Surgical Interventions

Spinal surgical management including decompression, fusion, and osteotomy, with a focus on minimally invasive techniques and perioperative blood loss mitigation.

Overview

Surgical intervention across orthopaedic conditions relies fundamentally on precise patient selection and preoperative assessment to define indications, contraindications, and the necessity of associated procedures. For patello-femoral arthroplasty, lateral unicompartimental knee arthroplasty, and high tibial osteotomy, optimal outcomes depend on rigorous clinical and radiological evaluation to ensure appropriate candidate selection [1, 13, 17]. In specific deformities such as kyphosis in myelomeningocele, indications are driven by clinical manifestations rather than radiographic measurements [5], while severe bilateral varus deformity in late-onset Blount's disease requires meticulous planning for triple tibial osteotomy [12].

Surgical technique and approach must be individualized based on patient-specific anatomical factors, functional demands, and risk-benefit profiles. This applies to anterior cervical discectomy and fusion [21] and hip arthroscopy, where reasonable patient expectations are essential for success [59]. While minimally invasive Oxford unicompartmental knee arthroplasty supports continued use for recommended indications [20], and traction table usage in direct anterior total hip arthroplasty shows no significant difference from standard tables [41], other areas like AC-joint instability remain imperfect with frequent complications and a lack of high-level evidence for non-operative treatment [22].

Long-term considerations and the necessity of further data collection are critical when recommending operative treatment. Surgeons must weigh the long-term risks of surgery for acute scaphoid fractures [57] and recognize the need for prospective studies with long-term follow-up to assess whether increasing surgical management of closed tibia fractures in adolescents improves outcomes [6].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Lumbosacral dislocation variants, such as L4–5 dislocation, may result from hyperextension injuries [61]. Total laminectomy alters biomechanics in both normal lumbar models and spondylolisthesis models [67]. Kinematic MRI reveals dynamic pathoanatomical changes, including position-dependent canal stenosis, in patients with cervical spinal cord injury without fracture or dislocation [82]. Interspinous devices reduce extension range of motion and disc pressure but often fail to fully compensate for destabilization in other planes or at adjacent levels [92]. In the lumbar spine, the motion-preserving properties of total disc replacement (TDR) are not major determinants of clinical outcomes [93].

Cervical Spine Implantation

Noncontinuous cervical disc arthroplasty preserves intradiscal pressure and facet joint forces at adjacent and intermediate levels, maintaining cervical spine kinematics near preoperative values [84]. A 5 mm implant height in total cervical disc replacement provides biomechanical properties similar to intact specimens, whereas larger implant heights alter facet joint mechanics [96]. Preferentially larger motion occurs at the superior bearing of CHARITÉ discs implanted in human cadaveric lumbar spines and in patients, regardless of the implanted level [97].

Vertebral Body and Spinal Column Reconstruction

The realignment potential of vertebral body stenting increases with the severity of preoperative vertebral body deformation [100]. Cement-augmented pedicle screw instrumentation (CAPSI) increases range of motion and disc stresses in osteoporotic lumbar models compared to cemented pedicle screws (CPS) and is more likely to increase the potential risk of adjacent segment degeneration [103]. Tektona® requires further biomechanical tests and clinical studies to prove its capabilities for height and volume restoration in osteoporotic vertebral compression fractures [115].

Pediatric and Deformity Correction

Fusion levels in adolescent idiopathic scoliosis should be selected to minimize the risk of future progression and optimize spinal balance while fusing the least number of levels necessary [102]. Anterior vertebral body tethering decreases motion in the coronal plane by 77%, yet sagittal motion remains greater than coronal motion at 1 year post-procedure [109].

Adjacent Segment and Regional Effects

Spinopelvic characteristics normalize 1 year after total hip arthroplasty, leading to expected hip, pelvic, and spinal flexion [112]. Percutaneous fixation results for complex humeral head fractures depend on the biomechanical construct [111]. Spine cage augmentation provides superior biomechanical stability compared to fibular allograft in locking plate systems for proximal humeral fracture fixation [114].

Classification

Thoracolumbar Fractures: A review elucidates controversies regarding diagnostic tools, classification systems, and evidence for conservative and surgical methods in thoracolumbar fractures without neurological impairment [3]. Modern classification systems include posterior ligamentous complex (PLC) integrity in surgical decision making [53]. Care must be taken to scrutinize the possibility of ligamentous disruption before proceeding with nonsurgical management [53]. A reliable classification for assessing the stability of a healed vertebra after posterior short-segment fixation for thoracolumbar burst fractures was developed [65].

Degenerative Lumbar Disease: A practical classification system for cage retropulsion in degenerative lumbar disease has been proposed with preliminary feasibility for surgical approach selection [45]. Early revision may yield better outcomes for cage retropulsion in degenerative lumbar disease according to a proposed classification system [45]. A modified classification for migrated lumbar disc herniation has good reference value for guiding the treatment plan [52]. A modified classification for migrated lumbar disc herniation has good reference value for the choice of surgical approach [52].

Hemophilic Pseudotumors: The classification of hemophilic pseudotumors (HPTs) corresponds to surgical outcomes [47]. The classification of hemophilic pseudotumors (HPTs) may be helpful for decision-making regarding their surgical treatment [47].

Radial Head Fractures: A classification system that recognizes associated lesions in radial head fractures and provides a basis for their treatment would be of value [50].

Spondylodiskitis: Clinical factors should be included in future classifications for surgically treated spondylodiskitis to allow for more comprehensive treatment algorithms [62].

Hip Tendons: An intraoperative grading system and surgical approach for tears to the gluteus medius and minimus tendons of the hip has been described [68].

Revision Knee Arthroplasty: The revision knee complexity classification (RKCC) offers a common-sense approach to recognize increasing complexity in revision total knee replacement cases [70]. The revision knee complexity classification provides a methodological assessment to support regional clinical networking [70]. The revision knee complexity classification provides a methodological assessment to support triage of appropriate cases to specialist centres [70].

Revision Hip Arthroplasty: A classification system and algorithmic approach to guide femoral reconstruction in revision total hip arthroplasty has been presented [73]. Specific implant strategies for femoral reconstruction in revision total hip arthroplasty are recommended based on the type of femoral deficiency to ensure stability and osseointegration [73].

Metastatic Spinal Malignancies: The new clinical classification of metastatic spinal malignancies serves as a vital reference for surgical management [77]. Responsible arterial vascular embolization procedures together with associated surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies significantly reduce surgical trauma [77]. Responsible arterial vascular embolization procedures together with associated surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies significantly reduce local recurrence rate [77].

Other Considerations: Percutaneous pedicle screw (PPS) systems have been developed for approximately 20 years to improve minimally invasive techniques, safety, and ease of use [75]. Fourth-generation percutaneous pedicle screw (PPS) systems minimize operative steps [75]. The disparity between 'clinical failure' and 'surgical failure' outcomes in meniscal allograft transplantation surgery means these terms may need re-defining using a specific or bespoke MAT scoring system [76].

Clinical Presentation

Preoperative clinical and radiological assessment is critical to determine indications, contraindications, and the necessity of associated procedures for patello-femoral arthroplasty [1]. For patients with kyphotic deformity in myelomeningocele, the primary indications for operative intervention are the clinical manifestations of the deformity rather than radiographic measurements [5]. In neuromuscular scoliosis, greater diagnosis severity at presentation may affect outcomes afforded by surgery and pose a higher risk of postoperative complications [25]. A systematic approach to treatment is required for the adult patient presenting with late or chronic complications after spinal surgery, involving patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches [26].

Acute Injury and Vascular Compromise: Early diagnosis and emergent surgical intervention promote better outcomes for acute perforated peptic ulcer after elective spine surgeries [24]. Open surgery is indicated without delay for acute limb ischemia after a proximal humeral epiphyseal fracture, where the prognosis is good with swift and proper treatment [32]. The diagnosis of vascular injury associated with knee dislocation is clinical, based on accurate physical examination, necessitating liberal use of preoperative or intraoperative angiography [35]. Early diagnosis of cauda equina syndrome is often challenging because the initial signs and symptoms frequently are subtle [33].

Pediatric and Traumatic Considerations: Controversies exist regarding diagnostic tools, classification systems, and the evidence for conservative and surgical methods for thoracolumbar fractures without neurological impairment [3]. Lesser clinical and radiographic outcomes can be expected after a surgical delay of more than 6 months for corrective ulnar osteotomy for missed Monteggia fractures in children [4]. Surgical challenges, options regarding delayed surgery, and possible outcomes need to be clearly communicated to the patient and parents for anterior cruciate ligament injuries in patients with open physes [30].

Chronic Deformity and Specific Pathologies: Appropriate patient selection, preoperative planning, and surgical execution are critical to achieving good outcomes in high tibial osteotomy [17]. The optimal treatment strategy for grade 2 central chondrosarcoma should be individualized based on histological features, tumour location, morbidity of resection, and patient-specific factors [36]. Surgery is considered resolutive for symptoms of popliteomeniscal fascicles, though there is controversy about the most appropriate technique [28]. Arthroscopic management serves as a minimally invasive alternative to open surgery for diagnosis and treatment of early-stage tuberculosis of the ankle [29].

Outcomes and Timing: All patient-reported outcomes improved from preoperative to short-term follow-up in adolescents and young adults undergoing lumbar disc herniation surgery, with no likely clinically important differences between short- and long-term follow-up within both groups [2]. Percutaneous endoscopic lumbar discectomy combined with lumbar hyperextension pressurization has better clinical efficacy and radiological outcomes for L4/5 single-segment lumbar disc herniation and may reduce recurrence rates and the need for secondary surgery [7]. The objective of the Delphi Trial is to identify the best timing of surgery for patients at risk for the development of neurological signs and symptoms [15].

Investigations

Plain radiography: Preoperative clinical and radiological assessment is critical to determine indications, contraindications, and the necessity of associated procedures for patello-femoral arthroplasty [1]. For thoracolumbar fractures without neurological impairment, diagnostic tools and classification systems remain subject to controversy [3]. In missed Monteggia fractures in children, lesser clinical and radiographic outcomes are expected after a surgical delay exceeding 6 months for corrective ulnar osteotomy [4]. Primary indications for operative intervention in kyphotic deformity in patients with myelomeningocele are the clinical manifestations of the deformity rather than radiographic measurements [5]. Radiographic evolution for reverse shoulder arthroplasty in malignant tumors of the proximal humerus is worrisome, necessitating long-term study to validate this therapeutic option [23]. Differences between 3D CT and 3D MRI regarding surface area and glenoid apposition in distal clavicle autograft versus Latarjet procedures were small and likely not clinically significant [66]. Comparative studies of fourth-generation minimally invasive and open hallux valgus surgery suggest similar clinical and radiological outcomes, though recurrence remains a challenge necessitating long-term follow-up [78]. CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery, with prevalence increasing more than two-fold from 6 months to 5 years post-surgery [91].

MRI: MRI-based components of mTLICS support personalized, image-guided management for stratifying three-tier treatment for thoracolumbar injuries, though prospective validation is needed [63]. In suspected cases of chronic exertional compartment syndrome, orthopedic surgeons should not hesitate to perform further imaging studies like MRI or scintigraphy [80]. Metal suppression magnetic resonance imaging techniques provide a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude to facilitate better-informed diagnostic decisions [85]. Clinical consideration of cartilaginous endplate herniation imaging features is needed in preoperative planning and postoperative management to enhance patient outcomes and satisfaction following percutaneous endoscopic lumbar discectomy [89].

CT: Preoperative imaging planning is important to identify patients who are not suitable for extreme lateral interbody fusion (XLIF) at L4/5 [42].

Other Considerations: Percutaneous endoscopic lumbar discectomy combined with lumbar hyperextension pressurization for L4/5 single-segment lumbar disc herniation has better clinical efficacy and radiological outcomes and may reduce recurrence rates and the need for secondary surgery [7]. Use of magnetic resonance fluoroscopy for preoperative marking of musculoskeletal tumors reduces the time needed for the intervention [48]. Pectoralis major pedicle bone grafting for Neer 4-part proximal humerus fractures yielded excellent clinical and radiological results compared to tricortical iliac grafting [49]. Despite advances in surgical techniques, implants, and imaging, there is a lack of consensus on the optimal treatment for subcritical bone loss in failed shoulder instability surgery [54]. The direct superior approach for total hip arthroplasty appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, but a randomized controlled trial with functional outcomes is needed [72]. Larger trials with long-term clinical and radiologic follow-up are needed to definitively address the controversy regarding the changing role of acromioplasty [87]. Both surgical sequences for degenerative hip-spine syndrome significantly improve postoperative clinical function scores and radiological parameters compared to preoperative assessments [90].

Treatment

Non-Operative

Conservative management remains the preferred approach for most symptomatic patients with isthmic spondylolisthesis in the adult, with success rates as high as 60% [60]. Recent trends indicate that nonoperative management is the most common treatment for proximal humerus fragility fractures in the elderly [69]. Nonoperative treatment results in fewer complications and additional surgeries compared to open reduction internal fixation for 3- and 4-part proximal humerus fractures [74]. For lateral compression fractures of the pelvis, short- and long-term outcomes show no difference between operatively and nonoperatively treated patients [8]. In the context of adult spinal deformity, while surgical treatment yields more improvement in HRQOL, conservative options are part of a spectrum ranging from orthosis to instrumented stabilization depending on the individual injury [37, 86]. Small, asymptomatic, medially-placed lesions of non-traumatic osteonecrosis of the femoral head may be treated with observation alone [88].

Operative

Indications: Preoperative clinical and radiological assessment is critical to determine indications, contraindications, and the necessity of associated procedures for patello-femoral arthroplasty [1]. Correct patient selection based on optimum surgical indications is essential for lateral unicompartimental knee arthroplasty [13]. The indication for triple tibial osteotomy must be well chosen and surgery meticulously planned for severe bilateral varus deformity in late-onset Blount's disease [12]. Surgical treatment is recommended for unstable osteochondritis dissecans lesions or those failing nonsurgical care [79]. Age is not a contraindication for decompressive lumbar spine surgery in elderly patients with lumbar spinal stenosis [44]. Operative management provides more effective relief than nonoperative treatment for degenerative lumbar stenosis in short-term follow-up [9]. Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes [51]. Posterior endoscopic decompression combined with anterior cervical discectomy and fusion is an effective surgical treatment for multilevel cervical spondylotic myelopathy [55]. Arthrodesis is at present the best surgical treatment for the persistently painful degenerative back [83].

Surgical Approach / Technique: Surgical technique selection for anterior cervical discectomy and fusion should be individualized, considering patient-specific anatomical factors, functional demands, and the risk-benefit profile of each approach [21]. Percutaneous endoscopic lumbar discectomy combined with lumbar hyperextension pressurization has better clinical efficacy and radiological outcomes for L4/5 single-segment lumbar disc herniation [7]. This combined technique may reduce recurrence rates and the need for secondary surgery for L4/5 single-segment lumbar disc herniation [7]. Both percutaneous and open posterior stabilization and decompression are safe and effective for AOSpine-type A3 thoracolumbar fractures with neurological deficit [39]. Minimally invasive endoscopic treatment for lumbar infectious spondylitis could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery [81]. Nonoperative treatment was uniformly successful for isolated greater trochanteric fracture using the direct anterior approach using a fracture table [71].

Implant Selection: Based on recent, high-quality RCTs, no single surgical approach consistently outperforms others regarding ROM, PROMs, and reoperation rates for total knee arthroplasty [58]. Results support the continued use of minimally invasive UKA for the recommended indications [20].

Alignment / Balancing Strategy: No specific alignment or balancing strategy evidence is present in the provided L1 data for this section.

Pain Management: No specific pain management regimen evidence is present in the provided L1 data for this section.

Adjuncts: No specific adjunct evidence is present in the provided L1 data for this section.

Setting of Care: No specific setting of care evidence is present in the provided L1 data for this section.

Revision: Further studies are needed to assess the long-term safety and efficacy of simultaneous bilateral shoulder arthroplasty [14]. Further studies are needed for long-term efficacy of one-hole split endoscope versus unilateral biportal endoscopy for lumbar spinal stenosis [56]. Prospective studies comparing the effects of nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed [9]. There has never been a properly conducted trial of surgery versus active conservative care for acute spinal cord injury, and it is still not known whether early surgery or active physiological management offers the better chance for recovery [64].

Other Considerations: Despite improvements in techniques, results for AC-joint instability remain imperfect with frequent complications [22]. There is a lack of high-level evidence such as prospective cohort studies or controlled studies for non-operative treatment of AC-joint instability [22]. Complications related to surgical treatment for adult spinal deformity are frequent, but most have minimal detrimental effect on HRQOL [37]. Arthrodesis for persistently painful degenerative back increases morbidity and mortality rates [83]. Arthrodesis for persistently painful degenerative back carries a risk of non-union [83]. Larger lesions of non-traumatic osteonecrosis of the femoral head have a 25% to 50% risk of progression [88]. All patient-reported outcomes improved from preoperative to short-term follow-up in adolescents and young adults undergoing lumbar disc herniation surgery, with no likely clinically important differences between short- and long-term follow-up seen within both groups [2]. After surgery for humeral avulsions of the glenohumeral ligament, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and satisfaction with treatment outcome [46]. Conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis [43].

Complications

Other Considerations: Patient-reported outcomes generally improve from preoperative to short-term follow-up in adolescents and young adults undergoing lumbar disc herniation surgery, with no likely clinically important differences between short- and long-term follow-up [2]. In contrast, further prospective studies with long-term follow-up are needed to assess whether the increasing rate of surgical management of closed tibia fractures in adolescents results in improved patient outcomes [6]. Short- and long-term outcomes showed no difference between operatively and nonoperatively treated patients with lateral compression fractures of the pelvis [8]. While short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment for degenerative lumbar stenosis, prospective studies comparing long-term natural history are needed [9]. The nature of complications in hip arthroscopy changed with experience, but no significant variation in the incidence was observed over a 9-year period [98]. Increased surgical experience may have contributed to improved surgical outcomes in the evolution of hip arthroscopy since 2008 [110]. Surgeon experience significantly modified patient selection, results, and complications for reverse shoulder arthroplasty, though it did not lead to operating on younger patients [99]. Long-term outcomes for minimally invasive spine surgery appear similar to conventional open surgery, with specific complications varying by procedure type [31]. The natural history of thoracolumbar burst fractures without neurology appears to be benign [113].

Other Considerations: The short-, mid-, and long-term results of the Latarjet procedure in a North American population indicate positive clinical outcomes [10]. Longer follow-up is needed to determine the durability and long-term outcomes of surgeries for displaced femoral neck fractures in workers' compensation patients aged 45-65 years [11]. Prospective randomized studies are needed to assess the long-term safety and efficacy of simultaneous bilateral shoulder arthroplasty [14]. Open reduction and fixation does not improve short-term outcome of medium-sized posterior fragments in AO type B ankle fractures, and longer follow-up is needed to evaluate intermediate or long-term effects [16]. No final conclusion regarding the long-term outcome of direct cementless metaphyseal fixation in knee revision arthroplasty can be made because the follow-up is short to mid-term [18]. Long-term follow-up is needed to identify the lasting implications of outcome differences following reverse total shoulder arthroplasty based on indication [19]. Complications including reoperation are frequent in semiconstrained total elbow arthroplasty for ankylosed and stiff elbows, but the risk can be lessened by careful preoperative planning and surgical technique [104]. In a cohort of early revision (<90 days) for direct anterior total hip arthroplasty, the longitudinal incision allowed for the management of early surgical complications with less morbidity compared to the horizontal (bikini) incision [106]. Arthroscopic and related surgery has a low complication rate, but surgeons must learn from complications that do occur through careful review and study of etiology and prevention [108]. Intercalary resection of the tibia for primary bone tumors was associated with frequent, often severe complications during the first postoperative years and a complication-free survival of 58% at 5 years [116]. Delayed surgery for plate fixation of clavicle fractures is associated with a higher risk of complications, although the outcome is generally good [117].

Recovery

Functional milestones: Patient-reported outcomes for adolescents and young adults undergoing lumbar disc herniation surgery improve from preoperative to short-term follow-up, with no likely clinically important differences observed between short- and long-term follow-up [2]. Short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment for degenerative lumbar stenosis [9]. The Latarjet procedure in a North American population demonstrates positive clinical outcomes at short-, mid-, and long-term intervals [10]. Functional results for standardized treatment of elbow fracture dislocations are encouraging at least at the short term, despite a high reoperation rate [40]. Patients with a preoperative duration of symptomatic medial knee overload or arthritis of two years or greater do not experience inferior patient-reported or clinical outcomes compared to those with a symptom duration of less than 2 years at mid-term follow-up [122]. Operatively and nonoperatively treated patients with lateral compression fractures of the pelvis show no difference in short- and long-term outcomes [8].

Rehabilitation protocol: For congenital scoliosis due to a single nonincarcerated thoracolumbar hemivertebra in children under 10 years old, a limited delayed surgery performed after 5 years but before 10 years of age with close follow-up can achieve satisfied results [123]. In cases of missed Monteggia fractures in children, lesser clinical and radiographic outcomes are expected after a surgical delay of more than 6 months for corrective ulnar osteotomy [4]. Regarding knee arthroscopy prior to subsequent knee arthroplasty, there is a variable time-dependent relationship with literature suggesting a delay between three months to one year, though no absolute guidelines exist for the timing [120]. For epithelioid sarcoma of the hand, aggressive surgical management with negative margins results in 71% of patients being alive without evidence of disease at the last follow-up, with 5- and 10-year survivorship rates of 85% [119]. Radiographic evolution following reverse shoulder arthroplasty for malignant tumors of the proximal humerus is worrisome [23].

Other Considerations: Simultaneous or staged operations for tandem spinal stenosis show no significant differences in operation time, blood loss, or complications among the three surgical groups; however, significant differences in reoperation rates and interval times were noted between staged operations [121].

Key Evidence

• [L5] Preoperative clinical and radiological assessment is critical to determine indications, contraindications, and the necessity of associated procedures. (10.1016/j.jisako.2024.01.003)
• [L3] All patient-reported outcomes improved from preoperative to the short-term follow-up, while no likely clinically important differences between the short- and long-term follow-up were seen within both groups. (10.1302/0301-620x.101b12.bjj-2019-0621.r1)
• [L4] This review attempts to elucidate controversies regarding diagnostic tools, classification systems, and the evidence for conservative and surgical methods based on recent literature. (10.1302/2058-5241.1.000029)
• [L4] Lesser clinical and radiographic outcomes can be expected after a surgical delay of more than 6 months. (10.1016/j.jse.2018.06.029)
• [L4] The primary indications for operative intervention are the clinical manifestations of the deformity rather than the radiographic measurements. (10.2106/00004623-199409000-00004)
• [L3] Further prospective studies with long-term follow-up are needed to assess whether this increase in surgical management results in improved patient outcomes. (10.5435/jaaos-d-17-00926)
• [L3] It has better clinical efficacy and radiological outcomes and may to some extent reduce recurrence rates and the need for secondary surgery. (10.1186/s13018-025-06323-9)
• [L3] However, short- and long-term outcomes showed no difference between operatively and nonoperatively treated patients. (10.1186/s12891-019-2583-3)
• [L5] Short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment, but prospective studies comparing the effects of nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed. (10.5435/00124635-199907000-00004)
• [L4] Short-, mid-, and long-term results indicate positive clinical outcomes. (10.1016/j.jseint.2025.04.033)
• [L3] Longer follow-up will help determine the durability and long-term outcomes of these surgeries. (10.1016/j.arth.2020.06.003)
• [L4] However, the indication must be well chosen and surgery meticulously planned. (10.1007/s00167-012-2061-z)
• [L4] Correct patient selection on the basis of optimum surgical indications, however, is essential. (10.1007/s00167-007-0342-8)
• [L4] Prospective randomized studies are needed to assess the long-term safety and efficacy of the procedure. (10.1016/j.jse.2021.12.041)
• [L2] The objective of this study is to identify the best timing of surgery for patients at risk for the development of neurological signs and symptoms. (10.1186/1471-2474-7-14)
• [L1] Longer follow-up is needed to evaluate intermediate or long-term effects. (10.1302/0301-620x.107b4.bjj-2024-0521.r3)
• [L5] Appropriate patient selection, preoperative planning, and surgical execution are critical to achieving good outcomes. (10.5435/jaaos-d-23-00323)
• [L3] Long-term follow-up is needed to identify the lasting implications of such outcome differences. (10.1016/j.jse.2023.09.033)
• [L3] The results support the continued use of minimally invasive UKA for the recommended indications. (10.1302/0301-620x.97b11.35634)
• [L3] Surgical technique selection should be individualized, considering patient-specific anatomical factors, functional demands, and the risk-benefit profile of each approach. (10.1186/s13018-025-05654-x)
• [L5] Despite improvements in techniques, results remain imperfect with frequent complications, and there is a lack of high-level evidence such as prospective cohort studies or controlled studies for non-operative treatment, leaving numerous open questions regarding the best treatment approach. (10.1007/s00167-019-05666-1)
• [L4] However, radiographic evolution is worrisome, and long-term study remains necessary to validate this therapeutic option with follow-up. (10.1016/j.jse.2014.04.006)
• [L4] Early diagnosis and emergent surgical intervention promote better outcomes. (10.1186/s12891-021-04443-x)
• [L2] Greater diagnosis severity at presentation may affect outcomes afforded by surgery and pose a higher risk of postoperative complications. (10.5435/jaaos-d-25-00064)
• [L5] A systematic approach to treatment is required for the adult patient presenting with late or chronic complications after spinal surgery, involving patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches. (10.5435/jaaos-d-16-00530)
• [L1] Although surgery is considered resolutive for symptoms, there is still controversy about the most appropriate technique. (10.1186/s13018-021-02290-z)
• [L4] It serves as a minimally invasive alternative to open surgery for diagnosis and treatment. (10.1186/s13018-018-1048-y)
• [L5] Surgical challenges, options regarding delayed surgery, and possible outcomes all need to be clearly communicated to the patient and parents. (10.5435/00124635-200612000-00005)
• [L4] Open surgery is indicated without delay, and the prognosis is good with swift and proper treatment. (10.1016/j.jse.2010.10.025)
• [L5] Early diagnosis is often challenging because the initial signs and symptoms frequently are subtle. (10.5435/00124635-200808000-00006)
• [L4] The diagnosis of vascular injury is clinical, based on accurate physical examination, and liberal use of preoperative or intraoperative angiography is essential. (10.1007/s00167-003-0423-2)
• [L3] The optimal treatment strategy should be individualized based on histological features, tumour location, morbidity of resection, and patient-specific factors. (10.1302/0301-620x.107b9.bjj-2024-1378.r1)
• [L3] Both treatment strategies are safe and effective; however, MIS could provide earlier pain relief and better functional outcomes compared with OS. (10.1186/s12891-023-06486-8)
• [L4] Functional results are encouraging at least at short term, despite the high reoperations rate. (10.1016/j.jseint.2020.12.004)
• [L1] Since numerous other surgical, radiological, functional outcome parameters and other complication rates showed no significant difference, no recommendation for a change in surgical technique seems justified. (10.1186/s13018-024-04852-3)
• [L4] Preoperative imaging planning is important to identify patients who are not suitable for this procedure. (10.1186/s13018-022-03320-0)
• [L4] Conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis. (10.1371/journal.pone.0130185)
• [L4] Age is not a contraindication for decompressive lumbar spine surgery. (10.1186/s13018-020-01968-0)
• [L4] The study proposes a practical classification system with preliminary feasibility in surgical approach selection for cage retropulsion, suggesting that early revision may yield better outcomes. (10.1186/s12891-026-09616-0)
• [L4] After surgery, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and satisfaction with treatment outcome. (10.1177/0363546516680608)
• [L4] The classification of HPTs corresponds to surgical outcomes, and may be helpful for decision-making regarding their surgical treatment. (10.2106/jbjs.22.00781)
• [L2] Use of magnetic resonance fluoroscopy reduces the time needed for the intervention. (10.2106/00004623-200408000-00021)
• [L2] Our technique yielded excellent clinical and radiological results. (10.1016/j.jse.2023.07.024)
• [L4] A classification system that recognizes the associated lesions and provides a basis for their treatment would be of value. (10.1097/01.blo.0000180606.30981.78)
• [L1] Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes. (10.1002/ksa.70284)
• [L3] The study confirmed that this classification has a good reference value for guiding the treatment plan and the choice of surgical approach. (10.1186/s13018-023-03688-7)
• [L5] Modern classification systems include PLC integrity in surgical decision making, and care must be taken to scrutinize the possibility of ligamentous disruption before proceeding with nonsurgical management. (10.5435/jaaos-d-22-00908)
• [L5] Despite advances in surgical techniques, implants, and imaging, several issues remain unresolved, including a lack of consensus on the optimal treatment for subcritical bone loss and limited high-level evidence comparing techniques. (10.1016/j.jisako.2025.101011)
• [L3] It is an effective surgical treatment for MCSM. (10.1186/s12891-023-06713-2)
• [L3] Further studies are needed for long-term efficacy. (10.1186/s13018-024-04743-7)
• [L1] The long-term risks of surgery should be considered when recommending operative treatment. (10.2106/jbjs.g.00673)
• [L1] Based on recent, high-quality RCTs, no single surgical approach consistently outperforms others regarding ROM, PROMs, and reoperation rates. (10.1016/j.arth.2025.11.013)
• [L5] Proper patient selection is key to a successful outcome, requiring assurance that the patient has reasonable expectations of postoperative outcomes. (10.5435/00124635-200607000-00006)
• [L4] Nonoperative treatment is the preferred approach in most symptomatic patients and is successful in as many as 60%. (10.5435/00124635-199607000-00004)
• [L4] The biomechanics of the lumbar spine may differ with each individual, and L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury. (10.1186/s12891-019-2921-5)
• [L2] These clinical factors should be included in future classifications to allow for more comprehensive treatment algorithms. (10.5435/jaaos-d-22-01199)
• [L3] Its MRI-based components support personalized, image-guided management, though prospective validation is needed. (10.1186/s12891-025-09124-7)
• [L5] There has never been a properly conducted trial of surgery versus active conservative care, so it is still not known whether early surgery or active physiological management offers the better chance for recovery. (10.1302/0301-620x.105b4.bjj-2023-0111)
• [L3] A reliable classification for assessing the stability of a healed vertebra was developed. (10.1186/s12891-020-03386-z)
• [L4] Differences between 3D CT and 3D MRI were small and likely not clinically significant. (10.1177/03635465231157430)
• [L5] In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models. (10.1186/s13018-024-04681-4)
• [L4] The study describes an intraoperative grading system and surgical approach for these tears. (10.1016/j.arth.2008.01.248)
• [L4] Recent trends show that in the elderly population, nonoperative management remains the most common treatment for PHFs. (10.1016/j.jse.2015.07.015)
• [L5] The revision knee complexity classification offers a common-sense approach to recognize increasing complexity in revision TKR cases, providing a methodological assessment to support regional clinical networking and triage of appropriate cases to specialist centres. (10.1007/s00167-019-05462-x)
• [L3] Nonoperative treatment was uniformly successful. (10.1016/j.arth.2018.02.051)
• [L3] While the DSA appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, a randomized controlled trial with functional outcomes in the postoperative phase is needed to evaluate this surgical approach formally. (10.1302/0301-620x.103b3.bjj-2020-0916.r1)
• [L4] The authors present a classification system and algorithmic approach to guide femoral reconstruction in revision total hip arthroplasty, recommending specific implant strategies based on the type of femoral deficiency to ensure stability and osseointegration. (10.2106/00004623-200300004-00001)
• [L1] Non-surgical treatment results in fewer complications and additional surgeries compared to open reduction internal fixation. (10.1177/1758573219831506)
• [L5] PPS systems have been developed for approximately 20 years to improve minimally invasive techniques, safety, and ease of use, with fourth-generation systems minimizing operative steps. (10.3390/medicina58081064)
• [L4] The disparity between 'clinical failure' and 'surgical failure' outcomes means these terms may need re-defining using a specific/ bespoke MAT scoring system. (10.1186/s12891-020-3165-0)
• [L3] Responsible arterial vascular embolization procedures together with associated surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies are worthy of clinical dissemination by significantly reducing surgical trauma and local recurrence rate. (10.1186/s12891-023-07092-4)
• [L4] Comparative studies suggest similar clinical and radiological outcomes, but recurrence remains a challenge necessitating long-term follow-up and standardized outcome measures. (10.1302/0301-620x.107b1.bjj-2024-0597.r2)
• [L4] Treatment is largely based on the stability of the fragment, with conservative management recommended for stable lesions in patients with open physis and surgical intervention for unstable lesions or those failing nonsurgical care. (10.5435/jaaos-d-23-00494)
• [L4] In suspected cases, orthopedic surgeons should not hesitate to perform further imaging studies like MRI or scintigraphy. (10.1007/s00167-006-0240-5)
• [L4] This procedure could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery. (10.1186/1471-2474-15-105)
• [L4] Kinematic MRI demonstrated dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation. (10.1186/s13018-023-03745-1)
• [L5] Arthrodesis is at present the best surgical treatment for the persistently painful degenerative back, though it increases morbidity and mortality rates and carries a risk of non-union. (10.2106/00004623-196345070-00016)
• [L5] Noncontinuous CDA could preserve IDP and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of cervical spine near preoperative values. (10.1186/s13018-020-1549-3)
• [L5] This review provides a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude, discussing commonly applied techniques and recent technological advances to facilitate better-informed diagnostic decisions. (10.5435/jaaos-d-24-01057)
• [L1] Larger trials with long-term clinical and radiologic follow-up are needed to definitively address the controversy. (10.1016/j.arthro.2012.06.003)
• [L2] The review provides an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head, emphasizing that small, asymptomatic, medially-placed lesions may be treated with observation alone while larger lesions have a 25% to 50% risk of progression. (10.1302/0301-620x.99b10.bjj-2017-0233.r2)
• [L3] These findings emphasize the need for clinical consideration of these imaging features in the preoperative planning and postoperative management to enhance patient outcomes and satisfaction. (10.1186/s13018-024-04746-4)
• [L3] Both surgical sequences significantly improve postoperative clinical function scores and radiological parameters compared to preoperative assessments. (10.1186/s12891-025-08687-9)
• [L3] CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery, with prevalence increasing more than two-fold from 6 months to 5 years post-surgery. (10.1186/s12891-017-1420-9)
• [L4] The paper reviews biomechanical studies to clarify the effects of interspinous devices on treated and adjacent spinal segments, noting that while devices reduce range of motion in extension and can reduce disc pressure, they often fail to fully compensate for destabilization in other planes or adjacent levels. (10.1155/2014/839325)
• [L1] This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes. (10.1302/0301-620x.95b1.29829)
• [L5] The study suggests that a 5 mm implant height provides biomechanical properties similar to intact specimens, whereas larger heights alter facet joint mechanics. (10.1186/s13018-020-02157-9)
• [L5] We found preferentially larger motion at the superior bearing of the CHARITE´ discs implanted in human cadaveric lumbar spines and in patients, regardless of the implanted level. (10.2106/jbjs.j.00638)
• [L4] The nature of complications changed with experience, but no significant variation in the incidence was observed over the 9-year period of experience with hip arthroscopy. (10.1016/j.arthro.2009.12.021)
• [L3] Experience did not lead us to operate on younger patients, but significantly modified patient selection, results, and complications. (10.1016/j.jse.2011.11.010)
• [L4] Given that fracture mobility is present, the realignment potential is sound and increases with the severity of preoperative vertebral body deformation. (10.1186/1471-2474-14-233)
• [L4] The article provides an evidence-based approach to selecting fusion levels that balances expert opinion with current literature to minimize the risk of future progression and optimize spinal balance while fusing the least number of levels necessary. (10.5435/jaaos-d-22-00547)
• [L5] Biomechanical analysis showed that both CPS and CAPSI increase ROM and disc stresses in osteoporotic lumbar models, but CAPSI is more likely to increase the potential risk of adjacent segment degeneration compared to CPS. (10.1186/s13018-020-01650-5)
• [L4] Because of the nature of the underlying pathology, complications, including reoperation, are frequent, but the risk can be lessened by careful preoperative planning and surgical technique. (10.2106/00004623-200009000-00006)
• [L4] In our cohort, the longitudinal incision allowed for the management of early surgical complications with less morbidity. (10.1016/j.arth.2024.05.078)
• [L5] Arthroscopic and related surgery has a low complication rate, but surgeons must learn from complications that do occur through careful review and study of etiology and prevention. (10.1016/j.arthro.2014.08.002)
• [L4] Motion in the coronal plane decreased by 77% following anterior vertebral body tethering. (10.2106/jbjs.20.01533)
• [L4] These developments, as well as increased surgical experience, may have contributed to improved surgical outcomes. (10.1016/j.arthro.2019.10.009)
• [L3] Results of percutaneous fixation depend on the biomechanical construct. (10.1016/j.jse.2018.06.034)
• [L2] This leads to patients having the expected hip, pelvic, and spinal flexion as demographically matched controls, thus potentially eliminating abnormal mechanics that contribute to the development or exacerbation of hip-spine syndrome. (10.2106/jbjs.21.01127)
• [L4] The natural history of thoracolumbar burst fractures without neurology would appear to be benign. (10.1302/0301-620x.98b1.36121)
• [L3] Spine cage augmentation provides superior biomechanical stability while achieving comparable clinical outcomes to fibular allograft. (10.1016/j.jse.2025.09.009)
• [L5] Further biomechanical tests and clinical studies have to proof Tektona®'s capabilities. (10.1186/s12891-020-03899-7)
• [L4] However, this procedure was associated with frequent, often severe complications during the first postoperative years and complication-free survival of 58% at 5 years. (10.1097/corr.0000000000003007)
• [L3] Delayed surgery is associated with a higher risk of complications, although the outcome is generally good. (10.1016/j.jse.2019.06.022)
• [L4] After aggressive surgical management with negative margins, 71% of the patients were alive without evidence of disease at the last followup, with a 5- and 10-year survivorship of 85%. (10.1097/01.blo.0000150317.50594.96)
• [L5] There is a variable time-dependent relationship between the timing of knee arthroscopy and the outcome of a subsequent knee arthroplasty, with literature suggesting a delay between three months to one year, though no absolute guidelines exist. (10.1016/j.arth.2025.02.004)
• [L3] The study found no significant differences in operation time, blood loss, or complications among the three surgical groups, but noted significant differences in reoperation rates and interval times between staged operations. (10.1186/s13018-021-02357-x)
• [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
• [L3] A limited delayed surgery after 5 years but before 10 years of age with close follow-up can achieve satisfied results. (10.1186/s13018-021-02865-w)

See Also

• Deformities
• Conservative Treatment
• Pain Management
• Surgical Complications

References

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[29] Arthroscopic management for early-stage tuberculosis of the ankle. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-018-1048-y

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[42] L4/5 accessibility for extreme lateral interbody fusion (XLIF): a radiological study. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03320-0

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[62] Evaluation of Classification Systems and Their Correlation With Clinical and Quality-of-life Parameters in Patients With Surgically Treated Spondylodiskitis. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-01199

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[80] Is the diagnosis as simple as the treatment? Diagnostic pitfalls in chronic exertional compartment syndrome?. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0240-5

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[82] Dynamic evaluation of the cervical spine by kinematic MRI in patients with cervical spinal cord injury without fracture and dislocation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03745-1

[83] Surgical Treatment of Degenerative Disease of the Back. The Journal of Bone & Joint Surgery. 1963. DOI: 10.2106/00004623-196345070-00016

[84] Biomechanical comparison of noncontiguous cervical disc arthroplasty and noncontiguous cervical discectomy and fusion in the treatment of noncontinuous cervical degenerative disc disease: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-1549-3

[85] Metal Suppression Magnetic Resonance Imaging Techniques in Orthopaedic and Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01057

[86] Chapter 46 Spine Trauma. 2020.

[87] The Changing Role of Acromioplasty. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.06.003

[88] An evidence-based guide to the treatment of osteonecrosis of the femoral head. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b10.bjj-2017-0233.r2

[89] Investigating the impact of cartilaginous endplate herniation on recovery from percutaneous endoscopic lumbar discectomy. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04746-4

[90] Optimal surgery sequence in the treatment of degenerative hip-spine syndrome: a propensity score-based inverse probability of treatment weighting analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08687-9

[91] Utilization of CT scanning associated with complex spine surgery. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1420-9

[92] Biomechanics of Interspinous Devices. BioMed Research International. 2014. DOI: 10.1155/2014/839325

[93] Segmental mobility, disc height and patient-reported outcomes after surgery for degenerative disc disease. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b1.29829

[96] The impact of different artificial disc heights during total cervical disc replacement: an in vitro biomechanical study. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-020-02157-9

[97] Asymmetric Motion Distribution Between Components of a Mobile-Core Lumbar Disc Prosthesis. Journal of Bone and Joint Surgery. 2012. DOI: 10.2106/jbjs.j.00638

[98] Do Complications in Hip Arthroscopy Change With Experience?. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2009.12.021

[99] Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon’s experience?. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.010

[100] Radiographic and safety details of vertebral body stenting: results from a multicenter chart review. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-233

[102] Surgical Level Selection in Adolescent Idiopathic Scoliosis: An Evidence-Based Approach. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00547

[103] Influence of cement-augmented pedicle screw instrumentation in an osteoporotic lumbosacral spine over the adjacent segments: a 3D finite element study. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01650-5

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