Introduction
There is a troubling lack of effective pain treatments after major surgery. Opioids remain dominant despite their many drawbacks, resulting in worse outcomes and higher costs. Locoregional anesthetics are increasingly employed, but their added value remains limited.
BR-003 is an implantable anesthetic designed for spine fixation surgery. It consists of a ring-shaped biodegradable hydrogel that is easily co-implanted with pedicle screws. Unlike injections, BR-003 stays in place and delivers bupivacaine to the surgical site for three days.
By reducing pain and opioid-related side-effects, BR-003 may help patients leave the hospital sooner and in better shape. Now, it is tested in humans for the first time.

Methods
Ongoing open-label Phase Ib study on BR-003 safety and pharmacokinetics. Two cohorts of 6 patients undergo posterior degenerative spine fixation in 2 hospitals. Per cohort, 3 patients undergo minimally invasive surgery (MIS) in a Dutch hospital, and 3 undergo open surgery in a Swiss hospital. Cohort 1 receives 4 pedicle screws with 4 BR-003 rings. Cohort 2 receives 6 screws with 6 rings.
The primary endpoint is bupivacaine Cmax. Secondary endpoints include pharmacokinetics, safety, and exploratory efficacy up to 6 weeks. Safety monitoring includes AEs, ECGs, X-rays, and blood tests. Efficacy is explored by comparing back pain in rest (AUC-NRS) and opioid use (MMEs) in the first 3 days to a recent observational cohort in the same hospitals. In MIS cohort 1, pre-emptive analgesia was restricted to assess the early effects of BR-003.

Results
Nine patients were included so far: full cohort 1 and 3 MIS patients in cohort 2. Bupivacaine Cmax remained 10x below the known toxic threshold. No serious adverse events were attributed to BR-003 to date. After MIS with BR-003, the average AUC-NRS in the first 3 days was 1.2 points lower (3.7 vs 4.9) despite restricted pre-emptive analgesia. After open surgery, the AUC-NRS was 1.6 points lower (1.4 vs 3.0). Total opioid use was 39% lower with BR-003 (MMEs 150 vs 247). Opioid use on day 2 and 3 was low, providing opportunities for earlier discharge.

Conclusion
This first-in-human study revealed no safety concerns to date. A substantial reduction was found in pain and opioid use compared to a recent observational cohort in the same hospitals. A large randomized controlled trial is planned to substantiate the impact of BR-003 on pain, opioid use, and enhanced recovery after spine fixation surgery.

Background
Screw loosening is a common cause for revision following spinal instrumentation using pedicle screws. The current gold standard to detect loosening of pedicle screws is radiation-emitting computed tomography imaging. However, solely based on medical imaging, clinicians are not able to reliably identify loose implants in a substantial amount of cases. Intraoperative extractional torque measurement disrupts the potentially intact bone-implant interface. To overcome these issues, we propose a new methodology for the radiation-free, non-destructive, and easy-to-integrate detection of screw loosening based on vibroacoustic sensing.

Methods
For the detection of a loose implant, we excite the vertebra of interest with a sine sweep vibration at the spinous process and use a custom highly-sensitive piezo vibration sensor attached directly at the screw head to capture the propagated vibration characteristics which are analyzed using a deep learning-based detection pipeline. To validate the proposed approach, we developed a biomechanically controlled simulation setup for pedicle screw loosening using custom 3D printed drill guides. We conducted experiments using four human cadaveric lumbar spine specimens and evaluated our algorithm in a leave-one-specimen-out cross-validation experiment.

Results
Vibroacoustic sensing reaches a sensitivity of 91.50 ± 6.58% and a specificity of 91.10 ± 2.27% for pedicle screw loosening detection.

Conclusion
The tested system could be used for the reliable intraoperative detection of loose pedicle screws as an alternative for the measurement of the extractional torque. Furthermore, we believe that the proposed work could serve as a strong proof-of-concept for the development of smart implants in spinal fusion surgery.

Introduction
Anterior lumbar interbody fusion (ALIF) surgery can damage nerve fibers and has been linked to sexual dysfunction in men. In women, sexual and urinary dysfunction following ALIF is barely investigated.

Research question
The aim of this study was to investigate the frequency of postoperative changes in sexual function and of incontinence in women following ALIF.

Material and Methods
We asked 173 female patients aged 18-60 years who had undergone a primary ALIF surgery in 2015-2022 in a large Swiss spine center to retrospectively answer a questionnaire about sexual function and incontinence pre- and postoperatively as well as their satisfaction with the surgery. We used exact McNemar test to compare paired data.

Results
Of all respondents (n = 84), 23 (27%) reported a worsening of sexual function following ALIF surgery, and these changes were persistent in 83%. Among individual symptoms of sexual dysfunction, the highest increase was observed for prevalence of vaginal dryness, which increased from 12% pre-operatively to 32% (p < 0.001), followed by dyspareunia, which increased from 8% to 21% (p = 0.001). Urinary incontinence increased from 25% to 41% (p < 0.001) and prevalence of faecal incontinence remained unchanged. Patient age, level of surgery and fusion material were not associated with worsening of sexual function. However, worsening of sexual function was associated with a lower level of satisfaction with the surgery outcome and a lower proportion of patients who would have the
surgery again.

Discussion and Conclusion
Female patients should receive preoperative information about potential changes in sexual function after ALIF.

Study Design Retrospective analysis of consecutively enrolled skeletally mature patients who underwent ALIF and/or LLIF interbody fusion for degenerative or deformity pathologies utilizing 3DPTi cages between 2020 and 2022 from a single surgeon spine registry.
Objective To determine the fusion rate in patients undergoing anterior lumbar interbody fusion (ALIF) and/or lateral lumbar interbody fusion (LLIF) with titanium cages.
Summary of Background Data Interbody composition is a key factor in the success of spinal fusion surgery. While the use of three-dimensional printed titanium (3DPTi) has been well established in other orthopaedic applications, the reports of titanium cages in anterior- or lateral-based spinal fusion are scarce.
Methods Fusion rate at 1-year follow-up was assessed by computed tomography (CT) scans and graded by Lenke-Bridwell classification. Flexion-extension lateral radiographs were assessed at 1-year postoperatively and fusion confirmed if less than 5 degrees range of motion was detected through the fused segment. Perioperative metrics including bone graft type, operative time, estimated blood loss, revisions within the first postoperative year, and clinical outcome assessed by the Oswestry Disability Index (ODI) were analyzed.
Results Seventy-three patients, with 130 fusion levels with 3DPTi cages were identified. 71.2% of patients were treated for degenerative pathologies, 24.7% for deformity pathologies and 4.1% for pseudoarthrosis. 5.5% of patients underwent a revision procedure with 3DPTi cages. Overall, 99.2% of interbody levels were fused on CT at 1-year postoperatively. On flexion-extension radiographs, all levels were deemed to be fused. Five patients (6.8%) required an additional surgery within the first two years. No revisions were required for cage subsidence/migration, or pseudoarthrosis. Median ODI significantly improved at 1-year postoperatively compared to baseline (median baseline ODI: 46; 1-year ODI: 22, p = 0.001).
Conclusion 3D-printed titanium cages for ALIF and LLIF result in excellent fusion rates at one year postoperatively without the need for rhBMP-2.

Introduction: Cervical disc arthroplasty (CDA) was established as a motion-sparing alternative to anterior cervical discectomy and fusion (ACDF) for degenerative cervical disease, achieving comparable patient-reported and clinical outcomes. Many unique CDA device designs are available, with distinct outcomes and complications identified. Despite these differences in device design and performance, there is a paucity of data on different modes of failure of CDA implants. To date, literature on complications associated with revision surgery for CDA is limited, mainly comparing CDA to fusion instead of comparing different CDA models. This study aimed to analyze revision cases due to complications related to CDA reported to the FDA Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database.

Methods: The MAUDE database was queried for data from January 2005 to September 2023. All the reported complication entries for the nine FDA-approved CDA devices were analyzed. The full-text entries of all complications were individually analyzed, reported, and grouped depending on the revision surgery performed. For each revision case, the device used, the associated complication, the time until revision, and the type of revision surgery were collected.

Results: In summary, 1,347 entries were analyzed from the MAUDE database, with the highest number of reports made to the database in 2018 (218). A total of 678 cases reported revision surgery for nine different CDA models: Mobi-C (239), M6 (167), Prodisc-C (88), Prestige (60), PCM (44), Bryan (35), Secure (23), Simplify (21) and Discover (1). The top three complications associated with CDA revision were implant migration (23.5%), neck pain (15.5%), and heterotopic ossification (6.6%). The top complication per device was migration for Mobi-C (26.4%), Prodisc-C (21.3%), Prestige (24.6%), PCM (84.1%), Bryan (48.6%), Secure (30.4%) and Discover (100%). For M6 the most common complications associated with revision surgery were osteolysis (18.6%) and neck pain (18.6%). Neck pain (23.8%) was the most common for the Simplify device.

Conclusion:
The MAUDE database highlights complications related to revision cases for CDA, which may not receive sufficient emphasis in existing published studies and can vary depending on the device. Nevertheless, the primary complications linked to CDA revision consistently include implant migration, neck pain, and heterotopic ossification.

Introduction: Traumatic thoracolumbar burst fractures are the most common spinal injuries and the proper treatment is controversial. In central Europe in particular, these fractures are often treated with minimally invasive anterior-posterior reduction and fusion, whereas a conservative approach is preferred in the USA. Independent of the treatment strategy, no data exists regarding the outcome related to return to activity level/sport. The aim of this study was to evaluate the return to sports and activity levels after 360° fusion in patients with thoracolumbar burst fractures without neurological deficits.
Methods: Between January 2013 and December 2022, 46 patients aged 18 to 40 years underwent partial or complete vertebral body replacement in the thoracolumbar region due to traumatic burst fractures without neurologic deficit as an isolated injury. Patients were contacted retrospectively by phone calls to assess their activities using a modified version of the Tegner activity scale at different time points: Before trauma, 3, 6, and 12 months post-surgery.
Results: After applying exclusion criteria, data collection was complete for 28 patients. The median modified Tegner activity scale was 5.4 before sustaining the fracture, declined to 2.9 at three months post-trauma, improved to 4.2 at six months, and reached 5.0 at 12 months. The majority (83%) of patients achieved their pre-accident activity level within 12 months. No significant differences were observed between patients with partial or complete corpectomy.
Conclusion: This is the first study assessing return to sports/physical activity based on the modified Tegner scale in young patients undergoing 360° fusion for spinal burst fractures. The majority of patients (83%) return to the pre-injury activity level within 12 months after surgery.

Introduction:
Carbon fiber-reinforced poly-ether-ether-ketone (CFR-PEEK) vertebral body replacements (VBR) promise low subsidence, reduced image artifacts, and improved radiation planning while maintaining fusion capabilities. This study evaluates the safety and efficacy of the novel Kong® modular, titanium-coated CFR-PEEK VBR for restoring sagittal alignment via anterior column reconstruction (ACR) of the thoracolumbar spine following high-energy trauma, osteoporotic fractures, or tumors.

Methods:
We retrospectively analyzed all patients undergoing ACR with the Kong® VBR from 2020 to 2021. Exclusion criteria were incomplete records. The primary outcome was the bi-segmental kyphotic angle (BKA) correction measured by the Cobb method. Secondary outcomes included craniocaudal subsidence, the cage height coefficient for evaluating the cage expansion locking mechanism, sagittal tilt, pedicle screw loosening, and spinal fusion status assessed by Bridwell's criteria on plain radiographs and CT scans. Clinical outcomes were evaluated using Odom's criteria (all patients), the Karnofsky Performance Status (tumors), and the AOSpine PROST-Score (trauma group). Complications were documented.

Results:
The cohort comprised 28 patients (15 high-energy and 7 osteoporotic fractures, 6 tumors; age: 61 ± 19 years; 33% female; follow-up: 17.7 ± 7.7 months). Postoperative BKA correction was significant at 14.4° (± 23.8°, p = 0.01). At last follow-up, a correction loss of 2.7° (± 25.2°, p = 0.60) was observed, with correction from baseline maintained at 15.3° (± 30.3°, p = 0.03). At last follow-up, subsidence was 0.5 ± 0.71 mm (range 0-2 mm; p = 0.05), and no changes in cage height coefficient (0.02 ± 0.10, range 0.0-0.5; p = 0.11) or sagittal tilt (0.8 ± 4.4°, range 0-22°; p = 0.38) were observed. No screw loosening occurred. Fusion (Bridwell Grade I or II) was achieved in 95% (CT) and 93% (radiographs) of cases. Neurological function improved in 88% of patients with initial deficits. At last follow-up, Karnofsky Performance Status improved by 17.9 points (p = 0.01), AOSpine PROST-Score was 56.9, and 92% of patients were rated as "excellent" or "good” according to Odom’s criteria. One (4%) early deep infection occurred, treated with debridement.

Conclusion:
Preliminary data suggest that the Kong® modular, expandable, titanium-coated CFR-PEEK VBR is a viable and effective option for ACR of the thoracolumbar spine for high-energy and osteoporotic fractures, and spinal tumors.

Introduction: Adjacent segment disease (ASD) is a frequent reason for revision surgery following primary spine fusion. A harmonic sagittal spinopelvic alignment (SPA) correlates with patient reported outcome measures (PROMs) in spinal deformity correction. However, the importance of SPA in short-segment lumbosacral fusion surgery for long-term outcome and prevention of ASD is largely unknown. This study aimed to explore how SPA affects revision surgery for ASD and postoperative PROMs after short-segment lumbosacral fusion.

Methods: This is a retrospective single-centre study in a tertiary academic institution. Patients who underwent a primary L4-S1 spinal fusion between 2003 and 2015 were followed-up by phone-call after a minimum of 5 years postoperative and the following PROMs were assessed: Oswestry Disability Index (ODI) and the 5-level EQ5D (EQ5D5L). Patients who underwent revision surgery for ASD (= ASD group) were compared to patients who did not (= controls). Various SPA parameters were measured on preoperative and initial postoperative standing radiographs.

Results: Among 86 patients with a mean follow-up of 12 ± 4 years, 32.6% (n = 28) underwent ASD revision surgery within 73 ± 59 months, accounting for 85% of all revisions. Age (53 ± 17 years), sex (57% female), BMI (26.6 ± 6.0) and follow-up time did not differ between the ASD group and controls. No significant difference in pre- and postoperative sagittal alignment parameters were found. However, preoperative pelvic incidence (53.7° vs. 59.6°), sacral slope (34.9° vs. 40.3°), and lumbar pelvic angle (8.8° vs. 12.1°) trended to be lower in the ASD group than the controls, although not reaching statistical significance. Post-surgery, the L3-L4 angle decreased significantly in the ASD group (7.3°, p = 0.013), but not in controls. Patients who underwent ASD revision exhibited higher ultimate ODI scores 24 (IQR = 13-39) vs. controls 11 (IQR = 2-28; p = 0.03) and lower EQ5D5L scores 70 (IQR = 55-85) vs. controls 85 (IQR = 70-90; p = 0.04).

Conclusion: SPA was not associated with ASD revision surgery in short-segment lumbo-sacral fusions > 5-year follow-up. This suggests that other factors, beyond radiographic parameters and SPA may exert greater influence on achieving favourable long-term-outcomes and averting ASD. Patients who underwent ASD revision surgery had worse scores in postoperative PROMs, which underlines the importance of ASD prevention and risk reduction.

Background Context Academic orthopaedic journals and specialty societies emphasize the importance of two-year follow-up for patient-reported outcome measures (PROMS) after spine surgery, but there are limited data evaluating the appropriate length of follow-up.
Purpose To determine whether PROMs, as measured by the Oswestry Disability Index (ODI), would change significantly after 2-months postoperatively after lumbar decompression surgery for disc herniation or spinal stenosis.
Study design Retrospective analysis of prospectively and consecutively enrolled patients undergoing lumbar decompression surgery.
Patient sample One hundred sixty-nine patients
Outcome Measures ODI, achievement of minimum clinically important difference (MCID), revisions.
Methods Patients without a preoperative baseline score were excluded. Completion of the ODI questionnaire was assessed at the follow-up points. The median ODI was compared at time baseline, 2-month, 1-year and 2-year follow-up. Risk of reoperation was assessed with receiver operating characteristic (ROC) analysis to identify at-risk ODI thresholds of requiring reoperation.
Results Median ODI significantly improved at all time points compared to baseline (median baseline ODI: 40; 2-month ODI: 16, p=0.001; 1-year ODI: 11.1, p=0.001; 2-year ODI: 8, p=0.001). Post-hoc analysis demonstrated no difference between 2-months, 1-year and 2-year postoperative ODI (p=0.9, p=0.468, p=0.606). The MCID was met in 87.9% of patients at two months, 80.7% at one year, and 87.3% at two years postoperatively. Twelve patients (7.7%) underwent revision surgery between 2 months and 2 years after the index surgery (median time to revision: 5.6 months). ROC curve analysis demonstrated that an ODI score ≥24 points at 2-months yielded a sensitivity of 85.7% and a specificity of 71.8% for predicting revision after lumbar decompression (AUC=0.758; 95% CI: 0.613-0.903). The Youden optimal threshold value of ≥24 points at 2-month postop ODI yielded an odd’s ratio (OR) for revision of 15.3 (CI: 1.8-131.8; p = 0.004). The positive predictive value and negative predictive value were 15.4% and 98.8%, respectively.
Conclusion Two-year clinical follow-up may not be necessary for future peer-reviewed lumbar decompression surgery studies given that ODI plateaus at 8 weeks. Patients with a score ≥ 24 points at 2-months postoperatively have a higher risk of requiring a second surgery within the first two years and warrant continued follow-up.

Introduction
Computerized navigation is currently widespreading around the world in spine surgery, allowing more accurate procedures especially to insert pedicle screws, becoming a gold standard in many facilities. Robotic guidance aims to stabilize a robotic arm after surgical planning of screw trajectory. The Mazor X Stealth is a recent device which combines robotic guidance and navigation. The purpose of the study was to compare operative and radiologic results and also radiation exposure between the Mazor X Stealth and the O-arm navigation for pedicle screw insertion.

Methods
All patients who required pedicle screw insertion for posterior lumbar fusion were prospectively included and divided into two groups : RG when operated on with the Mazor X Stealth, and NV when operated on with the O-arm and navigation as a control group. Age, number of levels operated, number of screws inserted, operative time in minutes (min), estimated blood loss (EBL in milliliters, ml), time to insert screws (in min) were collected. Satisfaction of screw positioning was assessed with the Gertzbein classification. Dosimetric data of the imaging devices were recorded for effective dose E calculation (in millisievert, mSv) using conversion factors. The absolute risk of cancer (AR, in %) equivalent to a whole-body acquisition was also calculated. Intraoperative and postoperative complications were recorded.

Results
100 patients were included, 50 in each group. Mean age was similar: 72 versus 69 in RG and NV respectively, p = 0.21. 227 vertebrae were operated: 106 in RG and 121 in NV. A total of 438 screws were inserted, 205 in RG and 233 in NV. Operative time was similar with 161 versus 151 minutes in RG and NV respectively (p = 0.37), as well as EBL (350 versus 454 ml, p = 0.13). Mean time to insert screws was significantly lower in RG, with 13 minutes versus 18 minutes in NV, p = 0.03; but time per screw was similar: 3.4 versus 3.8 respectively, p = 0.11. 97% screws were satisfactory in RG versus 99% in NV. Overall E was significantly higher in RG, with 7.24 and 5.77 mSv in NV, p < 0.01, as well as AR, with 3.6x10E-4% in RG and 2.9x10E-4% in NV (p < 0.01). Overall complication rate was 26% in RG and 36% in NV.

Conclusion
The Mazor X Stealth showed promising results especially in accuracy of pedicle screw insertion, operative parameters and also complications, but was inferior to the O-arm navigation in terms of radiation exposure.

Introduction
The gold standard for the assessment of bone mineral density (BMD) is dual-energy x-ray absorptiometry (DEXA). In principle, conventional magnetic resonance imaging (MRI) and radiography could also be used for estimating BMD, with the advantage of not requiring any ionizing radiation (for MRI) and potentially allowing for opportunistic examination and retrospective analysis of existing imaging databases. This study aimed at developing machine learning methods to estimate BMD and to detect osteopenia/osteoporosis from conventional lumbar MRI (T1-weighted and T2-weighted images) and planar radiography in combination with clinical data and imaging parameters of the acquisition protocol.

Materials and methods
A database of 429 patients subjected to lumbar MRI, planar radiographs and DEXA within 6 months was created from an institutional imaging database. Several machine learning models were trained and tested (373 patients for training, 86 for testing) with the following objectives: (1) direct estimation of the vertebral BMD; (2) classification of T-score lower than -1 or (3) lower than -2.5. The models took as inputs either the images or radiomics features derived from them, alone or in combination with metadata (age, sex, body size, vertebral level, parameters of the imaging protocol).

Results
The best-performing models achieved mean absolute errors (MAEs) of 0.15-0.16 g/cm2 for the direct estimation of BMD for the cases in the test set, and of 1.0-1.07 for the estimation of the T-score.
Regarding the classification of cases of low BMD, areas under the receiver operating characteristic (ROC) curve of 0.82 (MRIs) - 0.80 (radiographs) for the classification of T-scores lower than -1, and 0.80 (MRIs) - 0.65 (radiographs) for T-scores lower than -2.5 were obtained.

Conclusions
The models showed good discriminative performances in detecting cases of low BMD, and more limited capabilities for the direct estimation of its value. Being based on routine imaging and readily available data, such models are promising tools to retrospectively analyse existing datasets as well as for the opportunistic investigation of bone disorders.

Acknowledgements
The project has been partially funded by the ISSLS Clinical Research Grant 2023.

The incidence of H-/U-type fragility fractures of the sacrum among geriatric patients is increasing, but evidence on the best surgical stabilisation method is lacking. In this retrospective bi-centric comparative cohort study, we aimed to compare the outcomes and complications of transiliac-transsacral screw fixation (TIS) and lumbopelvic fixation (LPF), the two most common fixation methods for nondisplaced H-/U- type fragility fractures among geriatric patients.

Medical records of patients treated with TIS or LPF for nondisplaced H-/U-type fragility fractures of the sacrum at two level A trauma centres between 2012 and 2022 were analysed. Postoperative pain and mobility levels were assessed as primary outcomes before discharge and at six weeks and six months postoperatively. Surgery time, blood loss, and surgical complication rates were assessed as secondary outcomes. Statistical analyses consisted of Fisher’s exact tests for frequency distributions and Mann-Whitney-U tests and t-tests for group comparisons.

52 patients undergoing TIS (mean age: 78 ± 9 years) and 41 patients undergoing LPF (75 ± 10 years) with no discrepancy in demographic parameters were identified. There were no differences in pain levels between the two groups before discharge, at six weeks postoperatively, and at six months postoperatively (p > 0.05). There were no differences in mobility levels before surgery, before discharge, at six weeks postoperatively, and at six months postoperatively (p > 0.05). Duration of surgery was shorter after TIS (53 ± 48 min) compared to LPF (116 ± 36 min) (p < 0.0001). Intraoperative blood loss was lower for TIS (median 0ml) compared to LPF (median 200ml) (p < 0.0001). Postoperative radiculopathy was less frequent after TIS (n=1) compared to LPF (n=5) (p < 0.05). Median length of stay was shorter after TIS (11 days) compared to LPF (14 days) (p < 0.05). Rates of reoperations directly related to the index surgery rates were lower after TIS (n=2) compared to LPF (n=12) (p < 0.001). Implant failures were observed only after LPF (n=2).

Geriatric patients with nondisplaced H-/U- type fragility fractures of the sacrum may preferably be treated using TIS, as it is equivalent to LPF in terms of pain reduction and restoration of mobility, but allows for shorter operative time, less blood loss and lower complication rates. Prospective randomized studies should be conducted to substantiate our findings and develop distinct treatment recommendations.

Introduction
De novo spinal infections (DNSI) are a concerning and rising healthcare problem. The treatment decision in DNSI regarding conservative or surgical therapy is established on a case-to-case basis in the absence of clear guidelines. The recently proposed Spinal Infection Treatment Evaluation (SITE) score combines clinical and radiological variables to support decision-making, but it has not been validated among non-spine surgeons. We aimed to validate this novel score in a real-life setting among surgeons from different clinical specialties.
Methods:
A single-center study was conducted at our institution from 1/10/2023 until 31/12/2023. We collected clinical and radiological data of DNSI patients, previously treated at our institution and created fifteen representative case vignettes, which included all spinal locations and SITE scores. An online survey was designed to distribute the case vignettes among physicians from the departments that agreed to participate. Participants were asked to score each case and to evaluate the applicability (0-100 points) of the SITE score. We calculated intra-class correlation coefficients (ICC3) for the score reliability and ANOVA to compare the collected applicability scores, using R for statistical analysis.
Results:
Forty-eight survey forms were analyzed, of which seven and 41 were completed by spine surgeons, or colleagues from other specialties (internal medicine (n=20), orthopedic surgery not involved in spine surgery (n=10), infectiology (n=5), and other surgical disciplines (n=6)), respectively. Spine surgeons demonstrated good interobserver reliability (ICC3 = 0.78). Non-spine surgeons showed poor interobserver reliability to the overall SITE score (ICC3 = 0.48). Subgroup analysis by specialty revealed overall low reliability scores (< 0.6 for each subgroup). Participants with more frequent exposure to DNSI cases (> 10 per year; n=9) showed higher reliability, achieving similar scores to spine surgeons (ICC3=0.7). The applicability scores showed similar values for all spine locations and SITE score severities.
Conclusions:
We found acceptably high interobserver values for the SITE score only for spine surgeons and non-spine surgeons with frequent exposure to DNSI. The reliability of the score was much lower when applied by physicians from other specialties with lesser experience of DNSI, who would particularly benefit from such a score for decision-making in clinical practice.

Intro
Since first being described by Yasargil and Caspar in 1977, the microscopic interlaminar approach remains the surgical gold standard for surgical treatment of lumbar disc herniations. The first endoscopic technique to be developed was the monoportal endoscopic technique (UESS), but it remained largely unused due to its steep learning curve. The development of biportal endoscopy (BESS/UBE) has reawakened interest in endoscopic surgery due to its shorter learning curve while retaining the advantages of UESS. The goal of this study is to evaluate the learning of UBE in a single center by a single surgeon for the treatments of mono-segmental degenerative spinal pathologies.

Met
The surgeon followed a novel step by step online UBE course during the COVID pandemic. 54 patients were followed between November 2021 and October 2023 and were separated into 3 cohorts: lumbar disc hernia (LDH), lumbar spinal stenosis (LSS) and lumbar disc hernia + lumbar spinal stenosis (LDH-S). 48 were treated with UBE. EQ-5D-5L, ODI, VAS and SF-12 scores were analysed preoperatively, 6 w, 3 m and 6 months postoperatively, using ANOVA for 36 patients. The type and rate of complications were also reported. An operation length curve was constructed using a selected homogenous cohort from the LDH group.

Res
In the LDH cohort 37 patients were treated by UBE and 5 converted to open, 7 were treated by UBE in the LSS cohort with 1 conversion and all 4 patients were treated by UBE in the LDH-S cohort. The mean OR time was 76±19 minutes in the LDH cohort, 156±30 minutes for the LSS cohort and 109±27 minutes for the LDH-S cohort. EQ-5D-5L, ODI, SF-12 significantly improved for all cohorts between the preoperative and 6-week postoperative period (p < 0.001). Noted intraoperative complications were 2 dural tears, 2 facet joint lesions (needing fusion) and a transient cauda equina syndrome. Postoperative complications were 3 early recurrences of hernia (≤ 1 month), 2 epidural hematomas, an infection and a pulmonary embolism. The operation length curve showed that OR time and complication rates decreased with the progression of cases.

Con
UBE is a safe alternative to traditional microscopic surgery with low complication rates, especially when the initial learning curve of 24 cases is overcome. It is also possible to learn the technique successfully and efficiently through online mentoring, making the technique considerably more accessible to surgeons who cannot attend in-person training.

Introduction
Accurate landmark detection is essential for precise analysis of anatomical structures, supporting diagnosis, treatment planning, and monitoring in patients with spinal deformities. Conventional methods rely on laborious landmark identification by medical experts, which motivates automation. The proposed deep learning pipeline processes bi-planar radiographs to determine spinopelvic parameters and Cobb angles without manual supervision.

Methods
The whole dataset used for training and evaluation comprised 555 bi-planar radiographs from uninstrumented patients, manually annotated by a medical professional. In a pre-processing step, the pipeline determined the regions of interest (cervical spine, thoracolumbar spine, sacrum & pelvis). A segmentation network was trained for each ROI to identify vertebral bodies and pelvic landmarks. The network used a refined UNet architecture and was trained on 455 bi-planar radiographs using a Dice loss. To improve segmentation performance, the training data was augmented with artificially generated samples. The post-processing algorithm derived spinal alignment and angular parameters based on the segmentation output. The pipeline was evaluated on a test set of 100 previously unseen bi-planar radiographs. The performance metric utilized was the mean absolute difference between annotated and predicted landmarks. Additionally, the spinopelvic parameter predictions of the pipeline were compared to the measurements of two experienced medical professionals using the intraclass correlation coefficient.

Results
The pipeline was able to successfully predict the Cobb angles in 61% of all test cases and achieved mean absolute differences of 3.3° (3.6°) and averaged ICC of 0.88. For thoracic kyphosis, lumbar lordosis, sagittal vertical axis, sacral slope, pelvic tilt, and pelvic incidence the pipeline produced reasonable outputs in 69%, 58%, 86%, 85%, 84%, 84% of the cases. The MAD was 5.6° (7.8°), 4.7° (4.3°), 2.8mm (3.0mm), 4.5° (7.2°), 1.8° (1.8°) and 5.3° (7.7°), while the ICC was measured at 0.69, 0.82, 0.99, 0.61, 0.96 and 0.70, respectively.

Conclusion
Despite limitations in patients with severe pathologies and high BMI, the pipeline automatically predicted coronal and sagittal spinopelvic parameters, which has the potential to simplify clinical routines and large-scale retrospective data analysis.

Acknowledgments
The authors thank the Promedica Stiftung, Chur, for financial support.

Introduction:
In spinal deformity surgery, full navigation with intraoperative CT often requires multiple scans for extensive corrections. We introduced a workflow combining Brainlab Airo® navigation with the freehand (FH) technique in lower levels, requiring only one scan, reducing time and radiation exposure. Here, we assess the FH screw accuracy and safety of combined navigated/FH instrumentation.

Methods:
We retrospectively analyzed all patients undergoing neuromonitored open posterior instrumentation for adult idiopathic (AIS) or neuromuscular (NM) scoliosis from 2018 to 2023. Our workflow began with FH instrumentation below the deformity's apex, verified with a CT scan. Subsequent screws were navigated based on this scan. The accuracy of all screws was confirmed with C-arm fluoroscopy. Exclusions: Altered workflows or incomplete data. The primary outcome was FH screw accuracy on CT (Gertzbein-Robbins scale). Secondary outcomes were screw adjustments, scan time, dose-length product (DLP), screw loosening, curve correction (Cobb angles), and the SRS-22 questionnaire. We noted neurological and other complications.

Results:
In 31 patients (24 AIS, 7 NM; age: 16.5±4.7 years; BMI: 20.3±4.1; follow-up: 19.8±9.9 months), 560 screws were placed in 413 levels (278 FH in 206 levels; 282 navigated in 226 levels; 19 levels both techniques). FH accuracy reached Grade A in 254 screws (91.4%), Grade B in 10 (3.6%), Grade C in 2 (0.7%), Grade D in 1 (0.4%), with 11 outer breaches (4.0%). Four FH screws (1.4%) and one navigated screw (0.4%) were replaced. All screws were correct on final X-rays. Significant corrections were attained in the main (49.8±11.4°, p < 0.0001) and secondary curves (30.6±12.1°, p < 0.0001). Significant changes were found in clavicular height, pelvic and T1 tilt, while thoracic kyphosis, lumbar lordosis, C7 plumb line, and coronal balance did not change. Mean DLP was 91.1±30.4 mGy·cm and mean scan duration 18,479±4,037 ms. No screw loosening, neurological or screw-related complications occurred. Mean SRS-22 was 4.3±0.9 out of 5 across all items.

Conclusion:
In our approach, FH accuracy on CT matched the rates of up to 96% reported in purely navigated pedicle screws for pediatric deformity, without screw complications. Adding FH screws enabled accurate full-length navigation with a single scan. Despite lacking a control group, the data suggests that complementing navigation with FH screws is a viable option in pediatric deformity corrections.

Introduction:
Clinical studies have repeatedly highlighted the benefits of endoscopic transpedicular decompression for down-migrated lumbar disc herniations. However, the biomechanical effects on pedicle stability have not been studied up to now. The goal of this study was to analyze the effects of an endoscopic transpedicular approach with different drill diameters (6 and 8 mm) to compare them with the intact native side. In addition, the influence of bone quality on the resistance of the pedicle after transpedicular approach was investigated.

Methods:
Twenty-four vertebras originating from four fresh-frozen cadavers were tested under uniaxial compression load in a ramp-to-failure test: (1) the tunneled pedicle on one side, and (2) the native pedicle on the other side. Of the 24 lumbar vertebrae, 12 were assigned to a drill diameter of 6 mm and the other 12 to a diameter of 8 mm.

Results:
The median ratio of sustained force for the operated side compared to the intact contralateral side is equal to 74% (63 – 88) for both drill diameters combined. A transpedicular approach with 8 mm resulted in a decrease of the axial resistance force by 60 – 88% compared to the intact contralateral side (p = 0.002). A 6 mm drill hole resulted in a decrease of the axial resistance force by 66 – 84% compared to the intact opposite side (p = 0.01). No significant difference between the two different drill diameters was recorded (p=1). For all 3 subgroups (intact, 8 mm drilled, 6 mm drilled) the HU values and the absolute resistance force showed significant correlations (intact: ρ=0.859; p < 0.001 ; 8 mm drilled: ρ=0.902; p < 0.001; 6 mm drilled: ρ=0.835; p < 0.001).

Conclusion:
Transpedicular approach significantly reduces the axial resistance force of the pedicle, which may lead to pedicle fracture. Bone quality correlated positively with the absolute resistance force of the pedicle, whereas the influence of the drill hole diameter plays only a limited role.

Purpose To analyze the effect of endplate weakness prior to PLIF or TLIF cage implantation and compare it to the other intact endplate of the same vertebral body. In addition, the influence of bone quality on endplate resistance was investigated.
Methods Twenty-two lumbar vertebrae were tested in a ramp-to-failure test. One endplate of each vertebral body was tested intact and the other after weakening with a shaver (over an area of 200mm2). Either a TLIF or PLIF cage was then placed and the compression load was applied across the cage until failure of the endplate. Failure was defined as the first local maximum of the force measurement. Bone quality was assessed by determining the Hounsfield units (HU) on CT images.
Results With an intact endplate and a TLIF cage, the median force to failure was 1276.3N (693.1-1980.6N). Endplate weakening reduced axial endplate resistance to failure by 15% (0-23%). With an intact endplate and a PLIF cage, the median force to failure was 1057.2N (701.2-1735.5N). Endplate weakening reduced axial endplate resistance to failure by 36.6% (7-47.9%). Bone quality correlated linearly with the force at which endplate failure occurred. Both intact and weakened endplates showed a strong positive correlation with bone quality of  = 0.939 (p = 9.3E-11) and  = 0.840 (p = 1E-06), respectively.
Conclusion Weakening of the endplate during cage bed preparation significantly reduces the axial resistance of the endplate to failure: endplate load capacity is reduced by 15% with TLIF and 37% with PLIF. Bone quality correlates with the force at which endplate failure occurs.

Introduction
The addition of fusion to decompression surgery for lumbar degenerative spondylolisthesis and spinal canal stenosis remains disputable. Hence, the aim of this study was to assess the comparative effectiveness and selected healthcare resource utilization of patients undergoing decompression with or without fusion surgery at 3 years follow-up.

Methods
Using observational data from the multicenter prospective Lumbar Stenosis Outcome Study (LSOS) and a target trial emulation with index trial benchmarking approach, we assessed the comparative effectiveness of the two main surgical interventions for lumbar degenerative spondylolisthesis and spinal canal stenosis - fusion and decompression surgery alone. The outcome parameters were the change in EuroQol Health Related Quality of Life 5-Dimension 3-Level questionnaire, in back/leg pain intensity (Numeric Rating Scale), in satisfaction (Spinal Stenosis Measure satisfaction subscale) and healthcare resource utilization outcomes as physical therapy and oral analgesic use.

Results
153 patients underwent decompression alone and 62 had decompression plus fusion. After inverse probability weighting, 137 patients were included in the decompression alone group (mean age, 73.9 [7.5] years; 77 female [56%]) and 36 in the decompression plus fusion group (mean age, 70.1 [6.7] years; 18 female [50%]). We found no statistically significant standardized mean differences in EuroQol Health Related Quality of Life summary index change score at 3 years (EQ-5D-3L: 0.07 [95% confidence interval (CI), -0.25 to 0.39]). No between-group differences in change in back/leg pain intensity or satisfaction were found. Decompression plus fusion was associated with greater physical therapy utilization at 3 years follow-up.

Conclusions
Decompression alone should be considered the primary option for patients with lumbar degenerative spondylolisthesis and spinal stenosis.

Introduction: In children younger than 4-year-old, septic arthritis of the hip is more frequent than transient synovitis. This study aims to report the clinical outcomes and the microbiological results in a large group of children with confirmed K. kingae septic arthritis of the hip. Moreover, its purpose is also to assess the reliability of Kocher/Caird criteria to predict septic arthritis of the hip caused by K. kingae.
Methods: The medical charts of 140 children younger than 4-year-old suffering from a confirmed K. kingae septic arthritis of the hip were collected through a multicenter hospital database. Gender, age, temperature at admission, weight-bearing status, WBC, platelets count, CRP value, ESR and platelets count were extracted for each patient. Our attention focused on the Kocher/Caird prediction criteria for hip septic arthritis (body temperature, refusal to bear weight, leukocytosis, erythrocyte sedimentation rate, and C-reactive protein level) to assess their efficiency.
Results: All patients included in the study had confirmed K. kingae SAH; most of them presented with mild symptoms and near-normal laboratory. CRP (76.2%) had the best sensitivity for Kocher/Caird criteria, followed by weight bearing status (73.8%) and WBC count (69.6%). Body temperature and ESR exceeded cutoffs values of the Kocher/Caird algorithm in less than 50% of cases. Among 77 patients with full available Kocher criteria, 63.5% showed less than 40% probability to suffer from SAH. About the 50 children with completely available Caird criteria, 40% of them presented a 62.4% probability of SAH.
Conclusions: K. kingae septic arthritis of the hip can mimic many other medical conditions. Our results showed that Kocher & Caird criteria are insufficient to diagnose a septic arthritis of the hip due to K. kingae in pre-school aged children.

Transphyseal hematogenous osteomyelitis is a much more common infectious condition of what is recognized in the literature. A large proportion of acute or subacute pediatric hematogenous osteomyelitis can diffuse through the growth cartilage and therefore may be potentially responsible for growth disorders, leading to limb length discrepancy or angular deformities. The literature does not address this issue, and it is currently difficult to determine the real prevalence of this type of complications.

The present study aimed to identify both the prevalence of complications caused by transphyseal osteomyelitis, and factors influencing their occurrence.

All patients treated for transphyseal hematogenous osteomyelitis over a 17-year period at the University Hospitals of Geneva and the Gesù Bambino Hospital in Rome were retrospectively analyzed. Clinical, biological and bacteriological data were analyzed. Magnetic resonance imaging was reviewed for all patients to assess the surface area of growth plate involvement.
Restart of growth of the affected physeal cartilage was subsequently monitored by iterative radiological examination.

89 patients with a transphyseal hematogenous osteomyelitis were identified among a cohort of 594 hematogenous osteomyelitis (15.0%). Median age was 84 months [1; 167 months] with a bimodal distribution and peaks at 30 and 150 months of age; 59.6% (53/89) of patients were male. The lower limbs were most often affected, with the distal tibia and fibula accounting for 47.2% of all cases. Methicillin-sensitive Staphylococcus aureus and Kingella kingae were the most frequently identified pathogens, accounting for 41.2% of the total. Virulence factors, such as Panton-Valentin Leucocidin (PVL), Toxic Shock Syndrome Toxin (TSST), Accessory Gene Regulator (Agr) were recorded in 12.4% of cases. Transphyseal lesions affected in median 7.57% [0.79; 58.2] of the physeal surface and was greater than 7% in over 54.1% of cases. Complications affecting further growth were noted in 13% of THO. We noted that the presence of thrombocytopenia, marked leukocytosis on admission, and the presence of virulence factors significantly influence the occurrence of complications.

The prevalence of complications after THO was lower than suspected and occurred only 13% of cases. Finally, the presence of deep thrombocythemia, major leukocytosis and virulence factors, such as Agr, TSST, PVL, seems to strongly influence the occurrence of such complications.

Background: We carried out a historical narrative review of the studies on clinical and laboratory test algorithms for pediatric septic arthritis of the hip (SAH), to contextualize the Kocher and Caird criteria in their and our epoque.
Materials and Methods: The original papers by Kocher and Caird were critically appraised and their bibliography retrieved and studied. An extensive search of the literature on both the epidemiology and the clinical and laboratory criteria for SAH before and after the publication of the Kocher and Caird criteria was carried out. These studies were compared with Kocher and Caird and a historical overview was drawn.
Results: We retrieved 51 publications, including Kocher and Caird reports. By critically appraising Kocher and Caird’s studies, it emerged that their predictive criteria for SAH were originally validated in studies comparing SAH and transient synovitis of the hip (TSH) in children with a wide age range, without distinction for age subgroups. Moreover, these criteria were individuated and validated in a-priori-determined classes of patients—true SAH, presumed SAH, and true TSH—based on a joint fluid arthrocentesis (JFA) white blood cell count threshold of 50,000/mm3 and the results of JFA and blood cultures. Due to methodological differences among studies, validating Kocher and Caird criteria in different settings was not feasible. Moreover, the slow emergence of Kingella kingae in the pediatric osteoarticular infection scenario and the slow implementation of new diagnostic technologies have very likely contributed to the lack of validation of the Kocher Caird criteria, since the culture-negative cases could have been misdiagnosed and misclassified.
Conclusion: The Kocher and Caird algorithms completely ignore that clinical and biological aspects of SAH are closely related to a child's age and, above all, the pathogen responsible. They were also established in a period when the importance of Kingella kingae contribution was completely unknown. Further studies are required to define the biological markers that can unquestionably distinguish pediatric SAH (especially when due to K. kingae) and its mimics. New perspectives should be investigated by future research on the prediction rules of septic arthritis of the hip in children considering specifically the recipients’ age et the incriminated pathogens.

Introduction: As analyzing pediatric radiographs are always a challenge due to the growth plate and ossification centers we wanted to compare the gaze pattern behaviors of orthopedists and pediatricians when interpreting pediatric foot and ankle radiographs and their diagnostic accuracy. Our second aim was to assess the diagnostic accuracy of orthopedists and pediatricians with different levels of experience and Artificial Intelligence (AI) when interpreting pediatric foot and ankle radiographs.
Methods : Participants had to analyze 23 pediatric foot and ankle radiographs and to assess if there was a fracture. We selected the radiographs from patients who consulted in the emergency room. There was 10 normal x-rays and 13 x-rays with fracture of the foot and ankle. Their gaze pattern behaviors were assessed through an eye-tracker Eyelink 1000 Plus and the data collected in EvdentIDE (Okazolab). We analyzed the following eye-tracking data: amplitude of saccades, fixation duration of saccades, and count of saccades per second. We evaluated the diagnostic accuracy via the sensitivity and the specificity. Our artificial intelligence program was Gleamer.
Results : We had 25 participants (17 resident in orthopedic et 8 resident in pediatric). The orthopedists had a mean amplitude of saccades of 3.88 and a mean duration of saccades of 32.92ms. The pediatricians had a mean amplitude of saccades of 3.14 and a mean duration of saccades of 28.62ms. The difference between the two groups were significant (p < 0.0001). The orthopedists had a number of 3.07 fixations per second while the pediatricians had a number of 2.38 fixations per second. The orthopedists mean diagnostic accuracy was 74.4% : sensitivity of 76.5% and specificity of 76.3% and the mean diagnostic accuracy of the pediatricians was 72.92% with a sensitivity of 72.1% and specificity of 73.75%. For the AI, the sensitivity was 92% and the specificity 80%, with a mean of 87%.
Conclusion & perspectives: There’s a difference in the way of analyzing radiographs between orthopedic surgeon and pediatric physician. In general larger amplitudes of saccades are associated with a higher diagnostic accuracy. The AI doesn’t have a diagnostic rate of 100%.

Background:

Detecting developmental dysplasia of the hip (DDH) in infants is crucial, and various screening strategies have been proposed, including clinical examination and ultrasound. However, controversy exists regarding which screening method is optimal. There is no agreement on whether hip ultrasound should be performed on all newborns (universal screening) or only in those with risk factors or clinical instability of the hip during clinical examination (selective screening). We assessed the sensitivity of clinical screening for DDH conducted by experienced pediatric orthopedic surgeons in newborns.

Methods:

In this retrospective study, we compared the records of the clinical exam to the hip ultrasound according to Graf in 122 newborns aged between 0 -3 months treated at our tertiary care center for primary DDH.
Statistical analysis was applied to calculate the sensitivity of the clinical examination.

Results:

Clinical screening showed a sensitivity of 66%. This indicates that 34% of DDH cases would have not been diagnosed through clinical examination alone. Furthermore the sensitivity of the exam for unstable patients (Graf D, III and IV) was 91% and as low as 50% for stable patients (Graf IIA, IIB and IIC). This difference in sensitivity was statistically significant (P < 0.05).

Conclusion:

Clinical screening, even when conducted by experienced pediatric orthopedic surgeons, exhibited limited sensitivity. Universal ultrasound screening at birth provides a more comprehensive evaluation and has the potential to reduce delayed diagnoses and their associated complications.

Understanding the implications of decreased femoral torsion (FT) on dynamic
components of children and adolescents might help orthopaedic surgeons to optimise treatment to
avoid long-term damage. To date, there is limited evidence regarding the kinematic gait deviations
between children with FR and typically developing children (TDC) as well as regarding the
implications of FR on the adaptation of walking to running gait. An explorative 3D motion analysis
study was conducted to measure gait deviations during running and walking in patients with
decreased FT (n=15) compared to TDC (n=11). A linear mixed model was used to establish
comparisons within and between the aforementioned groups and investigate the relation between
the clinical examination, spatial parameter and difference mean hip rotation from running to
walking. Patients walked with an external mean hip rotation compared to an internal mean hip
rotation in controls and had higher peaks for the hip external rotation, knee valgus and out-toeing
in terms of foot progression angle. The same kinematic gait pattern was observed during running
and was significant for the peak knee valgus. With regard to the differences from running to
walking, patients turned their external rotated hip 3.84° internally, where controls kept the same
internal hip rotation. Patients revealed similar kinematic gait deviations during running compared to
walking as controls. The passive hip range of motion, torsions and velocity had no notable
influence on the difference mean hip rotation from running to walking. Patients with decreased FT
showed deviation in 3D gait kinematics. This study underscores the potential of 3D gait kinematics
to elucidate the functional implications of decreased FT and hence contribute to clinical evaluation
and decision making.

Background: Lower-extremity torsional abnormalities are a group of structural abnormalities impacting the foot progression angle, leading to an in-toeing or out-toeing gait depending on the direction of tibial torsion. Several clinical and radiological measurement methods are used, of which the CT scan is considered as the most accurate. Assessment with a CT scan include the use of the tibial plateau axis and the bimalleolar axis. However, we consider that the bimalleolar axis gives an inaccurate information about the foot position during the gait. The main aim of this study was to compare different tibial torsion assessments, considering a new method for the orientation of the ankle: TA (talar axis).

Methods: 120 CT-scans carried were retrospectively reviewed in pediatric patients. Clinical datas were collected from records. 4 measurements were performed: PTTA (proximal transtibial axis), PMTPA (posterior margin tibial plateau axis), IMA (intermalleolar axis) and TA (talar axis).

Results: 100 CT scans (38 girls, 62 boys) were included. Mean age was 11 ± 4.4 years old. Mean value of thigh-foot angle and bimalleolar angle were 15.6° ± 16° and 16.3° ± 16.5°. Mean value was -7.1° ± 14.7 for PTTA and -7.6° ± 14.2 for PMTPA without statistically difference (p > 0.05). Mean IMA was 5.8° greater than TA: 23° ± 16.2 vs 17° ± 16.9 with a statistically significant difference (p < 0.05). Mean tibial torsion angle was 27.3° and the mean time required for these measurements was 6'44'', with 2'24'' for PTTA, 36'' for PMTPA, 2'14'' for IMA and 1'12'' for TA.

Conclusion: The tibial torsion value may differ at the ankle level. PMTPA and TA should be used since it is a faster technique, in particular if the medial malleolus is not yet ossified.

Introduction : The too-long anterior process of the calcaneus (TLAPC) is a morphological anomaly which is recognized to generate an impingement due to both its interposition between the head of the talus and the cuboid and to its support on the navicular, causing pain facing the sinus tarsi and responible of subtalar stiffness. Nowadays, the diagnosis of TLAPC is defined on a calcaneonavicular distance (CND) less than 5-10 mm, based mainly on CT scans and plain radiography with small series of subjects. However, there is not a clear definition of normative values of the calcaneonavicular distance in a larger population that could be used to define a threshold for TLAPC and the distance that should be aimed after a surgical resection.

Methods : We rewieved 363 MRIs of healthy controls and 129 MRIs of symptomatic foot with a diagnosis of TLAPC. The calcaneonavicular distance was measured as the distance between the anterior process of the calcaneus and the navicular bone in sagittal and axial view in both groups.

Results : The mean CND was statistically different (p < 0.05) for all the measures compared between the control and TLAPC group. Surprisingly, the mean CND in the control group ranged from 4.51 ± 1.62 to 5.68 ± 2.01 mm according to the view used, and 40 to 45% of the subjects of the control group had values considered as pathological. The mean values in the symptomatic group were much smaller, from 2.65 ± 0.98 to 3.66 ± 1.08 mm. In addition, age seemed to play a major role in males, in which CND values decrease with bone maturation.

Conclusion : The results with our study could be used to defined a threshold of the normal and pathologic CND based on a large scale population study, and thus help to identify better the patients with TLAPC and the distance that should be aimed after surgical resection

Introduction
The cortical thickness index (CTI) is a radiological measure and correlates with diminishing local bone quality in the proximal femur. The aim of this study was to evaluate if a lower CTI is associated with a higher rate of peri- and postoperative surgical complications.

Material & Methods
A total of 228 prospectively enrolled patients treated with endomedullary nailing for trochanteric fracture (TFx) (AO/OTA 31A1.1 - 31A2.3) (n = 99) and hemi-/total hip arthroplasty für femoral neck fracture (AO/OTA 31B1-B3) (FNFx) (n = 129) with a mean age of 82 9.9 (50 - 99) years were reviewed. These cases were evaluated after a mean follow-up of 83  106 (1 - 450) days for surgery-related complications. Eighteen cases (7.9%) of complications undergoing revision surgery were identified. Patient demographics and radiographic measurements of these groups were compared to the cases without complications (n = 210) and statistically analysed.

Results
Of the 18 patients undergoing revision surgery, ten (55.6 %) demonstrated a biomechanical complication. Eight cases were revised due to infection (n = 4), seroma/hematoma (n = 3) or a running wound (n = 1). In the FNFx group no intraoperative fracture but two traumatic periprosthetic fractures occurred after a fall 59 and 36 days postoperatively. In the TFx group five cut - ins/outs of the helical blade. Among all analyzed variables, including age, body mass index and hemoglobin level, merely the CTI of the unaffected side in the TFx group was significantly lower in the complications as well as the biomechanical complications group (0.51 ±0.09, 0.58 ±0.05, 0.58 ±0.05; p = 0.029).

Conclusion
Poor local bone quality, indicated by a low CTI, is not associated with increased complication rates following surgically managed proximal femoral fractures. Other factors such as inadequate fracture reduction, improper blade positioning, and technical errors appear to be the primary contributors to biomechanical complications.

Background: Sepsis is a leading cause of mortality in polytrauma patients, especially beyond the first week, and its management is vital for reducing multiorgan failure and improving survival rates. This is particularly critical in geriatric polytrauma patients due to factors such as age-related physiological alterations and weakened immune systems. This study aimed to investigate various clinical and laboratory parameters associated with sepsis in polytrauma patients aged < 65 years and ≥ 65 years, with the secondary objective of comparing sources of infection in these patient groups.

Methods: A retrospective cohort study was conducted at the University Hospital Zurich from August 1996 to December 2012. Participants included trauma patients aged ≥ 16 years with an Injury Severity Score (ISS) ≥ 16 who were diagnosed with sepsis within 31 days of admission. Patients in the age groups < 65 and ≥ 65 years were compared in terms of sepsis development. The parameters examined included patient and clinical data as well as laboratory values. The statistical methods encompassed group comparisons with Welch’s t-test and logistic regression.

Results: A total of 3059 polytrauma patients were included in the final study. The median age in the group < 65 years was 37 years, with a median ISS of 28. In the patient group ≥ 65 years, the median age was 75 years, with a median ISS of 27. Blunt trauma mechanism, ISS, leucocytosis at admission, and anaemia at admission were associated with sepsis in younger patients but not in geriatric patients, whereas sex, pH at admission, lactate at admission, and Quick values at admission were not significantly linked with sepsis in either age group. Pneumonia was the most common cause of sepsis in both age groups.

Discussion: Various parameters linked to sepsis in younger polytrauma patients do not necessarily correlate with sepsis in geriatric individuals with polytrauma. Hence, it becomes critical to recognize imminent danger, particularly in geriatric patients. In this context, the principle of "HIT HARD and HIT EARLY" is highly important as a proactive approach to effectively address sepsis in the geriatric trauma population, including the preclinical setting.

INTRODUCTION
(Periprosthetic) acetabular fractures are increasingly common in the elderly population. While stable, undisplaced fractures are usually treated non-operatively, unstable and displaced fractures may require surgery. If fracture morphology and/or poor bone quality do not allow for a stable, anatomical reconstruction, a combined approach with internal fixation and total hip arthroplasty (THA) is indicated to ensure stable fixation of the cup. To minimize the surgical burden and to allow immediate full weight bearing, navigated percutaneous screw fixation of the anterior and posterior columns combined with THA (npSFTHA) was introduced at our institution in 2020. For periprosthetic fractures, column screw fixation was combined with revision THA. The aim of our study was to evaluate PROMs and the radiological outcomes.
METHODS
Retrospective single-centre study including all patients ≥60 years treated with npSFTHA between January 2020 and December 2023. Full weight bearing was encouraged in all patients immediately after surgery. ASA score, intraoperative blood loss, complications, and re-interventions were recorded. Analysis also included PROMs, walking abilities, the level of independence and radiographs. Data are presented as median values and range.
RESULTS
Forty-one patients (age 84 years (61-95) were eligible for inclusion. ASA score ≥3 was recorded in 36 patients (88%). Intraoperative blood loss was 600 mL (200-2700). Thirty-day mortality was 5%. One patient (2%) had a large seroma evacuated after 1 month, 2 other patients (5%) had revision for periprosthetic infections ≥10 months after the initial surgery. PROMs were available for 21 patients (51%) at a follow-up of 11 months (2-49). Death precluded data collection in 8 (20%), while cognitive impairment affected 11 patients (27%). One patient could not be contacted. EQ-5D-5L Index was 0.91 (0.22-1.00). EQ-VAS was 80 (0-100). FJS was 93 (2-100). Thirty-three patients (81%) returned to the same level of independence after surgery, with 32 patients (78%) still living at home. Pre-injury levels of walking abilities were regained by 32 patients (78%). Radiographic follow-up was available for 32 patients (78%) after 6 months (2-25) demonstrating a stable cup in 30 cases (94%) whereas loosening was observed in 2 patients (6%).
CONCLUSION
NpSFTHA was successful in the vast majority of our study group, with good restoration of walking abilities, quality of life, and of the level of independence.

Introduction
Minimal-invasive placement of a trans-sacral screw represents an increasingly popular method of fixation for Fragility Fractures of the Pelvis (FFP), with variable upper sacral anatomy representing the main challenge. Little is known about the variability of sacral anatomy in the geriatric population and the potential effect of osteoporosis on the upper sacral anatomy and thus S1 corridor morphology. Our aim was to examine the eligibility ( > 12 mm) of the S1 corridor for the trans-sacral screw placement in a geriatric population and to analyse what pelvic dysmorphism signs might serve as predictors for an ineligible S1 corridor.

Methods
We analysed S1 corridor in pelvic CT scans of 107 geriatric patients without history of fracture or other pelvic pathology. First, the eligibility for the trans-sacral screw placement was determined by measuring the width and the height of the central portion of the S1 corridor. Then, pelvises were examined for signs of dysmorphism. The correlation of these signs with the ineligible S1 corridor was analysed.

Results
In our geriatric population with average age of 79,55 ± 8.79 years (male:female 0.88) 44% of S1 corridors were not eligible for a trans-sacral screw. In this ineligible group the height was shown to be a more significant limiting dimension (90,9%), compared to the width in 68,2% (p < 0.05). Mamillary processes, not recessed sacrum and dysmorphic sacral foramina were present in 38,3%, 34,6%, and 26,2% respectively, with not recessed sacrum demonstrating a significant correlation with a too narrow S1 corridor (p < 0.05).

Conclusion
The analysed geriatric population demonstrates a high prevalence of a too narrow S1 corridor, which makes a placement of a trans-sacral screw risky or even impossible. The height of the S1 corridor represents the main limiting factor with a dysmorphism sign of a not recessed sacrum being a significant predictor for the ineligible S1 corridor.

Objectives: To investigate the usefulness of the routinely planned six week outpatient visit and X-ray in patients treated surgically for the most common upper extremity fractures including clavicula, proximal hu-merus, humerus shaft, olecranon, radial shaft and distal radius.
Method: This was a retrospective snapshot study of all patients treated surgically for the most common upper extremity fractures between 2019 and 2022 in a level 1 trauma center. The first outcome of interest was the incidence of abnormalities found on the X-ray made at the 6-weeks outpatient visit. Ab-normalities were defined as all differences between the intra-operative (or direct postoperative) and 6-weeks X-ray. In case an abnormality was detected, the hospital records were screened to deter-mine its clinical consequence. The clinical consequences were categorized into requiring either addi-tional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion (ROM). The second outcome of interest was the inci-dence of deviations from the local standard post operative treatment and follow-up protocol based on the 6-weeks outpatient visit as a whole. Deviations were also categorized into either requiring additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion.
Results; A total of 267 patients were included. Abnormalities on X-ray at 6-weeks were found in only 10 (3.7%) patients of which only 4 (1.5%) had clinical implications (in three patients extra imaging was required and in one patient it was necessary to deviate from standard weightbearing/ROM limita-tion regime). The clinical/radiological findings during the 6-weeks outpatient visit led to a deviation from standard in only 8 (3.0%) patients. Notably, the majority of these patients experienced symp-toms suggestive for complications.
Conclusion; The routine 6-weeks outpatient visit and X-ray, after surgery for common upper extremity fractures, rarely has clinical consequences. It should be questioned whether these routine visits are necessary and whether a more selective approach should be considered.

Introduction
Percutaneous sacroiliac screw placement is a challenging procedure in patients with pelvic fractures. To overcome these challenges, navigated techniques have emerged as an alternative to conventional 2D fluoroscopy for guiding screw placement. However, it remains to be seen whether navigated techniques truly have a beneficial effect on accuracy, radiation exposure and occurrence of complications. Therefore, a meta-analysis was performed to investigate these aspects.

Methods
The electronic databases were searched for both randomized clinical trials and observational studies comparing percutaneous sacroiliac screw fixation with 2D fluoroscopy to new navigated techniques. Effects were pooled and presented as odds ratio, mean difference and standardized mean difference with corresponding 95% confidence interval.

Results
In total 18 studies were included. New navigated techniques had a higher accuracy (OR 2.39, 95% CI 1.49;3.83). Also, fluoroscopy time (MD 72.13 seconds, 95% CI 7.73;92.91) and fluoroscopy frequency (MD 17.22 images in total, 95% CI 7.73;26.70) were lower for new navigated techniques. Radiation dose was higher for new navigated techniques (SMD 0.50, 95% CI 0.01;0.99). Surgery duration showed no significant difference. Similar results were found among in vitro studies. Complications were rare in both groups.

Conclusion
This meta-analysis demonstrated a higher accuracy of screw positioning, lower fluoroscopic frequency and time for navigated percutaneous sacroiliac screw fixation compared to conventional 2D fluoroscopy. Complications are acceptably low for both groups. Future studies should focus on which of the navigated techniques is the best and whether the implementation costs of a new technique outweigh its benefits.

Introduction: Trochanteric fractures are one of the most frequent fractures, affecting especially geriatric patients. Despite well-established treatment standards, complication rates remain high, not only due to general medical reasons, but also due to implant-related reasons. This retrospective study was set up to compare the complication rates of two different cephalomedullary nails (CMN) of the same manufacturer.
Methods: Patient identification was done through a keyword search of the electronic patient file database of a single institution, using the ICD-10 codes S72.XX between January 2017 and July 2021. The cases thus identified were then screened manually for the use of CMN. The study population was than separated in two groups using either the PFN-A or the TFN-A. Outcome parameters were all kind of reoperations, conversion to total hip arthroplasty (THA), and patient survival. Reoperations were differentiated as minor reoperation (any reoperation without exchange of any components, minor revision (exchange of cervical blade/screw only, definitive implant removal) or major revision (reosteosynthesis, conversion to THA). Furthermore, patient demographics, implant specifications and reasons for reoperation were collected. Fractures were classified according to the AO/ASIF classification. Quality of reduction and fixation were classified using the Baumgartner criteria, the Cleveland zones and the tip-apex-distance.
Results: In total 475 cases of CMN were detected, in 248 cases the PFN-A and in 244 the TFN-A was used. There were no differences between both groups regarding demographics, quality of reduction and fixation, and AO/ASIF classification. Reoperation and revision occurred mainly early, within less than a year. Overall, 75 (15,24%) reoperations were recorded with 33 (13.31%) in the PFN-A group and 42 (17.21%) in the TFN-A group. Higher rates of major revisions (2.02% vs. 7.38%) and implant failure were detected for the TFN-A group. Concerning nail specifications, the standard caput-collum-diaphyseal (CCD) was 130° in the TFN-A, whereas it was 125° in the PFN-A. The TFN-A was made of titanium, whereas the PFN-A was made of stainless steel.
Discussion: Reoperations, respectively conversion to THA were necessary mainly during the first month after internal fixation with CMN. In this cohort, the newer TFN-A seems to have a higher rate of major complications, such as nail breakage and cut-through/out/in, compared to the older PFN-A.

Background: Treatment of humeral greater tuberosity fractures is controversial. Besides a potentially altered function of the attached tendons, impingement of the dislocated fragment with the acromion potentially affects the shoulder's range of motion. CT-based 3D shoulder motion simulation could help predict potential impingement and facilitate choosing an appropriate treatment strategy.

Material and Methods: Shoulder CT scans of 27 patients suffering from greater tuberosity fractures were evaluated retrospectively. Mean age was 47 years, 66% of all patients were male, and nine patients underwent surgery. Bone segmentation was performed to generate patient-specific 3D models. Osseous shoulder motion simulations using the 3D models were generated. Osseus contact points (impingement location) were evaluated and compared to a control group with intact bones. Fracture displacement was measured on conventional plain film radiographs with three established methods and correlated to the shoulder motion simulations.

Results: Bone Segmentation and shoulder motion simulation were feasible for all analyzed cases. Nine patients with displaced GT fractures had significantly (p < 0.001) decreased simulated abduction (76°) compared to controls (96°). In these cases, subacromial impingement of the displaced GT fragment was noted in 5 of 9 patients (compared to none in the control group). Of the established conventional measurement techniques, only superior fragment displacement correlated with limited abduction (p = 0.01).

Discussion: Shoulder motion simulation using CT-based 3D models is feasible and allows visualizing the anatomical location of the bony impingement. In our dataset, established measurement techniques correlated with limited abduction. 3D shoulder motion simulations might facilitate decision-making for treating greater tuberosity fractures.

ABSTRACT
Background: Optimal treatment (i.e. nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment.
Methods: The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with one-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life.
Results: Mean age was 57.7 ±17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n=13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic non-union. The median HLOS was 7 (4-13) days, and median intensive care unit length of stay was 2 (1-5) days. Mean EQ-5D-5L index value was 0.83 ±0.18 one year after trauma. Polytrauma patients had a median HLOS of 10 (6-18) days, a pneumonia rate of 17.6% (n=77) and mortality rate of 1.7% (n=7). Elderly patients (65 years) had a median HLOS of 9 (5-15) days, a pneumonia rate of 19.7% (n=57) and mortality rate of 4.1% (n=12).
Conclusions: Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after one year. Future studies evaluating the benefit of operative stabilisation should use contemporary outcomes to establish the therapeutic margin of rib fixation.
Level of evidence: Level III, Therapeutic/Care Management.

Keywords: Multiple rib fractures; conservative treatment; nonoperative treatment; quality of life; mortality; pneumonia rate

Triaging is pivotal in the treatment of polytrauma patients. The Watson Trauma Pathway Explorer ® is an outcome prediction tool invented by the University Hospital of Zurich (European Level 1 Trauma Centre) in collaboration with IBM®, representing an artificial intelligence application to predict the most adverse outcome scenarios in polytrauma patients: Systemic Inflammatory Respiratory Syndrome (SIRS), sepsis and death within 21 days.
The question was how the early values of pH, Base excess (BE) and lactate would be associated with the incidence of death.
Data from 3653 patients in an internal database, with ongoing implementation, served for analysis. Patients were split in two groups according to the occurrence of death within 21 days.
pH, BE and lactate values were measured at formerly defined time points up until 48h after admission for both groups. Differences between groups were analyzed. The three laboratory parameters were tested as independent predictors for death at each time point, corrected for age, gender and ISS. The level of significance was set at p < 0.05.
The mortality rate was 26.9% (n = 981), with 9.9% (n = 361) of all patients dying within < 24h after admission to the trauma bay.
Group differences existed for the first 4h for pH, and continuously for BE and lactate. pH and BE at 4h were independent predictors for mortality (p = 0.037, respectively). For Lactate, this was true at 48h (p = 0.023).
The insights reporting very early, time-dependent differences in common laboratory parameters may be helpful in risk estimation of polytrauma patients, which could affect the decision on the extent of surgical treatment.

Introduction
Vascular compromise due to arterial injury is a rare but serious complication following proximal humerus fracture (PHF). We aimed to establish its incidence in a large urban population, and to identify clinical and radiographic predictors for this complication. We also evaluated the results of our protocol for treatment of these injuries.

Methods
A total of 3,515 adult patients (mean age 70 years, 72% female) with PHF were managed between 2015 and 2022 in a single tertiary trauma centre. We compared the demographics, clinical features and fracture configuration of patients with PHFs complicated by vascular compromise, with the remainder of the fracture population. The incidence of this complication was calculated from national population data and predictive factors for its occurrence were identified using multivariable regression analysis.

Results
During the study period, 18 patients (0.5%) sustained PHF with clinical evidence of vascular compromise giving an annual population incidence of 0.31 per 100,000. Their mean age was 68.7 (45-92) years and 10 (56%) were females. Multivariable analysis identified complete separation of the proximal shaft from the head with medial displacement (p < 0.001, OR 91.6)) and evidence of mixed pattern neurological deficit (brachial plexus palsy) (p =< 0.001, OR 683.8) as strong independent predictors of vascular compromise. Male gender was also more weakly associated with an increased risk of this complication (p = 0.04, OR 5.9). A policy of fracture reduction and reconstruction prior to any vascular surgical intervention was associated with favourable post-operative outcomes and the absence of vascular sequelae.

Conclusion
The classic signs of distal limb ischaemia are often absent in patients with proximal major vessel injury. Our study identified specific clinical and radiographic “red flags” which, when used in combination, it should increase the suspicion of a fracture with associated vascular injury and facilitate early diagnosis and intervention.

Introduction
Acetabular fractures in patients over 60 years-old are being increasingly observed. Postoperative weight-bearing protocols, such as non-weight bearing (NWB), partial weight bearing (PWB), or full weight bearing (FWB) are commonly selected after acetabular fractures open reduction and internal fixation (ORIF). NWB and PWB can increase post-operative complications as venous thromboembolism or infections, and are difficult to respect by elderly patients. FWB can theoretically displace the reduction. This study aims to compare outcomes among elderly patients undergoing acetabular fractures ORIF based on three distinct immediate postoperative weight-bearing protocols.

Method
Fifty-nine patients, aged 60 years and above, who underwent surgical treatment by ORIF for acetabular fractures, were retrospectively reviewed. Patients were categorized into three groups according to their postoperative weight-bearing protocol: FWB group (N=12; 20.4%), NWB group (N=11; 18.6%) and PWB group (N=36; 61%). Patient characteristics, clinical outcomes, and complications were assessed using medical records. Radiological outcomes were evaluated on preoperative and postoperative CT scans, as well as postoperative radiographs obtained during follow-up.

Results
The mean age of the cohort was 81 years (range: 60-95), with 47 males (70.1%). Charlson comorbidity index (CCI) and ASA score were slightly higher in FWB group. Associated fracture patterns, according to Letournel classification, were identified in 91.7% (N=11), 54.5% (N=5) and 77.8% (N=28) for FWB, NWB and PWB groups, respectively. There was no significant difference observed in terms of postoperative medical complications (42%, 45% and 46%, respectively). However, severe postoperative complications were slightly higher in the PWB group (14%; N=5) compared to the FWB group and NWB group (8% and 9%, respectively). There was no secondary displacement during follow-up assessments in the FWB group. Secondary THA procedure, due to symptomatic secondary hip arthritis, were performed in 8.1% for FWB group, 41.6% for NWB group and 13.9% for PWB group.

Conclusions
These results suggest that implementing an immediate postoperative full weight-bearing protocol may provide favorable outcomes in terms of medical complication rates and secondary THA requirements compared to partial weight-bearing, in particularly in elderly patients sustaining acetabular ORIF fractures.

Purpose: The pararectus approach is used more and more frequently, especially due to the increase of fractures of the acetabulum in old age concerning the anterior pillar as well as the quadrilateral surface. Coagulation of the iliolumbar vessels results in significantly reduced blood loss, but their morphology is highly variable and poorly studied lateral to the obturator nerve.

Material and Methods: Twelve body halves below L5 of six cadavers were examined. An extraperitoneal approach anterior to the psoas muscle to the sacroiliac joint (SIJ) was chosen. Here, the iliolumbar vessels lateral to the obturator nerve at the level of the SIJ were dissected and their position in relation to the anterior margin of the sacrum was measured. Afterwards, a dissection was performed further laterally between the psoas muscle and the iliac muscle; here, too, the iliolumbar vessels were dissected and their position in relation to the anterior margin of the sacrum was measured.

Results: A median of 4 iliolumbar vessels (range 3-5) were found at the level of the SIJ lateral to the obturator nerve, from 0 - 52 mm (mean 24mm) cranial to the anterior ala of the sacrum. A median of two iliolumbar vessel were found between the psoas and iliac muscles (range 1 - 4), at an average height of 21.4mm cranial to the anterior sacrum (range 5 - 42 mm).

Conclusions: The anatomic location and number of iliolumbar vessels in pararectus approach are highly variable and must be considered in its dissection.

Introduction
Distal clavicle fractures are typically classified according to their location relative to the coracoclavicular ligaments, on anteroposterior (AP) and 30° cephalic tilt radiographic views. Surgical intervention is advised for unstable or displaced fractures. However, reported consensus among clinicians using these views remains poor. The aim of this study was to assess the potential benefits of panorama, axial, and Alexander views in enhancing consensus among clinicians when evaluating distal clavicle fractures.
Methods
Thirty cases of distal clavicle fractures were evaluated by six observers, including two fellowship-trained shoulder surgeons, two fellowship-trained trauma surgeons, and two orthopedic residents. On AP and 30° cephalic tilt radiographs, evaluators categorized the fractures according to the Neer and AO classifications and evaluated displacement. On the panorama view, measurements focused on coracoclavicular distance (CCD), fracture angle (FA), and assessment of displacement. Axial view measurements included posterior displacement (PD), displacement ratio (PDR), fracture angle (FAA), and displacement assessment. Evaluation of the Alexander view involved dynamic displacement (DD) inspired by circle measurement and displacement assessment. Weighted kappa (k) and intraclass correlation coefficient (ICC) were used to quantify agreement among observers.
Results
Interrater agreement was substantial for Neer classification (k=0.78, p < 0.003) and moderate for AO classification (k=0.57, p=0.004). ICC were strong for CCD (0.87, p < 0.001), moderate for FA (0.69, p < 0.001), moderate for PD (0.64, p < 0.001), moderate for PDR (0.47, p < 0.001), weak for FAA (0.11, p=0.02) and strong for DD (0.71, p < 0.001). Interrater agreement for displacement were substantial on standard view (k=0.68, p < 0.001) and panorama view (k=0.73, p > 0.001), fair on axial view (k=0.38, p=0.23) and moderate for Alexander view (k=0.53, p=0.19).
Conclusion
The panorama view showed superior interobserver agreement for interpreting displacement compared to AP and 30° cephalic tilt X-rays, making it a valuable addition to standard radiographic work-up. Conversely, due to only fair to moderate agreement on axial and Alexander views, we do not recommend their systematic use when evaluating distal clavicle fractures.