, showed no superior clinical effectiveness for dual-level surgery compared with single-level surgery.
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Affiliation(s)
- Sara Tronstad
- Department of Orthopedic Surgery, Skien Hospital, Skien, Norway.
| | | | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway; Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Oslo, Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre og Romsdal Hospital Trust, Ålesund, Norway; Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Norbyhagen, Norway
| | - Eric Franssen
- Department of Orthopedic Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Neurosurgical Department, University Hospital of North Norway, Trømsø, Norway
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre og Romsdal Hospital Trust, Ålesund, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Hermansen E, Indrekvam K, Weber C, Brisby H. Postoperative Dural Sac Cross-Sectional Area as an Association for Outcome After Surgery for Lumbar Spinal Stenosis: Clinical and Radiologic Results From the NORDSTEN-Spinal Stenosis Trial (Spine, May 15, 2023). Spine (Phila Pa 1976) 2024; 49:E10. [PMID: 37823287 DOI: 10.1097/brs.0000000000004850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Norway
- Department of Quality and Health Technology, University of Stavanger, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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Indrekvam K, Bånerud IF, Hermansen E, Austevoll IM, Rekeland F, Guddal MH, Solberg TK, Brox JI, Hellum C, Storheim K. The Norwegian degenerative spondylolisthesis and spinal stenosis (NORDSTEN) study: study overview, organization structure and study population. Eur Spine J 2023; 32:4162-4173. [PMID: 37395780 DOI: 10.1007/s00586-023-07827-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/10/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE To provide an overview of the The Norwegian Degenerative spondylolisthesis and spinal stenosis (NORDSTEN)-study and the organizational structure, and to evaluate the study population. METHODS The NORDSTEN is a multicentre study with 10 year follow-up, conducted at 18 public hospitals. NORDSTEN includes three studies: (1) The randomized spinal stenosis trial comparing the impact of three different decompression techniques; (2) the randomized degenerative spondylolisthesis trial investigating whether decompression surgery alone is as good as decompression with instrumented fusion; (3) the observational cohort tracking the natural course of LSS in patients without planned surgical treatment. A range of clinical and radiological data are collected at defined time points. To administer, guide, monitor and assist the surgical units and the researchers involved, the NORDSTEN national project organization was established. Corresponding clinical data from the Norwegian Registry for Spine Surgery (NORspine) were used to assess if the randomized NORDSTEN-population at baseline was representative for LSS patients treated in routine surgical practice. RESULTS A total of 988 LSS patients with or without spondylolistheses were included from 2014 to 2018. The clinical trials did not find any difference in the efficacy of the surgical methods evaluated. The NORDSTEN patients were similar to those being consecutively operated at the same hospitals and reported to the NORspine during the same time period. CONCLUSION The NORDSTEN study provides opportunity to investigate clinical course of LSS with or without surgical interventions. The NORDSTEN-study population were similar to LSS patients treated in routine surgical practice, supporting the external validity of previously published results. TRIAL REGISTRATION ClinicalTrials.gov; NCT02007083 10/12/2013, NCT02051374 31/01/2014 and NCT03562936 20/06/2018.
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Affiliation(s)
- Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ingrid Fjeldheim Bånerud
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Erland Hermansen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Maren Hjelle Guddal
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tore K Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway (UiT), Tromsø, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
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10
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Hellum C, Rekeland F, Småstuen MC, Solberg T, Hermansen E, Storheim K, Brox JI, Furunes H, Franssen E, Weber C, Brisby H, Grundnes O, Algaard KRH, Böker T, Banitalebi H, Indrekvam K, Austevoll IM. Surgery in degenerative spondylolisthesis: does fusion improve outcome in subgroups? A secondary analysis from a randomized trial (NORDSTEN trial). Spine J 2023; 23:1613-1622. [PMID: 37355044 DOI: 10.1016/j.spinee.2023.06.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/16/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND CONTEXT Patients with spinal stenosis and degenerative spondylolisthesis are treated surgically with decompression alone or decompression with fusion. However, there is debate regarding which subgroups of patients may benefit from additional fusion. PURPOSE To investigate possible treatment effect modifiers and prognostic variables among patients operated for spinal stenosis and degenerative spondylolisthesis. DESIGN A secondary exploratory study using data from the Norwegian Degenerative Spondylolisthesis and Spinal Stenosis (NORDSTEN-DS) trial. Patients were randomized to decompression alone or decompression with instrumented fusion. PATIENT SAMPLE The sample in this study consists of 267 patients from a randomized multicenter trial involving 16 hospitals in Norway. Patients were enrolled from February 12, 2014, to December 18, 2017. The study did not include patients with degenerative scoliosis, severe foraminal stenosis, multilevel spondylolisthesis, or previous surgery. OUTCOME MEASURES The primary outcome was an improvement of ≥ 30% on the Oswestry Disability Index score (ODI) from baseline to 2-year follow-up. METHODS When investigating possible variables that could modify the treatment effect, we analyzed the treatment arms separately. When testing for prognostic factors we analyzed the whole cohort (both treatment groups). We used univariate and multiple regression analyses. The selection of variables was done a priori, according to the published trial protocol. RESULTS Of the 267 patients included in the trial (183 female [67%]; mean [SD] age, 66 [7.6] years), complete baseline data for the variables required for the present analysis were available for 205 of the 267 individuals. We did not find any clinical or radiological variables at baseline that modified the treatment effect. Thus, none of the commonly used criteria for selecting patients for fusion surgery influenced the chosen primary outcome in the two treatment arms. For the whole cohort, less comorbidity (American Society of Anesthesiologists Classification [ASA], OR = 4.35; 95% confidence interval (CI [1.16-16.67]) and more preoperative leg pain (OR = 1.23; CI [1.02-1.50]) were significantly associated with an improved primary outcome. CONCLUSIONS In this study on patients with degenerative spondylolisthesis, neither previously defined instability criteria nor other pre-specified baseline variables were associated with better clinical outcome if fusion surgery was performed. None of the analyzed variables can be applied to guide the decision for fusion surgery in patients with degenerative spondylolisthesis. For both treatment groups, less comorbidity and more leg pain were associated with improved outcome 2 years after surgery. TRIAL REGISTRATION NORDSTEN-DS ClinicalTrials.gov, NCT02051374.
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Affiliation(s)
- Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Fallanveien 6c, Oslo, Norway.
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Milada Cvancarova Småstuen
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Tore Solberg
- Institute of Clinical Medicine, The Arctic University of Norway (UiT), Tromsø, Norway; The Norwegian Registry for Spine Surgery (NORspine), University Hospital of North Norway, Tromsø, Norway
| | - Erland Hermansen
- Orthopedic Department, Møre and Romsdal Hospital Trust, Ålesund Hospital, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway; Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; Medical Faculty, University of Oslo, Oslo, Norway
| | - Håvard Furunes
- Gjøvik Hospital, Innlandet Hospital Trust, Brumunddal, Norway; Institute of Health and Society Studies, University of Oslo, Oslo, Norway
| | - Eric Franssen
- Department of Orthopedic, Stavanger University Hospital, Stavanger, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway; Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Helena Brisby
- Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Oliver Grundnes
- Department of Orthopedic, Akershus University Hospital, Oslo, Norway
| | | | - Tordis Böker
- Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital, Bergen, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital, Bergen, Norway
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11
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Aaen J, Banitalebi H, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Anvar M, Weber C, Solberg T, Grundnes O, Brisby H, Indrekvam K, Hermansen E. Is the presence of foraminal stenosis associated with outcome in lumbar spinal stenosis patients treated with posterior microsurgical decompression. Acta Neurochir (Wien) 2023; 165:2121-2129. [PMID: 37407851 PMCID: PMC10409656 DOI: 10.1007/s00701-023-05693-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/16/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND We aim to investigate associations between preoperative radiological findings of lumbar foraminal stenosis with clinical outcomes after posterior microsurgical decompression in patients with predominantly central lumbar spinal stenosis (LSS). METHODS The study was an additional analysis in the NORDSTEN Spinal Stenosis Trial. In total, 230 men and 207 women (mean age 66.8 (SD 8.3)) were included. All patients underwent an MRI including T1- and T2-weighted sequences. Grade of foraminal stenosis was dichotomized into none to moderate (0-1) and severe (2-3) category using Lee's classification system. The Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and numeric rating scale (NRS) for back and leg pain were collected at baseline and at 2-year follow-up. Primary outcome was a reduction of 30% or more on the ODI score. Secondary outcomes included the mean improvement on the ODI, ZCQ, and NRS scores. We performed multivariable regression analyses with the radiological variates foraminal stenosis, Pfirrmann grade, Schizas score, dural sac cross-sectional area, and the possible plausible confounders: patients' gender, age, smoking status, and BMI. RESULTS The cohort of 437 patients presented a high degree of degenerative changes at baseline. Of 414 patients with adequate imaging of potential foraminal stenosis, 402 were labeled in the none to moderate category and 12 in the severe category. Of the patients with none to moderate foraminal stenosis, 71% achieved at least 30% improvement in ODI. Among the patients with severe foraminal stenosis, 36% achieved at least 30% improvement in ODI. A significant association between severe foraminal stenosis and less chance of reaching the target of 30% improvement in the ODI score after surgery was detected: OR 0.22 (95% CI 0.06, 0.83), p=0.03. When investigating outcome as continuous variables, a similar association between severe foraminal stenosis and less improved ODI with a mean difference of 9.28 points (95%CI 0.47, 18.09; p=0.04) was found. Significant association between severe foraminal stenosis and less improved NRS pain in the lumbar region was also detected with a mean difference of 1.89 (95% CI 0.30, 3.49; p=0.02). No significant association was suggested between severe foraminal stenosis and ZCQ or NRS leg pain. CONCLUSION In patients operated with posterior microsurgical decompression for LSS, a preoperative severe lumbar foraminal stenosis was associated with higher proportion of patients with less than 30% improvement in ODI. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (22.11.2013) under the identifier NCT02007083.
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Affiliation(s)
- Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | | | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Dept. of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Nordbyhagen, Norway
| | - Helena Brisby
- Dept of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dept. of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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12
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Hermansen E, Myklebust TÅ, Weber C, Brisby H, Austevoll IM, Hellum C, Storheim K, Aaen J, Banitalebi H, Brox JI, Grundnes O, Rekeland F, Solberg T, Franssen E, Indrekvam K. Postoperative Dural Sac Cross-Sectional Area as an Association for Outcome After Surgery for Lumbar Spinal Stenosis: Clinical and Radiological Results From the NORDSTEN-Spinal Stenosis Trial. Spine (Phila Pa 1976) 2023; 48:688-694. [PMID: 36809364 PMCID: PMC10118242 DOI: 10.1097/brs.0000000000004565] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 02/23/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim was to investigate the association between postoperative dural sac cross-sectional area (DSCA) after decompressive surgery for lumbar spinal stenosis and clinical outcome. Furthermore, to investigate if there is a minimum threshold for how extensive a posterior decompression needs to be to achieve a satisfactory clinical result. SUMMARY OF BACKGROUND DATA There is limited scientific evidence for how extensive lumbar decompression needs to be to obtain a good clinical outcome in patients with symptomatic lumbar spinal stenosis. MATERIALS AND METHODS All patients were included in the Spinal Stenosis Trial of the NORwegian Degenerative spondylolisthesis and spinal STENosis (NORDSTEN)-study. The patients underwent decompression according to three different methods. DSCA measured on lumbar magnetic resonance imaging at baseline and at three months follow-up, and patient-reported outcome at baseline and at two-year follow-up were registered in a total of 393 patients. Mean age was 68 (SD: 8.3), proportion of males were 204/393 (52%), proportion of smokers were 80/393 (20%), and mean body mass index was 27.8 (SD: 4.2).The cohort was divided into quintiles based on the achieved DSCA postoperatively, the numeric, and relative increase of DSCA, and the association between the increase in DSCA and clinical outcome were evaluated. RESULTS At baseline, the mean DSCA in the whole cohort was 51.1 mm 2 (SD: 21.1). Postoperatively the area increased to a mean area of 120.6 mm 2 (SD: 46.9). The change in Oswestry disability index in the quintile with the largest DSCA was -22.0 (95% CI: -25.6 to -18), and in the quintile with the lowest DSCA the Oswestry disability index change was -18.9 (95% CI: -22.4 to -15.3). There were only minor differences in clinical improvement for patients in the different DSCA quintiles. CONCLUSION Less aggressive decompression performed similarly to wider decompression across multiple different patient-reported outcome measures at two years following surgery.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tor Å. Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ivar M. Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jens I. Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Eric Franssen
- Department of Orthopedic surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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13
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Høl PJ, Hallan G, Furnes O, Fenstad AM, Indrekvam K, Kadar T. Similarly low blood metal ion levels at 10-years follow-up of total hip arthroplasties with Oxinium, CoCrMo, and stainless steel femoral heads. Data from a randomized clinical trial. J Biomed Mater Res B Appl Biomater 2023; 111:821-828. [PMID: 36356214 PMCID: PMC10099800 DOI: 10.1002/jbm.b.35193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/21/2022] [Accepted: 10/29/2022] [Indexed: 11/12/2022]
Abstract
The use of inert head materials such as ceramic heads has been proposed as a method of reducing wear and corrosion products from the articulating surfaces in total hip arthroplasty, as well as from the stem-head taper connection. The aim of the present study was to compare the blood metal ion levels in patients with Oxinium and CoCrMo modular femoral heads, as well as monoblock stainless steel Charnley prostheses at 10 years postoperatively. The 150 patients with osteoarthritis of the hip joint included in a randomized clinical trial were grouped according to femoral head material. One group (n = 30) had received the Charnley monoblock stainless steel stem (DePuy, UK). The other patients (n = 120) received a Spectron EF CoCrMo stem with either a 28 mm CoCrMo or Oxinium modular head (Smith & Nephew, USA). After 10 years, 38 patients had withdrawn, 19 deceased, 7 revised due to aseptic loosening and 5 revised due to infection. The 81 patients with median age of 79 years (70-91) were available for whole blood metal ion analysis. The levels of Co, Cr, Ni and Zr in the blood were generally low with all the head materials (medians <0.3 micrograms/L) and no statistical difference between the groups were found (p = .2-.8). Based on the low blood metal ion values in our study groups, no indication of severe trunnion corrosion in patients with CoCrMo heads was observed, neither was there any beneficial reduction in metal ion exposure with the Oxinium femoral heads.
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Affiliation(s)
- Paul Johan Høl
- Biomatlab, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Hallan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,The Coastal Hospital at Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,The Coastal Hospital at Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Thomas Kadar
- Physical Medicine and Rehabilitation, Clinic of Habilitation and Rehabilitation, Haukeland University Hospital, Bergen, Norway
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14
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Dybvik V, Hermansen E, Banitalebi H, Myklebust TÅ, Indrekvam K. Is Repeated Preoperative Magnetic Resonance Imaging Necessary Before Planned Decompressive Surgery for Lumbar Spinal Stenosis? Int J Spine Surg 2023:8469. [PMID: 36963810 DOI: 10.14444/8469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Currently, there are different routines in Norwegian hospitals regarding how recent magnetic resonance imaging (MRI) of the lumbar spine should be performed before surgery. Patients with lumbar spinal stenosis from the Norwegian degenerative spondylolisthesis and spinal stenosis study, who had 2 preoperative MRIs performed within the year before surgery, were included. The aim of the present study was to evaluate the utility of repeated preoperative MRI for patients undergoing decompressive spine surgery for degenerative spinal stenosis. METHODS For all included patients, the changes between the 2 preoperative MRIs were investigated for disc degeneration (Pfirrmann's classification), foraminal stenosis (Lee's classification), spondylolisthesis, and central canal stenosis (Schizas score and dural sac cross-sectional area). RESULTS A total of 65 patients (78 levels) were included. Thirty-seven patients were women, and the mean age was 67 (range 48-79) years. Schizas score showed a clinically meaningful change of ±2 or 3 grades in 5 levels, and dural sac cross- sectional area was reduced in 47 levels with a mean change of -2.3 mm2. Three levels had a clinically relevant change in grade of foraminal stenosis of ±2. For disc degeneration, 53 of the levels had no change, and the rest of the levels had a change of ±1 grade. Increased spondylolisthesis was measured at 21 levels, and the mean slip was <2 mm. Also, 4 levels had >2 mm slip. CONCLUSION For patients undergoing surgery for lumbar spinal stenosis, repeated MRI within the year before planned surgery showed few significant changes in common radiological parameters. The benefit for the surgeon of repeat MRI is therefore limited. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Veronika Dybvik
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Clinical Development in Hofsteh BioCare, Ålesund, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital trust, Ålesund, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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15
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Aaen J, Banitalebi H, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Anvar M, Weber C, Solberg T, Grundnes O, Brisby H, Indrekvam K, Hermansen E. The association between preoperative MRI findings and clinical improvement in patients included in the NORDSTEN spinal stenosis trial. Eur Spine J 2022; 31:2777-2785. [PMID: 35930062 DOI: 10.1007/s00586-022-07317-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To investigate potential associations between preoperative MRI findings and patient reported outcome measures (PROMs) after surgery for lumbar spinal stenosis (LSS). METHODS The NORDSTEN trial included 437 patients. We investigated the association between preoperative MRI findings such as morphological grade of stenosis (Schizas grade), quantitative grade of stenosis (dural sac cross-sectional area), disc degeneration (Pfirrmann score), facet joint tropism and fatty infiltration of the multifidus muscle, and improvement in patient reported outcome measures (PROMs) 2 years after surgery. We dichotomized each radiological parameter into a moderate or severe category. PROMs i.e., Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ) and Numeric rating scale (NRS) for back and leg pain were collected before surgery and at 2 year follow-up. In the primary analysis, we investigated the association between MRI findings and ODI score (dichotomized to ≥ 30% improvement or not). In the secondary analysis, we investigated the association between MRI findings and the mean improvement on the ODI-, ZCQ- and NRS scores. We used multivariable regression models adjusted for patients' gender, age, smoking status and BMI. RESULTS The primary analysis showed that severe disc degeneration (Pfirrmann score 4-5) was significantly associated with less chance of achieving a 30% improvement on the ODI score (OR 0.54, 95% CI 0.34, 0.88). In the secondary analysis, we detected no clinical relevant associations. CONCLUSION Severe disc degeneration preoperatively suggest lesser chance of achieving 30% improvement in ODI score after surgery for LSS. Other preoperative MRI findings were not associated with patient reported outcome.
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Affiliation(s)
- Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | | | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Dept. of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Lørenskog, Norway
| | - Helena Brisby
- Dept of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dept. of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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16
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Banitalebi H, Aaen J, Storheim K, Negård A, Myklebust TÅ, Grotle M, Hellum C, Espeland A, Anvar M, Indrekvam K, Weber C, Brox JI, Brisby H, Hermansen E. A novel MRI index for paraspinal muscle fatty infiltration: reliability and relation to pain and disability in lumbar spinal stenosis: results from a multicentre study. Eur Radiol Exp 2022; 6:38. [PMID: 35854201 PMCID: PMC9296716 DOI: 10.1186/s41747-022-00284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fatty infiltration of the paraspinal muscles may play a role in pain and disability in lumbar spinal stenosis. We assessed the reliability and association with clinical symptoms of a method for assessing fatty infiltration, a simplified muscle fat index (MFI). METHODS Preoperative axial T2-weighted magnetic resonance imaging (MRI) scans of 243 patients aged 66.6 ± 8.5 years (mean ± standard deviation), 119 females (49%), with symptomatic lumbar spinal stenosis were assessed. Fatty infiltration was assessed using both the MFI and the Goutallier classification system (GCS). The MFI was calculated as the signal intensity of the psoas muscle divided by that of the multifidus and erector spinae. Observer reliability was assessed in 102 consecutive patients for three independent investigators by intraclass correlation coefficient (ICC) and 95% limits of agreement (LoA) for continuous variables and Gwet's agreement coefficient (AC1) for categorical variables. Associations with patient-reported pain and disability were assessed using univariate and multivariate regression analyses. RESULTS Interobserver reliability was good for the MFI (ICC 0.79) and fair for the GCS (AC1 0.33). Intraobserver reliability was good or excellent for the MFI (ICC range 0.86-0.91) and moderate to almost perfect for the GCS (AC1 range 0.55-0.92). Mean interobserver differences of MFI measurements ranged from -0.09 to -0.04 (LoA -0.32 to 0.18). Adjusted for potential confounders, none of the disability or pain parameters was significantly associated with MFI or GCS. CONCLUSION The proposed MFI demonstrated high observer reliability but was not associated with preoperative pain or disability.
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Affiliation(s)
- Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Jørn Aaen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Anne Negård
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Margreth Grotle
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Department of Physiotherapy, Faculty of Health Science, Oslo Metropolitan University, P.O. box 4, St. Olafs plass, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Orthopaedics, Institute for clinical sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erland Hermansen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Hofseth BioCare, Ålesund, Norway
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17
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Hermansen E, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Aaen J, Banitalebi H, Anvar M, Rekeland F, Brox JI, Franssen E, Weber C, Solberg TK, Furunes H, Grundnes O, Brisby H, Indrekvam K. Comparison of 3 Different Minimally Invasive Surgical Techniques for Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e224291. [PMID: 35344046 PMCID: PMC8961320 DOI: 10.1001/jamanetworkopen.2022.4291] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE Operations for lumbar spinal stenosis is the most often performed surgical procedure in the adult lumbar spine. This study reports the clinical outcome of the 3 most commonly used minimally invasive posterior decompression techniques. OBJECTIVE To compare the effectiveness of 3 minimally invasive posterior decompression techniques for lumbar spinal stenosis. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial used a parallel group design and included patients with symptomatic and radiologically verified lumbar spinal stenosis without degenerative spondylolisthesis. Patients were enrolled between February 2014 and October 2018 at the orthopedic and neurosurgical departments of 16 Norwegian public hospitals. Statistical analysis was performed in the period from May to June 2021. INTERVENTIONS Patients were randomized to undergo 1 of the 3 minimally invasive posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy, and spinous process osteotomy. MAIN OUTCOMES AND MEASURES Primary outcome was change in disability measured with Oswestry Disability Index (ODI; range 0-100), presented as mean change from baseline to 2-year follow-up and proportions of patients classified as success (>30% reduction in ODI). Secondary outcomes were mean change in quality of life, disease-specific symptom severity measured with Zurich Claudication Questionnaire (ZCQ), back pain and leg pain on a 10-point numeric rating score (NRS), patient perceived benefit of the surgical procedure, duration of the surgical procedure, blood loss, perioperative complications, number of reoperations, and length of hospital stay. RESULTS In total, 437 patients were included with a median (IQR) age of 68 (62-73) years and 230 men (53%). Of the included patients, 146 were randomized to unilateral laminotomy with crossover, 142 to bilateral laminotomy, and 149 to spinous process osteotomy. The unilateral laminotomy with crossover group had a mean change of -17.9 ODI points (95% CI, -20.8 to -14.9), the bilateral laminotomy group had a mean change of -19.7 ODI points (95% CI, -22.7 to -16.8), and the spinous process osteotomy group had a mean change of -19.9 ODI points (95% CI, -22.8 to -17.0). There were no significant differences in primary or secondary outcomes among the 3 surgical procedures, except a longer duration of the surgical procedure in the bilateral laminotomy group. CONCLUSIONS AND RELEVANCE No differences in clinical outcomes or complication rates were found among the 3 minimally invasive posterior decompression techniques used to treat patients with lumbar spinal stenosis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02007083.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Hofseth BioCare, Ålesund, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Eric Franssen
- Department of Orthopedics, Stavanger University Hospital, Stavanger, Norway
| | - Clemens Weber
- Department of Orthopedics, Stavanger University Hospital, Stavanger, Norway
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore K. Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Håvard Furunes
- Department of Surgery, Gjøvik Hospital, Innlandet Hospital Trust, Brumunddal, Norway
- Institute of Health and Society Studies, University of Oslo, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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18
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Banitalebi H, Espeland A, Anvar M, Hermansen E, Hellum C, Brox JI, Myklebust TÅ, Indrekvam K, Brisby H, Weber C, Aaen J, Austevoll IM, Grundnes O, Negård A. Reliability of preoperative MRI findings in patients with lumbar spinal stenosis. BMC Musculoskelet Disord 2022; 23:51. [PMID: 35033042 PMCID: PMC8760672 DOI: 10.1186/s12891-021-04949-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
Background Magnetic Resonance Imaging (MRI) is an important tool in preoperative evaluation of patients with lumbar spinal stenosis (LSS). Reported reliability of various MRI findings in LSS varies from fair to excellent. There are inconsistencies in the evaluated parameters and the methodology of the studies. The purpose of this study was to evaluate the reliability of the preoperative MRI findings in patients with LSS between musculoskeletal radiologists and orthopaedic spine surgeons, using established evaluation methods and imaging data from a prospective trial. Methods Consecutive lumbar MRI examinations of candidates for surgical treatment of LSS from the Norwegian Spinal Stenosis and Degenerative Spondylolisthesis (NORDSTEN) study were independently evaluated by two musculoskeletal radiologists and two orthopaedic spine surgeons. The observers had a range of experience between six and 13 years and rated five categorical parameters (foraminal and central canal stenosis, facet joint osteoarthritis, redundant nerve roots and intraspinal synovial cysts) and one continuous parameter (dural sac cross-sectional area). All parameters were re-rated after 6 weeks by all the observers. Inter- and intraobserver agreement was assessed by Gwet’s agreement coefficient (AC1) for categorical parameters and Intraclass Correlation Coefficient (ICC) for the dural sac cross-sectional area. Results MRI examinations of 102 patients (mean age 66 ± 8 years, 53 men) were evaluated. The overall interobserver agreement was substantial or almost perfect for all categorical parameters (AC1 range 0.67 to 0.98), except for facet joint osteoarthritis, where the agreement was moderate (AC1 0.39). For the dural sac cross-sectional area, the overall interobserver agreement was good or excellent (ICC range 0.86 to 0.96). The intraobserver agreement was substantial or almost perfect/ excellent for all parameters (AC1 range 0.63 to 1.0 and ICC range 0.93 to 1.0). Conclusions There is high inter- and intraobserver agreement between radiologists and spine surgeons for preoperative MRI findings of LSS. However, the interobserver agreement is not optimal for evaluation of facet joint osteoarthritis. Trial registration www.ClinicalTrials.gov identifier: NCT02007083, registered December 2013. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04949-4.
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Affiliation(s)
- Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Erland Hermansen
- Hofseth BioCare, Ålesund, Norway.,Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Orthopaedics, Institute for clinical sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Jørn Aaen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of medicine and health sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Oliver Grundnes
- Department of Orthopaedics, Akershus University Hospital, Lørenskog, Norway
| | - Anne Negård
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Lindberg MF, Aamodt A, Badawy M, Bergvad IB, Borchgrevink P, Furnes O, Gay C, Heir S, Holm I, Indrekvam K, Kise N, Lau B, Magnussen J, Nerhus TK, Rognsvåg T, Rudsengen DE, Rustøen T, Skou ST, Stubberud J, Småstuen MS, Lerdal A. The effectiveness of exercise therapy and education plus cognitive behavioral therapy, alone or in combination with total knee arthroplasty in patients with knee osteoarthritis - study protocol for the MultiKnee trial. BMC Musculoskelet Disord 2021; 22:1054. [PMID: 34930194 PMCID: PMC8690622 DOI: 10.1186/s12891-021-04924-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
Background One in five patients report chronic pain following total knee arthroplasty (TKA) and are considered non-improvers. Psychological interventions such as cognitive behavioral therapy (CBT), combined with exercise therapy and education may contribute to reduced pain an improved function both for patients with OA or after TKA surgery, but the evidence for the effectiveness of such interventions is scarce. This randomized controlled trial with three arms will compare the clinical effectiveness of patient education and exercise therapy combined with internet-delivered CBT (iCBT), evaluated either as a non-surgical treatment choice or in combination with TKA, in comparison to usual treatment with TKA in patients with knee OA who are considered candidates for TKA surgery. Methods The study, conducted in three orthopaedic centers in Norway will include 282 patients between ages 18 and 80, eligible for TKA. Patients will be randomized to receive the exercise therapy + iCBT, either alone or in combination with TKA, or to a control group who will undergo conventional TKA and usual care physiotherapy following surgery. The exercise therapy will include 24 one hour sessions over 12 weeks led by a physiotherapist. The iCBT program will be delivered in ten modules. The physiotherapists will receive theoretical and practical training to advise and mentor the patients during the iCBT program. The primary outcome will be change from baseline to 12 months on the pain sub-scale from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include the remaining 4 sub-scales from the KOOS (symptoms, function in daily living, function in sports and recreation, and knee-related quality of life), EQ-5D-5L, the Pain Catastrophizing Scale, the 30-s sit-to-stand test, 40-m walking test and ActiGraph activity measures. A cost-utility analysis will be performed using QALYs derived from the EQ-5D-5L and registry data. Discussion This is the first randomized controlled trial to investigate the effectiveness of exercise therapy and iCBT with or without TKA, to optimize outcomes for TKA patients. Findings from this trial will contribute to evidence-based personalized treatment recommendations for a large proportion of OA patients who currently lack an effective treatment option. Trial registration Clinicaltrials.gov: NCT03771430. Registered: Dec 11, 2018.
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Affiliation(s)
- Maren Falch Lindberg
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway. .,Department of Nursing Science, Faculty of Medicine, University of Oslo, Pb 1072 Blindern, 0316, Oslo, Norway.
| | - Arild Aamodt
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway
| | - Mona Badawy
- Coastal Hospital in Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ingvild B Bergvad
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway.,Institute of Health and Society, Faculty of Medicine, University of Oslo, PB 1072 Blindern, 0316, Oslo, Norway
| | - Petter Borchgrevink
- Department of Pain and Complex Disorders, St Olavs Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Norwegian University of Science and Technology, Høgskoleringen 1, 1491, Trondheim, Norway
| | - Ove Furnes
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Caryl Gay
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway.,Department of Family Health Care Nursing, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, 94122, USA
| | - Stig Heir
- Martina Hansens Hospital, Dønskiveien 8, 1346, Gjettum, Norway
| | - Inger Holm
- Institute of Health and Society, Faculty of Medicine, University of Oslo, PB 1072 Blindern, 0316, Oslo, Norway.,Department of Acute Medicine, Oslo University Hospital, Pb 4956 Nydalen, 0424, Oslo, Norway
| | - Kari Indrekvam
- Coastal Hospital in Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Nina Kise
- Martina Hansens Hospital, Dønskiveien 8, 1346, Gjettum, Norway
| | - Bjørn Lau
- Department of Psychology, Faculty of Medicine, University of Oslo, PB 1072 Blindern, 0316, Oslo, Norway
| | - Jon Magnussen
- Norwegian University of Science and Technology, Høgskoleringen 1, 1491, Trondheim, Norway
| | | | - Turid Rognsvåg
- Coastal Hospital in Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Daniil E Rudsengen
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway
| | - Tone Rustøen
- Department of Nursing Science, Faculty of Medicine, University of Oslo, Pb 1072 Blindern, 0316, Oslo, Norway.,Department of Acute Medicine, Oslo University Hospital, Pb 4956 Nydalen, 0424, Oslo, Norway
| | - Søren T Skou
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, 5230, Odense, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved, Slagelse and Ringsted Hospital, 4200, Slagelse, Denmark
| | - Jan Stubberud
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway.,Department of Psychology, Faculty of Medicine, University of Oslo, PB 1072 Blindern, 0316, Oslo, Norway
| | - Milada S Småstuen
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, PB 1072 Blindern, 0316, Oslo, Norway
| | - Anners Lerdal
- Department of Surgery, Lovisenberg Diaconal Hospital, Pb 4970 Nydalen, 0440, Oslo, Norway.,Institute of Health and Society, Faculty of Medicine, University of Oslo, PB 1072 Blindern, 0316, Oslo, Norway
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20
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Rognsvåg T, Lindberg MF, Lerdal A, Stubberud J, Furnes O, Holm I, Indrekvam K, Lau B, Rudsengen D, Skou ST, Badawy M. Development of an internet-delivered cognitive behavioral therapy program for use in combination with exercise therapy and education by patients at increased risk of chronic pain following total knee arthroplasty. BMC Health Serv Res 2021; 21:1151. [PMID: 34696785 PMCID: PMC8546935 DOI: 10.1186/s12913-021-07177-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/14/2021] [Indexed: 12/27/2022] Open
Abstract
Background Approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA). Due to the growing number of TKA procedures, this will affect an increasing number of people worldwide. Catastrophic thinking, dysfunctional illness perception, poor mental health, anxiety and depression characterize these non-improvers, and indicate that these patients may need individualized treatment using a treatment approach based on the bio-psycho-social health model. The present study developed an internet-delivered cognitive behavioral therapy (iCBT) program to be combined with exercise therapy and education for patients with knee osteoarthritis (OA) at increased risk of chronic pain after TKA. Methods The development process followed the first two phases of the UK Medical Research Council framework for complex interventions. In the development phase, the first prototype of the iCBT program was developed based on literature review, established iCBT programs and multidisciplinary workshops. The feasibility phase consisted of testing the program, interviewing users, condensing the program, and tailoring it to the patient group. A physiotherapist manual was developed and adapted to physiotherapists who will serve as mentors. Results The development process resulted in an iCBT program consisting of 10 modules with educational texts, videos and exercises related to relevant topics such as goalsetting, stress and pain, lifestyle, automatic thoughts, mindfulness, selective attention, worry and rumination. A physiotherapist manual was developed to guide the physiotherapists in supporting the patients through the program and to optimize adherence to the program. Conclusions The iCBT program is tailored to patients at risk of chronic pain following TKA, and may be useful as a supplement to surgery and/or exercise therapy. A multicentre RCT will evaluate the iCBT program in combination with an exercise therapy and education program. This novel intervention may be a valuable contribution to the treatment of OA patients at risk of chronic pain after TKA. Trial registration The RCT is pre-registered at ClinicalTrials.gov: NCT03771430 11/12/2018.
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Affiliation(s)
- Turid Rognsvåg
- Coastal Hospital in Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Hagaviksbakken 25, N-5217, Hagavik, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Maren Falch Lindberg
- Faculty of Medicine, Institute of Health and Society, Department of Nursing Science, Oslo, Norway.,Department of Research, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Anners Lerdal
- Department of Research, Lovisenberg Diaconal Hospital, Oslo, Norway.,Faculty of Medicine, Department of Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
| | - Jan Stubberud
- Department of Research, Lovisenberg Diaconal Hospital, Oslo, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Inger Holm
- Faculty of Medicine, Department of Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway.,Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Kari Indrekvam
- Coastal Hospital in Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Hagaviksbakken 25, N-5217, Hagavik, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Bjørn Lau
- Faculty of Medicine, Department of Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
| | - Daniil Rudsengen
- Department of Research, Lovisenberg Diaconal Hospital, Oslo, Norway.,Faculty of Medicine, Department of Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
| | - Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Mona Badawy
- Coastal Hospital in Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Hagaviksbakken 25, N-5217, Hagavik, Norway
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21
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Austevoll IM, Hermansen E, Fagerland MW, Storheim K, Brox JI, Solberg T, Rekeland F, Franssen E, Weber C, Brisby H, Grundnes O, Algaard KRH, Böker T, Banitalebi H, Indrekvam K, Hellum C. Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis. N Engl J Med 2021; 385:526-538. [PMID: 34347953 DOI: 10.1056/nejmoa2100990] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with lumbar spinal stenosis and degenerative spondylolisthesis, it is uncertain whether decompression surgery alone is noninferior to decompression with instrumented fusion. METHODS We conducted an open-label, multicenter, noninferiority trial involving patients with symptomatic lumbar stenosis that had not responded to conservative management and who had single-level spondylolisthesis of 3 mm or more. Patients were randomly assigned in a 1:1 ratio to undergo decompression surgery (decompression-alone group) or decompression surgery with instrumented fusion (fusion group). The primary outcome was a reduction of at least 30% in the score on the Oswestry Disability Index (ODI; range, 0 to 100, with higher scores indicating more impairment) during the 2 years after surgery, with a noninferiority margin of -15 percentage points. Secondary outcomes included the mean change in the ODI score as well as scores on the Zurich Claudication Questionnaire, leg and back pain, the duration of surgery and length of hospital stay, and reoperation within 2 years. RESULTS The mean age of patients was approximately 66 years. Approximately 75% of the patients had leg pain for more than a year, and more than 80% had back pain for more than a year. The mean change from baseline to 2 years in the ODI score was -20.6 in the decompression-alone group and -21.3 in the fusion group (mean difference, 0.7; 95% confidence interval [CI], -2.8 to 4.3). In the modified intention-to-treat analysis, 95 of 133 patients (71.4%) in the decompression-alone group and 94 of 129 patients (72.9%) in the fusion group had a reduction of at least 30% in the ODI score (difference, -1.4 percentage points; 95% CI, -12.2 to 9.4), showing the noninferiority of decompression alone. In the per-protocol analysis, 80 of 106 patients (75.5%) and 83 of 110 patients (75.5%), respectively, had a reduction of at least 30% in the ODI score (difference, 0.0 percentage points; 95% CI, -11.4 to 11.4), showing noninferiority. The results for the secondary outcomes were generally in the same direction as those for the primary outcome. Successful fusion was achieved with certainty in 86 of 100 patients (86.0%) who had imaging available at 2 years. Reoperation was performed in 15 of 120 patients (12.5%) in the decompression-alone group and in 11 of 121 patients (9.1%) in the fusion group. CONCLUSIONS In this trial involving patients who underwent surgery for degenerative lumbar spondylolisthesis, most of whom had symptoms for more than a year, decompression alone was noninferior to decompression with instrumented fusion over a period of 2 years. Reoperation occurred somewhat more often in the decompression-alone group than in the fusion group. (NORDSTEN-DS ClinicalTrials.gov number, NCT02051374.).
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Affiliation(s)
- Ivar M Austevoll
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Erland Hermansen
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Morten W Fagerland
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Kjersti Storheim
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Jens I Brox
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Tore Solberg
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Frode Rekeland
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Eric Franssen
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Clemens Weber
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Helena Brisby
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Oliver Grundnes
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Knut R H Algaard
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Tordis Böker
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Hasan Banitalebi
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Kari Indrekvam
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Christian Hellum
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
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Abstract
BACKGROUND A BHR (Birmingham hip resurfacing) prosthesis was implanted in 445 people in Norway. Adverse reactions can arise as a result of the release of metal ions from metal-on-metal joint surfaces made from cobalt-chromium alloy. The aim of the study was to analyse the release of metal ions during the first five years after surgery in patients with a BHR prosthesis and to investigate whether this was linked to clinical complications. MATERIAL AND METHOD Forty-four male patients (median age 53 years) implanted with a BHR prosthesis at the Coastal Hospital at Hagevik in the period October 2009 to May 2013 were monitored by means of blood samples before implantation and three months, one year, three years and five years afterwards. Analyses of cobalt and chromium in whole blood were performed. Function scoring was used to clinically assess the prosthetic joint. RESULTS Metal ion concentrations increased between the surgery date and one year later (p < 0.001), and subsequently remained stable. After five years, the median concentrations (min.- max.) of cobalt and chromium were 1.1 µg/L (0.4-6.3 µg/L) and 1.4 µg/L (0.4-11.7 µg/L) respectively for unilateral prostheses (n = 36), and 2.3 µg/L (1.6-28.5 µg/L) and 2.6 µg/L (1.7-14.1 µg/L) respectively for bilateral prostheses (n = 8). Five patients underwent revision surgery, while other patients had good hip function. INTERPRETATION Patients with a BHR prosthesis had a significant increase in cobalt and chromium in their blood one to five years after surgery, but the median levels were still well below the threshold value of 7 μg/L, which indicates an increased risk of complications.
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23
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Austevoll IM, Gjestad R, Solberg T, Storheim K, Brox JI, Hermansen E, Rekeland F, Indrekvam K, Hellum C. Comparative Effectiveness of Microdecompression Alone vs Decompression Plus Instrumented Fusion in Lumbar Degenerative Spondylolisthesis. JAMA Netw Open 2020; 3:e2015015. [PMID: 32910195 PMCID: PMC7489859 DOI: 10.1001/jamanetworkopen.2020.15015] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Conflicting evidence and large practice variation are present in the surgical treatment of degenerative spondylolisthesis. More than 90% of surgical procedures in the United States include instrumented fusion compared with 50% or less in other countries. OBJECTIVE To evaluate whether the effectiveness of microdecompression alone is noninferior to decompression with instrumented fusion in a real-world setting. DESIGN, SETTING, AND PARTICIPANTS This multicenter comparative effectiveness study with a noninferiority design assessed prospective data from the Norwegian Registry for Spine Surgery. From September 19, 2007, to December 21, 2015, 1376 patients at 35 Norwegian orthopedic and neurosurgical departments underwent surgery for lumbar spinal stenosis with degenerative spondylolisthesis without scoliosis. After excluding patients undergoing laminectomy alone, fusion without instrumentation, or surgery in more than 2 levels and those with a former operation at the index level, 794 patients were included in the analyses, regardless of missing or incomplete follow-up data, before propensity score matching. Data were analyzed from March 20 to October 30, 2018. EXPOSURES Microdecompression alone or decompression with instrumented fusion. MAIN OUTCOMES AND MEASURES A reduction from baseline of 30% or greater in the Oswestry Disability Index at 12-month follow-up. RESULTS After propensity score matching, 570 patients (413 female [72%]; mean [SD] age, 64.7 [9.5] years) were included for comparison, with 285 undergoing microdecompression (mean [SD] age, 64.6 [9.8] years; 205 female [72%]) and 285 undergoing decompression with instrumented fusion (mean [SD] age, 64.8 [9.2] years; 208 female [73%]). The proportion of each type of procedure varied between departments. However, changes in outcome scores varied within patients but not between departments. The proportion of patients with improvement in the Oswestry Disability Index of at least 30% was 150 of 219 (68%) in the microdecompression group and 155 of 215 (72%) in the instrumentation group. The 95% CI (-12% to 5%) for the difference of -4% was above the predefined margin of noninferiority (-15%). Microdecompression alone was associated with shorter operation time (mean [SD], 89 [44] vs 180 [65] minutes; P < .001) and shorter hospital stay (mean [SD], 2.5 [2.4] vs 6.4 [3.0] days; P < .001). CONCLUSIONS AND RELEVANCE Among patients with degenerative spondylolisthesis, the clinical effectiveness of microdecompression alone was noninferior to that of decompression with instrumented fusion. Microdecompression alone was also associated with shorter durations of surgery and hospital stay, supporting the suggestion that the less invasive procedure should be considered for most patients.
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Affiliation(s)
- Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Rolf Gjestad
- Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Tore Solberg
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health, Oslo University Hospital, Oslo, Norway
| | - Jens Ivar Brox
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Department of Physical Medicine and Rehabilitation, Oslo, University Hospital, Oslo, Norway
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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24
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Hermansen E, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Aaen J, Banitalebi H, Anvar M, Rekeland F, Brox JI, Franssen E, Weber C, Solberg T, Haug KJ, Grundnes O, Brisby H, Indrekvam K. Comparable increases in dural sac area after three different posterior decompression techniques for lumbar spinal stenosis: radiological results from a randomized controlled trial in the NORDSTEN study. Eur Spine J 2020; 29:2254-2261. [PMID: 32556585 DOI: 10.1007/s00586-020-06499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/27/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate changes in dural sac area after three different posterior decompression techniques in patients undergoing surgery for lumbar spinal stenosis. Decompression of the nerve roots is the main surgical treatment for lumbar spinal stenosis. The aim of this study was to radiologically investigate three commonly used posterior decompression techniques. METHODS The present study reports data from one of two multicenter randomized trials included in the NORDSTEN study. In the present trial, involving 437 patients undergoing surgery, we report radiological results after three different midline retaining posterior decompression techniques: unilateral laminotomy with crossover (UL) (n = 146), bilateral laminotomy (BL) (n = 142) and spinous process osteotomy (SPO) (n = 149). MRI was performed before and three months after surgery. The increase in dural sac area and Schizas grade at the most stenotic level was evaluated. Three different predefined surgical indicators of substantial decompression were used: (1) postoperative dural sac area of > 100 mm2, (2) increase in the dural sac area of at least 50% and (3) postoperative Schizas grade A or B. RESULTS No differences between the three surgical groups were found in the mean increase in dural sac area. Mean values were 66.0 (SD 41.5) mm2 in the UL-group, 71.9 (SD 37.1) mm2 in the BL-group and 68.1 (SD 41.0) mm2 in the SPO-group (p = 0.49). No differences in the three predefined surgical outcomes between the three groups were found. CONCLUSION For patients with lumbar spinal stenosis, the three different surgical techniques provided the same increase in dural sac area. CLINICAL TRIAL REGISTRATION The study is registered at ClinicalTrials.gov reference on November 22th 2013 under the identifier NCT02007083.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital,, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital,, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Frode Rekeland
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Eric Franssen
- Department of Orthopaedics, Stavanger University Hospital, Stavanger, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsö, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsö, Norway
| | - Knut Jørgen Haug
- Departement of Orthopedic Surgery, Telemark Regional Hospital, Skien, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg, Sweden.,Department of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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25
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Hermansen E, Myklebust TÅ, Austevoll IM, Rekeland F, Solberg T, Storheim K, Grundnes O, Aaen J, Brox JI, Hellum C, Indrekvam K. Clinical outcome after surgery for lumbar spinal stenosis in patients with insignificant lower extremity pain. A prospective cohort study from the Norwegian registry for spine surgery. BMC Musculoskelet Disord 2019; 20:36. [PMID: 30669998 PMCID: PMC6343340 DOI: 10.1186/s12891-019-2407-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/08/2019] [Indexed: 01/25/2023] Open
Abstract
Background Spinal stenosis is a clinical diagnosis in which the main symptom is pain radiating to the lower extremities, or neurogenic claudication. Radiological spinal stenosis is commonly observed in the population and it is debated whether patients with no lower extremity pain should be labelled as having spinal stenosis. However, these patients is found in the Norwegian Registry for Spine Surgery, the main object of the present study was to compare the clinical outcomes after decompressive surgery in patients with insignificant lower extremity pain, with those with more severe pain. Methods This study is based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients who had decompressive surgery in the period from 7/1–2007 to 11/3–2013 at 31 hospitals were included. The patients was divided into four groups based on preoperative Numeric Rating Scale (NRS)-score for lower extremity pain. Patients in group 1 had insignificant pain, group 2 had mild or moderate pain, group 3 severe pain and group 4 extremely severe pain. The primary outcome was change in the Oswestry Disability Index (ODI). Successfully treated patients were defined as patients reporting at least 30% reduction of baseline ODI, and the number of successfully treated patients in each group were recorded. Results In total, 3181 patients were eligible; 154 patients in group 1; 753 in group 2; 1766 in group 3; and 528 in group 4. Group 1 had significantly less improvement from baseline in all the clinical scores 12 months after surgery compared to the other groups. However, with a mean reduction of 8 ODI points and 56% of patients showing a reduction of at least 30% in their ODI score, the proportion of patients defined as successfully treated in group 1, was not significantly different from that of other groups. Conclusion This national register study shows that patients with insignificant lower extremity pain had less improvement in primary and secondary outcome parameters from baseline to follow-up compared to patients with more severe lower extremity pain.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Tor Åge Myklebust
- Department of Research, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway.,University Hospital of North, Norwegian National Registry for spine surgery, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, University of Oslo, Oslo, Norway
| | - Christian Hellum
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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26
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Austevoll IM, Gjestad R, Grotle M, Solberg T, Brox JI, Hermansen E, Rekeland F, Indrekvam K, Storheim K, Hellum C. Follow-up score, change score or percentage change score for determining clinical important outcome following surgery? An observational study from the Norwegian registry for Spine surgery evaluating patient reported outcome measures in lumbar spinal stenosis and lumbar degenerative spondylolisthesis. BMC Musculoskelet Disord 2019; 20:31. [PMID: 30658613 PMCID: PMC6339296 DOI: 10.1186/s12891-018-2386-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/19/2018] [Indexed: 11/21/2022] Open
Abstract
Background Assessment of outcomes for spinal surgeries is challenging, and an ideal measurement that reflects all aspects of importance for the patients does not exist. Oswestry Disability Index (ODI), EuroQol (EQ-5D) and Numeric Rating Scales (NRS) for leg pain and for back pain are commonly used patients reported outcome measurements (PROMs). Reporting the proportion of individuals with an outcome of clinical importance is recommended. Knowledge of the ability of PROMs to identify clearly improved patients is essential. The purpose of this study was to search cut-off criteria for PROMs that best reflect an improvement considered by the patients to be of clinical importance. Methods The Global Perceived Effect scale was utilized to evaluate a clinically important outcome 12 months after surgery. The cut-offs for the PROMs that most accurately distinguish those who reported ‘completely recovered’ or ‘much improved’ from those who reported ‘slightly improved’, unchanged’, ‘slightly worse’, ‘much worse’, or ‘worse than ever’ were estimated. For each PROM, we evaluated three candidate response parameters: the (raw) follow-up score, the (numerical) change score, and the percentage change score. Results We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying ‘completely recovered’ and ‘much better’ patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline. The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS. Conclusion For estimating a ‘success’ rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.
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Affiliation(s)
- Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Christies gate 6, 5007 Bergen, Bergen, Norway. .,The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.
| | - Rolf Gjestad
- Research Department, Division of Psychiatry, Haukeland University Hospital, Sanviksleitet 1, 5036 Bergen, Bergen, Norway
| | - Margreth Grotle
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, PB 4950 Nydalen, 0424, Oslo, Oslo, Norway.,Faculty of Health Science, OsloMet - Oslo Metropolitan University, PO box 4 St. Olavs plass, 0130, Oslo, Oslo, Norway
| | - Tore Solberg
- The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.,Department of Neurosurgery, University Hospital of Northern Norway, Sykehusvegen 38, 90919 Tromsø, Tromsø, Norway
| | - Jens Ivar Brox
- The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.,Department of Physical Medicine and Rehabilitation, Oslo University Hospital, PB 4950 Nydalen, 0424, Oslo, Oslo, Norway
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Christies gate 6, 5007 Bergen, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Christies gate 6, 5007 Bergen, Bergen, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, PB 4950 Nydalen, 0424, Oslo, Oslo, Norway
| | - Christian Hellum
- The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.,Division of Orthopaedic Surgery, Oslo University Hospital, 4950 Nydalen, 0424, Oslo, PB, Norway
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Austevoll IM, Hermansen E, Fagerland M, Rekeland F, Solberg T, Storheim K, Brox JI, Lønne G, Indrekvam K, Aaen J, Grundnes O, Hellum C. Decompression alone versus decompression with instrumental fusion the NORDSTEN degenerative spondylolisthesis trial (NORDSTEN-DS); study protocol for a randomized controlled trial. BMC Musculoskelet Disord 2019; 20:7. [PMID: 30611229 PMCID: PMC6320633 DOI: 10.1186/s12891-018-2384-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fusion in addition to decompression has become the standard treatment for lumbar spinal stenosis with degenerative spondylolisthesis (DS). The evidence for performing fusion among these patients is conflicting and there is a need for further investigation through studies of high quality. The present protocol describes an ongoing study with the primary aim of comparing the outcome between decompression alone and decompression with instrumented fusion. The secondary aim is to investigate whether predictors can be used to choose the best treatment for an individual. The trial, named the NORDSTEN-DS trial, is one of three studies in the Norwegian Degenerative Spinal Stenosis (NORDSTEN) study. METHODS The NORDSTEN-DS trial is a block-randomized, controlled, multicenter, non-inferiority study with two parallel groups. The surgeons at the 15 participating hospitals decide whether a patient is eligible or not according to the inclusion and exclusion criteria. Participating patients are randomized to either a midline preserving decompression or a decompression followed by an instrumental fusion. Primary endpoint is the percentage of patients with an improvement in Oswestry Disability Index version 2.0 of more than 30% from baseline to 2-year follow-up. Secondary outcome measurements are the Zürich Claudication Questionnaire, Numeric Rating Scale for back and leg pain, Euroqol 5 dimensions questionnaire, Global perceived effect scale, complications and several radiological parameters. Analysis and interpretation of results will also be conducted after 5 and 10 years. CONCLUSION The NORDSTEN/DS trial has the potential to provide Level 1 evidence of whether decompression alone should be advocated as the preferred method or not. Further on the study will investigate whether predictors exist and if they can be used to make the appropriate choice for surgical treatment for this patient group. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02051374 . First Posted: January 31, 2014. Last Update Posted: February 14, 2018.
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Affiliation(s)
- Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Hagavik, N- 5217, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Hagavik, N- 5217, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, N-6026, Ålesund, Norway
| | - Morten Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, N-0424, Oslo, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Hagavik, N- 5217, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of Northern Norway, N-9019, Tromsø, Norway.,Department of Clinical Medicine, University of Tromsø - The Arctic University of Norway, N-9019, Tromsø, Norway.,The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, N-9038, Tromsø, Bodø, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, N-0424, Oslo, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, N-0424, Oslo, Norway
| | - Greger Lønne
- Department of Orthopedic Surgery, Innlandet Hospital Trust, N-2609, Lillehammer, Lillehammer, Norway
| | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, N-6026, Ålesund, Norway
| | - Jørn Aaen
- Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.,Department of Research, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7600, Levanger, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, N-1474, Lørenskog, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital, N-0424, Oslo, Norway
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Badawy M, Espehaug B, Fenstad AM, Indrekvam K, Dale H, Havelin LI, Furnes O. Patient and surgical factors affecting procedure duration and revision risk due to deep infection in primary total knee arthroplasty. BMC Musculoskelet Disord 2017; 18:544. [PMID: 29268748 PMCID: PMC5740908 DOI: 10.1186/s12891-017-1915-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to assess which patient and procedure factors affected both the risk of infection as well as procedure duration. Additionally, to assess if procedure duration affected the revision risk due to deep infection in total knee arthroplasty (TKA) patients and in a subgroup of low-risk patients. METHODS 28,262 primary TKA with 311 revisions due to deep infection were included from the Norwegian Arthroplasty Register (NAR) and analysed from primary surgery from 2005 until 31st December 2015 with a 1 and 4 year follow up. The risk of revision due to deep infection was calculated in a multivariable Cox regression model including patient and procedure related risk factors, assessing Hazard Ratio (HR) with 95% confidence interval (CI). RESULTS Multivariate analysis showed statistically significant associations with revision due to deep infection and increased procedure duration for male patients, ASA3+ (American Society of Anesthesiologists) and perioperative complications. Procedure duration ≥110 min (75 percentile) had a higher risk of deep infection compared to duration <75 min (25 percentile), in the unadjusted analysis (HR = 1.8, 95% CI 1.3-2.5, p = 0.001) and in the adjusted analysis (HR = 1.5, 95% CI 1.0-2.1, p = 0.03). For low-risk patients, procedure duration did not increase the risk of infection. CONCLUSION Male patients, ASA 3+ patients and perioperative complications were risk factors both for longer procedure duration and for deep infection revisions. Patients with a high degree of comorbidity, defined as ASA3+, are at risk of infection with longer procedure durations. The occurrence of perioperative complications potentially leading to a more complex and lengthy procedure was associated with a higher risk of infection. Long procedure duration in itself seems to have minor impact on infection since we found no association in the low-risk patient.
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Affiliation(s)
- Mona Badawy
- Coastal Hospital in Hagavik, 5217, Hagavik, Norway. .,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway.
| | - Birgitte Espehaug
- Center for Evidence-based Practice, Bergen University College, 5021, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, 5021, Bergen, Norway
| | - Kari Indrekvam
- Coastal Hospital in Hagavik, 5217, Hagavik, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
| | - Håvard Dale
- Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
| | - Leif I Havelin
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, 5021, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, 5021, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
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29
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Badawy M, Fenstad AM, Bartz-Johannessen CA, Indrekvam K, Havelin LI, Robertsson O, W-Dahl A, Eskelinen A, Mäkelä K, Pedersen AB, Schrøder HM, Furnes O. Hospital volume and the risk of revision in Oxford unicompartmental knee arthroplasty in the Nordic countries -an observational study of 14,496 cases. BMC Musculoskelet Disord 2017; 18:388. [PMID: 28882132 PMCID: PMC5590160 DOI: 10.1186/s12891-017-1750-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/31/2017] [Indexed: 12/13/2022] Open
Abstract
Background High procedure volume and dedication to unicompartmental knee arthroplasty (UKA) has been suggested to improve revision rates. This study aimed to quantify the annual hospital volume effect on revision risk in Oxfordu nicompartmental knee arthroplasty in the Nordic countries. Methods 14,496 cases of cemented medial Oxford III UKA were identified in 126 hospitals in the four countries included in the Nordic Arthroplasty Register Association (NARA) database from 2000 to 2012. Hospitals were divided by quartiles into 4 annual procedure volume groups (≤11, 12-23, 24-43 and ≥44). The outcome was revision risk after 2 and 10 years calculated using Kaplan Meier method. Multivariate Cox regression analysis was used to assess the Hazard Ratio (HR) of any revision due to specific reasons with 95% confidence intervals (CI). Results The implant survival was 80% at 10 years in the volume group ≤11 procedures per year compared to 83% in other volume groups. The HR adjusted for age category, sex, year of surgery and nation was 0.87 (95% CI: 0.76-0.99, p = 0.036) for the group 12-23 procedures per year, 0.78 (95% CI: 0.68-0.91, p = 0.002) for the group 24-43 procedures per year and 0.82 (95% CI: 0.70-0.94, p = 0.006) for the group ≥44 procedures per year compared to the low volume group. Log-rank test was p = 0.003. The risk of revision for unexplained pain was 40-50% higher in the low compared with other volume groups. Conclusion Low volume hospitals performing ≤11 Oxford III UKAs per year were associated with an increased risk of revision compared to higher volume hospitals, and unexplained pain as revision cause was more common in low volume hospitals.
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Affiliation(s)
| | - Anne M Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | | | - Kari Indrekvam
- Coastal Hospital, 5253, Hagavik, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Leif I Havelin
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Otto Robertsson
- The Swedish Knee Arthroplasty Register, Lund, Sweden.,Department of Clinical Sciences, Lund University Faculty of Medicine, Orthopedics, Lund, Sweden
| | - Annette W-Dahl
- The Swedish Knee Arthroplasty Register, Lund, Sweden.,Department of Clinical Sciences, Lund University Faculty of Medicine, Orthopedics, Lund, Sweden
| | | | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Alma B Pedersen
- The Danish Knee Arthroplasty Register, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik M Schrøder
- Department of Orthopaedic surgery, Næstved Hospital, Næstved, Denmark
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway
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30
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Hermansen E, Austevoll IM, Romild UK, Rekeland F, Solberg T, Storheim K, Grundnes O, Aaen J, Brox JI, Hellum C, Indrekvam K. Study-protocol for a randomized controlled trial comparing clinical and radiological results after three different posterior decompression techniques for lumbar spinal stenosis: the Spinal Stenosis Trial (SST) (part of the NORDSTEN Study). BMC Musculoskelet Disord 2017; 18:121. [PMID: 28327114 PMCID: PMC5361830 DOI: 10.1186/s12891-017-1491-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/15/2017] [Indexed: 11/22/2022] Open
Abstract
Background There are several posterior decompression techniques for lumbar spinal stenosis (LSS). There is a trend towards performing less invasive surgical procedures, but no multicentre randomized controlled trials have evaluated the relative efficacy of these techniques at short and long-term. Method/design A multicentre randomized controlled trial [the Spinal Stenosis Trial (SST) (part of the NORDSTEN study)] including 465 patients aged 18–80 years with neurogenic claudication or radiating pain and MRI findings indicating lumbar spinal stenosis without spondylolisthesis is performed to compare three posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy and spinous process osteotomy. The primary outcome is change in Oswestry Disability Index (ODI 2 years postoperatively). Secondary outcomes are change in EQ-5D, Zurich Claudication Questionnaire, and Numeric Rating Scale for leg-pain and back-pain. Also recorded were Global Perceived Effect score, complications, length of hospital stay, reoperation rate 2 years postoperatively, difference in recurrence of symptoms or postoperative instability, and MRI change in the dural sac area. Further, a 5 and 10 years follow-up is planned with the same outcome measures. Discussion Newer and less invasive techniques are increasingly favoured in surgery for LSS. This trial will compare the clinical and radiological results of three different techniques, and may contribute to better clinical decision making in the surgical treatment of LSS. Trial registration ClinicalTrials.gov reference: NCT02007083 (November 22, 2013).
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway. .,Department of Orthopaedics, Oslo University Hospital, Oslo, Norway.
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulla Kristina Romild
- Department of Research, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway.,Norwegian National Registry for spine surgery, University Hospital of North Norway, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Lørenskog, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, University of Oslo, Oslo, Norway
| | - Christian Hellum
- Department of Physical Medicine and Rehabilitation, University of Oslo, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Austevoll IM, Gjestad R, Brox JI, Solberg TK, Storheim K, Rekeland F, Hermansen E, Indrekvam K, Hellum C. The effectiveness of decompression alone compared with additional fusion for lumbar spinal stenosis with degenerative spondylolisthesis: a pragmatic comparative non-inferiority observational study from the Norwegian Registry for Spine Surgery. Eur Spine J 2016; 26:404-413. [PMID: 27421276 DOI: 10.1007/s00586-016-4683-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 06/02/2016] [Accepted: 06/22/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the effect of adding fusion to decompression in patients operated for lumbar spinal stenosis with a concomitant lumbar degenerative spondylolisthesis. METHODS After propensity score matching, 260 patients operated with decompression and fusion and 260 patients operated with decompression alone were compared. Primary outcome measures were leg and back pain [Numeric Rating Scale (NRS), 0-10] and Oswestry Disability Index (ODI, 0-100) at 12 months. RESULTS At 12-month follow-up, the fusion group rated their pain significantly lower than the decompression alone group [leg pain 3.0 and 3.6, respectively, mean difference -0.6, 95 % confidence interval (CI) -1.2 to -0.05, p = 0.03 and back pain 3.3 and 3.9, respectively, mean difference -0.6, 95 % CI -1.1 to -0.1, p = 0.02]. ODI was not significantly different between the groups (21.0 versus 23.3, mean difference -2.3, 95 % CI -5.8 to 1.1, p = 0.18). Seventy-four percent of the fusion group and 63 % of the decompression alone group achieved a clinically important improvement in back pain (difference in proportion of responders = 11 %, 95 % CI 2-20 %, p = 0.01), corresponding to a number needed to treat of 9 patients (95 % CI 5-50). There was no significant difference in responder rate for leg pain (74 and 67 %, respectively, difference 7 %, 95 % CI -1 to 16 %, p = 0.09) or for ODI (67 and 59 %, respectively, difference 8 %, 95 % CI 0-18 %, p = 0.06). The duration of surgery and hospital stay was longer for the fusion group (mean difference 68 min, 95 % CI 58-78, p < 0.01 and mean difference 4.2 days, 95 % CI 3.5-4.8, p < 0.01). CONCLUSION In the present non-inferiority study, we cannot conclude that decompression alone is as good as decompression with additional fusion. However, the small differences in the groups' effect sizes suggest that a considerable number of patients can be treated with decompression alone. A challenge in future studies will be to find the best treatment option for each patient.
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Affiliation(s)
- Ivar M Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.
| | - Rolf Gjestad
- Division of Mental Health Care, Haukeland University Hospital, Bergen, Norway.,Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Tore K Solberg
- Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway.,Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway.,Clinic for Surgery and Neurology, Department of Orthopedics, Oslo University Hospital, University of Oslo, Oslo, Norway
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Hermansen E, Romild UK, Austevoll IM, Solberg T, Storheim K, Brox JI, Hellum C, Indrekvam K. Does surgical technique influence clinical outcome after lumbar spinal stenosis decompression? A comparative effectiveness study from the Norwegian Registry for Spine Surgery. Eur Spine J 2016; 26:420-427. [PMID: 27262561 DOI: 10.1007/s00586-016-4643-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/31/2016] [Accepted: 05/31/2016] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The aim of this study was to compare the clinical outcome of spinal process osteotomy with two other midline-retaining methods, bilateral laminotomy and unilateral laminotomy with crossover, among patients undergoing surgery for lumbar spinal stenosis. METHODS This cohort study was based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients were operated on between 2009 and 2013 at 31 Norwegian hospitals. The patients completed questionnaires at admission for surgery, and after 3 and 12 months. The Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were duration of surgery and hospital stay, Numeric Rating Scale (NRS) for back pain and leg pain, and EQ-5D and EQ-VAS. The patients were classified into one of three treatment groups according to the surgery they had received, and a propensity score was utilized to minimize bias. The three treatment groups were divided into subgroups based on Propensity Scores, and the statistical analyses were performed with and within the Propensity Score stratified subgroups. RESULTS 103 patients had spinal process osteotomy, 966 patients had bilateral laminotomy, and 462 patients had unilateral laminotomy with crossover. Baseline clinical scores were similar in the three groups. There were no differences in improvement after 3 and 12 months between treatment groups. At 12 months, mean ODI improvement was 15.2 (SD 16.7) after spinous process osteotomy, 16.9 (SD 17.0) after bilateral laminotomy, and 16.7 (SD 16.9) after unilateral laminotomy with crossover. There were no differences in the secondary clinical outcomes or complication rates. Mean duration of surgery was greatest for spinal process osteotomy (p < 0.05). Length of stay was 2.1 days (SD 2.1) in the bilateral laminotomy group, 3.5 (SD 2.4) days for unilateral laminotomy, and 6.9 days (SD 4.1) for spinous process osteotomy group (p < 0.05). CONCLUSION In a propensity scored matched cohort, there were no differences in the clinical outcome 12 months after surgery for lumbar spinal stenosis performed using the three different posterior decompression techniques. Bilateral laminotomy had shortest duration of surgery and shortest length of hospital stay. Surgical technique does not seem to affect clinical outcome after three different midline-retaining posterior decompression techniques.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ulla Kristina Romild
- Department of Research, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of North Norway, Tromsø, Norway.,Norwegian National Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Christian Hellum
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Jonsson BA, Kadar T, Havelin LI, Haugan K, Espehaug B, Indrekvam K, Furnes O, Hallan G. Oxinium modular femoral heads do not reduce polyethylene wear in cemented total hip arthroplasty at five years: a randomised trial of 120 hips using radiostereometric analysis. Bone Joint J 2016; 97-B:1463-9. [PMID: 26530646 DOI: 10.1302/0301-620x.97b11.36137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the five-year outcome of a randomised controlled trial which used radiostereometric analysis (RSA) to assess the influence of surface oxidised zirconium (OxZr, Oxinium) on polyethylene wear in vivo. A total of 120 patients, 85 women and 35 men with a mean age of 70 years (59 to 80) who were scheduled for primary cemented total hip arthroplasty were randomly allocated to four study groups. Patients were blinded to their group assignment and received either a conventional polyethylene (CPE) or a highly cross-linked (HXL) acetabular component of identical design. On the femoral side patients received a 28 mm head made of either cobalt-chromium (CoCr) or OxZr. The proximal head penetration (wear) was measured with repeated RSA examinations over five years. Clinical outcome was measured using the Harris hip score. There was no difference in polyethylene wear between the two head materials when used with either of the two types of acetabular component (p = 0.3 to 0.6). When comparing the two types of polyethylene there was a significant difference in favour of HXLPE, regardless of the head material used (p < 0.001). In conclusion, we found no advantage of OxZr over CoCr in terms of polyethylene wear after five years of follow-up. Our findings do not support laboratory results which have shown a reduced rate of wear with OxZr. They do however add to the evidence on the better resistance to wear of HXLPE over CPE.
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Affiliation(s)
- B A Jonsson
- Haukeland University Hospital, Bergen, Norway
| | - T Kadar
- Haukeland University Hospital, Bergen, Norway
| | - L I Havelin
- Haukeland University Hospital, Bergen, Norway
| | - K Haugan
- Trondheim University Hospital, Trondheim, Norway
| | - B Espehaug
- Haukeland University Hospital, Bergen, Norway
| | - K Indrekvam
- Haukeland University Hospital, Bergen, Norway
| | - O Furnes
- Haukeland University Hospital, Bergen, Norway
| | - G Hallan
- Haukeland University Hospital, Bergen, Norway
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Abstract
BACKGROUND AND PURPOSE Previous studies have found different outcomes after revision of knee arthroplasties performed after high tibial osteotomy (HTO). We evaluated the risk of revision of total knee arthroplasty with or without previous HTO in a large registry material. PATIENTS AND METHODS 31,077 primary TKAs were compared with 1,399 TKAs after HTO, using Kaplan-Meier 10-year survival percentages and adjusted Cox regression analysis. RESULTS The adjusted survival analyses showed similar survival in the 2 groups. The Kaplan-Meier 10-year survival was 93.8% in the primary TKA group and 92.6% in the TKA-post-HTO group. Adjusted RR was 0.97 (95% CI: 0.77-1.21; p = 0.8). INTERPRETATION In this registry-based study, previous high tibial osteotomy did not appear to compromise the results regarding risk of revision after total knee arthroplasty compared to primary knee arthroplasty.
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Affiliation(s)
- Mona Badawy
- Kysthospital in Hagavik, Hagavik,Correspondence:
| | - Anne M Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen
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Harboe K, Ellingsen CL, Sudmann E, Gjerdet NR, Søreide K, Indrekvam K. Can bone apposition predict the retention force of a femoral stem? An experimental weight-bearing hip-implant model in goats. BMC Musculoskelet Disord 2015; 16:102. [PMID: 25927813 PMCID: PMC4423176 DOI: 10.1186/s12891-015-0560-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 04/21/2015] [Indexed: 11/24/2022] Open
Abstract
Background The increasing incidence of prosthesis revision surgery in the Western world has led to an increased focus on the capacity for stem removal. We previously reported on a femoral stem implanted in goats with an approximate 15% reduction in retention force by drilling longitudinally orientated grooves on the side of the stem. In this current study, we aimed to histologically evaluate the bony apposition towards this stem and correlate this apposition with the pullout force. Methods We analyzed the femora of 22 goats after stem removal. All stems remained in place for 6 months, and the goats were allowed regular loading of the hip during this time. For histological evaluation, all femora were immersed in EDTA and decalcified until sufficiently soft for standard technique preparation. We evaluated bone apposition, the presence of foreign particle debris and other factors. The apposition was evaluated with a scoring system based on semi-quantitative bone apposition in four quadrants. Kappa statistics were calculated for the score. We correlated the retention force with the amount of bone apposition. Results The stem drilling was the only significant factor influencing the retention force (p = 0.020). The bone apposition Kappa score comparing poor and good apposition scores was fair (κ = 0.4, 95% CI 0.00–0.88). Signs of foreign body reaction were noted in 5 of 22 goats. Conclusions Based on the current findings in an experimental goat model, it appears that the effect of drilling tissue/bone out of the longitudinal grooves has a more significant impact on the retention force required to remove the stem than the amount of bone apposition outside the stem grooves. This observation may be further explored in the research of stem designs that are potentially easier to remove.
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Affiliation(s)
- Knut Harboe
- Department of Orthopedic Surgery, Stavanger University Hospital, P.O. Box 8100, Stavanger, 4068, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | | | - Einar Sudmann
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Nils Roar Gjerdet
- Department of Clinical Dentistry, Biomaterials, University of Bergen, Bergen, Norway.
| | - Kjetil Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway. .,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
| | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway. .,Kysthospitalet in Hagevik, Clinic of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.
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36
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Harboe K, Gjerdet NR, Sudmann E, Indrekvam K, Søreide K. Assessment of retention force and bone apposition in two differently coated femoral stems after 6 months of loading in a goat model. J Orthop Surg Res 2014; 9:69. [PMID: 25127722 PMCID: PMC4237892 DOI: 10.1186/s13018-014-0069-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/18/2014] [Indexed: 12/02/2022] Open
Abstract
Background Since the introduction of uncemented hip implants, there has been a search for the best surface coating to enhance bone apposition in order to improve retention. The surface coating of the different stems varies between products. The aim was to assess the retention force and bone adaption in two differently coated stems in a weight-bearing goat model. Materials and methods Hydroxyapatite (HA) and electrochemically deposited calcium phosphate (CP; Bonit®) on geometrically comparable titanium-based femoral stems were implanted into 12 (CP group) and 35 (HA group) goats. The animal model included physiological loading of the implants for 6 months. The pull-out force of the stems was measured, and bone apposition was microscopically evaluated. Results After exclusion criteria were applied, the number of available goats was 4 in the CP group and 11 in the HA group. The CP-coated stems had significantly lower retention forces compared with the HA-coated ones after 6 months (CP median 47 N, HA median 1,696 N, p = 0.003). Bone sections revealed a lower degree of bone apposition in the CP-coated stems, with more connective tissue in the bone/implant interface compared with the HA group. Conclusion In this study, HA had better bone apposition and needed greater pull-out force in loaded implants. The application of CP on the loaded titanium surface to enhance the apposition of bone is questioned.
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Affiliation(s)
- Knut Harboe
- Department of Orthopaedic Surgery, Stavanger University Hospital, Stavanger 4068, Norway.
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Abstract
BACKGROUND AND PURPOSE Some studies have found high complication rates and others have found low complication rates after unicompartmental knee arthroplasty (UKA). We evaluated whether hospital procedure volume influences the risk of revision using data from the Norwegian Arthroplasty Register (NAR). MATERIALS AND METHODS 5,791 UKAs have been registered in the Norwegian Arthroplasty Register. We analyzed the 4,460 cemented medial Oxford III implants that were used from 1999 to 2012; this is the most commonly used UKA implant in Norway. Cox regression (adjusted for age, sex, and diagnosis) was used to estimate risk ratios (RRs) for revision. 4 different volume groups were compared: 1-10, 11-20, 21-40, and > 40 UKA procedures annually per hospital. We also analyzed the reasons for revision. RESULTS AND INTERPRETATION We found a lower risk of revision in hospitals performing more than 40 procedures a year than in those with less than 10 UKAs a year, with an unadjusted RR of 0.53 (95% CI: 0.35-0.81) and adjusted RR of 0.59 (95% CI: 0.39-0.90). Low-volume hospitals appeared to have a higher risk of revision due to dislocation, instability, malalignment, and fracture than high-volume hospitals.
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Affiliation(s)
| | - Birgitte Espehaug
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen,Center for Evidence-based Practice, Bergen University College, Bergen
| | - Kari Indrekvam
- Kysthospital in Hagevik, Hagavik,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway.
| | - Leif I Havelin
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway.
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway.
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Laborie LB, Markestad TJ, Davidsen H, Brurås KR, Aukland SM, Bjørlykke JA, Reigstad H, Indrekvam K, Lehmann TG, Engesæter IØ, Engesæter LB, Rosendahl K. Selective ultrasound screening for developmental hip dysplasia: effect on management and late detected cases. A prospective survey during 1991-2006. Pediatr Radiol 2014; 44:410-24. [PMID: 24337789 DOI: 10.1007/s00247-013-2838-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/19/2013] [Accepted: 11/08/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Early treatment is considered essential for developmental dysplasia of the hip (DDH), but the choice of screening strategy is debated. OBJECTIVE We evaluated the effect of a selective ultrasound (US) screening programme. MATERIALS AND METHODS All infants born in a defined region during 1991-2006 with increased risk of developmental dysplasia of the hip, i.e. clinical hip instability, breech presentation, congenital foot deformities or a family history of DDH, underwent US screening at age 1-3 days. Severe sonographic dysplasia and dislocatable/dislocated hips were treated with abduction splints. Mild dysplasia and pathological instability, i.e. not dislocatable/dislocated hips were followed clinically and sonographically until spontaneous resolution, or until treatment became necessary. The minimum observation period was 5.5 years. RESULTS Of 81,564 newborns, 11,539 (14.1%) were identified as at-risk, of whom 11,190 (58% girls) were included for further analyses. Of the 81,564 infants, 2,433 (3.0%) received early treatment; 1,882 (2.3%) from birth and 551 (0.7%) after 6 weeks or more of clinical and sonographic surveillance. An additional 2,700 (3.3%) normalised spontaneously after watchful waiting from birth. Twenty-six infants (0.32 per 1,000, 92% girls, two from the risk group) presented with late subluxated/dislocated hips (after 1 month of age). An additional 126 (1.5 per 1,000, 83% girls, one from the risk group) were treated after isolated late residual dysplasia. Thirty-one children (0.38 per 1,000) had surgical treatment before age 5 years. Avascular necrosis was diagnosed in seven of all children treated (0.27%), four after early and three after late treatment. CONCLUSION The first 16 years of a standardised selective US screening programme for developmental dysplasia of the hip resulted in acceptable rates of early treatment and US follow-ups and low rates of late subluxated/dislocated hips compared to similar studies.
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Badawy M, Espehaug B, Indrekvam K, Engesæter LB, Havelin LI, Furnes O. Influence of hospital volume on revision rate after total knee arthroplasty with cement. J Bone Joint Surg Am 2013; 95:e131. [PMID: 24048562 DOI: 10.2106/jbjs.l.00943] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The number of total knee replacements has substantially increased worldwide over the past ten years. Several studies have indicated a correlation between high hospital procedure volume and decreased morbidity and mortality following total knee arthroplasty. The purpose of the present study was to evaluate whether there is a correlation between procedure volume and the risk of revision following total knee arthroplasty with use of hospital volume data from the Norwegian Arthroplasty Register. METHODS Thirty-seven thousand, three hundred and eighty-one total knee arthroplasties that were reported to the Norwegian Arthroplasty Register from 1994 to 2010 were used to examine the annual procedure volume per hospital. Hospital volume was divided into five categories according to the number of procedures performed annually: one to twenty-four (low volume), twenty-five to forty-nine (medium volume), fifty to ninety-nine (medium volume), 100 to 149 (high volume), and ≥150 (high volume). Cox regression (adjusted for age, sex, and diagnosis) was used to estimate the proportion of procedures without revision and the risk ratio (RR) of revision. Analyses were also performed for two commonly used prosthesis brands combined. RESULTS The rate of prosthetic survival at ten years was 92.5% (95% confidence interval, 91.5 to 93.4) for hospitals with an annual volume of one to twenty-four procedures and 95.5% (95% confidence interval, 94.1 to 97.0) for hospitals with an annual volume of ≥150 procedures. We found a significantly lower risk of revision for hospitals with an annual volume of 100 to 149 procedures (relative risk = 0.73 [95% confidence interval, 0.56 to 0.96], p = 0.03) and ≥150 procedures (relative risk = 0.73 [95% confidence interval, 0.54 to 1.00], p = 0.05) compared with hospitals with an annual volume of one to twenty-four procedures. Similar results were found when we analyzed two commonly used prosthesis brands. CONCLUSIONS In the present study, there was a significantly higher rate of revision knee arthroplasties at low-volume hospitals as compared with high-volume hospitals.
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Affiliation(s)
- Mona Badawy
- Kysthospital in Hagavik, Hagaviksbakken 25, 5217 Hagavik, Norway. E-mail address for M. Badawy: . E-mail address for K. Indrekvam:
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Hermansen E, Moen G, Barstad J, Birketvedt R, Indrekvam K. Laminarthrectomy as a surgical approach for decompressing the spinal canal: assessment of preoperative versus postoperative dural sac cross-sectional areal (DSCSA). Eur Spine J 2013; 22:1913-9. [PMID: 23494757 DOI: 10.1007/s00586-013-2737-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 02/28/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Surgery for lumbar spinal stenosis (LSS) is today the most frequently performed procedure in the adult lumbar spine. Long-term benefit of surgery for LSS is well documented both in randomized and in non-randomized trials. In this paper, we present the results from laminarthrectomy as an alternative surgical approach, which have theoretical advantages over other approaches. In this study, we wanted to study the clinical and radiological results of laminarthrectomy. Dural sac cross-sectional areal (DSCSA) is an objective method to quantify the degree of central stenosis in the spinal canal, and was used to measure whether we were able to achieve an adequate decompression of the spinal canal with laminarthrectomy as a surgical approach. MATERIALS AND METHODS All patients operated on with this approach consecutively in the period 1 January 2008 to 31 March 2009 were included in the study. All perioperative complications were noted. Clinical results were measured by means of a questionnaire. The patients that agreed to attend the study had an MRI taken of the operated level. DSCSA before and after surgery of the actual level were measured by three observers. We then performed a correlation test between increase of area and clinical results. We also tested for inter- and intra-observer reability. RESULTS Fifty-six laminarthrectomy were performed. There were 17% complications, none of them were life-threatening or disabling. 46 patients attended the study and answered the questionnaire. Thirty-four patients (83%) reported clinical improvement, whereas six (13%) patients reported no improvement, and two (4%) patients reported that they were worse. Mean ODI was 23.0. Mean EQ-5D was 0.77. Mean VAS-score for back-pain was 3.1 and mean VAS-score for leg-pain was 2.8. Mean DSCSA were measured to 80 mm(2) before surgery and 161 mm(2) after surgery. That gave an increase of DSCSA of 81 mm(2) (101%). We found a significant positive correlation between increase of area and clinical results. We also found consistent inter- and intra-observer reability. DISCUSSION In this study, the clinical results of laminarthrectomy were good, and comparable with other reports for LSS. The rates of complications are also comparable with other reports in spinal surgery. A significant increase in the spinal canal diameter was achieved. Within the limitations a retrospective study gives, we conclude that laminarthrectomy seems to be a safe and effective surgical approach for significant decompressing the adult central spinal canal, and measurement of DSCSA, before and after surgery seems to be a good way to quantify the degree of decompression.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.
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Kadar T, Furnes O, Aamodt A, Indrekvam K, Havelin LI, Haugan K, Espehaug B, Hallan G. The influence of acetabular inclination angle on the penetration of polyethylene and migration of the acetabular component. ACTA ACUST UNITED AC 2012; 94:302-7. [DOI: 10.1302/0301-620x.94b3.27460] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this prospective study we studied the effect of the inclination angle of the acetabular component on polyethylene wear and component migration in cemented acetabular sockets using radiostereometric analysis. A total of 120 patients received either a cemented Reflection All-Poly ultra-high-molecular-weight polyethylene or a cemented Reflection All-Poly highly cross-linked polyethylene acetabular component, combined with either cobalt–chrome or Oxinium femoral heads. Femoral head penetration and migration of the acetabular component were assessed with repeated radiostereometric analysis for two years. The inclination angle was measured on a standard post-operative anteroposterior pelvic radiograph. Linear regression analysis was used to determine the relationship between the inclination angle and femoral head penetration and migration of the acetabular component. We found no relationship between the inclination angle and penetration of the femoral head at two years’ follow-up (p = 0.9). Similarly, our data failed to reveal any statistically significant correlation between inclination angle and migration of these cemented acetabular components (p = 0.07 to p = 0.9).
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Affiliation(s)
- T. Kadar
- Haukeland University Hospital, Department
of Orthopaedic Surgery, Jonas Liesvei 65, Bergen
5021, Norway
| | - O. Furnes
- Haukeland University Hospital, Department
of Orthopaedic Surgery, Jonas Liesvei 65, Bergen
5021, Norway
| | - A. Aamodt
- Trondheim University Hospital, Department
of Orthopaedic Surgery, PostBox 3250 Sluppen, Trondheim
NO-7006, Norway
| | | | - L. I. Havelin
- Haukeland University Hospital, Department
of Orthopaedic Surgery, Jonas Liesvei 65, Bergen
5021, Norway
| | - K. Haugan
- Trondheim University Hospital, Department
of Orthopaedic Surgery, PostBox 3250 Sluppen, Trondheim
NO-7006, Norway
| | - B. Espehaug
- Haukeland University Hospital, Department
of Orthopaedic Surgery, Jonas Liesvei 65, Bergen
5021, Norway
| | - G. Hallan
- Haukeland University Hospital, Department
of Orthopaedic Surgery, Jonas Liesvei 65, Bergen
5021, Norway
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Kadar T, Hallan G, Aamodt A, Indrekvam K, Badawy M, Havelin LI, Stokke T, Haugan K, Espehaug B, Furnes O. A randomized study on migration of the Spectron EF and the Charnley flanged 40 cemented femoral components using radiostereometric analysis at 2 years. Acta Orthop 2011; 82:538-44. [PMID: 21895504 PMCID: PMC3242949 DOI: 10.3109/17453674.2011.618914] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE We performed a randomized study to determine the migration patterns of the Spectron EF femoral stem and to compare them with those of the Charnley stem, which is regarded by many as the gold standard for comparison of implants due to its extensive documentation. PATIENTS AND METHODS 150 patients with a mean age of 70 years were randomized, single-blinded, to receive either a cemented Charnley flanged 40 monoblock, stainless steel, vaquasheen surface femoral stem with a 22.2-mm head (n = 30) or a cemented Spectron EF modular, matte, straight, collared, cobalt-chrome femoral stem with a 28-mm femoral head and a roughened proximal third of the stem (n = 120). The patients were followed with repeated radiostereometric analysis for 2 years to assess migration. RESULTS At 2 years, stem retroversion was 2.3° and 0.7° (p < 0.001) and posterior translation was 0.44 mm and 0.17 mm (p = 0.002) for the Charnley group (n = 26) and the Spectron EF group (n = 74), respectively. Subsidence was 0.26 mm for the Charnley and 0.20 mm for the Spectron EF (p = 0.5). INTERPRETATION The Spectron EF femoral stem was more stable than the Charnley flanged 40 stem in our study when evaluated at 2 years. In a report from the Norwegian arthroplasty register, the Spectron EF stem had a higher revision rate due to aseptic loosening beyond 5 years than the Charnley. Initial stability is not invariably related to good long-term results. Our results emphasize the importance of prospective long-term follow-up of prosthetic implants in clinical trials and national registries and a stepwise introduction of implants.
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Affiliation(s)
| | - Geir Hallan
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | | | | | - Mona Badawy
- Hagevik Hospital, Haukeland University Hospital, Hagavik
| | | | - Terje Stokke
- Department of Radiology, Haukeland University Hospital, Bergen
| | - Kristin Haugan
- Department of Orthopaedic Surgery, Trondheim University Hospital, Trondheim
| | - Birgitte Espehaug
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
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Kadar T, Hallan G, Aamodt A, Indrekvam K, Badawy M, Skredderstuen A, Havelin LI, Stokke T, Haugan K, Espehaug B, Furnes O. Wear and migration of highly cross-linked and conventional cemented polyethylene cups with cobalt chrome or Oxinium femoral heads: a randomized radiostereometric study of 150 patients. J Orthop Res 2011; 29:1222-9. [PMID: 21360584 DOI: 10.1002/jor.21389] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 01/25/2011] [Indexed: 02/04/2023]
Abstract
This randomized study was performed to compare wear and migration of five different cemented total hip joint articulations in 150 patients. The patients received either a Charnley femoral stem with a 22.2 mm head or a Spectron EF femoral stem with a 28 mm head. The Charnley articulated with a γ-sterilized Charnley Ogee acetabular cup. The Spectron EF was used with either EtO-sterilized non-cross-linked polyethylene (Reflection All-Poly) or highly cross-linked (Reflection All-Poly XLPE) cups, combined with either cobalt chrome (CoCr) or Oxinium femoral heads. The patients were followed with repeated RSA measurements for 2 years. After 2 years, the EtO-sterilized non-cross-linked Reflection All-Poly cups had more than four times higher proximal penetration than its highly cross-linked counterpart. Use of Oxinium femoral heads did not affect penetration at 2 years compared to heads made of CoCr. Further follow-up is needed to evaluate the benefits, if any, of Oxinium femoral heads in the clinical setting. The Charnley Ogee was not outperformed by the more recently introduced implants in our study. We conclude that this prostheses still represents a standard against which new implants can be measured.
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Affiliation(s)
- Thomas Kadar
- Department of Orthopaedic Surgery, Haukeland University Hospital, N-5021 Bergen, Norway.
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Affiliation(s)
- F-A. Ravnskog
- Kysthospitalet i Hagevik, Haukeland University Hospital, Bergen, Norway
| | - B. Espehaug
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - K. Indrekvam
- Kysthospitalet i Hagevik, Haukeland University Hospital, Bergen, Norway
- Department of Surgical Science, University of Bergen, Norway
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Aamodt A, Nordsletten L, Havelin LI, Indrekvam K, Utvåg SE, Hviding K. Documentation of hip prostheses used in NorwayA critical review of the literature from 1996–2000. ACTA ACUST UNITED AC 2009; 75:663-76. [PMID: 15762255 DOI: 10.1080/00016470410004021] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We have conducted a systematic review of the scientific literature concerning outcome and clinical effectiveness of prostheses used for primary total hip replacement (THR) in Norway. The study is based on two Health Technology Assessment reports from the UK (Faulkner et al. 1998, Fitzpatrick et al. 1998), reviewing the literature from 1980 to 1995. Using a similar search strategy, we have evaluated the literature from 1996 through 2000. We included 129 scientific and medical publications which were assessed according to a specific appraisal protocol. The majority (72%) were observational studies, whereas only 9% were randomized studies. We could not retrieve any peer-reviewed documentation for one third of the implants. The Charnley prosthesis had by far the best and most comprehensive evidence base with better than 90% implant survival after about 10 years. Survival of the Charnley prosthesis declines by about 10% during each of the two following decades. Except for the Charnley and Lubinus IP, no other prosthesis on the market in Norway has given long-term results (> 15 years). 5 other cemented implants have given comparable results at about 10 years of follow-up. Some uncemented stems have shown promising medium-term outcome, but no combination of uncemented cup and stem fulfilled the benchmark criterion of > or = 90% implant survival at 10 years, which we propose as a minimum requirement for unrestricted clinical use for prostheses used in primary THR. New or undocumented implants should be introduced through a four-step model including preclinical testing, small series evaluated by radiosterometry, randomized clinical trial involving comparison with a well-documented prosthesis, and finally, surveillance of clinical use through registers.
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Affiliation(s)
- Arild Aamodt
- Department of Orthopaedic Surgery, Trondheim University Hospital, Trondheim.
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Aamodt A, Nordsletten L, Havelin L, Indrekvam K, Utvåg SE, Sundberg KH. Documentation of hip prostheses used in Norway. SORT 2004. [DOI: 10.1080/759369226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
We treated 19 patients with piriformis muscle syndrome. All patients complained of pain in the buttocks and the posterior thigh. Clinically the buttock was tender and passive stretching increased the pain. In ten patients skin sensation was reduced and three had a limp. All patients were treated with tenotomy. At follow-up after an average of 8 (1-16) years, eight patients had pain relief. Two-thirds of the patients evaluated their clinical state as being better.
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Affiliation(s)
- K Indrekvam
- Hagevik Orthopaedic Hospital, University of Bergen, Norway.
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Mohr E, Indrekvam K. [Quality assurance in hip prosthesis surgery. New type hip prostheses, review of a 3-year material]. Tidsskr Nor Laegeforen 1996; 116:846-8. [PMID: 8644097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This article deals with the short-term results of prosthetic replacement of the hip joint. The investigation was carried out three years after the introduction of a new hip prosthesis - the ITH (" International Total Hip") prosthesis. Our results were analysed retrospectively, the primary goal being quality assessment of the results of our hip surgery. We found that the results of hip prosthetic surgery with the ITH-prosthesis were satisfying, although the frequency of complications was rather high: 185 implantations of the ITH-prosthesis gave 13 cases of deep venous thrombosis; one case of deep infection and subsequent revision surgery; four cases of dislocation of the prosthesis, of which two cases have been subsequently revised; one case of perforation of the femur with later revision; and one case of permanent paralysis of the femoral nerve. The overall rate of revisions was 2.7%. The overall survival of the prosthesis according to Kaplan Meier was 97% after three years.
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Affiliation(s)
- E Mohr
- Kirurgisk avdeling Fylkessjukehuset i Haugesund
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Abstract
The right femur in 40 rats was reamed, and in 40 others it was additionally nailed. Analysis of bone blood flow was performed by the distribution of radiolabeled microspheres at different postoperative time intervals. Blood-flow measurements were accompanied by analyses of hydroxyproline and calcium contents. Immediately after reaming, the blood flow of the diaphyseal part of the femur was reduced to approximately one third of that of the intact femur, whereas the contents of hydroxyproline and calcium were reduced by 10 percent. Within 1 week, the blood flow was normal. This study provides evidence that the presence of a nail does not interfere with the restoration of bone blood flow. Restoration of blood flow in bone apparently is a rapid process. The replacement of hydroxyproline and calcium contents seemed to be linked to flow, as no increase in these constituents were found until the blood flow had approximated the level of the intact femur.
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Affiliation(s)
- K Indrekvam
- University of Bergen, Orthopedic Division, Haukeland Hospital, Norway
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Indrekvam K, Gjerdet NR, Engesaeter LB, Langeland N. Effects of intramedullary reaming and nailing of rat femur. A mechanical and chemical study. Acta Orthop Scand 1991; 62:582-6. [PMID: 1767653 DOI: 10.3109/17453679108994501] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This study was undertaken to explore the association between mechanical and chemical effects of intramedullary reaming and nailing. The right femora of 80 rats were reamed and nailed with steel nails. Forty rats were evaluated from 3 days to 24 weeks postoperatively. The other 40 rats had the nail removed after 12 weeks, and they were then followed from 3 days to 24 weeks after nail extraction. Evaluation consisted of in vivo strain recording, geometric measurements, mechanical three-point bending test, and chemical analyses of hydroxyproline and calcium contents. Reaming and nailing caused immediate weakening of the bone as measured by in vitro mechanical tests, but within 3 weeks the mechanical properties were fully restored, whereas in vivo strain remained reduced throughout the experimental period in rats with nails. Removing the nail increased in vivo strain to a level close to that of the intact femur. Remodeling of the bone resulted in greater external anteroposterior diameter, cross-sectional area, area moment of inertia, and amount of hydroxyproline and calcium in the operated on femur as compared with the intact side. This indicates that the repair processes resulted in greater bone mass of the operated on femur than of the intact femur. Thus, there is evidence that nailing techniques effectively assist tissues by repair and remodeling.
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Affiliation(s)
- K Indrekvam
- University of Bergen, Surgical Research Laboratory, Norway
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