Importance The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. Objective To provide new and updated evidence-based recommendations for the prevention of SSI. Evidence Review A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. Findings Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. Conclusions and Relevance This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

/pdf/centers-for-disease-control-and-prevention-guideline-for-the-hp9zbxiudj.pdf

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017

STUDY DESIGN Prospective radiographic and clinical analysis. OBJECTIVE Investigate the relationship between spino-pelvic parameters and patient self reported outcomes on adult subjects with spinal deformities. SUMMARY OF BACKGROUND DATA It is becoming increasingly recognized that the study of spinal alignment should include pelvic position. While pelvic incidence determines lumbar lordosis, pelvic tilt (PT) is a positional parameter reflecting compensation to spinal deformity. Correlation between plumbline offset (sagittal vertical axis [SVA]) and Health Related Quality of Life (HRQOL) measures has been demonstrated, but such a study is lacking for PT. METHODS This prospective study was carried out on 125 adult patients suffering from spinal deformity (mean age: 57 years). Full-length free-standing radiographs including the spine and pelvis were available for all patients. HRQOL instruments included: Oswestry Disability Index, Short Form-12, Scoliosis Research Society. Correlation analysis between radiographic spinopelvic parameters and HRQOL measures was pursued. RESULTS Correlation analysis revealed no significance pertaining to coronal plane parameters. Significant sagittal plane correlations were identified. SVA and truncal inclination measured by T1 spinopelvic inclination (T1-SPI) (angle between T1-hip axis and vertical) correlated with: Scoliosis Research Society (appearance, activity, total score), Oswestry Disability Index, and Short Form-12 (physical component score). Correlation coefficients ranged from 0.42 < r < 0.55 (P < 0.0001). T1-SPI revealed greater correlation with HRQOL compared to SVA. PT showed correlation with HRQOL (0.28 < r < 0.42) and with SVA (r = 0.64, P < 0.0001). CONCLUSION This study confirms that pelvic position measured via PT correlates with HRQOL in the setting of adult deformity. High values of PT express compensatory pelvic retroversion for sagittal spinal malalignment. This study also demonstrates significant T1-SPI correlation with HRQOL measures and outperforms SVA. This parameter carries the advantage of being an angular measurement which avoids the error inherent in measuring offsets in noncalibrated radiographs.

Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity.

Study design Current concepts review. Objective Outline the basic principles in the evaluation and treatment of adult spinal deformity patients with a focus on goals to achieve during surgical realignment surgery. Summary of background data Proper global alignment of the spine is critical in maintaining standing posture and balance in an efficient and pain-free manner. Outcomes data demonstrate the clinical effect of spinopelvic malalignment and form a basis for realignment strategies. Methods Correlation between certain radiographic parameters and patient self-reported pain and disability has been established. Using normative values for several important spinopelvic parameters (including sagittal vertical axis, pelvic tilt, and lumbar lordosis), spinopelvic radiographic realignment objectives were identified as a tool for clinical application. Because of the complex relationship between the spine and the pelvis in maintaining posture and the wide range of "normal" values for the associated parameters, a focus on global alignment, with proportionality of individual parameters to each other, was pursued to provide clinical relevance to planning realignment for deformity across a range of clinical cases. Conclusion Good clinical outcome requires achieving proper spinopelvic alignment in the treatment of adult spinal deformity. Although variations in pelvic morphology exist, a framework has been established to determine ideal values for regional and global parameter in an individualized patient approach. When planning realignment surgery for adult spinal deformity, restoring low sagittal vertical axis and pelvic tilt values are critical goals, and should be combined with proportional lumbar lordosis to pelvic incidence.

Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery.

Study design Prospective multicenter study evaluating operative (OP) versus nonoperative (NONOP) treatment for adult spinal deformity (ASD). Objective Evaluate correlations between spinopelvic parameters and health-related quality of life (HRQOL) scores in patients with ASD. Summary of background data Sagittal spinal deformity is commonly defined by an increased sagittal vertical axis (SVA); however, SVA alone may underestimate the severity of the deformity. Spinopelvic parameters provide a more complete assessment of the sagittal plane but only limited data are available that correlate spinopelvic parameters with disability. METHODS.: Baseline demographic, radiographical, and HRQOL data were obtained for all patients enrolled in a multicenter consecutive database. Inclusion criteria were: age more than 18 years and radiographical diagnosis of ASD. Radiographical evaluation was conducted on the frontal and lateral planes and HRQOL questionnaires (Oswestry Disability Index [ODI], Scoliosis Research Society-22r and Short Form [SF]-12) were completed. Radiographical parameters demonstrating highest correlation with HRQOL values were evaluated to determine thresholds predictive of ODI more than 40. Results Four hundred ninety-two consecutive patients with ASD (mean age, 51.9 yr) were enrolled. Patients from the OP group (n = 178) were older (55 vs. 50.1 yr, P Conclusion ASD is a disabling condition. Prospective analysis of consecutively enrolled patients with ASD demonstrated that PT and PI-LL combined with SVA can predict patient disability and provide a guide for patient assessment for appropriate therapeutic decision making. Threshold values for severe disability (ODI > 40) included: PT 22° or more, SVA 47 mm or more, and PI - LL 11° or more.

Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis.

A new method for the treatment of scoliosis is described in which a metal system of rods and hooks is implanted, and distraction and compression forces applied, to correct the curve and stabilize the treated segments in the corrected position by skeletal fixation. The technique and principles of this method of treatment and a summary of the preliminary results are given.

JBJS classics: Treatment of scoliosis: Correction and internal fixation by spine instrumentation

Background: There is an increasing recognition of the clinical importance of the sagittal plane alignment of the spine. A prospective study of several radiographic parameters of the sagittal profile of the spine was conducted to determine the physiological values of these parameters, to calculate th

Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects.

Background: Patellar height variations can be responsible for many functional disorders in children. The Caton-Deschamps index to measure patellar height has been described for adults. Our goal was to determine Caton-Deschamps index values in a pediatric population.

Methods: Lateral radiographs of the knee were analyzed in a cohort of 300 healthy patients. All radiographs were done to evaluate the patients after minor trauma and all were reported to be normal by a senior radiologist. The cohort was divided into ten groups on the basis of the age of the child. Radiographic measurements were done by a computer-assisted technique. Intraobserver and interobserver reliability studies were performed prior to the descriptive analysis of the data.

Results: Mean patellar length (and standard deviation) was 33.39 ± 7.4 mm. Mean patellar tendon length was 34.57 ± 6.7 mm. The mean Caton-Deschamps index was 1.06 ± 0.21. Patellar and patellar tendon length significantly increased with age, whereas the Caton-Deschamps index significantly decreased. Intraobserver and interobserver reliability studies showed excellent reliabilities with an intraclass correlation coefficient that was between 0.930 and 0.944 (95% confidence interval).

Conclusions: The Caton-Deschamps index is a simple and reliable index for evaluating patellar height in children as well as adults. It is an alternative to the Insall-Salvati index measurement, in which reproducibility is poor due to difficulties in determining the distal point of the patellar tendon, and to the Koshino index, which is complex to use. In our study, there was a correlation between the Caton-Deschamps index and age, due to the progressive patellar ossification that begins at the proximal part of the patella. The Caton-Deschamps index is a pertinent and reliable ratio to evaluate patellar height in children and adolescents. To make an accurate diagnosis of patellar disorders in children, the normal, age-based Caton-Deschamps values need to be considered.

Is the Caton-Deschamps index a valuable ratio to investigate patellar height in children?

Recent studies suggested a predominant role of spinopelvic parameters to explain lumbosacral spondylolisthesis pathogeny. We compare the pelvic incidence and other parameters of sagittal spinopelvic balance in adolescents and young adults with developmental spondylolisthesis to those parameters in a control group of healthy volunteers. We compared the angular parameters of the sagittal balance of the spine in a cohort of 244 patients with a developmental L5–S1 spondylolisthesis with those of a control cohort of 300 healthy volunteers. A descriptive and correlation study was performed. The L5 anterior slipping and lumbosacral kyphosis in spondylolisthesis patients was described using multiple regression analysis study. Our study demonstrates that the related measures of sagittal spinopelvic alignment are disturbed in adolescents and young adults with developmental spondylolisthesis. These subjects stand with an increased sacral slope, pelvic tilt and lumbar lordosis but with a decreased thoracic kyphosis. Pelvic incidence was significantly higher in spondylolisthesis patients as compared with controls but was not clearly correlated with the grade of slipping. We showed the same “sagittal balance strategy” in spondylolisthesis patients as in the control group regarding correlations between pelvic incidence, sacral slope, pelvic tilt and lumbar lordosis. We believe that the lumbosacral kyphosis is a stronger factor than pelvic incidence which need to be taken into account as a predominant factor in theories of pathogenesis of lumbosacral spondylolithesis. We thus believe that increased lumbar lordosis associated with L5–S1 spondylolisthesis is secondary to the high pelvic incidence and is an important factor causing high shear stresses at the L5–S1 pars interarticularis. However, the “local” sagittal imbalance of the lumbosacral junction is compensated by adjacent mobile segments in the upper lumbar spine, the pelvis orientation and the thoracic spine. The result is not optimal but a satisfactory global sagittal balance of the trunk, even in the most severe grade of slipping.

/pdf/is-there-a-sagittal-imbalance-of-the-spine-in-isthmic-3npslf4ddw.pdf

Is there a sagittal imbalance of the spine in isthmic spondylolisthesis? A correlation study.

Scoliosis is a common deformity in many types of neuromuscular disease. Severe spinal curvature can cause difficulty in sitting. Conservative and surgical treatment of neuromuscular scoliosis differs from idiopathic scoliosis, being more complex and with a higher complications rate. Non-surgical measures rarely fully control progressive scoliosis, but aim to prevent spinal deformities secondary to muscular hypotonia or contracture. Twenty-four hour bracing should be adjusted throughout growth, and may induce functional impairment and loss of independence. Corrective surgery requires multidisciplinary management and perioperative screening. Pelvic obliquity is commonly associated with neuromuscular scoliosis, making sitting difficult: correction needs to be considered during surgical planning. The goal of surgical correction is to obtain and maintain a well-balanced spine above a well-positioned pelvis. Preoperative multidisciplinary assessment enables potential problems of terrain to be anticipated. Respiratory function investigation will guide possible non-invasive perioperative ventilation. Nutritional and psychosocial assessment should also be incorporated in this preparation, as should overall postoperative care. Implementing this overall strategic planning can achieve a good surgical and functional result in the vast majority of cases.

Review articleNeuromuscular scoliosis

Summary Purpose of the study: Traumatic lumbosacral dislocation is a rare lesion often characterised by a fracture dislocation of L5-S1 articular facets associated with anterior L5 slipping. Because of its rarity, the surgical strategy of lumbosacral traumatic dislocation remains controversial. We report the most important series of traumatic lumbosacral dislocation. The cases of six men and five women are presented. We discuss the diagnosis and surgical treatment options regarding the different type of lesions. A moderate anterior slipping of L5 over S1 was present in eight cases. The lesion was a bilateral lumbosacral fracture dislocation in eight cases, a pure lateral dislocation in two cases and a unilateral rotatory dislocation in one case. Patients were multiple-trauma patients in eight cases. A radicular deficit was present in two cases. All patients were treated surgically with a posterior osteosynthesis and fusion. A circumferential fusion was made in six cases. In four cases, the anterior fusion was made during the posterior approach. The postoperative course was favorable in all the cases. One patient necessitated secondarily an iterative posterior lumbosacral fixation and anterior fibular bone graft because of a lumbosacral pseudarthrosis. Traumatic dislocation of the lumbosacral junction is a rare and severe spinal fracture which occurs in patients after high energy trauma and could be initially misdiagnosed. We devised a new classification based on anatomical lesions. Treatment is always surgical, requiring reduction, osteosynthesis, and fusion. In case of L5 anterior slipping, it is crucial to assess the L5S1 disc by MRI or surgical exploration for disc disruption. In such case, we recommend to perform circumferential fusion to prevent lumbosacral pseudarthrodesis.

Raphaël Vialle

Papers

Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects.

Is the Caton-Deschamps index a valuable ratio to investigate patellar height in children?

Is there a sagittal imbalance of the spine in isthmic spondylolisthesis? A correlation study.

Review articleNeuromuscular scoliosis

Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy