The outcome of allografts and anterior instrumentation in spinal tuberculosis

Management of Tuberculosis of the Hip With Antitubercular Therapy and Single-Stage Total Hip Replacement: A Case Report

Hip tuberculosis (TB) is not a common disease, and this devastating illness requires complete treatment. This case study describes the treatment of a 25-year-old female who suffered from hip TB. She came with right hip discomfort, limping, and a restricted range of movement. The clinical examination showed a fixed flexion deformity, adduction, internal rotation, and leg shortening. Radiographic imaging showed arthritis with hip joint space narrowing, bone erosion, and bone disintegration. Laboratory testing revealed increased inflammatory markers, and a synovial fluid investigation showed tuberculous arthritis. The initial treatment consisted of a regular four-drug antitubercular therapy (ATT) regime for six months and then an additional four months of isoniazid and rifampicin. This therapy resulted in improved clinical symptoms and decreased inflammatory markers. However, the level of joint degeneration required surgical intervention. Due to substantial joint damage, the patient received a hybrid total hip replacement (THR) after completing ATT, confirming that the infection had been cured. Intraoperative observations included synovial enlargement, bone erosions, and significant cartilage damage. The patient underwent a rehabilitation program following surgery to regain mobility and hip joint range of motion. The patient reported substantial pain relief and functional improvement at the one-year follow-up with no signs of implant loosening or infection recurrence.

One-stage total hip arthroplasty for advanced hip tuberculosis combined with developmental dysplasia of the hip: A case report

BACKGROUND

A patient with advanced tuberculosis of the hip joint combined with Crowe type IV developmental dysplasia of the hip (DDH) and a drainage sinus is a rare condition. There are no previous reports of this condition, and it is a complex challenge for surgeons to develop a treatment scheme.

CASE SUMMARY

We report a 73-year-old male patient with severe hip pain and drainage sinus of the left hip for one month. Approximately 40 years ago, a drainage sinus occurred at the lateral left hip was healed at the local hospital with anti-infectious therapy. After the sinus healed, gradual pain occurred in the left hip for 40 years. Approximately one month prior, hip pain was sharply aggravated, and a drainage sinus reoccurred in the left hip. The X-ray and computed tomography examinations showed destruction of the head and neck of the left femur, as well as an acetabular deformity. The results of Mycobacterium tuberculosis antibody and Xpert were positive. Therefore, the patient was diagnosed with advanced TH combined with Crowe type IV DDH. After 22 d of treatment with anti-tuberculosis chemotherapy, the sinus healed, and the patient underwent one-stage total hip arthroplasty (THA) surgery consisting of debridement, osteotomy, and joint replacement. After surgery, the patient received anti-tuberculosis chemotherapy drugs for nine months, with no recurrent infection. After one year of follow-up, the Harris score of the patient increased from 21 pre-THA to 86.

CONCLUSION

Although drainage sinuses are a contraindication to one-stage THA, one-stage THA is still an effective and safe surgical method after the sinus heals.

Tricortical iliac crest allograft with anterolateral single rod screw instrumentation in the treatment of thoracic and lumbar spinal tuberculosis

To assess the effectiveness of tricortical iliac crest allografts with anterolateral instrumentation after single-stage surgery for thoracic and lumbar spinal tuberculosis (TB). Fifty-six patients with thoracic and lumbar spinal TB underwent single-stage anterior radical debridement, interbody fusion with tricortical iliac crest allografts and anterolateral single rod instrumentation. All patients were given 18 months of antituberculosis chemotherapy. The patients were followed up regularly, and their clinical manifestations, roentgenogram results, erythrocyte sedimentation rate (ESR) and liver function test were the results to be concerned. Radiographs were analysed before surgery, immediately after surgery, and at the final follow-up examination. Mean follow-up period was 37.5 months in 52 patients, and 4 patients were lost to follow-up. No patients had superficial wound infections, and all the incisions healed within 2 weeks. No graft fracture, collapse, or sliding was observed. The average bony fusion time was 10.6 months. Bony fusion was observed in all 52 patients within 18 months. The average degrees of kyphotic correction loss for thoracic and lumbar spine were 6.71° and 2.78° respectively. Although it took a long time to achieve solid fusion, tricortical iliac crest allografts were found to be convenient and safe to be used in spinal TB surgery. They may be effective options for interbody fusion, deformity correction and correction maintenance with anterolateral single rod instrumentation.

Mini-open anterior approach focal cleaning combined with posterior internal fixation for thoracolumbar tuberculosis: Follow-up of 149 cases

OBJECTIVE

To investigate the clinical efficacy and safety of mini-open anterior approach focal cleaning combined with posterior internal fixation for thoracolumbar tuberculosis.

METHODS

A total of 149 patients with thoracolumbar tuberculosis were reviewed retrospectively and divided into 3 groups: mini-open anterior approach (group A), conventional anterior extraperitoneal approach (group B), and posterior approach (group C). After the operation, drainage tubes were routinely placed and the draining fluid was collected on the 4th day for the PCR detection of Mycobacterium tuberculosis (MTB), Mycobacterium tuberculosis DNA test (MTD), and Roche culture. Patients' surgical information, Cobb's angles, and postoperative complications were also compared.

RESULTS

There was no significant difference in operation time, blood loss, hospital stay, or preoperative Cobb's angle among three groups. There existed obvious differences in the postoperative Cobb's angle and incidence of postoperative complications between group A and group C, as well as group B and group C. There was no obvious difference in the positive rate of MTB among the three groups by rapid culture plus Roche culture test. However, statistically significant differences in the positive rate of MTB were found between group A and group C by PCR detection, and between group A and group B by MTD.

CONCLUSION

Mini-open anterior approach focal cleaning combined with posterior internal fixation resulted in small Cobb's angles, low incidence of postoperative complications and low positive rates of MTB, without increasing operation time, blood loss and hospital stay, rendering it as a safe and effective method to treat patients with thoracolumbar tuberculosis.

Total hip replacement in tuberculosis of hip: A systematic review

Total hip replacement (THR) in patients with tuberculous arthritis of the hip is controversial. The timing of surgery, type of prosthesis, reactivation of the disease, high complication rates and the long-term survival of the reconstruction are the major conc erns. There is little information regarding this concern in the literature. We conducted a systematic review of published studies on Total Hip Replacement in patients with Tuberculosis of the hip. A search of Pubmed and Google Scholar database articles published between January 2000 and July 2017 was performed. Thirteen articles were identified, comprising 226 patients. The mean follow-up was 5.48 years. Antituberculosis treatment was given for atleast 2 weeks pre-operatively and continued post-operatively for between six and 18 months after THR. Three patients had reactivation of infection. At the final follow-up, the mean Harris hip score was 89.98. Total Hip Replacement in tuberculosis of hip is safe and efficient way to save the joint function. The most important factors to achieve success include the accurate diagnosis, efficient pre- and postoperative anti-tuberculosis therapy, thorough debridement, two stage procedure for patients with sinus(es).

Total Hip Arthroplasty Indicated for a Tuberculous Coxitis Complicating a Controlled Acquired Imunodefficiency Syndrom Condition: A Preliminary Report Concerning a Case

Introduction:

Total hip arthroplasty (THA) remains controversial in active tuberculosis (TB) infection because of the risks of septic loosening and reactivation of the infection. We present a rare case of THA in a patient positive for the human immunodeficiency virus (HIV) with active tuberculous coxitis. The aim of this work is to share our experience and our preliminary results.

Case Report:

The patient was a 53-year-old Black African woman, positive for the HIV, who was operated for implantation of a THA via the Hardinge approach indicated for a severe painful hip with restriction of joint movement and limp. A creamy-white liquid was noticed in the hip joint which was negative for urgent Gram-staining. The surgery was completed with the implantation of a hybrid THA. The post-operative period was uneventful, and she was put on antituberculous drugs following a positive histology result for TB, and to continue her antiretroviral drugs. She still has a satisfactory result for 3 years since her surgery.

Conclusion:

On condition that the patient is put simultaneously on triple antibiotics and antituberculous drugs, we propose that THA could be an option in patient presenting with the association of HIV infection and active tuberculous coxitis.

Bone substitutes and expanders in Spine Surgery: A review of their fusion efficacies

STUDY DESIGN

A narrative review of literature.

OBJECTIVE

This manuscript intends to provide a review of clinically relevant bone substitutes and bone expanders for spinal surgery in terms of efficacy and associated clinical outcomes, as reported in contemporary spine literature.

SUMMARY OF BACKGROUND DATA

Ever since the introduction of allograft as a substitute for autologous bone in spinal surgery, a sea of literature has surfaced, evaluating both established and newly emerging fusion alternatives. An understanding of the available fusion options and an organized evidence-based approach to their use in spine surgery is essential for achieving optimal results.

METHODS

A Medline search of English language literature published through March 2016 discussing bone graft substitutes and fusion extenders was performed. All clinical studies reporting radiological and/or patient outcomes following the use of bone substitutes were reviewed under the broad categories of Allografts, Demineralized Bone Matrices (DBM), Ceramics, Bone Morphogenic proteins (BMPs), Autologous growth factors (AGFs), Stem cell products and Synthetic Peptides. These were further grouped depending on their application in lumbar and cervical spine surgeries, deformity correction or other miscellaneous procedures viz. trauma, infection or tumors; wherever data was forthcoming. Studies in animal populations and experimental in vitro studies were excluded. Primary endpoints were radiological fusion rates and successful clinical outcomes.

RESULTS

A total of 181 clinical studies were found suitable to be included in the review. More than a third of the published articles (62 studies, 34.25%) focused on BMP. Ceramics (40 studies) and Allografts (39 studies) were the other two highly published groups of bone substitutes. Highest radiographic fusion rates were observed with BMPs, followed by allograft and DBM. There were no significant differences in the reported clinical outcomes across all classes of bone substitutes.

CONCLUSIONS

There is a clear publication bias in the literature, mostly favoring BMP. Based on the available data, BMP is however associated with the highest radiographic fusion rate. Allograft is also very well corroborated in the literature. The use of DBM as a bone expander to augment autograft is supported, especially in the lumbar spine. Ceramics are also utilized as bone graft extenders and results are generally supportive, although limited. The use of autologous growth factors is not substantiated at this time. Cell matrix or stem cell-based products and the synthetic peptides have inadequate data. More comparative studies are needed to evaluate the efficacy of bone graft substitutes overall.

Reconstruction of the Odontoid Process by a Tricortical Iliac Crest Graft in a Case of Tuberculosis of C1, C2, and C3 Vertebrae

Tuberculosis (TB) is an emerging disease which affects about one-third of the world’s population, especially in developing countries. TB of the spine is the most common type of skeletal TB. Cervical spine TB is rare, constituting 2-3% of all cases of spinal TB. We would like to present an unusual case of tuberculosis of the C1, C2, and C3 vertebrae with neurological deficit and its difficult management. A new method of treatment was done for this patient, which included reconstruction of the odontoid process using a tricortical iliac crest graft that was fixed with an anterior cervical plate. On follow-up, there was good incorporation of the graft. The neurological condition of the patient improved and was normal with partial restriction of neck movements. We suggest this technique to be worthwhile for treatment of this disease at this location.

Surgical treatment of lumbosacral tuberculosis by one-stage debridement and anterior instrumentation with allograft through an extraperitoneal anterior approach

BACKGROUND

This study was aimed to investigate the clinical outcome of lumbosacral tuberculosis treatment by one-stage radical debridement with bone allograft reconstruction and anterior instrumentation via a retroperitoneal approach.

METHODS

We retrospectively analyzed a series of 43 patients with lumbosacral tuberculosis in whom the lumbosacral junction was exposed via an anterior midline retroperitoneal approach. After radical debridement, two parallel tricortical iliac crest bone allografts were placed to reconstruct the anterior column, and then anterior fixation was performed.

RESULTS

The mean follow-up period was 34 months (range, 24-91 months), during which no obvious loss of correction was observed. No case experienced recurrence, tuberculous peritonitis, erectile dysfunction, or retrograde ejaculation.

CONCLUSIONS

The midline retroperitoneal approach provides direct and safe access to lesions of lumbosacral tuberculosis. Two parallel structural iliac crest allografts and anterior instrumentation effectively stabilize the lumbosacral junction.

Tuberculosis of hip: A current concept review

Tuberculosis (TB) of the hip is second to spine only hence a good number of cases are visiting the medical facilities every year. Many present in the advanced stage of the disease due to delayed diagnosis. In early stages of TB of hip, there is a diagnostic dilemma when plain X-rays are negative. In the present time, diagnostic modalities have improved from the days when diagnosis was based essentially on clinicoradiological presentation alone. By the time definite radiological changes appear on plain X-ray, the disease has moderately advanced. The modern diagnostic facilities like ultrasonography (USG) or magnetic resonance imaging of the hip joint, USG guided aspiration of synovial fluid and obtaining the material for polymerase chain reaction and tissue diagnosis must be utilized. In the treatment, current emphasis is more on mobility with stability at hip. Joint debridement, skeletal traction, and mobilization exercises may give more satisfying results as compared to the immobilization by hip spica. Adults with advanced arthritis and healed infection should be informed and discussed the various treatment modalities including the joint replacement. More and more surgeons are taking up the challenge of putting the total hip replacement in the active stage of the disease. Until the long term results in active disease are well established, we recommend it for the healed disease only in selected cases.

Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation

BACKGROUND CONTEXT

Traditional focal debridement involves clearing of cold abscesses, caseous necrosis, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Reports have demonstrated that approximately 13% to 26% of patients were not better or relapsed after traditional focal debridement; these patients required a second surgery or prolonged antituberculous therapy. The presence of retained and diseased focal tissues requiring removal remains poorly understood. The contents of these retained tuberculous foci, improvement of surgical strategies, and improvement in spinal tuberculosis success rate are key subjects for discussion.

PURPOSE

To explain the contents of foci and explore the surgical methods and curative effect of complete debridement.

STUDY DESIGN

Retrospective study of the curative effect of treatment of thoracolumbar spinal tuberculosis by using complete debridement.

PATIENT SAMPLE

A total of 289 patients were included.

OUTCOME MEASUREMENT

The outcomes were evaluated clinically by Frankel grading. The status of the anterior fusion was assessed according to the Moon standard. Eradication of infection was determined by the level of C-reactive protein and erythrocyte sedimentation rate. X-ray, computed tomography, and magnetic resonance imaging were used to evaluate disease localization and morphology.

METHODS

A total of 289 patients with spinal tuberculosis (150 male and 139 female patients, aged 18-82; average age, 41.0±1.4 years) were included in this study. Damage to the vertebrae was as follows: 86 patients had thoracic damage, 49 had thoracolumbar damage, 125 had lumbar damage, and 47 had lumbosacral segment damage. After 2 to 4 weeks of antituberculous therapy, all patients underwent anterior debridement, deformity correction, graft fusion, and internal fixation. In this study, complete debridement was defined as the clearing of any damage or disease, including psoas abscesses, granulomas, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Tuberculosis cavities, sclerotic walls, and bony bridges that had no support and that were eroded by the foci were also removed. A total of 108 patients underwent anterior fixation with the Zephir system (Medtronic Sofamor-Danek, Minneapolis, MN, USA), Z plates (Medtronic Sofamor-Danek), or Ventrifix (China Great Wall Corporation, Beijing, China). A total of 181 patients underwent fixation, posterior correction, and one or two second anterior debridements and graft fusions. Posterior fixation, including TSRH (Medtronic Sofamor-Danek), Cotrell-Dubousset (Medtronic Sofamor-Danek), General Spinal System (WeiGao Orthopaedic Devices Company, Weihai City, China), or UPASS (WeiGao Orthopaedic Devices Company), was performed. All patients underwent structural bone grafting, including autologous iliac bone (251 patients), titanium mesh (32 patients), and rib (6 patients).

RESULTS

The 289 patients were followed for 72.0±2.8 months, with 265 patients (91.69%) completely treated and 24 incompletely treated, including 3 who suspended chemotherapy because of liver or renal failure. Twenty-one patients (7.27%) failed to have a complete debridement, including 16 with incomplete bone debridement, 6 of whom underwent a second surgery, and 10 who received conservative therapy; 5 of this group had incomplete abscess debridement, 3 underwent a second surgery, and 2 received puncture aspiration of abscess under computed tomographic guidance; the second surgery rate was 3.81%. Twenty-two patients had surgery complications, including three with graft displacement, five with wound infection and fat liquefaction, four with pleural effusion, six with pain at the graft harvesting site, and four with incisional hernia. Bone graft healing was observed 4.3±1.2 months after surgery. The Cobb angle before and after surgery and at the final follow-up was 22.16±11.51°, 8.11±4.83°, and 9.96±3.49°, respectively, with a mean correction of 63.40% after surgery; however, a 1.85±1.34° loss was observed at the final follow-up with loss rate of 8.35%.

CONCLUSIONS

Sclerotic bone, multiple cavities, and bony bridges are foci in spinal tuberculosis. Clearing tuberculous foci, sclerotic bone, multiple cavities, and bony bridges to increase the curative effect is an effective treatment method.

Total hip replacement for patients with active tuberculosis of the hip: a systematic review and pooled analysis

The timing of total hip replacement (THR) in patients with active tuberculosis (TB) of the hip is controversial, because of the potential risk of reactivation of infection. There is little information about the outcome of THR in these patients. We conducted a systematic review of published studies that evaluated the outcome of THR in patients with active TB of the hip. A review of multiple databases referenced articles published between 1950 and 2012. A total of six articles were identified, comprising 65 patients. TB was confirmed histologically in all patients. The mean follow-up was 53.2 months (24 to 108). Antituberculosis treatment continued post-operatively for between six and 15 months, after debridement and THR. One non-compliant patient had reactivation of infection. At the final follow-up the mean Harris hip score was 91.7 (56 to 98). We conclude that THR in patients with active TB of the hip is a safe procedure, providing symptomatic relief and functional improvement if undertaken in association with extensive debridement and appropriate antituberculosis treatment.

One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series

PURPOSE

The purpose of this study is to compare the clinical outcomes of surgical management by one-stage posterior debridement, transforaminal lumbar interbody fusion (TLIF) and instrumentation and combined posterior and anterior approaches for lumbar spinal tuberculosis, and determine the clinical effectiveness of the posterior only surgical treatment for lumbar spinal TB at the same time.

METHODS

Thirty-seven patients who suffered lumbar tuberculosis were treated by two different surgical procedures in our center from May 2004 to June 2012. All the cases were divided into two groups: 19 cases in Group A underwent one-stage posterior debridement, TLIF and instrumentation, and 18 cases in Group B underwent posterior instrumentation, anterior debridement and bone graft in a single-stage procedure. The operation time, blood loss, lumbar kyphotic angle, recovery of neurological function and fusion time were, respectively, compared between Group A and Group B.

RESULTS

The average follow-up period for Group A was 46.6 ± 16.7 months, and for Group B, 47.5 ± 15.0 months. It was obvious that the average operative duration and blood loss of Group A was less than those of Group B. Lumbar tuberculosis was completely cured and the grafted bones were fused in 10 months in all patients. There was no persistence or recurrence of infection and no differences in the radiological results in both groups. The kyphosis was significantly corrected after surgical management. The average pretreatment ESR was 60.7 ± 22.5 mm/h, which became normal (9.0 ± 2.8 mm/h) within 3 months in all patients.

CONCLUSIONS

Surgical management by one-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis is feasible and effective. This approach obtained better clinical outcomes than combined posterior and anterior surgeries.

Spinal tuberculosis: diagnosis and management

The spinal column is involved in less than 1% of all cases of tuberculosis (TB). Spinal TB is a very dangerous type of skeletal TB as it can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. Therefore, early diagnosis and management of spinal TB has special importance in preventing these serious complications. In order to extract current trends in diagnosis and medical or surgical treatment of spinal TB we performed a narrative review with analysis of all the articles available for us which were published between 1990 and 2011. Althoug h the development of more accurate imaging modalities such as magnetic resonance imaging and advanced surgical techniques have made the early diagnosis and management of spinal TB much easier, these are still very challenging topics. In this review we aim to discuss the diagnosis and management of spinal TB based on studies with acceptable design, clearly explained results and justifiable conclusions.

Surgical management for thoracic spinal tuberculosis in the elderly: posterior only versus combined posterior and anterior approaches

PURPOSE

To compare the clinical outcomes of surgical management by posterior only and combined posterior and anterior approaches for thoracic spinal tuberculosis in the elderly.

MATERIALS AND METHODS

This was a retrospective cohort study. Thirty-six cases of thoracic spinal tuberculosis treated by two different surgical procedures in our center from January 2004 to June 2009 were studied. All the cases were divided into two groups: 20 cases in Group A underwent single-stage posterior debridement, transforaminal fusion and instrumentation, and 16 cases in Group B underwent posterior instrumentation, anterior debridement and bone graft in a single- or two-stage procedure. The operation time, blood loss, correction rate, recovery of neurological function, fusion time and complications were, respectively, compared between Group A and Group B.

RESULTS

All patients were followed up for an average of 35.1 ± 5.8 months (range 26-45 months). It was obviously that the average operative duration, blood loss, hospitalization and complication rate of Group A was less than those of Group B. Spinal tuberculosis was completely cured and the grafted bones were fused in 10 months in all patients. There was no persistence or recurrence of infection and no differences in the radiological results in both groups. The kyphosis was significantly corrected after surgical management. However, loss of correction also occurred in both groups.

CONCLUSION

Our study showed that the posterior approach only procedure obtained better clinical outcomes than combined posterior and anterior surgeries. It might be a better surgical treatment for thoracic spinal tuberculosis in aged patients with poor health status, especially for cases in early phase of bone destruction and/or mild and moderate kyphosis.

Instrumented circumferential fusion for tuberculosis of the dorso-lumbar spine. A single or double stage procedure?

PURPOSE

The purpose of this study was to present our experience in treating dorso-lumbar tuberculosis by one-stage posterior circumferential fusion and to compare this group with a historical group treated by anterior debridement followed by postero-lateral fusion and stabilization.

METHODS

Between 2003 and 2008, 32 patients with active spinal tuberculosis were treated by one-stage posterior circumferential fusion and prospectively followed for a minimum of two years. Pain severity was measured using Visual Analogue Scale (VAS). Neurological assessment was done using the Frankel scale. The operative data, clinical, radiological, and functional outcomes were also compared to a similar group of 25 patients treated with anterior debridement and fusion, followed 10-14 days later by posterior stabilization and postero-lateral fusion.

RESULTS

The mean operative time and duration of hospital stay were significantly longer in the two-stage group. The mean estimated blood loss was also larger, though insignificantly, in the two-stage group. The incidence of complications was significantly lower in the one-stage group. At final follow-up, all 34 patients with pre-operative neurological deficits showed at least one Frankel grade of neurological improvement, all 57 patients showed significant improvement of their VAS back pain score, the mean kyphotic angle has significantly improved, all patients achieved solid fusion and 43 (75.4%) patients returned to their pre-disease activity level or work.

CONCLUSION

Instrumented circumferential fusion, whether in one or two stages, is an effective treatment for dorso-lumbar tuberculosis. One-stage surgery, however, is advantageous because it has lower complication rate, shorter hospital stay, less operative time and blood loss.

Surgical treatment of spondylodiscitis. An update

CONCEPT

Spondylodiscitis refers to an infection affecting the intervertebral disk, the vertebral body or the posterior arch of the vertebra being aetiologically, pyogenic, granulomatous (tuberculosis, brucellosis, or fungal infection) or parasitic.

DIAGNOSIS

Spondylodiscitis diagnosis is based on clinical symptoms, a combination of erythrocyte sedimentation rate with C-reactive protein (CRP) tests and, less useful, leukocytosis. Blood culture is also a very cost-effective method of identifying organisms. Plain radiographs are useful, however changes may take several months to appear. Radionuclide tests are currently less used; nevertheless, fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) shows encouraging results particularly when magnetic resonance images (MRI) are unconvincing in the distinction between degenerative changes and infection. MRI with gadolinium enhancement is the choice for image diagnosis.

MANAGEMENT

Medical management is usually the basis for treatment, alone or in combination with surgery. Surgical approach, either by endoscopy or open, is indicated for biopsy when clinical evolution is unsatisfactory and no micro-organism has been isolated, and also whenever a root, spinal cord or dural compression is seen on MRI; spinal instability or severe deformity are also clear indications for surgical treatment. Less invasive surgery either CT-scan guided or, particularly, by endoscopy has good results. However open surgery is still the standard. The anterior approach allows for anterior disc and bone debridement. The posterior approach is indicated when posterior elements are involved or in the presence of an epidural abscess. Although good results have been claimed, the use of instrumentation in the presence of an infected focus is controversial, as the use of cages or BMPs are.

Future Prospects for Periodontal Bioengineering Using Growth Factors

Polypeptide growth factors have demonstrated strong potential to repair defects associated with teeth and dental implants. Over the past two decades, intense research efforts have led to the clinical development of several growth factors or biologic agents, including bone morphogenetic proteins, platelet-derived growth factor, fibroblast growth factors, and enamel matrix proteins. Several of these growth factors are now being used clinically for a variety of applications, such as the promotion of periodontal regeneration, sinus floor augmentation, and root coverage procedures. Although clinical results have been promising and growth factors add another dimension to clinical care, optimization of growth factor targeting approaches to periodontal wounds remains a challenge. Enhancement of growth factor local application to improve bioavailability, bioactivity, and allowance of three-dimensional reconstruction of complex anatomic defects is a goal. This article will highlight developments for growth factor delivery to better stimulate the wound healing response for periodontal and bone regeneration in the maxillofacial region.

Cementless total hip arthroplasty for the treatment of advanced tuberculosis of the hip

The question of whether a total hip arthroplasty (THA) should be attempted in a patient with a current or previous tuberculosis infection continues to cause controversy. The goal of this study was to evaluate the clinical result of cementless THA for the treatment of advanced tuberculosis of the hip. Eight patients with advanced tuberculosis of the hip treated by cementless THA were retrospectively analyzed. None of the patients had draining sinus preoperatively. For patients with a confirmed preoperative diagnosis of tuberculosis and elevated C-reactive protein and erythrocyte sedimentation rate, antituberculous medication was prescribed for at least 2 weeks preoperatively. Inflamed soft tissues and destroyed bones were completely curetted out intraoperatively. All 8 patients received 1-stage cementless THA after thorough debridement. Antituberculous medications were prescribed for all patients for the first 6 months postoperatively. No patient experienced wound-healing complications. Mean Harris Hip Score was 35 (range, 30-43) preoperatively and 91 (range, 87-95) at last follow-up. At an average 46-month follow-up (range, 34-59 months), no reactivation of tuberculosis was detected. All 8 patients revealed stability by bone ingrowth on both the socket and femoral stem. Cementless THA is a safe and effective procedure for advanced tuberculosis of the hip. With thorough debridement followed by a complete course of antituberculous chemotherapy, active tuberculous infection should not be considered a contraindication for THA.

Surgical outcome of 2-stage (posterior and anterior) surgical treatment using spinal instrumentation for tuberculous spondylitis

STUDY DESIGN

A prospective study on the clinical outcomes in patients with tuberculous spondylitis treated by a 2-stage operation (posterior and anterior) using posterior spinal instrumentation.

OBJECTIVE

To evaluate the clinical outcomes of the 2-stage surgical treatment (first stage: placement of posterior instrumentation and second stage: anterior debridement and bone grafting) for tuberculous spondylitis.

SUMMARY OF BACKGROUND DATA

There have been few reports describing the effects of 2-stage surgical treatment for tuberculous spondylitis.

METHODS

Ten patients (5 men and 5 women) with tuberculous spondylitis were treated by 2-stage operations. Age at the initial operation was 64.6+/-14.8 years (average+/-SD) (range: 47 to 83 y). The clinical outcomes were evaluated before and after the surgery in terms of hematologic examination, pain level, and neurologic status. Bone fusion and changes in sagittal alignment were examined radiographically.

RESULTS

All patients showed suppression of infection, bony fusion, relief of pain, and recovery of neurologic function. No significant changes were observed in kyphosis angle at the final follow-up. There were no incidences of severe complications or recurrence.

CONCLUSIONS

Our results showed that posterior and anterior 2-stage surgical treatment for tuberculous spondylitis is a viable surgical option for cases in which conservative treatment has failed. However, the changes in sagittal alignment showed that this strategy provides limited kyphosis correction.

Total hip arthroplasty in patients with active tuberculosis of the hip with advanced arthritis

Osteoarticular tuberculosis (TB) in the hip and other joints is increasing and patients in developing countries commonly present with advanced joint destruction. We asked whether TB is reactivated after THA in these patients. We retrospectively reviewed 12 patients with an average age of 45 years who had advanced stages of hip destruction secondary to mycobacterium TB and who were treated with primary THA and prescribed perioperative antituberculous medication for 12 to 18 months postoperatively. Diagnosis in all these patients was confirmed by histopathology and culture. The minimum followup was 25 months (average, 41 months; range, 25-58 months). We observed no reactivation of TB in 11 patients who had Harris hip scores ranging from 86 to 97. One patient who postoperatively did not comply with the antituberculous chemotherapy had reactivation and superimposed infection through a nonhealing sinus tract; that patient underwent component removal and resection arthroplasty. When the infected tissue can be débrided and adequate antituberculous therapy is instituted the outcome of joint arthroplasty may not be adversely affected. THA in the tuberculous hip has a low risk of reactivation and produces good functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic case series (no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Fibular allograft and anterior plating for dislocations/fractures of the cervical spine

BACKGROUND

Subaxial cervical spine dislocations are common and often present with neurological deficit. Posterior spinal fusion has been the gold standard in the past. Pain and neck stiffness are often the presenting features and may be due to failure of fixation and extension of fusion mass. Anterior spinal fusion which is relatively atraumatic is thus favored using autogenous grafts and cages with anterior plate fixation. We evaluated fresh frozen fibular allografts and anterior plate fixation for anterior fusion in cervical trauma.

MATERIALS AND METHODS

Sixty consecutive patients with single-level dislocations or fracture dislocations of the subaxial cervical spine were recruited in this prospective study following a motor vehicle accident. There were 38 males and 22 females. The mean age at presentation was 34 years (range 19-67 years). The levels involved were C5/6 (n = 36), C4/5 (n = 15), C6/7 (n = 7) and C3/4 (n = 2). There were 38 unifacet dislocations with nine posterior element fractures and 22 were bifacet dislocations. Twenty-two patients had neurological deficit. Co-morbidities included hypertension (n = 6), non-insulin-dependent diabetes mellitus (n = 2) and asthma (n = 1). All patients were initially managed on skull traction. Following reduction further imaging included Computerized Tomography and Magnetic Resonance Imaging. Patients underwent anterior surgery (discectomy, fibular allograft and plating). All patients were immobilized in a Philadelphia collar for eight weeks (range 7-12 weeks). Eight patients were lost to follow-up within a year. Follow-up clinical and radiological examinations were performed six-weekly for three months and subsequently at three-monthly intervals for 12 months. Pain was analyzed using the visual analogue scale (VAS). The mean follow-up was 19 months (range 14-39 months).

RESULTS

Eight lost to followup, hence 52 patients were considered for final evaluation. The neurological recovery was 1.1 Frankel grades (range 0-3) and two patients with root involvement recovered. At six months bony trabeculae at the graft-vertebrae interface were noted. There were 12 (20 %) cases of graft collapse and one case of angulation which showed no progression. At six months the VAS was 3 (range 0-6). There was no limitation of neck motion at six months in 47 patients.

CONCLUSION

Fresh frozen fibular allografts are suitable and cost-effective for anterior fusion in cervical trauma.

A long-term follow-up study of anterior tibial allografting and instrumentation in the management of thoracolumbar tuberculous spondylitis

Object

The purpose of this study was to determine the efficacy of anterior instrumentation following radical debridement and tibial allografting and its long-term progression in patients with multilevel spinal tuberculosis.

Methods

This prospective observational study was undertaken to analyze 22 patients with multilevel spinal tuberculosis (Pott disease) who underwent anterior radical debridement, decompression, and fusion using anterior spinal instrumentation and tibial allograft replacement between 1999 and 2001. Clinical outcomes were assessed using the American Spinal Injury Association (ASIA) Impairment Scale and a visual analog scale (VAS). Preoperative and postoperative plain radiographs were obtained, and the focal kyphotic angle of the surgically treated spinal segments and the overall sagittal and coronal contours of the thoracic and lumbar spine were evaluated in all patients.

Results

The mean follow-up time was 84 months (range 36–96 months). All patients demonstrated clinical healing of the tuberculosis infection. All patients showed evidence of successful bone fusion. The mean late postoperative kyphosis correction was 74% (range 63–91%). On average, 2° (range 0–5°) of loss of correction was noted in the local kyphotic angle postoperatively in late follow-up findings. Evaluation of the surgical effect on sagittal global contours showed a significant correction rate in thoracic, thoracolumbar, and lumbar regions. The mean late postoperative coronal plane alignment correction was 99%. The ASIA Impairment Scale scores demonstrated significant improvement in late follow-up results in our series. Surgical decompression also resulted in a dramatic reduction of overall pain in all patients (late postoperative VAS score 1.61 ± 0.81).

Conclusions

Anterior tibial allografting and instrumentation provide correction of the curvature, prevention of further deformation, improvement of sagittal and coronal balance, and restoration of neurological function in patients with spinal tuberculosis.

Tuberculosis of the spine: a review

We analyzed 124 papers published in the English language literature to define the indications and timing of surgery in spinal TB and to evaluate the outcome of various surgical procedures for kyphosis and neural outcome. Surgery in spinal tuberculosis is indicated for diagnostic dilemma, neural complications, and prevention of kyphosis progression. Up to 76% canal encroachment is compatible with a normal neurologic state as the spinal cord tolerates gradually developing compression. Patients with relatively preserved cord size, but with edema/myelitis and predominantly fluid compression on MRI respond well to nonoperative treatment. We believe patients with extradural compression by granulation tissue with little fluid component compressing or constricting the cord circumferentially with cord edema/myelitis or myelomalacia need early surgical decompression. Transthoracic transpleural anterior decompression and extrapleural anterolateral decompression have similar results in the dorsal spine. Instrumented stabilization helps prevent graft-related complications when postdébridement defects exceed two disc spaces (4-5 cm). Progression of kyphosis may occur in a short-segment disease despite instrumented stabilization. Its outcome in a long-segment disease needs observation. The correction of healed kyphosis requires multistage surgery and is fraught with complications. Prospective studies are needed to define surgical approach, steps, stages, problems, and obstacles to correct severe kyphosis in spinal TB.

Surgical results in patients with tuberculosis of the spine and severe lower-extremity motor deficits: a retrospective study of 48 patients

Object

Significant numbers of patients with spinal tuberculosis (TB), especially in developing countries, still present late after disease onset with severe neurological deficits. The authors conducted a study to assess the outcome in these patients.

Methods

Fifty-nine patients with spinal TB and severe motor deficits underwent surgery at the authors' center during the past 10 years. Data obtained in 48 patients with a minimum of 3 months of follow up (mean follow-up period 12.8 months) were analyzed. The disease in 34 patients was characterized by Frankel Grade A/B (Medical Research Council Grade 0/5) and in 14 patients by Frankel Grade C (unable to walk even with support) at admission. Thirty (88%) of the 34 patients with Frankel Grade A/B status and 13 (92.8%) of the 14 patients with Frankel Grade C status at admission experienced improvement to Frankel Grade D/E (walking with or without support) at the last follow-up examination 3 or more months after surgery. The degree of improvement exhibited by patients with a Frankel Grade A/B spinal cord injury was comparable to that shown by patients with Frankel Grade C status. Even patients with flaccid paraplegia, gross sensory deficit, prolonged weakness, spinal cord signal changes demonstrated on magnetic resonance imaging, and bladder involvement have experienced dramatic improvement in motor function since surgery. A significant number of the patients have shown remarkable improvement in other symptoms such as pain (91.6%), spasticity (88%), and bladder symptoms (88%).

Conclusions

A significant proportion of patients with spinal TB and severe motor deficits experience remarkable improvement after surgical decompression and hence should undergo surgery even though they may be suffering from paraplegia of considerable duration.

Tratamento da tuberculose da coluna vertebral: conservador ou cirúrgico?

Desde a primeira descrição por Percivall Pott da tuberculose de coluna vertebral, tem-se evoluído muito na abordagem dessa doença. Porém ainda existem muitas controvérsias em relação à prevenção das deformidades. Os objetivos de nosso estudo são avaliar as características clínicas e radiológicas de pacientes com tuberculose de coluna e comparar o tratamento conservador isolado com o cirúrgico associado a antibioticoterapia, principalmente quanto à deformidade residual e déficit neurológico. Nosso trabalho é retrospectivo com avaliação de prontuários e radiografias iniciais e ao final do seguimento. O quadro neurológico foi avaliado através da escala da ASIA e as deformidades foram medidas pelo método de Cobb. Foram avaliados 38 pacientes, 11 pacientes foram operados e 27 receberam somente antibioticoterapia. 15 pacientes tinham déficit neurológico, todos melhoraram independente do tipo de tratamento. A média de cifose torácica focal e regional no início do seguimento foi respectivamente 48,8º e 47,86º. Houve aumento da deformidade na região torácica, segmento mais acometido, de 6,3º focal e 9,8 regional ao final de 5 anos. O tipo de tratamento não influenciou na progressão da cifose. Paciente com menos de 15 anos e cifose maior que 30º tiveram pior prognóstico quanto à progressão da deformidade.

Antibiotic–polymethylmethacrylate strut: an option for treating cervical pyogenic spondylitis

✓ Antibiotic–polymethylmethacrylate (PMMA) cement and beads constitute an effective system of local drug delivery of antibiotic agents in patients with bone and soft-tissue infections. Debridement followed by implantation of antibiotic–PMMA beads and systemic administration of antibiotic agents has achieved a 100% success rate in treating chronic osteomyelitis; however, there have been no reports of an antibiotic–PMMA strut for treating spinal pyogenic spondylitis. In this case report we describe a 57-year-old woman with C5–6 pyogenic spondylitis, progressive kyphotic deformity, and neurological deficits. The patient underwent anterior C-5 and C-6 corpectomy and spinal reconstruction in which we used an antibiotic–PMMA strut. The strut was 14 mm in diameter and contained PMMA and vancomycin powder. The operation was technically successful, and no complication related to anesthesia or the surgical procedure occurred. At the 12-month follow-up examination, dynamic radiographs revealed cervical spine stabilization. The patient’s neck pain subsided and she recovered neurologically with no residual infection. No antibiotic–PMMA strut dislodgment or failure was identified; however, 9.8% subsidence of the strut into the vertebrae was observed. The long-term outcome in this case requires further evaluation.

Single-stage anterior autogenous bone grafting and instrumentation in the surgical management of spinal tuberculosis

STUDY DESIGN

Results of single-stage anterior autogenous bone grafting and instrumentation for spinal tuberculosis were reported.

OBJECTIVE

To determine the efficacy of anterior instrumentation following radical debridement and autogenous bone grafting in patients with spinal tuberculosis over a 3-year period at a single institution.

SUMMARY OF BACKGROUND DATA

Patients with spinal tuberculosis have been not always successfully treated by radical debridement and bone grafting with or without supplementary posterior instrumentation and fusion, although most surgeons use posterior instrumentation to support anterior strut grafts.

METHODS

In this prospective study, the authors evaluated 39 patients (22 male and 17 female; average age, 48 years) with spinal tuberculosis, who underwent single-stage anterior radical debridement, autogenous bone grafting, and instrumentation. The average follow-up period was 39.9 months (range, 30-54 months).

RESULTS

A solid fusion was achieved in all cases; there were 2 cases of draining fistula formation. Of all 28 patients with preoperative kyphosis, the deformity was corrected from an average of 13.5 degrees on admission to an average of 1.9 degrees after surgery. No significant loss of deformity correction was noted in these patients. There was no other recurrence of the tuberculous infection.

CONCLUSIONS

The authors think that the single-stage anterior autogenous bone grafting and instrumentation are a safe and effective method in the surgical management of spinal tuberculosis.

Instrumentation in patients with spinal infection

Object

Placement of instrumentation in the setting of a spinal infection has always been controversial. Although the use of allograft and autograft bone has been accepted as safe, demonstrations of the effectiveness of titanium have been speculative, based on several retrospective reviews. The authors' goal in this study was to demonstrate the effectiveness of instrumentation in the setting of a spinal infection by retrospectively reviewing their cases over the last 4 years and searching the literature regarding instrumentation in patients with pyogenic spinal infections.

Methods

The authors conducted a retrospective review of their cumulative data on spinal infections. Diagnosis was based on subjective and objective clinical findings, along with radiographic and laboratory evaluation of infection and mechanical stability. Patients with medically managed disease and those who did not receive instrumentation were eliminated from this review.

Of 105 patients with spinal infections who were admitted to the neurosurgical service between January 2000 and June 2004, 30 underwent surgical debridement necessitating spinal instrumentation. There were 17 women and 13 men in this group ranging from 28 to 86 years of age. Follow-up duration ranged from 3 to 54 months. There was one death, which occurred 3 months postsurgery. In three patients a deep wound infection developed, necessitating intervention, and two patients experienced a graft expulsion. Twenty-nine patients went on to demonstrate adequate fusion based on follow-up neuroimaging studies.

Conclusions

The goal of neurosurgical intervention in the setting of spinal infection is to obtain an organism culture and the debridement of infection while maintaining neurological and mechanical stability. The authors demonstrate the effectiveness of radical debridement of infected bone and placement of instrumentation in patients with spinal infections.

The role of anterior spinal instrumentation and allograft fibula for the treatment of pott disease

STUDY DESIGN

The authors retrospectively reviewed 28 patients with multilevel Pott disease who underwent anterior radical débridement, decompression, and fusion with anterior spinal instrumentation and fibular allograft replacement.

OBJECTIVES

To assess the efficacy of allograft fibular fusion and anterior spinal stabilization as an alternative treatment of spinal tuberculosis.

SUMMARY OF BACKGROUND DATA

The results of anterior surgery in preventing late or early spinal deformity from Pott disease have been closely related to the status of the segmental stability and graft materials, especially in cases of multisegmental involvement. The use of allograft and anterior spinal instrumentation in tuberculous spondylitis remains controversial because of the risk of persistence and recurrence of infection in the presence of devitalized bone graft, which may also be prone to poor incorporation.

METHODS

Between 1993 and 1998, a total of 28 patients with Pott disease (two or more segments involved) underwent anterior débridement, allograft fusion, and stabilization. The patients were given antituberculosis treatment in the postoperative period according to a standardized protocol. The authors retrospectively analyzed their experience in tuberculous spondylitis, with particular attention to method, allograft incorporation, and anterior spinal instrumentation. Incorporation of the allograft was evaluated by either static or dynamic (flexion/extension) radiographs.

RESULTS

None of the patients used external support in the postoperative period. A minimum of 3 years' follow-up was achieved in 26 patients. The overall fusion rate was 96%. There were no graft problems. Two patients died in the early postoperative period as a result of multiorgan failure. One patient suffered from an instrumentation failure. No other complications were observed. The segmental correction was maintained successfully in all of the patients. The mean correction loss was 6 degrees.

CONCLUSION

The use of anterior spinal stabilization accompanied with a structural allograft fibula is effective after proper radical débridement for interbody fusion, deformity correction, and maintenance in cases of multisegment-involved Pott disease.