Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

OBJECTIVE

To explore the clinical efficacy of the treatment of comminuted trochanteric fractures and trochanteric osteotomy non-union in revision total hip arthroplasty with tension-band fixation.

METHODS

A retrospective review of 295 revision total hip operations performed between 1992 and 1998 was undertaken. Twenty hips of 19 patients with comminuted fractures or nonunion of the greater trochanter were stabilized with tension band technique. Multiple 2.0 mm k-wires and tension-band wires were placed through the intact cortex distally and the abductor tendon proximally in the pattern "8".

RESULTS

The average follow-up was 30 months. The Harris Hip Score improved on average from 45 preoperatively to 89 at follow-up. Sixteen hips with intra-operative trochanteric fracture through osteolytic bone and four hips with symptomatic trochanteric nonunion were approached with tension band fixation. Perioperative loss of fixation in one patient required a repeated surgery. The same fixation at the second operation achieved an uneventful healing. Two patients had a 2 cm proximal migration of one K-wire without loss of bony fixation. The trochanteric fractures healed with no further proximal wire migration. One patient had loss of fixation with trochanteric escape at 6 weeks post-operatively. The patient has abductor weakness with Trendleburg limp but without pain. On average, radiographic examination showed that healing occurred at 16.6 weeks postoperatively. Six patients developed grade 1 heterotopic ossification and two patients grade 3. All were asymptomatic. None of the 19 patients experienced a dislocation during the follow-up.

CONCLUSIONS

Tension-band fixation for greater trochanter can enhance the success rate of revision total hip arthroplasty without a deficient abductor mechanism.

Posterior approach for arthroscopic reduction and antegrade fixation of avulsion fracture of the posterior cruciate ligament from the tibia with cannulated screw and washer

Avulsion fracture of the posterior cruciate ligament (PCL) is a rare condition, and arthroscopically assisted reattachment of the surgical fixation of the fragment is not always an easy task. Only a few reports describe techniques for arthroscopic fixation of avulsion of the PCL.We report on a case treated arthroscopically with reduction and antegrade fixation of an avulsion fracture of the tibial attachment of the PCL with a cannulated screw and washer through an additional posterolateral portal. Postoperative morbidity was reduced, and rehabilitation was accelerated. Fixation with a cannulated screw and washer is technically simple and allows for stable fixation and immediate postoperative mobilization and pain-limited weight-bearing, even in cases of a comminuted fragment. The safe zone for an additional posterolateral portal and the technique for placing instruments and a guidewire to avoid neurovascular structures is defined.

Treatment of metastatic disease of the tibia

Metastatic lesions to bone outnumber primary bone malignancies. Osseous metastases to the tibia tend to be less common than osseous metastases to other long bones. This study examined the treatment options for a population of patients with metastatic disease to the tibia, with surgical intervention being the cornerstone of treatment for the osseous lesion. A multicenter study had 592 patients with metastatic disease to the bone, with 26 lesions occurring in the tibia (4.4%) during a 13-year period. No patient had concurrent metastases distal to the elbow. After confirmation of metastatic disease, treatment consisted of surgical intervention in all patients, including plate osteosynthesis, intramedullary rodding and cementation, endoprosthetic replacement, and in most patients, postoperative radiation therapy. In 96% of patients, the reconstruction outlasted their life expectancy. All patients were satisfied with their reconstruction. Four complications were encountered in the postoperative period, all requiring additional surgery. Aggressive treatment of osseous metastasis is justified in patients with metastatic disease despite a limited life expectancy. Intervention by an orthopaedic oncologist may result in fewer reconstructive failures. Surgical intervention contributes to an improved quality of life and limb function, ease of nursing care, and may help in maintaining patient independence.

Radiographic verification of pedicle screw pilot hole placement in thoracic spine using Kirschner wires versus spiral wires

OBJECTIVE

To evaluate the feasibility of the pedicle screw pilot holes placement in thoracic spine using the spiral wires as the guide pin.

METHODS

The pedicle screw pilot holes were drilled within the center of the pedicle and the lateral and medial pedicle walls were violated in 9 human dried thoracic vertebrae. Kirschner wires or spiral wires were separately placed in the holes, and then the posteroanterior and lateral radiographs were taken. The radiographs were evaluated by 3 experienced spine surgeons and 3 young orthopedists. After radiographs were shown to these observers, they combined the posteroanterior and lateral radiographs in each place and determined whether the pedicle screw pilot hole violated the pedicle cortex or not. The results were analyzed by a statistical software.

RESULTS

Sensitivity, specificity and accuracy of the method using spiral wires to detect pedicle pilot hole placement were significantly higher than those of using Kirschner wires. With a true posteroanterior radiograph, the sensitivity, specificity and accuracy of the method using spiral wires approximated or attained 100%.

CONCLUSIONS

The method of intrapedicular pilot hole placement verification using spiral wires is effective for guiding the accurate placement of pedicle screws.

Maxillary distraction using a trans-sinusal distractor: technical note

In this pilot study, the principle of distraction osteogenesis was used to advance the midface of a boxer dog. A modified high Le Fort I-type osteotomy was performed. Following a latency period of 5 days the maxilla was distracted 14 mm in 14 consecutive days at a rate of 1 mm per day. Ten weeks after the completion of the distraction, multiple biopsies were taken across the distraction gap. Histological observation showed bone deposition in the osteotomy sites. Soft and hard tissue formation resulted in complete healing across the distraction gap. The maxillary sinus was used to accommodate the distraction device. Superimposition of the standardized lateral cephalograms taken at the end of distraction and 14 months after the removal of the distractors showed no sign of relapse in the achieved sagittal advancement of the maxilla. This small, intraoral trans-sinusal placed distractor has a completely new conceptual design, and may be helpful in distraction of maxilla in children and adults with midfacial hypoplasia.

Reconstruction of maxillectomy defect by transport distraction osteogenesis

The study aimed to explore the feasibility of posterior maxillectomy reconstruction by transport distraction in a primate model. In each of 14 male adult rhesus monkeys, posterior partial maxillectomy was performed on one side of maxilla to create a posterior maxillary deflect. Immediately after the maxillectomy, a dentoalveolar segment anterior to the defect was osteotomized as transport segment and a custom-made transport distractor was fixed on the residual maxilla. After a latency period of 5 days, the distractor was activated 1 mm daily to move the transport segment backward to the defect. This process lasted about 2 weeks. The transport segment was allowed to consolidate and the animals were sacrificed at different defined intervals. Transport distraction was successful in six animals. Three other cases were completed with minor wound dehiscence and one had a small oro-antral fistula with subsequent maxillary sinusitis. New bone bridging the distraction gap was confirmed by radiography and histology in the animals completing distraction. Reconstruction of posterior maxillectomy defect is proven feasible by transport distraction osteogenesis.

[The importance of Dunn's procedure in the treatment of slipped femoral epiphysis]

The slipped upper femoral epiphysis (SUFE) is a condition also known as 'coxa vara' of the adolescent, in which lesions of the growth plate are responsible for the development of sudden or gradual displacement of the femoral head. The disease is most frequent in the 10-15 years' age group, usually in boys who also have endocrine disorders. Both acute and chronic presentations are described. The clinical symptoms and especially the X-Ray features are diagnostic. Treatment options include orthopedic (conservative) measures or surgery, depending on several conditions, such as: the clinical picture, the degree of the femoral displacement, and the age of the patient. The chronic, long-lasting cases are generally associated with poor results. The paper presents our experience in using the Dunn's procedure in 7 chronic cases of slipped upper femoral epiphysis in children. It appears that surgery by using Dunn's procedure is an effective treatment in patients with SUFE.

Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance

STUDY DESIGN

Radiographic analysis, outcomes analysis (pain scale, Oswestry, SRS-24), and accumulation of complications. Outcomes and complications collected prospectively. Radiographic analysis performed retrospectively.

OBJECTIVES

To assess the benefits and stress complications of pedicle subtraction osteotomies for patients with fixed sagittal imbalance.

SUMMARY OF BACKGROUND DATA

Few reports on pedicle subtraction osteotomies exist in the peer-review literature for conditions other than trauma and ankylosing spondylitis.

MATERIALS AND METHODS

Thirty-three consecutive patients with sagittal imbalance treated with lumbar pedicle subtraction osteotomy at one institution (minimum 2-year follow-up) were analyzed. Complications were also analyzed for the entire group of consecutive pedicle subtraction osteotomies done at our institution to date (n = 66).

RESULTS

For the 33 patients with minimum 2-year follow-up, there were significant improvements in the overall Oswestry score (P 0.0001) and pain score (P = 0.0001). Most patients reported improvement in pain and self-image and reported overall satisfaction based on ultimate SRS-24 questionnaire. There was one pseudarthrosis in the lumbar spine through an area of pedicle subtraction osteotomy (area of previous laminectomy and nonunion), and six patients had thoracic pseudarthroses (levels other than the osteotomy level) and one patient had a pseudarthrosis at L5-S1. Two patients had acute angular kyphosis at the thoracolumbar junction at the proximal end of the construct. Five patients who experienced transient neurologic deficits resolved their deficits after central canal enlargement.

CONCLUSIONS

The clinical result with pedicle subtraction osteotomy is reduced with pseudarthrosis in the thoracic or lumbar spine and subsequent breakdown adjacent to the fusion. For patients with a degenerative sagittal imbalance etiology the results were worse and the complications were higher. Central canal enlargement is critical.

Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture

STUDY DESIGN

Retrospective study.

OBJECTIVES

To compare the surgical results between combined anterior-posterior procedures and posterior closing wedge osteotomy procedures in patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fractures.

SUMMARY OF BACKGROUND DATA

Combined anterior-posterior procedures are usually recommended in cases of kyphotic deformities with neurologic deficit secondary to osteoporosis. However, combined anterior-posterior surgery is associated with significant morbidity in elderly patients.

MATERIALS AND METHODS

Twenty-six patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fracture were indicated for operative intervention using either a combined anterior-posterior surgery (n = 11) or a posterior closing wedge osteotomy procedure (n = 15). The results of the two procedures were analyzed. The average patient age at the operation was 62.6 years (range: 50-82) with a 12:14 male-to-female ratio. Mean follow-up was 3.5 years (range: 2.1-5.4). Preoperative interval from injury to operation was 15.4 months (range: 1-36). There were 20 thoracolumbar (T12-L1) fractures and six lumbar fractures indicated for operative intervention.

RESULTS

In the combined anterior-posterior group, the mean operative time was 351 minutes with a mean blood loss of 2,892 mL. In the posterior closing wedge osteotomy group, the mean operative time was 215 minutes with blood loss of 1,930 mL. Eighteen patients showed a postoperative improvement in Frankel grading, 64% (7/11) in the combined anterior-posterior group, and 73% (11/15) in posterior closing wedge osteotomy group. There were no neurologic or vascular complications in either group. In the combined anterior-posterior group, there were five complications: two postoperative pneumonias, one superficial infection, and two distal screw loosening. There were only two complications in the posterior closing wedge osteotomy group: two distal screw loosening. One of the four cases of distal screw loosening required surgical revision. The other three cases were treated by bracing for more than 6 months.

CONCLUSIONS

Although technically demanding, the posterior closing wedge osteotomy procedure demonstrated a better surgical result with significant less mean operative time and mean blood loss (P < 0.05). It may be a better alternative than a combined anterior-posterior procedure in patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fracture.

Posterior hemivertebra resection with transpedicular instrumentation: early correction in children aged 1 to 6 years

STUDY DESIGN

Retrospective study with clinical evaluation of posterior hemivertebra resection with transpedicular instrumentation in very young children.

OBJECTIVE

Assessment of early intervention in congenital scoliosis by posterior approach with transpedicular instrumentation.

SUMMARY OF BACKGROUND DATA

Hemiepiphysiodesis and hemiarthrodesis are unpredictable in their effects. Hemivertebra resections in older children often require a long fusion segment because of secondary structural curves.

MATERIALS AND METHODS

Twenty-eight consecutive cases of congenital scoliosis in very young children were operated on by hemivertebra resection by a posterior-only approach with transpedicular instrumentation. Mean age at time of surgery was 3 years and 4 months. They were retrospectively studied with a mean follow-up of 3.5 years.

RESULTS

Mean Cobb angle of the main curve was 45 degrees before surgery, 14 degrees after surgery, and 13 degrees at latest follow-up. Compensatory cranial curve improved from 17 degrees before surgery to 5 degrees after surgery, compensatory caudal curve improved from 22 degrees to 8 degrees. The angle of kyphosis was 22 degrees before surgery and 10 degrees after surgery. There was one infection, two pedicle fractures, and three implant failures. In two patients additional operations were performed because of new developing deformities.

CONCLUSIONS

Correction surgery of congenital scoliosis should be performed early, before the development of severe local deformities and secondary structural changes, especially in patients with expected deterioration. Posterior resection of the hemivertebra with transpedicular instrumentation allows for early intervention in very young children. Excellent correction in the frontal and sagittal planes, and a short segment of fusion allows for normal growth in the unaffected parts of the spine.

Thoracolumbar deformity arthrodesis to L5 in adults: the fate of the L5-S1 disc

STUDY DESIGN

A retrospective clinical and radiographic analysis of long adult deformity fusions terminating at L5.

OBJECTIVES

To define the results of thoracolumbar fusions to L5 in adult deformity patients with critical evaluation for potential subsequent L5-S1 disc degeneration and L5 implant loosening.

SUMMARY OF BACKGROUND DATA

Few studies have reported the results of long adult fusions to L5 and the potential for subsequent advanced L5-S1 disc degeneration is unknown.

MATERIALS AND METHODS

Thirty-four consecutive patients fused from the thoracic spine to L5 at a single institution were evaluated at a mean follow-up of 5.6 years (2.1-14.3 years). SRS-24 functional outcome questionnaire results were obtained for all patients at most recent follow-up.

RESULTS

By latest follow-up, subsequent advanced L5-S1 disc degeneration (SAD) developed in 19 of 31 patients (61%) assessed as having "healthy" discs before surgery. SAD was associated with a forward shift in sagittal balance (P = 0.02) and need for revision surgery (P = 0.02). Risk factors for the development of SAD were preoperative positive sagittal balance (P = 0.01), younger age (P = 0.03), and the presence of even mild radiographic degeneration before surgery (P = 0.004). Loss of L5 implant fixation occurred in six patients (18%) and was associated with deep seating of L5 within the pelvis (P = 0.0001). Inferior SRS-24 outcome measures were associated with preoperative advanced L5-S1 disc degeneration and the development of postoperative sagittal imbalance.

CONCLUSIONS

Subsequent L5-S1 DDD developed in 61% of patients after long adult fusions to L5 and was associated with a significant loss of sagittal alignment and an increased likelihood for or definite need for another operation. Loss of L5 implant fixation is not uncommon, especially in patients with a deep-seated L5 vertebra.

Avascular necrosis of the femoral head after surgery for lumbar spinal stenosis

STUDY DESIGN

Case report.

OBJECTIVE

To report a previously undescribed complication of lumbar spinal surgery under prolonged hypotensive anesthesia.

BACKGROUND DATA

Avascular necrosis of bone most commonly affects the femoral head. The etiology of the condition is understood in only 75% of cases. There have been no prior reports of this condition following lumbar spine surgery carried out under hypotensive anesthetic.

METHODS

Notes review, clinical examination, plain radiographs, and magnetic resonance imaging diagnosed three patients who developed avascular necrosis of the femoral heads (five joints in total) after surgery for lumbar spinal stenosis. All three were treated with total hip replacement (five joints), and the diagnosis of avascular necrosis was confirmed in two by histopathological examination.

RESULTS

All three patients have recovered full mobility following hip replacement surgery. None had any residual symptoms of lumbar spinal stenosis or hip disease, and none of them had shown any clinical evidence of avascular necrosis in any other bone.

CONCLUSIONS

The development of avascular necrosis of the femoral heads following surgery for spinal stenosis may be due to hypotensive anesthesia, prone positioning on a Montreal mattress, or a combination of the two. Careful intraoperative positioning may reduce the risk of this occurring after spinal surgery. However, close postoperative surveillance and a high index of suspicion of worsening hip pathology in patients who appear to mobilize poorly after lumbar spinal surgery may be the only method of early detection and treatment for this condition.

A comparison between the prone and lateral position for performing a thoracoscopic anterior release and fusion for pediatric spinal deformity

STUDY DESIGN

Retrospective review of all patients who had a single stage thoracoscopic anterior release and spine fusion followed by a posterior spinal fusion with posterior instrumentation.

OBJECTIVE

To analyze the results and complications of patients undergoing a thoracoscopic anterior release and fusion comparing those performed prone with those in the lateral position.

SUMMARY OF BACKGROUND DATA

The lateral position has traditionally been used when performing a thoracoscopic anterior spinal release and fusion during a single-stage anterior spinal release and fusion/posterior spinal fusion with instrumentation. Although some have reported the thoracoscopic technique in the prone position, there are no direct comparison studies between the prone and lateral position.

METHODS

A retrospective review was performed of all patients who had a single stage thoracoscopic anterior spinal release and fusion and posterior spinal fusion with instrumentation from a single institution. The medical record was reviewed to determine demographic data, positioning of the patient, levels fused, anesthesia time, operative time, chest tube drainage, and complications. Radiographs were reviewed to determine preoperative curve magnitude and postoperative curve correction. The Student t test was used to compare groups and statistical significance was defined as P < 0.05.

RESULTS

There were 16 patients in the prone group and 27 in the lateral group. Adolescent idiopathic scoliosis was the most common diagnosis in both groups. All patients had a single-stage thoracoscopic anterior spinal release and fusion/posterior spinal fusion with instrumentation. In the prone group, the patient was positioned prone on a Hall-Relton frame or roll (small patients) for both the anterior spinal release and fusion and posterior spinal fusion with instrumentation. There were no significant differences between the prone and lateral groups with respect to age, gender, height, weight, and curve magnitude (73.8 degrees vs. 71.5 degrees ). There were fewer fused anterior levels in the prone group (5.3 vs. 6.2) (P = 0.05). When analyzing parameters that reflect potential difficulties imposed by the prone position, there were no statistically significant differences noted between groups, although there was a trend toward less anterior operative time per disc (24.3 vs. 25.9 minutes/disc), greater blood loss/anterior disc level (33.5 vs. 26.8 cc/disc), greater total chest tube drainage (445 vs. 419 cc), and less days with the chest tube in place (2.2 vs. 2.3 days) for the prone group when compared to the lateral group. There were statistically significant differences between the prone and lateral groups with respect to anesthesia preparation time (42.8 vs. 64.8 minutes), delay between the completion of the anterior procedure and the start of the posterior procedure (11.8 vs. 69.5 minutes), and the incidence of complications related to the use of single-lung ventilation (0 vs. 14.8%)(P < 0.05). Patients in the prone group required less time on oxygen after surgery (34.8 vs. 51.6 hours) and were discharged home earlier (4.6 vs. 5.5 days) (P < 0.05).

CONCLUSIONS

A thoracoscopic anterior spinal release and fusion in the prone position appears to achieve the same results as when performed in the lateral position for pediatric spinal deformity. The prone position saves time in the operating room due to decreasing the time needed by the anesthesiologists and the transition time between the anterior and posterior procedures. Potentially serious complications related to single-lung ventilation are avoided with bilateral-lung ventilation in the prone position.

Gorham disease of the cervical spine-a case report and review of the literature

STUDY DESIGN

A case report and literature review of Gorham disease involving the cervical spine.

OBJECTIVES

To describe the clinical course and surgical management of Gorham disease of the cervical spine. The pathologic features and various treatment methods are also discussed.

SUMMARY OF BACKGROUND DATA

Gorham disease is a rare idiopathic disease that possesses distinctive clinical, pathologic, and radiologic features. It is a variant form of osseous angiomatosis associated with massive osteolysis of bone. Eight cases with cervical involvement have been reviewed in the literature and five cases were fatal.

METHODS

We reported a 49-year-old man with Gorham disease of the cervical spine. Repeated surgical attempts to stabilize the cervical spine were required due to progression of the disease.

RESULTS

The patient has achieved a satisfactory functional outcome and remains fully independent.

CONCLUSION

In summary, Gorham disease is a rare entity with an unclear etiology. The long indolent course with the presence of radiographic and pathologic findings usually provides the diagnosis. There is no consensus on treatment, and evaluation of the treatment options is difficult due to the unknown natural history.

Treatment recommendations for idiopathic scoliosis: an assessment of the Lenke classification

OBJECTIVE

To determine the usefulness of the treatment recommendation criteria based on the Lenke classification for treatment of idiopathic scoliosis. DESIGN A retrospective radiographic review of 183 patients who underwent anterior and/or posterior fusion for the treatment of idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Recent studies have proven that the Lenke system is relatively efficient and consistent in classifying scoliosis curves. However, the recommendations regarding fusion level have yet to be established as reliable.

MATERIALS AND METHODS

One hundred eighty-three patients with idiopathic scoliosis and with a minimum follow-up period of 24 months were included in the study and classified according to the Lenke system. Among these patients, 135 patients were treated with fusion and instrumentation in accordance with the Lenke classification system and are described as Group I. The 48 patients whose treatments were not based on the Lenke system constitute Group II. These two groups were compared in regard to the correction of the Cobb angle and the trunk shift after surgery in order to establish the effectiveness and reliability of the treatment recommendations based on the Lenke classification system.

RESULTS

Type 1 primary thoracic curve: there was no difference between the results from the group with selective thoracic fusion (Group I) and from the group with both thoracic and lumbar curves fused (Group II). Type 2 double thoracic scoliosis: the correction of the upper thoracic curve, the first thoracic vertebral tilt, and left shoulder elevation were better in the group with both thoracic curves fused (Group I) than in the group with midthoracic fusion (Group II). Type 3 double major scoliosis: the lumbar curve correction was better in the group with both thoracic and lumbar curves fused (Group I) than in the group with selective thoracic fusion (Group II), and decompensation occurred more frequently in Group II. Type 4 triple major scoliosis: because there were only two patients with this type of curve, no analysis was completed. Type 5 thoracolumbar or lumbar curve: there was no difference between the results from the group with selective thoracolumbar or lumbar fusion (Group I) and the group with thoracic and lumbar curves fused (Group II). Type 6 double major scoliosis with larger lumbar curve: the thoracic curve correction was better in the group with both curves fused (Group I) than in the group with only the lumbar curve fused (Group II).

CONCLUSION

Better radiologic results were achieved through the use of the Lenke classification system for the selection of fusion levels by avoiding unnecessary fusion of the nonstructural lumbar or thoracic spine as well as avoiding undercorrection of the structural secondary curves.

Staged posterior surgery for severe adult spinal deformity

STUDY DESIGN

Retrospective analysis with prospective outcomes.

OBJECTIVE

To analyze the strategy of dividing one prolonged, complex, posterior surgery into two smaller posterior procedures staged during one hospitalization.

SUMMARY OF BACKGROUND DATA

When operating on complex revision adult deformity, the posterior surgery alone can be unduly prolonged, placing patients at risk for hemodynamic complications associated with protracted same-day surgery.

MATERIALS AND METHODS

Forty-two consecutive adults with severe deformity and 2 years or more of follow-up were included. Thirty-three presented for revision surgery. Twenty-two had more than one previous fusion. During first-stage posterior surgery, existing implants were removed, decompressions performed, and new fixation points established. Five to 7 days later, patients underwent second-stage posterior surgery, consisting of osteotomies (34 patients), completion of instrumentation, and fusion. Anterior surgery was performed during either stage as necessary. Age at surgery was 47 (range 18-68); 4.8 (range 1-9) levels were fused anteriorly and 11.3 (range 4-17) levels posteriorly.

RESULTS

No major perioperative medical complications occurred (e.g., myocardial infarction, pulmonary embolus, death). All completed staged surgery as planned. Only five required any postoperative intubation. There was only one perioperative deep infection, one superficial infection, and one sterile seroma. No medical or surgical complication could be related to the staging of posterior surgery. SRS-24 and radiographic outcomes were excellent at >or=2-year follow-up.

CONCLUSION

Staged posterior surgery can be performed safely with few surgical complications and no major medical complications, as well as excellent outcomes in a population known to be at high risk. Such staging can be useful in performing complex posterior revision and osteotomy surgery while limiting hemodynamic stresses.

En bloc vertebrectomy and dural resection for chordoma: a case report

STUDY DESIGN

Case report.

OBJECTIVES

Report a surgical technique for dural reconstruction after vertebrectomy.

SUMMARY OF BACKGROUND DATA

None available.

METHODS

Clinical case analysis: chordoma from T12 to L2 with infiltration of the dura.

RESULTS

Forty-six months after vertebral resection and reconstruction, the patient is disease free.

CONCLUSIONS

Wide en bloc resection is required for local control in chordoma. When the tumor permeates the dura, resection not including the dura is intralesional with high risk of local recurrence. Therefore, a proper wide resection consists in vertebrectomy removing the dura infiltrated by the tumor. The two-stage dural reconstruction had strongly limited the leakage of liquor during surgery, and the dural patch provided extra strength anteriorly, where the dural suture is more difficult.

Revision strategies for lumbar pseudarthrosis

Management and avoidance of lumbar pseudarthrosis are among the most common and challenging tasks faced by reconstructive spine surgeons. The risks of pseudarthrosis can be broadly divided into two categories: those within a surgeon's control and those not within his/her control. These include biological factors, graft choices, site preparation, and surgical design. The authors review the biological factors that affect fusion and how they can be manipulated to avoid or manage lumbar pseudarthrosis. Surgical planning and construct design to prevent or treat pseudarthrosis will also be discussed. Additionally, the importance of restoring sagittal balance will be reviewed.

Back pain and function 23 years after fusion for adolescent idiopathic scoliosis: a case-control study-part II

STUDY DESIGN

A consecutive series of patients with adolescent idiopathic scoliosis, treated between 1968 and 1977 before age 21 years with distraction and fusion using Harrington rods (surgically treated: n = 156; 145 females and 11 males) were followed-up at least 20 years after completion of the treatment.

OBJECTIVES

To determine the long-term outcome in terms of back pain and function in patients surgically treated for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Few reports on long-term outcome of back pain and function have previously been presented for this group of patients. Results presented are not conclusive regarding effects on back pain and its correlation to a fusion extending into the lower lumbar spine.

MATERIALS AND METHODS

One hundred forty-two (91%) of the patients were reexamined as part of an unbiased personal follow-up. This included a clinical examination and evaluation of curve size (Cobb method) and degenerative findings in full standing frontal and lateral radiographs. Validated questionnaires in terms of general and disease-specific quality of life aspects as well as present back and pain symptoms were used. One hundred thirty-nine had complete follow-up. An age- and sex-matched control group of 100 individuals was randomly selected and subjected to the same examinations.

RESULTS

The deterioration of the curves was 3.5 degrees for all curves and eight (5.1%) of the patients treated with fusion had undergone some additional curve-related surgical procedure. The patients had significantly more degenerative disc changes than the controls. Lumbar pain, although mild (2.4 on visual analogue scale), was significantly more frequent among the patients than the controls (65 vs. 47%, P = 0.0079). Only 25% of the patients admitted daily pain, and analgesics were sparsely used. No major differences of back function and general health-related quality of life were noted between the patients or the controls. Except for having been on sick-leave ever because of the back (45% vs. 19%, P = 0.0040) no differences could be seen in sociodemographic variables between the groups. Furthermore, no differences could be found between patients fused to L3 or higher (n = 102) versus L4 or lower (n = 37). No correlation could be found between pain and its localization and various variables on the scoliotic curve, body mass index, or smoking. Persisting discomfort and/or sensory loss were noted significantly more often among the patients who had the autologous bone harvesting performed through a separate incision over the iliac crest (24.3%) than among those in whom this was performed through an elongated midline incision (4.6%, P = 0.0015).

CONCLUSIONS

Minimal pain and no dysfunction occurred (mean) 23 years after fusion for adolescent idiopathic scoliosis compared with normal straight controls. Significantly more pain in the scar region occurred when bone graft from an incision over the posterior iliac crest was used for harvesting bone to the fusion compared with an incision performed as an elongation of the midline incision used for the scoliosis surgery.

EndoButton-assisted repair of distal biceps tendon ruptures

This report represents a multifactorial investigation of a new technique in which a titanium EndoButton was used for repair of distal biceps tendon ruptures. Cadaveric cases were used to demonstrate the anatomic efficacy and safety of the procedure. Biomechanical testing was done to compare the fixation strength of traditional techniques with the EndoButton repair. Finally, clinical results of the repair were evaluated. In 15 fresh-frozen cadavers the mean distance of the button from the posterior interosseous nerve was 9.3 mm. Instron testing showed a mean pullout strength of 253 N for the Mitek G4 Superanchor, 177 N for a conventional bone bridge, and 584 N for the titanium button. The button was 3 times stronger than the bone bridge (P =.0001) and 2 times stronger than the Mitek anchor (P =.0007). Fourteen patients who had their tendons repaired by this technique were evaluated at a mean of 20 months postoperatively. BTE (Baltimore Therapeutic Equipment, Baltimore, MD) testing revealed recovery of 97% of flexion strength and 82% of supination strength. Patients were able to participate in an aggressive rehabilitation program and were able to regain strength and function rapidly, with satisfactory return to preinjury activities and occupations. This technique is safe, simple, and stronger than any currently available anchoring techniques and gives the surgeon a choice in bone preparation. By using a single anterior elbow approach, the development of synostosis associated with two incision techniques can be minimized.

Surgeon perceptions of the complications and value of threaded fusion cages as a spine fusion technique: results of a consensus survey

BACKGROUND CONTEXT

Threaded cage technology has had a meteoric rise in usage. It has been touted as a procedure with low risk and minimal complications.

PURPOSE

To gauge the spine surgical community's general consensus regarding cage usage and its complications.

STUDY DESIGN/SETTING

A canvassing questionnaire regarding threaded cage usage and complications was sent to members of the North American Spine Society.

PATIENT SAMPLE

A total of 665 doctors reported on their perception of 22,585 cages placed by the second year after pre-market approval from the Food and Drug Administration approval.

OUTCOME MEASURES

A nonscientific canvassing questionnaire was thought to give a consensus of surgical outcome perception in a large number of caregivers with hopes of understanding general trends.

METHODS

Simple statistical measurements were used to report perceived complications by surgeons involved in performing threaded cage surgical procedures.

RESULTS

Sixty-nine percent of doctors reported at least one complication with threaded cages, but the complication incidence was low. Visceral injuries were reported in 0.1%; vascular injuries, 1.0%; cage displacement and dislodgement, 1.4%; temporary and permanent neurologic injuries, 2.25% and 0.56%, respectively; infection 0.34%; retrograde ejaculation 1.2% and revision surgery recorded for 2.7%. Those rating cages as fair to poor (16.5%) were those physicians reporting the longest experience with this technology.

CONCLUSIONS

The general consensus is that threaded cages have low complication rates and high satisfaction rates, 83.5%. The data represent a convenience sampling and is not scientific.