Apex Of Deformity Research Articles

Experimental identification of the corrective capabilities of the spring technique in addressing multiapical femoral deformities

Background. The technique of multiapical deformities correction with several orthopedic hexapods (one for each apex of deformity) is accepted as a standard one. However, usage of two or more hexapods on one segment is uncomfortable for the patient. Besides, software calculation for each of them is difficult and laborious for an orthopedic surgeon. Application of only one orthopedic hexapod with one software calculation is the advantage of the spring technique (ST) of multiapical deformities correction. However, its application is hindered by the fact that the corrective capabilities of this technique have not been studied yet. The aim of the study was to identify by the bench test the corrective capabilities of the spring technique and compare them with the capabilities of the standard one. Methods. The bench test was performed using plastic models of the femur. One-ring modules were used to fix each of the bone fragments. Foam rubber discs were used to imitate soft tissues. The mobile ring was moved relative to the base one in translation, angulation, distraction and rotation. The movement was stopped if one of the struts reached its minimum or maximum length, as well as if one of them touched a frame, transosseous elements or “soft tissues”. The Mann-Whitney U-test was used for statistical analysis. Results. When using all the six struts equipped with standard threaded rods, the corrective capabilities of the spring technique are 58-97% (on average 72%) lower than of the standard one. When replacing 2-6 (depending on the type of motion) threaded rods with longer ones, the capabilities of ST increases by 36-466% (on average 257%). This provides better result for ST in translation (in three directions), varus and recurvation angulation. Conclusions. Corrective capabilities of the spring technique in 5 out of 11 types of motions are better than the capabilities of the standard technic if struts of the orthopedic hexapod are equipped with threaded rods of greater length.

Controlling the Apex in Early Onset Scoliosis Through Active Apex Correction (APC) Non Fusion Growth Modulating Technique, Is It a Myth?

A multicenter retrospective study. To determine the rate of Apex facet fusion in children with Early Onset Scoliosis treated surgically with the Active Apex Correction (APC) technique. Seventeen patients were treated with the APC technique as index surgery for Early Onset Scoliosis with more than 1year of follow-up. A 3D CT scan was done to determine the facet fusion rate in the deformity's apex controlled with posterior tethering. The average follow-up time was 26.4months (12-56), Average age at index surgery was 81.2months (30-132), and average number of surgeries done 1.3. Apical vertebrae studied for facet fusion were the 3 vertebrae in the apex in each patient that were subjected to posterior tethering according to the APC technique. In total they were 86 apical vertebrae (172 Facets studied with 86 convex side, 86 concave side). Our observations showed that 29 facet joints were fused (16% of the total facets studied),15 were on the convex, 14 on the concave side (no statistically significant difference). Regarding the facet joint distance in the non-fused facets was 0.99mm on the convex side and 1.08mm on the concave side with no statistical significance difference. APC for Early Onset Scoliosis achieves apical growth modulation and control utilizing posterior tethering without inducing fusion. This study demonstrated that APC is an effective non-fusion technique through the low incidence of facet fusion levels at the Apex, limiting the crankshaft phenomena seen in cases with apex control through arthrodesis.

Surgical treatment of scoliosis in patients with osteogenesis imperfecta: a single institution case series.

Osteogenesis imperfecta (OI) is a connective tissue disorder characterized by skeletal deformities, bone fragility, and spinal complications. Various studies' insights underscored the impact of scoliosis on pulmonary function, positive outcomes with spinal fusion, and improved functional abilities post-surgery. However, partial loss of correction remains inevitable. This study examines six surgically treated OI patients with scoliosis. Surgical intervention using a posterior approach with pedicle screws and hooks aimed to correct spinal deformities. Preoperative, postoperative, and follow-up radiological assessments were conducted, revealing significant reductions in scoliotic angles post-surgery. Complications included infections and proximal junctional kyphosis requiring revision surgeries. Despite the challenges posed by poor bone quality and implant stability, no implant failures occurred in this series. Ponte osteotomies at the apex of deformity aided in corrective maneuvers. Surgical treatment of scoliosis in patients affected by OI is challenging and may be associated with perioperative and postoperative complications. Ponte osteotomy may improve the correction and reduce necessary force at the time of correction.

Current advancements in diagnosing and managing cavovarus foot in paediatric patients.

The cavovarus deformity is a pathological condition characterised by an anomalous elevation of the longitudinal arch. This condition results from a significant hindfoot varus and forefoot equinus deformity. This phenomenon comprises diverse anomalies and therapies and exhibits a prevalence of 25% within the populace. A thorough clinical evaluation is required to identify deformities in the cavovarus foot. Weight-bearing radiographs play a crucial role in identifying the apex of deformity and quantifying the required extent of correction. Cavus feet are frequently linked with neurological conditions affecting sensory and motor nerves. Identifying the optimal treatment for individual patients necessitates the performance of clinical and radiographic evaluations. Inaccurate diagnosis of a neurological disorder can lead to inappropriate surgical intervention, relapse, and inadequate reconstruction. When faced with progressive anomalies, it is crucial to implement a phased surgical protocol promptly to avoid exacerbating malalignment. Various surgical procedures have been recorded, including soft tissue releases, tendon transfers, osteotomies, and arthrodesis, which are selected based on the nature and extent of the deformity assessment findings, with the ultimate goal of reaching a foot that is both plantigrade and balanced. Due to a lack of research on this topic, the present review aims to furnish the most recent literature update on the manifestation, imaging evaluation, and optimal therapeutic interventions currently accessible for individuals afflicted with cavovarus deformities and to assist healthcare providers in selecting the most suitable therapy for paediatric patients with this condition in their routine clinical practice.

Fractures atypiques de l’ulna: effet de la courbure de de l’ulna sur la localisation et ma survenue des fractures

IntroductionUlnar fractures associated with long-term bisphosphonate (BPs) therapy are rare, and the nature and extent of this potential risk remains unknown. Although ulna is generally considered a “straight bone”, it actually features a bow anatomically. For this reason, we speculated that ulnar bow may have a role in the development of atypical ulnar fractures (AUFs). Therefore, we compared the location and depth of ulnar bow between AUF patients and patients with atypical fractures other than the ulna. We aimed to answer: (1) whether a correlation exists between the location of the ulna bow and the location of AUFs, (2) whether the degree of ulnar bow affects the occurrence of AUFs. HypothesisUlnar bowing could play a critical role in the location and occurrence of AUFs. MethodsWe retrospectively reviewed the radiographs and medical records of 64 patients with atypical fractures admitted to our department between May 2010 to July 2020. The bow of the ulna was measured using anteroposterior (AP) and lateral radiographs. Bone angulation was described as apex of deformity, with apex lateral bow designated as AP plane bowing and apex posterior bow marked as lateral plane bowing. ResultsIn all patients with atypical fractures, bow locations were measured at the proximal third level to the index line in 68 % of AP plane and 72 % of lateral plane. In patients with AUFs, fracture sites occurred in the range of 20 % to<40 %, except in one patient. Fracture site versus apex lateral bow location and fracture site versus apex posterior bow location showed a statistically significant correlation coefficient of 0.81 (p<0.001) and 0.69 (p=0.003), respectively. In lateral plane, there was a significant difference between AUF patients and patients with atypical fractures other than the ulna in ulnar bow depth (p=0.014). However, no statistically significant differences were found in AP plane (p=0.110). DiscussionIn AUFs, fracture site was highly correlated with ulnar bowing location, and, as the degree of apex posterior bow increased, occurrence of AUFs increased. These findings are helpful in understanding the role of bowing as the ulnar geometry in the development of AUF and early identification of the location of suspicious AUF. Level of evidenceIV.

Tips and Pearls in Spinal Osteotomy

Background and Aim: Spinal osteotomy is a general term for techniques applied to correct spinal deformity. The aims of osteotomy are to create a normal range of spine curvature, pain relief, and to improve quality of life. In the cases where spinal deformities cannot be corrected using instrumentation alone or by facet or ligament release, osteotomy is indicated. In spinal osteotomies, spinal alignment is corrected by removing part of the spinal bone. Osteotomies can be performed as anteroposterior or posterior-only procedures with a greater predilection for posterior-only procedures. Different types of osteotomy are available, including the Smith-Petersen osteotomy (SPO), Ponte osteotomy (PO), pedicle subtraction osteotomy (PSO), corner osteotomy (CO), or bone-disc-bone osteotomy (BDBO), vertebral column decancellation (VCD) and vertebral column resection (VCR). Methods and Materials/Patients: In this narrative study, to provide up-to-date information, we precisely reviewed articles in the osteotomies context. Using the keywords spinal osteotomy, spinal deformity, Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection (VCR), vertebral column decancellation (VCD), Ponte osteotomy (PO), corner osteotomy (CO), all the relevant articles were retrieved from PubMed, Google Scholar, Medline, and critically reviewed and analyzed. Results: In the spine surgery, osteotomy is performed to correct the deformity in uncorrectable spinal deformity. The suitable type of osteotomy is selected based on the etiology, type, and apex of deformity, surgeon's experience, availability of blood and bleeding control agents, and availability of intensive care. A wider acceptance of posterior-only procedures exists in osteotomy. Conclusion: In spinal deformity surgery, more degrees of correction are needed for better cosmetic results, and for this purpose, spinal osteotomy has a central role. For this reason, all spine surgeons should be familiar with these osteotomy techniques.

Comprehensive assessment of the morpho-functional state of the back skin integument in adolescents with idiopathic scoliosis

BACKGROUND: In the formation of scoliotic deformity of the spinal column, the skin of the back on the protruding parts of the body is a vulnerable area. However, the study of the characteristics of the skin condition of the back of adolescents with idiopathic scoliosis has not been given due attention.&#x0D; AIM: To conduct a comprehensive assessment of the morphological and functional properties of the skin of the back of adolescents with idiopathic scoliosis and to determine the information content of the research methods used.&#x0D; MATERIALS AND METHODS: In 20 adolescents with idiopathic scoliosis, the skin of the back was examined. The following methods were used: visual clinical examination, local thermometry, laser Doppler flowmetry, esthesiometry, elastometry, histological methods.&#x0D; RESULTS: Visually, in 70% of cases, a change in the skin was revealed. In the region of the spinal deformity apex, the skin temperature was higher on the convex side than on the concave side. In the skin of the paravertebral region, capillary blood flow from the convex side and in the distal spine was more intense than on the concave side. In the dermatomes corresponding to the apex of the deformity, hyperesthesia, hypesthesia, and the absence of thermal sensitivity were noted. In the paravertebral and scapular projections, in the region of the deformity apex, the lowest indicators of skin elasticity were recorded, compared with the areas located above and below. Histostructural differences in the skin were revealed in the area of the convex and concave sides of the apex of the deformity. On the convex side, a significant decrease in the thickness of the epidermis and dermis, an increase in the thickness of the subcutaneous fat, a greater severity of reactive-destructive changes in the fibrous, vascular and innervating components of the dermis were determined.&#x0D; CONCLUSIONS: The use of an integrated approach in the study of the skin of the back of adolescents with idiopathic scoliosis made it possible to identify the features of structural and functional changes, which indicates the information content of the selected methods. The results obtained must be taken into account when planning the treatment and rehabilitation process of patients with this pathology.

Atypical fractures of the ulna: Effect of bowing of the ulna on fracture location and occurrence

IntroductionUlnar fractures associated with long-term bisphosphonate (BPs) therapy are rare, and the nature and extent of this potential risk remains unknown. Although ulna is generally considered a “straight bone”, it actually features a bow anatomically. For this reason, we speculated that ulnar bow may have a role in the development of atypical ulnar fractures (AUFs). Therefore, we compared the location and depth of ulnar bow between AUF patients and patients with atypical fractures other than the ulna. We aimed to answer: (1) whether a correlation exists between the location of the ulna bow and the location of AUFs, (2) whether the degree of ulnar bow affects the occurrence of AUFs. HypothesisUlnar bowing could play a critical role in the location and occurrence of AUFs. MethodsWe retrospectively reviewed the radiographs and medical records of 64 patients with atypical fractures admitted to our department between May 2010 to July 2020. The bow of the ulna was measured using anteroposterior (AP) and lateral radiographs. Bone angulation was described as apex of deformity, with apex lateral bow designated as AP plane bowing and apex posterior bow marked as lateral plane bowing. ResultsIn all patients with atypical fractures, bow locations were measured at the proximal third level to the index line in 68% of AP plane and 72% of lateral plane. In patients with AUFs, fracture sites occurred in the range of 20% to<40%, except in one patient. Fracture site versus apex lateral bow location and fracture site versus apex posterior bow location showed a statistically significant correlation coefficient of 0.81 (p<0.001) and 0.69 (p=0.003), respectively. In lateral plane, there was a significant difference between AUF patients and patients with atypical fractures other than the ulna in ulnar bow depth (p=0.014). However, no statistically significant differences were found in AP plane (p=0.110). DiscussionIn AUFs, fracture site was highly correlated with ulnar bowing location, and, as the degree of apex posterior bow increased, occurrence of AUFs increased. These findings are helpful in understanding the role of bowing as the ulnar geometry in the development of AUF and early identification of the location of suspicious AUF. Level of evidenceIV.

Identification of the Apex of the Medial Longitudinal Arch Break in Progressive Collapsing Foot Disorder

Category: Midfoot/Forefoot Introduction/Purpose: Progressive Collapsing Foot Disorder (PCFD) is caused by failure of both dynamic and static structures. The aim of this study was to identify the anatomical location of the medial longitudinal arch break in symptomatic flat foot deformity and analyze its relationship with Meary's angle. Methods: We analyzed weight-bearing radiographs of 81 patients [mean age 53.7 years (range, 18-81) with 101 flat feet. The apex of the medial arch break was determined on the lateral foot radiographs as the intersection of the anatomical axis of the talus and the first metatarsal. Therefore, the overall centre of rotation of angulation (CORA) of the medial arch break was documented as the angle at its apex (Meary's angle). Each separate joint angulation was then calculated to determine if the overall CORA was made of separate CORAs. Correlations between the apex location, and the number of apices, with Meary's angle were conducted. Results: There was an isolated apex of deformity in 50.4% (51/101) of cases. These were localised at talonavicular joint (TNJ) in 47% (24/51), the naviculocuneiform joint (NCJ) in 52.9% (27/51) and none at the cuneiform-first metatarsal joint (C-1MTJ). The remaining 49.5% (50/101) had combination apices with the primary deformity being at TNJ in 58% (29/50), the NCJ in 40% (20/50), and 2% (1/50) at the C-1MTJ. The mean Meary's angle was -17.9° for isolated and -18° for combination which was not statistically significant (p=0.92). There was no statistical difference in the talonavicular uncoverage angle between the single and combination apices group (p= 0.99). Conclusion: The apex of the medial arch break occurs distal to the talonavicular joint in the majority of cases, and thereby the main insertion points of the posterior tibial tendon and spring ligament. In 52.9% (27/51) of cases, the deformity occurs solely distal to the TNJ and in 58% (29/50) cases, it involves joints in addition to the TNJ. These will involve pathology of other structures, including the naviculocuneiform ligament. Surgical strategies in successfully correcting Progressive Collapsing Foot Disorder will therefore need to address joints distal to the TNJ in the majority of cases.

Multilevel non-contiguous thoracic pedicle subtraction osteotomy for fixed rounded hyperkyphotic deformity of the thoraco-lumbar junction with anterior bony fusion: technical note

BackgroundFixed severe hyperkyphotic deformities spread over more than five vertebral levels represent a therapeutic challenge, especially when the deformity apex is located at the thoraco-lumbar junction, thus requiring a huge amount of correction. The aim of this article is to describe an innovative all-posterior corrective technique based on multilevel non-contiguous thoracic pedicle subtraction ostoeotomy (PSO).Materials and methodsA retrospective review of three patients with fixed severe thoracic hyperkyphosis (a deformity angle of over 70°) with a thoraco-lumbar apex (between T11 and L1) treated by simultaneous two-level thoracic PSO and thoraco-lumbar posterior fusion was performed. Radiographic and clinical records were evaluated pre-operatively, post-operatively and at last follow-up (after a minimum of 2 years). Each variable was presented as mean ± SD (standard deviation). Statistical analyses were performed using paired t-tests (P value < 0.05 was considered significant).ResultsThe mean local deformity angle decreased by 75% (from 81.3° ± 2.1° to 20.7° ± 1.4°, p < 0.001), the post-operative thoracic kyphosis decreased by 46% (from 61.4° ± 2.4° to 33.2° ± 0.9°, p < 0.001) and the sagittal vertical axis decreased by 73% (from 14.7 cm ± 0.8 cm to 3.9 cm ± 0.3 cm, p < 0.001). No differences were observed in the radiological results between post-operative values and those at the final follow-up. The average Oswestry Disability Index (ODI) score reduced from 65.7 ± 1.8 pre-operatively to 17.3 ± 1.7 at last follow-up (p < 0.001). No neurological, mechanical nor infective complication occurred.ConclusionsThe presented technique, although technically demanding, proved to be a safe and effective alternative for the management of fixed severe thoraco-lumbar junction hyperkyphotic deformities.Level of evidence: IVTRIAL REGISTRATION Retrospectively registered

A Modified Self-Growing Rod Technique for Treatment of Early-Onset Scoliosis.

The patient is positioned prone on a radiolucent table, and the spine is prepared and draped in a standard fashion. A posterior midline skin incision is made from the upper to the lower instrumented level. Subperiosteal exposure of the spine is carried out, ensuring that capsules of the facet joints are spared. Pedicle screws are inserted bilaterally at the cranial and caudal ends of the instrumentation. Fixation with pedicle screws of at least 3 levels at the top and bottom end is usually advised; in nonambulatory patients with pelvic obliquity, caudal fixation can be extended to the pelvis with bilateral iliac screws. Sublaminar wires are positioned bilaterally at every level between the cranial and caudal ends of the instrumentation and are passed as medially as possible to avoid damage to the facet joints. Four 5-mm cobalt-chromium rods are cut, contoured, and inserted at each end of the construct. Ipsilateral rods are secured with use of sublaminar wires, making sure that they overlap over a sufficient length to allow for the remaining spinal growth. Correction of the deformity is achieved with use of a combination of cantilever maneuvers and apical translation by progressive and sequential tightening of the sublaminar wires. The wound is closed in layers over a subfascial drain. The patient is allowed free mobilization after surgery. No postoperative brace is required. Nonoperative alternative treatment for EOS includes serial cast immobilization and bracing4. Alternative surgical treatments include traditional growing rods5, magnetically controlled growing rods6, the vertical expandable prosthetic titanium rib-expansion technique7, and the Shilla technique8. The use of compression-based systems (i.e., staples or tether)9 or early limited fusion has also been reported by other authors. The main advantage of our technique is that it relies on physiological spinal growth and does not require surgery or external devices for rod lengthening, which is particularly beneficial in frail patients with a neuromuscular disease in whom repeated surgery is not advised. Segmental fixation by sublaminar wires allows good control of the deformity apex during growth. Concerns regarding early fusion of the spine have not been confirmed in our mid-term follow-up study10. This technique allows correction of the deformity and continuous spinal growth in the years following surgery. At 6.0 years postoperatively, the average main curve correction was reported to be 61% and the average pelvic obliquity correction was 69%. The spine was reported to lengthen an average of 40.9 mm (range, 14.0 to 84.0 mm) immediately postoperatively, and the T1-S1 segment was reported to continue growing at 10.5 mm/year (range, 3.6 to 16.5 mm/year) thereafter10. The most common complication is rod breakage at the thoracolumbar junction, which seems to be more common in patients with idiopathic or cerebral palsy EOS and during the pubertal growth spurt10. Subperiosteal exposure of the spine should be carried out, making sure to preserve facet joints in the unfused area of the spine.Achieve segmental fixation with use of sublaminar wires at every level and pedicle screws at the top and bottom ends of the instrumentation.If pelvic imbalance is present and the patient is nonambulatory, pelvic fixation with iliac screws is advised.First round correction of the deformity is achieved with a cantilever technique; correction fine-tuning can be performed by tightening sublaminar wires.Consider utilizing thicker rods in cases of idiopathic or cerebral palsy EOS. EOS = early-onset scoliosisAP = anteroposteriorEV = end vertebraSSEP = somatosensory evoked potentialsMEP = motor evoked potentialsPJK = proximal junctional kyphosisSMA = spinal muscular atrophyCP = cerebral palsyPACU = post-anesthesia care unit.

P105. When does the construct need to extend to the thoracic spine in patients undergoing correction for cervical deformity?

<h3>BACKGROUND CONTEXT</h3> Thoracolumbar malalignment is often seen in patients presenting with cervical deformities. For operative cervical deformity (CD) patients, it is unknown when the thoracic spine should be included in the construct. <h3>PURPOSE</h3> To investigate the CD patients in whom fusion to the thoracic spine was warranted. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> A total of 72 CD patients. <h3>OUTCOME MEASURES</h3> Radiographic parameters; complications, distal junctional kyphosis [DJK], reoperation; Health-Related Quality-of-Life [HRQLs]: NDI, NRS-neck, mJOA. <h3>METHODS</h3> Included: operative CD patients (C2-C7 lordosis < -15°, TS-CL >35°, segmental cervical kyphosis >15° across any 3 vertebra between C2-T1, C2-C7 SVA >4cm, McGregor's slope >20°, or CBVA > 25°) with baseline (BL) and up to 2-year (2Y) data. Patients with UIV at or above C4 and LIV extending beyond C7 into the thoracic spine were isolated (CT fusions). CT fusion patients were further stratified to upper and lower thoracic LIVs: T1-T4 [Short Fusion], beyond T4 [Long Fusion]. CT fusion patients were identified as having an optimal outcome at 2-year postop if they 1) did not have DJF and 2) had Virk et al. good clinical outcome [≥2 of the following: NDI <20 or meeting MCID, mild myelopathy (mJOA ≥14), NRS-Neck ≤5 or improved by ≥2 points from baseline]. Univariate analysis compared patients with long fusion and optimal outcome (L/Success) vs patients with short fusion and treatment failure (S/Fail). Multivariate analysis and ROC curve assessed demographic, surgical, and radiographic predictors of S/ Fail and L/S Success status. Conditional inference tree (CIT) determined cut-off values for the continuous predictors. <h3>RESULTS</h3> Seventy-two cervical deformity patients with CT fusion included (60.3±9.0years, 60% F, 29.4±7.6 kg/m2, levels fused: 7.8±3.2). By approach, 61% posterior-only and 39% combined. Fifty-nine patients (82%) had CT fusions with LIV of T4 or above, while 13 patients (18%) had fusions extending below T4. Thirty-two patients (44.4%) met the optimal outcome criteria, with no difference by fusion length (p=0.171). Eight patients qualified as long fusions with treatment success, while 35 patients were classified as short fusions with treatment failure. Regression analysis identified the predictors of treatment success in patients with fusion construct extending beyond T4: baseline sacral slope ≤33.5° (OR: 15.0), not undergoing high grade (PSO or VCR) osteotomy (OR: 15.0) and being Ames descriptor type C (OR: 13.5); all p<0.05). ROC curve accounting for these factors resulted in an AUC of 82.0%. Regression analysis identified predictors of treatment failure in patients with short fusion construct: levels fused >6 (OR: 4.3), Ames descriptor type CT (OR: 11.5), Ames cSVA modifier grade 1 or 2 at BL (OR: 4.56), and Flatneck Lafage morphotype (OR: 4.5); all p<0.05. Multivariate regression and ROC curve accounting for these factors resulted in an AUC of 84.3%. <h3>CONCLUSIONS</h3> Treatment success in patients with fusion constructs extending into the thoracic spine vs treatment failure in patients with short fusions may be reliably predicted by the location of the deformity apex, measures of surgical invasiveness, and preoperative deformity severity. Specifically, treatment success in longer fusions is related to deformity apex in the cervical spine and having deformity where adequate correction does not necessitate high grade osteotomy. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Clinical, radiological, and functional outcomes of posterior-only three-column osteotomy in congenital kyphosis : a minimum of two years' follow-up.

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach. Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded. The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient. Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J2021;103-B(7):1309-1316.

Clinical, radiological and functional outcome of posterior-only three-column osteotomy in healed, post-tubercular kyphotic deformity: a minimum of 2-year follow-up.

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy. The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded. The median age of the study population was 16years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5min and the mean operative blood loss was 701 ± 312ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9mm v/s postoperative: 5.5 ± 16.3mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient. Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.

Incidence and Risk Factors for Neurological Deterioration in Posterior Corrective Surgeries for Severe Angular Kyphotic Deformities: A 10-Year Institutional Retrospective Study.

Study Design:Retrospective case-control study.Objective:Neurological deficit is one of the dreaded complications of kyphotic deformity correction procedures. There is inconsistency in the reports of neurological outcomes following such procedures and only a few studies have analyzed the risk factors for neurological deficits. We aimed to analyze the factors associated with neurological deterioration in severe kyphotic deformity correction surgeries.Methods:We performed a retrospective study of 121 consecutive surgically treated severe kyphotic deformity cases (49 males, 56 females) at a single institute (May 1st 2008 to May 31st 2018) and analyzed the risk factors for neurological deterioration. The demographic, surgical and clinical details of the patients were obtained by reviewing the medical records.Results:105 included patients were divided into 2 groups: Group A (without neurological deficit) with 92 patients (42 males, 50 females) and Group B (with neurological deficit) with 13 patients (7 males, 6 females) (12.4%). Statistically significant difference between the 2 groups was observed in the preoperative sagittal Cobbs angle (p < 0.0001), operative time (p = 0.003) and the presence of myelopathic signs on neurological examination (p = 0.048) and location of the apex of deformity (p = 0.010) but not in other factors.Conclusions:Preoperative Sagittal Cobbs angle, presence of signs of myelopathy, operative time and location of apex in the distal thoracic region were significantly higher in patients with neurological deterioration as compared to those without neurological deterioration during kyphotic deformity correction surgery. Distal thoracic curve was found to have 4 times more risk of neurological deterioration compared to others.

Fatty infiltration of the cervical extensor musculature, cervical sagittal balance, and clinical outcomes: An analysis of operative adult cervical deformity patients

PurposeTo assess preliminary associations between fatty-infiltration (FI) of cervical spine extensor musculature, cervical sagittal balance, and clinical outcomes in cervical deformity (CD) patients. MethodsOperative CD patients (C2-C7 Cobb > 10°, CL > 10°, cSVA > 4 cm, or CBVA > 25°) with pre-operative (BL) MRIs and 1-year (1Y) post-operative MRIs or CTs were assessed for fatty-infiltration of cervical extensor musculature, using dedicated imaging software at each C2-C7 intervertebral level and the apex of deformity (apex). FI was gauged as a ratio of fat-free-muscle-cross-sectional-area (FCSA) over total-muscle-CSA (TCSA), with lower ratio values indicating greater FI. BL-1Y associations between FI, sagittal alignment, and clinical outcomes were assessed using appropriate parametric and non-parametric tests. Results22 patients were included (Age 59.22, 71.4%F, BMI 29.2, CCI:0.75, Frailty: 0.43). BL deformity presentation: TS-CL: 29.0°, C2-C7 Sagittal Cobb:-1.6°, cSVA:30.4 mm. No correlations were observed between BL fatty-infiltration, sagittal alignment, frailty, or clinical outcomes (p > 0.05). Following surgical correction, C2-C7 (BL: 0.59 vs 1Y:0.67, p = 0.005) and apex (BL: 0.59 vs. 1Y: 0.66, p = 0.33) fatty-infiltration decreased. Achievement of lordotic curvature correlated with C2-C7 fatty infiltration reduction (Rs: 0.495, p < 0.05), and patients with residual postoperative TS-CL and cSVA malalignment were associated with greater apex fatty-infiltration (Rs: −0.565, −0.561; p < 0.05). C2-C7 FI improvement was associated with NRS back pain reduction (Rs: −0.630, p < 0.05), and greater apex fatty-infiltration at BL was associated with minor perioperative complication occurrence (Rs: 0.551, p = 0.014). ConclusionsDeformity correction and sagittal balance appear to influence the reestablishment of cervical muscle tone from C2-C7 and reduction of back pain for severely frail CD patients. This analysis helps to understand cervical extensor musculature’s role amongst CD patients.

High Tibial Osteotomy for Genu Varum in Adults: Do Proprietary Implants Limit the Quality of Correction?

The surgical technique of proximal tibial osteotomy for genu varum in adults has evolved from a procedure using closing wedges of estimated sizes with staple fixation in the 1960s to using standard trauma internal fixation implants and, more recently, to gradual correction with software-guided hexapod external fixators. In the last two decades, implant manufacturers have also produced anatomical implants specific for such corrective osteotomies. This study evaluates the limits of using such proprietary implants for proximal tibial osteotomy in genu varum.Materials and methodsScanograms (teleradiograms) of lower limbs of a patient were used to derive skiagrams (two-dimensional bony outlines of the extremities). From these, two-dimensional and three-dimensional models of varus deformities of the tibia with different values of mechanical medial proximal tibial angle (mMPTA, from 85° to 40°) were created. An analysis of the created deformity was carried out and a simulation for surgical correction was performed using an open wedge high tibial osteotomy with fixation using a proprietary (Tomofix, Synthes) implant. In addition, a 3D simulation technique was used to check the accuracy of the results obtained from the 2D simulation.ResultsIn cases of mMPTA ≥80° with localisation of the apex of varus deformity at the level of the knee joint line, the standard technique used with the proprietary medial tibial plate produces good results.In cases of mMPTA ≤70°, fixation of the osteotomised fragments by the proprietary medial plate is poor owing to the anatomical contours of the implant. In these cases, a different type of osteosynthesis is needed.In cases of mMPTA ≤70°, the distance between the lower edge of the bone plate and the medial surface of the tibia after a proximal tibial osteotomy exceeds 11 mm and will result in unacceptable soft tissue tension around the implant.Mechanical axis deviation to the Fujisawa point produces mMPTA values outside the reference range of normal values.ConclusionAn osteotomy of the proximal tibia using a prescribed technique linked to a proprietary implant achieves good results only if performed within a certain range of deformity values. Pronounced varus deformities require a fundamentally different approach. This study reveals that surgeons undertaking corrective proximal tibial osteotomies for genu varum need to perform a comprehensive analysis of the deformity to allow for appropriate selection of patients. This will enable a consideration of the size and other characteristics of the deformity that will reduce the technical complications that may arise if the correction was performed using the recommended technique linked to a proprietary implant.How to cite this articleSolomin LN, Chugaev DV, Filippova AV, et al. High Tibial Osteotomy for Genu Varum in Adults: Do Proprietary Implants Limit the Quality of Correction? Strategies Trauma Limb Reconstr 2020;15(1):13–22.

P81. Mitigating distal migration of apex by reducing apical vertebral wedging alongside guided growth technique: active apex compression technique

BACKGROUND CONTEXT Distraction system either cause immense morbidity to the patient by several consecutive and invasive distraction episodes or are extremely expensive and not immediately affordable for a major of patients worldwide. SHILLA procedure, although it doesn't result in consecutive surgeries, there still remains severe complications of loss of correction or reappearance of deformity through crankshafting or adding-on (for eg, distal migration). The main culprit of this complication is the vertebral growth anteriorly at the apex, which mostly remains unmodulated by static fusion posteriorly. The current study presents a modified approach to SHILLA that could help dynamically remodulate, ie, reverse modulate, the apex of the deformity. PURPOSE To determine if active remodulation in the apex of the curve is possible in scoliosis and kyphoscoliosis patients, using a modified SHILLA; APC technique for guided growth. STUDY DESIGN/SETTING A retrospective cohort with paired control group. PATIENT SAMPLE Twenty patients paired as follows: (1) 20 adjacent vertebra; (2) 20 compressed wedged vertebra. OUTCOME MEASURES The convex and concave heights of the wedged vertebra were recorded at the time of the surgery and at follow up, both using CT. For comparison a control vertebra was chosen, whose physical dimensions were in par with the wedged vertebra to record the normal growth rate of the particular duration of follow up and age. METHODS The study consisted of 20 patients with either scoliosis or kyphoscoliosis undergoing an index surgery or revision surgery and demonstrating a clear radiographic evidence of vertebral wedging at the apex. All patients were under 8 years of age with Risser less than or equal to 2, and the major Cobb's angle more than 40°. The surgical procedure involved was a modified version of SHILLA, either using rod to screw (SHILLA screws from Medtronic) sliding mechanism or the analogous rod to domino (4.5 mm rod in 5.5 mm domino) sliding mechanism. In this modified technique, the most wedged vertebra was selected followed by insertion of pedicle screws in the convex side of the vertebrae above and below the wedged one. No screws were put on the concave side of the apex. All surgeries were performed under intraoperative neuromonitor and C-arm. Additionally, no cast or brace were used for these patients postoperatively. The patients were followed for a period of at least 8 months. The convex and concave heights of the wedged and control vertebrae were recorded at the time of the surgery and at follow-up, both using CT. The main difference between a wedged vertebra and the control vertebra was the compression forces being applied at the convex end for the wedged vertebra, with the expectations of reducing local longitudinal growth rate. In the control group no such forces were applied. RESULTS The wedged vertebra demonstrated a 17% average increase (p=0.00014) in the proportion of concave to convex heights ratio, whereas the control vertebra didn't show any relative change in the wedged vertebra heights at the follow ups. CONCLUSIONS Active apex correction, instead of apical fusion in SHILLA remodulates the apex vertebra, which may in turn help mitigate loss of correction on long term due to crankshafting and adding-on. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

THREE-COLUMN OSTEOTOMY OF THE SPINE DURING REVISION SURGERY IN A PATIENT WITH CONGENITAL ANGULAR THORACOLUMBAR KYPHOSCOLIOSIS

A clinical case of surgical treatment of a female adolescent patient with multiple malformations, congenital thoracolumbar kyphoscoliosis, severe lower paraparesis and impaired functions of pelvic organs is presented with a review of the literature on the problem under consideration. During the course of treatment over several years, the patient underwent repeated revision surgical interventions because of implant instability and infectious complications. The last stage of treatment included a three-column osteotomy of the spine at the deformity apex with posterior instrumented fixation. A significant correction of the deformity was achieved. Based on the results of 18-month follow-up, the correction is maintained, the implant is stable. The patient reports a significant improvement in the quality of life.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P109. Effect of cervical deformity correction on stenosis, spinal canal and cord compression utilizing magnetic resonance and computed tomography imaging modalities

BACKGROUND CONTEXT Cervical deformity (CD), often degenerative in etiology, is typically accompanied by the onset of symptomatic spinal stenosis. It is hypothesized that causation of spinal canal and cord compressive forces is multifactorial, with reduction of compressive forces being a key driver of symptom alleviation. PURPOSE To quantify and assess the relationship between postoperative changes to sagittal alignment, canal or cord decompression, and symptom alleviation. STUDY DESIGN/SETTING Retrospective review of a prospective CD database. PATIENT SAMPLE Twenty-seven CD patients. OUTCOME MEASURES Stenotic Levels, Pavlov Ratio, Spinal Canal Cross-Sectional Area, Spinal Cord Cross-Sectional Area, mJOA scores, NSR Neck Pain scores. METHODS ConsecutiveCD patients (C2–C7 Cobb>10°, CL>10°, cSVA>4 cm, or CBVA>25°) undergoing multilevel fusion. Those with pre-operative magnetic resonance imagings (MRIs) and 1-year post-operative cervical MRI or CT scans were assessed for spinal canal and cord cross-sectional area, using dedicated imaging software at each interspace and body from C2–C7, and the apex of deformity[apex]. Stenotic vertebral levels were measured using Pavlov's method from C2 to C7: a ratio of canal to vertebral body RESULTS A total of 27 patients were included (61±10 years, 64.2%F, BMI: 29.6±8.0, CCI: 0.81±1.1). BL radiographic assessment: TS-CL: 34.0±17.2; Cervical Lordosis: −1.6±15.7; cSVA: 36.3±18.5; PI-LL: 0.12±19.3; Pelvic Tilt: 20.1±11.6; SVA: 0.94±71.6. Ames classification deformity descriptors: C: 57.7%, CT: 30.8%, T: 7.7%, S: 3.8%. Surgical approach included 7.4% anterior, 51.9% posterior, 40.7% combined; 23(79%) patients had decompression procedures, all patients had an osteotomy, and mean fusion length was 8.6±4.2 levels. Following surgical intervention, mean canal cross-sectional area (267.5 mm2 vs. 320.5 mm2, p=.025), apex canal cross-sectional area (240 mm2 vs. 301.3 mm2, p=.039), and apex cord cross-sectional area (60.6 mm2 vs. 70.1 mm2, p=.019) all increased (regardless of decompression procedure status). Decreased stenotic levels (4.11vs. 2.97, p=.003) and improved apex pavlov ratios (0.76vs. 0.91, p=.032) were also observed. Cervical kyphosis correction correlated with Δ in stenotic levels (rs: 0.664, p=.001), Δ in mean C2–C7 pavlov ratio (rs: 0.601, p=.004), and Δ in apex canal area (rs: 0.562, p=.024). TS-CL correction correlated with Δ in stenotic levels (rs: 0.751, p CONCLUSIONS Sagittal realignment was associated with reduction of symptomatic stenosis and cord compressive forces, regardless of decompression status. Stenotic level reduction was associated with improved mJOA scores, while alleviation of dynamic radial compressive forces at the apex of deformity significantly reduced patient neck pain.