Adjunctive Use of Bone Growth Stimulation Increases Cervical Spine Fusion Rates in Patients at Risk for Pseudarthrosis

STUDY DESIGN

A prospective multicenter clinical trial (NCT03177473) was conducted with a retrospective cohort used as a control arm.

OBJECTIVE

The purpose of this study was to evaluate cervical spine fusion rates in subjects with risk factors for pseudarthrosis who received pulsed electromagnetic field (PEMF) treatment.

SUMMARY OF BACKGROUND DATA

Certain risk factors predispose patients to pseudarthrosis, which is associated with prolonged pain, reduced function, and decreased quality of life.

METHODS

Subjects in the PEMF group were treated with PEMF for 6 months postoperatively. The primary outcome measure was fusion status at the 12-month follow-up period. Fusion status was determined using anterior/posterior, lateral, and flexion/extension radiographs and computed tomography (without contrast).

RESULTS

A total of 213 patients were evaluated (PEMF, n=160; Control, n=53). At baseline, the PEMF group had a higher percentage of subjects who used nicotine ( P =0.01), had osteoporosis ( P <0.05), multi-level disease ( P <0.0001), and were >65 years of age ( P =0.01). The PEMF group showed over two-fold higher percentage of subjects that had ≥3 risk factors (n=92/160, 57.5%) compared with the control group (n=14/53, 26.4%). At the 12-month follow-up, the PEMF group demonstrated significantly higher fusion rates compared with the control (90.0% vs. 60.4%, P <0.05). A statistically significant improvement in fusion rate was observed in PEMF subjects with multi-level surgery ( P <0.0001) and high BMI (>30 kg/m 2 ; P =0.0021) when compared with the control group. No significant safety concerns were observed.

CONCLUSIONS

Adjunctive use of PEMF stimulation provides significant improvements in cervical spine fusion rates in subjects having risk factors for pseudarthrosis. When compared with control subjects that did not use PEMF stimulation, treated subjects showed improved fusion outcomes despite being older, having more risk factors for pseudarthrosis, and undergoing more complex surgeries.

Practical Methods of Assessing Coronal Alignment and Outcomes in Adult Spinal Deformity Surgery: A Comparative Analysis

STUDY DESIGN

Asymptomatic cohort: prospective, cross-sectional, multicenter. Symptomatic: retrospective, multisurgeon, single-center.

OBJECTIVE

To assess the association between cranial coronal alignment and adult spinal deformity (ASD) surgical risk and outcomes.

SUMMARY OF BACKGROUND DATA

ASD leads to decreased quality of life. Studies have shown that coronal malignment (CM) is associated with worse surgical outcomes.

MATERIALS AND METHODS

A total of 468 adult participants were prospectively enrolled in the asymptomatic cohort. Totally, 172 symptomatic ASD patients with 2-year follow-ups were retrospectively enrolled in the symptomatic cohort. Three cranial plumb line parameters: the positions of the plumb lines from the midpoint between the medial orbital rims (ORB-L5), the odontoid (OD-L5), and the C7 centroid (C7-L5) relative to the L5 pedicle, were measured. Each subject had plumb line medial (M), touching (T), or lateral (L) to either pedicle. The association between each group of patients and radiographic parameters, intraoperative variables, patient-reported outcomes, and clinical outcomes were analyzed.

RESULTS

In the asymptomatic cohort, OD-L5 was medial to or touching the L5 pedicle in 98.3% of volunteers. In the symptomatic patients, preoperative OD-L5-L exhibited higher mean age (56.2±14.0), odontoid-coronal vertical axis (OD-CVA) (5.5±3.3 cm), Oswestry disability index (ODI) score (40.6±18.4), pelvic fixation rate (56/62, 90.3%), OR time (528.4±144.6 min), median estimated blood loss (1300 ml), and durotomy rate (24/62, 38.7%). A similar pattern of higher CVA, preoperative ODI, intraoperative pelvic fixation rate, OR time, estimated blood loss, and durotomy rate was observed in ORB-L5-L and C7-L5-L patients. Final follow-up postoperative OD-L5-L was associated with higher rates of proximal junctional kyphosis (13.0%) and pseudarthrosis (17.4%).

CONCLUSION

Preoperative OD-L5, ORB-L5, and C7-L5 lateral to pedicles were associated with worse preoperative ODI and higher intraoperative complexity. Postoperative OD-L5-L was associated with higher rates of proximal junctional kyphosis and pseudarthrosis. Postoperative CM, approximated by the cranial plumb line lateral to the L5 pedicles, was associated with sagittal plane complications.

Impact of Teriparatide on Complications and Patient-Reported Outcomes of Patients Undergoing Long Spinal Fusion According to Bone Density

BACKGROUND

Surgery for adult spinal deformity (ASD) poses substantial risks, including the development of symptomatic pseudarthrosis, which is twice as prevalent among patients with osteoporosis compared with those with normal bone mineral density (BMD). Limited data exist on the impact of teriparatide, an osteoanabolic compound, in limiting the rates of reoperation and pseudarthrosis after treatment of spinal deformity in patients with osteoporosis.

METHODS

Osteoporotic patients on teriparatide (OP-T group) were compared with patients with osteopenia (OPE group) and those with normal BMD. OP-T patients were matched with OPE patients and patients with normal BMD at a 1:2:2 ratio. All patients had a minimum 2-year follow-up and underwent posterior spinal fusion (PSF) involving >7 instrumented levels. The primary outcome was the 2-year reoperation rate. Secondary outcomes included pseudarthrosis with or without implant failure, proximal junctional kyphosis (PJK), and changes in patient-reported outcomes (PROs). Clinical outcomes were analyzed using conditional logistic regression. Changes in PROs were analyzed using a mixed-effects model.

RESULTS

Five hundred and forty patients (52.6% normal BMD, 32.9% OPE, 14.4% OP-T) were included. In the unmatched cohort, 2-year reoperation rates (odds ratio [OR] = 0.45 [95% confidence interval (CI): 0.20 to 0.91]) and pseudarthrosis rates (OR = 0.25 [95% CI: 0.08 to 0.61]) were significantly lower in the OP-T group than the OPE group. Seventy-eight patients in the OP-T group were matched to 156 patients in the OPE group. Among these matched patients, at 2 years, 23.1% (36) in the OPE group versus 11.5% (9) in the OP-T group had a reoperation (OR = 0.45, p = 0.0188), 21.8% (34) versus 6.4% (5) had pseudarthrosis with or without implant failure (OR = 0.25, p = 0.0048), and 6.4% (10) versus 7.7% (6) had PJK (OR = 1.18, p = 0.7547), respectively. At 2 years postoperatively, PROs were better among OP-T patients than OPE patients. Subsequently, 78 patients in the OP-T group were matched to 156 patients in the normal BMD group. Among these matched patients, there was no significant difference in 2-year reoperation (OR = 0.85 [95% CI: 0.37 to 1.98]), pseudarthrosis (OR = 0.51 [95% CI: 0.181 to 1.44]), and PJK rates (OR = 0.77 [95% CI: 0.28 to 2.06).

CONCLUSIONS

Osteoporotic patients on teriparatide demonstrated lower reoperation and symptomatic pseudarthrosis rates 2 years postoperatively compared with osteopenic patients. Moreover, patient-reported and clinical outcomes for osteoporotic patients on teriparatide were not different from those for patients with normal BMD.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

SPECT/CT and PET/CT for the Evaluation of Persistent or Recurrent Pain After Spine Surgery: A Systematic Review and Case Series

OBJECTIVE

The differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery.

METHODS

A systematic review was conducted according to PRISMA guidelines across 5 databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies.

RESULTS

A total of 2,444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine.

CONCLUSIONS

PET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging.

Approche de la douleur chronique au poignet chez les adultes: Revue des pathologies courantes à l'intention des praticiens des soins primaires

OBJECTIF

Élaborer une approche pour déterminer, investiguer et initialement prendre en charge les causes courantes de la douleur chronique au poignet que voient les professionnels des soins primaires.

SOURCES DE L'INFORMATION

Les données probantes et la littérature scientifique pertinentes ont été recensées à l'aide de la base de données PubMed.

MESSAGE PRINCIPAL

Les consultations pour une douleur chronique au poignet sont fréquentes en soins primaires. L'anatomie complexe du poignet est propice à la multiplicité des diagnostics différentiels. Les éléments de l'anamnèse, les constatations aux examens physiques et aux investigations, et la prise en charge qui sont applicables aux pathologies suivantes sont présentés : pseudarthrose du scaphoïde, arthrose de l'articulation carpométacarpienne du pouce, instabilité du ligament scapholunaire, lésions au complexe triangulaire fibrocartilagineux, ténosynovite de De Quervain, tendinopathie de l'extenseur ulnaire du carpe, syndrome du tunnel carpien et kystes ganglionnaires. Lors de l'évaluation de la douleur chronique au poignet, l'imagerie diagnostique par radiographies peut servir d'outil auxiliaire important, mais ne devrait pas l'emporter sur la suspicion clinique. L'imagerie avancée (tomodensitométrie ou imagerie par résonance magnétique) devrait généralement être plus judicieusement prescrite par un chirurgien de la main, lorsqu'il s'agit de préciser le diagnostic et d'orienter le traitement.

CONCLUSION

La douleur chronique au poignet est un problème invalidant sur le plan fonctionnel, dont la prise en charge optimale est un diagnostic et un traitement sans délai. Une anamnèse et un examen physique rigoureux sont les pierres angulaires d'une évaluation efficace. Lorsque le diagnostic est tardif, certaines pathologies du poignet peuvent entraîner des issues relativement défavorables, comme la pseudarthrose du scaphoïde causant une arthrose diffuse du poignet.

Biomechanical comparison of two different compression screws for the treatment of odontoid fractures in human dens axis specimen

BACKGROUND

Lag screw osteosynthesis for odontoid fractures has a high rate of pseudoarthrosis, especially in elderly patients. Besides biomechanical properties of the different screw types, insufficient fragment compression or unnoticed screw stripping may be the main causing factors for this adverse event. The aim of the study was to compare two screws in clinical use with different design principles in terms of compression force and stability against screw stripping.

METHODS

Twelve human cadaveric C2 vertebral bodies were considered. Bone density was determined. The specimens were matched according to bone density and randomly assigned to two experimental groups. An odontoid fracture was induced, which were fixed either with a 3.5 mm standard compression screw or with a 5 mm sleeve nut screw. Both screws are certified for the treatment of odontoid fractures. The bone samples were fixed in a measuring device. The screwdriver was driven mechanically. The tests were analyzed for peak interfragmentary compression and screw-in torque with a frequency of 20 Hz.

FINDINGS

The maximum fragment compression was significantly higher with screw with sleeve nut at 346.13(SD ±72.35) N compared with classic compression screw at 162.68(SD ±114.13) N (p = 0.025). Screw stripping occurred significantly earlier in classic compression screw at 255.5(SD ±192.0)° rotation after reaching maximum compression than in screw with sleeve nut at 1005.2(SD ±341.1)° (p = 0.0039).

INTERPRETATION

Screw with sleeve nut achieves greater fragment compression and is more robust to screw stripping compared to classic compression screw. Whether the better biomechanical properties lead to a reduction of pseudoarthrosis has to be proven in clinical studies.

L1-pelvic angle: a convenient measurement to attain optimal deformity correction

PURPOSE

(1) Evaluate the associations between L1-pelvic angle (L1PA) and both sagittal vertical axis (SVA) and T1-pelvic angle (T1PA), and (2) assess the clinical impact of L1PA.

METHODS

A single-institution retrospective cohort study was undertaken for patients undergoing adult spinal deformity (ASD) surgery from 2013 to 2017. Ideal L1PA was defined as (0.5xPelvic Incidence)-21. Pearson correlation was performed to compare L1PA, SVA, and T1PA. Univariate/multivariate regression was performed to assess the effect of L1PA on mechanical complications, controlling for age, BMI, and postoperative pelvic incidence-lumbar lordosis mismatch (PI/LL). Due to the overlapping nature of patients with pseudarthrosis and rod fracture, these patients were analyzed together.

RESULTS

A total of 145 patients were included. Mean preoperative L1PA, SVA, and T1PA were 15.5 ± 8.9°, 90.7 ± 66.8 mm, and 27.1 ± 13.0°, respectively. Mean postoperative L1PA, SVA, and T1PA were 15.0 ± 8.9°, 66.7 ± 52.8 mm, and 22.3 ± 11.1°, respectively. Thirty-six (24.8%) patients achieved ideal L1PA. Though the correlation was modest, preoperative L1PA was linearly correlated with preoperative SVA (r2 = 0.16, r = 0.40, 95%CI = 0.22-0.60, p < 0.001) and T1PA (r2 = 0.41, r = 0.62, 95%CI = 0.46-0.76, p < 0.001). Postoperative L1PA was linearly correlated with postoperative SVA (r2 = 0.12, r = 0.37, 95%CI = 0.18-0.56, p < 0.001) and T1PA (r2 = 0.40, r = 0.62, 95%CI = 0.45-0.74, p < 0.001). Achieving ideal L1PA ± 5° was associated with a decreased risk of rod fracture/pseudarthrosis on univariate and multivariate regression (OR = 0.33, 95%CI = 0.12-0.86, p = 0.024). No association between achieving ideal L1PA and patient-reported outcomes was observed.

CONCLUSION

L1PA was modestly correlated with SVA and T1PA, and achieving ideal L1PA was associated with lower rates of rod fracture/pseudarthrosis. Future studies are warranted to better define the clinical implications of achieving a normal L1PA.

LEVEL OF EVIDENCE

III.

Scaphoid fracture non-union: a systematic review of the arthroscopic management

BACKGROUND AND AIM

There is no consensus regarding the most appropriate treatment of scaphoid nonunion. This systematic review aimed to investigate whether wrist arthroscopy exerts a positive influence on bone union and clinical outcomes.

METHODS

We searched the literature on Medline (PubMed), Web of Science, Embase and Scopus databases using the combined keywords "scaphoid" AND "arthroscopy" AND "pseudoarthrosis" OR "nonunion". Eighteen studies were finally included in our review. The quality of the studies was assessed using the Coleman Methodological Score.

RESULTS

Our systematic review has shown that arthroscopic management of scaphoid nonunion achieves a high rate of union and satisfactory clinical outcomes with minimal complications.

CONCLUSIONS

There is need to perform randomized controlled trials reporting on the use of arthroscopy. In addition, the different pattern of pseudoarthrosis should be better classified to manage the patients who will benefit after the management.

Complications and Avoidance in Adult Spinal Deformity Surgery

Adult spinal deformity (ASD) is a complex disease that can result in significant disability. Although surgical treatment has been shown to be of benefit, the complication rate in the perioperative and postoperative periods can be as high as 70%. Some of the most common complications of ASD surgery include intraoperative cerebrospinal fluid leak, high blood loss, new neurologic deficit, hardware failure, proximal junctional kyphosis/failure, pseudarthrosis, surgical site infection, and medical complications. For each of these complications, one or more strategies can be utilized to avoid and/or minimize the consequences.

Lumbar Pedicle Subtraction Osteotomy (PSO): A Novel Surgical Technique for Correction of Sagittal and Coronal Imbalance Using Laterally Based Satellite Rods

STUDY DESIGN

Operative video and supplemental manuscript.

OBJECTIVE

To present a novel step-by-step approach to performing a lumbar pedicle subtraction osteotomy (PSO) using laterally based satellite rods.

SUMMARY OF BACKGROUND DATA

Multi-rod constructs have demonstrated paramount for decreasing rates of pseudarthrosis after PSOs. Multi-rods constructs can be achieved using either "satellite" rods (rods not connected to the primary rods) and/or "accessory rods" (rods connected to the primary rods).

METHODS

A step-by-step approach to performing a lumbar PSO using a laterally based satellite rod configuration is provided through a case example and surgical technique video.

RESULTS

Lateral satellite rods can be particularly useful from a surgical perspective, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site (symmetric and/or asymmetric), and serve as the final fixation rods across the PSO without needing to be exchanged.

CONCLUSIONS

Use of laterally based satellite rods is a useful technique for lumbar PSOs, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site, and serve as the final fixation rods across the PSO without needing to be exchanged.

"Mother and baby plate": a strategy to improve stability in proximal fractures of the ulna

INTRODUCTION

Proximal ulna fractures with a large zone of comminution, such as in the context of Monteggia injuries, require mechanically strong osteosyntheses as they occur in regions with high physiological joint load. Consequently, implant failure and pseudarthrosis are critical and devastating complications, especially with the background of mainly young patients being affected. An effective solution could be provided by adding a small second plate 90° angulated to the standard dorsal plate in the area of non-union. Thus, this study investigates whether, from a biomechanical point of view, the use of such a mini or baby plate is worthwhile.

MATERIALS AND METHODS

Comminuted fractures distal to the coronoid process, equivalent to Jupiter type IIb fractures, are generated on artificial Sawbones® of the ulna and stabilized using two different plate osteosyntheses: in the first group, a dorsal locking compression olecranon plate is used (LCP group). In the second group, a small, ulnar 5-hole olecranon plate is added as a baby plate in addition to the mother plate at the level of the fracture zone (MBP group). Dynamic biomechanical loading in degrees of flexion from 0° to 90° is carried out to determine yield load, stiffness, displacement, and changes in fracture gap width as well as bending of the dorsal plate.

RESULTS

The "mother-baby-plate" osteosynthesis had a significantly higher yield load (p < 0.01) and stiffness (p = 0.01) than the LCP group. This correlates with the increased movement of the proximal fracture element during cyclic testing for the LCP group compared to the MBP group as measured by an optical metrology system.

CONCLUSIONS

Here, we show evidence that the addition of a small plate to the standard plate is highly effective in increasing the biomechanical stability in severe fractures equivalent to Jupiter type IIb. As it hopefully minimizes complications like pseudarthrosis and implant failure and as the additional preparatory effort leading to compromised blood supply is regarded to be negligible, this justifies and highly advises the use of a mother-baby-plate system.

Lower 25-hydroxyvitamin D (25OHD) levels, diabetes and age are associated with foot and ankle fracture treatment complications

Objective

This study investigated the nutritional status, 25-hydroxyvitamin D (25OHD), albumin and risk factors associated with complications in patients with foot and ankle fragility fractures.

Subjects and methods

Prospective study, developed with patients who suffered fractures due to fragility of the foot and ankle (n = 108); the type of fractured bone, fracture mechanisms and classification were studied and also pseudoarthrosis, treatment, surgical dehiscence, anthropometry, 25OHD and albumin. The Chi-square or Fisher's exact test, Mann-Whitney and Kruskal-Wallis tests were used in the statistical analysis and the multiple logistic regression analysis was used to identify the risk factors associated with complications.

Results

The factors that, together, were associated with treatment complications were the level of 25OHD (p = 0.0055; OR = 0.868 [1,152]; 95% CI = 0.786; 0.959 [1.043;1.272]) and diabetes (p = 0.0034; OR = 30,181; 95% CI = 3.087; 295.036). The factors that, together, were associated with the presence of any complication, were age (p = 0.0139; OR = 1.058; 95% CI = 1.011; 1,106) and 25OHD level (p = 0.0198; OR = 0.917; 95% CI = 0.852; 0.986). There was a complication probability above 0.40 associated with lower 25OHD levels (values below 20 ng/mL) and older age (over 50 years).

Conclusion

Lower or abnormal levels of 25OHD were associated with pseudoarthrosis, and age and 25OHD were both risk factors for treatment complications in patients with foot and ankle fractures.

Is lower screw density associated with mechanical complications in adult spinal deformity surgery?

PURPOSE

To assess the impact of screw density on: (1) rod fracture/pseudarthrosis, (2) proximal/distal junctional kyphosis/failure (PJK/DJK/PJF), and (3) deformity correction judged by sagittal vertical axis (SVA) and T1-pelvic angle (T1PA).

METHODS

A single-center, retrospective cohort study of patients undergoing adult spinal deformity (ASD) surgery from 2013 to 2017 was undertaken. Screw density was calculated by dividing the number of screws placed by the total instrumented levels. Screw density was then dichotomized at our calculated mean density to ≥ 1.65 and < 1.65. Outcomes consisted of mechanical complications and the amount of correction obtained.

RESULTS

145 patients underwent ASD surgery with 2-year follow-up. Mean screw density (range) was 1.6 ± 0.3 (1.00-2.00). The most common levels with missing screws were L2 (n = 59, 40.7%), L3 (n = 57, 39.3%) and L1 (n = 51, 35.2%), located mainly along the concavity in 113(80.0%) patients and apices in 98 (67.6%) patients. Rod fracture/pseudarthrosis: 23/32 (71.8%) patients with rod fracture and 35/46 (76.0%) with pseudarthrosis had missing screws within two levels of the rod fracture/pseudarthrosis. Logistic regression showed no significant association between screw density and rod fracture/pseudarthrosis.

PJK/F

15/47 (31.9%) patients with PJK and 9/30 (30.0%) with PJF had missing screws within three levels of the upper instrumented vertebra (UIV). Logistic regression showed no significant association between screws density and PJK/F. Correction obtained: linear regression failed to show any significant association between screw density and SVA or T1PA correction.

CONCLUSION

These findings showed that no significant association was found between screw density and mechanical complications or the amount of correction obtained, though approximately 3 out of 4 patients with rod fracture/pseudarthrosis had missing screws at or within two levels of the pathology. The prevention of mechanical complications is likely multifactorial and subject to both patient's characteristics and surgical techniques.

LEVEL OF EVIDENCE

III.

[Unity is Strength - the Underrated Strength of Tendons in Pseudoarthrosis]

Bei einem Sturz beim Fußballspielen zog sich der gesunde, damals 38 Jahre alte Patient eine skapholunäre (SL-) Bandläsion links zu. In Folge waren innerhalb von sieben Jahren insgesamt 13 operative Eingriffe nötig, bis eine vollständige Konsolidation der zuletzt angestrebten Skapho-Trapezio-Trapezoidal-(STT)-Arthrodese erreicht wurde. 5 Jahre nach der Verletzung auf der linken Seite kam es im Rahmen eines Distorsionstraumas rechts ebenfalls zu einer SL-Bandverletzung bei dem Patienten. Bei einem Stadium Geissler III wurde in einem auswärtigen Spital eine dynamische Stabilisierung mit einer ECRL-Sehnenplastik durchgeführt. Bei zunehmender SL-Dissoziation wurde aufgrund der Erfahrung mit der gleichen Problematik links schlussendlich eine Panarthrodese des rechten Handgelenkes vorgenommen.

Measuring compressive loads on a 'smart' lumbar interbody fusion cage: Proof of concept

There are several complications associated with lumbar interbody fusion surgery however, pseudarthrosis (non-union) presents a multifaceted challenge in the postoperative management of the patient. Rates of pseudarthrosis range from 3 to 20 % in patients with healthy bone and 20 to 30 % in patients with osteoporosis. The current methods in post-operative follow-up - radiographs and CT, have high false positive rates and poor agreement between them. The aim of this study was to develop and test a proof-of-concept load-sensing interbody cage that may be used to monitor fusion progression. Piezoresistive pressure sensors were calibrated and embedded within a polyether ether ketone (PEEK) interbody cage. Silicone and poly (methyl methacrylate) (PMMA) were inserted in the graft regions to simulate early and solid fusion. The load-sensing cage was subjected to distributed and eccentric compressive loads up to 900 N between synthetic lumbar vertebral bodies. Under maximum load, the anterior sensors recorded a 56-58 % reduction in pressure in the full fusion state compared to early fusion. Lateral regions measured a 36-37 % stress reduction while the central location reduced by 45 %. The two graft states were distinguishable by sensor-recorded pressure at lower loads. The sensors more effectively detected left and right eccentric loads compared to anterior and posterior. Further, the load-sensing cage was able to detect changes in endplate stiffness. The proof-of-concept 'smart' cage could detect differences in fusion state, endplate stiffness, and loading conditions in this in vitro experimental setup.

One miniplate versus two miniplates in the fixation of mandibular angle fractures. An updated systematic review and meta-analysis

PURPOSE

The aim of this study is to compare the outcomes after using one miniplate fixation in the external oblique ridge versus two miniplate fixation for mandibular angle fractures.

METHODS

A systematic review of MEDLINE (via PubMed), Scopus and Cochrane Library database was performed (last search date: 04 February 2022) according to the PRISMA guidelines. The research question was addressed using the PICO criteria. Only comparative studies between the two techniques were included. Random-effects model meta-analyses were performed.

RESULTS

Seventeen studies, comprising a total of 1667 patients, 846 undergoing one miniplate fixation and 854 undergoing two miniplate fixation for mandibular angle fractures were identified. No statistically significant differences were observed regarding surgical site infection (odds ratio [OR]= 0.94, 95% confidence interval [CI]: [0.69] - [1.28], p = 0.68, I²=0.00%), post-operative malocclusion (OR= 0.97, 95% CI: [0.53] - [1.18], p = 0.25, I²=0.00%), post-operative neurosensory dysfunction (OR= 0.67, 95% CI: [0.37] - [1.22], p = 0.19, I²=73.93%), pseudoarthrosis formation (OR=0.90, 95% CI: [0.58] - [(1.39], p = 0.63, I²=0.00%). Wound dehiscence was marginally less common in the one miniplate group (OR=0.52, 95% CI: [0.28] - [0.98], p = 0.04, I²=54.34%). The probability of scarring formation (OR=0.13, 95% CI: [0.05] - [0.32], p = 0.00, I²=0.00%) and hardware failure (OR=0.36, 95% CI [0.21] - [0.62], p = 0.00, I²=29.33%) were statistically significantly higher in the two miniplates arm.

CONCLUSION

One miniplate fixation and two miniplates fixation of mandibular angle fractures have similar results regarding post operative infection, malocclusion, neurosensory dysfunction and pseudoarthrosis formation while wound dehiscence, hardware failure and scarring seem to be more common when two miniplates are used as a fixation technique.

[Application of cortical bone trajectory screw and sacral alar screw internal fixation for surgical treatment of lumbar adjacent segment degeneration]

Objective: To explore the application of cortical bone trajectory screw (CBTS) and sacral alar screw (SAS) internal fixation in the treatment of lumbar adjacent segment degeneration (ASD) and evaluate its clinical effect. Methods: Data of 24 patients who were diagnosed with ASD and treated by CBTS or SAS in Beijing Chaoyang Hospital were retrospectively reviewed. There were 14 males and 10 females with a mean age of (67.9±8.2) years. The patients were followed-up for (2.6±0.4) years. Perioperative parameters including operation time, intraoperative blood loss and postoperative time on the ground were counted. All patients were followed-up for at least 2 years. Visual analogue scale (VAS) and the Oswestry disability index (ODI) were compared between pre-operation and at the last follow-up. The internal fixation-related complications, pseudarthrosis and adjacent re-degeneration were evaluated in the follow-up. Results: There were 14 proximal ASD patients, 8 distal ASD patients, 1 both ends ASD patient and 1 ASD patient in between the fusion surgeries. Bone mineral density (BMD) T score of the adjacent vertebrae was -1.98±0.91 on average. The ASD patients were re-operated with CBTS and SAS internal fixation technique. A small incision was made in the revision surgery and the original fixation was not completely cut open and removed. The mean operation time was (125±36) min, mean blood loss was (85±33) ml. The postoperative ambulation time was (3.1±1.9) days, and the hospitalization time was (9.0±2.6) days. Before the operation, the average VAS (back pain) score was 5.2±1.0, the average of VAS (leg pain) score was 6.8±1.9 and ODI was 56.6%±12.8%. VAS score was reduced to 1.4±0.6 (waist pain) and 0.9±0.4 (leg pain). ODI was improved to 13.8%±6.3%. All the difference between preoperative and the last follow-up was statically significant (all P<0.01). No internal fixation failure, pseudarthrosis and adjacent re-degeneration were observed in the final follow-up. Conclusion: The application of CBTS and SAS internal fixation techniques in the surgical treatment of lumbar ASD has the advantages of less trauma, faster postoperative recovery, reliable internal fixation, and fewer complications, especially in patients with low bone mineral density.

How I do it? Uniportal full endoscopic pseudoarthrosis release of left L5/S1 Bertolotti's syndrome under intraoperative computer tomographic guidance in an ambulatory setting

BACKGROUND

There is limited literature on technique full endoscopic pseudoarthrosis release of Bertolotti syndrome.

METHODS

Uniportal full endoscopic pseudoarthrosis release technique applies for patients presenting with symptomatic Bertolotti's syndrome. Full-thickness endoscopic drilling is carried out from most ventrolateral margin of pseudoarthrosis articulating with the highest part of sacral ala (PH) point to dorsal medioinferior margin of pseudoarthrosis adjacent to superior articular process (MS) point. Complete pseudoarthrosis release was confirmed with an intraoperative 3D imaging system.

CONCLUSION

The uniportal full endoscopic pseudoarthrosis release is a good alternative to open surgery to release pseudoarthrosis in L5/S1 Bertolotti's syndrome in an ambulatory setting.

C1-C2 Injury: Factors influencing mortality, outcome, and fracture healing

BACKGROUND

C1-C2 injury represents 25-40% of cervical injuries and predominantly occurs in the geriatric population.

METHODS

A prospective multicentre study was conducted under the aegis of the french spine surgery society (SFCR) investigating the impact of age, comorbidities, lesion type, and treatment option on mortality, complications, and fusion rates.

RESULTS

A total of 417 patients were recruited from 11 participating centres. The mean ± SD age was 66.6 ± 22 years, and there were 228 men (55%); 5.4% presented a neurological deficit at initial presentation. The most frequent traumatic lesion was C2 fracture (n = 308). Overall mortality was 8.4%; it was 2.3% among those aged ≤ 60 years, 5.0% 61-80 years, and 16.0% > 80 years (p < 0.001). Regarding complications, 17.8% of patients ≤ 70 years of age presented with ≥ 1 complication versus 32.3% > 70 years (p = 0.0009). The type of fracture did not condition the onset of complications and/or mortality (p > 0.05). The presence of a comorbidity was associated with a risk factor for both death (p = 0.0001) and general complication (p = 0.008). Age and comorbidities were found to be independently associated with death (p < 0.005). The frequency of pseudoarthrosis ranged from 0 to 12.5% up to 70 years of age and then constantly and progressively increased to reach 58.6% after 90 years of age.

CONCLUSIONS

C1-C2 injury represents a serious concern, possibly life-threatening, especially in the elderly. We found a major impact of age and comorbidities on mortality, complications, and pseudarthrosis; injury pattern or treatment option seem to have a minimal effect.

Analysis of Gene Expression of Pseudoarthrosis Tissue in Congenital Short Femur, Initial Study and First Exprerience

PURPOSE OF THE STUDY Although the congenital short femur is morphologically well characterized, changes at the molecular level have not been described in the literature so far. The absence of such information, along with the unknown aetiology of the defect, was the motivation for analysing angiogenesis and osteogenesis in the pseudoarthrosis (false joint) tissue in PFFD patients compared to physiological bone. The authors expected differences in gene expression, particularly in the quantity of expressed genes. MATERIAL AND METHODS A piece of bone was removed during an elective surgery procedure, placed in an RNA stabilization reagent, which prevents RNA degradation, and deep frozen. Thereafter, RNA was isolated and the profile of transcription was analysed by biochip analysis (SuperArray Bioscience Corporation). In total, it is possible to detect 113 genes of osteogenesis and angiogenesis. From the end of 2005 until the end of 2008, samples of 7 patients with PFFD and 3 physiological bone samples were examined. Several analyses were repeated to confirm the results; in total 13 chips for osteogenesis and 11 chips for angiogenesis expression were used. RESULTS Differences in the quantity and representation of the genes were noted. Some genes were considered over-expressed in PFFD tissue compared with the control sample (e.g. the gene for calcitonin receptor, collagen XII, I alpha 2, collagen II, IX, FGFR2, fibronectin, integrin) and other genes under-expressed (e.g. the gene for annexin A5, collagen XVIII alpha1, collagen I alpha1, cathepsin K, FGFR1, FGFR3, IGF2, VEGFB). CONCLUSIONS The differences in gene expression confirmed the authors' hypothesis. So far, the results cannot be generalized; this is the first step for follow-up experiments to confirm the suggested information and to integrate it with clinical findings, such as the alternative blood supply of affected extremity in some patients. Key words: proximal femoral focal deficiency, gene expression, microarray analysis, angiogenesis, osteogenesis.

Anterior reconstruction versus posterior osteotomy in treating Kümmell's disease with neurological deficits: A systematic review

OBJECTIVE

This study aimed to conduct a systematic review of literature comparing the clinical effectiveness and safety between anterior reconstruction (AR) and posterior osteotomy (PO) in the treatment of Kümmell's disease with neurological deficits.

METHODS

We systematically reviewed the literature in PubMed, EMBASE, Cochrane Database of Systematic Reviews, and the Web of Science for "spin*," "surg*," "Kümmell's disease," "Kummell's disease," "Kummell disease," "vertebral osteonecrosis," "vertebral pseudarthrosis," "intravertebral vacuum cleft," "delayed vertebral collapse," and "compression fracture nonunion". Quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation method.

RESULTS

A total of 10 publications involving 268 Kümmell's disease patients with neurological deficits were included in this review, with 7 studies of low- or very low-quality. There were 37.7% and 62.3% of patients receiving AR and PO, respectively. For clinical outcomes, AR group showed no significant differences in pain, neurological dysfunction, and imaging outcome improvements compared with patients who underwent PO. However, the incidence of implant-related complications including loose screw, screw fracture, screw disconnection, and plate dislodgment, was higher in AR group compared with PO group (21.6% vs. 14.3%). As another major complication, AR group more often required a second surgery.

CONCLUSION

This systematic review demonstrated that both AR and PO could improve pain, neurological dysfunction and imaging outcomes. However, serious comorbidities, multilevel corpectomies and/or severe osteoporosis highly required PO. Design discrepancies were found in the current studies, further higher-quality studies are warranted.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Prognostic factors for post surgical complications in bone infection and pseudarthrosis]

Bone infection and nonunion are the main orthopedic and traumatic complications whose treatment remains a challenge because multiple factors are involved in the rate of failures when you try to correct them. Knowing these factors were the problem that caused the research through a prospective longitudinal study of 83 patients of 43.3 ± 16.1 years old. They were treated for aseptic and septic nonunion, osteomyelitis, osteitis, malunion or infected joint replacement. The cases were classified with or without postoperative complications and outcome related to systemic and local factors taken prognostic model Cierny-Mader as factors affecting immune surveillance, metabolism and local vascularization. For bivariate analysis of data Χ² it was applied or where appropriate Fishers exact test; for multivariate analysis model not conditional binary logistic regression method was applied Wald backward to select the significant prognostic factors. The alpha error was set 0.05. General complications occurred in 51.8% of cases. Local factors (lymphedema, arteritis, venous insufficiency, loss of skin) with an OR of 5.0 (95% CI 1.0-24.9, p = 0.03), septic nonunion with OR of 5.0 (95% CI 1.9-13.0, p = 0.001) and segmental fractures with an OR of 3.2 (95% CI 0.8-13.0, p = 0.07) were the prognostic factors identified in the bivariate analysis; however, the logistic regression only selected as the septic pseudoarthrosis as a significant factor. It is necessary to detect and if necessary control or eliminate those factors that can directly affect poor postoperative results.

Anterior cervical fusion: the role of anterior plating

Treatment of cervical pathology requires a clear understanding of the biomechanical benefits and limitations of cervical plates, their indications, and their associated complications. The use of anterior cervical plates has evolved significantly since their early application in cervical trauma. They have become widely used for anterior cervical decompression and fusion for cervical spondylosis. Plate design has undergone significant refinement and innovation, from the initial unlocked plates requiring bicortical purchase to the latest rotationally and translationally semiconstrained dynamic plates. Excellent clinical results have been reported for single-level anterior cervical decompression and fusion with or without plate fixation; however, the addition of an anterior cervical plate clearly leads to earlier fusion and better clinical results in longer fusions. Longer fusions should ideally consist of corpectomies and strut grafting because the decreased number of fusion surfaces tends to lead to higher fusion rates. Although anterior plate fixation leads to higher fusion rates in fusions of three or more levels, the associated pseudarthrosis rate is still high. The use of dynamic plates, through increased load sharing across the graft and decreased stress shielding, may improve fusion rates, particularly in long fusions. Nevertheless, adjuvant posterior fixation is recommended for fusions of more than three vertebral levels. Anterior plate fixation may be of particular benefit in the management of traumatic injuries, in revision settings, and in the treatment of smokers. Complications unique to plate fixation include hardware breakage and migration as well as ossification of the adjacent disk levels.

"Sandwich technique" in the surgical treatment of primary complex fractures of the femur and humerus

In this prospective study, our aim was to determine the clinical and radiographic outcomes of the surgical treatment of primary complex problem femoral and humeral shaft fractures treated by a new technique called "sandwich technique." A total of 45 patients with comminuted, complex and/or osteopoenic fractures of the femur or humerus (30 femoral and 15 humeral fractures) were treated using this technique. The patients were followed up for a mean of 25 months. In 24 (85.7%) of 28 patients with femoral fractures and in 14 (93.3%) of 15 patients with humeral fractures, union was achieved within 3-6 months of the operation (mean: 4.5 months). The total union rate was 88.4%. The pseudoarthrosis rate was 12%. There was no infection or implant failure seen during the follow-up period. The cortical allograft struts can be used to provide collateral support to weakened osteopoenic/osteoporotic bone. This technique provides a union rate of about 88% in osteoporotic and/or complex primary humerus or femur fractures.

Pseudarthrosis of the hip joint

1. The operation of pseudarthrosis of the hip joint is described and the results are assessed in ninety-three patients.

2. The result was good in eighty-three cases and poor in seven cases. Three patients died as a result of the operation.

3. Pseudarthrosis is the most satisfactory and the most reliable operation: 1) in ankvlosing spondylitis, and 2) in patients over sixty years of age with disabling osteoarthritis.

4. The more formidable operation of cup arthoplasty may prove to be superior in younger patients with osteoarthritis.

Pseudarthrosis of the tibia in childhood

1. The results of the by-pass grafting operation in eleven cases of pseudarthrosis of the tibia in childhood are presented.

2. The operation was successful in securing sound bone union in nine cases, and unsuccessful in two.

3. The causes of failure in the two unsuccessful cases are analysed.

4. The possible causes of occurrence and persistence of tibial pseudarthrosis in childhood are discussed.

5. It is suggested that the pseudarthrosis results from a fatigue fracture of a congenitally abnormal tibia, but that its persistence depends entirely on mechanical factors.

6. There is evidence to suggest that the underlying congenital abnormality may arise from dysplasia of the mesenchyme.

Anterior lumbar interbody fusion with threaded fusion cages and autologous bone grafts

The goal of this study was to evaluate the ability of Ray threaded fusion cages, when used in an anterior approach, to restore intervertebral height and to improve the functional and occupational performance of the patients. The present study was initiated because insertion of fusion cages through a posterior approach causes destruction of facet joints and violation of the spinal canal. The anterior approach for insertion of threaded fusion cages to accomplish lumbar interbody fusion was evaluated in a series of 13 patients suffering monosegmental disc disease. The patients' functional and occupational performance was evaluated using the Prolo score. Radiological measurements were used to evaluate disc height and degree of penetration into the endplates, and to confirm fusion. Seven of the 13 patients were short-term failures and had to be revised within 2 years. The study found that revised patients had poorer Prolo scores than non-revised patients. Although for the non-revised patients, the mean Prolo scores remained relatively stable during the 1st year, they dropped after 3 years. We were not able to identify any further clinical or radiological differences between the groups. These results indicate that although the anterior approach seems technically suitable for insertion of threaded fusion cages, destruction of the anterior longitudinal ligament and the anterior part of the annulus fibrosis appears to result in destabilisation of the motion segment.

The surgical treatment of nonunion of the proximal metaphysis of the femur

Nonunion of the proximal femur is a severe pathology, often provoked by the inopportune or improper use of a therapeutic aid: nonsurgical (primary nonunion), surgical (secondary nonunion). Surgical treatment of this nonunion may thus be characterized by different degrees of difficulty, depending on whether or not it is the sequela of surgery or of nonsurgical treatment. In lax nonunion, with atrophy of the segments and regions of necrotic bone interposed, modeling resection is required to correct the functional axes. The condylar blade-plate may be opposed by a cortical graft--to improve stability of the assembly--protecting the medial wall and providing the screws with excellent hold.

Congenital pseudarthrosis of the clavicle

1. Congenital pseudarthrosis of the clavicle is described.

2. The distinction from cranio-cleido-dysostosis and from birth fracture is stressed.

3. Details are given of two patients reported in the literature and a further nine patients are described.

4. The embryology, natural history and treatment of the condition are discussed.

Anterior cervical discectomy and fusion

A retrospective review of 94 patients who had undergone anterior cervical discectomy and fusion was performed to analyze the result in patients who had a diagnosis of posterolateral spondylosis, disc herniation, or both. Although in 23 of 94 patients additional adjacent asymptomatic levels of spondylosis were noted, only the symptomatic levels were addressed in the 94 cases. Postoperatively two cases of dysphagia were noted, as well as a 4% pseudarthrosis rate. There was an 88% good or excellent result when no additional spondylosis was present, but only a 60% good or excellent result when just the symptomatic levels were addressed, leaving unoperated adjacent levels of spondylosis.

Bone reconstruction after giant-cell tumor resection at the proximal end of the humerus with vascularized iliac crest graft. A report of three cases

Giant-cell tumors at the proximal humerus were treated by wide excision and immediate bone replacement using free vascularized iliac crest grafts. The early results (30 months) in three patients have been satisfactory.

[Stimulation of reparative osteogenesis with chips of allogenic bone matrix]

Results of the clinical application of decalcified bone (bone matrix) in the treatment of patients with the delayed consolidation of bone fractures, false articulation, bone defects and other pathology have shown the bone matrix to be a good stimulator of reparative osteogenesis.

[Creation of reaction-less pseudoarthrosis on the ulna of the dog (author's transl)]

The model situation of so called "avital, avascular" pseudoarthrosis was surgiclly induced in 25 beagle dogs using defectosteotomy and heat-necrotization of both ulna bones. The clinical evolution was examined weekly using roentgengraphy and each 4th week by scintigraphy. According to roentgen pictures three stages can be identified: 1. Reaction of the bone on surgical trauma (until 4th week). 2. Sequestration or asepticosteolysis (until 18th week). 3. Consolidation of the pseudoarthrosis model-situation (after 18th week). Scintigraphy revealed by the continuing so called "avital" pseudoarthrosis an enhanced metabolism activity at the tips of both bone fragments. The cause for these active metabolic processes evoking enhanced activity on both fragment ends during scintigraphy wich is not demonstrable with roentgen device are the pulling, pushing and tensile strengths originating from a connective-tissue-cord existing between them. The results of scintigraphy lead us to use the term "reaction-less pseudoarthrosis" instead of "avascular" or "avital" for this model of pseudoarthrosis.

Disc excision and spine fusion in the management of lumbar disc disease. A minimum ten-year followup

Seventy-nine percent of 312 patients who underwent lumbar disc surgery were evaluated at least 10 years postoperatively (mean equal to 13.7 years). Residual back and nerve root symptoms and functional impairment were equally as common among the 143 patients who underwent fusion as they were among the 64 patients who did not. Thirty percent of the patients whose spines were fused and 37.7% of those patients whose spines were not fused were considered long-term failures because of persistent symptoms or the need for reoperation. Thirty-seven percent of the fusion patients had persistent graft donor site symptoms. Examined patients showed a high percentage of residual neurologic defects. An unexplained positive Trendelenburg sign was present in 14.8% of the fusion patients and in 18.2% of the patients whose spines were not fused. Although retrospective studies often have problems of accuracy, this analysis confirms other observations that midline spinal fusion offers few benefits in the management of lumbar disc disease.

[Multiple fractures of the lower extremities (a propos of 50 patients)]

According to a study of 50 multiple fractures of the lower limbs, the frequency of associated lesions justifies the creation of new multiple injury units, well equipped in which may be found specialists of all branches of surgery. Although internal fixation in one stage as an emergency, is ideal in all fractures, one should in fact be circumspect for the danger of infection should lead one to avoid carrying out internal fixation if this is not absolutely necessary.