A prospective comparative study of kyphoplasty using the Jack vertebral dilator and balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures

Innovative minimally invasive implants for osteoporosis vertebral compression fractures

With increasing population aging, osteoporosis vertebral compression fractures (OVCFs), resulting in severe back pain and functional impairment, have become progressively common. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) as minimally invasive procedures have revolutionized OVCFs treatment. However, PVP- and PKP-related complications, such as symptomatic cement leakage and adjacent vertebral fractures, continue to plague physicians. Consequently, progressively more implants for OVCFs have been developed recently to overcome the shortcomings of traditional procedures. Therefore, we conducted a literature review on several new implants for OVCFs, including StaXx FX, Vertebral Body Stenting, Vesselplasty, Sky Bone Expander, Kiva, Spine Jack, Osseofix, Optimesh, Jack, and V-strut. Additionally, this review highlights the individualized applications of these implants for OVCFs. Nevertheless, current clinical studies on these innovative implants remain limited. Future prospective, randomized, and controlled studies are needed to elucidate the effectiveness and indications of these new implants for OVCFs.

Management of Spinal Deformities and Evidence of Treatment Effectiveness

INTRODUCTION

The review evaluates the up-to-date evidence for the treatment of spinal deformities, including scoliosis and hyperkyphosis in adolescents and adults.

MATERIAL AND METHODS

The PubMed database was searched for review articles, prospective controlled trials and randomized controlled trials related to the treatment of spinal deformities. Articles on syndromic scoliosis were excluded and so were the articles on hyperkyphosis of the spine with causes other than Scheuermann's disease and osteoporosis. Articles on conservative and surgical treatments of idiopathic scoliosis, adult scoliosis and hyperkyphosis were also included. For retrospective papers, only studies with a follow up period exceeding 10 years were included.

RESULTS

The review showed that early-onset idiopathic scoliosis has a worse outcome than late-onset idiopathic scoliosis, which is rather benign. Patients with AIS function well as adults; they have no more health problems when compared to patients without scoliosis, other than a slight increase in back pain and aesthetic concern. Conservative treatment of adolescent idiopathic scoliosis (AIS) using physiotherapeutic scoliosis-specific exercises (PSSE), specifically PSSR and rigid bracing was supported by level I evidence. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS. For adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot as yet be drawn.For hyperkyphosis, there is no high-quality evidence for physiotherapy, bracing or surgery for the treatment of adolescents and adults. However, bracing has been found to reduce thoracic hyperkyphosis, ranging from 55 to 80° in adolescents. In patients over the age of 60, bracing improves the balance score, and reduces spinal deformity and pain. Surgery is indicated in adolescents and adults in the presence of progression of kyphosis, refractory pain and loss of balance.

DISCUSSION

The available evidence reviewed has suggested that different approaches are needed towards the management of different spinal deformities. Specific exercises should be prescribed in children and adolescents with a Cobb angle in excess of 15°. In progressive curves, they should be used in conjunction with bracing. Clarity regarding differences and similarities is given as to what makes PSSE and PSSR specific exercises. As AIS is relatively benign in nature, conservative treatment should be tried when the curve is at a surgical threshold, before surgery is considered. Similarly, bracing and exercises should be prescribed for patients with hyperkyphosis, particularly when the lumbar spine is afflicted. Surgery should be considered only when the symptoms cannot be managed conservatively.

CONCLUSION

There is at present high quality evidence in support of the conservative treatment of AIS. The current evidence supports the use of PSSE, especially those using PSSR, together with bracing in the treatment of AIS. In view of the lack of medical consequences in adults with AIS, conservative treatment should be considered for curves exceeding the formerly assumed range of conservative indications.There is, however a lack of evidence in support of any treatment of choice for hyperkyphosis in adolescents and spinal deformities in adults. Yet, conservative treatment should be considered first. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS and hyperkyphosis. Additionally, surgery needs to be considered with caution, as it is associated with a number of long-term complications.

Percutaneous cement augmentation for osteoporotic vertebral fractures

Thoracolumbar vertebral fracture incidents usually occur secondary to a high velocity trauma in young patients and to minor trauma or spontaneously in older people.

Osteoporotic vertebral fractures are the most common osteoporotic fractures and affect one-fifth of the osteoporotic population.

Percutaneous fixation by ‘vertebroplasty’ is a tempting alternative for open surgical management of these fractures.

Despite discouraging initial results of early trials for vertebroplasty, cement augmentation proved its superiority for the treatment of symptomatic osteoporotic vertebral fracture when compared with optimal medical treatment.

Early intervention is also gaining ground recently.

Kyphoplasty has the advantage over vertebroplasty of reducing kyphosis and cement leak.

Stentoplasty, a new variant of cement augmentation, is also showing promising outcomes.

In this review, we describe the additional techniques of cement augmentation, stressing the important aspects for success, and recommend a thorough evaluation of thoracolumbar fractures in osteoporotic patients to select eligible patients that will benefit the most from percutaneous augmentation. A detailed treatment algorithm is then proposed.

Cite this article: EFORT Open Rev 2017;2:293–299. DOI: 10.1302/2058-5241.2.160057

Review of Percutaneous Kyphoplasty in China

STUDY DESIGN

Review article.

OBJECTIVE

The article mainly reviewed the development and current situation of percutaneous kyphoplasty (PKP) in China, aiming to introduce native efforts and progress for PKP procedure on the exploring road.

SUMMARY OF BACKGROUND DATA

Since PKP was first reported in China in 2002, Chinese orthopedic researchers have performed lots of clinical applications and studies on the treatment of osteoporotic vertebral compression fracture, spinal metastatic tumor, hemangioma, myeloma, vertebral nonunion, and so on.

METHODS

We reviewed the papers on PKP published by native researchers in English and Chinese via Pubmed, EMBASE, the Scopus database, and a series of Chinese databases including Wanfang Data, China National Knowledge Infrastructure (CNKI), and the China Science and Technology Journal Database. The large sample capacity researches, convictive systematic analysis, and overviews were mainly elected as convictive evidence to describe the overall situation of clinical outcomes, complications, and the various technical aspects used to improve conventional surgical management and clinical applications of PKP in China.

RESULTS

Until October 2015, 211 articles in English and 2352 studies in Chinese about PKP were reported by 1443 Chinese institutions from 22 provinces around China. More than 50976 patients reported through published articles have received the treatment of PKP. With the technique gradually improved, including puncture, bone cement infusion, vertebral expander instruments, diagnosis, and treatment of special type of vertebral fractures, PKP is performed with the better efficacy and less complication.

CONCLUSION

With the progression of minimally invasive spinal surgery around the world, PKP in China has been performed with a trend towards a rapid, safe, and effective treatment. Digital, real-time and artificial intelligence are the directions of future development of PKP.

LEVEL OF EVIDENCE

4.

Evaluation of surgical outcome of Jack vertebral dilator kyphoplasty for osteoporotic vertebral compression fracture-clinical experience of 218 cases

Background

Osteoporotic vertebral compression fracture is a serious complication of osteoporosis. Various vertebral kyphoplasty surgeries, which have their own unique features, are commonly used for osteoporotic vertebral compression fracture. Based on the anatomic property of the thoracolumbar vertebral pedicle that its horizontal diameter is twice that of the vertical diameter, we designed Jack vertebral dilator for better restoration of the vertebral height by manipulating the mechanical force.

Methods

A total of 218 patients (236 vertebrae) with osteoporotic vertebral compression fracture were treated with Jack vertebral dilator. Surgery was successfully completed in all cases, and all the 218 patients were followed up for an average of 14.2 months (range 3 to 30 months).

Results

Bone cement leakage occurred in 12 cases, but no symptoms were reported. No other complications were noticed. The VAS scores were 8.2 ± 1.3, 1.7 ± 0.9, and 1.8 ± 0.8 and the ODI was 78.2 ± 13.3 %, 18.5 ± 7.3 %, and 20.9 ± 6.8 % before surgery and 1 week after surgery and at the final follow-up, respectively. The anterior vertebral body height was 19.3 ± 3.2, 25.1 ± 2.6, and 24.9 ± 2.6 mm and the central vertebral body height was 18.7 ± 3.0, 24.8 ± 3.0, and 24.5 ± 2.9 mm before surgery and 1 week after surgery and at the final follow-up, respectively. Cobb angle was 16.2° ± 6.6°, 8.1° ± 5.6°, and 8.5° ± 5.6° before surgery and 1 week after surgery and at the final follow-up, respectively.

Conclusions

Jack vertebral dilator kyphoplasty for osteoporotic vertebral compression fracture is safe, feasible, and effective and has the prospect of further broad application in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-016-0371-4) contains supplementary material, which is available to authorized users.

Does balloon kyphoplasty improve the global spinal alignment in osteoporotic vertebral fracture?

PURPOSE

Balloon kyphoplasty (BKP) has been a well-accepted procedure in the treatment of osteoporotic vertebral compression fracture (OVCF), whereas it remains unclear whether or not this procedure has an impact on the global spinal alignment. The purpose of this study is to evaluate the effect of BKP on the global spinal alignment in OVCF.

METHODS

Fifty-six consecutive patients who had undergone BKP for symptomatic OVCF were retrospectively reviewed with a mean follow-up of 32 months. They were seven males and 49 females with a mean age of 75 years. Radiographic assessment was performed using upright whole spine radiographs. The parameters included vertebral kyphosis, mid-vertebral body height and global sagittal spinal alignment (C7 plumb line deviation). Clinical outcomes were evaluated using visual analog scale of back pain.

RESULTS

Fifty-one of 56 patients (91.1 %) achieved immediate pain relief. Vertebral kyphosis significantly decreased from 18 to 14 degrees, but 43 patients (76.8 %) still had more than 10 degrees of local kyphosis. Subsequent vertebral compression fractures were observed in seven patients (12.5 %). Anterior deviation of a C7 plumb line (C7PL) was 3.1 cm pre-operatively, 3.1 cm postoperatively, and significantly increased to 5.9 cm at the final follow-up. Consistent results were obtained in those with pre-operative sagittal imbalance (>5 cm anterior deviation of C7PL) and with pre-existing OVCFs.

CONCLUSIONS

BKP contributed to immediate pain relief, but did not improve the global sagittal spinal alignment after OVCF. This procedure should be solely indicated for painful OVCF or non-union, and could not be expected to restore the global sagittal alignment.

Percutaneous vertebral body augmentation: an updated review

There are many medical conditions like osteoporosis, tumor, or osteonecrosis that weaken the structural strength of the vertebral body and prone it to fracture. Percutaneous vertebral augmentation that is usually applied by polymethylmethacrylate is a relatively safe, effective, and long lasting procedure commonly performed in these situations. In this paper, we updated a review of biomechanics, indications, contraindications, surgical techniques, complications, and overall prognosis of these minimally invasive spinal procedures.

Comparison of radiological and clinical results of balloon kyphoplasty according to anterior height loss in the osteoporotic vertebral fracture

BACKGROUND CONTEXT

Percutaneous kyphoplasty is effective for pain reduction and vertebral height restoration in patients with osteoporotic vertebral fractures. However, in cases of severely collapsed fractures involving the loss of more than 70% of the vertebral height, kyphoplasty is technically difficult to perform and the outcomes remain unknown.

PURPOSE

To compare the vertebral height restoration rate, kyphotic angle, and clinical results of patients who underwent kyphoplasty according to the degree of anterior vertebral height loss. In addition, to determine the feasibility and effects of kyphoplasty on severely collapsed osteoporotic vertebral fractures.

STUDY DESIGN/SETTING

A retrospective study.

PATIENT SAMPLE

A total of 129 patients (145 vertebrae) who underwent kyphoplasty for osteoporotic painful vertebral fracture and followed up for more than 1 year between September 2005 and August 2012 were recruited for the analysis.

OUTCOME MEASURES

The patients' kyphotic angle, anterior vertebral height, and anterior vertebral height restoration ratio 1 year after surgery were compared. Pre- and postoperative pain around the fractured vertebra and the radiological and clinical results according to bone mineral density (BMD) were also compared.

METHODS

Patients were divided into three groups for comparison, according to radiographic findings. Patients with an anterior height compression ratio more than 70% at the time of fracture comprised Group I, patients with a compression ratio of 50-70% comprised Group II, and those with a compression ratio of 30-50% comprised Group III.

RESULTS

Group I showed a greater extent of anterior height restoration immediately after surgery compared with the other groups, which noticeably decreased over time. All three groups showed significant restoration of the anterior vertebral height between pre- and postoperative values. The anterior vertebral height 1 year after surgery did not differ between Group I and Group II but was significantly higher in Group III. There was no correlation between the BMD and restoration or decrease of anterior vertebral height over time. Pain around the fractured vertebra significantly decreased in all groups immediately and 1 year after surgery compared with preoperative levels, although the pain level 1 year after surgery did not differ significantly between the groups.

CONCLUSIONS

In patients with an anterior vertebral compression ratio more than 70% because of osteoporotic vertebral fracture, although the anterior height and kyphotic angle were significantly lower than those of patients with an anterior vertebral compression ratio of 30% to 50%, kyphoplasty significantly improved the degree of pain, restored the anterior vertebral height, and maintained the kyphotic angle. Therefore, kyphoplasty can be a useful approach in patients with an anterior vertebral compression ratio more than 70%.

Surgical procedure and initial radiographic results of a new augmentation technique for vertebral compression fractures

PURPOSE

Recently, a new minimally invasive technique called 'vertebral body stenting' (VBS) was introduced for the treatment of osteoporotic vertebral fractures. The technique was developed to prevent the loss of reduction after deflation of the balloon and to reduce the complication rate associated with cement leakage.

METHODS

The amount of kyphosis correction, improvement of vertebral body height and quantitative cement leakage rate by applying CT-based quantitative volumetry after VBS were measured in 27 patients (55 vertebra) and compared with a control group (29 patients, 61 vertebrae), which was treated with conventional vertebroplasty.

RESULTS

After VBS, a significant improvement was seen in vertebral height, compared to conventional vertebroplasty. The mean improvement in segmental kyphosis and vertebral kyphosis were 5.8° (p < 0.05) and 3.5° (p < 0.05), respectively. In the VBS group, the mean injected volume of cement per vertebral body was 7.33 cm(3) (3.34-10.19 cm(3)). The average amount of cement outside the vertebrae was 0.28 cm(3) (0.01-1.64 cm(3)), which was 1.36% of the applied total cement volume. In the vertebroplasty group, the applied mean volume of the cement per level was 2.7 cm(3) (1-5.8 cm(3)) and the average amount of cement outside the vertebrae was 0.15 cm(3) (0.01-1.8 cm(3)), which was 11.5% (0.2-60%) of the applied total volume of cement.

CONCLUSION

The frequency of cement leakage after VBS was 25.5% compared to 42.1% in the vertebroplasty group. VBS led to a significant decrease in the leakage rate compared with conventional vertebroplasty.

CT fluoroscopy-guided vertebral augmentation with a radiofrequency-induced, high-viscosity bone cement (StabiliT(®)): technical results and polymethylmethacrylate leakages in 25 patients

OBJECTIVE

To assess the technical results of CT fluoroscopy-guided, radiofrequency-induced vertebral augmentation (StabiliT®) in terms of vertebral height restoration and polymethylmethacrylate (PMMA) leakages, occurring in 25 individual patients with vertebral compression fractures and osteolysis.

MATERIALS AND METHODS

From 07/2010 to 08/2011, 25 patients (16 women, nine men; age 71 ± 14; range 41-89) with painful vertebral compression fractures due to osteoporosis (n = 19), metastases (n = 2) or multiple myeloma (n = 4) underwent vertebral augmentation with a radiofrequency-activated, high-viscosity polymethylmethacrylate (PMMA) bone cement (StabiliT® Vertebral Augmentation system; DFINE Europe GmbH, Mannheim) under local anesthesia. Thirty-four vertebrae (Th5-L5) were treated in 27 sessions under CT fluoroscopy guidance (128-row CT, Somatom Definition AS, Siemens, Erlangen) using a unilateral access and a cavity-creating osteotome prior to remote-controlled, hydraulically driven cement injection. 1/2/3 levels were treated in 21/5/1 session(s). Vertebral height change in the midsagittal plane (anterior, midvertebral, posterior endplate distance) and PMMA leaks were retrospectively evaluated using the postinterventional CT.

RESULTS

All patients were successfully treated in the first session. Mean (MV ± SD) procedure time and amount of injected PMMA were 56 ± 14 min and 4.5 ± 1.4 ml, respectively. Mean anterior/midvertebral/posterior height gain was +7.1/+9.7/+0.4%. Small local vertebral leaks were observed in 18/34 vertebrae (53%) without any clinical sequelae. No major complications occurred.

CONCLUSIONS

CT fluoroscopy-guided, RF-induced vertebral augmentation with a high-viscosity bone cement (StabiliT®) was safe and technically successful in all patients. Using a hydraulic cement injection technique, a moderate restoration of anterior and midvertebral height was seen while the system was not markedly superior to standard vertebroplasty regarding the frequency of minor asymptomatic PMMA leaks.

Minimum Two-year Results of Revision Total Knee Arthroplasty Following Infectious or Non-infectious Causes

Purpose

To compare clinical outcome of revision total knee arthroplasty (TKA) between the infected and non-infected groups.

Materials and Methods

This study compared the clinical and radiographic results of 21 infected and 15 non-infected revision TKAs at a minimum 2-years follow-up. Clinical evaluations were assessed using the range of motion (ROM), Hospital for Special Surgery (HSS) score, Knee Society Knee Score (KSKS), Knee Society Function Score (KSFS), and Western Ontario and McMaster Universities (WOMAC) score. Radiologic evaluations were assessed using the radiographic results of the American Knee Society and joint line change.

Results

Patients operated for non-infectious causes had significantly better postoperative ROM than the infected group (infected group, 101.7°; non-infected group, 117.8°). The infected group achieved significantly poor HSS (79.2 vs. 85.5), KSKS (75.5 vs. 86.6), KSFS (76.9 vs. 85.5), WOMAC (30.3 vs. 21.2) scores than the non-infected group. Postoperative joint line elevation was lower in the infected versus non-infected group (0.5 mm vs. 2.1 mm), but there was no significant difference.

Conclusions

Revision TKA is an effective treatment that can provide successful results in the infected as well as non-infected patients. The overall results of non-infected revision were more satisfactory than infected revision.

Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies?

PURPOSE

Whilst patients undergoing total knee replacements generally have good relief of their symptoms, up to 20% complain of persisting pain. Revision rates have therefore been rising, particularly so for unexplained pain. We reviewed the causes of painful total knee replacements including extrinsic causes.

METHODS

Forty-five consecutive patients referred to our department with painful total knee replacement were reviewed with our standard protocol, including history and examination, inflammatory markers and radiological studies including radiographs of the hip and knee and computed tomography scan of the knee joint.

RESULTS

Of the 45 patients, 15 patients had degenerative hip and lumbar spine disease which resolved after injections of the relevant joints. Nine patients had unexplained pain.

CONCLUSIONS

Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.