Dual versus Single Attending Surgeon Performance of Spinal Deformity Surgery? A Meta-Analysis

BACKGROUND

The inclusion of two surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intra-operative blood losses. Therefore, this meta-analysis will assess the benefits of a having two surgeons compared to one surgeon during spine surgeries.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss (EBL).

RESULTS

Thirteen studies were included. A greater rate of complications was seen in patients operated upon by one surgeon (OR=0.50; 95% CI: 0.25-0.99, p=0.05). Furthermore, operative room time (MD=-82.73; 95% CI: -111.42- -54.03, p<.001), and LOS (MD=-0.91; 95% CI: -1.12- -0.71, p<.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes.

CONCLUSION

The presence of two surgeons in the OR was shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach.

Will ChatGPT be Able to Replace a Spine Surgeon in the Clinical Setting?

OBJECTIVE

This study evaluates ChatGPT's performance in diagnosing and managing spinal pathologies.

METHODS

Patients underwent evaluation by two spine surgeons (and the case was discussed and a consensus was reached) and ChatGPT. Patient data, including demographics, symptoms, and available imaging reports, were collected using a standardized form. This information was then processed by ChatGPT for diagnosis and management recommendations. The study assessed ChatGPT's diagnostic and management accuracy through descriptive statistics, comparing its performance to that of experienced spine specialists.

RESULTS

A total of 97 patients with various spinal pathologies participated in the study, with a gender distribution of 40 males and 57 females. ChatGPT achieved a 70% diagnostic accuracy rate and provided suitable management recommendations for 95% of patients. However, it struggled with certain pathologies, misdiagnosing 100% of vertebral trauma and facet joint syndrome, 40% of spondylolisthesis, stenosis, and scoliosis, and 22% of disc-related pathologies. Furthermore, ChatGPT's management recommendations were poor in 53% of cases, often failing to suggest the most appropriate treatment options and occasionally providing incomplete advice.

CONCLUSIONS

While helpful in the medical field, ChatGPT falls short in providing reliable management recommendations, with a 30% misdiagnosis rate and 53% mismanagement rate in our study. Its limitations, including reliance on outdated data and the inability to interactively gather patient information, must be acknowledged. Surgeons should use ChatGPT cautiously as a supplementary tool rather than a substitute for their clinical expertise, as the complexities of healthcare demand human judgment and interaction.

Hybrid vs all pedicle screws constructs in adolescent idiopathic scoliosis: a metaanalysis of clinical and radiological outcomes

BACKGROUND

Adolescent idiopathic scoliosis (AIS) affects around 1 to 3% of young individuals, leading to spinal deformities typically exceeding a Cobb angle of 10 degrees without congenital or neuromuscular causes. Advances in treatment now include various surgical techniques such as posterior fusion utilizing all-pedicle screw constructs or hybrid constructs.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until February 2024. Comparative studies in which the cohort was separated into two groups (HC and PSC) were included. Data consisting of, surgery-related outcomes, sagittal radiographic outcomes, coronal radiographic outcomes, and patient-reported outcomes, was extracted and compared.

RESULTS

Twenty-eight studies including 3435 patients were included. Higher rates of complications (Odds-Ratio = 1.99, p < 0.00001) and reoperations (Odds-Ratio = 2.82, p < 0.00001) were seen in the hybrid group. Better radiographic coronal correction was seen in the PSC group in both the major curve (Mean Difference = 5.97, p < 0.00001) and the secondary curve (Mean Difference = - 10.73, p < 0.0001). However, restoration of sagittal alignment was better in the HC group when assessing thoracic kyphosis (Mean Difference = 2.97, p = 0.02) and lumbar lordosis (Mean Difference = 3.17, p = 0.005).

CONCLUSION

While all-pedicle screw constructs demonstrated greater stability in AIS compared to hybrid constructs, resulting in reduced rates of reoperations and complications, as well as improved correction of major and secondary curves, they were unable to fully restore optimal sagittal alignment.

Implant density in adolescent idiopathic scoliosis: a meta-analysis of clinical and radiological outcomes

BACKGROUND

Adolescent idiopathic scoliosis (AIS) affects 1-3% of adolescents, and treatment approaches, including the density of constructs in surgical fusion, vary among orthopedic surgeons. Studies have sought to establish whether high-density or low-density constructs offer superior clinical and radiological outcomes, yet conclusive results are lacking. This meta-analysis aims to provide a definitive answer to the controversial and ambiguous question surrounding the efficacy of different pedicle screw densities in treating AIS.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. The studied outcomes were Major Cobb angle, major curve correction, lumbar curve, kyphosis (T5-T12), lumbar lordosis, coronal balance, LIV Tilt angle, TAV translation, LAV translation, apical trunk rotation, trunk shift, SRS-22, operative time, blood loss, complications and cost.

RESULTS

Twenty-four studies (total of 1985 patients, 1045 in LD group and 940 in HD group) were included in this meta-analysis. A statistically significant better improvement in ATR (p = 0.02) and LIV tilt angle (p = 0.02) was seen in the high-density group. On the other hand, longer operative time (p = 0.002), blood loss (p = 0.0004) and costs (p = 0.02) were seen in the high-density group. No difference was seen in the remaining radiographic and clinical outcomes between both surgeries.

CONCLUSION

Both low-density (LD) and high-density (HD) screw constructs show comparable and satisfactory radiographic and QOL for AIS patients. Furthermore, HD constructs had increased costs, operative time, and blood loss associated. However, a definitive conclusion cannot be made and more studies taking into account multiple additional variables are necessary to do so.

Intensive Care Unit Admission After Spine Surgery: A Narrative Review

INTRODUCTION

Intensive care unit (ICU) admissions constitute a substantial financial challenge for health care systems and patients and are linked to various potentially life-altering complications. A wide range of patient-related, surgical, and medical factors are associated with an increased risk of ICU admission following spine surgery.

DISCUSSION

The most notable examples include lung, heart, and kidney disease, as well as estimated blood loss and length of surgery. Various scores that include the most significant patient- and procedure-related factors have been described to assess the risk associated with surgery for individual patients. To date, the fusion risk score and the American Society of Anesthesiologists score have been the most useful in predicting postoperative complications and admission to the ICU. However, other risk factors have also been implicated in ICU admission and length of stay. The current scores must further adapt by using the available evidence to fulfill their intended purpose. Moreover, a handful of measures have shown efficacy in decreasing ICU admission and length of stay, with their benefits still to be demonstrated by future research.

CONCLUSION

This review underscores the risk factors predictive of ICU admission following spine surgery and will help surgeons and clinicians in patient stratification. However, future studies are needed to validate the role of protective measures in preventing ICU admissions and the significance of certain risk factors.

Unilateral Versus Bilateral Cages in Lumbar Interbody Fusions: A Meta-Analysis of Clinical and Radiographic Outcomes

BACKGROUND

Bilateral cages are often used for interbody fusion. However, this procedure may not be possible in some cases making unilateral cages a reasonable alternative. The literature remains divided on the clinical and radiological distinctions when comparing unilateral to bilateral cages in lumbar interbody fusion. Thus, this meta-analysis will analyze the clinical and radiographic outcomes between these 2 groups.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, surgery-related parameters, and patient reported outcomes.

RESULTS

Lower rates of pseudoarthrosis, subsidence, were reported in the bilateral cages group (P = 0.01, P = 0.001, respectively) whereas shorter operative time (OR time), and lower estimated blood loss were seen in unilateral cage group (P < 0.001, and P = 0.003). There was no statistically significant difference in the remaining analyzed outcomes.

CONCLUSIONS

Unilateral cages were shown to be superior due to their reduced OR time and estimated blood loss. As for the higher rate of pseudoarthrosis, this outcome may not be related to the cage numbers and it did not affect clinical outcomes. Nevertheless, one must consider other factors such as radiographic sagittal parameters before making a surgical decision.

Pulsed lavage in joint arthroplasty: A systematic review and meta-analysis

BACKGROUND

Knee and hip osteoarthritis affects millions of people around the world and is expected to rise even more in frequency as the population ages. Joint arthroplasty is the surgical management of choice in these articulations. Heterotopic ossification and radiolucent lines formation are two frequent problems faced in hip and knee replacements respectively. Some studies show that the usage of pulsed lavage may prevent their formation.

AIM

To compare pulsed lavage to standard lavage in joint arthroplasty.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. Only comparative studies were included. The clinical outcomes evaluated were the heterotopic ossification formation in hip replacements, radiolucent lines formation, and functional knee scores in knee replacements.

RESULTS

Four studies met the inclusion criteria and were included in this meta-analysis. Pulsed lavage was shown to reduce the formation of radiolucent lines (P = 0.001). However, no difference was seen in the remaining outcomes.

CONCLUSION

Pulsed lavage reduced the formation of radiolucent lines in knee replacements. No difference was seen in the remaining outcomes. Furthermore, the clinical significance of these radiolucent lines is poorly understood. Better conducted randomized controlled studies and cost-effectivity studies are needed to reinforce these findings.

Approaches in Anterior Column Support in Adult Spinal Deformity Surgery: A Meta-Analysis of Clinical and Radiologic Outcomes

OBJECTIVE

This meta-analysis was conducted to compare anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) in terms of postoperative complications, improvement in radiographic parameters, and patient-reported outcomes.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) databases were searched up to June 2023. The studied outcomes were the rate of rod failures, rod failures requiring revision surgery, all complications, all revision surgeries, the change in pelvic tilt, sacral slope, Cobb angle, lumbar lordosis (LL), sagittal vertical axis, the postoperative pelvic incidence-LL, and LL, and the improvement in back pain and Oswestry Disability Index (ODI).

RESULTS

Six studies were included in this meta-analysis. ALIF showed higher postoperative lordosis (P = 0.003) and better improvement in ODI (P = 0.0001). No difference was seen in the remaining outcomes between ALIF and TLIF.

CONCLUSIONS

Although ALIF had better improvement in ODI, the mean difference was 6.5 points, which is below the minimal clinically important difference, stripping this result of any clinical value. Furthermore, even though ALIF had better postoperative lordosis, the change in LL postoperatively was not different between ALIF and TLIF. With no difference in complications, sagittal and coronal alignment, and patient-reported outcomes, TLIF was shown in this study to be favored instead of ALIF in adult spinal deformity surgery to avoid all the double approach-related comorbidity.

Management of Bennett's fracture: A systematic review and meta-analysis

Background

First described in 1882, Bennett's fracture is an intra-articular fracture of the first metacarpal associated with a dislocation of the carpometacarpal joint. Usually, open reduction internal fixation is used to manage such fractures. However, closed reduction has shown good outcomes recently. This meta-analysis compares closed reduction to open reduction internal fixation in the management of Bennett's fracture.

Methods

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until August 2023. The clinical outcomes consisted of post-traumatic arthritis, grip and pinch strengths, range of motion, functional scores, and mean adduction deformity.

Results

Six retrospective studies were included in this meta-analysis. Our results show higher grip and pinch strengths, better extension and flexion of the thumb, and lower mean adduction deformity in the open reduction internal fixation group.

Conclusion

Higher grip and pinch strengths, better extension and flexion of the carpometacarpal joint, and a smaller mean adduction deformity of the thumb in the open reduction internal fixation group. No differences were seen in the remaining outcomes. However, a higher rate of complications is associated with open reduction internal fixation. Nevertheless, more randomized controlled studies are needed to confirm such results.

Level of evidence

III.

Tyrosine kinase inhibitors in osteosarcoma: Adapting treatment strategiesa

Osteosarcoma (OS) is an aggressive primary bone malignancy that metastasizes rapidly. The standard of care has changed little over the previous four decades, and survival rates have plateaued. In this context, tyrosine kinase inhibitors (TKIs) emerge as potential treatments. A literature search was conducted to collect data related to receptor tyrosine kinase genetic alterations and expression in OS specimens. Gene amplification and protein expression of these receptors were linked to prognosis and tumor behavior. Relevant TKIs were evaluated as monotherapies and as parts of combination therapies. Certain TKIs, such as apatinib, regorafenib, and cabozantinib, present a potential therapeutic avenue for OS patients, especially when combined with chemotherapy. Producing long-lasting responses and enhancing quality of life remain key goals in OS treatment. To this effect, optimizing the use of TKIs by identifying biomarkers predictive of response and assessing promising TKIs in larger-scale trials to validate the efficacy and safety outcomes relative to these drugs reported in phase II clinical trials. To this effect, it is necessary to identify biomarkers predictive of response to TKIs in larger-scale trials and to validate the efficacy and safety of these drugs reported in phase II clinical trials.

Management of Displaced Metacarpal Shaft Fractures: A Systematic Review and Meta-analysis

Background

Affecting mainly the working population, metacarpal shaft fractures account for up to 31% of hand fractures. To manage this entity, conservative management can be equal to operative management. However, surgeons tend to favor operative management in order to reduce the rate of complications, such as shortening and malunion. This meta-analysis was conducted to compare conservative to operative management of displaced metacarpal shaft fractures.

Methods

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until August 2023. The clinical outcomes consisted of postoperative shortening, Disabilities of Arm, Shoulder, and Hand (DASH) score, and mean grip strength.

Results

Only three studies were included in this meta-analysis. Operative management was shown to reduce postoperative shortening (p<0.00001). However, conservative management had a better postoperative DASH score (p=0.001).

Conclusion

Better DASH scores were seen in the conservative group, but there was a higher postoperative shortening. However, studies have shown that the shortening has no effect on the functional outcome. Nevertheless, more randomized controlled studies and cost-effectiveness studies are needed to confirm these findings.

Epidemiology of bone tumors in Lebanon: a retrospective study from 2000 to 2022 at a tertiary center

Aim

Bone tumors are rare and have an uneven geographic distribution.

Methods

730 patients diagnosed with bone tumors were included in this retrospective analysis.

Results

With a 64% rate of malignancy, the most common tumors were metastasis (40%) mostly in the axial skeleton, Osteosarcoma (9%) mostly in the femur, Osteochondroma (8%) mostly in the femur, giant cell tumors (7%) mostly in the knee, and Ewing's sarcoma (6%) mostly in the axial skeleton.

Conclusion

Even though a some of the tumors have a predilection for certain localizations in the human body, they may differ in the middle-eastern population. One must also pay attention to the higher rates of malignancies as compared with other cohorts.

What is the best referral strategy for axial spondyloarthritis? A prospective multicenter study in patients with suspicious chronic low back pain

OBJECTIVE

To assess the value of referral strategies for axial spondyloarthritis (axSpA) in patients with suspicious chronic inflammatory low back pain (LBP), to estimate the value of inflammatory back pain (IBP) for referral, and to identify the predictive factors of the final diagnosis of axSpA in Middle Eastern Arab countries.

METHODS

The study was multicentric, prospective, and conducted in LBP first-line clinics (rheumatology, internal, family medicine, orthopedic surgery, neurosurgery, and neurology). Consecutive adult patients aged under 45years were included in case of LBP suspicious of inflammatory nature according to the first-line physician. The rheumatologist's final diagnosis was the gold standard. The diagnostic properties of ten referral strategies (Brandt I, II, III, Hermann, RADAR, RADAR 2/3, MASTER, Braun, CAFASPA, and ASAS) and of IBP were calculated. A multivariable logistic regression identified the clinical predictive factors of axSpA.

RESULTS

In 515 referred patients, axSpA was confirmed in 48%, refuted in 43%, and diagnosis remained inconclusive in 9%. The optimal referral strategy was the MASTER (PLR 3.3), which comprises IBP, good response to NSAIDs, positive HLA-B27, and SpA family history. Considering strategies without HLA-B27, the RADAR 2/3 had a PLR of 2.9 (IBP, good response to NSAIDs, any extra-musculoskeletal manifestation). The predictive factors for axSpA were MRI sacroiliitis, positive HLA-B27, high CRP, psoriasis, IBP, and longer symptom duration. Of all patients, 35% were self-referred, 16% were referred by primary care physicians, and 15% by neuro/orthopedic surgeons.

CONCLUSION

Optimizing physicians' awareness of these clinical features may enhance referral in axSpA.

Transforaminal lumbar interbody fusion using banana-shaped and straight cages: meta-analysis of clinical and radiological outcomes

PURPOSE

Transforaminal lumbar interbody fusion (TLIF) surgery rate increased over the last decade. There is no consensus about the better shape of cage to use in TLIF. This meta-analysis was conducted to compare the shape focusing on bony union, lordosis restoration as well as perioperative complications.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched till September 2022. The clinical outcomes consisted of the bony union, segmental and lumbar lordosis restoration, quality of life, and operation-related outcomes.

RESULTS

Only 5 studies were included in this meta-analysis. Straight-shaped cages tended to have a lower subsidence rate compared to banana-shaped cages (p = 0.10), had a better restoration of segmental lordosis (p < 0.0001), better disc height restoration (p = 0.01), as well as a higher Oswestry Disability Index decrease (p = 0.0002).

CONCLUSION

Straight-shaped cages had a better restoration of lumbar lordosis, disc height, and a lower subsidence rate when compared to banana-shaped cages. This may be explained by the absence of the optimal placement of the curved cages, which is at the most anterior part of the disc space. Better conducted randomized controlled trial could strengthen these findings.

Exceptional Spinal Mobility Caused by Charcot Disease: Case Description with Several Years of Follow-Up

A spinal cord injury is now the most common cause of Charcot Spinal Arthropathy (CSA). Paraplegia, loss of pain sensation, laminectomies, and spinal fusions involving more than 5 levels are all risk factors for developing this condition. Low back pain and spinal abnormalities are common symptoms. Circumferential arthrodesis is the chosen treatment. Implant failure and new-onset CSA, which necessitates re-instrumentation, are some of the risks associated with this treatment. This is the case of a patient with a post-traumatic spinal cord injury presenting with spinal Charcot disease with a very long follow-up. We report a unique complication with the replacement of the discal space and portions of the vertebral bodies by fibrotic tissue with an extraordinary spinal movement in the coronal and sagittal planes. Recurrent Charcot disease at the same level or at a caudal level is a devastating complication in spinal surgery. Since this disease naturally exposes the patient to iterative surgeries, it would be wise to limit the extent of the arthrodesis to an optimal number of levels sufficient to ensure perfect stability of the construct and not to be very extensive from the first surge. The risk would increase the fused levels which limit the availability of mobile buffer levels and increase the stress on the remaining levels. Regular follow-ups to the patient should be done to detect recurrence at the same site or distal to the instrumentation.

Molecular and biologic biomarkers of Ewing sarcoma: A systematic review

With an annual incidence of less than 1%, Ewing sarcoma mainly occurs in children and young adults. It is not a frequent tumor but is the second most common bone malignancy in children. It has a 5-year survival rate of 65-75%; however, it has a poor prognosis when it relapses in patients. A genomic profile of this tumor can potentially help identify poor prognosis patients earlier and guide their treatment. A systematic review of the articles concerning genetic biomarkers in Ewing sarcoma was conducted using the Google Scholar, Cochrane, and PubMed database. There were 71 articles discovered. Numerous diagnostic, prognostic, and predictive biomarkers were found. However, more research is necessary to confirm the role of some of the mentioned biomarkers. .

Vertebroplasty versus Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: A Meta-Analysis

BACKGROUND

One of the most frequent consequences of osteoporosis is osteoporotic vertebral compression fractures, which makes it one of the most prevalent health care crises in the world. Two things are needed to manage them: 1) pain management, and 2) fracture stabilization. To take care of both, 2 methods are commonly used: 1) vertebroplasty and 2) kyphoplasty (KP) without a clear consensus on which is the better one. A meta-analysis was done comparing both techniques in the management of osteoporotic vertebral compression fractures.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched updated to October 2022. Two reviewers determined the eligibility of the studies independently. Only 8 studies were included in the meta-analysis. The clinical outcomes consisted of the complications (cement leakage, adjacent level fractures), the visual analog scale scores, Oswestry disability index, kyphotic wedge angle, and vertebral body height restoration.

RESULTS

KP was shown to be superior to vertebroplasty in terms of reducing cement leakage, and increasing postoperative vertebral body height. The comparison of the rest of the outcomes was statistically insignificant between both techniques.

CONCLUSIONS

Although KP could significantly increase postoperative vertebral body height and decrease the risk of cement leakage, the fact that it is more costly and has a longer operative time raises the question about the cost effectiveness of the procedure.

Scheuermann's kyphosis: update on pathophysiology and surgical treatment

Scheuermann's Kyphosis (SK) is a rigid spinal kyphosis. Several theories have been proposed concerning its pathogenesis, but it is, to this day, still unknown. It has a prevalence of 0.4-8.3% in the population with a higher incidence in females. Clinical examination with x-rays is needed to differentiate and confirm this diagnosis. Non-surgical management is reserved for smaller deformities and in skeletally immature patients, whereas surgery is recommended for higher deformities. Combined anterior and posterior approach was considered the gold standard for the surgical treatment of this disease, but there is an increasing trend toward posterior-only approaches especially with use of segmental fixation. This study reviews the pathophysiology of SK while proposing a treatment algorithm for its management.

Posterior scoliosis correction with thoracoplasty: effect on pulmonary function with a mean follow-up of 4.8 years

PURPOSE

To perform a study to investigate the influence of posterior scoliosis surgery and thoracoplasty on pulmonary function.

METHODS

This was a retrospective observational study of 37 patients with AIS who underwent posterior instrumented surgical correction with thoracoplasty. There was a minimum of 2 years follow-up. Clinical outcomes were measured using the SRS-22 questionnaires. Radiological outcomes were evaluated using standing posteroanterior and lateral radiographs. All patients had pulmonary function tests to evaluate pulmonary volume and flow (forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC)) both before surgery and at the final follow-up.

RESULTS

There were three males and 34 females. The mean age of patients was 14.6 years (range 11-21 years). The mean length of follow was 58 months (range 24-124 months). The average main thoracic Cobb angle in the coronal plane was corrected from 50.0° ± 12.4° preoperatively to 16.6° ± 6.3° postoperatively. The average thoracolumbar Cobb angle in the coronal plane was corrected from 28.2° ± 10.6° preoperatively to 10.1° ± 7.2°. The average thoracic kyphosis angle was corrected from 17.4° ± 11.0° preoperatively to 21.8° ± 10.5°. In terms of the Quality of life Outcomes (QoL), there was a significant increase (p < 0.001) in the mean SRS 22 scores from 3.8 preoperatively to 4.3 postoperatively. A statistically significant increase in the absolute forced expiratory volume in one second (FEV1) from pre-operative values with a p value < 0.001 was seen. There was a statistically significant increase in percentage predicted forced expiratory volume in one second from preoperative values with a p value of 0.008. There was also a statistically significant increase in the absolute forced vital capacity (FVC) from preoperative values with a p value < 0.001. The average percentage predicted forced vital capacity did increase on final follow-up from before surgery, but the increase was not statistically significant.

CONCLUSIONS

We have demonstrated that pulmonary function post-thoracoplasty not only reaches pre-operative levels, but significantly surpasses it with regards to the majority of the pulmonary parameters measured in this study. We also demonstrated satisfactory radiological correction and clinical outcomes.

Congenital scoliosis: a narrative review and proposal of a treatment algorithm

Congenital scoliosis (CS) is a spinal deformity resulting from underlying spinal malformations with an incidence of 0.5–1/1000 births.

CS makes up 10% of scoliotic deformities, of which 25% do not progress, 25% progress mildly and 50% need treatment depending on the age, curve characteristics and magnitude and type of anomaly.

CS is associated with non-vertebral anomalies (genitourinary, musculoskeletal, cardiac, ribs anomalies, etc.) and intraspinal anomalies (syrinx and tethered cord).

Imaging should include whole spine X-rays, CT scanner with reconstruction to better delineate the vertebral anomalies and MRI to visualize the neural elements.

Treatment of CS in the majority of cases is non-surgical and relies on fusion techniques (in situ fusion and hemiepiphysiodeis), resection techniques (hemiverterba resection), and growth-friendly techniques (distraction and instrumentation without fusion).

Posterior Minimally Invasive Transpedicular Approach for Giant Calcified Thoracic Disc Herniation

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Posterior surgery for thoracic disc herniation was associated with increased morbidity and mortality and new minimally invasive approaches have been recommended for soft disc herniation but not for calcified central disc. The objective of this study is to describe a posterolateral microscopic transpedicular approach for central thoracic disc herniation.

METHODS

This is a single center retrospective review of all the cases of giant thoracic calcified disc herniation as defined by Hott et al. Presence of myelopathy, percentage of canal compromise, T2 hypersignal, ASIA score, and ambulatory status were recorded. This posterolateral technique using a tubular retractor was thoroughly described.

RESULTS

Eight patients were operated upon with a mean follow-up of 16 months. Mean canal compromise was 61%. Mean operative time was 228 minutes and mean operative bleeding was 250 mL. There were no cases of dural tear or neurologic degradation.

CONCLUSION

This is the first report of posterior minimally invasive transpedicular approach for giant calcified disc herniation. There were neither cases of neurological deterioration nor increased rate of dural tears. This technique is thus safe and could be recommended for treatment of this rare disease.

Measurement of biceps tendon retraction after arthroscopic tenotomy

BACKGROUND

One of the treatment options for long head of the biceps tendon (LHBT) pathology is tenotomy. To our knowledge, no study in the literature has evaluated the degree of retraction after tenotomy. The goals of this study were to determine the distance of this retraction and to identify its relationship with patient characteristics.

METHODS

We conducted an observational prospective survey over a 3-month period among 30 patients operated on arthroscopically by the same surgeon between August 2018 and April 2019. A radiopaque device was introduced inside the LHBT before tenotomy. Radiographs were obtained to evaluate the distance of retraction on day 1, day 30, and day 90.

RESULTS

Thirty patients were included, of whom 63.3% (19) were women. Surgery was performed for a rotator cuff tear in 10 patients (33.3%) and for subacromial impingement in the remainder of patients (66.7%) after failure of conservative management. The mean retraction of the LHBT (distance between the glenoid and clip) increased from 1.9 cm (day 1) to 3.5 cm (day 90). Three radiographic measurements were performed, and all 3 showed significant increases from day 1 to day 90. According to the Student t test, the mean retraction in the subacromial impingement group was significantly higher than that in the rotator cuff tear group on day 1, day 30, and day 90. Body mass index, younger age, sex, and dominant hand did not show any relation with LHBT retraction (P > .05). The mean LHBT retraction was significantly higher on day 90 in patients presenting with a positive Popeye sign (P < .05).

CONCLUSION

At 3 months of follow-up, the mean LHBT retraction was 3.5 cm from the glenoid and 2.5 cm from the greater tuberosity. It dynamically increased from day 1 to day 90. The LHBT will retract and sit beyond the transverse humeral ligament in the bicipital groove. The LHBT retracts significantly more when early mobilization of the shoulder is allowed.

Is There Still a Place for Convex Hemiepiphysiodesis in Congenital Scoliosis in Young Children? A Long-Term Follow-up

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

To evaluate the long-term effect of convex growth arrest (CGA) on coronal deformity correction in congenital scoliosis.

METHODS

Twenty-two patients with congenital scoliosis operated by 1-staged double approach hemiephysiodesis by bone grafting of the convex side without instrumentation are included. Eighteen curves had an isolated hemivertebra while 4 curves had congenital bar. Subgroup analysis was performed according to age at surgery (3 years cutoff), type of malformation (hemivertebra vs congenital bar), and severity of curve (35° cutoff).

RESULTS

Patients' mean age at surgery was 3 years (range 0.5-8 years), with a mean frontal Cobb angle of 40.59°. Mean follow-up is 10.7 years (range 5.5-25 years). Overall results showed mean frontal Cobb angle reduction of 35.47% (40.59° to 27.41°). Detailed analysis showed that 15 curves had a mean correction of 51.8%, 5 stabilized and 2 had a mean aggravation of 25.11%. Subgroup analysis revealed that patients operated ≤3 years of age had mean cobb angle correction of 43.1% versus 21.49% in patients operated >3 years (P = .140). Mean correction of 44.5% was gained in curves with isolated hemivertebra compared with 1.3% in curves with congenital bar (P = .004). A 58.17% mean correction was reached in curves ≤35° versus 23.68% in curves >35° (P = .032).

CONCLUSIONS

A limited convex hemiepiphysiodesis still has a place in congenital scoliosis care when it is performed in patients ≤3 years old, with curves ≤35°, and with isolated hemivertebra. It spares patients the risks of vertebral resection and instrumentation, while fusing the same number of levels.

Correction of adult spinal deformity with a minimally invasive fusionless bipolar construct: Preliminary results

INTRODUCTION

Fusion in adult spinal deformity has a high rate of complications. Fusionless constructs in children and percutaneous fixation in adults are now being used routinely. The aim of this study was to evaluate the preliminary results of a minimally invasive fusionless surgical technique used to correct adult spinal deformity.

MATERIALS AND METHODS

Thirty-eight patients with an average age of 45 years (15-76) with major spinal deformity requiring extensive arthrodesis from the upper thoracic region to the pelvis were operated consecutively and followed prospectively. Two hooks were implanted at the top and two iliosacral screws at the bottom. Two large rods connected by dominos to two small rods joined the upper hooks to the lower screws. The surgical data (operative time and bleeding), the radiological findings (Cobb angle, sagittal parameters, C7-plumbline AP and lateral), the complication rate and the morbidity were evaluated at the last follow-up visit.

RESULTS

The primary curvature was reduced by 40% from a mean of 58.5° (26-146) to 35.2° (3-109) (p<0.001). A clear decrease in operating time (270min) and blood loss (50cc/level) were observed. The length of hospitalization averaged 18 days (6-66), including an 8-15 day long preoperative traction period for 11 patients. We found 7 infectious complications, 11 early mechanical complications and one case of paraplegia due to severe kyphoscoliosis.

CONCLUSION

The corrections obtained are comparable to those reported in the literature for standard constructs. Most patients had an uneventful postoperative course. The early complications observed led us to very carefully select the indications. Long-term follow-up is essential.

The relationships between bone variables and physical fitness across the BMI spectrum in young adult women

In this cross-sectional study we aimed to evaluate the relationship between physical fitness and bone variables across the body mass index (BMI) spectrum in women aged 20-35 years. The study included 13 underweight women (BMI < 18.5 kg/m²), 24 normal weight women (BMI 18.5-24.9 kg/m²), and 20 overweight/obese women (BMI ≥ 25 kg/m²) aged between 20 and 35 years. Bone mineral density (BMD) and content (BMC) at the whole body, lumbar spine, and femoral neck, lumbar spine trabecular bone score, femoral neck geometry were assessed using dual-energy X-ray absorptiometry. Cardiorespiratory fitness and lower limb muscle power were estimated using the 20-m shuttle run test and the Sargent jump test, respectively. The associations between bone variables and physical fitness were different according to BMI categories. Correlations between physical fitness and bone parameters are particularly significant in normal BMI and less significant in low and high BMI. Multivariate ANCOVA regression models demonstrated that absolute VO_2max (L/min) is a strong determinant of all the bone parameters regardless of BMI. Implementing strategies for increasing VO_2max (L/min) by increasing lean mass and promoting resistance and/or high-intensity interval training could be effective to optimize bone health in underweight and overweight young adult women.

Bone Geometric Properties of the Femoral Neck in Underweight Eumenorrheic Women

The aim of this study was to describe femoral neck (FN) geometry among eumenorrheic underweight women around the age of peak bone mass. Proximal femur geometry and body composition were assessed in 12 underweight women and in 24 healthy controls using dual-energy X-ray absorptiometry. The Hip Structural Analysis program was used to determine bone geometry at the FN. The cross-sectional area (CSA) and the cross-sectional moment of inertia (CSMI) were significantly lower in underweight women than in controls (p < 0.05). There was a trend toward lower sectional modulus (Z) and strength index in underweight women (p < 0.15). Body weight, body mass index, and lean mass (LM) were positively correlated with CSA, CSMI, Z, and neck-shaft angle (r = 0.428-0.611, p < 0.05). After controlling for body weight, body mass index, and LM, the differences in CSA, CSMI, Z, and neck-shaft angle were no more statistically significant between the 2 groups. The multivariate analysis retained LM as the main predictor of CSA, CSMI, and Z in the whole population. The present study suggests that thinness is associated with low resistance to axial forces (CSA) and bending load (Z and CSMI) in adult eumenorrheic women. LM seems to be a key determinant of FN geometry in underweight women.

Percutaneous fixation of thoracolumbar vertebral fractures

Surgical treatment of patients with thoracolumbar vertebral fracture without neurological deficit is still controversial.

Management of vertebral fracture with percutaneous fixation was first reported in 2004.

Advantages of percutaneous fixation are: less tissue dissection; decreased post-operative pain; decreased bleeding and operative time (depending on the steep learning curve); better screw positioning with fluoroscopy compared with an open freehand technique; and a decreased infection rate.

The limitations of percutaneous fixation of vertebral fractures include increased radiation exposure to the patient and the surgeon, together with the steep learning curve for this technique.

Adding a screw at the level of the fractured vertebra has the advantages of incorporating fewer motion segments with less operative time and bleeding. This also increases the axial, sagittal and torsional stiffness of the construct.

Percutaneous fixation alone without grafting is sufficient for treating type A and B1 (AO classification) thoracolumbar fractures with satisfactory results concerning kyphosis reduction when compared with open instrumentation and fusion and with open fixation.

Type C and B2 fractures (ligamentous injuries) should undergo fusion since the ligamentous healing is mechanically weak, increasing the risk of instability.

This review offers a detailed description of percutaneous screw insertion and discusses the advantages and disadvantages.

Cite this article: EFORT Open Rev 2018;3:604-613. DOI: 10.1302/2058-5241.3.170026.

Anterolateral Cervical Kyphoplasty for Metastatic Cervical Spine Lesions

Study Design

Retrospective case series.

Purpose

To evaluate the clinical and radiological efficacy of anterolateral kyphoplasty for cervical spinal metastasis.

Overview of Literature

Although the spine is the third most common site of tumor metastasis, the cervical spine is the least commonly affected (incidence, 10%–15%). Surgical decompression is highly challenging because of the proximity of neural and vascular elements. Kyphoplasty for cervical spine metastasis has been described in small case reports with promising results.

Methods

Retrospective analysis of a prospective collected single-center spine metastasis database was done for cervical kyphoplasty cases. Data pertaining to age, sex, primary tumor diagnosis, modified Tokuhashi score, Spinal Instability Neoplastic Score (SINS), preoperative Visual Analog Scale (VAS) score, and analgesic medication were extracted. Postoperative data included VAS score at postoperative day 1, duration of hospitalization, self-reported functional outcome, and VAS score at the last follow-up.

Results

Eleven patients (mean age, 62.5 years) with cervical spine metastases were treated with 15-level kyphoplasty. Mean Tokuhashi score was 8.1, and mean SINS was 7.85. Mean preoperative pain score was 7.1, and 82% of patients used opioid analgesics. Mean total bleeding volume was 100 mL. Mean complication-free length of stay was 2.6 days with a decrease in postoperative pain (VAS score=2.8, p <0.05). There was a 56% decrease in opioid dosage and the number of consumed analgesics (1.09, p =0.004). Eighty-two percent of the patients reported excellent improvement at the last follow-up self-assessment.

Conclusions

To our knowledge, this case series represents the largest series of vertebral augmentation using balloon kyphoplasty for cervical spinal metastasis. This technique is associated with low postoperative complications as well as significant decrease in pain, use of opioids, and length of hospital stay. The main indications for vertebral kyphoplasty are lytic lesions of the cervical spine, painful lesions refractory to medical treatment, SINS score of 6–10, and absence of posterior wall defect.

Selecting the lowest instrumented vertebra in adolescent idiopathic scoliosis: Comparison of the Lenke, Suk, and Dubousset criteria

BACKGROUND

Selection of the lowest instrumented vertebra (LIV) in patients undergoing selective fusion for Lenke type 1 or 2 adolescent idiopathic scoliosis (AIS) varies widely across centres around the world.

HYPOTHESIS

Lenke, Suk, and Dubousset criteria show moderate agreement for LIV selection.

METHODS

Sixty-eight patients with Lenke type 1 or 2 AIS managed by selective posterior fusion and followed-up for at least 2 years were included in a retrospective observational study. Agreement among Lenke, Suk, and Dubousset criteria for LIV selection was assessed. For surgery, the LIV was selected based on Dubousset criteria. Retrospectively, in each patient, the LIV selected by the Lenke and Suk criteria sets was identified on the preoperative images. The patients were then divided into two groups based on whether the Dubousset LIV was identical versus more distal than the LIV identified retrospectively by the Lenke or Suk criteria. The primary evaluation criterion was coronal balance.

RESULTS

The LIVs selected by the Lenke, Suk, and Dubousset criteria were identical in 57% of cases. The LIV selected by the Dubousset criteria were identical to that selected by the Lenke or Suk criteria in 70% of patients. No significant between-group differences were found for any of the evaluation criteria assessed preoperatively, postoperatively, or at last follow-up.

DISCUSSION

Agreement among the Lenke, Suk, and Dubousset criteria was moderate, confirming the working hypothesis. No coronal malalignment developed in the patients whose actual LIV was distal to the LIV selected by the Lenke or Suk criteria, supporting the validity of Dubousset criteria for LIV selection. When selecting the LIV, all three criteria sets should be assessed. The LIV is the vertebra selected by all three if they agree or by the Dubousset criteria if they do not.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Surgical site infection in spinal metastasis: incidence and risk factors

BACKGROUND

Surgical site infection (SSI) in spinal metastasis surgery represents the most common postoperative surgical complication with high morbidity and mortality.

OBJECTIVE

This study aims to evaluate the incidence of SSI in spinal metastasis surgery and its risk factors.

STUDY DESIGN

This is a retrospective analysis of a prospectively collected data.

METHODS

Preoperative, operative, and postoperative data were collected together with the modified Tokuhashi score and Frankel score at all time checkpoints. Surgical site infection was divided into superficial and deep SSI, as well as early (<90 days) and late SSI. Multiple logistic regression analysis was performed to identify independent risk factors, with p<.05 as significance threshold.

RESULTS

A total of 297 patients were included, with an incidence of SSI of 5.1% (superficial SSI: 3.4%; deep SSI: 1.7 %). Cervicothoracic surgery was associated with the highest incidence of SSI, whereas cervical surgery had the lowest incidence. Smoking, higher number of spinal metastasis, elevated body mass index (BMI), and higher ASA (American Society of Anesthesiologist) score were the preoperative factors associated with increased risk of SSI. Increased intraoperative blood loss and increased number of fixed vertebra increased the SSI incidence. SSI increased hospital stay by a mean of 12 days. When all these variables are analyzed in a multiple regression model, only surgical time≥4 hours and ASA≥3 were found to be independent risk factors for the occurrence of SSI.

CONCLUSION

This paper represents the largest series of spinal metastasis with a mean incidence of SSI of 5.1%. Smoking, higher BMI, higher number of spinal metastasis, higher ASA score, higher number of fused vertebra, intraoperative bleeding≥2000 mL, and neurologic deterioration are risk factors for SSI occurrence. Only ASA≥3 and operative duration≥4 hours are independent risk factors for this complication occurrence. Finally, SSI occurrence is associated with increased hospital stay, increased 30-day mortality rate, and decreased survival rates.

L5 incidence: an important parameter for spinopelvic balance evaluation in high-grade spondylolisthesis

BACKGROUND

In high-grade spondylolisthesis (HGSPL), the pelvic incidence (PI) is not a reliable measurement because of doming of the sacrum. Measurement of L5 incidence (L5I) was described as a tool to measure pelvic morphology in HGSPL and for surgical follow-up.

OBJECTIVE

We aimed to evaluate L5I in HGSPL and its relationship to other spinopelvic parameters.

STUDY DESIGN

A retrospective study of a cohort of 184 patients with HGSPL was carried out.

METHODS

Whole spine radiographs were analyzed for PI, pelvic tilt (PT), sacral slope, lumbar lordosis (LL), L5I, L5 tilt (L5T), L5 slope, lumbosacral kyphosis, and slip percentage. Statistical analysis and correlation were made (Pearson correlation test; p<.05). In accordance to Cohen, statically significant correlation were considered strong if R>0.5, moderate if 0.3<R<0.5, and small if R<0.3.

RESULTS

A total of 184 cases were analyzed, with a female-to-male ratio of 2.35 and a mean age of 20.1 years. Sacral doming was present in 73% of the cases. Mean L5I incidence was 65.2° and strongly correlated to other sagittal parameters, especially PT (R=0.7), LL (R=0.7), L5T (R=0.77), and L5 slope (R=0.83). There was less but still strong correlation to Dubousset lumbosacral kyphosis (Dub-LSK) angle (R=-0.63) and percentage of slippage (R=0.56). L5 tilt showed nearly perfect correlation to PT (R=0.95). Forty-four percent of the cases were balanced HGSPL, whereas 56% of the cases were unbalanced HGSPL. L5 incidence was found to be a good predictor of local imbalance with a cutoff of L5I=61.

CONCLUSION

This paper describes L5I, which is a positional parameter in HGSPL. L5 incidence is a simple and reliable measure in the preoperative setting in HGSPL. Its correlation with spinal sagittal parameters (especially PT and LL) is strong and was found to be better than Dub-LSK. There is also a good correlation between L5I and HGSPL pelvic parameters (slip percentage and lumbosacral kyphosis). We recommend its use for evaluation of surgical correction and recommend the value of 60° as cutoff value to define spinopelvic balance in HGSPL.

Is S1 Alar Iliac Screw a Feasible Option for Lumbosacral Fixation?: A Technical Note

Nonunion at the lumbosacral junction is a classic complication of long construct and deformity corrections. Iliac fixations have been extensively studied in the literature and have demonstrated superior biomechanical proprieties and lower complication rates. S2 alar iliac screws address the drawbacks of classical iliac screws but demonstrate similar biomechanical advantage. The main aim of this paper was to describe the S1 alar iliac (S1AI) screw fixation technique while evaluating our early results. S1AI screw fixation technique has the advantage of being able to achieve pelvic fixation without dissection to the S2 pedicle entry and is therefore a viable option for salvage of a failed S1 promontory screw.

Vitamin D and Trabecular Bone Score in a Group of Young Lebanese Adults

The relationship between vitamin D and trabecular bone score (TBS) in young adults remains unclear. The aim of this study was to explore the relationship between 25-hydroxyvitamin D [25(OH)D] serum levels and TBS in a healthy adult population. A total of 54 men and 61 women whose ages range from 18 to 35 participated in the present study. Participants with 25(OH)D insufficiency (between 21 and 29 ng/mL) were 55.7%, and those with 25(OH)D deficiency (≤20 ng/mL) were 11.4%. TBS positively correlated with 25(OH)D in men (r = 0.393; p <0.05) and women (r = 0.324; p < 0.05). In both genders, TBS was significantly higher in 25(OH)D-sufficient participants (≥30 ng/mL). The present study provides evidence that vitamin D positively affects bone health and suggests that maintaining adequate vitamin D status may be essential for optimal TBS values.

Positive Correlations Between Free Vitamin D and Bone Variables in a Group of Young Lebanese Women

Optimizing bone mass in adulthood is of great importance to prevent the occurrence of osteoporosis in later age. Vitamin D is an essential component of bone health. Low-serum vitamin D is associated with low bone mineral density (BMD), which is an important predictor of fracture risk. However, most cells, apart from renal tubular cells, are exposed to free rather than to total 25-hydroxyvitamin D. Whether free vitamin D would be a better marker than total vitamin D is still under debate. The aim of the present study was to explore the relationships between serum total vitamin D, vitamin D-binding protein (BP), free vitamin D, and bone parameters in a group of young Lebanese women. This study included 88 young female adults aged between 18 and 35 yr. Body composition and BMD were assessed by dual-energy X-ray absorptiometry, and the lumbar spine trabecular bone score was derived. Bone mineral content (BMC) and BMD were measured at the whole body (WB), the lumbar spine (L1-L4), the total hip (TH), and the femoral neck (FN). To evaluate hip bone geometry, dual-energy X-ray absorptiometry scans were analyzed at the FN, the intertrochanteric region, and the femoral shaft by the Hip Structure Analysis program. The cross-sectional area, the index of axial compression strength, and the section modulus (Z), as well as index of bending strength, were measured from bone mass profiles. Composite indices of FN strength (compressive strength index [CSI], bending strength index, and impact strength index [ISI]) were calculated as previously described. Direct measurement of free 25-hydroxyvitamin D concentrations was performed by immunoassay, which detects free vitamin D by ELISA on a microtiter plate. Serum vitamin D BP was measured using a Quantikine ELISA kit, which employed the quantitative sandwich enzyme immunoassay technique. Serum free vitamin D was positively correlated with WB BMC (r = 0.26, p < 0.05), WB BMD (r = 0.29, p < 0.05), L1-L4 BMD (r = 0.28, p < 0.05), TH BMD (r = 0.34, p < 0.01), FN BMD (r = 0.29, p < 0.05), CSI (r = 0.24, p < 0.05), and ISI (r = 0.28, p < 0.05). No positive correlations were detected between the total vitamin D level, the vitamin D BPs, and BMD. The positive associations between free vitamin D and several bone variables (WB BMC, WB BMD, L1-L4 BMD, TH BMD, FN BMD, CSI, bending strength index, and ISI) remained significant after adjustment for weight. In conclusion, the current study suggests that the free vitamin D serum level is a stronger positive determinant of bone parameters and hip bone strength indices in young female adults than total serum vitamin D.

A New, Easy, Fast, and Reliable Method to Correctly Classify Acetabular Fractures According to the Letournel System

Background:

Accurate classification of acetabular fractures remains difficult. To aid in the classification of acetabular fractures and to aid in teaching, our department developed a diagnostic algorithm that involves the use of 1 standardized 3-dimensional reconstruction of a computed tomography (CT) scan (an exopelvic view without the femoral head) with 8 anatomical landmarks. The algorithm was integrated into a smartphone application (app). The main objective of this study was to test the efficacy of this algorithm and smartphone app.

Methods:

Fourteen reviewers (3 experts, 3 fellows, 3 residents, and 5 novice reviewers) evaluated a set of 35 CT scans of acetabular fractures in 2 phases. During the first phase, the scans (including axial 2-dimensional views and 3-dimensional (3D) multiplanar reconstruction views) were assessed by each reviewer twice, with an interval of 4 weeks between the readings to decrease recall bias. During that phase, the reviewers were provided with a diagram of the Letournel classification system with no guidelines for interpretation. During the second phase, performed 4 weeks after the first phase, 1 standardized 3D reconstruction (an exopelvic view without the femoral head) was reviewed twice, with an interval of 4 weeks between the readings. During that phase, the reviewers used the smartphone app. The primary outcome was the accuracy of classification. Interobserver reliability, reading time, and time needed for accurate classification were noted.

Results:

The accuracy of fracture classification was 64.5% when the standard method of analysis was used and 83.4% when the app was used (p < 0.001). Improvement was noted in all groups, with the expert group showing the least improvement (88.6% to 97.2%, p = 0.04) and the novice group showing the most improvement (42.0% to 75.5%, p < 0.001). Furthermore, use of the app greatly increased the accuracy of classification of complex fractures. The average reading time was 71.8 minutes when the standard method was used and 37.4 minutes when the app was used. The interobserver reliability improved in all groups to an excellent reliability (interclass correlation coefficient [ICC] > 0.79).

Conclusions:

The Letournel classification system is difficult to understand and to learn but remains the only system guiding the surgical strategy for acetabular fractures. The impact of diagnostic algorithms is debatable. The most important finding of the present study is the high accuracy for inexperienced groups when the app was used. Another important finding is the high reliability of this method for the diagnosis of complex acetabular fractures.

Fracture liaison service: report on the first successful experience from the Middle East

This study aims to assess for the first time in the Middle East, the clinical benefits of an FLS model established in a hospital in Beirut, Lebanon. It shows a significant 54% relative risk reduction in re-fracture incidence, confirming the patient-oriented benefit of diffusing this system in the Middle East region.

PURPOSE/INTRODUCTION

Few hospitals in Lebanon applied Fracture Liaison Service (FLS) program. A type A FLS is established at Bellevue hospital in Beirut in July 2013. This study aims to assess its clinical benefits and efficacy.

METHODS

Patients aged 50 years and above presenting to our hospital with minimal trauma fracture from July 2012 till June 2014 are enrolled. These are divided into two groups, before (group A) and after (group B) FLS implementation. Both groups are compared for re-fracture incidence, bone health assessment; osteoporosis treatment maintenance, and death in a 2-year follow-up.

RESULTS

Nighty-eight patient composing group B are compared to 100 patients in the group A. Around 65% of patients in the FLS group underwent Dexa osteodensitometry following their fracture compared to 28% in the comparator group (p < 0.001). About 54% of patients in group B maintained osteoporosis treatment compared to 26% in group A (p < 0.001). Sixteen percent of patients died in the FLS study group compared to 16% of patients in the comparator group (p = 0.950). A second fracture, happened in 8.2% of patients in the FLS study group compared to 18% of the patients in the comparator group p = 0.004. Number needed to treat reached 10.2 patients.

CONCLUSIONS

The statistical analysis results go with the overwhelming evidence concerning FLS importance in promoting bone health assessment and osteoporosis treatment in fracture patients. It also confirms the clinical value and the patient-oriented benefit of an implementation of such a system.

Percutaneous cement augmentation for osteoporotic vertebral fractures

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

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

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

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

Early intervention is also gaining ground recently.

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

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

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

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

Improved acetabular fracture diagnosis after training in a CT-based method

BACKGROUND

Acetabular fractures remain challenging to diagnose, particularly when they are complex. An accurate diagnosis is nevertheless crucial to select the best surgical strategy. None of the training methods described to date relies on the Letournel classification with a detailed analysis of each abnormality seen by computed tomography (CT). We therefore prospectively assessed a CT-based diagnostic method by (1) determining the rate of correct diagnoses by orthopaedic surgeons before and after training in the method, (2) comparing the times needed to read the CT images before and after training, (3) and assessing the repeatability of the method.

HYPOTHESIS

Training in the CT-based diagnostic method significantly increases the rate of correct diagnoses.

METHOD

The CT-based diagnostic method involves analysing eight anatomical landmarks in the anterior, posterior, and no man's land zones. From our institutional database (450 cases between 2007 and 2016), we selected 35 acetabular fractures that replicated the overall distribution of fracture types. The images were reviewed by 10 inexperienced and 3 experienced readers before and after they received training in the CT-based diagnostic method. The rates of correct diagnoses and times needed to read the images were compared. Finally, an additional reading was performed to allow an assessment of reproducibility.

RESULTS

After training, the rate of correct diagnoses by the unexperienced readers improved by 16.64% for all fractures combined (from 212/350, 60.5% [37-83%] to 270/350, 77.14% [63-86%]; P=0.001) and by 25.9% for associated fractures (from 90/180, 50% [11-89%] to 114/140, 75.6% [61-90%]; P=0.003). Mean time required by the inexperienced readers to interpret the 35 sets of images decreased after training, from 66.1 to 47.6min (i.e., a 1.22-minute decrease per patient, P=0.001). None of the study variables changed significantly after training of the experienced readers (P>0.05). Reproducibility among the inexperienced readers was 0.78.

CONCLUSION

Analysing the eight anatomical landmarks located in the anterior, posterior, and no man's land zones is a simple and reproducible method for diagnosing all fracture patterns defined by the Letournel classification.

LEVEL OF EVIDENCE

Level III, non-randomised prospective case-control diagnostic study.

The added value of intraoperative CT scanner and screw navigation in displaced posterior wall acetabular fracture with articular impaction

Posterior wall with transverse acetabular fractures represents the most common type of acetabular fractures and is generally associated with poorer outcomes. This is caused by improper visualization of the fragments leading to imperfect reductions. Navigation in pelvic and acetabular trauma is reserved nowadays to non-displaced or mildly displaced fractures. To add to that, perioperative control of reduction is difficult using the conventional X-ray. The described 3D imaging method allowed proper reduction control. On the other hand, screw navigation of acetabular screws enabled better control of screw position as well as screw placement in otherwise inaccessible zones. In conclusion, peroperative 3D imaging and screw navigation optimize fracture reduction promoting better radiological and functional results.

Management of spinal infections in children with cerebral palsy

Cerebral palsy patients who undergo posterior spinal instrumentation for scoliosis are at a greater risk of surgical site infection compared to adolescents with idiopathic scoliosis. Many infecting organisms are reported. Risk factors include patients' specific factors, nutritional status as well as surgery related factors. Although surgical management is still controversial, it is always based on irrigation and debridement followed or not by implant removal. The purpose of this paper is to review the pathophysiology of surgical site infection in this patient population and to propose a treatment algorithm, based on a thorough review of the current literature and personal experience.

DELTOID FLAP for MANAGEMENT of MASSIVE IRREPARABLE ROTATOR CUFF TEARS: Case Series

BACKGROUND

Muscle transfer has been reported as a good surgical option to reconstruct the deficient rotator cuff. The purpose of this study is to report the outcome of deltoid muscle flap transfer to restore shoulder function in patients with massive irreparable rotator cuff tear.

MATERIAL AND METHODS

This is a retrospective descriptive case series. Included patients had a lesion of two or more tendons of the rotator cuff or lesion of one tendon of more than 5 cm in width and no lesion to the subscapularis. Evaluation was done using the Constant score, visual analog scale for satisfaction and quality of life.

RESULTS

Twenty patients met the inclusion criteria. Three patients were lost to follow-up. The remaining (9 males and 8 females) had a mean follow-up period of 40.5 months. The mean age at surgery was 61.3 years. Thirty-five percent of patients were involved in heavy labor while the lesions affected the dominant side in 70% of the cases. Mean preoperative Constant score was 40.8 and increased to 78.8 (p < 0.05) with a difference of +38 points on the raw Constant score and an improvement rate of 64%. The greatest improvement involved essentially pain and quality of life (improvement rate of 82%) (p < 0.05). Eighty-nine percent of patients have good and excellent self-reported results.

CONCLUSION

More than just a salvage procedure, deltoid muscle flap seems to be an adequate option in terms of appropriate pain relief, function recovery as well as patient satisfaction. Keywords: massive rotator cuff tears, deltoid muscle flap

SYNOVIAL CHONDROMATOSIS OF THE POSTERIOR COMPARTMENT OF THE KNEE: A Case Report & Literature Review Focusing on Arthroscopic Treatment

Synovial chondromatosis is a rare panarticular synovial disease affecting large joints and especially the knee. When the disease is localized in the knee, it affects the anterior compartment. We report the case of a posterior localized disease with a review of the literature focusing on arthroscopic treatment.

Is percutaneous proximal gracilis tenotomy as effective and safe as the open procedure?

PURPOSE

There is currently an increasing trend for percutaneous surgical interventions mainly in children with cerebral palsy (CP). The purpose of this study was to evaluate the effectiveness and safety of percutaneous proximal gracilis tenotomy (PPGT) in children with CP scheduled for hip adductor tenotomy.

METHODS

This is a prospective study of 59 hips in 31 consecutive patients with CP scheduled for hip adductor tenotomy in the setting of multilevel tenotomies or hip osteotomy (femoral or Dega). A pediatric orthopedic surgeon conducted a percutaneous adductor longus and gracilis tenotomy through the same stab wound. Another surgeon extended the wound to explore what had been cut during the PPGT, and completed the tenotomy if necessary (open proximal gracilis tenotomy; OPGT). Hip abduction with the hip and knee extended (HA) was assessed by a third surgeon (1) immediately before PPGT, i.e., directly after percutaneous adductor longus tenotomy (prePPGT), (2) after PPGT (postPPGT), and (3) following OPGT (postOPGT), using a goniometer, in a standardized reproducible manner. All three surgeons were blinded to each other's findings. Primary end-points included the percentage of muscle portion sectioned percutaneously and the improvement of HA angle. Comparison between HA before and after PPGT was performed using a paired t test with 95 % confidence interval (CI), and comparison between HA after PPGT and OPGT was performed using a Student's t-test with 95 % CI. The bleeding was assessed and other iatrogenic lesions were identified. The relationship between HA after PPGT and the percentage of muscle portion sectioned percutaneously was evaluated by calculating the Pearson correlation coefficient (p < 0.01).

RESULTS

Mean HA measured 33.71 degrees prePPGT and increased to 45.90 degrees postPPGT (p < 0.0001). The postOPGT HA averaged 48.71 degrees with no statistically significant gain compared with postPPGT (p = 0.21). The muscular portion of gracilis origin was cut to an average of 91.95 %; completely in only 14 hips, between 90 and 100 % in 35 hips, between 70 and 90 % in 9 hips, and between 60 and 70 % in 1 hip. The gain in HA did not correlate with the extent of the muscular portion sectioned percutaneously (R = -0.043). Minimal accidental section of adductor brevis postPPGT was encountered in 39 hips. Considerable bleeding postPPGT with hematoma formation requiring hemostasis during the open control procedure occurred in 30 hips. Partial iatrogenic injury of the anterior branch of the obturator nerve was encountered in one patient bilaterally with severe adductor contracture, due to an anatomic too medial variant.

CONCLUSIONS

This is the only prospective study concerning the outcome of PPGT. Although PPGT is fast, simple and effective, it is not as safe as the open procedure even when performed correctly by an experienced surgeon, mainly because of the increased risk of bleeding. The findings of the current study do not support its use as a 'standard-of-care' technique in children with hip adductor contracture.

LEVEL OF EVIDENCE

Level II therapeutic study-prospective comparative study.