A 10-Week Program of Combined Hippotherapy and Scroth’s Exercises Improves Balance and Postural Asymmetries in Adolescence Idiopathic Scoliosis: A Randomized Controlled Study

Introduction: The most frequent type of spine abnormality throughout adolescence was adolescent idiopathic scoliosis (AIS). Hippotherapy improved posture, balance and gait of different musculoskeletal conditions. Therefore, this study aims to see how hippotherapy combined with Schroth exercises affected postural asymmetry and dynamic balance in AIS compared to traditional physiotherapy (Schroth exercises) alone. Materials and methods: In this randomized controlled trial, fifty-two patients with AIS (10–18 years, 37 girls and 15 boys) participated. They were arbitrarily allocated into two groups: experimental (19 female/8 male; aged 14.74 ± 1.79 years; Cobb angle 18.59 ± 2.66 degrees) and control (18 female/7 male; aged 15.04 ± 1.81 years; Cobb angle 19.32 ± 2.69 degrees) groups. Both groups received Schroth exercises for 10 weeks, three days/week. The experimental group additionally received hippotherapy training. Pre-treatment and post-treatment assessment for the scoliotic, kyphotic angle, pelvic obliquity, pelvic torsion and vertical spinal rotation and the anteroposterior, mediolateral and overall stability indices were assessed using the formetric system 4D and Biodex Balance System, respectively. Results: After intervention, both groups illustrated significant improvements in all examined variables (p < 0.05). The experimental group illustrated significant improvements in scoliotic angle, kyphotic angle, pelvic obliquity, pelvic torsion and vertical spinal rotation and the stability indices compared to the control group (p < 0.05). Conclusion: In adolescence idiopathic scoliosis, hippotherapy training combined with Schroth exercises improves posture asymmetry and balancing ability more effectively than Schroth exercises alone.

Incidence and risk factors of iatrogenic coronal malalignment after adult spinal deformity surgery: a single-center experience

OBJECTIVE The authors’ objectives were: 1) to evaluate the incidence and risk factors of iatrogenic coronal malalignment (CM), and 2) to assess the outcomes of patients with all three types of postoperative CM (iatrogenic vs unchanged/worsened vs improved but persistent). METHODS A single-institution, retrospective cohort study was performed on adult spinal deformity (ASD) patients who underwent > 6-level fusion from 2015 to 2019. Iatrogenic CM was defined as immediate postoperative C7 coronal vertical axis (CVA) ≥ 3 cm in patients with preoperative CVA < 3 cm. Additional subcategories of postoperative CM were unchanged/worsened CM, which was defined as immediate postoperative CVA within 0.5 cm of or worse than preoperative CVA, and improved but persistent CM, which was defined as immediate postoperative CVA that was at least 0.5 cm better than preoperative CVA but still ≥ 3 cm; both groups included only patients with preoperative CM. Immediate postoperative radiographs were obtained when the patient was discharged from the hospital after surgery. Demographic, radiographic, and operative variables were collected. Outcomes included major complications, readmissions, reoperations, and patient-reported outcomes (PROs). The t-test, Kruskal-Wallis test, and univariate logistic regression were performed for statistical analysis. RESULTS In this study, 243 patients were included, and the mean ± SD age was 49.3 ± 18.3 years and the mean number of instrumented levels was 13.5 ± 3.9. The mean preoperative CVA was 2.9 ± 2.7 cm. Of 153/243 patients without preoperative CM (CVA < 3 cm), 13/153 (8.5%) had postoperative iatrogenic CM. In total, 43/243 patients (17.7%) had postoperative CM: iatrogenic CM (13/43 [30.2%]), unchanged/worsened CM (19/43 [44.2%]), and improved but persistent CM (11/43 [25.6%]). Significant risk factors associated with iatrogenic CM were anxiety/depression (OR 3.54, p = 0.04), greater preoperative sagittal vertical axis (SVA) (OR 1.13, p = 0.007), greater preoperative pelvic obliquity (OR 1.41, p = 0.019), lumbosacral fractional (LSF) curve concavity to the same side of the CVA (OR 11.67, p = 0.020), maximum Cobb concavity opposite the CVA (OR 3.85, p = 0.048), and three-column osteotomy (OR 4.34, p = 0.028). In total, 12/13 (92%) iatrogenic CM patients had an LSF curve concavity to the same side as the CVA. Among iatrogenic CM patients, mean pelvic obliquity was 3.1°, 4 (31%) patients had pelvic obliquity > 3°, mean preoperative absolute SVA was 8.0 cm, and 7 (54%) patients had preoperative sagittal malalignment. Patients with iatrogenic CM were more likely to sustain a major complication during the 2-year postoperative period than patients without iatrogenic CM (12% vs 33%, p = 0.046), yet readmission, reoperation, and PROs were similar. CONCLUSIONS Postoperative iatrogenic CM occurred in 9% of ASD patients with preoperative normal coronal alignment (CVA < 3 cm). ASD patients who were most at risk for iatrogenic CM included those with preoperative sagittal malalignment, increased pelvic obliquity, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite the CVA, as well as those who underwent a three-column osteotomy. Despite sustaining more major complications, iatrogenic CM patients did not have increased risk of readmission, reoperation, or worse PROs.

Preoperative pelvic obliquity: possible relation to postoperative coronal decompensation in thoracolumbar/lumbar adolescent idiopathic scoliosis

OBJECTIVE Pelvic obliquity is frequently observed in patients with adolescent idiopathic scoliosis with thoracolumbar/lumbar (TL/L) curve. This study aimed to assess pelvic obliquity changes and their effects on clinical outcomes of posterior fusion surgery. METHODS Data in 80 patients (69 with type 5C and 11 with type 6C adolescent idiopathic scoliosis) who underwent posterior fusion surgery were retrospectively analyzed. Pelvic obliquity was defined as an absolute pelvic obliquity angle (POA) value of ≥ 3°. The patients were divided into groups according to preoperative pelvic obliquity. Moreover, patients with preoperative pelvic obliquity were divided based on POA change from preoperative values versus 2 years postoperatively. Patients were divided based on the presence of selective or nonselective TL/L fusion. Radiographic parameters and clinical outcomes were compared between these groups. RESULTS Among 80 patients, 41 (51%) showed preoperative pelvic obliquity, and its direction was upward to the right for all cases. Coronal decompensation 2 years postoperatively was significantly elevated in patients with preoperative pelvic obliquity (p < 0.05). Thirty-two patients (40%) displayed pelvic obliquity 2 years postoperatively. Among 41 patients with preoperative pelvic obliquity, 22 patients (54%) were in the group with a decrease in POA, and 19 were in the group with no decrease. The group with no decrease in POA showed significant TL/L curve progression throughout the postoperative follow-up period. The patients with nonselective fusion showed a significantly lower incidence of pelvic obliquity at 2 years postoperatively. CONCLUSIONS Postoperative coronal decompensation more frequently occurred in patients with preoperative pelvic obliquity than in those without pelvic obliquity preoperatively. In addition, postoperative pelvic obliquity changes may be related to residual lumbar curve behavior.

An algorithmic approach to total hip arthroplasty in patient with post-polio paralysis and fixed pelvic obliquity

Aims Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening. Methods In all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment. Results The mean Harris Hip Score at the latest follow-up was 79.2 (68 to 90). There was significant improvement in the coronal pelvic obliquity from 16.6o (SD 7.9o) to 1.8o (SD 2.4o; p < 0.001). Radiographs of all ten hips showed stable prostheses with no signs of loosening or migration, regardless of whether paralytic or non-paralytic hip was replaced. No complications, including dislocation or infection related to the surgery, were observed in any patient. The subtrochanteric shortening osteotomy done in two patients had united by nine months. Conclusion Simultaneous correction of soft tissue contractures is necessary for obtaining a stable hip with balanced pelvis while treating hip arthritis by THA in patients with PPRP and fixed pelvic obliquity. Cite this article: Bone Jt Open 2021;2(9):696–704.

Pelvic Obliquity, It Is Not a Neutral Angle in the Normal Population

Introduction: The definition of pelvic obliquity angle (PO) still unclear in the normal population. Several factors might cause the obliquity i.e. hip osteoarthritis, developmental dysplasia of hip, trauma, scoliosis and spine related factors. Perhaps, pelvic obliquity is expressed as a deviation of neutral alignment in the normal population. We developed present study to evaluate the distribution of pelvic obliquity angle in normal population.Method: present study retrospectively enrolled on 134 cases (70 female and 64 male) without any problem of spine, pelvic and lower extremity abnormality who referred to our institution from January 2017 to January 2018 for non-orthopedic problems. We retrospectively reviewed radiographs from institutional PACS and measured pelvic obliquity angle using mediCAD Classic software (version 3.50.0.1, Hectec, Landstuhl, Germany). Finally, all data were analyzed with SPSS software (version 24.0, USA).Result: present study show that all data has significant relationship in one sample T test. All PO angles were normally distributed in kurtosis and skewness test. The patients were aged with a mean of 39.6 ±16.8 in current study. The mean of PO angle was 2.18 ±1.6 in all patients and 0.13 standard error of mean. There was no significant differences between male and female genders (2.07 ±1.6 vs 2.27±1.6, P=0.47). This study reveal that age and PO angle had not any correlation (P=0.165).Conclusion: despite this fact, there was an attitude that PO angle normally is in neutral alignment, our result uncover that the normal range of PO angle was not neutral and ranged from 0.58 to 4.4 degrees with one standard deviation from mean in the normal population.

Biomechanical Evaluation and Comparison of Clinically Relevant versus Non-relevant Leg Length Inequalities

BackgroundLeg length inequalities (LLIs) are a frequent condition in every population. It is common clinical practice to consider LLIs of 2cm and more as relevant and to treat those. However, the amount of LLIs that need treatment is not clearly defined in literature and the effect of real LLIs on the musculoskeletal system above and below 2cm have not been studied biomechanically before.Research question: Are the spine and pelvis affected differently in patients with LLIs <2cm and ≥2cm.MethodsBy using surface topography, we evaluated 32 patients (10 females, 22 male) with real LLIs of ≥2cm (mean: 2.72cm; n=10) and compared their pelvic position and spinal posture to patients with LLIs <2cm (mean: 1.24cm; n=22) while standing and walking. All patients were measured with a surface topography system during standing and while walking on a treadmill. To compare patient groups, we used Student t-tests for independent samples.ResultsPelvic obliquity was significantly higher in patients with LLI ≥2cm during the standing trial (p=0.045) and during the midstance phase of the longer leg (p=0.023) while walking. Further measurements did not reveal any significant differences (p=0.06-0.706).ConclusionThe results of our study suggest that relevant LLIs of ≥2cm mostly affect pelvic obliquity and do not lead to significant alterations in the spinal posture during a standing trial. Additionally, we demonstrated that LLIs are better compensated when walking, showing almost no significant differences in pelvic and spinal posture between patients with LLIs smaller and greater than 2 cm. This study shows that LLIs ≥2cm can still be compensated; however, we do not know if the compensation mechanisms may lead to long-term clinical pathologies.

Static postural differences between male and female equestrian riders on a riding simulator

This study aimed to compare static posture of male and female riders on a riding simulator. Ten female and five male riders underwent a 5 min standardised exercise programme on the simulator, they were then videoed for 10 s from each the left, right, and rear views whilst stationary on the simulator. Two-dimensional kinematic analysis of the videos showed that male riders had a more neutrally positioned pelvis in the sagittal plane (median left: 6.47°, right: 5.24°) with females demonstrating a posterior pelvic tilt (L: 14.04°, R: 13.55°). Females showed significantly greater pelvic obliquity (median female: 1.99°, male: 0.73°), trunk lean (F: 1.60°, M: 0.43°), and shoulder tilt (F: 1.79°, M: 0.57°) in the frontal plane, demonstrating an overall greater postural asymmetry. Previous studies of elite riders have shown a more anteriorly rotated pelvis to be more desirable. Symmetry of riding position is favourable as it allows movements to be performed with ease and ensures even force distribution through the saddle to the horse. Male riders may therefore have a biomechanical advantage over females when it comes to maintaining a desirable riding position. This research should now be extended to study riders on the horse in motion.

Coronal Compensation Mechanism of Pelvic Obliquity in Patients With Developmental Dysplasia of the Hip

Study Design: Descriptive retrospective study. Objective: DDH is a common lower limb deformity. It has been reported that this deformity can change the sagittal alignment of spine and pelvis. Sacral obliquity (SO) and iliac obliquity (IO) have been proven simple and reliable pelvic-lower limb coronal parameters to evaluate the coronal balance of the pelvis. To study the spine-pelvic coronal compensation mechanism of pelvic obliquity in patients with developmental dysplasia of the hip (DDH). Methods: We collected the data of 110 patients with DDH in our hospital from January 2009 to December 2019, who underwent total hip arthroplasty. We used ICC (Intraclass correlation coefficient) to test the reliability of the measurement result of SO and IO in patients with DDH. A paired t-test was used for the statistical analysis. Results: The intra observer reliability of IO and SO was 0.965 and 0.875 respectively, and the inter observer reliability of IO and SO was 0.887 and 0.889 respectively. The sacroiliac joint and spine can compensate for pelvic obliquity in patients with DDH. We classified the compensatory mechanism into 3 types according to the different imaging performances. Conclusions: The sacroiliac joint has a considerable compensatory ability to ensure coronal balance. We clarified and classified the compensatory mechanism of pelvic obliquity into 3 types. We differentiated the pelvic obliquity in patients with DDH and in those with scoliosis, which is clinical significant to understand the process of development of the disease.