Background: The purpose of the present study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic and trauma surgery departments in university hospitals in Germany in order to clarify current challenges. Methods: In this cross-sectional study, an online-based anonymous survey was conducted within the Convention of University Professors of Orthopaedic and Trauma Surgery in Germany from April 3 to April 11, 2020. A bipolar 5-point Likert scale (with possible responses of “totally disagree,” “rather disagree,” “neutral,” “rather agree,” and “totally agree”) was applied. Fifty-two (69.3%) of 75 clinic directors participated. Results: Communication and cooperation with the government, hospital administration, and other departments during the COVID-19 pandemic were mainly perceived as appropriate. However, only 7 respondents (13.7%) totally agreed or rather agreed with the statement that the authorities are supporters of orthopaedic and trauma surgery departments. Substantial financial and personnel changes in orthopaedic and trauma surgery departments of university hospitals were reported, resulting in an average reduction of 49.4% in operating room capacity and an expected 29.3% loss of revenue. In addition, 14.7% of physicians were reallocated from orthopaedic and trauma surgery to other care-delivery environments. Conclusions: Our study demonstrated that the COVID-19 pandemic has had a substantial impact on orthopaedic and trauma surgery departments in German university hospitals. Distinct structural and financial effects were noted. Nevertheless, the present study demonstrates the commitment of our specialty to overcome the pandemic by providing competent personnel as well as close cooperation with the hospital administration and other departments. Clinical Relevance: To our knowledge, this is the first Germany-wide survey among the heads of orthopaedic and trauma surgery departments in university hospitals on the impact of the COVID-19 pandemic. The survey results may help to inform system-wide decision-making in Germany, in Europe, and beyond.

Purpose: Even though spinal infections are associated with high mortality and morbidity, their therapy remains challenging due to a lack of established classification systems and widely accepted guidelines for surgical treatment. This study’s aim therefore was to propose a comprehensive classification system for spinal instability based on the Spinal Instability Neoplastic Score (SINS) aiding spine surgeons in choosing optimal treatment for spontaneous spondylodiscitis. Methods: Patients who were treated for spontaneous spondylodiscitis and received computed tomography (CT) imaging were included retrospectively. The Spinal Instability Spondylodiscitis Score (SISS) was developed by expert consensus. SINS and SISS were scored in CT-images by four readers. Intraclass correlation coefficients (ICCs) and Fleiss’ Kappa were calculated to determine interrater reliabilities. Predictive validity was analyzed by cross-tabulation analysis. Results: A total of 127 patients were included, 94 (74.0%) of which were treated surgically. Mean SINS was 8.3 ± 3.2, mean SISS 8.1 ± 2.4. ICCs were 0.961 (95%-CI: 0.949–0.971) for total SINS and 0.960 (95%-CI: 0.946–0.970) for total SISS. SINS yielded false positive and negative rates of 12.5% and 67.6%, SISS of 15.2% and 40.0%, respectively. Conclusion: We show high reliability and validity of the newly developed SISS in detecting unstable spinal lesions in spontaneous spondylodiscitis. Therefore, we recommend its use in evaluating treatment choices based on spinal biomechanics. It is, however, important to note that stability is merely one of multiple components in making surgical treatment decisions.

Study design: Narrative review. Objectives: With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review’s purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. Methods: We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. Results: Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. Conclusions: As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.

Background: In spine surgery, surgical site infection (SSI) is one of the main perioperative complications and is associated with a higher patient morbidity and longer patient hospitalization. Most factors associated with SSI are connected with asepsis during the surgical procedure and thus with contamination of implants and instruments used which can be caused by pre- and intraoperative factors. In this systematic review we evaluate the current literature on these causes and discuss possible solutions to avoid implant and instrument contamination. Methods: A systematic literature search of PubMed addressing implant, instrument and tray contamination in orthopaedic and spinal surgery from 2001 to 2019 was conducted following the PRISMA guidelines. All studies regarding implant and instrument contamination in orthopaedic surgery published in English language were included. Results: Thirty-five studies were eligible for inclusion and were divided into pre- and intraoperative causes for implant and instrument contamination. Multiple studies showed that reprocessing of medical devices for surgery may be insufficient and lead to surgical site contamination. Regarding intraoperative causes, contamination of gloves and gowns as well as contamination via air are the most striking factors contributing to microbial contamination. Conclusions: Our systematic literature review shows that multiple factors can lead to instrument or implant contamination. Intraoperative causes of contamination can be avoided by implementing behavior such as changing gloves right before handling an implant and reducing the instruments’ intraoperative exposure to air. In avoidance of preoperative contamination, there still is a lack of convincing evidence for the use of single-use implants in orthopaedic surgery.

Purpose: While the etiopathogenesis of adolescent idiopathic scoliosis (AIS) remains unclear, it is assumed that muscular asymmetries contribute to curve progression. As previous studies have found asymmetries of the thoracic paraspinal muscles in AIS patients, our study’s aim was to analyze differences in the erector spinae, multifidus, quadratus lumborum, and psoas muscles of the lumbar spine depending on the curve’s radiographic characteristics. Methods: We retrospectively included all patients who received posterior reposition spondylodesis for AIS treatment at our institution. Patients were classified according to the Lenke classification. Muscle cross-sectional areas were obtained from magnetic resonance imaging of the lumbar spine. Data were analyzed with the Wilcoxon rank sum test, the Kruskal–Wallis test with post hoc testing, or the Spearman’s correlation coefficient. Results: Seventy-four (14 males and 60 females) AIS patients with a median age of 16 (IQR ± 4) years and a mean Cobb angle of 56.0° (± 18.0°) were included. In curve types Lenke 1 and 2 (n = 45), the erector spinae (p < 0.001) and multifidus (p < 0.001) muscles had a significantly larger cross-sectional area on the convex side, whereas the quadratus lumborum (p = 0.034) and psoas (p < 0.001) muscles each had a significantly larger cross-sectional area on the lumbar contralateral side. Conclusion: Our results show an asymmetry of the lumbar spine’s muscles which depends on both the convexity and the extent of the scoliotic curve. While our results cannot prove whether these differences are the deformity’s cause or effect, they may contribute to a better understanding of AIS pathogenesis and may allow for more specific preoperative physiotherapy.

Objective: Even though lumbosacral transitional vertebrae (LSTV) are one of the most common congenital anomalies of the spine, their effect on surrounding soft tissues is not well-studied. We therefore aimed at analyzing the association between LSTV and changes in volume, mass, symmetry, and degeneration of lumbar and trunk muscles.Materials and methods: Abdomen–pelvis CT scans were analyzed in patients with LSTV and a matched control group. LSTV were classified according to the Castellvi classification. Muscles were segmented from the remaining soft tissue and their cross-sectional area and volume were examined at five defined levels. Threshold segmentation was used to differentiate between muscle fibers and fat tissue. Matched pairs were compared using Wilcoxon rank sum tests. For comparison of categorical data, chi-squared tests were performed and for associations between the degree of fusion and muscle size and degeneration, Spearman’s correlation coefficients were calculated. Inter- and intrarater reliabilities were evaluated by computing intraclass correlation coefficients.Results: Forty-six patients with LSTV and 46 controls were included. Muscle volume of the paraspinal and trunk muscles was significantly lower (707.0 cm³vs. 809.7 cm³,p < 0.001) and fatty muscle changes were significantly increased in all but the caudal paravertebral muscles of LSTV patients (M. psoasp < 0.04, M. quadratus lumborump < 0.001, paravertebral musclesp = 0.011, M. rectus abdominisp < 0.001, M. obliquus abdominisp < 0.001). Correlations between the degree of Castellvi classification and muscle volume were significant (p = 0.001).Conclusion: LSTV are associated with a reduction in muscle volume and an increase in muscle degeneration of both lumbar and trunk muscles.