[Corrective osteotomies around the knee joint using hexapods]

OBJECTIVE

Correction of deformities around the knee joint in the frontal and sagittal axis, torsion, length and translation.

INDICATIONS

Complex deformities of the proximal tibia, and to a lesser extent of the distal femur, which cannot be treated with acute correction using plate or nail osteosynthesis.

CONTRAINDICATIONS

Nicotine abuse, soft tissue problems, lack of patient compliance.

SURGICAL TECHNIQUE

First, mounting of the proximal ring of the ring fixator strictly parallel to the joint line in 2 planes, fixation with 3 or 4 pins or wires. Then mounting of the distal ring, fixation also with 3 or 4 wires, connection of both rings with 6 struts (movement units with which the length can be adjusted). Then the fibula osteotomy is performed in the transition from the distal to the middle third, and finally the tibial osteoclasia is performed via a mini-incision as a drill hole chisel osteotomy in the CORA (center of rotation and angulation) of the malposition.

POSTOPERATIVE MANAGEMENT

Immediately postoperatively, the deformity is defined usimg computer software, the exact position and size of the ring and struts are entered, and a knee image is taken in 2 planes with X‑ray signal adapter (beacon) on the ring fixator to plan the continuous correction. Thereupon continuous correction of the deformity via daily rotation on the 6 struts, which is done by the patients themselves at home after the hospital stay. At the time of correction, pain-adapted partial weight-bearing with 20 kg up to half body weight. After completion of the correction, repeat X‑ray diagnosis and check whether the correction goal has been achieved. If necessary, reprogram a program for renewed continuous correction if residual deformity remains. When the correction goal is reached, X‑ray check. After 6 weeks, with bony consolidation, gradual loading. The treatment of the correction can either be carried out in the ring fixator (wearing time of 0.5-1 year not unusual) or secondarily via a change of procedure to plate osteosynthesis.

RESULTS

We report on 25 knee joint corrections in 23 patients (12 women and 11 men) using hexapods (Taylor spatial frame) during the period 2016-2023. One patient had a femoral and a tibial fixator at the same time; another patient had a triple fixator at the tibia. The mean age was 32 (6-73) years. 15 left and 10 right corrections were performed. 19 fixators had been applied tibial, 5 fixators femoral, and 1 fixator cross-jointly (for contracture). The indications were 6 congenital complex deformities, 10 posttraumatic complex deformities, 3 pseudarthroses after correction osteotomies, 2 patients with osteomyelitis, 1 knee contracture and 1 infection after fracture osteosynthesis with nails. The forms of correction performed were varizations and valgizations in frontal axis, extension and flexion in sagittal plane, torsional corrections, lengthening also after acute shortening (pseudarthrosis resection) and segmental transport. Acute shortening without lengthening was also treated with the fixator only until bone healing and a Masqualet procedure was bridged with it. The average duration of fixator wear was 144 (31-443) days. All patients were followed up until final metal removal. There were 19 change of procedure to another osteosynthesis procedure (18 plate osteosynthesis, 1 ESIN); 6 times the treatment in TSF (Taylor Spatial Frame) was performed until final bone healing.

RCC (reinforced criss-cross construct): an easy and effective multi-rod thoraco-lumbar posterior reconstruction technique

STUDY DESIGN

Surgical technical note and literature review.

OBJECTIVES

To describe a technique that uses 4 rod constructs in cases of complex thoracolumbar spinal deformity correction or revision surgeries based on the hybrid use of two different types of purchase points by a staggered pedicle screw fixation. It utilizes two rods on either side of the spine using a lateral and medial entry point of pedicle screws in the vertebral body.

METHODS

Pedicle screws using extra-pedicular technique are more converging screws and are inserted alternately in the vertebral body and connected by rods. The left-out alternate vertebral bodies are fixed by a relatively straighter pedicle entry screw and connected to each other by a separate rod. So, two trajectories are independently used for a four-rod construct. This reconstruction has been named RCC (reinforced criss-cross construct). The screws in the index case were placed by free hand method, but we have increasingly utilized navigation guidance for placement of screws in recent times.

RESULTS

We present a surgical technical note in a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV-AIDS). He was diagnosed to have multi-drug-resistant (MDR) tuberculous spondylodiscitis, complicated with Immune reconstitution inflammatory syndrome (IRIS) and implant failure resulting in kyphosis and thoracic myelopathy. RCC with pharmacological management achieved healing and union, which was maintained at 4 years follow-up. Our method of four-rod construct provides a strong and lasting construct in the management of spinal deformities and three-column osteotomies. It provides good structural support to the spine till bony union is achieved.

CONCLUSION

Hybrid multi-rod construct like RCC provides a rigid mechanical support to the instrumentation and reduces the chances of rod failure especially in complex thoraco-lumbar spinal deformity correction surgeries.

The posterior superior iliac rim screw as an adjunct to pelvic fixation in complex spinopelvic stabilization

BACKGROUND

Fixation to the ilium is a commonly used alternative or supplement to sacral fixation in complex spinopelvic reconstructions. This can be achieved with traditional posterior superior iliac spine or S2 alar-iliac screws. Posterior superior iliac rim screws may be considered to achieve or enhance pelvic fixation. The objective of this case series was to describe the use of and indications for posterior superior iliac rim screws.

METHODS

A retrospective review was performed of the medical records and radiographic data for three patients who underwent complex lumbosacral reconstructions involving the use of posterior superior iliac rim screws to enhance pelvic fixation. The cases included a 35-year-old with bilateral sacral fractures, a 43-year-old with extensive metastatic sarcoma to the sacrum, and a 48-year-old with multiple lumbar and pelvic fractures. An overview of the key surgical techniques is provided.

RESULTS

All three patients tolerated the procedure, without any unexpected post-operative complications or deficits. Radiographs at last follow-up showed stable fixation and no hardware issues.

CONCLUSIONS

The use of posterior superior iliac rim screws as an adjunct method of fixation in complex spinopelvic reconstructions is a feasible option that can be considered in the fixation armamentarium.

Association Between Preoperative Narcotic Use with Perioperative Complication Rates, Patient Reported Pain Scores, and Ambulatory Status After Complex Spinal Fusion (≥5 Levels) for Adult Deformity Correction

OBJECTIVE

The widespread over-use of narcotics has been increasing. However, whether narcotic use impacts surgical outcomes after complex spinal fusion remains understudied. The aim of this study was to evaluate whether there is an association between preoperative narcotic use with perioperative complication rates, patient-reported pain scores, and ambulatory status after complex spinal fusions.

METHODS

The medical records of 134 adult (age ≥18 years) patients with spinal deformity undergoing elective, primary complex spinal fusion (≥5 levels) for deformity correction in a major academic institution from 2005-2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, pain scores, and ambulatory status were collected for each patient.

RESULTS

Patient demographics and comorbidities were similar between both cohorts, except that the Narcotic-User cohort had a greater mean age (57.5 years vs. 50.7 years; P = 0.045) and prevalence of depression (39.4% vs. 16.2%; P = 0.003). Complication rates were similar between both cohorts. The Narcotic-User cohort had significantly higher pain scores at baseline (6.7 ± 2.4 vs. 4.0 ± 3.4; P < 0.001) and at the first postoperative pain score reported (6.7 ± 2.8 vs. 5.3 ± 2.9; P = 0.013), but had a significantly greater improvement from baseline to last pain score (Narcotic-User: -2.5 ± 3.9 vs. Non-User: -0.5 ± 4.7; P = 0.031). The Narcotic-User cohort had significantly greater ambulation on the first postoperative ambulatory day compared with the Non-User cohort (103.8 ± 144.4 vs. 56.4 ± 84.0; P = 0.031).

CONCLUSIONS

Our study suggests that the preoperative use of narcotics may impact patient perception of pain and improvement after complex spinal fusions (≥5 levels). Consideration of patients' narcotic status preoperatively may facilitate tailored pain management and physical therapy regimens.