Preoperative Visual Analogue Score Research Articles

The Role of Preoperative Skin Traction in Reducing Pain in Patient with Hip Fracture

Background: Hip Fracture including neck of femur and trochanteric fractures are very common in young and old age. These types of injuries in young age are mainly due to malnutrition, tumor, physical inactivity and athletic participation causing high energy trauma. In old age it is mainly due to osteoporotic bones especially in females. Objective: To compare mean pain score in patients with hip fractures treated with and without skin traction prior to surgical intervention. Study Design: Randomized control trial. Settings: Orthopedics department, Chaudhry Muhammad Akram Teaching & Research Hospital, affiliated with Azra Naheed Medical College Lahore-Pakistan. Duration: 2 Years from 01-01-2017 to 31-12-2019. Methodology: Data of all the hip fractures presenting in Orthopedic emergency was collected. This includes fracture neck of femur and trochanteric fractures. Results: Application of skin traction did not result in improvement of pain score significantly. 15.0% of respondents were in the age groups of 25-40 years, 38.0% patients were between 41-60 years of age and 47% patients more than 61 years of age. 69.0% were female patients and 32.0% were male patients. Mean preoperative visual analogue score (VAS) score of all patients 2.3900 (out of 10 score). Mean Preoperative visual VAS score of patients (with skin traction) 2.5400. In other group (without skin traction), mean preoperative VAS score 2.2400. Conclusion: Preoperative skin traction in hip fractures of adult patient should not be considered mandatory in reducing pain and hence it is not useful.

Superior capsular reconstruction using a porcine dermal xenograft for irreparable rotator cuff tears: outcomes at minimum two-year follow-up

To evaluate midterm outcomes of arthroscopic superior capsular reconstruction (SCR) using a decellularized porcine dermal xenograft in patients with massive, irreparable rotator cuff tears and to determine the influence of concomitant, repairable subscapularis tears. This is a retrospective study of 56 patients with a minimum 2-year follow-up. Preoperative and postoperative range of motion, American Shoulder and Elbow Surgeonsscore, Subjective Shoulder Value, and visual analog score for pain were measured. Postoperative data were collected at 3, 6, 12, 24, and 36 months. Of the 56 patients who underwent arthroscopic SCR, there were 39 men and 17 women. The mean age at operation was 65 ± 9 years, and the mean follow-up was 34 ± 8 months. The mean preoperative American Shoulder and Elbow Surgeons improved from 41 ± 19 to 78 ± 18 at 24 weeks, to 86± 16 at 12 months, and to 90±9 at 24 months, P < .0001. Similarly, the mean preoperative Subjective Shoulder Value improved from 39 ± 17 to 74 ± 18 at 24 weeks, to 80 ± 18 at 12 months, and to 80 ± 11 at 24 months, P < .0001. The mean preoperative visual analog score improved from 6.5 ± 2.1 to 1.4 ± 2.2 at 24 weeks, to 0.7± 1.1 at 12 months, and to 0.2 ± 0.4 at 24 months, P < .0001. There were no differences in outcome scores between patients with intact vs. repaired subscapularis. Similarly, no statistically significant differences were found in forward flexion or external rotation after SCR between patients with an intact vs. repaired subscapularis. Failure of the SCR graft was observed on magnetic resonance imaging in 14 patients, 4 of whom opted for revision to reverse shoulder arthroplasty. Eleven patients were truly pseudoparalytic before surgery; in 5 cases, pseudoparalysis was reversed after SCR. SCR can alleviate pain and disability from irreparable rotator cuff tears and provide significant improvements in shoulder function; however, the xenograft technique resulted in inconsistent reversal of true pseudoparalysis. No difference was found between patients who required concomitant subscapularis repair vs. those who did not.

Proximal femoral nail anti rotation under local anesthesia for femoral intertrochanteric fractures in high-risk patients

To compare the clinical efficacy under local anesthesia and general anesthesia proximal femoral nail anti-rotation(PFNA) fixation for intertrochanteric fracture of femur in high risk patients. From February 2018 to February 2019, 32 patients underwent PFNA operation due to intertrochanteric fracture of femur, including 16 patients undergoing PFNA operation under local anesthesia, 9 males and 7 females, aged 54 to 98 (82.43±9.30) years and hospitalized for (10.94±5.30) days;16 patients undergoing PFNA operation under general anesthesia, 6 males and 10 females, aged 51 to 83 (72.69±9.48) years and hospitalized for (12.88±4.12) days. The patients' gender, age, fracture AO classification, preoperative VAS (visual analogue score), preoperative ASA condition grade, postoperative 1st day resting state VAS, hospitalization cost and length of stay were recorded. All patients recovered well, the wound healed well, and the ability of lower limb activity was restored. The average follow-up time was 4.6 months. There was significant difference in age between two groups (P< 0.05);there was no significant difference in sex ratio, AO classification of fracture and VAS before operation (P>0.05). There was no significant difference on ASA between two groups (P>0.05), but there was significant difference on ASA≥grade Ⅲ between two groups (P<0.05). In local anesthesia group, VAS pain score was 4.19±1.50, which was tolerable. There was no significant difference in postoperative 1st day resting state VAS, average hospitalization cost and average length of stay between two groups(P>0.05). Under the multi-disciplinary diagnosisand treatment mode, the method of PFNA operation is safe and feasible, the patients with local anesthesia are older, and the proportion of patients with ASA≥grade Ⅲ is higher, which is better for some elderly high-risk patients than general anesthesia.

Outcome of transpedicular screw fixation with posterior interbody fusion in management of Spondylolysthesis.

Background: Spondylolysthesis represents a particular and relatively frequent mechanism of intervertebral instability. It could cause low back pain due to forward or anterior displacement of one vertebra in relation the adjacent lower vertebra. There are many treatment intervention. However, there was no consensus on the ideal approach. Aim of the work: To assess the outcome of trans-pedicular screw fixation with posterior inter-body fusion in management of lumber and lumbosacral Spondylolysthesis. Patients and methods: This is prospective study, included twenty patients who underwent surgical lumbar laminectomy and disc removal with lumbar pedicle screw fixation with inter body fusion for patients with Spondylolysthesis who failed conservative measures. Results: The mean preoperative visual analogue score (VAS) for pain was 7.75 ± 0.72 that decreased to 1.35 ± 0.59 at the end of postoperative sixth month, with statistically significant decrease. In addition, the majority of cases had no significant complications, although complication rate was 25%. Conclusion: Posterolateral fusion with pedicle Screws fixation minimizes dislocation, achieves adequate decompression, corrects the sagittal axis, and accomplishes fusion. We successfully achieved solid fusion with good mechanical alignment in majority of the patients.

Efficacy of c-arm scopy-guided erector spinae plane block (ESPB) in postoperative pain control and reduction of opioid side effects in spinal instrumentation surgery

Background: Spinal instrumentation surgery causes significant pain in patients. As a result, patients are exposed to excessive opioid use and the associated side effects, as well as prolonged hospital stay, resulting in economic burden. Local anaesthetics can help both reduce postoperative pain and minimize the side effects associated with systemically administered opioid analgesics.&#x0D; Objective: The aim of this retrospective study was to investigate the effect of erector spinae plane block on analgesia in spinal instrumentation surgery and to reduce the side effects of excessive opioid use.&#x0D; Materials and Methods: We reported a retrospective study. Thirty patients, who underwent spinal instrumentation surgery from 2017 to 2018, were chosen from the hospital records. We performed spinal instrumentation and decompression by laminectomy to all patients under general anaesthesia. While 15 of these patients underwent erector spinae plane block, these patients received patient-controlled analgesia postoperative period. The other 15 patients received only patient-controlled analgesia postoperative period. We analyzed patients' data for differences in preoperative and postoperative visual analogue scores, nausea vomiting scores, constipation life quality scale, patient-controlled analgesia shot count and mean opioid consumption of patients.&#x0D; Results: The data of 30 patients undergoing lumbar spinal instrumentation surgery were retrospectively analyzed. There was no significant difference in the age, preoperative VAS, preoperative ODI and sex between the two groups (p?0,05). In addition, there were statistically significant differences in postoperative VAS, postoperative ODI, Nausea Vomiting Score, Constipation Life Quality Score (CLQS), petidin consumption and PCA shot count (p &lt;0.05). In all variables with significant differences, the values ??in the block group were lower than the non-block group.&#x0D; Conclusion: ESPB provides effective analgesia and reduces side effects due to excessive opioid usage.

Efficacy and Safety of Foraminoplasty Performed Using an Endoscopic Drill to Treat Axillary Disc Herniation

To evaluate the efficacy and safety of foraminoplasty using percutaneous transforaminal endoscopic discectomy (PTED) (performed with the aid of an endoscopic drill) to treat patients with axillary disc herniations. From October 2016 to October 2018, 83 patients with single segmental axillary disc herniations diagnosed via magnetic resonance imaging who had undergone PTED were retrospectively evaluated. Of these, 38 and 45 underwent foraminoplasty using a trephine and an endoscopic drill, respectively. The 2 groups did not differ significantly in terms of age, sex, the herniated segment, the preoperative visual analog score (VAS), or the Oswestry disability index (ODI) (all P > 0.05). Foraminoplasty-related index scores were recorded. We found no significant between-group difference in the VAS and ODI scores at any time after surgery; in contrast, the scores improved significantly compared with those before surgery (both P < 0.05). Compared with the trephine group, the fluoroscopy time was shorter in the endoscopic drill group but the foraminoplasty and total operation times were longer. Foraminoplasty featuring endoscopic drilling can be used to treat axillary-type lumbar disc herniations. The radiation exposure time is less than that of the trephine approach, but the drilling approach is less efficient. The short-term clinical outcomes afforded by the 2 methods do not differ.

Retroperitoneal Approach for Ilioinguinal, Iliohypogastric, and Genitofemoral Neurectomies in the Treatment of Refractory Groin Pain After Inguinal Hernia Repair.

Inguinal hernia repair is one of the most commonly performed surgical procedures. Postoperative neuropathic groin pain is a potentially disabling complication and can be due to a neuroma of the ilioinguinal, iliohypogastric, and/or genitofemoral nerves. In this article, we present our operative technique-a retroperitoneal approach to the ipsilateral ilioinguinal, iliohypogastric, and genitofemoral nerves with neurectomy and proximal transposition of these nerves-for management of neuropathic pain. A retrospective review was performed of 12 of the patients who underwent this surgery at our institution. Three of 12 patients underwent a selective neurectomy, whereas 9 of 12 underwent a triple neurectomy; 3 of the 9 patients who underwent triple neurectomy also had a retroperitoneal peripheral nerve stimulator placed at the time of neurectomy. Pain visual analog scores (VASs) demonstrated significant improvement after neurectomy (preoperative pain VAS of 85 ± 11 vs postoperative pain VAS of 47 ± 32, P = 0.0027). Eight of 12 patients experienced partial or complete pain relief, whereas 4 of 12 patients had no pain relief. There were no major complications, and the minor complication rate was low for all patients and primarily related to peripheral nerve stimulator placement. This retroperitoneal approach to triple neurectomy for treatment of refractory groin pain in postoperative inguinal hernia repair patients is safe and effective for an otherwise devastating problem.

L5-S1 FAR LATERAL DİSK HERNİASYONLU HASTALAR İÇİN İNTERTRANSVERS FASYA AÇILMADAN MEDİAN İNSİZYON İLE GERÇEKLEŞTİRİLEN LATERAL MİKROŞİRÜRJİKAL YAKLAŞIM: 12 HASTANIN RETROSPEKTİF DEĞERLENDİRİLMESİ

<div><!--block-->Objective: HL5-S1 far lateral lumbar disc herniations (FLLDH) are extremely rare disc pathologies and herniated disc is located on the lateral side of the pedicle. The aim of this study is to evaluate 12 patients suffering from L5-S1 FLLDH who were operated on using/via the lateral interpedicular microsurgical approach and to discuss in the context of the current literature.&nbsp;<br><br>Material and Method: 12 patients (5 male and 7 females) with L5-S1 FLLDH partcicpated/participated in this study. All patients were operated on between the year 2015 and 2017 at the same medical center using the lateral interpedicular microsurgical approach. After the midline skin incision, thoracolumbar fascia was opened at the side of the herniation, a subperiosteal dissection of paravertebral muscles was carried out and Taylor retractors were placed. Subsequently, minimal amounts of bone were removed from the fascet joints and pars interarticularis, the exiting nerve root was explored at the lateral of the pars interarticularis and a microsurgical removal of herniation was performed.&nbsp;<br><br>Results: The mean visual analog scores (VAS) decreased from 9.25±0.75 to 0.76±0.75 postoperatively and the difference between the preoperative and postoperative VAS scores was statistically significant (p=0.0001). 6 months after surgery 5 patients were graded as excellent (41.7%), 6 patients were good (50%) and 1 patient was fair (8.3%) according to the MacNab classification.&nbsp;<br><br>Conclusion: The lateral interpedicular microsurgical approach with median incision without opening intertransverse fascia is a safe, easy and minimally invasive technique for the surgical treatment of L5-S1 FLLDH.&nbsp;</div>

Postoperative pain after posterior lumbar interbody fusion: is it worth it?

Introduction Posterior lumbar interbody fusion (PLIF) is a widely accepted procedure for many lumbar degenerative disorders. However, it has been suspected for causing significant postoperative pain in the first few months. Patients and methods This prospective study included 36 consecutive patients who underwent a single-level PLIF procedure and were followed up for at least 1 year. At one-year follow-up, there were 20 females and 16 males, with an average age of 60.7 y (range: 39–81 y). All patients were operated in a standardized fashion, with bone graft taken from the iliac crest. Postoperatively, all patients received a standardized analgesic regimen. The modified Oswestry disability index (ODI) and visual analog score (VAS) were assessed preoperatively, at 3 months, at 6 months, and at 1 year postoperatively. Patients who had an obvious surgical reason for postoperative pain such as pedicular screw misplacement, postoperative hematoma, infection, wound problems, loose osseous fragment impingement on neural structures and postoperative pedicle, vertebral body, endplate fracture, or sacroiliac joint violation were excluded from the study. Results The most common indication for PLIF was lumbar stenosis with instability (n=18) and at 1-year follow-up, all 36 patients achieved bony intervertebral body fusion. The average preoperative ODI was 67.33% (range: 56–82%), and the mean preoperative VAS was 7 (range: 5–9). At 3 months, there was a significant improvement in relation to the preoperative ODI and VAS (P less than 0.0001 for both). Yet, at 6 months and at one year, there was a significant improvement when compared with the preoperative ODI and VAS (P Conclusion For many patients, PLIF is a painful experience, and strict adherence to the details of the operation are necessary to optimize the overall outcome. Still, the iliac crest graft is a major source of postoperative pain, although there is a significant overall improvement of the ODI and VAS at 1 year, and most patients report that they benefited from this operation. This series is based only on a single-center experience, and hence larger multicentric studies are needed to produce reliable data. Confounding this small series is individual pain perception and the inherent subjectivity of the ODI and the VAS.

A study on clinicoradiological outcome of posterior and posterolateral decompression and stablisation with pedicle screws and fusion for tuberculosis of dorsal and lumber spine

INTRODUCTION: Tuberculosis is ubiquitous in distribution. Globally, nearly 30 million people suffer from tuberculosis. 3 million deaths occur due to tuberculosis per year. India has burden of 6 million cases. Recent increase in the incidence is due to concomitant tuberculosis with HIV infection and drug resistance. Of these 1-3% constitutes skeletal system involvement. Spinal tuberculosis(50%) is the most common form of skeletal tuberculosis. The evolution of treatment of tuberculosis of spine have passed through different phases of development from Pre-antitubercular era through Postantitubercular era and from Radical surgery through Middle path regimn. Traditionally, the anterior approach is the gold standard approach because vertebral bodies and disc spaces are most commonly affected, and the anterior approach allows direct access to the diseased vertebral bodies for debridement and abscess drainage, allows wide decompression and reconstruction of the defect. A combined anterior debridement and posterior instrumentation helps to overcome stability related drawbacks of anterior approach alone. However, it entails two surgeries (single event or staged) with additional morbidity and is indicated for patients with significant deformity. In posterior or posterolateral approaches anterior and lateral column can be reached through extra pleural approach. Posterior approach provides excellent exposure for circumferential spinal cord decompression, allows multiple level posterior instrumentation above and below the level of pathology, more stable construct ,less morbid surgery, allows earlier rehabilitation and is a familiar approach. AIM OF THE STUDY: The aim of this prospective study is to analyse the clinicoradiological outcome of posterior and posterolateral decompression, stabilisation with pedicle screws and fusion for tuberculosis of dorsal and lumbar spine done in our institution from July 2010 to June 2012. OBJECTIVES : (a) To study the effectiveness of posterior and posterolateral decompression, stabilisation with pedicle screws and fusion for tuberculosis of dorsal and lumbar spine. (b) To study the improvement in the angle of kyphosis. (c) To show that posterior surgery allows early mobilisation. (d) To evaluate that posterior surgery associated with reduced morbidity and mortality. MATERIALS AND METHODS: This study was conducted in our Hospital on 15 patients with Tuberculosis of Dorsal and Lumbar spine from July 2010 to June 2012. All patients were treated with posterior or posterolateral approach and stabilised with Pedicle screw system. Selection criteria: The Inclusion criteria is age group of 12 to 70 years of age, mild to moderate amount of cold abscess. no improvement with conservative treatment and worsening of neurological deficit. Patients less than 12 years of age,huge cold abscess, severe kyphotic deformity with internal gibbus and patients not fit for anaesthesia are excluded from the study. During study age of patient, mode of presentation, Level of the lesion and associated co morbid condition are considered. Anti tuberculous therapy started. RESULTS: This study was conducted in our Hospital on 15 patients with Tuberculosis of Dorsal and Lumbar spine from July 2010 to June 2012. All patients were treated with posterior or posterolateral approach and stabilised with Pedicle screw system. The mean follow up period was 12 months (range 6-26 months). The following are the results of the study: The mean duration between surgery and onset of symptoms was 10.2 months (range 5-14 months). The mean surgical time was 3 hours 20 minutes (range 2h 20 min-4hr 10 min). The average blood loss was 800 ml (400 ml – 1500 ml). The mean preoperative Visual analog score was 8.7 (range7-10)which improved to 1.7(1-4) at final follow up implying better pain score postoperatively. The mean preoperative ESR value was 111.8 which improved to 31.7 at final follow up which indicates improvement in disease activity. Before surgery, 7 patients were classified as Frankel grade C,2 patients each with grade B,D and E& one patient with grade A.After surgery,all patients with grade C improved to one grade. Out of 2 patients with grade B,one improved to grade C and other improved to grade D.Of the patients with grade D, one improved to grade E and the other remained with grade D.One patient with grade A havenot recovered. The mean preoperative kyphosis in the thoracic and thoracolumbar spine was 27.9 degrees which was corrected to a mean of 9.5 degrees in the final follow up radiographs implying better correction and maintenance of kyphosis. CONCLUSION: The posterior/posterolateral approach (extracavitory approach) gives a reasonable access to the lateral and anterior aspects of the cord for an equally good decompression of the cord. It is a less morbid approach and avoids problems associated with thoracotomy and laprotomy. It facilitates early mobilization and avoids problems of prolonged recumbency. It provides better functional outcome and significantly better sagittal plane and kyphosis correction. Posterior approach preferred because of its familiarity, its simplicity, and its low complication rate.

Percutaneous fixation assisted by O-arm-based navigation for thoracolumbar fractures without neurologic deficits

Objective To investigate the clinical efficacy of percutaneous fixation assisted by O-arm-based navigation for thoracolumbar fractures without neurologic deficits. Methods A retrospective case control study was conducted to analyze the clinical data of 35 thoracolumbar fracture patients without neurologic deficits admitted to Henan Provincial People's Hospital from January 2018 to December 2018. There were 26 males and 9 females, aged 17-51 years, with an average age of 30.4 years. The injured segments were distributed at T11 in 10 patients, T12 in 15, L1 in 11, and L2 in 4 patients. A total of 19 patients (22 vertebrae, 98 pedicle screws) were treated with O-arm guided navigation assisted percutaneous internal fixation (Group A), and 16 patients (18 vertebrae, 82 pedicle screws) were treated with C-arm guided percutaneous internal fixation (Group B). The operation time, accuracy rate of nail placement, complications, Cobb angle of fracture vertebral body, visual analogue score (VAS) and Japanese Orthopaedic Association (JOA) score were recorded and compared before operation, 7 days after operation and at the last follow-up. Results The patients were followed up for 2-12 months [(7.2±2.9)months] in Group A and 3-13 months [(7.1±3.3)months] in Group B. The operation time was (70.5±11.2)minutes in Group A and (81.3±10.9)minutes in Group B (P 0.05). The VAS at day 7 after operation was (2.3±1.1)points and (2.8±1.0)points in Group A and Group B, respectively, while the VAS at the final follow-up was (0.7±0.7)points and (0.8±0.7)points in Group A and Group B respectively. The postoperative VAS was significantly decreased compared with the preoperative VAS (P 0.05). The JOA at day 7 after operation was (21.1±2.2)points and (21.8±2.5)points in Group A and Group B respectively, while the JOA at the final follow-up was (24.9±2.2)points and (23.8±1.9)points in Group A and Group B respectively. The postoperative JOA was significantly increased compared with the preoperative JOA (P 0.05). Conclusion For thoracolumbar fractures without neurologic deficits, percutaneous fixation assisted by O-arm-based navigation can shorten the operation time and deliver a higher accuracy rate in the placement of pedicle screws, in addition to the similar effects with percutaneous fixation assisted by C-arm in pain relief, function improvement and correction of fracture vertebral kyphosis. Key words: Spinal fractures; Fracture fixation, internal; Navigation

Comparing the efficacy of core decompression with autologous bone marrow mononuclear cell grafting with impacted bone grafting in treating bilateral femoral head necrosis

Objective To compare the efficacy of core decompression with autologous bone marrow mononuclear cell grafting with impacted bone grafting in treating bilateral femoral head necrosis. Methods From January 2011 to January 2017, a total of 44 patients with bilateral femoral head necrosis (88 hips) were admitted to the Department of Orthopaedics, China-Japan Friendship Hospital, including 35 males and 9 females with aged 34.9±7.2 years old (ranged from 22-48 years). Core decompression with autologous bone marrow mononuclear cell and impacted bone grafting were conducted to each hip joint for every patient. All patients were followed up for every 3 months at the first year postoperatively and for every 6 months thereafter. The following clinical measurement were recorded, Harris hip score (HHS), visual analogue score (VAS), the anterior-posterior and frog lateral radiographs, and CT. The 5-year survival rate of the hip was calculated with the endpoint event being defined as a need for total hip arthroplasty or other surgical intervention, or a HHS less than 70. Results The postoperative follow-up duration was 50.5±34.2 months in the impacted bone grafting group and 54.0±33.1 months in the core decompression with autologous bone marrow mononuclear cells group. Fifteen hips in the impacted bone grafting group and 13 hips in the core decompression with autologous bone marrow mononuclear cell group failed during the follow-up. The 5-year cumulative survival rates of the hips in two groups were 64.7% and 72.1%, respectively [HR=1.178, 95%CI(0.561, 2.477)]. In the impacted bone grafting group, the 5-year survival rates of the hip joints at the ARCO IIIB+IIIC and IIIA stages were 42.9% and 74.2%, respectively [HR=3.258, 95%CI(1.172, 9.059)]. In the core decompression with autologous bone marrow mononuclear cell group, the 5-year survival rates of hips at the ARCO stage I, II and IIIA stages were 50.0%, 75.3%, and 71.4%, respectively (χ2=0.757, P=0.685). Age, gender, BMI, preoperative HHS and etiology did not affect the effects of core decompression with autologous bone marrow mononuclear cell grafting or impacted bone grafting (P>0.05). The preoperative VAS of the impacted bone grafting group and the core decompression with autologous bone marrow mononuclear cell grafting group were 4.80±0.62 and 3.27±1.17, respectively (t=8.625, P<0.001). At the last follow-up, the VAS was reduced to 2.84±1.95 and 2.25±2.08, respectively (t=2.712, P=0.01; t=7.087, P<0.001) with significant difference in postoperative VAS between the two groups (t=2.489, P=0.017). The preoperative HHS of the impacted bone grafting group and the core decompression with autologous bone marrow mononuclear cell grafting group were 77.02±5.03 and 82.57±5.71, respectively (t=7.822, P<0.001). At the last follow-up, the HHS increased to 81.57±12.81 and 83.55±12.87, respectively. The difference between the preoperative and postoperative HHS was statistically significant in the impacted bone grafting group (t=2.389, P=0.021) but not in the core decompression with autologous bone marrow mononuclear cell grafting group (t=0.451, P=0.654). There was no significant difference in postoperative HHS between the two groups (t=1.353, P=0.183). Conclusion Both impacted bone grafting and core decompression with autologous bone marrow mononuclear cell grafting are safe and effective methods in treating femoral head necrosis. The ARCO stage is a risk factor affecting the prognosis of hips after impacted bone grafting, which has no effect on the mid-term survival of hips after core decompression with autologous bone marrow mononuclear cell grafting. Key words: Femur head necrosis; Bone transplantatio; Transplantation, autologous; Bone marrow transplantation

Clinical application and effect of individual 3D printing model on pedicle screw placement for upper cervical spine fracture

Objective To investigate the accuracy and feasibility of individual 3D printing model for pedicle screw placement in treating patients with upper cervical spine fracture. Methods A retrospective case control study was conducted to analyze the clinical data of 30 patients with upper cervical spine fracture admitted to Ningbo No.6 Hospital from August 2013 to December 2018. There were 19 males and 11 females, aged 45-67 years with an average age of 53.5 years. The 15 patients in the study group were treated with pedicle screw fixation and another 15 patients in the control group were treated with traditional freehand screw fixation. A total of 120 pedicle screws were implanted, with 60 screws in each group. The operation time, intraoperative blood loss, preoperative and postoperative visual analogue score (VAS), Japan Orthopedic Association (JOA) score were recorded. The position and grade of screws were evaluated according to Kawaguchi's evaluation method of screw grade after operation. The patients took monthly reexamination for the first three months after discharge. In the first two months after discharge, the patients took X-ray examination for observation of screw loosening or rupture of internal fixation. At the third month after operation, the patients took CT of cervical spine for observation of bone healing and fusion. Results The mean follow-up duration was 17.8 months (range, 13-21 months). The study group had shorter operation time (99.13±3.04)minutes compared with the control group (107.00±6.92) minutes (P 0.05), but the VAS in study group was significantly lower than that in control group (P 0.05). No serious complications such as spinal cord or vertebral artery injury occurred. At 3 months after operation, CT showed that the fracture of cervical vertebra healed. Conclusion Individualized 3D printed cervical spine model can guide the pedicle screw placement for upper cervical spine fracture, which can shorten the operation time, reduce the postoperative pain of patients, improve the accuracy of screw placement, and reduce the risks related to operation. Key words: Cervical vertebrae; Fracture fixation, internal; 3D printing model

Treatment of Adult Scoliosis Fractional Curve With Minimally Invasive Surgery: Anterior Versus Posterior Approach?

Abstract INTRODUCTION The fractional curve in adult scoliosis often causes radiculopathy and may be managed in varied manners with minimally invasive (MIS) deformity correction. There are inherent risks and benefits to anterior and posterior interbody reconstruction techniques, and the purpose of this study was to evaluate for differences in outcomes or complication rates by fractional curve treatment via MIS anterior vs. posterior interbody fusion METHODS Inclusion criteria were age = 18 yr, and one of the following: coronal cobb &gt; 20°, SVA &gt; 5 cm, PT &gt; 20°, PI-LL &gt; 10°. Patients were treated with circumferential MIS (cMIS) surgery or hybrid MIS surgery and had 2-yr minimum follow-up. Patient were divided into two groups: anterior or posterior interbody fusion at the lumbosacral junction (L4-S1). HRQOL measures included Oswestry Disability Index (ODI), visual analog score (VAS). RESULTS A total of 112 patients who underwent MIS adult deformity surgery with minimum 2-yr follow up. A total of 74 patients underwent anterior and 38 patients underwent posterior interbody reconstruction at L4-S1 utilizing MIS technique. Preoperative spinopelvic parameters, radiographic parameters, and VAS were not different, but ODI was higher in the anterior group (53 vs 48, P = .047). Complications and reoperation rates were not different (P = .089, P = .597), but posterior had more infections (15.8% vs 2.7%, P = .01). When subdivided for cMIS only surgery, 38 had anterior and 19 underwent posterior interbody fusions in the fractional curve. Pre- and postoperative VAS leg, ODI, and fractional curve magnitude were not different. In the anterior surgery cohorts, laminectomies at L4-S1 were performed in 22% of hybrid cases and in 8% of cMIS cases. CONCLUSION Treatment of the fractional curve of adult scoliosis appears to be similarly effective in reducing VAS, ODI, and fractional curve magnitude regardless of anterior vs posterior approach. However, posterior interbody reconstruction was associated with higher infection rate than anterior, regardless of application in cMIS or hybrid technique.

Fusion technique does not affect short-term patient-reported outcomes for lumbar degenerative disease

Background/ContextDegenerative lumbar disease can be addressed via an anterior or posterior approach, and with or without the use of an interbody cage. Although several studies have compared the type of approach and technique, there is a lack of literature assessing patient-reported outcome measures (PROMs) and radiographic parameters between different fusion techniques. PurposeTo determine whether the surgical approach and fusion technique for lumbar degenerative disease had an effect on short-term PROMs and radiographic parameters. Study Design/SettingRetrospective Cohort Study. Patient SampleThree hundred and ninety-one patients who underwent a 1–3 level lumbar spine fusion procedure at a high-volume academic center were retrospectively identified. Patients were divided into three groups based on the type of fusion they underwent: posterolateral fusion (PLF), anterior lumbar interbody fusion (ALIF), or transforaminal lumbar interbody fusion (TLIF). Outcome MeasuresPROMs: Short Form-12 (SF-12) Physical Component Score (PCS) and Mental Component Score (MCS), Oswestry Disability Index (ODI), Visual Analog Score (VAS) Back, VAS Leg. Spinopelvic measurements: Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Lumbar Lordosis (LL), Segmental Lordosis (SL), PI–LL mismatch. MethodsPatients with less than 1-year follow-up were excluded from the cohort. Pre- and postoperative spinopelvic measurements were obtained for all patients. Univariate analysis (Chi-squared/Fisher's exact test or ANOVA test with post-hoc Bonferroni test) was used to compare among the three groups in the PROMs and radiographic spinopelvic parameters. Multiple linear regression was used to determine if fusion technique was an independent predictor of change in each patient outcome. ResultsTwo hundred and sixteen patients were included in the PLF group, 33 patients in the ALIF group, and 142 patients in the TLIF group. The PLF group was significantly older at baseline (p<.001) and had lower preoperative diagnosis rates of degenerative scoliosis and disc herniations (p<.001), whereas the ALIF group underwent a higher proportion of three-level fusions (p<.001). There was no significant difference in spinopelvic parameters preoperatively, however the ALIF group showed significantly more improvement in SL postoperatively (p=.004) than the PLF and TLIF groups. Within each group, SL improved for the PLF and ALIF groups (p=.002 for both), but not for the TLIF group (p=.238). Comparing patient outcomes, the ALIF group reported lower preoperative VAS Leg scores (p=.031), however, this difference resolved postoperatively. Stratifying for preoperative diagnosis, there were no significant differences in outcomes, except for a greater improvement in VAS Leg scores for degenerative scoliosis patients undergoing ALIF. Using multivariate analysis, fusion technique was not found to be a significant predictor of change in any patient outcome or in odds of revision. ConclusionsLumbar degenerative disease can be treated with several different fusion techniques, however, the relationship between type of fusion and PROMs is not established. Based on the findings in this study, the ALIF group showed greater improvement in SL compared with the PLF and TLIF groups, however, there was no difference noted in overall LL, PI–LL mismatch or other spinopelvic parameters. Despite these radiographic findings, patient outcome measures remained similar between all three fusion types.

CLINICAL EFFECTIVENESS OF LUMBAR EPIDURAL INJECTION FOR SPINAL DISC HERNIATION: A RANDOMISED CONTROL TRIAL.

Purpose: Lumbar epidural is an established procedure, which is commonly used to control pain in cases of disc herniation secondary to lumbar disc disease. We conducted the present study to evaluate the clinical effectiveness of lumbar epidural injection using image intensifier comparing to injection using loss of resistance technique with no fluoroscopy. We also evaluated the outcome of these patients with patients treated conservatively with opioid or other analgesia as a control group. Setting: Epsom General Hospital, an elective part of Epsom &amp; St Helier’s University Hospital spine services. Study Design: Prospective randomized controlled trial. Period: April 2013 and October 2013. Material and Methods: Single center, after seeking appropriate ethical approval in our institution. Group allocation for loss of resistance and II was done by list schedulers independent to the knowledge of trial, operating list become available to research team on the day of procedure. Fifty-five patients were included in each group. A single clinician performed all procedures and the same combination of local anaesthetic and steroid were injected in all patients. Preoperative and postoperative visual analogue score (VAS) and Oswestry Disability Index (ODI) were obtained for each patient. Conclusions: There is a better outcome demonstrated in both injection groups when compared with control. The post-operative scores did not statistically differ significantly between fluoroscopic and loss of resistance groups. The final results of this trial question the efficacy and cost effectiveness of epidural injections using image intensifier and may be used as a reference to change the current practice within several hospitals as cost saving measure. Level of Evidence: 1.

Trochleoplasty is a Viable Option for Patellar Instability in Patients with Severe Trochlear Dysplasia: a Minimum 1-year Follow-Up Prospective Study

Objectives: Patellar instability caused by trochlear dysplasia may be addressed by sulcus-deepening trochleoplasty. A paucity of data exists from the United States regarding this procedure and no long term follow up. The purpose of this study was to evaluate the outcome data of patients undergoing sulcus-deepening trochleoplasty for high-grade trochlear dysplasia at our institution. Methods: Sixty-four patients (71 knees) with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty using the Dejour method from 2011-2018. Thirty-six of 71 knees (50.6%) had prior surgery and failed prior surgical management for patellar instability. Concomitant procedures during trochleoplasty were performed at varying rates. Radiographic analysis, physical examination, and clinical follow-up were obtained for all patients. At enrollment, patients completed preoperative visual analog scores (VAS), international knee documentation committee (IKDC) and Kujala scores, which were repeated at their 6 month, 1 year, 2 year, 3 year, and 4 year follow-up visits. Preoperatively, the patellotrochlear index (PTI), trochlear spur height, and trochlear depth were all measured. The patient’s sulcus angle was measured preoperatively and postoperatively on sunrise (merchant) view xray. Of the entire cohort, 43 patients (49 knees) had at least one year complete follow-up including xrays, physical exam, and patient-reported outcome measures and were included in the study. Results: The majority of patients were female (81.6%) with a mean age of 19.6 (+/- 6.8y). Follow-up ranged from 12 months to 78.4 months (mean 27.7 +/- 15.4). At the time of enrollment, mean BMI was 27.1 kg/m2 (+/-6.3) with one current smoker and one diabetic patient. Mean duration of symptoms prior to surgery was 75.2 months (+/- 72.5; r: 4-370mos). All knees were either Dejour B (81.3%) or D (18.8%) with a mean Caton-Deschamps index (CDI) of 1.20 (+/-0.2). Mean spur height preoperatively was 7.41 mm (+/1.84 mm) with a mean trochlear depth -0.18 (+/-2.71). Mean patellotrochlear index (PTI) was 0.41 (+/0.41). There were zero episodes of recurrent instability. All patients reported clinically significant improvements compared with baseline preoperative outcome scores. The mean preoperative IKDC score was 49.99, which improved to 79.86 (p&amp;lt0.001), and the mean preoperative Kujala score was 55.88, which improved to 85.80 (p&amp;lt0.001). Patients reported high satisfaction rates (9.5 +/-1.6 out of 10). All but 1 patient (96.9%) returned to work while 88.2% of patients were able to return to sport. Ten knees (20.4%) developed arthrofibrosis and required manipulation under anesthesia while eight of which underwent simultaneous arthroscopic lysis of adhesions. At the latest follow-up, mean knee range of motion was 132.4 +/- 13.2 degrees. Preoperative VAS was 3.31 (right) and 4.16 (left) while postoperative was 1.31 (right) and 1.76 (left) (p=0.007 R, 0.002 L). Radiographic analysis of the sulcus angle demonstrated a significant decrease from 148.86 degrees (+/-11.42) preoperatively to 135.11 degrees (+/-8.85) postoperatively (p&lt;0.001). Conclusion: In the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty can provide a reliable and successful surgical solution to recurrent patellar instability. At a minimum of one year follow-up, the majority of patients were satisfied with their outcome corroborated by their subjective, validated outcome measures.

Effects of Mobilization Time on Occurrence of New Fractures after Vertebroplasty.

Introduction Osteoporotic vertebral fracture treatment options include vertebroplasty, in which development of new fractures is among the possible complications which may develop during the postoperative period. We aim to evaluate whether or not postoperative mobilization time has effect on occurrence of new fractures. Materials and Methods A total of 126 patients, consisting of 30 (39.7%) males and 96 (60.3%) females, who underwent sedation-assisted vertebroplasty under local anesthesia between January 2014 and June 2017 were retrospectively evaluated. Preoperative and postoperative visual analogue scores (VASs) and mobilization time (hours) were assessed. Day of new fracture occurrence during follow-up was assessed. Results The mean follow-up period was 9 months (7–13 months). The most common fracture segment was the L1 vertebra (15.9%). The preoperative VAS was 8.29 ± 0.95, and the postoperative VAS was 2.33 ± 0.91. The change in VAS was statistically significant (p=0.01, p < 0.05). Of all the patients, 21 (16.66%) had developed new fractures. No statistical difference was observed between mobilization time (hours) and formation of new fractures (p=0.48, p > 0.05). Conclusion We came to the conclusion that mobilization time (hours) was not a risk factor in the development of new fractures. In addition, there is no relationship between mobilization time and localization of new fractures.

Outcomes of Core Decompression with or without Nonvascularized Fibular Grafting in Avascular Necrosis of Femoral Head: Short Term Followup study.

Background:Avascular necrosis (AVN) of the femoral head usually occurs in the third to fifth decade. The treatment options depend on the stage of disease varying from nonoperative treatment to surgical procedure including core decompression (CD) with or without nonvascularized or vascularized fibular graft, muscle pedicle bone grafting, osteotomies, and arthroplasty. Finite life of the total hip arthroplasty (THA) prosthesis limits its use in young adults or in middle aged. In this study, we envisage to evaluate the clinicoradiological outcomes of CD and nonvascularized fibular grafting in early stages of AVN femoral head.Materials and Methods:Our study is longitudinal observational study including 76 hips (46 patients) in the age group of 18–48 years (mean 30.07 years). Ficat and Arlet staging system was used and only early stages, that is, Stage 1 (n = 36 hips) and Stage 2 (n = 40 hips) were included in the study. The cases with traumatic AVN were excluded. All patients in Stage 1 underwent CD (Group 1) and those in Stage 2 underwent CD and fibular grafting (Group 2). Preoperative Harris Hip Score (HHS), visual analog score (VAS), plain radiographs, and magnetic resonance imaging (MRI) were compared with serial postoperative HHS, VAS, plain radiographs, and MRI taken at different intervals.Results:Average period of followup was 53.5 months (44–63 months). Radiological progression was not seen in 55 hips out of 76 hips (72.3%), whereas 21 hips (27.6%) demonstrated signs of progression and collapse. Failure of surgery was defined as progression of the disease, which was 25% (n = 9) in Group 1and 30% (n = 12) Group 2. Median values of HHS at the end of the followup in Group 1 was 77 and in Group 2 was 71.5 compared to the preoperative HHS of 48 and 62 in Group 1 and 2, respectively. Median values of VAS at the end of the followup in Stage 1 was 0 and in Stage 2 was 2 compared to the preoperative VAS of 6 and 8 in Group 1 and Group 2, respectively.Conclusion:CD with or without fibular grafting is effective in preserving the sphericity of the femoral head and to delay the progression of the AVN of femoral head in the early stages, that is, Stage 1 and Stage 2 and aids in the early revascularization of ischemic femoral head and is a useful modality to negate or delay the requirement of THA.

Comprehensive treatment algorithm for management of thoracic and lumbar tubercular spondylodiscitis by single-stage posterior transforaminal approach.

Surgery in tubercular spondylodiscitis involves radical debridement and fusion by combined anterior and posterior or all posterior approaches with a posterolateral window with its associated morbidities. This study evaluates the outcome of a comprehensive treatment algorithm for thoracic and lumbar tubercular spondylodiscitis by a single-stage posterior transforaminal approach. One hundred and twenty-six patients with tubercular spondylodiscitis between T1 and S1 who underwent posterior surgery with/without fusion by transforaminal approach with a minimum follow-up of 2years were analyzed. Radiological outcome was assessed by documenting healing with magnetic resonance imaging/computed tomography and radiographical fusion, while clinical outcome was assessed by visual analog score (VAS) for pain and Frankel grading for neurological recovery. Of the 114 patients available for follow-up with a mean age of 53years, complete radiological healing was observed in all patients (100%) with radiographical fusion in 97.4% and neurology recovered to Frankel E in all 37 patients with deficit. The preoperative VAS score of 9.2 improved significantly to 1.7 postoperatively, and all patients returned to their preoperative occupational activities at the final follow-up. This comprehensive treatment algorithm of single-stage posterior surgery by transforaminal approach in thoracic and lumbar tubercularspondylodiscitis provided good clinical and radiological outcomes. It aids in achieving the same surgical goals, obviating the need for extensive posterior or combined surgical approaches.