A comparison of the simplified olecranon and digital methods of assessment of skeletal maturity during the pubertal growth spurt

Assessment of skeletal age is important in children’s orthopaedics. We compared two simplified methods used in the assessment of skeletal age. Both methods have been described previously with one based on the appearance of the epiphysis at the olecranon and the other on the digital epiphyses. We also investigated the influence of assessor experience on applying these two methods.

Our investigation was based on the anteroposterior left hand and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1 ) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal growth spurt. A total of nine observers examined the radiographs with the observers assigned to three groups based on their experience (experienced, intermediate and novice). These raters were required to determined skeletal ages twice at six-week intervals. The correlation between the two methods was determined per assessment and per observer groups. Interclass correlation coefficients (ICC) evaluated the reproducibility of the two methods.

The overall correlation between the two methods was r = 0.83 for boys and r = 0.84 for girls. The correlation was equal between first and second assessment, and between the observer groups (r ≥ 0.82). There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%) and observer effect (ICC ≤ 3%) for each method. There was no significant (p < 0.05) difference between the levels of experience.

The two methods are equally reliable in assessing skeletal maturity. The olecranon method offers detailed information during the pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossified.

Cite this article: Bone Joint J 2014;3:1556–60

Intermediate clinical and radiological results of cervical TDR (Mobi-C) with up to 2 years of follow-up

The interest in cervical total disc replacement (TDR) as an alternative to the so-far gold standard in the surgical treatment of degenerative disc disease (DDD), e.g anterior cervical discectomy and fusion (ACDF), is growing very rapidly. Many authors have established the fact that ACDF may result in progressive degeneration in adjacent segments. On the contrary, but still theoretically, preservation of motion with TDR at the surgically treated level may potentially reduce the occurrence of adjacent-level degeneration (ALD). The authors report the intermediate results of an undergoing multicentre prospective study of TDR with Mobi-C prosthesis. The aim of the study was to assess the safety and efficacy of the device in the treatment of DDD and secondary to evaluate the radiological status of adjacent levels and the occurrence of ossifications, at 2-year follow-up (FU). 76 patients have performed their 2-year FU visit and have been analyzed clinically and radiologically. Clinical outcomes (NDI, VAS, SF-36) and ROM measurements were analyzed pre-operatively and at the different post-operative time-points. Complications and re-operations were also assessed. Occurrences of heterotopic ossifications (HOs) and of adjacent disc degeneration radiographic changes have been analyzed from 2-year FU X-rays. The mean NDI and VAS scores for arm and neck are reduced significantly at each post-operative time-point compared to pre-operative condition. Motion is preserved over the time at index levels (mean ROM = 9 degrees at 2 years) and 85.5% of the segments are mobile at 2 years. HOs are responsible for the fusion of 6/76 levels at 2 years. However, presence of HO does not alter the clinical outcomes. The occurrence rate of radiological signs of ALD is very low at 2 years (9.1%). There has been no subsidence, no expulsion and no sub-luxation of the implant. Finally, after 2 years, 91% of the patients assume that they would undergo the procedure again. These intermediate results of TDR with Mobi-C are very encouraging and seem to confirm the efficacy and the safety of the device. Regarding the preservation of the status of the adjacent levels, the results of this unconstrained device are encouraging, but longer FU studies are needed to prove it.

Percutaneous vertebroplasty in a broken vertebral titanium implant (titanium mesh cage)

We report the case of a percutaneous consolidation of a broken vertebral implant (Surgical Titanium Mesh Implants; DePuy Spine, Raynham, MA, USA) by vertebroplasty. Four years after anterior spondylectomy with cage implantation and stabilization with posterior instrumentation, the patient was admitted for excruciating back pain. Radiographs showed fracture of the cage, screw, and rod. An anterior surgical approach was deemed difficult and a percutaneous injection of polymethyl methacrylate into the cage was performed following posterior instrumentation replacement. This seems to be an interesting alternative to the classical anterior surgical approach, which is often difficult in postoperative conditions.

[Pedicle closing-wedge osteotomy for the treatment of fixed sagittal imbalance]

PURPOSE OF THE STUDY

The aim of this study was to analyze x-ray results in patients who underwent pedicle subtraction osteotomy for complex deformations (flat back, kyphosis) leading to fixed sagittal imbalance.

MATERIAL AND METHODS

Thirty-four patients underwent surgery between 1996 and March 2003 in two centers, the orthopedic surgery unit devoted to spinal surgery and sports traumatology at the Strasbourg University Hospitals and the spinal surgery unit at the Chenove Clinic (Dijon). The series included 20 women and 14 men, mean age 46.5 years (range 14-74 years) treated for: postoperative flat back (n = 19), kyphoscoliosis (n = 6), ankylosing spondylarthritis (n = 5), and malunion (n = 4). After careful planning to achieve the necessary degree of correction, the patient was installed on a Cotrel table with a stable support enabling limited blood loss and facilitated reduction maneuvers via elevation of the lower limbs. The technique started by resection of the posterior arch, the transverse processes, and the pedicles, followed by partial resection of the body with a chisel under fluoroscopic control. The closure was achieved by in situ reduction with compressive rotation. Adjacent discs were then evaluated to search for any opening which could be filled by an anterior graft to complete the stabilization. The osteosynthesis used 2-, 4-, and 6-rod assemblies. The 6-rod assemblies enabled anchoring the fixation above and below before the osteotomy. Two prebent rods completed the assembly at reduction after osteotomy. Weight-bearing started on day 4. A protective corset was worn for three months by 19 patients. The patients resumed their occupational activities on average 6.73 months postoperatively without change in activity for 63%. Overall satisfaction was close to 90% excellent outcome.

RESULTS

All clinical results were analyzed with the Profil software of Surgiview. X-ray data were analyzed with Spineview. A self-administered clinical questionnaire was used to evaluate pain, result of the operation, and the impact on the patient's body image. On average, the wedge osteotomy measured 28.9 degrees for correction of lumbar lordosis by 31.5 degrees with a maximum of 65 degrees. The misalignment at C7 was reduced from 51 mm to 2 mm. At the pelvic level, version improved 16 degrees, sacral slope 8 degrees. There were four dura mater breaches which had to be sutured, but with no clinical consequence (one progression to meningocele). Mean intraoperative blood loss was 1400 cc (300-4500cc) for a mean operative time of 260 minutes (165-450 min). There were two early infections at day 15 postop which resolved with antibiotics. Four patients developed resolutive sciatica (n = 2) or cruralgia (n = 2) during the following months. The short-term follow-up revealed eight non-unions (25%) with rupture of osteosynthesis material and loss of correction. The opening in the adjacent discs and the insufficient posterior closure explained this mechanical complication.

CONCLUSION

Pedicle subtraction osteotomy is an original operative technique reserved for specialized centers. A well-experienced team is needed to control the risks involved. Sagittal balance should be one of the important goals for modern spinal surgery.

Long term follow-up of two sibs with an autosomal recessive form of chrondrodysplasia punctata and epilepsy

Long term follow-up of two sibs with an autosomal recessive form of chrondrodysplasia punctata and epilepsy: A variety of osteodysplasias are referred to with the term chondrodysplasia punctata (CDP). Here we report on two sibs, a boy and a girl, with probable autosomal recessive form of CDP and epilepsy followed-up for 30 and 19 years, respectively. Family history was unremarkable but for consanguinity. Pregnancies and deliveries were uneventful. At birth, length was 46 (-3SD) and 45 (-4SD) cm, respectively. Craniofacial dysmorphism was noted: severe nasal hypoplasia, flat face, hypertelorism, a low nasal bridge, short stature. Skeletal abnormalities included epiphyseal stippling in the thoracic spine, bilateral proximal and distal humeri, femur, tibia and bilateral carpal and tarsal bones. The boy had a hemivertebrae T12, with absence of a rib. After the age of 6 years facial dysmorphism had improved. Final height was 154 cm (-3SD) in the boy and 158 cm (-0,5SD) in the girl. The boy was operated on for scoliosis. Both sibs had club feet, the girl had also genu valgum. IQ was evaluated to be 55 in the girl and 83 in the boy. The first non febrile generalized seizure appeared in the boy when he was 11 months of age, and in the girl when she was 25 months of age. Both had many other seizures and were taking antiepileptics. EEG were abnormal. Karyotypes were normal. Extensive screening for metabolic disorders was normal. Acquired in utero CDP were excluded. We suggest the sibs described in this report have yet another provisionally unique possibly autosomal recessive syndrome, with CDP and epilepsy as phenotypic traits.

Explicit calibration method and specific device designed for stereoradiography

The three-dimensional geometry of the human spine is noteworthy information that can be obtained by stereoradiographic methods. These methods are based on the identification of anatomical structures in several views which are obtained by rotation of a patient standing on a turntable. Calibration algorithms for computer vision or photogrammetry are well documented, but they generally yield calibration devices which are cumbersome for the use in clinical stereoradiography. This paper presents a calibration method adapted to a two-view stereoradiography calibration (frontal and lateral incidences) and based on a simplified geometric modeling of the radiological environment. The a priori knowledge yields four calibration equations related to the vertical and horizontal planes of both views, leading to a specific calibration procedure and device. Moreover this device is attached to the stereoradiographic system (directly integrated on the turntable) in order to facilitate clinical applications. A validation was performed on 26 dried lumbar vertebrae in order to evaluate clinical situation. The mean accuracy of the stereoradiographic reconstruction was 1.2mm.

Pre and post 3D modeling of scoliotic patients operated with in situ contouring technique

A three-dimensional segmental analysis was performed on the stereoradiographic reconstructions of ten right thoracic scoliotic patients. From the quantitative model of the spine and pelvis, the vertebral and intervertebral orientations were computed pre and post operatively. These orientations allow to determine the apical and junctional zones of the high thoracic, thoracic and lumbar curves. The apical zone corresponds to the maximum of vertebral axial rotation. Pre operatively, the tendency was T7 for the thoracic transverse apex with 20 AE of axial rotation. The junctional zone corresponds to the maximum of vertebral lateral rotation and the maximum of intervertebral axial rotation. The tendency was T5 and T12 for the junctional vertebrae of the thoracic curve with, at both levels, 30 AE of vertebral lateral rotation and 10 AE of intervertebral axial rotation. The surgical correction obtained by in situ contouring technique was evaluated through these 3D orientations. The vertebral axial rotation at the high thoracic, thoracic and lumbar apex was corrected with respectively 52%, 60% and 60%.

[Results of lumbar and lumbosacral fusion: clinical and radiological correlations in 113 cases reviewed at 3.8 years]

PURPOSE OF THE STUDY

Spinal fusion requires the use of hardware for reduction and stabilization. We present the clinical and radiological behavior of a population of patients with lumbar and lumbosacral spinal fusion.

MATERIALS AND METHODS

Between 1990 and 1992, 113 patients were operated for lumbar and lumbosacral fusion. Mean age of the population was 43 years and mean follow-up was 3.8 years. Most of the fusions were L4-S1 fusions. 56% of the patients had a previous surgery. Thirteen patients in the series were reoperated and analyzed separately. In the majority of the cases, the indication for surgery was back pain with or without leg pain. Diagnoses were: spondylolisthesis, discopathy, scoliosis, and pseudoarthrosis. The spine was fused and reduced using two lordotic rods. Peroperative and postoperative lordosis were calculated on X-rays. Clinical results were analyzed with the Beaujon-Lassale score.

RESULTS

Mean improvement was significantly better for spondylolisthesis than for other pathologies (85.6% versus 77.1%). Returning to work was possible for 85.5% of those with improvement and was not possible for 69.8%. The gain achieved in lordosis at surgery was lost at last follow-up. The lordosis of the construct appeared to protect against the development of discopathies above and below the construct. Discopathis led to a poor score. The rate of non-union was 7.9%, the rate of repeated surgery 6.1% and the rate of hardware removal 23.8%. At last follow-up, improvement was achieved in 45.6% of the 13 patients of the series who had repeat surgery.

DISCUSSION

The results in our series are similar to those reported by others. Lumbar lordosis is an important factor: if lost, more interbody fusions may be subsequently required. Diagnosis of non-union is difficult and reoperation is the only sure manner to prove it by applying distraction-compression manoeuvres on the screws. All non-unions presented were symptomatic; incidence in the series was thus probably higher. Non-union and reoperation with a longer fusion are perhaps correlated with insufficient elasticity in the osteosynthesis. Optimal rod elasticity is a factor which remains to be defined.

CONCLUSION

Clinical results of lumbar and lumbosacral fusions are not unsatisfactory, but in our series almost one patient out of three had to be reoperated. One of the reasons for so many reoperations is certainly hardware rigidity. Hardware was not removed without testing the fusion as this is the only means of sure diagnosis of non-union. Reoperation should not be considered a failure in this difficult surgery of back pain which requires long-term surgical follow-up.

Percutaneous laser photocoagulation of spinal osteoid osteomas under CT guidance

BACKGROUND AND PURPOSE

Spinal osteoid osteomas are rare; when they occur, they are usually treated by surgical or percutaneous excision. The aim of percutaneous interstitial laser photocoagulation (ILP) of osteoid osteomas under CT guidance is thermal destruction of the nidus using low-power laser energy, thus precluding bone resection and open surgery.

METHODS

Three cases of spinal osteoid osteomas were treated with percutaneous ILP of the nidus. Under CT guidance, the needle was positioned in the center of the nidus, at least 8 mm from neurologic structures. Using a high-power semiconductor diode laser (805 nm) with a 400-microm optical fiber, we delivered 600 to 800 joules to the nidus, depending on its size. The procedure was performed with the patient under neuroleptanalgesia and required overnight hospitalization.

RESULTS

Complete pain relief was obtained in all three patients within 24 hours of the procedure, and no major complications were incurred. Follow-up ranged from 20 months to 60 months.

CONCLUSION

Percutaneous ILP of spinal osteoid osteoma is a promising, simple, precise, and minimally invasive technique and may be an alternative to traditional surgical and percutaneous ablations.

[Enlargement in managment of lumbar spinal stenosis]

Lumbar stenosis has been well discussed recently, especially at the 64th French Orthopaedic Society (SOFCOT: July 1989). The results of different surgical treatments were considered as good, but the indications for surgical treatment were not clear cut. Laminectomy is not the only treatment of spinal stenosis. Laminectomy is an approach with its own rate of complications (dural tear, fibrosis, instability... ).Eight years ago, J. Sénégas described what he called the "recalibrage" (enlargement). His feeling was that, in the spinal canal, we can find two different AP diameters. The first one is a fixed constitutional AP diameter (FCAPD) at the cephalic part of the lamina. The second one is a mobile constitutional AP diameter (MCAPD) marked by the disc and the ligamentum flavum. This diameter is maximal in flexion, minimal in extension. The nerve root proceeds through the lateral part of the canal: first above, between the disc and the superior articular process, then below, in the lateral recess bordered by the pedicle, the vertebral body and the posterior articulation. With the degenerative change the disc space becomes shorter, the superior articular process is worn out with osteophytes. These degenerative events are complicated by inter vertebral instability increasing the stenosis. The idea of the "recalibrage" is to remove only the upper part of the lamina with the ligamentum flavum and to cut the hypertrophied anterior part of the articular process from inside. If needed the disc and other osteophytes are removed. The surgery is finished with a ligamentoplasty reducing the flexion and preventing the extension by a posterior wedge.Our experience in spine surgery especially in scoliosis surgery, showed us that it was possible to cure a radicular compression without opening the canal. The compression is then lifted by the 3D reduction and restoration of an anatomy as normal as possible. Lumbar stenosis is the consequence of a degenerative process. Indeed, hip flexion, obesity or quite simply overuse, involve an increase in the lumbar lordosis. The posterior articulations are worn out and the disc gets damaged by shear forces. The disc space becomes shorter with a bulging disc, and the inferior articular process of the superior vertebra goes down. This is responsible of a loss of lordosis. For restoring the sagittal balance the patient needs more extension of the spine. Above and below the considered level the degenerative disease carries on extending to the whole spine. At the level considered, because of local extension, the inferior facet moves forward, the disc bulges, the ligamentum flavum is shortened and the stenosis is increased. This situation is improved by local kyphosis: the inferior facet moves backward, the disc and the ligamentum flavum are stretched with a quite normal posterior disc height and most often there is no more stenosis. Myelograms show this very well with a quite normal appearance lying, clear compression standing, worse in extension and improved, indeed disappeared in flexion. CT scan and MRI don't show that because they are done lying. The expression of the clinical situation is the same, mute lying and maximum standing with restriction of walking. For us lumbar stenosis is operated with lumbar reconstruction without opening the canal. The patient is in moderate kyphosis on the operating table. Pedicle screws rotated to match a bent rod allow reduction of the spine. The posterior disc height is respected and not distracted, and the anterior part of the disc is stretched in lordosis. The inferior facet is cut for the arthrodesis and no longer compresses the dura. The canal is well enlarged and the lumbar segment in lordosis is the best protection of the adjacent levels at follow-up. This behaviour responds to the same analysis as the ≪recalibrage≫ (enlargement). The mobile segment is damaged by the degenerative disease, the stenosis is a consequence of this damage. It's logical to treat the instability and to restore the normal static anatomy; thus bone resection is not necessary. At the present time all the lumbar stenoses with reduction in flexion are instrumented with spinal reduction and arthrodesis without opening the canal. The laminoarthrectomy and the enlargement are done when there is a fixed arthrosis which is rare in our practice and found in an older population. The follow-up shows a loss of reduction in some cases after reduction-instrumentation-arthrodesis and poses the question of an interbody fusion. We don't open the canal only for fusion (PLIF) if this is not necessary for the treatment of the stenosis. We think that, in such a situation, the future is ALIF with endoscopical approach. The problem is to determine which disc demanding this anterior fusion, is able to regenerate or not.

Epithelioid sarcoma of the spine: a case report

STUDY DESIGN

This case report illustrates a patient presenting with sciatica and diagnosed with epithelioid sarcoma involving the spine.

OBJECTIVES

The treatment of this patient involved multiple mass resections and decompressions of the spinal canal. Radio- and chemotherapy were applied once a clear diagnosis was obtained.

SUMMARY OF BACKGROUND DATA

Epithelioid sarcoma is a rare tumor mainly arising in the extremities. Confusion with a benign inflammatory process are possible. Treatment after histologic diagnosis involves wide resection. To our knowledge, this report represents the first case of epithelioid sarcoma involving the spine.

METHODS

After initial discectomy, recurrent scarring and mass formation required multiple decompression procedures and fusion. The initial pathology revealed inflammatory reaction on fibrosis. In a later procedure, the histologic diagnosis of epithelioid sarcoma was made. Radiotherapy and chemotherapy were begun immediately.

RESULTS

Despite aggressive resections, radiotherapy, and chemotherapy, the patient died 3 months after the last surgical procedure.

CONCLUSION

Spinal epithelioid sarcoma can be mistaken for a benign inflammatory process. After a histologic diagnosis, aggressive wide resection is necessary. Multiple recurrences are documented with this tumor in other sites. Prognosis in trunk involvement is less favorable than involvement of the extremities. The role of adjuvant radio- and chemotherapy is unclear for spinal involvement.

[Intra-operative fractures: analysis]

51 fractures during total hip arthroplasty were studied. Fractures appeared to be predisposed to several factors: osteoporosis (20%), revision (32%), neck fractures (30%), ankylosis of the hip (16%). The risk seemed greater with non cemented prostheses. Consolidation was obtained in 60.6 days : no statistical difference was found with respect to the type of fracture or treatment.Such fractures do not seem to jeopardize the stability of the femoral component in the long-term.

[Cotrel-Dubousset instrumentation in the treatment of scoliosis]

The authors describe the operative principles of the C.D. device reviewing implantable material (rods and hooks, screws and transverse system). The principles of this surgical approach (2 rods) which offers the possible distraction and contraction where necessary, are described. Good derotation is achieved and a strong and stable square support device enabling the patient to be got out of bed rapidly without any need for post-operative support. The post-operative care is extremely easy and a rapid return to school activity is possible.