Adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders

Advantages of Combined Use of Claw Hooks and Sublaminar Wires as the Upper Foundation of Long Fixation from the Thoracic Spine to the Pelvis in Osteoporotic Cases: A Finite Element Analysis of Proximal Junction Stress

Introduction

This study aimed to compare the biomechanical stress at the proximal junctional aspect between the conventional pedicle screw (PS) fixation (PSF) and the low PS density fixation (LPF) method.

Methods

This study involved 10 patients, half of whom have non-osteoporosis and the other half have osteoporosis. We made two types of intact models (one is from the upper thoracic-to-pelvis model, and the other is from the lower thoracic-to-pelvis model). From the intact models, we constructed two kinds of fusion models: (1) PSF and (2) LPF. The LPF method was as follows: The claw hooks (the combination of the down-going transverse process hooks and facet hooks) were set at the upper instrumented vertebra (UIV) and sublaminar wires at the thoracic spine and PSs at the lumbo-pelvis.

Results

Upper thoracic to pelvis fixation model In non-osteoporosis, no significant difference between the PSF and LPF is found. In osteoporosis, the von Mises stresses of the vertebra body at UIV, UIV+1, and disc were significantly lower in LPF than in PSF. Lower thoracic-to-pelvis fixation model In non-osteoporosis, the average von Mises stress of the vertebral body at UIV+1 and the maximum stress at UIV were lower in LPF than in PSF; however, no significant difference was found in the others. In osteoporosis, the von Mises stress was significantly lower in LPF than in PSF.

Conclusions

The claw hooks stabilized the vertebra body at UIV firmly, and sublaminar wires reduced load translation from the fixed spine.

Complications After Open Reduction and Internal Fixation for Distal Radius Fractures in Patients With and Without Rheumatoid Arthritis

PURPOSE

Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications.

METHODS

Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups.

RESULTS

Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group.

CONCLUSIONS

Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

[Rheumatoid instability in the cervical spine : Diagnostic and therapeutic strategies]

BACKGROUND

The involvement of the cervical spine in rheumatoid arthritis (RA) continues to be of clinical importance even in this age of biologics. Pathophysiological changes begin with an isolated atlantoaxial subluxation and may progress to a complex craniocervical and subaxial instability. The onset of cervical myelopathy can occur at any time and leads to a deterioration of the prognosis for the patient.

THERAPY

Treatment of the rheumatoid cervical spine should be aimed at improvement of the symptoms and prevention of further progress of the disease. In the case of instability, this is only possible by surgical treatment. The increasing usage of biological agents has led to a change in the clinical picture of the cervical involvement in RA patients. There are fewer patients presenting with isolated atlantoaxial instability. In contrast, the number of patients with complex craniocervical and/or subaxial instabilities is increasing. Complex cervical instabilities may require a longer fusion from the occiput to the upper thoracic spine. Modern operative techniques make this complex surgery also possible in severely disabled patients with a high comorbidity.

Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project

INTRODUCTION AND PURPOSE

Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study.

METHODS

Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D).

RESULTS

Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001).

CONCLUSIONS

Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.

Occipitosacral Fusion for Multiple Vertebral Fractures with Kyphotic Deformity in a Patient with Mutilating Rheumatoid Arthritis: A Case Report

Osteoporotic vertebral fractures are well-known complications of rheumatoid arthritis. The management of multiple vertebral fractures with kyphotic deformity is controversial. We present a case of a patient with mutilating rheumatoid arthritis who had multiple vertebral fractures with kyphotic deformity after occipitothoracic fusion for rheumatoid cervical disorder. Occipitosacral fusion was effective to create stable spine with better sagittal alignment in this case, but careful clinical assessment for early detection and management of postoperative insufficient pelvic fracture were required.

Distal Junctional Disease after Occipitothoracic Fusion for Rheumatoid Cervical Disorders: Correlation with Cervical Spine Sagittal Alignment

Study Design Retrospective radiographic study. Objective We have performed occipitothoracic (OT) fusion for severe rheumatoid cervical disorders since 1991. In our previous study, we reported that the distal junctional disease occurred in patients with fusion of O-T4 or longer due to increased mechanical stress. The present study further evaluated the association between the distal junctional disease and the cervical spine sagittal alignment. Methods Among 60 consecutive OT fusion cases between 1991 and 2010, 24 patients who underwent O-T5 fusion were enrolled in this study. The patients were grouped based on whether they developed postoperative distal junctional disease (group F) or not (group N). We measured pre- and postoperative O-C2, C2-C7, and O-C7 angles and evaluated the association between these values and the occurrence of distal junctional disease. Results Seven (29%) of 24 patients developed adjacent-level vertebral fractures as distal junctional disease. In group F, the mean pre- and postoperative O-C2, C2-C7, and O-C7 angles were 12.1 and 16.8, 7.2 and 11.2, and 19.4 and 27.9 degrees, respectively. In group N, the mean pre- and postoperative O-C2, C2-C7, and O-C7 angles were 15.9 and 15.0, 4.9 and 5.8, and 21.0 and 20.9 degrees, respectively. There were no significant differences between the two groups. The difference in the O-C7 angle (postoperative angle - preoperative angle) in group F was significantly larger than that in group N (p = 0.04). Conclusion Excessive correction of the O-C7 angle (hyperlordotic alignment) is likely to cause postoperative distal junctional disease following the OT fusion.