Comparison of thoracic pedicle screw to hook instrumentation for the treatment of adult spinal deformity

STUDY DESIGN

Retrospective, case-control, matched cohort.

OBJECTIVE

Compare the radiographic and clinical outcomes of adult spinal deformity patients treated with thoracic pedicle screw (TPS) or thoracic hook constructs.

SUMMARY OF BACKGROUND DATA

The efficacy of TPS instrumentation for pediatric spinal deformity correction has been established. Little is known about TPS use in adult spinal deformity.

METHODS

Fifty-six patients (average age, 49 years; average follow-up, 3.58 years) were treated with TPS or thoracic hook constructs for coronal (n = 20) or sagittal (n = 36) plane deformities. Patients were evaluated radiographically and with SRS scores.

RESULTS

Coronal deformities treated with TPS demonstrated improved main thoracic curve correction compared with hook constructs at last follow-up (24.8 degrees vs. 13.8 degrees; P < 0.05), despite having larger (59.8 degrees vs. 44.9 degrees; P < 0.05) and more rigid preoperative curves (29.3% vs. 44.9% correction on side-bending radiographs; P < 0.001). Sagittal deformities treated with TPS constructs demonstrated greater thoracolumbar kyphosis correction than hook constructs at last follow-up (12.1 degrees vs. 2.5 degrees; P < 0.05). No TPS patient had a thoracic pseudarthrosis. Four hook patients (14%) had thoracic pseudarthroses.

CONCLUSIONS

TPS instrumentation allows greater coronal and sagittal plane correction and may reduce the risk of thoracic pseudarthrosis compared with hook constructs when treating adult spinal deformities.

Surgical correction of spinal deformities following spinal cord injury occurring in childhood

This article reports on the surgical treatment of 14 consecutive patients with paralytic spinal deformities secondary to spinal cord injury occurring in childhood. Eleven patients underwent a posterior spinal fusion and three patients underwent a combined anterior and posterior spinal arthrodesis. Luque rods were used in all but one patient. The spinal fusion extended to the sacrum in 10 patients. No patient developed postoperative wound infections or medical complications. Four patients (28.6%) who underwent initially a posterior spinal arthrodesis developed pseudarthrosis. This was treated successfully by a combined anterior and posterior spinal fusion in two patients. The remaining patients underwent a revision posterior spinal fusion with recurrence of the nonunion in one patient. A combined anterior and posterior spinal arthrodesis could be considered the treatment of choice for patients with severe deformities who can tolerate anterior surgery. If pseudarthrosis develops following posterior spinal fusion, this can be best treated by a combined anterior and posterior revision procedure with instrumentation.

[Pelvic stabilization in cases of septic instability. Triangular osteosynthesis in case of infection related vertical pelvic ring instability]

The combination of transiliac screws and lumbopelvic distraction osteosynthesis is usually an appropriate procedure to treat vertical pelvic ring instabilities under the condition of full weight bearing. In this case, due to the extent of septic destruction of the dorsal portion of the iliac bone, the common triangular fixation method using conventional pedicle screws was not possible. Using the transiliac dorsoventral screw position with special long screws, we achieved high mechanical triangular stability sufficient for pelvic ring fusion despite the large bony defect.

[Comparison of open versus percutaneous treatment for humeral head fracture]

BACKGROUND

The hypothesis of this study was that percutaneous techniques lower the risk of post-traumatic avascular necrosis.

MATERIALS AND METHODS

In this retrospective study 83 patients were followed up clinically and radiologically for signs of avascular necrosis and nonunion after open or percutaneous treatment of proximal humerus fractures. Mean age was 50 years. Fractures were classified in 22 patients (26.5%) as two part, in 21 patients (25.3%) as three part, in 39 patients (47%) as four part, and in 1 patient (1.2%) as fracture dislocation (Neer classification). Fractures were treated in 12 patients (14.5%) by ORIF (open reduction and internal fixation) and in 71 patients (85.5%) by CRPF (closed reduction and percutaneous fixation). Both groups were statistically equally distributed according to fracture type (Mann-Whitney U, p=0.267) and age (One-way-Annova, p=0.740). The postoperative regime did not differ between the two groups.

RESULTS

Patients suffered significantly more avascular necrosis after open treatment [five patients (50%) versus eight patients (12.7%) in the percutaneous group, Mann-Whitney, p=0.004]. The risk for avascular necrosis and nonunion increased with age. Mean age of patients with avascular necrosis was 57 years, and the age of patients with nonunion was 67 years.

CONCLUSION

Percutaneous treatment of humeral head fractures seems to be a reliable method for lowering the risk of avascular necrosis in young patients.

Radiological Risk Factors of Pseudoarthrosis and/or Instrument Breakage After PLF With the Pedicle Screw System in Isthmic Spondylolisthesis

OBJECTIVE

Several studies have reported favorable results of posterolateral fusion (PLF) with pedicle screw systems (PSs) for isthmic spondylolisthesis. However, the best indication and limitations of this method still remain unclear. The present study aimed to analyze the radiological risk factors of pseudoarthrosis and/or instrumentation failure after PLF with PSs in isthmic spondylolisthesis, and to determine the limitations of this method.

METHODS

The study group comprised of 101 patients with isthmic spondylolisthesis who underwent PLF with PSs. Follow-up was performed for more than 5 years. Statistical analyses with multivariate logistic regression models were used to identify risk factors of pseudoarthrosis and/or instrument failures associated with PLF with PSs.

RESULTS

Average follow-up was 8 years. Fusion rate was 95%. There were instrument breakage in 6 patients, and pseudoarthrosis in 5. Statistical analysis with a logistic regression model revealed that preoperative % disc height (odds ratio: 3.60 per 10%, P<0.01) and slip angle (odds ratio: 4.48 per 10 degrees kyphosis, P<0.05) were the most crucial risk factors of pseudoarthrosis and/or instrument breakage when performing PLF for isthmic spondylolisthesis.

CONCLUSIONS

In conclusion, PLF with PSs provided satisfactory results with high fusion rate. However, there were complications including pseudoarthrosis or instrument breakage in specific conditions. Preserved disc height and presence of segmental kyphosis were risk factors of these complications. Statistically, % disc height within 20% without segmental kyphosis was the best indication for PLF with PSs.

Outcome of Girdlestone's resection arthroplasty following complications of proximal femoral fractures

Twenty two patients who underwent a Girdlestone resection arthroplasty of the hip (pseudarthrosis coxae) following failed operative treatment for hip trauma from 1993 to 2002 were retrospectively reviewed. The indications included failed osteosynthesis of fractures of the neck of the femur (n=8), septic hemiarthroplasty (n=9), aseptic loosening of hemiarthroplasty (n=3) and recurrent dislocation of a hemiarthroplasty (n=2). The mortality was 68.2% (15 patients, mean age: 78.8 years, 80% females) with a mean time interval between operation and death of 25.6 months. All the seven surviving Girdlestone patients had failed hemiarthroplasties previously. One of these had subsequently undergone re-implantation of a femoral prosthesis, and was excluded from the study. There were four females and two males. The age ranged from 62 to 94 years with a mean age of 79.6 years. There were 4 right-sided and 2 left-sided operations. The patients were followed-up for a mean 37.1 months (range : 6 months to 8 years). Pain relief was achieved in 100% patients with none to mild pain. All the patients had infection control. Four patients needed a frame support for walking, while the remaining two were chairbound. Overall 83.3% patients expressed their satisfaction with the Girdlestone procedure. The Girdlestone operation appears as a viable solution to achieve pain relief and to control infection at the cost of limited mobility in this specific subgroup of patients with failed operative treatment for hip trauma.

Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the incidence of and risk factors for pseudarthrosis in long adult spinal instrumentation and fusion to S1.

SUMMARY OF BACKGROUND DATA

Few studies on pseudarthrosis in long adult spinal instrumentation and fusion to S1 exist.

METHODS

A clinical and radiographic assessment of 144 adult patients with spinal deformity (average age 52.0 years; range 21.1-77.6) who underwent long (5-17 vertebrae, average 11.9) spinal instrumentation and fusion to the sacrum at a single institution between 1985 and 2002, with a minimum 2-year follow-up (average 3.9; range 2-14) was performed.

RESULTS

Of 144 patients, 34 (24%) had pseudarthroses. There were 17 patients who had pseudarthroses at T10-L2 and 15 at L5-S1. A total of 24 patients (71%) presented with multiple levels involved (2-6). Pseudarthrosis was most commonly detected within 4 years postoperatively (31 patients; 94%). Factors that statistically increased the risk of pseudarthrosis were: thoracolumbar kyphosis (T10-L2 > or = 20 degrees vs. < 20 degrees, P < 0.0001); osteoarthritis of the hip joint (P = 0.002); thoracoabdominal approach (vs. paramedian approach, P = 0.009); positive sagittal balance > or = 5 cm at 8 weeks postoperatively (vs. < or = 5 cm, P = 0.012); age at surgery older than 55 years (vs. 55 years or younger, P = 0.019); and incomplete sacropelvic fixation (vs. complete sacropelvic fixation, P = 0.020). Fusion from upper thoracic spine (T2-T5) did not statistically increase the pseudarthrosis rate compared to lower thoracic spine (T9-T12) (P = 0.20). Patients with pseudarthrosis had significantly lower Scoliosis Research Society 24 outcome scores (average score 71/120) than those without (average score 90/120; P < 0.0001) at ultimate follow-up.

CONCLUSION

The overall prevalence of pseudarthrosis following long adult spinal deformity instrumentation and fusion to S1 was 24%. Thoracolumbar kyphosis, osteoarthritis of the hip joint, thoracoabdominal approach (vs. paramedian approach), positive sagittal balance > or = 5 cm at 8 weeks postoperatively, older age at surgery (older than 55 years), and incomplete sacropelvic fixation significantly increased the risks of pseudarthrosis to an extent that was statistically significant. Scoliosis Research Society 24 outcomes scores at ultimate follow-up were adversely affected when pseudarthrosis developed.

Spinal fusion with Cotrel-Dubousset instrumentation for neuropathic scoliosis in patients with cerebral palsy

STUDY DESIGN

Retrospective.

OBJECTIVE

To report on the treatment of patients with cerebral palsy and neuropathic scoliosis with third-generation instrumented spinal fusion by Cotrel-Dubousset instrumentation.

SUMMARY OF BACKGROUND DATA

Second-generation instrumented spinal fusion is considered the standard for progressive neuropathic scoliosis in cerebral palsy, despite high complication rates. Evidence is needed to evaluate the increasing use of third-generation instrumented spinal fusion in similar patients.

METHODS

Patients with cerebral palsy and spinal deformity treated consecutively by 1 surgeon with Cotrel-Dubousset instrumentation and minimum 2-year follow-up were reviewed. An outcome questionnaire was administered at final follow-up.

RESULTS

A total of 60 patients were included. Mean age was 15 years at surgery. Mean follow-up was 79 months. There were 26 anteroposterior and 34 posterior-only procedures. Correction of coronal deformity and pelvic obliquity averaged 60% and 40%, respectively. Major complications affected 13.5% of patients, and included implant loosening, deep infection, and pseudarthrosis. Minor complications affected 10% of patients. Outcome questionnaires showed marked improvements in the areas of satisfaction, function, and quality of life after surgery.

CONCLUSIONS

Segmental, third-generation instrumented spinal fusion provides lasting correction of spinal deformity and improved quality of life in patients with cerebral palsy and neuropathic scoliosis, with a lower pseudarthrosis rate compared to reports on second-generation instrumented spinal fusion.

Prothèses totales de hanche après échec de fixation de fractures per et sous-trochantériennes chez les sujets âgés

PURPOSE OF THE STUDY

Most pertrochanteric fractures can be successfully fixed with osteosynthesis. Osteosynthesis fails however is a small number of patients who require re-operation for implantation of a total hip prosthesis. This situation occurs in particular when the material has penetrated the acetabulum and in elderly subjects. Although this type of arthroplasty is routine practice, few series have been reported. We present here outcome and complications of total hip arthroplasty after failure of per- and sub-trochanteric fracture fixation.

MATERIAL AND METHODS

Between 1990 and 2000, twenty patients aged 79 years on average (range 62-78 years) underwent revision for total hip arthroplasty after failure of osteosynthesis for fracture of the upper femur. A gliding THS had been used for fixation in 18 patients, a plate in one and a Gamma nail in one. Osteosynthesis failure was related to early disassembly in ten patients, pseudarthrosis in eight and malunion in two. Revision was performed via a posterolateral approach in all cases. A standard total hip prosthesis was used in 16 patients, a longer femoral stem was required in four. Femoral components were cemented in 18 patients and non-cemented in two. The cup was a standard cemented cup in 12, retaining and cemented in eight.

RESULTS

Mean operative time and blood loss were greater than in first-intention arthroplasties. All patients had lost their independence prior to the revision procedure. Despite their age, all recovered independence after a stay in rehabilitation. Most still required crutches. Use of a retaining cup enabled avoiding dislocation in all cases. For those who did not have a retaining cup, dislocation was the most frequent complication (3/12). The difficulties observed were: 1) elimination of associated infection before surgery; many of these elderly subjects had altered ESR and CRP values for various reasons; 2) abnormal position of the trochanteric mass because of a rotation defect; 3) malunion of the upper femur in the frontal or sagittal planes; 4) more or less easily achieved positioning of the femoral piece on the calcar; 5) difficult intraoperative identification of limb length due to loss of usual landmarks on the lesser and greater trochanter; 6) removal of fracture screws which sometimes required use of a trephine and bridging the last screw hole with a longer centromedullary stem. The most frequent postoperative orthopedic problems were leg length discrepancy (1-2 cm for eight patients), gluteus medius insufficiency, limping and pain at palpation of the trochanteric area.

DISCUSSION

Despite the difficult technique and the potential complications which are more important than for first-intention arthroplasties, this series demonstrates that total hip prosthesis is a reliable solution for treating fixation failures of the upper femur.

Posterior correction and fixation without anterior fusion for pseudoarthrosis with kyphotic deformity in ankylosing spondylitis

STUDY DESIGN

Retrospective review.

OBJECTIVE

To assess the effectiveness of posterior correction and fixation without anterior fusion for pseudarthrosis with kyphosis in patients with ankylosing spondylitis.

SUMMARY OF BACKGROUND DATA

Anterior fusion is the current surgical treatment for pseudarthrosis with kyphosis in ankylosing spondylitis. The unique characteristic in ankylosing spondylitis is the superior ability to bridge and fuse the large anterior opening-wedge gap created by posterior osteotomy to correct the kyphosis without anterior fusion after the osteotomy site is adequately fixed. This ability may persist even if pseudarthrosis is present.

METHODS

A total of 30 consecutive patients with ankylosing spondylitis (mean age 41.7 years, range 29-55) underwent posterior correction and fixation without anterior fusion to treat pseudarthrosis with kyphosis. Mean follow-up was 4.7 years (range 2.2-9.1). Radiographic and clinical results and complications were assessed.

RESULTS

Local kyphosis was substantially corrected from 45.5 degrees (range 37 degrees-68 degrees) to 7.5 degrees (0 degrees-14 degrees), with a mean correction of 38 degrees. All patients had no evidence of nonunion on x-ray at the level of the pseudarthrosis at final follow-up. None had a notable loss of correction. No major complication occurred. There were 3 patients with neurologic deficits who had postoperative improvement.

CONCLUSION

Posterior correction and fixation is effective for treating pseudarthrosis with kyphosis in ankylosing spondylitis. No anterior fusion procedure was necessary.

Graft resorption with the use of bone morphogenetic protein: lessons from anterior lumbar interbody fusion using femoral ring allografts and recombinant human bone morphogenetic protein-2

STUDY DESIGN

This is a prospective cohort study examining the results and radiographic characteristics of anterior lumbar interbody fusion (ALIF) using femoral ring allografts (FRAs) and recombinant human bone morphogenetic protein-2 (rhBMP-2). This was compared to a historical control ALIF using FRAs with autologous iliac crest bone graft (ICBG).

OBJECTIVE

To determine whether the use of rhBMP-2 can enhance fusion ALIF with stand-alone FRAs.

SUMMARY OF BACKGROUND DATA

ALIF is a well-accepted procedure in reconstructive spine surgery. Advances in spinal surgery have produced a multitude of anterior interbody implants. The rhBMP-2 has promoted fusion in patients undergoing ALIF with cages and threaded allograft dowels. The FRA still remains a traditional alternative for anterior support. However, as a stand-alone device, the FRA has fallen into disfavor because of high rates of pseudarthrosis. With the advent of rhBMP-2, the FRA may be more attractive because of its simplicity and remodeling potential. It is important to understand the implications when rhBMP-2 is used with such structural allografts.

METHODS

A total of 36 consecutive patients who underwent ALIF with stand-alone FRAs by a single surgeon (E.G.D.) at 1 institute were included. A cohort of 9 consecutive patients who received FRAs filled with rhBMP-2 was followed prospectively. After noticing suboptimal results, the senior author terminated this method of lumbar fusion. A total of 27 prior consecutive patients who received FRAs filled with autogenous ICBG were used for comparison. Analyzing sequential radiographs, flexion-extension radiographs, and computerized tomography with multiplanar reconstructions determined nonunions. Minimum follow-up was 24 months.

RESULTS

Pseudarthrosis was identified in 10 of 27 (36%) patients who underwent stand-alone ALIF with FRAs and ICBG. Nonunion rate was higher among patients who received FRAs with rhBMP-2 (i.e., 5 of 9 [56%]). Statistical significance was not established because of the early termination of the treatment group (P > 0.3). Of interest, radiographs and computerized tomography revealed early and aggressive resorption of the FRAs when used with rhBMP-2. This preceded graft fracture and even disintegration, resulting in instability and eventual nonunion.

CONCLUSION

The use of rhBMP-2 did not enhance the fusion rate in stand-alone ALIF with FRAs. In fact, the trend was toward a higher nonunion rate with rhBMP-2, although this was not significant with the numbers available. This result appears to be caused by the aggressive resorptive phase of allograft incorporation, which occurs before the osteoinduction phase.

Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis

BACKGROUND

There have been few detailed reports concerning pseudarthrosis following spinal instrumentation and arthrodesis in adults with spinal deformity since the introduction of modern segmental fixation techniques. The purposes of this study were to analyze the prevalence, risk factors, and outcome scores on the Scoliosis Research Society Instrument-24 associated with pseudarthrosis following instrumentation and arthrodesis for the treatment of spinal deformity in adults.

METHODS

A clinical and radiographic assessment of 232 adults with spinal deformity who were treated surgically at a single institution was conducted. The average age of the patients was 40.8 years, and the operation was a primary procedure in 150 patients and a revision procedure in eighty-two patients. All patients who underwent a long (four vertebrae or more) spinal instrumentation and arthrodesis with a minimum follow-up of two years were included in the analysis. Clinical outcomes were assessed with the Scoliosis Research Society questionnaire.

RESULTS

Forty patients had a pseudarthrosis. Factors that were found to be significantly associated with pseudarthrosis were preoperative thoracolumbar kyphosis of >20 degrees (p < 0.0001), an age of more than fifty-five years (p = 0.001), arthrodesis to S1 compared with arthrodesis to L5 or a cephalad level (p = 0.002), and arthrodesis of more than twelve vertebrae (p = 0.037). Patients with a pseudarthrosis had lower total outcome scores on the Scoliosis Research Society questionnaire, on the average, than those without a pseudarthrosis (p = 0.001).

CONCLUSIONS

The prevalence of pseudarthrosis following long arthrodesis with use of modern segmental spinal instrumentation for the treatment of spinal deformity in adults was 17%, and the clinical outcome in these patients can be negatively affected by the pseudarthrosis.

Die rheumatisch bedingte Instabilität der oberen Halswirbelsäule

Rheumatic manifestation at the cervical spine occurs in more than 50% of all cases in the natural course of this disease. The first cervical manifestation takes place in the upper cervical spine. The initial involvement of the C1/C2 segment leads to atlantodental subluxation. Progressive destruction can result in vertical instability, which is characterized by cranial subluxation of the odontoid process with the danger of resulting stenosis and cervical myelopathy. The goal of diagnosis has to be the early recognition of these changes to establish an effective treatment protocol. Persistent pain, neurological deficits, and progressive radiological signs for instability are indications for operative stabilizing procedures. These procedures avoid progressive destruction and improve the prognosis regarding pain decrease, regression of neurological deficits, and life expectancy.

Carpal collapse in patients with rheumatoid arthritis

The inflammation of the wrist and carpal collapse play an important role in the deformity of the rheumatoid hand and leads to functional limitation. The aim of this study was to evaluate carpal collapse and related clinical variables in patients with rheumatoid arthritis (RA). Carpal height ratio (CHR) indicating the degree of carpal collapse was measured in 33 female RA patients with a mean age of 41.9+/-10.3 years and 30 female healthy control subjects with a mean age of 40.5+/-9.2 years. The normal range of the carpal collapse was defined in our study population and the incidence of carpal collapse was determined. The correlation between carpal collapse and clinical and laboratory variables including pain by visual analog scale, Ritchie articular index, erythrocyte sedimentation rate, C-reactive protein, health assessment questionnaire indicating functional status, and Larsen roentgenological evaluation were determined. Subgroup analyses were also performed in patients with and without carpal collapse. The mean disease duration of the patients was 12.4+/-5.5 years. The mean CHR index of the patients was significantly lower than in the control group (0.47+/-4.3 and 0.54+/-1.4 respectively). CHR <0.48 was defined as carpal collapse in our study group. Seventeen patients (51.5%) had carpal collapse in the patient group. None of the clinical or laboratory variables except levels of disease duration and Larsen score was correlated with carpal collapse as represented by CHR. The best related clinical variable with carpal collapse was found as duration of disease. The mean duration of disease and the Larsen score were significantly higher in patients with carpal collapse than those without collapse. Other clinical parameters and functional status were similar between patients with and without carpal collapse. In conclusion, although various clinical parameters and functional disability in patients with RA may not be correlated with radiological malalignment, the carpal collapse may be more common in RA than is generally recognized.

Spinal Pseudoarthrosis: A Rare Complication in Psoriatic Arthritis

Discovertebral erosion with pseudoarthrosis is a well-known complication in ankylosing spondylitis but it is seldom mentioned in psoriatic arthritis. We report a 53-year-old woman with an 8-year history of psoriatic arthritis who developed severe low back pain followed by sudden onset of numbness in the lower limbs, weakness and dysesthesia. Abnormal contour of L1 and L2 vertebrae and intervertebral disc space was noted during radiologic examination. Pseudoarthrosis was suspected based on extensive osseous resorption and reactive sclerosis about the discovertebral junction on magnetic resonance imaging study. She underwent emergency operation due to spinal instability with neurologic deficit. Pseudoarthrosis was confirmed intraoperatively. No evidence of infection or neoplasms was found. This case shows that pseudoarthrosis can be complicated in patients with psoriatic arthritis, and this possibility should be considered in patients with previously quiescent disease.

Pseudoarthrosis of vertebral fracture: radiographic and characteristic clinical features and natural history

BACKGROUND

We examined mobility based on radiographic appearance, clinical appearance, and the natural course of osteoporotic vertebral pseudoarthrosis (VPA) in a prospective study in 34 consecutive cases of VPA in 27 patients with osteoporosis.

METHODS

Conventional lateral, lateral flexion, and extension stress radiography (XP) and supine cross-table lateral XP were performed. Anterior vertebral body height and vertebral kyphotic angle were measured to assess vertebral mobility. If vertebral cleft or vertebral instability, which means a difference in vertebral body height between conventional and supine cross-table lateral XP, was present, VPA was diagnosed. Back pain was classified into five grades.

RESULTS

The average anterior vertebral height was 9.9 +/- 5.6 mm on conventional lateral XP; it increased to 11.4 +/- 6.5 mm on extension stress XP (not significant) and 18.3 +/- 5.7 mm on cross-table lateral XP (significant). The vertebral kyphotic angle was 24.1 degrees +/- 9.7 degrees on conventional lateral XP; it decreased to 21.6 degrees +/- 9.8 degrees on extension stress XP (not significant) and 11.8 degrees +/- 8.5 degrees on cross-table lateral XP (significant). Intravertebral clefts were detected by conventional lateral XP, extension stress XP, and supine cross-table XP in 3 of 34 (8.8%), 7 of 21 (33.3%), and 28 of 34 (82.4%) vertebral compression fractures (VCFs), respectively. Surgical treatment was performed in seven patients (two because of severe pain and five because of neurological deficits) and in one patient who died. Except in these eight patients, back pain decreased by at least one grade with time in 18 of 19 patients (95%) in whom the clinical course was analyzed. Radiographic follow-up using supine cross-table XP was performed in 15 of 19 patients. Although 11 of these 15 patients (73%) showed vertebral instability on supine cross-table lateral XP, 10 of 11 patients (91%) did not complain of intolerable back pain during daily activity at the final follow-up.

CONCLUSIONS

VPA is often detected on supine cross-table lateral XP but not usually on extension stress XP. Despite the presence of vertebral instability, many patients did not complain of intolerable back pain during their daily activity. Surgical treatment to alleviate back pain should be performed for painful VPA after conservative treatment for about 4 months.

[Pseudoarthrosis of acromion due to politraumatism. Treatment with autologus graffting intercalar of iliac crest]

The fractures of the scapula are not very frequent, an incidence around the 0,4 and 1% of the fractures that affect the upper limb. The acromion fracture means the 7% of the fractures that affect to the scapula. They usually appear in politraumatized patients with more serious lesions that can mask them and postpose this way their diagnosis and treatment. We present a clinical case of a 56 year-old patient with the antecedent of politraumatism that presented a clear atrophic pseudoartrosis of the acromion of their right shoulder with painful clinic and movement limitation. It was treated with surgery by intercalary bone grafting fixed by osteosynthesis plate obtaining good clinical and radiological results. Actually the painful clinic has disappeared completely.

Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid

Achieving union using conventional grafts has a high chance of failure in patients with recalcitrant non-union (persistent pseudarthrosis) of the scaphoid bone, an avascular proximal fragment and previous failed surgeries because of poor host bed vascularity. Eleven patients with long-standing non-union were treated with vascularized pedicle bone grafting and supplementary corticocancellous grafting. Five had screw fixation and six were fixed with K-wires. The average age of the patients was 28 years, average duration of the non-union was 39 months and mean radiological follow-up was 32 months. There were no significant skeletal complications, although two patients developed neuromata. At review, only six of the 11 non-unions were united. Whilst this is a difficult clinical problem and achieving union is a formidable challenge, we believe that there is a role for such extensive surgery in order to achieve good postoperative function.

Surgical treatment for scoliosis in Marfan syndrome

STUDY DESIGN

Review of results of patients with Marfan syndrome treated with instrumented posterior fusion alone for scoliosis.

OBJECTIVE

To analyze the results of surgical treatment for scoliosis in Marfan syndrome.

SUMMARY OF BACKGROUND DATA

Few studies have been reported in the literature on surgical treatment for scoliosis in Marfan syndrome, analyzing long-term results of posterior instrumented fusion.

METHODS

Twenty-three patients with Marfan syndrome with a mean age of 17 years (range, 11-31 years) were treated surgically from 1982 to 1995 for scoliosis, using a posterior instrumented fusion alone (Harrington rod with sublaminar wires in the first 16 cases, and a more recent hybrid instrumentation in the remaining 7 cases). All of the patients received a long posterior instrumented fusion, including 12.3 levels on average (range, 9-17), extending the fusion area to vertebrae that were neutral and stable in both coronal and sagittal planes before surgery. Patients were analyzed as two different groups (Group 1 and Group 2) according to the different posterior instrumentations employed: Group 1 included 16 patients treated by the Harrington distraction rod technique with sublaminar wires, while Group 2 included 7 patients treated using more recent hybrid instrumentations. Presentation features, complications, and results were analyzed.

RESULTS

At a minimum follow-up of 7 years (maximum, 18 years), all 23 patients were reviewed. The mean age was 26.8 years (range, 20-38 years). The average preoperative scoliosis value of 69.91 degrees was initially corrected to 38.17 degrees, averaged 40.89 degrees 1 year after surgery, and was finally equal to 44.09 degrees at the last follow-up. Differences in terms of scoliosis correction achieved with different instrumentations (Groups 1 and 2) did not reach statistical significance. In Group 2 patients, the percentage of postoperative correction was slightly lower (44.23%) than that of Group 1 (46.55%) but remained more stable at the last follow-up (40.97% vs. 36.38% of Group 1). There were 11 complications in 10 of the 23 patients (43.4%); two complications occurred in 1 patient. Intraoperatively, dural tears occurred in 2 cases (8.6%). Pseudarthrosis with instrumentation failure in 2 cases (8.6%) required revision surgery. Five (21.7%) distal hook dislodgements with moderate loss of scoliosis correction, 1 (4.3%) mild loss of correction without instrumentation failure, and 1 asymptomatic cervicothoracic junctional kyphosis. did not require surgery. All complications occurred among the 16 Group 1 patients, treated using the Harrington rod instrumentation with sublaminar wires.

CONCLUSIONS

These results seemed to demonstrate that a satisfactory stabilization of scoliosis can be achieved by posterior instrumentation alone in patients with Marfan syndrome. Instrumented posterior fusion should be extended to include vertebrae that are neutral and stable in both coronal and sagittal planes before surgery, in order to ensure stabilization of the deformity and reduce the risks of decompensation of the spine.

Operative Therapie bei Spondylolyse und Spondylolisthese

The therapy for spondylolysis and spondylolisthesis is challenging in view of the large variety of treatment options. A general, standardized therapeutic concept has still not been established. Adequate therapy depends on different parameters and personal experience. Beside direct repair surgery of spondylolysis and low grade spondylolisthesis, dorsal, ventral and combined dorsoventral surgery, with or without instrumentation, are indicated depending on patients age and severity of the slip. Complications such as pseudarthrosis and progression of the slip develop in a given percentage of cases, but these are not significantly correlated with clinical symptoms. Decompression is necessary in high grade slippage with neurologic impairment, especially paresis. Reposition is associated with a higher risk of neurologic complications. Fusion in situ without instrumentation, even in moderate and severe spondylolisthesis, shows good clinical results with high fusion rates and without the increased risk of progression and pseudarthrosis. In many cases, it is an effective, safe and economic therapeutic option.

Cage migration in spondylolisthesis treated with posterior lumbar interbody fusion using BAK cages

STUDY DESIGN

A retrospective study was conducted to review the complication of cage migration in posterior lumbar interbody fusion (PLIF) with the Bagby and Kuslich method.

OBJECTIVE

To review and analyze cage migration in spondylolytic spondylolisthesis treated with PLIF using paired BAK cages.

SUMMARY OF BACKGROUND DATA

PLIF with cages has been introduced to treat spondylolisthesis for several years. Theoretically, this technique offers several advantages. BAK system gained popularity rapidly in recent few years. However, most reports focused on clinical effects; only a few studies had been carried out to review complications. As one of the major complications, cage migration into vertebral body or spinal canal may result in severe or disastrous consequence, only a few reports discussed on this issue.

METHODS

From October 1997 to August 2000, 118 patients with spondylolytic spondylolisthesis underwent single-level PLIF using paired BAK cages filled with morselized autogenous bone; 88 of them were followed up for more than 2 years with an average of 3 years and 10 months. The complication of cage migration and its sequelae were reviewed.

RESULTS

Three cases of cage retropulsion and four cases of cage subsidence were found in the current study. The rate of cage migration in patients with no posterior instrumentation was significantly higher compared with that rate in those with posterior instrumentation (16.7% vs. 0%). For patients with no posterior instrumentation, 4 of 8 cases with total facetectomy and 3 of 34 cases with partial facetectomy developed cage migration; the rate of cage migration was 16% for patients with preoperative Grade I olisthesis and 17.6% for those with preoperative Grade II olisthesis (P > 0.05). All patients with cage subsidence lost some degree of lumbar lordosis and disc height, 2 of them finally obtained suboptimal fusion, the other 2 developed pseudarthrosis and received additional posterior instrumentation and intertransverse fusion. Two patients with cage retropulsion developed severe lumbar stenosis and have to remove their dislocated cages. The other one received conservative treatment.

CONCLUSION

An 8% rate of cage migration was found in the current study, and 4 of 7 cases with cage migration received revision surgery. Several factors may contribute to the cage migration, including lack of posterior instrumentation and total facetectomy. Revision surgery for cage migration was technically challenging.

[Massive spongioplasty and external fixation in the posttraumatic pseudoarthrosis management--a case review]

The authors of this case review present three cases of posttraumatic pseudoarthroses as complications of open fractures of the forearm and the course of their treatment. External fixation with the Ilizar external fixation apparatus and bridging spongioplasty was applied in all patients. In the first presented case, the external fixation and spongioplasty was required after resection of the atrophic posttraumatic pseudoarthrosis. In the remaining two cases, furthermore, transposition of the distal fragment of the radius using distraction in order to correct its position against the distal part of the ulna, was required. The pseudoarthroses healed in all three subjects. The case review highlights the key significance of the external fixation method and the massive spongioplasty.

Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance

STUDY DESIGN

Clinical, radiographic, and outcomes assessment comparing two surgical techniques. Clinical data were collected prospectively. The radiographic analysis was done retrospectively.

OBJECTIVES

Smith-Petersen (chevron type) osteotomy (SPO) and pedicle subtraction osteotomy (PSO) have been used to correct fixed sagittal imbalance. This study compares the results of these two methods. Our hypotheses were that when comparing three or more SPOs to a single PSO, the correction of kyphotic angle at the osteotomy site would be nearly identical in each group, the correction in C7 plumb and lumbar lordosis would be identical, the SPO group would have equal tendencies to decompensation as the PSO group, blood loss would be identical in the two groups, and improvement in Oswestry scores would be identical in each group.

SUMMARY OF BACKGROUND DATA

Many papers have described the surgical technique and results of SPOs and PSOs. No effort has been made to compare the results of the respective techniques at a single institution.

METHODS

Thirty patients who underwent SPO were compared with 41 patients who underwent PSO (follow-up, 2-11.5 years). All patients' surgeries were performed at one institution between 1989 and 2001. Fourteen patients in the SPO group had three or more osteotomies. All of the PSOs were performed at one segment. Patients were evaluated by preoperative and ultimate postoperative standing radiographs and a prospectively collected database with outcomes questionnaires.

RESULTS

The mean correction of the kyphotic angle at the osteotomy sites for the SPOs was 10.7 degrees per segment. For those with three or more SPOs, the average total correction was 33.0 degrees +/- 9.2 degrees, and 31.7 degrees +/- 9.0 degrees for the PSO group. However, the improvement in sagittal balance was statistically significantly less with three or more SPOs (5.5 +/- 4.5 cm)than with one PSO (11.2 +/- 7.2 cm; P < 0.01). Comparing three or more SPOs to one PSO, the SPO group decompensated the patients more substantially to the concavity (P < 0.02). The mean estimated blood loss (adding up all anterior and posterior surgeries) for the procedure was 1,398 +/- 738 mL in the SPO group (1,392 +/- 664 mL in the three or more SPO group), and 2,617 +/- 1,645 mL in the PSO group (P < 0.001; P < 0.01). The mean Oswestry score improved from 42.3 +/- 14.2 before surgery to 21.3 +/- 14.8 at the last visit in the SPO group. In the PSO group, it improved from 47.9 +/- 15.8 before surgery to 29.7 +/- 18.3 at the last visit (P = 0.35).

CONCLUSION

When comparing three or more SPOs (14 patients) to one pedicle subtraction procedure (41 patients), the correction in kyphosis was nearly identical. There was a significantly greater likelihood of decompensating the patient to the concavity with three or more SPOs than with a single PSO (P < 0.02). The blood loss was substantially greater with the PSO group (P < 0.001).

Down syndrome and scoliosis: a review of a 50-year experience at one institution

STUDY DESIGN

Retrospective review case series.

OBJECTIVE

To evaluate the incidence, patterns, and treatment of scoliosis in a Down syndrome population.

SUMMARY OF BACKGROUND DATA

Despite a preponderance of literature concerning cervical abnormalities in Down syndrome, there is little information concerning scoliosis in this patient group. We examined the 50-year history of treating scoliosis at our institution in patients with Down syndrome.

METHODS

Following institutional review board approval, chart review identified patients with Down syndrome with scoliosis. We performed a radiographic review of curve pattern, and determined results of brace and operative treatment.

RESULTS

A total of 379 patients were identified as having Down syndrome. There were 33 patients diagnosed with scoliosis, for an incidence of 8.7%. Mean follow-up was 4.15 years (range 0-12). The double major curve predominated with 18 (55%). Of 33 patients, 16 (49.5%) had previously undergone thoracotomy for congenital heart defects. There were 8 (24%) patients who were braced for an average of 26.5 months (range 12-63), with an average progression in brace of 10 degrees (range 0 degrees-44 degrees), 3 of whom went on to spinal fusion. There were 7 (21.2%) patients who underwent spinal fusion, including 6 posterior spinal fusions and 1 anterior spinal fusion. Four patients had complications, including 3 pseudarthroses, 4 implant failures, 3 superior junctional kyphosis, and 1 infection, for a 57% complication rate.

CONCLUSIONS

Scoliosis developed in 8.7% of patients with Down syndrome. There was a high rate of cardiac surgery within this population. Bracing was ineffective for the majority of the patients treated. Although surgery has a high rate of complications, there was only one patient who underwent reoperation.

Lessons learned from cervical pseudoarthrosis in ankylosing spondylitis

This case report illustrates three learning points about cervical fractures in ankylosing spondylitis, and it highlights the need to manage these patients with the neck initially stabilised in flexion. We describe a case of cervical pseudoarthrosis that is a rare occurrence after fracture of the cervical spine with ankylosing spondylitis. This went undetected until the development of myelopathic symptoms many months later. The neck was initially stabilised in flexion using tongs, and then slowly extended before anterior and posterior fixation was performed. The myelopathic symptoms resolved, and the patient had a good result at 18 months. We conclude that any increased movement of the spine after trauma in ankylosing spondylitis must be considered suspect and fully investigated.