Minimum Two-year Follow-up Research Articles

Outcomes of Hip Arthroscopy in Patients With Previous Lumbar Spine Surgery: A Matched-Pair Controlled Comparative Study With Minimum Two-Year Follow-Up

The purpose of this study was to conduct a matched-pair analysis to determine the effect of prior lumbar spine surgery (LSS) on clinical outcomes of hip arthroscopy. Data were prospectively collected on all patients undergoing hip arthroscopy during the study period from April 2008 to December 2012. Patients were excluded if they had previous hip conditions or had undergone prior hip surgery. Patients in the LSS group (history of LSS) were matched in a 1:1 ratio to a control group (no history of LSS) according to age ±5years, gender, body mass index categories, Tönnis grade, and labral treatment. The following outcomes were recorded in each group: modified Harris Hip Score, Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale, Hip Outcome Score-Activities of Daily Living, and visual analogue scale (VAS) score for pain, patient satisfaction, and rates for revision hip arthroscopies and conversion to total hip arthroplasty (THA). During the study period, 1,405 hip arthroscopies were performed with 1,017 eligible for matching. A total of 873 (85.8%) patients had a minimum 2-year follow-up. Fifty-seven patients were matched in each group. Both groups demonstrated significant improvement in patient-reported outcome (PRO) and VAS scores. The LSS group had a lower mean for all preoperative PRO scores. There was no significant difference for the postoperative mean PRO score and change in the PRO score compared with the control group except for NAHS. The mean change in the NAHS demonstrated a greater magnitude of improvement in the LSS group. There was no significant difference between mean VAS scores, patient satisfaction, and rates for revision arthroscopy and conversion to THA between the groups. Prior LSS does not adversely affect outcomes of hip arthroscopy at a minimum 2-year follow-up. These patients have lower preoperative scores but similar magnitude of improvement and revision/THA rates compared with a matched comparative group of patients without prior LSS. Level II, retrospective analysis of prospectively collected data.

Spine Deformity With Fused Ribs Treated With Proximal Rib- Versus Spine-Based Growing Constructs

Study DesignRetrospective review of prospectively collected data. ObjectiveTo compare the use of spine-based versus rib-based implants for the treatment of early-onset scoliosis (EOS) in the setting of rib fusions. Summary of Background DataTreatment for severe early-onset spinal deformity with rib fusions includes growing spine devices with proximal rib or spine anchors. The results of treatment, however, have not been compared between spine-based versus rib-based proximal anchors. Methods169 patients with rib fusions treated with rib-based or spine-based constructs and minimum two-year follow-up were included. Sixteen patients were treated with proximal spine-based anchors and 153 with proximal rib-based devices (VEPTRs). Overall, 104 of the patients with rib-based fixation underwent thoracoplasty at the index surgery. We evaluated change in T1–T12 and T1–S1 height, coronal Cobb angle, kyphosis, and number of lengthening/revision surgeries. ResultsKyphosis increased a mean of 7° in the rib-based group and decreased a mean of 20 degrees in the spine-based group (p = .002). Major Cobb angle decreased in both groups (p < .0001); however, the spine-based group had greater Cobb angle improvement (24 vs. 11 degrees, p = .04). From implant and lengthening of distraction devices, there was a mean 3.3-cm (22%) increase in T1–T12 height and a mean of 8.0 lengthenings in the rib-based group compared with a 5.7-cm increase and 6.3 lengthening surgeries in the spine-based group. Patients with rib-based constructs had a mean of 11 total procedures, whereas spine-based patients had a mean of 8. ConclusionsPatients underwent a mean of eight lengthening surgeries before final fusion or cessation of lengthening with a modest 2.3-cm increase in T1–T12 height. Compared with proximal rib anchors, proximal spine anchors controlled kyphosis and improved Cobb angle correction for early-onset scoliosis with rib fusions.

Cumulative Anesthesia Exposure in Patients Treated for Early-Onset Scoliosis

BackgroundEarly-onset scoliosis (EOS) is a potentially life-threatening condition that requires early intervention to prevent severe deformity and pulmonary compromise. Observational studies have demonstrated that children receiving multiple procedures requiring general anesthesia are at a higher risk for adverse neurocognitive outcomes. We sought to characterize anesthetic exposure in EOS patients and to determine risk factors for increased exposure. We hypothesized that patients treated for EOS were at risk of receiving large amounts of cumulative anesthesia in childhood because of the need for early intervention to preserve pulmonary function. We sought to determine which factors impacted the amount of anesthesia patients received over the course of treatment. MethodsRecords of all EOS patients treated at a tertiary referral center from 2000 to 2014 were reviewed. Patients with a minimum two-year follow-up, under age 10 at diagnosis, were included. Anesthesia was recorded in three categories: 1) orthopedic surgeries; 2) nonorthopedic surgeries; and 3) imaging/associated procedures. Diagnoses included congenital, idiopathic, neuromuscular, and syndromic scoliosis. Treatment groups were: observation, bracing, Mehta casting, growing spine, or fusion. ResultsMean cumulative anesthesia time was 1606 minutes. Patients with neuromuscular (mean 2132 minutes, p = .006) or congenital scoliosis (1875 minutes, p < .001) received more anesthesia than those with idiopathic scoliosis (754 minutes). Patients treated by fusion (2036 minutes, p < .001) or growing spine (2855 minutes, p < .001) received more anesthesia than those treated by bracing. ConclusionsDisease severity, non-idiopathic diagnoses, and longer length of follow-up were associated with increased anesthesia. Patients who presented at earlier ages, and those treated by Mehta casting, were more likely to exceed three hours of anesthesia prior to age 3. Level of EvidenceIII

In Search of the Ever-Elusive Postoperative Shoulder Balance: Is the T2 UIV the Key?*

Study DesignMulticenter review of prospectively collected data. ObjectiveThe purpose of this study was to evaluate whether a UIV of T2 reliably results in level shoulders postoperatively. Summary of Background DataAdolescent idiopathic scoliosis (AIS) patients with a risk of a high left shoulder postoperatively are generally recommended to have instrumentation to T2, those with neutral shoulders a T3 UIV, and those with an elevated right shoulder are recommended a UIV of T4 or below in order to achieve postoperative shoulder balance. MethodsA prospective, multicenter AIS database was queried for subjects with minimum two-year follow-up who underwent posterior spinal fusion to correct their main thoracic deformity. Subjects were grouped based on their proximal fusion level. A high shoulder was defined as >1 cm difference on radiographs. ResultsA total of 626 subjects met inclusion criteria and were divided by UIVs of T2 189, T3 205, and T4 232. Preoperatively, the groups had similar rates of balanced shoulders (T2 47%, T3 49%, T4 45%) and high left shoulders (T2 8.5%, T3 8.8%, and T4 7.3%). Postoperatively, there was a greater percentage of postoperative shoulder imbalance for T2 (45%) and T3 (48%) UIV groups as compared to T4 (34%, p = .008). As expected, the T2 (46%) and T3 (49%) groups had significantly better upper thoracic curve correction as compared to the T4 group (42%, p < .001). ConclusionsThe selection of a T4 UIV results in more shoulder balance postoperatively than T2 or T3, regardless of which shoulder was elevated preoperatively. The selection of a T2 UIV does not guarantee postoperative shoulder balance following posterior treatment of main thoracic curves; however, when compared to the more caudal UIV of T4, an improved upper thoracic curve correction can be anticipated. Level of EvidenceLevel 3.

Risk factors for recurrent lumbar disc herniation after discectomy.

There are many reports about the risk factors for recurrence after lumbar disc surgery. However, there are none about whether lumbosacral transitional vertebrae (LSTV) are associated with recurrent lumbar disc herniation (LDH). We investigated various risk factors for recurrent LDH after discectomy including LSTV. A total of 119 patients who had undergone a discectomy for L4-5 disc herniation were evaluated with a minimum follow-up of twoyears. Clinical parameters including age, gender, body mass index (BMI), and smoking status, and radiological parameters including type of herniated disc, degree of disc degeneration, LSTV, and sagittal range of motion (SROM) in flexion-extension radiography were evaluated. SROM was measured by the difference of the lordotic angle between the flexion and extension view. Recurrent disc herniation at L4-5 developed in 21 (17.6%) of the 119 patients. The mean period between primary surgery and recurrence was 17.6 ± 21.1months. LSTV was found in 11 (52.4%) of the 21 patients who had recurrence and seven (7.1%) of the 98 patients in the non-recurrent group. SROM at L4-5 was 11.68 ± 4.24° in the recurrent group and 9.04 ± 3.65° in the non-recurrent group with a significant difference (p = 0.004). Multiple logistic regression analyses confirmed that LSTV and a larger SROM were significant risk factors for recurrent disc herniation at L4-5. Lumbosacral transitional vertebrae and a hypermobile disc in flexion-extension radiography were found to be risk factors for recurrent lumbar disc herniation.

The Avon patellofemoral joint arthroplasty: two- to 18-year results of a large single-centre cohort.

This study reports on the medium- to long-term implant survivorship and patient-reported outcomes for the Avon patellofemoral joint (PFJ) arthroplasty. A total of 558 Avon PFJ arthroplasties in 431 patients, with minimum two-year follow-up, were identified from a prospective database. Patient-reported outcomes and implant survivorship were analyzed, with follow-up of up to 18 years. Outcomes were recorded for 483 implants (368 patients), representing an 86% follow-up rate. The median postoperative Oxford Knee Score (0 to 48 scale) was 35 (interquartile range (IQR) 25.5 to 43) and the median Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, 0 to 100 scale) was 35 (IQR 25 to 53) at two years. There were 105 revisions, 61 (58%) for progression of osteoarthritis. All documented revisions were to primary knee systems without augmentation. The implant survival rate was 77.3% (95% confidence interval (CI) 72.4 to 81.7, number at risk 204) at ten years and 67.4% (95% CI 72.4 to 81.7 number at risk 45) at 15 years. Regression analysis of explanatory data variable showed that cases performed in the last nine years had improved survival compared with the first nine years of the cohort, but the individual operating surgeon had the strongest effect on survivorship. Satisfactory long-term results can be obtained with the Avon PFJ arthroplasty, with maintenance of patient-reported outcome measures (PROMs), satisfactory survival, and low rates of loosening and wear. Cite this article: Bone Joint J 2018;100-B:1162-7.

Wednesday, September 26, 2018 3:35 PM – 5:05 PM Preserving Spinal Motion: 85. The incidence of subsequent cervical spine surgery after cervical disc arthroplasty: a minimum two-year follow-up

BACKGROUND CONTEXT In recent years, cervical disc arthroplasty (CDA) has emerged as an alternative surgical option to cervical arthrodesis. CDA is a motion-sparing device that mimics natural cervical motion, theoretically reducing adjacent level pathology. Surgical intervention rates following CDA have been reported via the FDA IDE studies as well as in several larger series. However, these studies and their findings may not be generalizable to the spine surgery community. PURPOSE Identify risk factors and incidence of subsequent cervical spine surgery in patients undergoing primary CDA. STUDY DESIGN/SETTING New York Statewide Planning and Research Cooperative Systems (SPARCS) database. METHODS We analyzed the SPARCS inpatient database from 2005 to 2015 to identify patients who underwent isolated CDA. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to extract the index CDA procedure (84.61, 84.62) and to identify patient demographics and re-operation procedures. Patients were longitudinally followed until September 2015, corresponding to a minimum of two-year follow-up, to determine the incidence of subsequent cervical spine re-operation, which included another primary CDA, revision CDA, anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), and laminectomy without fusion. Univariate and multivariate analyses were used to identify demographic risk factors for subsequent re-operation. RESULTS A total of 835 patients underwent an inpatient CDA procedure between January 2005 and September 2013. After 2007, there was a decreasing number of inpatient CDA procedures performed in New York State (m=−33 cases/year, p CONCLUSIONS We identified a 7.5% incidence of subsequent cervical spine surgery after inpatient CDA, and a 4.4% re-operation rate at two years. Inpatient CDA procedures have been declining since 2008. Female sex was the only patient demographic factor to significantly influence the odds of cervical spine re-operation. Further investigation is needed to evaluate for the presence of these trends in outpatient databases. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Arthroscopic labral reconstruction using fascia lata allograft: shuttle technique and minimum two-year results.

ABSTRACTThe purpose of this study was to describe the shuttle technique of acetabular labral reconstruction using allograft fascia lata and report minimum two-year clinical outcomes in a prospective patient cohort. We present a shuttle technique to introduce and fixate the allograft, by which the need to fix the free end of the graft from inside the joint is avoided. Between October 2010 and March 2014, 693 hip arthroscopic surgeries were performed by the senior author. Of these 693 patients, 34 patients underwent a labral reconstruction procedure using allograft fascia lata and the shuttle technique and met inclusion criteria. Outcome measures were collected at minimum two years postoperatively. 91.2% (31) of reconstruction patients were available for follow-up at minimum two years after surgery with 12.9% (4) of these patients converting to total hip arthroplasty at average time 27.9 months post-surgery. For the remaining reconstruction patients, mean mHHS increased from 64.0 preoperatively to 84.6 postoperatively (P = 0.0015), SF-12 Physical from 38.9 to 49.0 (P = 0.0004), SF-12 Mental from 49.5 to 55.6 (P = 0.0095), iHOT-12 from 36.4 to 68.1 (P = 0.0017), HOS-ADL from 62.6 to 81.6 (P = 0.0032) and HOS-SS from 32.9 to 65.7 (P < 0.0001). Arthroscopic acetabular labral reconstruction using fascia lata allograft and a shuttle technique appears to be an effective procedure for the treatment of labral pathology through minimum two-year follow-up. While it is difficult to discern the direct influence of the labral reconstructive procedure given the treatment of often concomitant intra-articular pathology, this patient cohort has fared similarly to other cohorts of labral reconstruction patients. No major adverse events are reported.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P118. Outcomes of patients with Parkinson's disease undergoing cervical spine surgery for radiculopathy and myelopathy with minimum two-year follow-up

BACKGROUND CONTEXT Parkinson's disease (PD) is a neuromuscular disorder that affects both mobility and resting tone. This may make patients susceptible to spine malalignment and frequent candidates for surgical interventions. However, there is little evidence comparing the outcomes of PD patients in cervical spinal fusion (CF). PURPOSE This study evaluated the: (1) demographics; (2) complications (medical and surgical); (3) length of stay; (4) hospital charges; (5) reoperations; and (6) readmissions following cervical spine surgery. We hypothesized that patients who have Parkinson's Disease will experience similar postoperative outcomes to other CF patients. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE All patients with cervical radiculopathy and myelopathy who underwent any cervical spinal fusion (anterior or posterior) between 2009 and 2011 and were eligible for at least 2-year follow-up were identified from the New York Statewide Planning and Research Cooperative System (SPARCS). Patients with Parkinson's disease were identified and propensity score matched by age, sex, and DEYO index. A total of 134 propensity score matched patients with and without PD were included. OUTCOME MEASURES Demographic information, complications, length of stay, reoperations, and readmissions. METHODS The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify all patients with cervical radiculopathy and myelopathy who underwent any cervical spinal fusion (anterior and posterior) from 2009 to 2011 with 2-year follow-up surveillance. Patients with PD were then identified and propensity matched at a 1:1 ratio with patients without PD based on demographics and DEYO index. Demographics, insurance status, and hospital-related parameters were compared between the two groups. Logistic regression was performed to identify any predictive factors for postoperative outcomes. RESULTS There were a total of 134 CF patients included, with 67 patients in the PD group and 67 patients in the nonPD group. PD patients were less commonly white (74.6vs. 91.0%, p=.024) but all other demographics were comparable between the groups. PD patients had significantly longer length of stay (7.3vs. 3.6days, p=.004) and higher total hospital charges ($77,439.13vs. $45,761.24, p=.008) compared to nonPD patients. Overall (41.8vs. 40.3%, p=.861), medical (38.8vs. 31.3%, p=.365) and surgical (11.9vs. 11.9%, p=1) complication rates were comparable between PD and nonPD patients, respectively. However, PD patients did have higher rates of altered mental status (6.0vs. 0%, p=.042) than nonPD patients. PD patients also had comparable reoperation (14.9vs. 13.4, p=.804) and readmission (85.1vs. 74.6%, p=.132) rates as nonPD patients. Regression analysis revealed that Deyo index was the lone significant predictor of higher two-year complication (OR1.936, p .05). CONCLUSIONS This study compared 2-year outcomes between Parkinsonrs Disease and nonPD patients following cervical spinal fusion. PD patients and nonPD patients had comparable rates of complications, reoperations and readmissions at least two years after CF. PD was also not a significant predictor for any adverse outcomes. This study suggested that spine surgeons should not preclude PD patients from undergoing cervical spinal fusion because of a pre-existing PD diagnosis.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P85. Radiographic outcome and complications after single-level lumbar extended pedicle subtraction osteotomy for fixed global sagittal malalignment: a retrospective analysis of 55 adult spinal deformity patients with minimum two-year follow-up

BACKGROUND CONTEXT Various three-column osteotomy techniques, including the extended pedicle subtraction osteotomy (ePSO), may correct global and regional malalignment in adult spinal deformity (ASD) patients. In contrast to the traditional PSO (Schwab grade 3 osteotomy), there is limited literature reporting outcomes for ePSO (Schwab grade 4 osteotomy) in ASD surgery. PURPOSE The objective of this study was to provide focused investigation of radiographic outcomes and complications for patients undergoing single-level lumbar ePSO for ASD. STUDY DESIGN/SETTING Retrospective review of prospectively-maintained, single-center, multisurgeon database of consecutive ASD patients. PATIENT SAMPLE Consecutive ASD patients. OUTCOME MEASURES Radiographic parameters (including segmental lordosis through the ePSO site) and associated complications. METHODS Fifty-five consecutive ASD patients in whom sagittal malalignment was treated with single-level lumbar ePSO at our institution between 2010 and 2015 were analyzed. Radiographic analyses included assessment of segmental lordosis through the ePSO site (sagittal Cobb's angle measured from the superior endplate of the vertebra above and inferior endplate of the vertebra below the ePSO), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence and LL mismatch, thoracic kyphosis (TK), and sagittal vertical axis (SVA) on standing long-cassette radiographs. Patients with minimum 2-year follow-up were included and complications were analyzed for the entire group. RESULTS Overall, the average postoperative increase in ePSO segmental lordosis and overall LL was 41°±14° (range: 7°–69°, p CONCLUSIONS ePSO is an effective technique to correct sagittal malalignment in ASD. In comparison to traditional PSO techniques, ePSO may allow greater focal correction with comparable complication rates, especially with interbody cage placement at the ePSO site and use of accessory supplemental rods.

Endoscopic Repair of Partial Thickness Under-Surface Tears of The Abductor Tendon (pusta): Clinical Outcomes with Minimum Two-year Follow-up

Objectives:To report the minimum two-year outcomes of trans-tendinous repairs of Partial Thickness Undersurface Tears of the Abductor (PUSTA) tendon using patient reported outcomes (PROs), visual analog scale (VAS), and patient satisfaction scores.Methods:All patients who underwent endoscopic trans-tendinous gluteus medius repair between October 2009 and May 2013 at one institution were prospectively evaluated. Exclusion criteria consisted of less than two-year follow-up, previous hip surgery, inflammatory arthritis, open surgery, full thickness abductor tear, and worker’s compensation patients. All patients had a documented pre-operative physical exam with strength testing (0-5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively, at 3 months postoperatively, and annually thereafter. The PRO scores collected were mHHS, HOS-ADL, HOS-SSS, NAHS, and VAS. Preoperative strength and gait were compared to latest follow-up.Results:There were 25 patients that fit our criteria. Significant improvement in PRO scores were demonstrated for mHHS, HOS-ADL, HOS-SSS, NAHS, and VAS from 54.9-76.2, 50.2-80.6, 30.1-67.3, 51.9-82.4, and 7.1-2.7 respectively (p<0.001). There were 11 patients with objective weakness prior to surgery; seven of these patients moved up at least one strength grade by final follow-up. There were 14 patients who had a Trendelenbrug gait pre-operatively, 12 of them had a normal gait at latest follow-up (p-<0.001). Average patient satisfaction was 7.5. There were no revision surgeries, and no complications noted.Conclusion:PUSTA lesions can be treated successfully with endoscopic trans-tendinous repair preserving the intact attachment of superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to non-operative treatment, as patients demonstrated clinical benefit at greater than 2 years follow up that exceeds substantial clinical benefit and minimally clinical important difference.

A 27-year Meta-analysis of Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty is an alternative to ankle arthrodesis for the treatment of end-stage arthritis while maintaining greater ankle motion and functionality. Early generation implants had unacceptably high complication rates. However, increasing surgical experience and newer third-generation designs have the potential to offer better outcomes. A previous systematic review reported results from studies published between 1990 and 2005, focusing on second-generation implants. We performed a systematic review of the literature addressing the intermediate-long-term outcomes of interest in total ankle arthroplasty studies published since 2006, and we compared our findings to those from earlier generation implants. Methods: A comprehensive search of MEDLINE for all articles published from 3/25/2006 to 2/1/2017 was conducted with a minimum two-year follow-up. Two reviewers evaluated each study to determine whether it was eligible for inclusion and abstracted the data of interest. Meta-analytic pooling of group results across studies was performed. The analysis focused on third-generation ankle implants. Results: The previous systematic review identified 10 studies (n=852), whereas we identified 40 studies (n=4835). The prior study showed a five and ten-year survival rate of 78% and 77%, respectively; respective rates were 86% (p=0.001) and 76% (p=0.53) in ours and similar to the previous study. The revision rate following TAR was 7% in the earlier review (loosening/subsidence, 28%). In ours, the revision rate following TAR was 9.6% (p=0.10) (component loosening, 37%); 3.4% (p=0.02) of ankles were converted to arthrodesis. The mean post-operative Ankle-Hindfoot score was 78.2 points in the prior review and 80.1 (p=0.20) points for ours. There is significant (p&lt;0.0001) heterogeneity (I2=92.94%) between the studies; a meta-analysis of proportions showed that 81.6%of subjects had good outcomes while 46.6% had an excellent outcome. Conclusion: Based on these findings, the outcomes for third-generation total ankle arthroplasty have no significant differences in survival rates when compared to second-generation implants. However, functional scores, range of motion, and overall patient outcomes were significantly higher in the third-generation implants. However, data from early generation studies were sparse in comparison, so direct comparative studies are needed to strengthen this conclusion.

Repeat Surgical Interventions Following “Definitive” Instrumentation and Fusion for Idiopathic Scoliosis: 25-Year Update*

Study DesignSingle-institution, retrospective review of prospectively collected data on pediatric patients with adolescent idiopathic scoliosis (AIS) undergoing spinal fusion with a minimum two-year follow-up. ObjectiveTo determine the rate of reoperation in AIS patients undergoing spine fusion from 2008 to 2012. Summary of Background DataRecent trends in the surgical treatment of AIS have included increased use of all–pedicle screw constructs, smaller implants, more posterior-only approaches, and improved correction techniques. MethodsA retrospective review of 467 patients undergoing spinal fusion from 2008 to 2012 was performed. Demographic, clinical, radiographic, and surgical data were collected prospectively on all patients for the index procedure and any reoperations. Data were compared to previously published cohorts of patients from the authors' institution who underwent spinal fusion for AIS between 1988 and 2007. ResultsThe rate of reoperation in this five-year cohort of patients was 9.9%. The most common indications for reoperation were infection (4.5%: 2.4% delayed infections and 2.1% acute infections), symptomatic implants (2.1%), and misplaced pedicle screws (1.7%). When compared to the 2003-2007 cohort, the rate of reoperation for acute infection and malpositioned pedicle screws increased significantly (p = .01 and p = .04), whereas the rate of reoperation for curve progression decreased (p = .01). Reoperations for acute infections and malpositioned pedicle screws also increased significantly (p = .047 and p = .042) compared with the 1988-2002 cohort, whereas the rate of reoperation for pseudarthrosis decreased (p = .002). ConclusionReoperation rates for AIS have not improved with more sophisticated implants and techniques, predominantly because of increased acute infections and malpositioned pedicle screws despite decreasing pseudarthrosis rates and curve progression. Level of EvidenceLevel II.

No differences in the efficacy among various core decompression modalities and non-operative treatment: a network meta-analysis

Core decompression (CD) has been used to treat early-stage (pre-collapse) osteonecrosis of the femoral head (ONFH) in an attempt to prevent collapse. Recently, other adjunctive treatments including bone grafting (BG) and bone marrow mononuclear cells (BMMC) were combined to traditional CD to improve the results. We assessed the efficacy of various CD modalities and non-operative treatment through a network meta-analysis (NMA). Nine randomized controlled trials with a minimum twoyear follow-up were retrieved from PubMed, Embase, and Cochrane Library search. Treatment modalities categorized into five; (1) traditional CD alone, (2) CD combining BG, (3) CD combining BMMC, (4) CD combining BG and BMMC, and (5) non-operative treatment. The rate of conversion to total hip arthroplasty (THA) and the radiologic progression were compared among the five treatments. A total of 453 hips were included in our NMA; 151 hips in CD, 70 hips in CD combining BG, 116 hips in CD combining BMMC, 25 hips in CD combining BG and BMMC, and 91 hips in non-operative treatment. There were no differences in the rate of THA conversion across all five treatment modalities. The pooled risk ratio compared with non-operative treatment for THA conversion was 0.92 (95% CI, 0.19-4.43; p = 0.915) in traditional CD; 4.10 (95% CI, 0.37-45.42; p = 0.250) in CD combining BG; 0.30 (95% CI, 0.04-2.49; p = 0.267) in CD combining BMMC; and 1.78 (95% CI, 0.05-63.34; p = 0.750) in CD combining BG and BMMC. No significant differences were found in terms of the radiologic progression across all treatments. In the current NMA, we did not find any differences in the rates of THA conversion and radiologic progression across all CD modalities and non-operative treatment. These results question the assumption that CD changes the natural course of ONFH. Considering that size of necrotic portion is the major determinant of future collapse of the necrotic femoral head and the collapse does not occur in small lesions even without any treatment, a large-scale randomized controlled trial is necessary to confirm the effectiveness of CD. Level I, meta-analysis.

Growth-Friendly Surgery Is Effective at Treating Early-Onset Scoliosis Associated With Goldenhar Syndrome

ObjectiveTo evaluate the radiographic results and complications of growth-friendly (GF) surgery in the treatment of early-onset scoliosis (EOS) associated with Goldenhar syndrome. BackgroundGoldenhar syndrome has been associated with spinal deformity, which may be progressive. Efficacy and complication rate of GF treatment has not been reported for this population of patients with EOS. MethodsPatients with Goldenhar syndrome and EOS with two years' follow-up were identified from two international multicenter EOS databases. Scoliosis, kyphosis, spine height, and hemithoracic height/width were determined preimplant, immediately postoperative, and at the two-year follow-up. Severity of complications (SV) was recorded (Smith et al. JPO 2015). ResultsTen patients met inclusion criteria and had a mean age of 4.6 ± 2.5 years at GF implantation (one spine and nine rib-based). Mean preoperative scoliosis was 64°, postimplant 52°, and at mean follow up of 2.4 ± 0.5 years was 50° (p = .09). Preoperative kyphosis was 36°, postimplant 38°, and final 42° (p = .08). Preoperative T1–S1 height was 23.5 cm, postimplant 23.6 cm, and final 27.3 cm (p = .06). Preoperative convex hemithoracic height was 10.4 cm, postimplant 7.9 cm, and final 12.8 cm (p < .05). Preoperative concave hemithoracic height was 8.4 cm, postimplant 8.8 cm, and final 9.9 cm (p = .30). Preoperative right hemithoracic width was 8.02 cm, postimplant 7.22 cm, and final 7.86 cm (p = .07). Preoperative left hemithoracic width was 7.18 cm, postimplant 7.86 cm, and final 8.60 cm (p = .43). Eight patients had ≥1 complication with SV I (n = 7), SV II (n = 2), and SV IIA (n = 7). These included infection (n = 4), migration (n = 3), pneumonia (n = 2), and instrumentation failure (n = 2). ConclusionAt minimum two-year follow-up, GF surgical intervention for the treatment of EOS associated with Goldenhar syndrome trended toward improvements in scoliosis and spine height, but had a significant improvement in convex hemithoracic height; however, the majority of patients experienced severity grade I or II complications. Level of EvidenceLevel IV.

Minimum Two-Year Follow-up of Anterior Cruciate Ligament Reconstruction in Patients with Generalized Joint Laxity.

The purposes of this investigation were to compare outcomes of anterior cruciate ligament (ACL) reconstruction between patients with generalized joint laxity and those without it and to investigate the effect of generalized joint laxity on outcomes of ACL reconstruction from 2 to 8 years postoperatively. We retrospectively reviewed 163 patients who had undergone unilateral ACL reconstruction from January 2001 to December 2008. Patients were divided into 2 groups according to presence or absence of generalized joint laxity. The proportions of patients with meniscectomy, graft rupture, and contralateral ACL rupture were compared. Rupture rates were compared with Kaplan-Meier analysis. The Lachman test, pivot-shift test, and anterior translation measured with the KT-2000 arthrometer were evaluated. The Lysholm knee score and International Knee Documentation Committee (IKDC) subjective score were compared. The IKDC objective grade and radiographic grade were also evaluated. Follow-up assessments were performed at 2, 5, and 8 years postoperatively. The proportions of meniscectomy, graft rupture, and contralateral ACL rupture in patients with generalized joint laxity were higher than in patients without generalized joint laxity during the whole evaluation period. However, differences in proportions and cumulative rupture rates did not reach significance (p > 0.05). Patients with generalized joint laxity had less stability and poorer functional outcomes at the 8-year follow-up compared with patients without generalized joint laxity. With regard to the Lachman test and anterior translation, poorer results were shown in patients with generalized joint laxity than in patients without generalized joint laxity during the whole evaluation period. The results of pivot-shift testing differed significantly at 5 years (p = 0.002) and 8 years (p = 0.007). Patients with generalized joint laxity also had worse Lysholm knee scores and IKDC subjective scores during the whole evaluation period; these differences may not be clinically important. Comparisons between serial outcomes measured at 2, 5, and 8-year follow-ups within each patient group showed that anterior translation (p = 0.002), Lysholm knee score (p = 0.014), and IKDC subjective score (p = 0.002) deteriorated over time, although the values at 8 years were similar to those at 5 years, in patients with generalized joint laxity. Generalized joint laxity as an inherent physiologic characteristic of patients was related to a significant adverse effect on stability and functional outcomes of ACL reconstruction for patients followed for 2 to 8 years. Generalized joint laxity should be considered a risk factor for poor outcomes after ACL reconstruction. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Hip Arthroscopy in Adolescents: A Comparison of Acute Versus Chronic Presentation. Two-Year Minimum Follow-up.

Hip arthroscopy has been shown to be effective in managing various hip pathologies, including labral tears in adolescent patients. The purpose of this study was to ascertain whether outcomes of hip arthroscopy in patients under the age of 18 treated for labral tears differ depending on whether the presentation was acute or chronic. We also present the outcomes of the largest prospectively collected study on hip arthroscopy performed for labral tears in adolescents. Patient reported outcome scores (PROs) for 194 patients undergoing hip arthroscopy for hip pathology, who were 18 or under at the time of surgery were prospectively collected and retrospectively reviewed. Modified Harris hip score (mHHS), Nonarthritic hip score (NAHS), Hip Outcome score-sport specific scale (HOS-SSS) and Visual Analogue Score (VAS) were the PROs collected. The overall cohort was assessed for outcome and a comparison was made between those patients who presented with acute onset of symptoms versus those who presented with insidious onset. There was significant improvement in all the PROs for the overall cohort, with improvement maintained over an average of 38.5 months. There was no significant difference in outcome scores, between the acute and chronic groups except for change in VAS. Preoperative scores in the acute group were significantly lower, while postoperative scores did not differ. A trend toward more improvement was noted for the acute group. Overall need for revision surgery was 12%, with a higher rate of revision in the acute group. Hip arthroscopy in adolescent patients being treated for intra-articular pathology is a safe procedure with favorable outcomes at minimum 2-year follow-up, with no significant difference in final outcomes between patients with acute onset of symptoms as opposed to those with more a more chronic presentation. Reoperation rate may be higher in patients with an acute onset. Level II.

A novel percutaneous achievement and maintenance of reduction and screw fixation for acute displaced scaphoid fractures: minimum two-year follow-up.

The purpose of this study was to introduce a novel method of percutaneous achievement and maintenance of reduction for acute displaced scaphoid fractures and evaluate the feasibility of this method in treating acute displaced scaphoid fractures as well as explore its indications. From February 2012 to March 2014, 15 patients with acute displaced scaphoid fractures were treated with our technique. Two Kirschner wires were used to achieve and maintain the reduction of the scaphoid fractures throughout the entire process of the traditional percutaneous screw fixation process. The following parameters including function scores according to modified Mayo wrist scoring system, range of motion (ROM) of the wrist, grip strength, pinch strength, healing time, time to return to work, and final outcomes were recorded. All patients were followed up with a mean period of 2.5years (range, 2-3.5years). All fractures healed with a mean of 9.3weeks (range, 7-11.5weeks). All patients returned to pre-injury level of activity within sixweeks. The functional scores averaged 90.3 (range, 80-100). ROM of the wrist was equal to that of the contralateral side at threemonths postoperatively. Grip strength and pinch strength compared with contralateral were 98% and 92%, respectively. All were satisfied with the final outcomes. Our technique is successfully performed in acute displaced scaphoid fractures resulting in shortened immobilization and prompt functional recovery. It broadens the indications of the percutaneous method, which means the advantages of the percutaneous method are maximally reserved whilst the drawbacks of open reduction were avoided.

Health-Related Quality of Life Scores Underestimate the Impact of Major Complications in Lumbar Degenerative Scoliosis Surgery

Study DesignRetrospective cohort. ObjectiveTo examine Charlson Comorbidity Index (CCMI) as a marker for deterioration in health status not reflected in standard Health Related Quality of Life (HRQOL) measures. Summary of Background DataHRQOL has become a primary metric for assessing outcomes following spinal deformity surgery. However, studies have reported limited impact of complications on postoperative HRQOL outcomes. MethodsWe examined serial CCMI, complications, and HRQOL outcomes for 138 adult lumbar deformity patients treated surgically with a minimum two-year follow-up that included 126 females (91%) with a mean age of 59.8 years (range, 40.2–78.5). Patients with no, minor, or major complications were compared at baseline and at one and two years postoperation. ResultsMinor complications were observed in 26 patients (19%) and major complications in 15 (11%). Major complications included motor deficit (7), deep vein thrombosis (4), and respiratory failure (3). There was no difference in preoperative SF-36 Physical Component Summary or Scoliosis Research Society–22R (SRS-22R) scores among the groups at baseline. Preoperative CCMI was lowest in the No Complication group (3.52 ± 1.70) followed by the Major (4.00 ± 1.13) and Minor Complication groups (4.15 ± 1.71, p = .165). At one year, there was a significantly greater CCMI deterioration in the Major Complication group (0.80 ± 1.01) compared to both the Minor (0.08 ± 0.27) and No Complication groups (0.27 ± 0.47, p < .001). There was no significant difference in SF-36 Physical Component Summary or SRS-22R scores among the three groups. Similar findings were observed at two years. ConclusionsDespite similar one- and two-year HRQOL improvement, patients with major complications had greater deterioration in CCMI. As CCMI is predictive of medical and surgical risk, patients who sustained a major complication now carry a greater likelihood of adverse outcomes with future interventions, including any subsequent spinal surgery. Although this increased risk may not alter the patient's perception of his or her current health status, it may be important, and should be recognized as part of the shared decision-making process. Level of EvidenceLevel II, high-quality prognostic study.

S2 Alar Iliac Fixation in Long Segment Constructs, a Two- to Five-Year Follow-up

Study DesignRetrospective review of patients having undergone S2 alar-iliac (S2AI) fixation for long fusions with a minimum two-year follow-up. ObjectivesTo report on fusion rates, complications, technique-specific complications of patients having undergone S2AI fixation. Summary of background dataSacropelvic fixation continues to be a challenge when performing long fusions to the pelvis. S2AI screws have been found to provide solid biomechanical fixation and have been found to have good clinical results in short-term follow-up for pediatric and adult patients. MethodsCases were retrospectively reviewed in patients who had placement of S2AI screws for long fusions with at least a two-year follow-up. Demographic data, complications, and reoperations were reviewed. Complications were broken into minor and major categories similar to previous series on pelvic fixation. ResultsThere were 86 cases identified. Minor and major complications occurred in 29% and 24% of patients, respectively, with the majority of minor complications being intraoperative dural tears. Revision surgery for all causes was performed in 23% of the cohort. Fusion rate at L5–S1 for patients without preoperative pseudarthrosis was 95.3%. Preoperative L5–S1 pseudoarthrosis was identified in 20 patients, 17 (95%) of these went onto fusion after one surgery. There was evidence of S2AI screw lucency in 10.4% of cases. However, the majority of these were asymptomatic. ConclusionsSacropelvic fixation using the S2AI technique provides safe, durable fixation with low rates of technique-specific complications and limited need for hardware removal. Complication rates in this series were similar to other series on long fusions to the pelvis. Additionally, fusion rates were high at L5–S1 for both patients with and without preoperative L5–S1 pseudarthrosis. It appears that the S2AI technique is a powerful option for patients with previous L5–S1 pseudarthrosis. Level of EvidenceLevel III.