Dorsal Fusion Research Articles

Implantation of C2 prosthesis with dorsal fusion C0-C4 due to pathologic C2 fracture. Case report and literature review.

Pathological destruction of the axis vertebra leads to a highly unstable condition in an upper cervical spine. As surgical resection and anatomical reconstruction of the second cervical vertebrae represents a life threatening procedure, less radical approaches are preferred and only few cases of C2 prosthesis are described in literature. The focus of this case report is a 21-year-old man with a pathological fracture of C2 managed primarily surgically with the C1-C3 dorsal fusion. Due to the progression of giant cell tumor and destruction of the axis vertebra, C2 prosthesis through anterior approach and dorsal occipito-cervical fusion C0-C4 were performed. Postoperative infection was managed surgically with a 2-staged dorsal debridement, ostheosynthesis material change and autologous bone graft. After a 4 week-intravenous therapy with the ceftriaxone in combination with the amoxicillin/clavulanate, followed by 12 week per oral therapy with amoxicillin/clavulanate in combination with ciprofloxacin, the complete recovery of the infection was achieved. Radiotherapy was initiated 2 months after the last revision surgery and the patient showed a good clinical outcome with stable construct at a 1 year follow-up. A review of literature of all reported C2 prosthesis cases was performed CONCLUSION: C2 prosthesis allows a more radical resection in pathological processes involving the axis vertebra. Combined with the posterior fusion, immediate stability is achieved. Anterior surgical approach is through a highly unsterile oral environment which presents a high-risk of postoperative infection.

Thirty-Three-Year Follow-up Following Silicone Scaphoid Arthroplasty: A Case Report.

A 64-year-old man presented with a 3-year history of right wrist pain and swelling 33 years after a silicone scaphoid arthroplasty for chronic scaphoid nonunion. Radiographs demonstrated a deformed scaphoid implant, carpal and distal radius cysts, and mild carpal collapse. He elected to undergo a wrist arthrodesis with a dorsal fusion plate after failing conservative management. Although carpal bone silicone implant arthroplasties of the wrist have long been abandoned, our patient was pain free and fully functional for 3 decades. He was pleased to undergo serial examinations with radiographs for 30 years without any therapeutic intervention.

Myelomeningocele: Long-Term Neurosurgical Management.

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.

The loop-tail mouse model displays open and closed caudal neural tube defects.

Neural tube defects (NTDs) are the second most common cause of congenital malformations and are often studied in animal models. Loop-tail (Lp) mice carry a mutation in the Vangl2 gene, a member of the Wnt-planar cell polarity pathway. In Vangl2+/Lp embryos, the mutation induces a failure in the completion of caudal neural tube closure, but only a small percentage of embryos develop open spina bifida. Here, we show that the majority of Vangl2+/Lp embryos developed caudal closed NTDs and presented cellular aggregates that may facilitate the sealing of these defects. The cellular aggregates expressed neural crest cell markers and, using these as a readout, we describe a systematic method to assess the severity of the neural tube dorsal fusion failure. We observed that this defect worsened in combination with other NTD mutants, Daam1 and Grhl3. Besides, we found that in Vangl2+/Lp embryos, these NTDs were resistant to maternal folic acid and inositol supplementation. Loop-tail mice provide a useful model for research on the molecular interactions involved in the development of open and closed NTDs and for the design of prevention strategies for these diseases.

Interspinous and spinolaminar synthetic vertebropexy of the lumbar spine

PurposeTo develop and test synthetic vertebral stabilization techniques (“vertebropexy”) that can be used after decompression surgery and furthermore to compare them with a standard dorsal fusion procedure.MethodsTwelve spinal segments (Th12/L1: 4, L2/3: 4, L4/5: 4) were tested in a stepwise surgical decompression and stabilization study. Stabilization was achieved with a FiberTape cerclage, which was pulled through the spinous process (interspinous technique) or through one spinous process and around both laminae (spinolaminar technique). The specimens were tested (1) in the native state, after (2) unilateral laminotomy, (3) interspinous vertebropexy and (4) spinolaminar vertebropexy. The segments were loaded in flexion–extension (FE), lateral shear (LS), lateral bending (LB), anterior shear (AS) and axial rotation (AR).ResultsInterspinous fixation significantly reduced ROM in FE by 66% (p = 0.003), in LB by 7% (p = 0.006) and in AR by 9% (p = 0.02). Shear movements (LS and AS) were also reduced, although not significantly: in LS reduction by 24% (p = 0.07), in AS reduction by 3% (p = 0.21). Spinolaminar fixation significantly reduced ROM in FE by 68% (p = 0.003), in LS by 28% (p = 0.01), in LB by 10% (p = 0.003) and AR by 8% (p = 0.003). AS was also reduced, although not significantly: reduction by 18% (p = 0.06). Overall, the techniques were largely comparable. The spinolaminar technique differed from interspinous fixation only in that it had a greater effect on shear motion.ConclusionSynthetic vertebropexy is able to reduce lumbar segmental motion, especially in flexion–extension. The spinolaminar technique affects shear forces to a greater extent than the interspinous technique.

Multistage surgical treatment of early-onset scoliosis in patients with Ehlers-Danlos syndrome: A series of observations

BACKGROUND: EhlersDanlos syndrome (EDS) is a group of hereditary pathological conditions caused by various disorders of collagen biosynthesis. The study analyzed the results of multistage surgical treatment of early scoliosis in patients with severe spinal deformities due to EDS. No similar observations have been found in the literature.
 CLINICAL CASES: Four patients with a verified diagnosis of EDS and progressive spinal deformities were subjected to multistage surgical treatment using the VEPTRII instrumentation, which included periodic distractions and final spinal fusion with segmental instrumentation. Stage-by-stage surgical treatment was initiated from the age of 3 to 6 years. In 3 of 4 cases, the kyphotic component prevailed over the scoliotic one (86140 vs. 21110). The number of staged distractions ranged from 6 to 10. The age of the final stage (correction and dorsal fusion) was 914 years (surgery was performed in three of four cases). The primary correction was 3056, the loss of correction before the final stage was 1435, and the correction during the final stage was 2240. A significant correction of the frontal and sagittal imbalances of the spine was noted. Blood loss during the final fusion was 540750 mL, and the operation time was 310350 min. Ten complications occurred, of which 9 were associated with implants and disappeared during staged distractions. No neurological and vascular complications occurred.
 DISCUSSION: Scoliosis occurring in the first decade of life in patients with EDS is characterized by early-onset, rapid progression, and tendency to form a significant kyphotic component of spinal deformity.
 CONCLUSIONS: Multistage treatment of early scoliosis in patients with EDS using VEPTRII tools allows for obtaining quite satisfactory results and has not severe complications. The final fusion gives a significant corrective effect; however, new research and accumulation of data are needed to optimize the treatment process.

Infectious Spondylodiscitis of the Lumbar Spine: Conservative Antibiotic Therapy vs. Antibiotic Therapy with Surgery, and the Time of Surgery.

Infectious spondylodiscitis of the lumbar spine is a common serious disease for which evidence-based therapeutic concepts are still lacking. This retrospective study compared the impact of the health status of patients on the length of hospital stay with regard to the treatment concept, i.e., antibiotic therapy or antibiotic therapy in combination with fixation surgery. The study included 54 consecutive patients with infectious spondylodiscitis of the lumbar spine who had been treated at our clinic between 2004 and 2013. Records included patient demographics, concomitant diseases, the neurological status and treatment modality, and the length of hospital stay. 40 men and 14 women with a mean age of 64.2 (30-89) years were included. 13 patients were only treated with antibiotics (group A), 7 patients with abscess decompression (group B), 18 patients with early dorsal fusion (<10 days after admission) (group C), and 16 patients with late dorsal fusion (≥10 days after admission; group D). Patients undergoing early dorsal fusion had a significantly shorter hospital stay (33.2 days) than patients undergoing late dorsal fusion (57.0 days), P = 0.016. Mean hospital stay of patients treated with antibiotics was 30.3 days, that of patients receiving abscess decompression 57.8 days. Patients receiving only antibiotics had a significantly lower CRP level at admission than patients undergoing early fusion, P < 0.05. Patients with one or more relevant chronic concomitant diseases showed faster recovery, shorter hospital stays, and earlier return to daily routine after early dorsal fusion than after late dorsal fusion or abscess evacuation alone.

Ventral and dorsal fusion as correction of craniocervical and atlantoaxial instability using O-Arm system versus C-arm procedure – a single centre review of 200 patients

Ventral and dorsal fusion as correction of craniocervical and atlantoaxial instability using O-Arm system versus C-arm procedure – a single centre review of 200 patients

Pediatric cervical kyphosis in the MRI era (1984-2008) with long-term follow up: literature review.

Pediatric cervical kyphosis in the MRI era (1984-2008) with long-term follow up: literature review.

The Feasibility of C1-C2 Screw-rod Fixation in the Children 5 Years of Age and Younger.

Atlantoaxial fixation is technically challenging in younger children. The C1-C2 screw-rod fixation technique is established for adults but limited data about the clinical and radiographical outcome for the treatment of children with 5 years of age or younger is available. All files of children who were consecutively treated for spinal disorders were reviewed. Inclusion criteria for further evaluation were: 0 to 5 years of age at initial procedure; detailed surgical report of a posterior C1-C2 fusion with mass lateral and pedicle screw-rod fixation as described by Harms; a minimum clinical and radiographical follow-up of 24 months. The postoperative and last follow-up computed tomography scan and radiographs were used to assess the positioning and stability of the C1-C2 screw-rod construct. Eleven patients (3 boys) with a mean age of 46 months (range: 8 to 66 mo) fulfilled inclusion criteria and were evaluated retrospectively. The mean clinical and radiographical follow-up was 79 months (range: 24 mo to 170 mo). The diagnosis was atlantoaxial rotatory dislocation (4 cases), C1-C2 instability with subluxation (3 cases), atlantoaxial dislocation and os odontoideum (1 case), type II odontoid fracture (1 case), traumatic odontoid epiphysiolysis (1 case), and traumatic rupture of the transverse ligament with C1 subluxation (1 case). Intraoperatively and postoperatively no new neurovascular or vascular complication occurred. C1 lateral mass screws were placed correctly in all cases. Twenty-two C2 pedicle screws were placed correctly (85.7%), and 3 screws showed penetration of the pedicle wall (14.3%). No implant revision, implant failure, and pseudarthrosis were noted. Loss of correction was noted in 1 patient with unilateral C1-C2 fixation and a repeated dorsal fusion procedures were performed. A repeat procedure for implant removal and segmental release was performed in 3 patients to increase the axial rotation of the head. The C1-C2 screw-rod fixation is a safe technique that achieves solid fixation of the atlantoaxial complex in young children with various disorders. The technique preserves the joint and allows for segmental release via implant removal.

Surgery for craniovertebral junction pathologies: minimally invasive anterior submandibular retropharyngeal key-hole approach

BackgroundOur objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches.MethodsDuring the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1–C2 fusion according to Harms. C1–C2 decompressive laminectomy was performed in all four cases. Ventral C1–C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR—similarly to the traditional anterior retropharyngeal surgery—preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor.ResultsThe MIS ASR approach was a success in all four cases, there were no intra- and postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm2/6.05 cm2) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement.ConclusionBased on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risk of complications.

The Use of the Raabe Aspirator in Intraoperative neurophysiological Monitoring during Decompression and Stabilization Interventions for Degenerative Diseases and Injuries of the Lumbar Spine

Background. Raabe probe is a suction device with monopolar motor fibers mapping capabilities. A number of technical characteristics make it possible to use it for intraoperative neurophysiological monitoring during posterior lumbar fusion surgery.The aim of this study was to analyze our experience of Raabe probe using for intraoperative neurophysiological monitoring during posterior lumbar fusion surgery.Methods. Ninety-eight patients (55 women and 43 men) with degenerative changes and injuries of the lumbar spine were included into the study, mean age – 56.3 ± 12.8 years. Patients underwent the following operations: 85 cases (86.7 %) – spinal roots decompression with fusion by dorsal and ventral implants, 12 cases (12.2 %) – decompression with only dorsal fusion, 1 case (1.0 %) – dorsal fusion without decompression. In all cases intraoperative neurophysiological monitoring control by B. Calancie method with Raabe probe using was performed.Results. With a critical current threshold of 12 mA, the sensitivity of the method is 94 %, the specificity is 97 %. Comparing the thresholds of the M-response at the stage of screw stimulation, no statistically significant differences were found between the groups of true-positive and false-positive results, both for interested (p = 0.09) and intact (p = 0,16) screws. At the stage of the impactor stimulation, the threshold of the M-response in the true-positive group made11.39 ± 7.97 mA, and in the false-positive group – 24.16 ± 8.85 mA (p &lt; 0.05).Conclusion. Raabe probe application for intraoperative neurophysiological monitoring during posterior lumbar fusion surgery show the high sensitivity and specificity. The most reliable sign of pedicle wall breach is a threshold below than 12 mA at the stage of the impactor stimulation.

Retrospective Comparison of Minimally Invasive and Open Monosegmental Lumbar Fusion, and Impact of Virtual Reality on Surgical Planning and Strategy.

Spinal fusion for symptomatic lumbar spondylolisthesis can be accomplished using an open or minimally invasive surgical (MIS) technique. Evaluation of segmental spondylolisthesis and instabilities and review of their therapies are inseparably connected with lumbar tomographic imaging. We analyzed a cohort of patients who underwent MIS or open monosegmental dorsal fusion and compared surgical outcomes along with complication rates. We furthermore evaluated the influence of virtual reality (VR) visualization on surgical planning in lumbar fusion. Patient files were retrospectively analyzed regarding patient- and disease-related data, operative performance, surgical outcomes, and perioperative surgical complications. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans were retrospectively visualized via VR software. A questionnaire evaluated the influence of three-dimensional (3D) VR images versus two-dimensional CT and MRI scans on therapy planning, fusion method, and surgical technique and procedure. Overall, 171 patients were included (MIS/open: 90/81). MIS was associated with less blood loss, shorter surgery time and hospital stay, lower complication rates, equivalent long-term patient-reported outcomes, but lower fusion rates and higher late reoperation rates than open surgery. Image presentation using VR significantly influenced the recommended surgical therapies (decompression only/decompression and fusion; p = 0.02), had no significant influence on the recommended fusion method (rigid/dynamic/stand-alone; p = 0.77), and, in cases of rigid fusion, a significant influence on the recommended technique (MIS/open; p = 0.03) and fusion procedure (p = 0.02). In patients with monosegmental degenerative or isthmic spondylolisthesis, MIS fusion was advantageous concerning perioperative complication rates and perioperative surgical outcomes, but disadvantageous regarding fusion and reoperation rates compared to open fusion. 3D-VR-based analysis of sectional images significantly influenced the recommended surgical planning.

Complications and Factors Associated with Reoperation following Total Wrist Fusion.

Background Total wrist fusion can be elected to relieve pain in patients with osteoarthritis and rheumatoid arthritis. This study aimed to investigate the overall complications and the factors associated with reoperation and soft tissue complication after total wrist fusion. Methods We retrospectively identified adult patients who underwent total wrist fusion using Current Procedural Terminology (CPT) codes, International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) and verified these by medical chart review. We included patients ( n = 215) who were treated at a single institutional system from January 1, 2002 to January 1, 2019. The mean age was 53.3 ± 15.0 years and the median follow-up was 6.1 years (interquartile range [IQR] =1.7-9.0). The most common indications for wrist fusion included inflammatory arthritis ( n = 66, 31%), degenerative arthritis ( n = 59, 27%), and posttraumatic arthritis ( n = 47, 22%). All wrist fusions were performed using a dorsal fusion plate or dorsal spanning plate, either with a local autograft ( n = 167, 78%), iliac crest autograft ( n = 2, 1.0%), allograft ( n = 7, 3.3%), a combination of both ( n = 16, 7.4%), or without a graft ( n = 23, 11%). We performed a multivariable logistic regression to evaluate factors associated with reoperation. In addition, we performed a similar analysis to identify the factors associated with soft tissue complication after total wrist fusion. Results Forty-one (19%) patients underwent reoperation at a median of 6.9 months (IQR = 3.9-18). The indications included symptomatic implants ( n = 12, 27%), implant failures ( n = 8, 20%), infections ( n = 7, 17%), and nonunions ( n = 6, 15%). In multivariable analysis, total wrist fusion of the dominant hand (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.1-4.7, p = 0.033) was associated with a higher reoperation rate. Soft tissue complications occurred in 20 patients (9.3%) consisting of hematomas ( n = 8, 3.7%), observed blistering ( n = 5, 2.3%), and observed wound dehiscence ( n = 4, 1.9%). In multivariable analysis, smoking (OR: 2.5, CI: 0.95-6.4, p = 0.010) was independently associated with soft tissue complication after total wrist fusion. Seventy-two (33%) patients had a postoperative complication including symptomatic hardware ( n = 16, 7.4%), implant failure ( n = 11, 5.1%), infection ( n = 11, 5.1%), nonunion ( n = 8, 3.7%), and carpal tunnel syndrome ( n = 4, 1.9%). Conclusion Roughly one-third (33%) of the patients undergoing total wrist fusion experience a postoperative complication and 19% of the patients underwent a reoperation. Total wrist fusion of the dominant hand results in higher reoperation rates. The risk of a soft tissue complication after total wrist fusion is increased in smokers.

A possible novel technique for intraoperative imaging of the vertebral artery during arthrodesis of the upper cervical spine

In elderly, the fractures in C1-C2 are a common entity. Poor bone quality and wide range of motion hamper the natural bone fusion, thus making surgery often the only possible way to deal with the underlying pathology. The proximity to important neurovascular structures represents the stabilization in this segment a challenge to the surgical team.There are two major techniques, which are used to achieve a dorsal fusion in the C1-C2 Segment: Goel/Harms and Magerl techniques. The reported risk for damaging the vertebral artery in both techniques lies between 8% and 9,5% using a C-Arm. In Goel/Harms technique lateral mass screws in C1 and pedicle screws in C2 are placed. A transarticular screw is placed on both sides C1-C2 in Magerl technique in order to achieve stabilization of the C1-C2 Segment.By using the new navigational methods for a better imaging of the bony structures (O-Arm), this risk could be reduced further down. The risk for injury of the vertebral artery using the O-Arm navigation depends on the pathology, which is operated, ranging from 0, 3% to 2%.A further problem represents the anatomical variations of the vertebral artery, of which the high-riding vertebral artery being the most important one, reported between 10 and 14,5% of the cases according to the literature review.The novel technique for intraoperative imaging of the vertebral artery represents a fusion between an intraoperative O-Arm and intraoperative application of contrast, thus intraoperatively seeing the exact way of the vertebral artery. Also, after the insertion of the screws, a second CT scan with the O-Arm could be performed, yet again with contrast, to see whether the perfusion of both vertebral arteries is preserved. The significance of this method could bring the injuries of the vertebral artery to 0% independently on the technique, which has been used.This method could be used not only for craniocervical stabilization but also for removal of complex tumors in craniocervical junctions, whereas the vertebral artery is encompassed.

Atlas assimilation: spectrum of associated radiographic abnormalities, clinical presentation, and management in children below 10years.

To analyze the varied presentation and management of atlas assimilation with associated radiographic abnormalities in children in the MRI era METHODS: Database analysis of 313 children (less than 10years) RESULTS: Atlas assimilation (AA) was associated with atlantoaxial dislocation in 12, abnormal skull base and Chiari I abnormality in 42, C2-C3 segmentation failure and instability and Chiari I abnormality in 74, and condylar hypoplasia and basilar invagination in 74. Proatlas segmentation failures were 54, atlantoaxial rotary dislocation in 26 with Goldenhar's syndrome, abnormal C1 atlas posterior arch causing dynamic compression of cord in 31 children. Vascular compromise was documented in 26 children. The study encompassed ages 6months to 10years. Cranial nerves commonly affected were glossopharyngeal, vagal, and hypoglossal nerves. Children below 2years presented with torticollis, failure to thrive, difficulty swallowing, and motor and sensory deficits. Craniovertebral junction instability associated with AA was treated with custom-built craniocervical orthosis below 5years. Closed reduction of instability or basilar invagination was attempted with neuromuscular blockade under anesthesia and traction above age 5years. Successful reduction was treated with dorsal foramen magnum and atlas decompression with occiput-C2 dorsal fusion using rib grafts below the age of 5years and instrumentation after that. Follow-up was 2 to 32years. Neurological recovery was seen in nearly all patients. Children with atlas assimilation and associated abnormalities may be symptomatic in early childhood. The treatment depends on the age and tailored to the abnormalities present. The long-term results have been successful.

Vertebral column resection for severe kyphosis.

Vertebral column resection is an excellent tool for the correction of sharp angular deformities. Preoperative planning is crucial, and a 3D model is helpful. The spinal column is stabilized before any resection is performed. The dorsal fusion mass holds the dura and spinal cord suspended with the adhesions while the anterior decompression is being performed. The correction is performed by shortening with compression, rod exchange, in situ bending, cantilever, and compression. The anterior column support is important. Multiple rods prevent early rod failure. The cord is covered with bone graft to prevent mechanical compression from muscle or a hematoma.The video can be found here: https://youtu.be/FlBE5SFa2Gw.

Clinical Outcome of Dorsal Cervical C1-C2 Fusion Using C1 Lateral Mass Screws, C2 Lamina Screws, and Interarcual Bone Graft Technique.

To evaluate the clinical and radiologic results of patients treated with dorsal cervical C1-C2 fusion using C1 lateral mass screws, C2 lamina screws, and interarcual bone graft. We retrospectively analyzed the clinical and radiologic results of eight patients treated from 2011 to 2016. Neck pain, neurologic deficits, use of analgesics, vertebral artery injury, C2 root injury, radiologic fusion rate, malposition of screws, and implant failure were examined on day 3 and at 3 and 12 months postoperatively. One patient required revision surgery for a right-sided medial cutout of a lamina screw. None of the patients had vascular or neurologic complications. All patients were pain free and had ceased all analgesic therapy at the first follow-up examination. At the 1-year follow-up there were no complaints of neck pain, no radiologic signs of implant failure were found, and a bony union between C1 and C2 was present in all patients. Dorsal cervical C1-C2 fusion using C1 lateral mass screws, C2 lamina screws, and interarcual bone graft are less common techniques, although they can be used safely and demonstrated excellent clinical results with regard to pain relief and a high fusion rate. The technique is an ideal alternative when other techniques are not safe for anatomical reasons.

Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.

OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

Quality of Early Union After First Metatarsophalangeal Joint Arthrodesis

The aim of the present retrospective cohort study was to assess the quality of union and the clinical outcomes in patients who had undergone first metatarsophalangeal joint (MTPJ) fusion using a dorsal plate and plantar lag screw. From March 2011 to December 2012, the clinical and radiographic data of 39 patients (41 feet) who had undergone first MTPJ fusion using a compressive locking plate were retrospectively reviewed. All patients had undergone postoperative computed tomography at 6 weeks postoperatively to assess union. The average metatarsophalangeal angles improved from 23° ± 16° preoperatively to 14° ± 5° postoperatively. The dorsiflexion of the hallux at the preoperative assessment averaged 17° ± 11° and 23° ± 5° postoperatively. At 6 weeks postoperatively, the computed tomography scans demonstrated 3 complete fusions (7.3 %) and 38 partial unions (92.7%). Also at 6 weeks, the mean ± standard deviation joint bridging was 54% ± 14.6%. The forefoot American Orthopaedic Foot and Ankle Society scale score had improved significantly from 50 ± 13 preoperatively to 80 ± 7 at >1 year of follow-up (p = .001). Hardware removal was performed in 8 cases because of pain in 7 and infection in 1. Revision arthrodesis was required in 2 cases because of nonunion. At 6 weeks postoperatively, partial bony joint bridging could be observed in most cases after arthrodesis of the first MTPJ with the dorsal fusion plate.