Radiographic Evidence Of Fusion Research Articles

Radiographic fusion and subsidence rates for stand-alone cage versus anterior cage-plate construct in ACDF

Study DesignRetrospective cohort BackgroundThe addition of an anterior cervical plate to a structural allograft during ACDF is thought to provide extra stability and enhance fusion, but it may increase the risk of complications like dysphagia. Stand-alone cages were designed to provide this extra stability without the need for the plate, but these may increase a patient's risk of subsidence, cervical dislocation, and cervical kyphosis. The purpose of this study was to assess reoperation rates and radiographic outcomes during follow-up longer than 6 months for patients who underwent ACDF with a cage and plate compared to stand-alone cage. MethodsACDF cases were retrospectively identified for four fellowship trained spine surgeons from 2016 – 2020 from two academic hospitals. A total of 57 stand-alone structural allograft constructs were matched via propensity scoring with a cohort of 65 patients with plate-secured structural allograft constructs. The primary outcome was reoperation rate within the follow-up period and secondary outcomes included complications, operative characteristics, readmission within 30 days, reoperation within 30 days and within follow-up, and radiographic outcomes. Immediate post-operative radiographs were compared to final follow-up radiographs at least 6 months post-operation to assess for evidence of subsidence, fusion, and change in cervical kyphosis using the Cobb angle technique. ResultsThere were 5 patients (5.26 %) in the stand-alone cohort and 4 patients (3.15 %) in the plate cohort that had cervical reoperation at any time in follow-up (P = 0.83). At final follow-up, 58 patients (92.1 %) in the plate group and 37 patients (75.5 %) in the stand-alone group had radiographic evidence of fusion (P = 0.015). There were 38 patients (77.6 %) in the stand-alone group and 29 patients (46 %) in the plate group with evidence of subsidence (P = 0.0007). Patients with subsidence had a greater change in kyphosis angle at final follow-up and this change was significantly decreased in the plate group compared to the stand-alone group. ConclusionThe use of anterior cage-plate constructs in ACDF produces higher rates of fusion and lower rates of subsidence than stand-alone cage constructs. Subsidence significantly increases the change in kyphosis angle between post-op and final follow-up, and the presence of a spanning plate significantly reduces this angle change compared to stand-alone cages. There were no statistically significant differences in reoperation rates, regardless of radiographic evidence of subsidence.

494 Comparison of Disc Height Restoration and Subsidence Rates Between Static Versus Expandable Titanium Cages for Lateral Lumbar Interbody Fusion

INTRODUCTION: It has been shown that expandable cages for transforaminal lumbar interbody fusion (TLIF) are associated with increased rates of subsidence. However, as lateral lumbar interbody fusion (LLIF) cages offer substantially larger footprints, this may offset the risks. METHODS: A retrospective review was performed of a consecutive adult patients undergoing LLIF with either static or expandable cages from 2013-2021. Demographics and surgical details were collected. Posterior disc height (PDH), subsidence, and fusions status were compared between patients with static and expandable cages. Follow-up were reported at minimum 6-months and 1-year. RESULTS: A total of 120 patients had 173 cages implanted: 96 patients with 143 static cages vs. 24 patients with 30 expandable cages. Mean age was 63.4 and 62.4% were male. There were no significant differences in age, gender, BMI, smoking, or osteoporosis. Overall, PDH was significantly increased following LLIF (4.1 v 7.4 mm, p < 0.001). Static and expandable cage types had similar magnitude (3.7 v 3.3 mm, p = 0.311) and percentage (89.0% v 121.5%, p = 0.127) change in PDH, respectively. Overall incidence of cage subsidence at 6-months and 1-year was 6.9% and 10.4% respectively. There was no significant difference in subsidence rates between cage types at 6 months (7.0% v 6.7%, p = 0.949) and 1-year (11.2 v 6.7%, p = 0.461). Radiographic evidence of fusion was present in 92.7% of cases at 1-year, and both cage types achieved similar fusion rates as well (92.2% v 95.6%, p = 0.555). CONCLUSIONS: LLIF static and expandable cages offer similar PDH restoration depending on surgical goals. Expandable cages seem to be less prone to subsidence than smaller TLIF cage counterparts and offer similar fusion rates to static cages. Larger cohort studies are warranted to further validate these findings which are ongoing.

122 Prospective, Randomized, Blinded Clinical Trial Comparing PEEK and Allograft Spacers in Patients Undergoing ACDF Surgeries

INTRODUCTION: The biomechanical qualities as well as osteoconductive, osteogenic, and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. METHODS: Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. Radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional postoperative radiographic assessment. RESULTS: A total of 120 patients were enrolled and randomized. Comparing clinical outcomes, no differences in arm or neck pain scores were noted, however, there was a statistically significant (<0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency towards lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (p=0.72) in the PEEK and allograft groups, respectively. At the 24-month follow-up, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24-month follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. CONCLUSIONS: Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK vs. allograft-assisted ACDF surgeries.

227. Prospective, randomized, blinded clinical trial comparing PEEK and allograft spacers in patients undergoing ACDF surgeries

BACKGROUND CONTEXT The biomechanical qualities as well as osteoconductive, osteogenic and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. PURPOSE The main objective of the study was to examine clinical and radiological outcomes in patients undergoing ACDF surgeries randomized to receive either PEEK or structural bone allografts. STUDY DESIGN/SETTING A prospective, randomized, blinded clinical trial was initiated at a single center. PATIENT SAMPLE A total of 120 patients were enrolled and randomized. OUTCOME MEASURES All patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment. METHODS Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. RESULTS Comparing clinical outcomes, no differences in arm or neck pain scores were noted, however there was a statistically significant (< 0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency towards lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (p=0.72) in the PEEK and allograft groups, respectively. At 24 months follow-up time, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24 months follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. CONCLUSIONS Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK vs allograft-assisted ACDF surgeries. There was a tendency for improved clinical outcomes in the allograft patient group. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. The biomechanical qualities as well as osteoconductive, osteogenic and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. The main objective of the study was to examine clinical and radiological outcomes in patients undergoing ACDF surgeries randomized to receive either PEEK or structural bone allografts. A prospective, randomized, blinded clinical trial was initiated at a single center. A total of 120 patients were enrolled and randomized. All patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment. Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. Comparing clinical outcomes, no differences in arm or neck pain scores were noted, however there was a statistically significant (< 0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency towards lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (p=0.72) in the PEEK and allograft groups, respectively. At 24 months follow-up time, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24 months follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK vs allograft-assisted ACDF surgeries. There was a tendency for improved clinical outcomes in the allograft patient group.

387 Minimally Invasive TTC Arthrodesis - Novel Arthroscopic Assisted Hindfoot Nailing

Abstract Aim Tibiotalocalcaneal arthrodesis is a salvage procedure for advanced primary degenerative joint disease of the hindfoot and ankle, failed primary fixation, post-traumatic osteoarthritis, or Charcot disease. Hindfoot nailing has been associated with complications in up to 40% of cases. There is limited literature on arthroscopic arthrodesis, as an advanced and minimally invasive technique. Our aim is to evaluate this pioneering minimally invasive procedure in terms of radiological and operative outcomes. Method We conducted a retrospective analysis of all patients who underwent this procedure at a single centre by a specialist foot and ankle service. We noted procedure indication, post-operative complications, and post-operative outcome in all patients. Outcomes include wound defects or infection, radiographic evidence of fusion, fixation failure, venous thromboembolism (VTE), and reoperation. Results A total of 12 patients underwent surgery with an average age of 75± 22 years. Indication for surgery included: 2 patients requiring fusion for severe primary osteoarthritis, 3 patients underwent primary arthrodesis following trauma and 7 patients underwent arthrodesis as a salvage procedure following failed primary fracture management. No patients had post-operative wound complications that required re-admission or a return to theatre, no VTE events, no fixation failures and 1 removal of screw for prominence. 6 patients have clinical and radiographic evidence of fusion, with the remaining 6 patients still under active follow-up and all still within 4 months of their fusion surgery. Conclusions Our current experience suggests that arthrodesis is achievable with this novel minimally invasive approach, which is a safe and reproducible procedure without increase in operative complications.

19. Long-term experience with anterior cervical discectomy and fusion using a bio-resorbable cage: results from a prospective study

<h3>BACKGROUND CONTEXT</h3> Current cervical interbody cage technology is not without limitations. One strategy to overcome its shortcomings led to the development of biodegradable cages. Animal studies and early clinical experience demonstrated gradual resorption of the cage with excellent bony incorporation and high fusion rates. Although much has been written about their advantageous characteristics, most studies followed their patients for short periods. Little has been published on the long-term follow-up of these cages. <h3>PURPOSE</h3> We describe our experience with biodegradable cages made from a resorbable composite material (40% polylactide (PLLA) and 60% beta-tricalcium phosphate (b-TCP)). These were reported to have a high breaking strength but minimal risk of subsidence. They also gradually resorbed, allowing for greater ease in the assessment of bony bridging. <h3>STUDY DESIGN/SETTING</h3> The authors conducted this prospective cohort study with the approval of our local ethics board. This study was conducted at a University Teaching Hospital in Jeddah, Saudi Arabia. <h3>PATIENT SAMPLE</h3> Consecutive patient sample propspectively enrolled. <h3>OUTCOME MEASURES</h3> Radiographic evidence of fusion, cage resorption, cervical alignment measures, failure requiring re-operation. <h3>METHODS</h3> The aim was to describe fusion and complication rates in patients undergoing anterior cervical discectomy and fusion (ACDF) with this novel biodegradable cage. Imaging was acquired and reviewed at preoperative visit, immediately postoperatively and at last follow-up. Systematic literature review: PubMed and EMBASE were searched for experience with these cages in cervical fusion at other centers. <h3>RESULTS</h3> Our center enrolled 27 patients (14 male and 13 female) until termination of this study. Median age was 60 years. Nineteen percent were smokers and 37% were diabetic. In total, 47 cages were implanted. The number of levels operated was: single-level in six cases, two-level in 12 cases, three-level in seven cases and four-level in two cases. Median follow-up was 34 months (IQR = 29.5-38 months). At final follow-up, 85% achieved fusion. Across all levels operated, we encountered a near-uniform loss of disc height and correction. Two patients required revisions due to cage-related complications and two patients developed asymptomatic screw fractures and are being followed. When removing industry-sponsored material, the literature review demonstrated very unfavourable experience with high rates of failure, similar to our series. <h3>CONCLUSIONS</h3> Our long-term experience with resorbable PLLA cages does not support their adoption into clinical practice. Our literature review supports this notion secondary to an unacceptably high complication and revision rate in other clinical settings. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Prospective, Randomized, Blinded Clinical Trial Comparing PEEK and Allograft Spacers in Patients Undergoing Anterior Cervical Discectomy and Fusion Surgeries.

Prospective, randomized, blinded clinical trial. To examine clinical and radiological outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF) surgeries randomized to receive either polyether-ether-ketone (PEEK) or structural bone allografts. The biomechanical qualities as well as osteoconductive, osteogenic, and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however, as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. Radiographic and clinical outcomes were assessed at 3, 6, 12, and 24 months with an additional postoperative radiographic assessment. A total of 120 patients were enrolled and randomized. Comparing clinical outcomes, no differences in arm or neck pain scores were noted; however, there was a statistically significant (≤0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency toward lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (P = 0.72) in the PEEK and allograft groups, respectively. At 24 months' follow-up time, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24 months' follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK versus allograft-assisted ACDF surgeries. Although MCID comparisons suggest that allograft and PEEK-treated patients have similar clinical outcomes, testing that incorporates the magnitude of the change suggests that there may be a statistically significant greater magnitude of improvement for the allograft group patients, but further studies with a larger sample size would be helpful to determine if a true effect exists.

Arthrodesis for Primary Osteoarthritis of Trapeziometacarpal Joint Using Multiple Kirschner Wires and Tension Band Wire in Female Patients Older than 40.

Background: The purpose of this study was to evaluate the results of arthrodesis with multiple Kirschner (K)-wires and tension band wire for primary osteoarthritis of trapeziometacarpal (TM) joint in female patients aged 40 years or older. Methods: We retrospectively obtained data regarding all female patients 40 years or older who underwent TM joint arthrodesis for TM joint osteoarthritis with K-wires and tension band wire over a 10-year period from 2009 till 2019. Thumb length, active range of motion (ROM) at the metacarpophalangeal (MCP) joint, active ROM of radial and volar adduction and abduction and key pinch strength was measured. Patient-reported outcomes were assessed using a pain and satisfaction questionnaire and the DASH score. We also recorded postoperative complications. Results: The study included 60 thumbs in 49 patients with an average age 60 years and a mean follow-up of 40 ± 21 months. All but one thumb had radiographic evidence of fusion within 6 months and the union rate was 98%. Key pinch strength increased from 2.3 to 4.9 kg after surgery. Total arc of motion in radial adduction-abduction decreased from 16° to 10°. Total arc of motion in volar adduction-abduction decreased from 25° to 9°. One patient experienced attritional rupture of the flexor pollicis longus tendon attributed to a K-wire penetration into the carpal tunnel. Although 46 thumbs (77%) had no or mild hardware-related symptoms, they underwent hardware removal after solid bone union. In 23 thumbs with follow-up period longer than 48 months, two thumbs developed scaphotrapeziotrapezoid joint arthritis and two thumbs developed metacarpophalangeal joint arthritis. Conclusions: We found that arthrodesis with multiple K-wires and tension band wire is a valuable option in the management of trapeziometacarpal joint osteoarthritis in female patients aged 40 years or older. Level of Evidence: Level IV (Therapeutic).

441 Prospective, Randomized, Double-Blinded Clinical Trial Comparing PEEK and Allograft Spacers in Patients Undergoing Transforaminal Lumbar Interbody Fusion Surgeries

INTRODUCTION: Allograft and polyether-ether-ketone (PEEK) radiographic, biomechanical, histological properties have been extensively studied and both spacers have their advantages and shortcomings. There are no comparative randomized or double-blinded spinal fusion clinical trials reported to date. METHODS: A prospective, randomized, controlled, double-blinded clinical trial was initiated at a single center. All patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment. RESULTS: A total of 138 patients undergoing transforaminal lumbar interbody fusions (TLIF) were randomized (1:1) to receive either cortical allograft or PEEK interbody lordotic spacers. RhBMP-2 was used in 96.7% allograft and 98.4% PEEK group patients. Although no differences were detected between the allograft and PEEK patient groups at any of the follow-up time points, there was a highly significant (p&lt;0.0001) improvement in all clinical outcome measures. Overall, evidence of radiographic fusion was achieved in 118 (97.5%) patients at the 24 months follow-up. Three patients, all in the allograft group, had pseudoarthrosis and underwent revision surgeries. Postoperative improvement of sagittal alignment, anterior (ABH) or posterior body height (PBH) was initially achieved, but it was mainly lost or reduced at the final follow-up and there were no statistically significant differences between the groups. At the end of the study, improvement and maintenance of lumbar lordosis were achieved in 43.3% and 49.2% patients and segmental alignment in 38.3% and 36.1% for the allograft and PEEK patient groups, respectively. Similarly, ABH was improved and maintained in 28.3% and 36.1% patients and PBH in 28.3% and 44.3% for the allograft and PEEK groups, respectively. CONCLUSION: Although allograft-assisted surgeries may have reduced fusion rates, the study findings demonstrated that TLIF surgery with two different types of cages and in conjunction with rhBMP-2 resulted in similar radiological or clinical outcomes and a highly statistically significant improvement in all clinical outcome measures at the end of the study regardless of the randomization group.

19. Anterior lumbar interbody fusion with porous titanium interbody cages is associated with equivalent fusion rates and patient reported outcomes as bone morphogenetic protein-2

<h3>BACKGROUND CONTEXT</h3> Although frequently used for anterior lumbar interbody fusion (ALIF), concerns regarding the use of recombinant human bone morphogenetic protein 2 (BMP-2) include off-label use, elevated cost and adverse outcomes such as osteolysis. The growing evolution of porous implant technology in promoting osseous integration via ingrowth provides an opportunity for a paradigm shift by relying less on biologic-assisted through-growth and leveraging implant on-growth and in-growth in similar fashion to porous metallic implants used in other orthopedic settings such as hip arthroplasty. <h3>PURPOSE</h3> This study compared perioperative clinical and radiographic outcomes between patients undergoing ALIF with the assistance of BMP-2 in a nonporous, traditional window interbody cage vs those with no biologic using a minimal-window porous titanium interbody cage. <h3>STUDY DESIGN/SETTING</h3> Retrospective clinical. <h3>PATIENT SAMPLE</h3> This study retrospectively examined 75 consecutive patients who underwent 1- or 2-level ALIF between 2014 and 2020 with the use of BMP-2 in a nonporous PEEK cage vs a porous titanium interbody cage and no biologic. All patients had surgery with the senior surgeon and were followed for a minimum follow-up of 6-months postoperatively. <h3>OUTCOME MEASURES</h3> Patient demographics, comorbidities, postoperative complications, and preoperative, immediate and final postoperative patient-reported outcomes (PROs) were assessed. Rates of reoperation were recorded, and arthrodesis was evaluated using Bridwell radiographic criteria and CT when available. Pre- and postoperative radiographic parameters were evaluated for differences in spinopelvic alignment and correction. <h3>METHODS</h3> Statistical methods included student's t-test and chi-square for continuous and categorical variables, respectively. Continuous variables were reported as means and standard deviations, and categorical variables as proportions. The threshold for statistical significance was set to p < .05. <h3>RESULTS</h3> Forty-three (13 female, 30 male) and 32 (19 female, 13 male) patients were assessed in the BMP-2 and titanium cage cohorts, respectively. On PRO assessment, baseline VAS leg among BMP-2 patients (6.87, SD: 1.96 vs 5.16, SD: 2.41; p = .023) while the titanium cage group reported worse VAS back scores (6.23, SD: 2.39 vs 7.82, SD: 1.40; p = .023). However, there were no significant differences recorded in postoperative PRO surveys between groups. Correction of spinopelvic alignment was equally maintained between groups at final follow-up when compared to immediate postoperative radiographs. Similarly, disc spaces were equivalently upheld across cohorts, with the exception of greater degeneration among BMP-2 patients at the L4-L5 anterior (-1.78, SD: 3.00 vs -0.07, SD: 2.63; p = .039) and foraminal (-2.34, SD: 3.11 vs -0.07, SD: 2.06; p = .006) disc spaces. Interbody subsidence was similar at the superior (1.13, SD: 0.84 vs 1.28, SD: 0.88; p = .458) and inferior endplates (0.55, SD: 0.79 vs 0.91, SD: 1.27; p = .154), and radiographic evidence of fusion was observed at equivalent rates (90% vs 90.9%, p = .776). There were no differences in the rates of secondary surgeries for adjacent segment disease (ASD) (4.6% vs 0%, p = .222) or index-level revisions (9.1% vs 18.8%, p = .219). <h3>CONCLUSIONS</h3> Porous titanium interbody cages for ALIF may be equivalent to BMP-2 in nonporous PEEK in achieving arthrodesis, alignment durability and reoperation rates. Although long-term follow-up is necessary, the use of porous titanium implants without external biologics is an intriguing paradigm change which may produce similar outcomes at lower costs. <h3>FDA DEVICE/DRUG STATUS</h3> Alphatec Identiti Cage (Approved for this indication), Recombinant Human Bone Morphogenetic Protein-2 (Approved for this indication)

Prospective, randomized, double-blinded clinical trial comparing PEEK and allograft spacers in patients undergoing transforaminal lumbar interbody fusion surgeries

Allograft and polyether-ether-ketone (PEEK) radiographic, biomechanical, histological properties have been extensively studied and both spacers have their advantages and shortcomings. There are no comparative randomized or double-blinded spinal fusion clinical trials reported to date. The study's primary objective was to prospectively investigate clinical and radiological outcomes in patients undergoing lumbar interbody fusions and randomized to receive either PEEK or structural bone allografts. A prospective, randomized, double-blinded clinical trial was initiated at a single center. A total of 138 patients were enrolled, randomized and 121 patients completed the study. The primary clinical outcome parameters were scored from standardized patient-reported questionnaires. The severity of lower back and leg pain was evaluated using the 11-point Visual Analog Scale (VAS). The Oswestry Disability Questionnaire was used to evaluate chronic disability and activities of daily living. Health-related quality of life and functional outcomes were assessed using Health-related Quality of Life Questionnaire (SF-36 v2). Two scores within the scoring algorithm were analyzed: Physical Component (PCS) and Mental Component Summary (MCS). The primary radiological outcomes included restoration and maintenance of vertebral body height, lumbar sagittal and segmental alignment, and fusion status. All patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment. A total of 138 patients undergoing transforaminal lumbar interbody fusions (TLIF) were randomized (1:1) to receive either cortical allograft or PEEK interbody lordotic spacers. Although no differences were detected between the allograft and PEEK patient groups at any of the follow-up time points, there was a highly significant (p<.0001) improvement in all clinical outcome measures. Overall, evidence of radiographic fusion was achieved in 118 (97.5%) patients at the 24 months follow-up. Three patients, all in the allograft group, had pseudoarthrosis and underwent revision surgeries. Postoperative improvement of sagittal alignment, anterior (ABH) or posterior body height (PBH) was initially achieved, but it was mainly lost or reduced at the final follow-up and there were no statistically significant differences between the groups. At the end of the study, improvement and maintenance of lumbar lordosis were achieved in 43.3% and 49.2% patients and segmental alignment in 38.3% and 36.1% for the allograft and PEEK patient groups, respectively. Similarly, ABH was improved and maintained in 28.3% and 36.1% patients and PBH in 28.3% and 44.3% for the allograft and PEEK groups, respectively. Although allograft-assisted surgeries may have reduced fusion rates, the study findings demonstrated that TLIF surgery with two different types of cages and in conjunction with rhBMP-2 resulted in similar radiological or clinical outcomes and a highly statistically significant improvement in all clinical outcome measures at the end of the study regardless of the randomization group.

Single-level fusion without decompression for high-grade spondylolithesis in adolescents: a novel surgical strategy

There is no consensus on the optimal surgical treatment for high-grade spondylolisthesis (HGS) in adolescents. The purpose of this study was to assess the radiographic and clinical outcomes of a novel surgical approach to HGS consisting of a single-level anterior reduction, placement of a lordotic cage, and circumferential fixation without decompression. This was a retrospective consecutive case series of 11 adolescents who underwent anterior reduction through placement of a lordotic cage followed by posterior fusion using pedicle screws and rods confined to L5-S1. Radiographic data included slip percentage, slip angle, lumbar lordosis, and pelvic sagittal parameters assessed at clinical visits preoperatively and at 2years postoperatively. A telephone survey was conducted to obtain current information about function, activity level, work status, and retrograde ejaculation. Patients were followed for an average of 7.8years (range 2-16). Mean age was 15.5years (range 12-19). The mean percent slip corrected from 55 to 18%. The average slip angle was + 17.1° preoperatively and - 14.1° at final assessment (average correction of 20.7°). Thirty-six percent (4/11) of patients improved by three Meyerding grades and an additional 55% (6/11) improved by two grades. Complications included one instance each of superficial infection, wound dehiscence, and transient neuralgia. There were no cases of instrumentation failure, cage subsidence, pseudoarthrosis, or retrograde ejaculation. Radiographic evidence of fusion was observed in all cases. Single-level anterior reduction and circumferential fusion without decompression appears to be a safe and effective alternative for the surgical treatment of pediatric HGS. IV.

THE EFFECT OF PLATE AND SCREWS ON SINGLE-LEVEL ANTERIOR CERVICAL DISCECTOMY AND FUSION

Objective: To evaluate radiographic and clinical outcomes following anterior cervical discectomy and fusion with cage and plate in patients with degenerative spondylosis. Methods: A prospective study. Patients were performed this technique between August 2013 and October 2017. Radiographic follow-up included static and flexion/extension radiographs obtained to assess fusion, focal and segmental kyphosis, and change in disc space height. The Odom’s criteria and NDI were used to assess outcomes at most recent follow-up. Results: Twenty-two patients with singlelevel degenerative spondylosis underwent ACDF with cage and plate during the study period. The mean duration of follow-up was 17.6 ± 7.3 months. Radiographic evidence of fusion was present in 21 patients (95.5%). The focal alignment at operated level on postoperative radiographs was slightly changed (mean α2 was 4.30 ± 5.50) and segment alignment was a little increased lordosis with mean Cobb angle β2 was 15.70 ± 12.40. Mean decrease in disc space height was 5.4 ± 2.4%. Six patients (27.3%) had dysphagia. Fifteen patients (68.2%) had excellent results according to Odom’s criteria. The mean post-operation NDI score was 5.1 ± 5.8 (median 2.5 range 1-21). Conclusions: Single-level ACDF with cage and plate for cervical spondylosis is an effective treatment, achieves high rate of fusion and preserves the alignments of cervical spine. Key words: Anterior Cervical Discectomy and Fusion, cervical spondylosis

The Anterolateral Thigh-Medial Femoral Condyle Chimeric Flow-through Flap for Posttraumatic Wrist Arthrodesis

Wrist arthrodesis in the setting of segmental bone loss can have high failure rates. Therefore, vascularized bone grafting has been advocated for select patients. Patients suffering concomitant large soft tissue loss present even greater challenge. To that end, we describe for the first time successful anterolateral thigh-medial femoral condyle chimeric flow-through flap for posttraumatic wrist arthrodesis and soft tissue coverage. This is a case report of a 19-year-old male laborer who suffered a large blast injury resulting in significant bone and soft tissue injury to the dominant right hand and wrist. After multiple debridements, there was a segmental bone defect from the distal radius and ulna to the metacarpal bases, as well as a 12×8 cm dorsal soft tissue defect. This was reconstructed with a anterolateral thigh-medial femoral condyle chimeric flow-through flap and concomitant wrist arthrodesis in a single stage. Besides a donor site thigh seroma, recovery was uneventful with clinical and radiographic evidence of fusion by >9 weeks postoperation.

Anterior lumbar interbody fusion (ALIF): biometrical results and own experiences

Lumbar fusion is a mainstay in the treatment of low back pain resulting from degenerative disc disease. Anterior lumbar interbody fusion (ALIF) has become a reasonable treatment technique to achieve indirect foraminal decompression with high fusion rates. The aim of the study was to analyse the biometrical parameters of the lumbar spine and the clinical outcome. The medical records of 51 patients treated with ALIF between 2012 and 2016 were retrospectively reviewed. Anterior and posterior disc height (DH), lumbar lordosis (LL), local disc angle (LDA) and foraminal dimensions were obtained on pre- and postoperative plain radiographs and computed tomography scans using ImageJ and Surgimap software according to the pedicle–pedicle technique. To evaluate the interbody fusion status on the last follow-up CT scans, we used Bridwell criteria. Preoperative and 12 months postoperative Oswestry Disability Index (ODI) scores were determined for all patients. The average length of hospitalisation was 4 days. Most of the patients had degenerative disc disease with foraminal stenosis. Five patients had early complications like paresthesia of lower limbs, sympathetic dysfunction or wound infections, but there were no major complications. Statistically significant (P < .01) improvement was observed in foraminal dimensions (area = 49%, height = 33% and width = 19%), anterior DH (49%), posterior DH (69%), LDA (47%) and LL (17.5%). Posterior DH correlated significantly with foramen height improvement. Radiographic evidence of fusion according to the modified Bridwell criteria (grade I and grade II) was observed in 96% (49/51) of the patients in the last CT of the lumbar spine. We also observed significant improvement in functional recovery in 94% of patients. The mini-open ALIF approach is a reasonable alternative to the more extensive posterior approaches. ALIF significantly restores the height of the intervertebral disc, indirectly increases foraminal dimensions, increases lordosis angle with significant short and long-term pain relief and functional recovery.

Correlation of Anterior Interbody Graft Choice With Patient-Reported Outcomes in Cervical Spine Trauma

Study Design:Ambispective observational cohort study.Objectives:Synthetic graft usage avoids morbidity associated with harvest and reduces operative time. This study aims to evaluate outcomes of anterior cervical stabilization surgery using a synthetic cage in comparison with iliac crest bone graft (ICBG) following cervical spine trauma.Methods:An ambispective review was conducted on patients from the Alfred Trauma Registry. Consecutive patients treated at a level 1 trauma center, aged 18 years and older who were treated with standalone anterior cervical stabilization following spine trauma (2011-2016) were included in the study. Primary outcome measures were patient overall satisfaction, Neck Disability Index (NDI), neck pain 10-point visual analogue scale (VAS-neck) and arm pain 10-point visual analogue scale (VAS-arm). Secondary outcome measures were radiographic evidence of fusion and rate of revision surgery. All patients had follow-up for at least 1 year.Results:Between 2011 and 2016, 114 traumatic disc levels in 104 patients were treated. ICBG was used in 32% and polyetheretherketone (PEEK) cage in 68% of the patients. Both groups had similar demographic metrics. There was no significant difference in primary outcome measures between the graft types: (1) patient satisfaction (P = .15), (2) NDI (P = .11), (3) VAS-neck (P = .13), and (4) VAS-arm (P = .20). Radiology based fusion assessment 6 months postsurgery did not show statistical significance (P = .10). The rates of revision surgery were similar.Conclusions:This study showed no significant difference in patient-reported outcome measures when comparing the usage of PEEK cage and ICBG in anterior stand alone cervical spine stabilization. Level 1 evidence studies are required to further investigate this finding.

Single-center, consecutive series study of the use of a novel platelet-rich fibrin matrix (PRFM) and beta-tricalcium phosphate in posterolateral lumbar fusion.

To evaluate the radiographic and clinical outcomes of the combination of platelet-rich fibrin matrix (PRFM) with beta-tricalcium phosphate (β-TCP) and bone marrow aspirate (BMA) as a graft alternative in posterolateral lumbar fusion procedures. Researchers evaluated 50 consecutive patients undergoing one-level to three-level posterolateral lumbar fusion procedures, resulting in a total of 66 operated levels. The primary outcome was evidence of radiographic fusion at 1-year follow-up, assessed by three independent evaluators using the Lenke scoring system. Secondary outcomes included back and leg VAS scores, incidence of reoperations and complications, return-to-work status, and opioid use. At 1-year follow-up, radiographic fusion was observed in 92.4% (61/66) of operated levels. There was significant improvement in VAS scores for both back and leg pain (p < 0.05). Compared to baseline figures, the number of patients using opioid analgesics at 12-months decreased by 38%. The majority (31/50) of patients were retired, yet 68% of employed patients (n = 19) were able to return to work. No surgical site infections were noted, and no revision surgery at the operated level was required. This is the first report to analyze the combination of PRFM with β-TCP and BMA for PLF procedures. Our results indicate a rate of fusion similar to those reported using iliac crest bone graft (ICBG), while avoiding donor site morbidity related to ICBG harvesting such as hematoma, pain, and infection. These slides can be retrieved under Electronic Supplementary Material.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters

BACKGROUND CONTEXT The need for improved fusion technology led to the development of a lumbar interbody fusion implant with unique biomechanical characteristics that has the potential to enhance bone on-growth and through-growth. The proprietary implant using truss-based technology allows loading along the trusses throughout the fusion volume of the device which may promote stem cell differentiation into osteoblast and speed up the fusion process. PURPOSE It is hypothesized that fusions performed using the truss-based technology will result in higher fusion rates and reduced times for bone formation due to the biomechanical properties of the implant design when compared to annular implant designs. The purpose of this study was to evaluate the performance of the truss-based technology with two different graft materials, crushed cancellous allograft bone or autologous bone marrow aspirate. STUDY DESIGN/SETTING Prospective, randomized clinical trial performed in a university setting. PATIENT SAMPLE Between January 2015 and February 2016, 42 consecutive patients were recruited, consented and randomized into one of two previously defined study groups and underwent the index study procedure. There was one patient in Group 2 that withdrew from the study prior to surgery. In addition, there were 2 patient deaths due to cardiac events (one in each group) determined to be unrelated to the surgical procedure. OUTCOME MEASURES The clinical outcome measures included the Oswestry Disability Index (ODI), Visual/Analog Scales (VAS) separately assessing back and leg pain, EQ5-D and adverse events. METHODS Patients were randomized into one of two treatment groups (Group 1: crushed cancellous allograft bone vs. Group 2: autologous bone marrow aspirate [BMA] both receiving one- or two-level lumbar interbody fusion with supplemental fixation. It was determined that a total of 40 patients (20 patients per group) were needed to achieve a statistical significance level of 0.05. The 4WEB Anterior Spine Truss System Interbody Fusion Device (ASTS; 4WEB Medical, Frisco, TX, USA) was used in all cases. Clinical and radiographic data was obtained prior to hospital discharge and at 3, 6 and 12-months postoperatively. All radiographs were independently reviewed. RESULTS Except for changes from the preoperative assessment for total EQ-5D (p CONCLUSIONS The clinical and radiographic results from this prospective, randomized study have shown that reliable clinical and radiographic evidence of fusion can be obtained utilizing a truss-based web technology implant independent of the use of either crushed cancellous homologous bone chips or BMA alone. As a result of these findings, there may be intraoperative biologic cost reduction implications across multiple patient populations.

Return to Play After Anterior Cervical Discectomy and Fusion in Professional Athletes.

Background:Data are limited on return to play after anterior cervical discectomy fusion (ACDF) in professional athletes.Purpose:To determine the rate and time of return to play among professional athletes after ACDF.Study Design:Case series; Level of evidence, 4.Methods:This study involved the prospective and retrospective review of patient charts and diagnostic studies as well as an internet search to collect data on a consecutive series of professional athletes who underwent cervical fusion by 1 of the 2 senior authors between 1982 and 2016. Demographic data included sport, preoperative symptoms and radiologic findings, date of surgery, level of surgery, postoperative symptoms and radiologic findings, and confounding factors (eg, other orthopaedic injuries). An internet search engine was used to determine date of return to play and length of career after surgery.Results:A total of 27 ACDFs were performed on 26 professional athletes: 12 National Football League athletes, 5 National Hockey League athletes, 5 Major League Baseball athletes, 3 National Basketball Association athletes, and 1 Major League Soccer athlete. Twenty-six procedures (96.3%) showed clinical and radiographic evidence of fusion, and 20 of 25 eligible players returned to play (80%). At the conclusion of this study, 2 players were still in the rehabilitation phase and expected to return at the start of the next National Football League season. The mean time to return to play in a professional game was 9.5 months (range, 5.0-20.2 months). Of 15 players who returned to play but had retired by the time of this study, the mean career length after fusion was 3.2 years (range, 0.1-8.0 years). Clinical follow-up ranged from 1 to 96 months, with a mean of 22.1 months and mode of 11 months.Conclusion:After single-level ACDF, 80% of professional athletes were able to return to sport at approximately 9 months. The study findings will help athletes, physicians, and teams better predict outcome after ACDF surgery.

A Retrospective Study

Category: Ankle Introduction/Purpose: Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure for end-stage pathology of the tibiotalar and subtalar joints including primary arthritis, severe deformity, failed total ankle arthroplasty, failed ankle arthrodesis with subsequent subtalar arthritis, talus avascular necrosis and Charcot arthropathy. Although many different fixation techniques of TTCA have been proposed, there is still no consensus gold standard fixation strategy. The various options include plate and screw constructs, intramedullary nails and external fixator systems. The purpose of this study is to report our experience with rigid fixation using a commercially available 4.5 mm locking plate for TTCA. Methods: We retrospectively reviewed the clinical charts and radiographs of 17 patients who underwent TTCA during the time period of 2012-2014. We used a lateral surgical approach with fibular osteotomy and a 4.5 mm Smith and Nephew™ PERI-LOC ankle fusion plate. Two senior foot and ankle surgeons at our institution performed all surgeries. The main outcomes were postoperative fusion rate and complication rate. Results: Of the 17 patients, 9 were male and 8 were female with a mean age of 53. 29% of patients had diabetes mellitus and 69% were either current or former smokers. The average BMI was 32.9. The average follow up was 17.7 months. The nonunion rate in our patient series was 76%. Nonunion was defined as no radiographic evidence of fusion at 6 months post-surgery. This failure rate is very high in comparison to historical data of nonunion rates in TTCA, which are often reported to be 7-26%. Only four out of 17 patients had a successful arthrodesis using this locked plate construct. Complications included nonunion, hardware failure (with screws and/or plate fracture), deep infection (35% of patients), and pseudoarthrosis. Conclusion: Too rigid of fixation with thick stainless steel plates and locking screw constructs can lead to failure in tibiotalocalcaneal arthrodesis. Increased nonunion rates due to overly rigid fixation has been demonstrated in many other contexts but never in the foot and ankle literature.