Significant Loss Of Correction Research Articles

The modified Kostuik transilial bar technique has acceptable results in neuromuscular spinal deformity correction.

The aim of this study is to evaluate the results of the modified Kostuik transilial bar technique for neuromuscular scoliosis (NS). We reviewed the records of 21 patients treated for NS with this instrumentation. There were 14 females and seven males, with an average age of 15.6 years (range: 9-21 years). We determined patients' demographics, correction ratio of both curve and pelvic obliquity, loss of correction, screw loosening at first sacral vertebra, and clinical outcomes. Mean follow-up was 56 months (range: 34-96 months). There were no reoperations, no screw breakage, and no significant loss of correction. The mean preoperative coronal Cobb angle was 71.4°±8.7°, the initial postoperative measurements had a mean Cobb angle of 19.2°±7.2°, and at the last follow-up, the mean Cobb angle was 23.6°±6.9° (P<0.001). Pelvic obliquity decreased from 27.7°±12.4° to 9.1°±5.3° at follow-up and to 11.9°±6.3° at the last follow-up (P<0.001). The preoperative pelvic obliquity angle was significantly higher at the patients with screw loosening (P=0.016). There was one established as well as one possible pseudoarthrosis in our patients. The new technique does appear to possibly become an alternative to conventional lumbosacral fixation techniques. Integration of the bar with pipe-type connector onto the long spinal instrumentation with oblique connectors can prevent the most unenviable complications such as wide exposure, hardware prominence, reoperation, and pseudoarthrosis.

Loss of Pelvic Incidence Correction After Long Fusion Using Iliac Screws for Adult Spinal Deformity: Cause and Effect on Clinical Outcome.

Retrospective observational cohort study. To determine change in pelvic incidence (PI) and loss of correction after long fusion with iliac screws, the effect of iliac screw loosening, and global alignment according to postoperative PI. Posterior long fixation and fusion of the thoracic to the ilium is one of the most common surgical treatments for adult spinal deformity (ASD). Long fusion to the sacrum with iliac screws decreases the PI by 3.9° after surgery. PI decreases once by long fusion with iliac screws. However, if the iliac screw loosens, PI may cause correction loss and return to the preoperative PI. We retrospectively reviewed the cases of 69 consecutive patients with ASD. Their mean age (SD) was 70.5 (7.3) years, 12% were male. PI was evaluated preoperatively, early- and 1-year postoperatively. We compared change in PI with and without loosening of iliac screws, spinopelvic parameters according to 1-year-postoperative PI. PI decreased significantly from 51.8° (9.3°) to 48.1° (9.5°) early postoperatively (P < 0.01). PI increased significantly from 48.1° (9.5°) to 49.6° (9.7°) within a year postoperatively (P < 0.01). Significant loss of PI correction (2.3°, P < 0.01) occurred within a year after surgery in patients with iliac screw loosening and was significantly different from the PI loss in those without screw loosening (53.9°, 48.2°, P = 0.03). Pelvic tilt, sacral slope, C7 sagittal vertical axis, global tilt, and T1 pelvic angle were significantly smaller in the group with PI <50° postoperatively at 1 year compared with the group with PI >50°. Although PI decreases after long fusion surgery with iliac screws, significant correction loss appears within a year. Loosening of iliac screws may exacerbate this loss. Patients with PI <50° postoperatively were able to maintain better global alignment. 3.

Single-stage anterior debridement, posterior instrumentation and global fusion in thoracic and thoracolumbar tubercular spondylodiscitis.

The present study evaluated the clinical and radiological outcomes in patients with tuberculosis of the thoracic and thoracolumbar spine, treated by an operative technique in which anterior debridement with posterior instrumentation and global fusion was performed through a single-stage posterior approach. Ninty-seven patients with spinal tuberculosis, between T1 and L1, in whom anterior debridement, bone grafting, with posterior instrumentation and fusion was performed through a single-stage posterior approach, with a minimum follow-up of 2years, formed the basis of this study. During each follow-up, neurological recovery was assessed using modified American Spinal Injury Association grading, healing of the disease was assessed by appearance of sclerosis and interbody fusion and the degree of kyphotic deformity was analysed using the modified Konstam's angle. Two hundred and twenty-six lesions were found in the radiographs of 97 patients with 28.9% of them having multiple lesions. The mean ± SD preoperative, post-operative, and 2-year follow-up kyphotic angle were 49.5 ± 18.4°, 22.6 ± 7.1° and 24.5 ± 7.6°, respectively, and showed significant kyphosis correction (P < 0.01). Sclerosis was seen as early as 3months in 82(84.5%) patients whereas interbody fusion started appearing at the end of 6months in 38.14% of patients and peaked at 1year. All patients recovered neurologically, with no significant loss of kyphosis correction, at final follow-up. The surgical technique described in this study had favourable clinical and radiological outcomes. Early surgery helps in having a definitive diagnosis and detects the presence of drug-resistant strains.

Lowest Instrumented Vertebrae Selection for Posterior Fusion of Lenke 5C Adolescent Idiopathic Scoliosis: Can We Stop the Fusion One Level Proximal to Lower-end Vertebra?

Background:The most appropriate fusion levels remains challenging, especially in Lenke type 5 curves. In Lenke 5 adolescent idiopathic scoliosis (AIS) generally fusion includes the lower end vertebra (LEV). This study determines whether it is appropriate to fuse mild to moderate Lenke 5 curves to LEV-1, if possible.Materials and Methods:Forty-two patients with mild to moderate Lenke 5 AIS that underwent posterior fusion were retrospectively evaluated. The preoperative goal was to stop the instrumentation at LEV-1 in all patients if possible. However, the final decision was made intraoperatively according to the alignment of the disc below lowest instrumented vertebra (LIV). In 19 patients, this goal was achieved and LIV was LEV-1, whereas 23 patients were fused to LEV. Hence, two groups occurred and they were compared in terms of coronal, sagittal, and LIV related parameters at 1 year and 3 years postoperatively. Surgical times were also noted. Clinical outcomes were assessed using scoliosis research society (SRS-22) and Short Form-36 questionnaires.Results:Two groups were well matched according to preoperative values. Postoperative radiographic results were also similar, except LIV disc angle and LIV translation, which were significantly higher in LEV-1 group at 1 and 3 years followup (P < 0.05). Surgical times were significantly longer in LEV group (P = 0.036). No significant correction loss was observed between 1 and 3 years followup. There were no significant differences regarding postoperative clinical outcomes except the activity domain of SRS-22, which was significantly higher in LEV-1 group, but the significance was weak (P = 0.045).Conclusions:Fusion to LEV-1was associated with the higher amount of LIV disc angle and LIV translation, which did not cause coronal and sagittal imbalance and decreased the quality of life scores. Hence, if intraoperatively a level disc below LIV can be achieved, fusion to LEV-1 may be an option in mild to moderate Lenke 5 curves, to save one more mobile segment.

Long-term results of multilevel surgery in adults with cerebral palsy.

Deterioration of gait in adolescent and adult patients with cerebral palsy can be associated with multiple factors. Multilevel surgery (MLS) is one option in adults with cerebral palsy to improve gait function with encouraging short-term results. It is a question whether these improvements are maintained over time. In a retrospective consecutive cohort study, adults with bilateral spastic cerebral palsy (BSCP) treated with MLS between 1995 and 2011 were scanned for potential inclusion. Patients needed to fulfill the following inclusion criteria: age at MLS > 17, standardized three-dimensional gait analysis (3D-GA) including clinical examination at pre-operative (E0), a short-term follow-up (E1) and at least sevenyears (E2) after the index MLS. Twenty adults (10 women, 10 men) with a Gross Motor Function Classification Level (GMFCS) I-III and a mean age at MLS of 24.8years were included in this study. The average long-term follow-up was 10.9years. The Gait Profile Score (GPS) was used as primary outcome measure. The GPS improved significantly from 13.8° before surgery to 11.2° at short-term (p = 0.007) and to 11.3° at long-term follow-up (p = 0.002). Mean GPS showed a slight deterioration between E1 and E2 due to a minority of six patients (30%) who showed a significant loss of correction. Surgical treatment in adults with BSCP was feasible and effective in the long-term. Significant improvement of gait and function was maintained in the majority of patients, while some patients were prone to develop crouch gait, hip flexion contractures, or pain.

Criteria for Ending the Distal Fusion at the L3 Vertebra vs. L4 in Surgical Treatment of Adolescent Idiopathic Scoliosis Patients with Lenke Type 3C, 5C, and 6C Curves: Results After Ten Years of Follow-up.

IntroductionThe selection of the most distal caudal vertebra in spinal fusion surgeries in adolescent idiopathic scoliosis patients with structural lumbar curvatures is still a matter of debate. The aim of this study was to determine the preoperative radiological criteria on the traction X-rays under general anesthesia (TrUGA) for selection between the L3 and L4 vertebrae and to assess the efficacy of these criteria via the long-term results of patients with Lenke Type 3C, 5C, and 6C curves.MethodsRadiological data of 93 patients (84 females, 9 males) who met the inclusion criteria were retrospectively evaluated. The relationship between the L3 vertebra and the central sacral vertebral line, the portion of the L3 vertebra in the stable zone of Harrington, the parallelism of the L3 with the sacrum, and the tilt and rotation of the L3 on TrUGA radiographs were evaluated for the selection of the lowest instrumented vertebrae (LIV). Clinical results were analyzed using the Scoliosis Research Society-22 (SRS-22) questionnaire.ResultsThe mean follow-up period of the study group was 149.3 months. According to the Lenke classification, 29 patients had Type 3C, 33 had Type 5C, and 31 had Type 6C curves. The preoperative analysis was based on standing anteroposterior (AP), supine traction, and bending X-rays, and the L3 vertebra was selected as the LIV in 37 patients (40%). These X-rays suggested L4 as the LIV in 56 patients (60%); however, based on our study criteria, the L3 vertebra was selected. No significant loss of correction was observed nor additional surgery due to decompensation was required in the follow-up period.Conclusion The use of TrUGA radiographs with the identified criteria is an efficient alternative method in the selection of the LIV in patients with Lenke Type 3C, 5C, and 6C curves.

SRS-Schwab Grade 4 osteotomy for congenital thoracolumbar kyphosis: a minimum of 2 years follow-up study.

Several osteotomy techniques including pedicle subtraction osteotomy and vertebral column resection have been employed in the correction of congenital kyphosis (CK) and satisfying outcomes have been demonstrated. However, the Scoliosis Research Society (SRS)-Schwab Grade 4 osteotomy, defined as resection of posterior elements, partial vertebral body, and superior adjacent disc, is rarely reported in the treatment of CK. The present study aimed to evaluate the efficiency and safety of SRS-Schwab Grade 4 osteotomy in patients with CK, and to propose its optimal indication. This is a retrospective analysis of clinical and radiographic outcomes of patients with CK undergoing SRS-Schwab Grade 4 osteotomy. Patients with thoracolumbar CK undergoing SRS-Schwab Grade 4 osteotomy from January 2010 to May 2015 followed up for at least 2 years were retrospectively reviewed. The thoracic kyphosis, lumbar lordosis, segmental kyphosis (SK), sagittal vertical axis (SVA), pelvic incidence, pelvic tilt, and sacral slope were measured on lateral spinal x-rays. Patients were required to fulfill the SRS-22 questionnaire at preoperation and the last follow-up. The sagittal spinal-pelvic parameters were assessed at preoperation, postoperation, and last follow-up. The comparison between preoperation and postoperation was performed by paired samples t test. A total of 38 patients with CK (17 male and 21 female) with an average age of 16.5±9.9 years were included. The mean operating time was 242.7±88.1 minutes and blood loss was 634.5±177.8 mL. The mean follow-up was 38.8±20.3 months. The SK was 49.5±11.7° at preoperation, 6.8±7.4° at postoperation (p<.001), and 8.0±8.1° at the last follow-up. No significant correction loss during follow-up was found in SK (p=.125). The SVA was improved from -36.0±18.3 mm at preoperation to 3.7±17.8 mm at postoperation (p<.001), and the correction was well maintained during follow-up (p=.113). Compared with preoperation, the mean postoperative scores of each domains of SRS-22 questionnaire improved at different levels. Intraoperative complications included one case with incidental dural tear and another with transient root injury. Proximal junctional kyphosis occurred in three patients at 6 months after operation and remained stable during the follow-up. At the last follow-up, all patients were identified to have achieved solid bony fusion. The SRS-Schwab Grade 4 osteotomy, if selected appropriately, could provide satisfying correction of congenital kyphosis. The correction could be well maintained during the longitudinal follow-up.

Opening-wedge high tibial osteotomy performed with locking plate fixation (TomoFix) and early weight-bearing but without filling the defect. A concise follow-up note of 48 cases at 10 years' follow-up.

Use of a locking plate during medial opening high tibial osteotomy (HTO) eliminates the need to fill the defect and its associated complications. It also allows early weight-bearing. Since long-term data with this type of construct are rare, we wanted to report the outcomes of a 51-patient cohort evaluated after a mean follow-up of 10.2years. The goals were to determine (1) the HTO survival and whether the correction was maintained between 2 and 10years later, (2) the stability of the functional outcomes, (3) the complication rate related to use of locking plates. The correction following medial opening HTO with a Tomofix™ plate without void filling is maintained after 10years' follow-up. Fifty-one patients ranging from 37 to 72years of age at the time of surgery between 2003 and 2005 underwent a medial opening HTO that was stabilized with a Tomofix™ locking plate (Synthes, Oberdorf, Switzerland) without void filling. Forty-eight patients were reviewed between March and September 2014; 1 patient had died and 2 were lost to follow-up. The mean HKA angle went from 172±3.18° (165-178°) preoperatively to 181±1.18° (176-185°) postoperatively, to 181±1.60° (176-185°) at 2years, and 180.8±2.4° (175-184°) at 10years' follow-up. This equates to a loss of correction of 0.71±1.9° (0-6°) (p=0.02) between 2 and 10years after the surgery. Five patients underwent total knee arthroplasty (TKA), thus the 10-year survival of the HTO procedure was 88% (95% CI: 81-98%). If the five TKA procedures are excluded, the mean IKS knee score went from 90±7.4 (66-98) at 2years' follow-up to 77±15.3 (43-97) at 10years (p>0.05). There were four complications in all (8%), of which three occurred within 2years (2 cases of nonunion and 1 surgical site infection) and one occurred later (infection after 118months that resolved once the hardware was removed and the patient given appropriate antibiotics). There were no complications related to the five subsequent TKA procedure and no bone grafting was required. There was a small (less than 1 degree) but statistically significant loss of correction and non-significant deterioration in the functional outcomes. Conversely, the complication rate did not increase over time, despite the lack of void filling, particularly in patients who subsequently underwent TKA. The 10-year survival was similar to other HTO procedures. This locking plate construct without void filling is reliable after 10years. Level IV, prospective study without control group.

Outcome of traditional growing rods for correction of apical vertebra rotation in early-onset scoliosis

Objective: To evaluate the correction result of traditional dual growing rods on apical vertebral rotation. Methods: This study recruited 19 early-onset scoliosis patients (6 boys and 13 girls) who had received traditional dual growing rods treatment at Department of Spine Surgery, Nanjing Drum Tower Hospital from January 2009 to July 2015. The age at initial surgery was (5.7±1.7)years(range, 3 to 9 years). Measurements of primary curve magnitude, height of T(1)-S(1), apical vertebral translation(AVR), apical vertebral body-rib ratio, apical vertebral rotation, thoracic rotation and rib hump were compared between pre-operatively, post-operatively, and at latest follow-up, through a paired-t test. Pearson correlation test was used for correlation analysis between parameters. Results: All patients had a follow-up of (49.5±12.8)months(range, 24 to 71 months). A total of 111 operative procedures were performed, among which there were 92 lengthening procedures, averagely 4.8 lengthening procedures per patient. The average interval for each lengthening procedure was 10 months. The Cobb angle of primary curve was notably decreased from (66.5±13.2)° to (35.2±10.9)°(t=24.013, P<0.01), and no significant correction loss was found at the latest follow-up ((36.7±10.7)°)(t=-1.324, P=0.202). In addition, significant correction of AVR, thoracic rotation, apical vertebral translation, apical vertebra body-rib ratio, and rib hump were noted after initial surgery. Whereas, these parameters significant increased during follow-up(all P <0.05) except for thoracic rotation. Pearson correlation analysis showed that the increase of AVR during follow-up significantly correlated with change of apical vertebra translation, apical vertebral body-rib ratio, and rib hump(r=0.652, 0.814, 0.695; all P<0.05). Conclusions: Significant correction of AVR can be achieved after initial surgery in early-onset scoliosis patients treated with traditional dual growing rods. However, such a technique can hardly prevent the deterioration of AVR during follow-up.

Segmental Pedicle Screw Instrumentation and Fusion Only to L5 in the Surgical Treatment of Flaccid Neuromuscular Scoliosis.

A retrospective cohort study was performed. The purpose of this study was to determine the efficacy and safety of stopping segmental pedicle screw instrumentation constructs at L5 in the treatment of neuromuscular scoliosis. Duchenne muscular dystrophy and spinal muscular atrophy are flaccid neuromuscular disorders in which gradual deterioration is the hallmark and have a lot of characteristics in common despite differences in etiology. Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of flaccid neuromuscular scoliosis and recommended to correct pelvic obliquity. However, the caudal extent of instrumentation and fusion in the surgical treatment of flaccid neuromuscular scoliosis has remained a matter of considerable debate and there have been few studies on the use of segmental pedicle screw instrumentation for flaccid neuromuscular scoliosis. From 2005 to 2007, a total of 27 consecutive patients with neuromuscular disorders (20 Duchenne muscular dystrophy and 7 spinal muscular atrophy), aged 11 to 17 years, underwent segmental pedicle screw instrumentation and fusion only to L5. Assessment was performed clinically and with radiologic measurements. Minimum 2-year follow-up was required for inclusion in this study. Twenty patients were enrolled in this study. No patient was lost to follow-up. All patients had L5 tilt of less than 15° and a coronal curve with apex L2 or higher preoperatively. Preoperative coronal curve averaged 70° (range: 51°-88°), with a postoperative mean of 15° (range: 5°-25°) and 17° (range: 6°-27°) at the last follow-up. The pelvic obliquity improved from 15° (range: 9°-25°) preoperatively to 5° (range: 3°-8°) postoperatively and 6° (range: 3°-8°) at the last follow-up. The L5 tilt improved from 9° (range: 2°-14°) preoperatively to 2° (range: 0°-4°) postoperatively and 2° (range: 0°-5°) at the last follow-up. Physiologic sagittal plane alignment was recreated after surgery and maintained long-term. There was no significant loss of correction of coronal curve and pelvic obliquity. There was no major complication. Segmental pedicle screw instrumentation and fusion to L5 was safe and effective in patients with flaccid neuromuscular scoliosis with apex L2 or higher and minimal L5 tilt of less than 15°. Segmental pedicle screw instrumentation ending at L5 offered the ability to correct spinal deformity and pelvic obliquity initially, intermediate and even long-term, with no major complications. This method in appropriate patients can be a viable alternative to instrumentation and fusion to the sacrum/pelvis in the surgical treatment of flaccid neuromuscular scoliosis. N/A.

Radiological and functional outcomes of high-grade spondylolisthesis treated by intrasacral fixation, dome resection and circumferential fusion: a retrospective series of 20 consecutive cases with a minimum of 2years follow-up.

Major concern during surgery for high-grade spondylolisthesis (HGS) is to reduce lumbosacral kyphosis and restore sagittal alignment. Despite the numerous methods described, lumbosacral fixation in HGS is a challenging technique associated with high complication rate. Few series have described outcomes and most of the results are limited to lumbosacral correction without global sagittal alignment analysis. This study aims at analyzing clinical and radiological outcomes of HGS patients treated with intrasacral rods on full spine radiographs. HGS patients (Meyerding III or higher) operated between 2004 and 2014 were reviewed. All patients underwent full spine stereoradiographic images. After L5 and S1 decompression, reduction and circumferential fusion with intrasacral rod fixation and fusion up to L4 were performed under fluoroscopy. The entry points for S1 screws were located 3-5mm above and 5mm lateral to the first sacral hole, toward the promontory. The two short distal fusion rods were then positioned into the sacrum guided by anteroposterior fluoroscopy using Jackson's technique. Then, sacral dome resection was performed and a PEEK cage was impacted in L5S1 after reduction. Postoperatively, the hip and knee were kept flexed at 45° for 1week and extended progressively. Preoperative, 3months postoperative and last follow-up (>2years minimum) clinical and radiographic data were collected. Sagittal parameters included lumbosacral angle (LSA), olisthesis, T1 spinopelvic inclination (T1SPi) and spinopelvic parameters. 20 HGS patients were included (8 ptosis, 5 Meyerding IV). The mean age was 14years. At final FU (7.2years±3), LSA kyphosis and olisthesis were reduced (65°±14 vs 99°±11, p<0.001 and 81%±19 vs 45%±18, p<0.001, respectively). While L1L5 lordosis decreased, T1T12 kyphosis increased. At FU, global alignment with T1SPi was -6°±3. No significant loss of correction was observed. Regarding complications, ten patients presented transient L5 motor deficit that occurred when patients were put in standing position. However, all recovered before 3months postoperatively. Intrasacral rod fixation appears to be an effective technique to correct LSA kyphosis, compensatory hyperlordosis and restore global sagittal alignment with a postoperative T1SPi corresponding to the value of the asymptomatic subject and achieve fusion. However, it remains a demanding technique with high risk of transient neurologic complications.

MECHANICAL COMPLICATIONS AND LOSS OF CORRECTION IN OSTEOTOMIES OF THE THREE COLUMNS

ABSTRACT Objectives: To observe the degree of correction and postoperative evolution of the spinopelvic parameters in patients with sagittal imbalance submitted to 3-column osteotomies. Methods: Retrospective analysis of 20 cases of 3-column osteotomies in patients with evident sagittal imbalance and minimum follow-up of one year, computing evolution of radiological data as a function of time, complications and reinterventions, and classification into subgroups by preoperative spinopelvic measures and complications. The variation of measures, quantitative and categorical variables, and differences between groups were evaluated using the Wilcoxon, Spearman, Fischer’s exact test, Kruskal-Wallis and Mann-Whitney tests. Results: There was improvement of all the sagittal parameters, ideal correction in 55% of the cases and maintained until the end of the follow-up in 40% of the cases. No correlation was found between obtaining optimal correction and data or preoperative measurements. Clinical and infectious complications did not affect the maintenance of the correction. The most common mechanical complications were pseudoarthrosis-related rod fracture at osteotomy (30%) and failures at the lower fixation level (15%). There was no significant difference in the maintenance of the correction between the groups with and without mechanical complications treated. In the untreated mechanical complications there was a significantly higher radiological worsening (p&lt;0.05) in the maintenance parameters of the curve correction (loss of 27.5 ± 14.39o vs. 3.69 ± 3.68o) and increased pelvic tilt (PT) (increase of 12.25 ± 7.27o vs. 1.13 ± 1.93o). Conclusion: The perfect correction was obtained in 55% of cases and the significant loss of correction occurred only in cases of untreated mechanical complications.

Expanding PSO technique for the treatment of congenital severe thoracic angular kyphotic deformity

Objective To evaluate the clinical efficacy and feasibility of using the expanding pedicle subtraction osteotomy (E-PSO) technique for the treatment of congenital severe thoracic angular kyphotic deformity. Methods We retrospectively reviewed a cohort of 13patients with congenital severe kyphosis admitted to our hospital from January 2010 to June 2015 including 5 males and 8 females, the average age is (34.9±20.5) years old (ranged 15-55 years old). The vertebral deformity in T7~8 3 cases, T8~9 3 cases, T9~10 2 cases, T10~11 4 cases, T9~11 1 case. All cases were treated by E-PSO technique. The multi-malformed vertebrae are considered as a complexus. And the osteotomy was performed within the complexus. The superior and inferior endplate of the complexus were reserved. After the osteotomy was completed, alternately pressed tightly closed the upper and lower parts. Results All cases were followed up for 10-42 months, with an average of 32 months. At the time of preoperation, postoperation and the last follow-up, the deformity angle was 107.0°±3.5°, 23.5°±1.5° and 23.5°±0.2°; TK was 98.1°±7.6°, 28.9°±3.0° and 29.5°±0.1°, LL was 94.1°±1.5°, 43.7°±1.3° and 44.1°±5.3°; SVA was (-0.6±39) mm, (1.6±7.9) mm and (6±0.7) mm, respectively; PI was 28.9°±1.6°, 31.7±12.3°and 31.9°±2.1°; PT was 17.7°±1.9°, 13.4°±3.4°and 13.1°±4.2°, SS was 11.3°±0.4°, 18.2°±1.1° and 18.7°±2.1°, respectively. The sagittal parameters and spinopelvic parameters except SVA were significantly improved in the post-operation and the last follow-up compared with the pre-operation according to the image data. No significant loss of correction occurred during the follow-up, and there was no statistical difference. The preoperative VAS score was (5.7±1.4) points, ODI score was (19.8±12.7) points. The last follow-up VAS score was (1.9±0.7) points, the ODI score was (9.2±0.7) points. No case of nerve damage, infection and other complications, and no dissection, displacement and rupture of internal fixation were found during the follow-up. Conclusion The use of E-PSO technique for the treatment of congenital severe thoracic kyphotic kyphosis is feasible and can achieve better curative effect. Key words: Kyphosis; Thoracic vertebrae; Kyphoplasty; Osteotomy

Short segment versus long segment posterior pedicular fixation of thoracolumbar fracture

Background: Fracture dislocation at the junction between thoracic and lumber segments of spinal column by direct or indirect high energy force which is usually managed with more than three vertebral level fixation. Short segment stabilization have a wide range of benefits including length of time utilized for surgical intervention, reduce functional and psychological disability postoperatively and local surgical site complications.Objective: Evaluate the efficacy of posterior short segment pedicle stabilization in T-L fracture clinically and radiologically. Also to compare outcome of pedicle fixation by long segment and short segment an finally we try to insert at least one screw in the fracture vertebra to strengthen the stabilization in case of short segment stabilisation.Patients and Method: This is a prospective study of 40 patients operated in medical city from Jan. 2013 to Dec. 2015.complaining from T-L fracture (T12, L1, L2) due to any type of trauma. A total of 17 of the patients (13 male and 4 female) underwent long segment fixation (group A) whereas 23(15 male and 8 female) of those patients have short segment fixation (group B). Long segment fixation includes two levels above and one or two level below with or without single screw placed in the vertebra that is broken. While short fixation involving vertebra above and vertebra below the fracture one.Results: In tis prospective male commonly involved with the mean age 35-40 years in both groups, also most common involved vertebrae was 1st lumber. According to Modified Mcnab criteria, good result acquired by most of the patients, and using radiological Cobb angle evaluation significant loss of correction occur.Conclusions: Short segment fixation in Thoracolumar region as effective as long segment. Short segment fixations are low coast with little complications at surgical site and need less blood replacement with less restriction of movement at the thoracolumbar junction.&#x0D;

مقارنة تثبيت الجزء القصير والجزء الطويل لكسر الفقرات الصدرية القطنية باستعمال تثبيت عنيقة قوس الفقرة من الخلف.

مقدمة:الكسر الخلعي عند المفصل بين الفقرات الصدريه مع الفقرات القطنية الناتج عن شدة خارجية ذات طاقة شديدة مباشرة أو غير مباشرة &nbsp;عادة يتم علاجها بتثبيت يصل الى ثلاث فقرات. تثبيت الفقرات باستعمال جزء صغير من العمود الفقري لديه فوائد عديدة منها قصر وقت العملية اضافة لتقليل العوامل النفسية والوظيفية التي تسبب عوق مابعد العملية مع المضاعفات في موقع العمليه في الجسم نفسه. الهدف من ألبحث تقييم كفاءة تثبيت جزء صغير من الفقرات عند حدوث كسر في جزء تمفصل الفقرات الصدرية مع الفقرات القطنية.كذلك نهدف لمقارنة نتائج التثبيت الفقرات باستعمال عدد قليل من الفقرات مع التثبيت باستعمال عدد كثير وأخيرا نحاول تثبيت على الاقل برغي واحد في جسم الفقرة المكسورة لكي تضيف قوة للتثبيت باستعمال عدد قليل من الفقرات. طريقة عمل البحث:هذه دراسة لأربعين مريض اجريت لهم العملية في مدينة الطب من شهر كانون الثاني 2013 ولغاية كانون اول 2015 كانوا يعانون من كسر عند تمفصل الفقرات الصدرية مع الفقرات القطنية (الفقرة الصدرية 12والقطنية الاولى والثانية)لأي سبب كان الشدة الخارجية. سبعة عشر مريض(13 رجال و&nbsp;&nbsp; 4 نساء) اجريت لهم عملية تثبيت جزء طويل من الفقرات (المجموعه &nbsp;(Aفيما كان عدد النساء ثمانية والرجال خمسة عشر في المجموعة الثانيهB.التثبيت باستعمال الجزء الطويل يتم فيه تثبيت فقرتين فوق واثنين اسفل الفقرة المكسورة مع او بدون برغي في الفقرة المكسورة اما التثبيت باستعمال عدد قليل من الفرات فيتم باستعمال فقرة فوق وأخرى اسفل الفقرة المكسورة. النتائج:في هذه الدراسة الرجال اكثر تعرض لمثل هذه الكسور مع متوسط عمر يتراوح بين 35 الى 40 سنة وأكثر تعرضا للكسر هي الفقرة القطنية الاولى. باستعمال مؤشرات مكناب المطورة اغلب المرضى كان مؤشرهم جيد و باستعمال مؤشر زاوية كوب نسبة ملحوظة من الزاوية المصححة يفقد. الاستنتاج:التثبيت باستخدام الجزء القصير للكسر الصدري القطني بكفاءة التثبيت باستخدام الجزء الطويل وكذلك اقل تكلفة مع مضاعفات قليلة في موقع العملية وفقدان قليل للدم كذلك اقل تحديد للحركة عند الارتباط الصدري القطني

Percutaneous minimally invasive Akin osteotomy in hallux valgus interphalangeus: a case series.

Phalangeal Akin osteotomy of the greater toe is a frequently used surgical procedure for correcting hallux valgus interphalangeus deformity. However, previous research did not investigate percutaneous techniques of the Akin osteotomy. It was the aim of this study to investigate feasibility, corrective potential, and safety of a percutaneous minimally invasive Akin osteotomy. We present a series of 81 feet, in which a percutaneous Akin technique was performed using a high-speed burr but no fixation device. The most important outcome parameters were determined as the proximal to distal phalangeal articular angle (PDPAA) (corrective effect of the osteotomy), the osteotomy healing (full, partly, no visibility of the osteotomy gap), and the integrity of the lateral cortical hinge. With regard to the main hypothesis we found significant changes in the PDPAA over the whole period of time (p<0.001). Post-hoc tests determined that the PDPAA changed from 10° pre-operatively (Md, IQR 4.3) to 2.3° post-operatively (Md, IQR 3.7) (p<0.001). Post-operatively no significant changes in PDPAA were found within the first sixweeks and from sixweeks to threemonths (no loss of correction). Osteotomy healing was satisfactory as well. Three months post-operatively, there were no patients with a fully visible osteotomy gap, 28.3% with a partly visible osteotomy gap, and 71.7% had no visible gap. Interestingly, we could not observe a statistically significant correlation between bone healing and the integrity of the lateral cortical hinge. From our findings we conclude that the minimally invasive Akin osteotomy without osseous fixation provides effective deformity correction without significant loss of correction thereafter. This procedure appears to be safe with regard to osseous healing. Surprisingly, the healing process of the osteotomy showed no dependence on the integrity of the lateral cortical hinge. Therapeutic, Level IV, retrospective case series.

The impact of ossified anterior longitudinal ligaments surrounding osteotomy vertebra on the lordosing capability of pedicle subtraction osteotomy in thoracolumbar kyphotic deformity secondary to ankylosing spondylitis

Objective To investigate anterior longitudinal ligaments (ALL) ossified surrounding osteotomy vertebra impact the lordosing effect of pedicle subtraction osteotomy (PSO) in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis (AS). Methods We retrospectively reviewed 102 AS patients with thoracolumbar kyphosis treated with single-level PSO at our institution from September 2007 to August 2015. There were 92 male and 10 female. The average age was (35.6±11.8) years old (range from 17 to 65 years old). Patients were stratified into ossified group (54 cases) and non-ossified group (48 cases) based on the presence of ALL ossification adjacent to osteotomy vertebra. Compared the contribution of adjacent disc wedging to total correction of each PSO segment between the ossified and non-ossified groups. The long-term correction loss of spine and pelvic sagittal morphology were also evaluated and compared between the 2 groups. Results Patients in the ossified group accomplished significantly lower amount of correction in single level segment of PSO (36.3°±6.9° vs. 41.5°±6.9°), and there was significant difference between the two groups. The contribution of adjacent disc wedging to total correction of PSO was significantly larger in the non-ossified group (22.9% vs. 7.8%, P<0.001). For subgroups with a minimum 2 year follow-up, loss of corrections concerned sagittal vertical axis (SVA), which was (1.7±4.5) cm vs. (-0.2±4.0) cm in ossified group and non-ossified group, and there was significant difference between the two groups. Pelvic tilt (PT) was 3.5°±8.2° vs. 2.0°±10.4°, lumbar lordosis (LL) was -7.9°±11.9° vs. -0.1°±11.9° and sacral slope (SS) was 4.5°±9.3° vs. 1.6°±7.9°, and there were all significant differences between the two groups. The change of adjacent disc wedging angle was marginally higher in the unossified group (-2.1°±6.2° vs. -0.1°±3.7°, P=0.09), but there was no significant difference between the two groups. No significant correction loss of osteotomy angle was observed in both groups. Conclusion Osteotomy vertebrae accompanied by unossified adjacent ALL in PSO of AS were prone to create more disc-originated lordosing effect immediately after surgery. However, a correction loss might occur more commonly during a long term follow-up. Key words: Vertebroplasty; Spondylitis, ankylosing; Kyphosis; Orthopedic procedures

One year follow-up of a case series using the iBalance medial opening wedge HTO system and an accelerated rehabilitation program

Objectives:To investigate the clinical outcome and postoperative alignment changes changes to following computer navigated medial opening wedge HTO using the iBalance HTO systemMethods:We performed a prospective observational series at a single centre of 20 consecutive patients undergoing computer navigated high tibial osteotomy by a single surgeon. The surgical device used to maintain the osteotomy was the Arthrex iBalance® HTO system. We compared preoperative and postoperative ROM, WOMAC, Lysholm, IKDC, alignment and the inferred tibial slope. We also measured the tibiofemoral angle on long leg weight bearing plain radiographs at 2 weeks, 6 weeks, 3 months and 1 year and calculated any change from the initial correction measured at 2 weeks to asses any loss of correction over 1-year time frame. We also correlated clinical outcome with loss of correction.Results:Regarding intraoperative results, the mean navigated correction to HKA was 5.4°±1.3°. No significant change was found to the knee sagittal angle posteroperatively (pre op mean 0.1°±4.4°, post op mean 0.81°±5.1°; p> 0.05). No significant change was found to the post operative ROM (pre op mean 125.4°±41.5°, post op mean 123.9°±34.4°; p> 0.05). The IKDC, Lysholm and WOMAC scores showed a significant difference, between 6 week to 3 months and 3 months to 6 months follow-up. After this time point scores did not show and statistical significant difference. The IKDC, Lysholm and WOMAC scores all demonstrate a general improvement over 12 months. One patient had to be removed from the study, as he had a lateral cortex breach at three months, and was converted to a TKR. There was a significant loss of correction between 2 weeks and 6 weeks, and again a significant loss of correction between 6 weeks and 3 months. However, the average loss of correction was measured radiographically to be 1.6°±1.7°, between 2 week and 12 month postoperative follow-up. Though this may be statistically significant, it is not clinically significant when compared to PROMs. We divided the loss of correction into greater than 1.5° and less than 1.5° and compared them to measured PROMs at all time points. We found no significant correlation between increased loss of correction and poorer PROM scores.Conclusion:Computer assisted iBalance medial opening wedge HTO with accelerated rehabilitation program does radiographically show loss of correction over 12 months. However it is not clinically significant when compared to PROMs. ROM and inferred tibial slope is preserved.

Three column osteotomy procedures through previous spinal fusion site for the revision surgical treatment in severe spi-nal deformity patients

Objective To investigate the safety and efficacy of three column osteotomy (3-CO) procedures through previ-ous spinal fusion site for the revision surgical treatment in severe spinal deformity patients. Methods From Oct. 2010 to May 2014 in our hospital, a total of 12 severe spinal deformity patients underwent 3-CO for the revision surgical treatment. There were 7 males and 5 females with the average age of (21.8±3.8) years, ranging from 18 to 30 years. The mean time from the initial opera-tion to the revision surgery was (10.2±4.8) years (ranging from 3 to 17 years). The reasons for revision were: curve progression in 7 patients, neurologic deficit in 2 cases, implant failure in 1 patient and pseudarthrosis in 2 patients. The coronal parameters includ-ing major Cobb angle and distance between C7 plumb line and center sacral vertical line (C7PL-CSVL), and the sagittal parameters including global kyphosis curve and sagittal vertical axis (SVA) were measured pre-operatively, post-operatively and at last follow-up, respectively. The operation time, intraoperative blood loss and complications were recorded. The paired t test was used to eval-uate the difference among pre-revision, post-revision and last follow-up. Results The average operation time was (451.7±83.1) min (range, 320-600 min) and the average blood loss was (4 016.7±1 080.0) ml (range, 2 700-6 000 ml). The average follow-up time after revision operation was (35.4±9.8) months (range, 24-49 months). The coronal Cobb angles of pre-revision and post-revi-sion were 83.8°±23.3°and 34.6°±13.7°. The average correction rate was 60.1% ±8.8%. At last follow-up, the average coronal Cobb angle was 34.9°±13.8°, there was no significant loss of correction. The pre-revision and post-revision values of global kypho-sis were 99.1°±13.3°and 38.7°±7.8° with a mean correction rate of 60.8% ±6.7%. At the last follow-up, the average global kypho-sis was 39.3°±7.5°and no loss of correction was found. For the C7PL-CSVL and SVA, pre-revision (30.3±17.1) mm and (40.1±31.1) mm were corrected to (14.3±7.6) mm and (19.1±12.3) mm immediately after revision operation, respectively. At final follow-up, the average C7PL-CSVL and SVA were(14.1±7.6) mm and (19.6±12.1) mm, the correction was well maintained. Obviously, two pa-tient's neurological status improved from Frankel C before revision surgery to Frankel E. Complications were encountered in five patients (41.7%), including SEP signal changed in 1 patient (8.3%), transient neurologic deficit after revision surgery in 1 patient (8.3%), cerebrospinal fluid leak in 1 patient (8.3%), and pleural effusion in 2 patients (16.7%). During the follow-up time, there was no patient experienced pseudarthrosis, implant failure, infection or significant loss of correction. Conclusion Based on re-sults of this study, it was concluded that 3-CO procedures through previous spinal fusion sites could obtain satisfactory and safety results in severe spinal deformity revision surgery. However, it is a technique-demanding procedure with more blood loss, longer operative time and higher risk of perioperative complications. Key words: Scoliosis; Kyphosis; Reoperation; Osteotomy; Spinal fusion

Posterior three-column osteotomies for the treatment of rigid thoracic kyphosis – a case series

ObjectiveTo evaluate the results and complications of a series of patients who underwent three-column osteotomy using the posterior approach for correction of complex cases of rigid dorsal kyphotic deformity. MethodsReview of clinical records and images of 15 consecutive cases of pedicle subtraction osteotomies, bone-disk-bone osteotomies, or vertebral column resection, recording the etiology, type and level of osteotomy, extension of fixation, complications, and pre- and post-surgical measurements of the sagittal curves and pelvic parameters. ResultsSix pedicle subtraction osteotomies were performed, one of which in two adjacent vertebrae, as well as two bone-disk-bone osteotomies and seven vertebral column resection, two of which were performed in two adjacent vertebrae. The mean correction was 39.3° for the angular kyphosis and 33.9° for dorsal kyphosis. The corrections were similar regardless of the kind of osteotomy, the operated spinal segment, or the approach in one or two levels, but this may be a sample effect.Eight complications were observed in six patients (40% of cases): two medical complications, five early and one late surgical complication (over 90 days after surgery). There were three reoperations within less than one year from the initial surgery and one case of persistent paraparesis. Clinical complications were resolved without sequelae. There was no significant loss of correction during the segment, except in two cases of major mechanical failure due to a junctional segment fracture. ConclusionDespite being complex and aggressive procedures, prone to various complications, osteotomies with resection of the three columns are highly effective in the correction of rigid kyphotic deformities and safe enough to justify its use in selected cases.