Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies

INTRODUCTION

Conventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies.

METHODOLOGY

We reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups-CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups.

RESULTS

Among 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p < 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse > 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three.

CONCLUSION

Our study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis. These slides can be retrieved under Electronic Supplementary Material.

Non-coding and Coding Transcriptional Profiles Are Significantly Altered in Pediatric Retinoblastoma Tumors

Retinoblastoma is a rare pediatric tumor of the retina, caused by the homozygous loss of the Retinoblastoma 1 (RB1) tumor suppressor gene. Previous microarray studies have identified changes in the expression profiles of coding genes; however, our understanding of how non-coding genes change in this tumor is absent. This is an important area of research, as in many adult malignancies, non-coding genes including LNC-RNAs are used as biomarkers to predict outcome and/or relapse. To establish a complete and in-depth RNA profile, of both coding and non-coding genes, in Retinoblastoma tumors, we conducted RNA-seq from a cohort of tumors and normal retina controls. This analysis identified widespread transcriptional changes in the levels of both coding and non-coding genes. Unexpectedly, we also found rare RNA fusion products resulting from genomic alterations, specific to Retinoblastoma tumor samples. We then determined whether these gene expression changes, of both coding and non-coding genes, were also found in a completely independent Retinoblastoma cohort. Using our dataset, we then profiled the potential effects of deregulated LNC-RNAs on the expression of neighboring genes, the entire genome, and on mRNAs that contain a putative area of homology. This analysis showed that most deregulated LNC-RNAs do not act locally to change the transcriptional environment, but potentially function to modulate genes at distant sites. From this analysis, we selected a strongly down-regulated LNC-RNA in Retinoblastoma, DRAIC, and found that restoring DRAIC RNA levels significantly slowed the growth of the Y79 Retinoblastoma cell line. Collectively, our work has generated the first non-coding RNA profile of Retinoblastoma tumors and has found that these tumors show widespread transcriptional deregulation.

Cauda equina syndrome in an obese pregnant patient secondary to double level lumbar disc herniation - A case report and review of literature

Introduction

Lumbar disc herniation during pregnancy poses a significant challenge to the spine surgeon towards achieving good clinical, maternal, and fetal outcomes. Surgical intervention is warranted in patients with significant neural deficits, and cauda equina syndrome and needs to be performed at the earliest in order to avoid irreversible neurological sequelae.

Case presentation

We report a 29-year-old primigravida in her 21st week of gestational period, who was diagnosed with cauda equina syndrome secondary to two level lumbar disc herniations. The lengthier surgical duration in performing double level disc herniations in an obese patient raises concerns in anesthetic dosing of drugs and surgical positioning which may result in fetal distress. A double level decompression and discectomy in prone position was done under general anesthesia. Despite the surgical challenges, the postoperative period was uneventful resulting in immediate pain relief and complete neurological recovery, followed by the delivery of a 2.7-kg healthy male child.

Discussion

Surgical intervention can be performed in pregnancy, to avoid irreversible neurological deficits, even in an obese individual with double level lumbar pathology. However, it is essential that the surgeon appraises the situation and involves an integrated multidisciplinary team comprising anesthetist, spine surgeon, obstetrician, and psychologist, and inculcates certain precautions in the perioperative management to achieve good surgical and fetal outcomes.

Coronal Vertebral Dislocation Due to Congenital Absence of Multiple Thoracic and Lumbar Pedicles: Report of Three Cases, Review of Literature, and Role of Intraoperative CT Navigation

STUDY DESIGN

Case report OBJECTIVE: To present three cases of coronal vertebral dislocation due to congenital multiple thoracic and lumbar pedicle agenesis.

SUMMARY OF BACKGROUND DATA

Congenital pedicle agenesis is an uncommon condition and is frequently identified as an incidental finding on diagnostic imaging in asymptomatic individuals. This agenesis is frequently limited to a single level and is commonly seen in the cervical and lumbar spine.

METHODS

We report three patients who presented with multiple thoracic and lumbar pedicle agenesis resulting in coronal vertebral dislocation. The patients presented with progressive kyphoscoliosis deformity. Identification of this malformation on conventional radiographs is difficult, and computed tomographic (CT) scan with 3D reconstruction provides a better delineation of the deformity.

RESULTS

Computed tomography showed complete absence of pedicles and dissociation of anterior column from the posterior column, resulting in coronal vertebral dislocation. Magnetic resonance imaging confirmed the absence of pedicles and decreased anteroposterior diameter, causing canal stenosis. Two patients were treated by spanning internal fixation, partial deformity correction, and posterior fusion, with satisfactory results.

CONCLUSION

Coronal vertebral dislocation can be easily missed on plain radiograph because many patients with severe scoliotic deformity have thin or sclerotic pedicles. Computed tomography is essential to demonstrate these anomalies. It is important to recognize pedicle aplasia early to prevent rapid progression of deformity and neurologic deficit.

Spinal Tuberculosis: Current Concepts

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB).

METHODS

A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "spinal tuberculosis," "diagnosis," "epidemiology," "etiology," "management," "surgery," and "therapy."

RESULTS

Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability.

CONCLUSIONS

The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

Unilateral sacroiliitis: differentiating infective and inflammatory etiology by magnetic resonance imaging and tissue studies

PURPOSE

Unilateral sacroiliitis (US) is an uncommon disease with varied etiology. The differentiation between infective and inflammatory causes for US based on MRI alone is often difficult. We studied the efficacy of MRI findings in comparison with tissue studies in the diagnosis of US.

METHODS

A retrospective analysis of patients who presented with US and evaluated with MRI, biopsy for histopathology and tissue cultures was performed. Patients with bilateral sacroiliitis, traumatic and postpartum sacroiliitis were excluded. Based on defined MRI criteria, the patients were divided into two groups-infective (group A) and inflammation (group B).

RESULTS

In total, 33 patients (mean age-33.4 ± 17.2 years) with MRI features of US had presented with unilateral gluteal pain (100%) and positive Patrick's test (91.9%). Based on the MRI features of severe subchondral marrow edema, widening of joint space, intra-articular abscess and periarticular muscle abscess, infective sacroiliitis (A) was diagnosed in 20/33 (60.6% cases). A total of 13/33 (39.3%) patients had features of inflammation (B), based on the following MRI criteria-subchondral sclerosis with minimal edema, erosions, maintained joint space without abscess/destruction. Tissue evidence of infection was positive in 13/20 (65%) patients in group A while it was negative in all group B patients.

CONCLUSION

MRI had high sensitivity (71%) and 100% specificity in diagnosing inflammatory sacroiliitis while it had low specificity, but 100% sensitivity for diagnosing infective sacroiliitis. Hence, patients diagnosed as inflammatory sacroiliitis in MRI are unlikely to benefit from further tissue studies while percutaneous biopsy is recommended in patients diagnosed in MRI as infective sacroiliitis.

The Effectiveness of Noninvasive Positive Pressure Ventilation in Subarachnoid Pleural Fistula: A Case Report and Literature Review

Subarachnoid pleural fistula (SPF) is an aberrant communication between the pleural cavity and subarachnoid space, resulting in uncontrolled cerebrospinal fluid drainage. The negative pressure of the pleural cavity creates a continuous suctioning effect, thereby impeding the spontaneous closure of these fistulas. Dural tears or punctures in cardiothoracic procedures, spinal operations, and trauma are known to cause such abnormal communications. Failure to recognize this entity may result in sudden neurological or respiratory complications. Hence, a high index of suspicion is required for early diagnosis and prompt management. Noninvasive positive pressure ventilation has been described to be effective in managing such fistulas, thus mitigating the high morbidity associated with exploratory surgery for primary repair. Herein, we describe the typical presentation of SPF and the clinical course, treatment, and follow-up of a patient who sustained SPF following anterior thoracic spinal surgery.

A Classification for Kyphosis Based on Column Deficiency, Curve Magnitude, and Osteotomy Requirement

BACKGROUND

There is a lack of a classification system providing uniformity in description and guiding management decisions for kyphotic spinal deformities. We developed such a classification based on column deficiency, flexibility of disc spaces, curve magnitude, and correlation with the corrective osteotomy required.

METHODS

A classification was developed based on analysis of 180 patients with thoracolumbar kyphosis requiring osteotomy. The deformity was classified as Type I if the anterior and posterior columns were intact (IA indicated mobile disc spaces and IB, ankylosed segments). Type II indicated deficiency of only 1 column (IIA = anterior column and IIB = posterior column). Type III indicated deficiency of both columns (IIIA = kyphosis of ≤60°, IIIB = kyphosis of >60°, and IIIC = buckling collapse). A prospective analysis of 76 patients was performed to determine interobserver variability and the ability of the classification to guide selection of osteotomies of increasing complexity, including the Ponte osteotomy, pedicle subtraction osteotomy, disc bone osteotomy, single vertebrectomy, multiple vertebrectomies, and anterior in situ strut fusion procedure.

RESULTS

The mean age of the 76 patients was 21.2 years, the mean kyphosis was 69.9° (range, 26° to 120°), and the mean follow-up duration was 30 months. Six deformities were classified as IA, 5 as IB, 5 as IIA, 2 as IIB, 13 as IIIA, 35 as IIIB, and 10 as IIIC. Four surgeons classifying the deformities had a high agreement rate (kappa = 0.83), with the highest agreement for Types IA, IB, and IIIB. A correlation between the type of deformity and the osteotomy performed demonstrated that the classification could indicate the type of osteotomy required. All 18 patients with Type-I or II kyphosis were treated with Ponte, pedicle subtraction, or disc bone osteotomy. Forty-three (90%) of the 48 patients with Type IIIA or IIIB underwent vertebrectomy (single in 27 [56%] and multiple in 16 [33%]), and only 5 (10%) underwent disc bone osteotomy. Seven of the 10 patients with Type-IIIC kyphosis were treated with multiple vertebrectomies, with 5 of them needing preoperative halo gravity traction; the other 3 patients underwent an anterior in situ strut fusion procedure.

CONCLUSIONS

The proposed classification based on the morphology of column deficiency, flexibility, and curve magnitude demonstrated a high interobserver agreement and ability to guide selection of the appropriate osteotomy.

CLINICAL RELEVANCE

A novel classification system for kyphosis based on spinal column deficiency, flexibility of disc spaces, and curve magnitude would bring uniformity in management and help guide surgeons in the choice of the appropriate corrective osteotomy.

RNA-Sequencing of Primary Retinoblastoma Tumors Provides New Insights and Challenges Into Tumor Development

Retinoblastoma is rare tumor of the retina caused by the homozygous loss of the Retinoblastoma 1 tumor suppressor gene (RB1). Loss of the RB1 protein, pRB, results in de-regulated activity of the E2F transcription factors, chromatin changes and developmental defects leading to tumor development. Extensive microarray profiles of these tumors have enabled the identification of genes sensitive to pRB disruption, however, this technology has a number of limitations in the RNA profiles that they generate. The advent of RNA-sequencing has enabled the global profiling of all of the RNA within the cell including both coding and non-coding features and the detection of aberrant RNA processing events. In this perspective, we focus on discussing how RNA-sequencing of rare Retinoblastoma tumors will build on existing data and open up new area's to improve our understanding of the biology of these tumors. In particular, we discuss how the RB-research field may be to use this data to determine how RB1 loss results in the expression of; non-coding RNAs, causes aberrant RNA processing events and how a deeper analysis of metabolic RNA changes can be utilized to model tumor specific shifts in metabolism. Each section discusses new opportunities and challenges associated with these types of analyses and aims to provide an honest assessment of how understanding these different processes may contribute to the treatment of Retinoblastoma.

Probing optically silent superfluid stripes in cuprates

Unconventional superconductivity in the cuprates coexists with other types of electronic order. However, some of these orders are invisible to most experimental probes because of their symmetry. For example, the possible existence of superfluid stripes is not easily validated with linear optics, because the stripe alignment causes interlayer superconducting tunneling to vanish on average. Here we show that this frustration is removed in the nonlinear optical response. A giant terahertz third harmonic, characteristic of nonlinear Josephson tunneling, is observed in La_1.885Ba_0.115CuO₄ above the transition temperature T_c = 13 kelvin and up to the charge-ordering temperature T_co = 55 kelvin. We model these results by hypothesizing the presence of a pair density wave condensate, in which nonlinear mixing of optically silent tunneling modes drives large dipole-carrying supercurrents.

Accuracy of pedicle screw insertion by AIRO® intraoperative CT in complex spinal deformity assessed by a new classification based on technical complexity of screw insertion

PURPOSE

To develop a classification based on the technical complexity encountered during pedicle screw insertion and to evaluate the performance of AIRO^® CT navigation system based on this classification, in the clinical scenario of complex spinal deformity.

MATERIALS AND METHODS

31 complex spinal deformity correction surgeries were prospectively analyzed for performance of AIRO^® mobile CT-based navigation system. Pedicles were classified according to complexity of insertion into five types. Analysis was performed to estimate the accuracy of screw placement and time for screw insertion. Breach greater than 2 mm was considered for analysis.

RESULTS

452 pedicle screws were inserted (T1-T6: 116; T7-T12: 171; L1-S1: 165). The average Cobb angle was 68.3° (range 60°-104°). We had 242 grade 2 pedicles, 133 grade 3, and 77 grade 4, and 44 pedicles were unfit for pedicle screw insertion. We noted 27 pedicle screw breach (medial: 10; lateral: 16; anterior: 1). Among lateral breach (n = 16), ten screws were planned for in-out-in pedicle screw insertion. Among lateral breach (n = 16), ten screws were planned for in-out-in pedicle screw insertion. Average screw insertion time was 1.76 ± 0.89 min. After accounting for planned breach, the effective breach rate was 3.8% resulting in 96.2% accuracy for pedicle screw placement.

CONCLUSION

This classification helps compare the accuracy of screw insertion in range of conditions by considering the complexity of screw insertion. Considering the clinical scenario of complex pedicle anatomy in spinal deformity AIRO^® navigation showed an excellent accuracy rate of 96.2%.

Pre-treatment of extracellular water soluble pigmented secondary metabolites of marine imperfect fungus protects HDF cells from UVB induced oxidative stress

The melanin precursor of fungal origin was found to be an excellent UVB inhibiting agent as experimented in HDF cells and in small animals.

Modified anterior-only reduction and fixation for traumatic cervical facet dislocation (AO type C injuries)

PURPOSE

Surgical reduction of uni and bi-facetal dislocations of the cervical spine (AO type C injuries) can be performed by posterior, anterior or combined approaches. Ease of access, low infection rates and less risks of neurological worsening has popularized anterior approach. However, the reduction of locked cervical facets can be intricate through anterior approach. We analyzed the safety, efficacy and outcomes at a minimum 1 year, of a novel anterior reduction technique for consecutively treated cervical facet dislocations.

MATERIALS AND METHODS

Patients with single level traumatic sub-axial cervical dislocation (n = 39) treated by this modified anterior technique were studied. The technique involved standard Smith-Robinson approach, discectomy beyond PLL, use of inter-laminar distracter to distract while Caspar pins were used as "joysticks" (either flexion-extension or lateral rotation moments are provided), to reduce the sub-luxed facets. Among 51 patients with cervical type C injury treated during the study period, 4 patients who had spontaneous reduction and 8 treated by planned global fusion were excluded.

RESULTS

39 patients of mean age 49.9 years were studied. The levels of injury included (C3-4 = 2, C4-5 = 5, C5-6 = 20, C6-7 = 12). 18 were bi-facetal and 21 were uni-facetal dislocation. One facet was fractured in 17 and both in 5 patients. 30% (n = 13) had a concomitant disc prolapse. The neurological status was as follows: 9 ASIA A, 9 ASIA C, 13 ASIA D and 8 ASIA E. All the patients were successfully reduced by this technique and fixed with anterior locking cervical locking plates. No supplemental posterior surgery was performed. 22 patients with incomplete deficit showed recovery. The mean follow-up was 14.3 months and there was no implant failure except one patient who had partial loss of the reduction.

CONCLUSION

Patients with traumatic sub-axial cervical dislocation (AO type C injuries) can be safely and effectively reduced by this technique. Other advantages include minimal blood loss, less risks of infection, shorted fusion zone, good fusion rate and neurological recovery.

Sacral Fractures and Associated Injuries

STUDY DESIGN

Literature review.

OBJECTIVE

The aim of this review is to describe the injuries associated with sacral fractures and to analyze their impact on patient outcome.

METHODS

A comprehensive narrative review of the literature was performed to identify the injuries associated with sacral fractures.

RESULTS

Sacral fractures are uncommon injuries that result from high-energy trauma, and that, due to their rarity, are frequently underdiagnosed and mistreated. Only 5% of sacral fractures occur in isolation. Injuries most often associated with sacral fractures include neurologic injuries (present in up to 50% of sacral fractures), pelvic ring disruptions, hip and lumbar spine fractures, active pelvic/ abdominal bleeding and the presence of an open fracture or significant soft tissue injury. Diagnosis of pelvic ring fractures and fractures extending to the lumbar spine are key factors for the appropriate management of sacral fractures. Importantly, associated systemic (cranial, thoracic, and abdominopelvic) or musculoskeletal injuries should be promptly assessed and addressed. These associated injuries often dictate the management and eventual outcome of sacral fractures and, therefore, any treatment algorithm should take them into consideration.

CONCLUSIONS

Sacral fractures are complex in nature and often associated with other often-missed injuries. This review summarizes the most relevant associated injuries in sacral fractures and discusses on their appropriate management.

Structural vertebral endplate nomenclature and etiology: a study by the ISSLS Spinal Phenotype Focus Group

PURPOSE

Vertebral endplate abnormalities may be associated with disc degeneration and, perhaps, pain generation. However, consensus definitions for endplate findings on spine MRI do not exist, posing a challenge to compare findings between studies and ethnic groups. The following survey was created to characterize the variability among the global spine community regarding endplate structural findings with respect to nomenclature and etiology.

METHODS

A working group within the International Society for the Study of the Lumbar Spine (ISSLS) Spinal Phenotype Focus Group was established to assess the endplate phenotype. A survey which consisted of 13 T2-weighted sagittal MRIs of the human lumbar spine illustrating the superior and inferior endplates was constructed based on discussion and agreement by the working group. A list of nomenclature and etiological terms with historical precedence was generated. Participants were asked to describe the endplates of each image and select from 14 possible nomenclatures and 10 etiological terms along with the option of free text response. The survey was entered into RedCap and was circulated throughout the ISSLS membership for data capture. Participants' demographics were also noted.

RESULTS

The survey was completed by 55 participants (87% males; 85% above 45 years of age, 39 clinicians, and 16 researchers). Sixty-eight percent of researchers and seventy-four percent of clinicians reported more than 16 and 20 years of research and clinical experience. Considerable variation existed in selection of nomenclature, etiology, and degree of severity of the endplate structural findings (reliability coefficients for single measures in each case were 0.3, 0.08, and 0.2, respectively). Sixty-seven percent regarded Modic changes as being a structural endplate finding. Approximately 84 and 80% of clinicians and researchers, respectively, agreed that a standardized endplate nomenclature and understanding the etiology is clinically important and needed.

CONCLUSIONS

This study found that variations exist with respect to endplate nomenclature and etiology between clinicians and basic scientists, and paves the way for a consensus process to formalize the definitions.

Ipsilateral Hip and Knee Dislocation with Open Tibial Fracture: A Case Report of a Limb Threatening Injury

INTRODUCTION

Hip or knee dislocations are usually treated as a surgical emergency, but ipsilateral hip and knee dislocation should be considered a dual emergency that must be addressed immediately and reduced at the earliest. We present here the sequence of events and the final functional outcome of one such rare injury manages by us.

CASE REPORT

A 22-year-old male was involved in a road traffic accident. He presented to the emergency department in 4 h injury time with painful deformities of the right hip and knee, along with Type I open wound right leg with abnormal mobility suggestive of fracture in the ipsilateral leg.

CONCLUSION

Simultaneous ipsilateral hip and knee fracture-dislocation with open tibial fracture is a rare injury that should be approached as limb-threatening injury and dual orthopedic emergency. We report this case for its rarity and to document that good results can be achieved with early appropriate treatment.

Dynamical Stability Limit for the Charge Density Wave in K_{0.3}MoO_{3}

We study the response of the one-dimensional charge density wave in K_{0.3}MoO_{3} to different types of excitation with femtosecond optical pulses. We compare direct excitation of the lattice at midinfrared frequencies with injection of quasiparticles across the low energy charge density wave gap and with charge transfer excitation in the near infrared. For all three cases, we observe a fluence threshold above which the amplitude-mode oscillation frequency is softened and the mode becomes increasingly damped. We show that all the data can be collapsed onto a universal curve in which the melting of the charge density wave occurs abruptly at a critical lattice excursion. These data highlight the existence of a universal stability limit for a charge density wave, reminiscent of the Lindemann criterion for the melting of a crystal lattice.

Unplanned 90-day readmissions in a specialty orthopaedic unit-A prospective analysis of consecutive 12729 admissions

INTRODUCTION

Unplanned readmissions are an undesirable and expensive outcome of clinical practice. Previous reported literature is limited by retrospective study designs and 30 day study intervals. We analyzed causes for 90-day unplanned readmission, temporal occurrence of major causes, possible predisposing factors, bed days lost and economic impact.

MATERIALS & METHODS

A prospective analysis of 12729 admissions was performed over 1 year in an Orthopaedic unit. Consecutive readmissions for unplanned circumstances within 90-days of discharge following the index procedure were included. Open injuries, polytrauma, primary osseous infections and planned readmissions were excluded.

RESULTS

We noted an overall readmission rate of 2.07% and subspecialty rate of 1.43%, 3.32%, 2.9% in trauma, spine and total joint arthroplasty (TJA) respectively. The leading cause was wound complications accounting for 49.62%, followed by medical causes (trauma -18.37%; TJA -27.5%) and aseptic pain (spine-31.6%). Though 87.1% of superficial surgical site infections (SSIs) occurred within 30 days, 21.1%, 41.2% and 60% of the deep SSIs in spine, trauma and TJA respectively occurred beyond 30 days. The financial burden amounted to INR 1,01,55,770 and mean bed days lost was 7.6 per readmission. Age ≥70 years, indoor-stay ≥10 days, health insurance and co-morbid illnesses were associated with readmissions (p < 0.05).

CONCLUSIONS

Our study showed that limiting analysis to 30 day unplanned readmissions would lead to failure in identification of 34.85% of readmissions especially deep surgical site infections in TJA and trauma.

Medial Open Wedge High Tibial Osteotomy for Varus Malunited Tibial Plateau Fractures

PURPOSE

To analyze radiologic and functional outcomes of varus malunited tibial plateau fractures managed with medial open wedge high tibial osteotomy (MOHTO).

METHODS

Eighteen patients with symptomatic varus malunited tibial plateau fractures with less than stage II arthritic changes managed from July 2009 to October 2013 were included. Patients with complex intra-articular step malunions and severe arthritic changes (stage III and IV) were excluded. Initially, diagnostic arthroscopy was performed followed by MOHTO stabilized with locking plate and tricortical autograft (n = 11, 61%) or a Puddu plate and allograft (n = 7, 39%). Patients were evaluated radiologically for union, medial proximal tibial angle, and tibial slope angle, and functional assessment was performed with a knee outcome survey based on activities of daily living.

RESULTS

The mean follow-up duration was 41.7 ± 12.1 months (range 25-61); all patients achieved radiologic union by a mean duration of 4.3 ± 1.2 months (range 3-8). The mean medial proximal tibial angle improved from 75.3° ± 3.7° (range 70.5°-85.2°) to a postoperative angle of 83.8° ± 3.6° (range 77.5°-90.4°) (P < .001). In 12 patients, an abnormal mean anterior slope of -5.5° ± 3.0° (range -1.1° to -13°) was corrected to a postoperative posterior slope of 5.8° ± 4.4° (range -1.1° to 14.1°) (P < .001). In 6 patients, a mean posterior slope of 17.4° ± 10.5° (range 1.4°-33°) was corrected to a postoperative posterior slope of 14.08° ± 5.6° (range 7.4-21.3) (P = .214). The mean knee outcome survey scores preoperatively were 25% ± 9.68% (range 8%-48%) and postoperatively were 85% ± 11.18% (range -52% to 98%, P < .001).

CONCLUSIONS

MOTHO for varus malunited tibial plateau fractures is safe and effective procedure that provides excellent functional outcomes, acceptable radiologic outcomes, and carries minimal complications.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.