Years Of Radiographic Follow-up Research Articles

Comparison of transforaminal lumbar interbody fusion outcomes in patients receiving rhBMP-2 versus autograft

Background ContextRecombinant human bone morphogenetic protein 2 (rhBMP-2) plays a pivotal role in complex spine surgery. Despite its limited approval, the off-label use of rhBMP-2 is prevalent, particularly in transforaminal lumbar interbody fusions (TLIFs). PurposeTo determine the effectiveness and safety of rhBMP-2 use in TLIF procedures versus autograft. Study DesignRetrospective cohort study. Patient SamplePatients older than 18 years undergoing spine surgery for lumbar degenerative spine disease at a single academic institution. Outcome MeasuresClinical outcome was determined according to patient records. Radiographic outcome was determined according to plain X-rays and computed tomography (CT). MethodsA retrospective study from 1997 to 2014 was conducted on 191 adults undergoing anterior-posterior instrumented spinal fusion with TLIF at a single academic institution. Patient data were gathered from operative notes, follow-up clinic notes, and imaging studies to determine complications and fusion rates. One hundred eighty-seven patients fit the criteria, which included patients with a minimum of one TLIF, and had a minimum 2-year radiographic and clinical follow-up. Patients were further classified into a BMP group (n=83) or non-BMP group (n=104). Three logistic regression models were run using rhBMP-2 exposure as the independent variable. The respective outcome variables were TLIF-related complications (radiculitis, seroma, osteolysis, and ectopic bone), surgical complications, and all complications. ResultsBone morphogenetic protein (n=83) and non-BMP (n=104) groups had similar baseline demographics (sex, diabetes, pre-existing cancer). On average, the BMP and non-BMP groups were similarly aged (51.9 vs. 47.9 years, p>.05), but the BMP group had a shorter follow-up time (3.03 vs. 4.06 years; p<.001) and fewer smokers (8 vs. 21 patients; p<.048). The fusion rate for the BMP and non-BMP groups was 92.7% and 92.3%, respectively. The pseudoarthrosis rate was 7.5% (14 of 187 patients). Radiculitis was observed in seven patients in the BMP group (8.4%) and two patients in the non-BMP group (1.9%). Seroma was observed in two patients in the BMP group (2.4%) and none in the non-BMP group. No deep infections were observed in the BMP group, and in one patient in the non-BMP group (0.96%). Although patients exposed to BMP were at a significantlygreater risk of developing radiculitis and seroma (odds ratio [OR]=4.53, confidence interval [CI]=1.42–14.5), BMP exposure was not a significant predictor of surgical complications (OR=0.32, CI=0.10–1.00) or overall complications (OR=1.11, CI=0.53–2.34). The outcome of TLIF-related complications was too rare and the confidence interval too wide for practical significance of the first model. ConclusionEvidence supports the hypothesis that off-label use of rhBMP-2 in TLIF procedures is relatively effective for achieving bone fusion at rates similar to patients receiving autograft. Patients exhibited similar complication rates between the two groups, with the BMP group exhibiting slightly higher rates of radiculitis and seroma.

Radiographic changes and clinical outcomes associated with an adjustable diaphyseal press-fit humeral stem in primary reverse shoulder arthroplasty

Press-fit humeral fixation in reverse shoulder arthroplasty (RSA) has become increasingly popular; however, radiographic analysis of these stems is limited. We aimed to evaluate the radiographic and clinical outcomes of an adjustable diaphyseal press-fit humeral stem in primary RSA. We conducted a retrospective review of 232 primary RSAs in 219 patients performed by a single surgeon using this system. Radiographic outcomes were evaluated in patients with at least 2 years of radiographic follow-up. Standardized postoperative digital radiographs were analyzed for loosening, osteolysis, and stress shielding. Clinical outcomes in patients who also had complete clinical data sets were evaluated at the most recent follow-up. Radiographic evidence of loosening was identified in 1 RSA (0.4%) associated with deep infection. Aseptic loosening was not observed. No stems were identified as being at high risk for loosening. Internal stress shielding was observed proximal to the coated diaphyseal component in 226 shoulders (97.4%). This finding was often visible at 3 months (92.7%) and predictably progressed on subsequent radiographs. Progression beyond the 2-year period was rarely seen (4.4%). No external stress shielding or osteolysis was observed. Thirty-six complications occurred in 33 patients (15.1%). At an average follow-up of 36.6 months, significant improvements were identified in all measured clinical outcomes (P < .001). Predictable fixation is achieved using an adjustable diaphyseal press-fit humeral system in primary RSA. Internal stress shielding is commonly observed but does not appear to compromise quality of fixation or clinical outcomes.

Impact of scapular notching on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 476 shoulders

Scapular notching is a complication unique to reverse total shoulder arthroplasty (rTSA), although its clinical implications are unclear and remains controversial. We retrospectively reviewed rTSA patients of a single implant design in 476 shoulders with a minimum 2-year clinical and radiographic follow-up. Clinical measures included active range of motion and American Shoulder and Elbow Surgeons scores, in addition to one or more of the Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test (SST), and University of California, Los Angeles Shoulder Rating Scale. Complications and rates of humeral radiolucencies were also recorded. Scapular notching was observed in 10.1% (48 of 476) of rTSAs and was associated with a longer clinical follow-up, lower body weight, lower body mass index, and when the operative side was the nondominant extremity. Patients with scapular notching had significantly lower postoperative scores on the Shoulder Pain and Disability Index, Constant, Simple Shoulder Test, and University of California, Los Angeles, Shoulder Rating Scale compared with patients without scapular notching. Patients with scapular notching also had significantly lower active abduction, significantly less strength, and trended toward significantly less active forward flexion (P = .0527). Finally, patients with scapular notching had a significantly higher complication rate and trended toward a significantly higher rate of humeral radiolucent lines (P = .0896) than patients without scapular notching. This large-scale outcome study demonstrates that patients with scapular notching have significantly poorer clinical outcomes, significantly less strength and active range of motion, and a significantly higher complication rate than patients without scapular notching. Longer-term follow-up is necessary to confirm that these statistical observations in the short-term will result in greater clinically meaningful differences over time.

Salto Talaris Total Ankle Arthroplasty: Clinical Results at a Mean of 5.2 Years in 78 Patients Treated by a Single Surgeon.

In recent years, the number of total ankle arthroplasty procedures performed has increased dramatically. We sought to report the clinical results of the largest cohort of patients treated with a modern fixed-bearing total ankle arthroplasty by a single surgeon. We retrospectively reviewed the charts of 78 consecutive patients (81 ankles) who underwent total ankle arthroplasty with a minimum clinical follow-up of 2 years. Sixty-three patients completed standardized questionnaires including the Foot and Ankle Disability Index (FADI), the Short Musculoskeletal Function Assessment (SMFA), the Short Form (SF)-36v2, and a visual analog scale (VAS) for pain. In addition, each patient underwent serial range-of-motion examination and radiographic implant evaluation at each follow-up appointment. Implant survival was 97.5% at a mean follow-up time of 5.2 years. There was 1 revision of a tibial component and 1 revision of a talar component. Thirty-six patients underwent a concurrent procedure at the time of the index surgery, with the most common being removal of previous hardware. Seventeen patients underwent additional procedures following the index surgery, with the most common being gutter debridement. Total range of motion averaged 35.5° preoperatively and 39.9° postoperatively (p = 0.02). Fifty-seven ankles (70%) had >2 years of radiographic follow-up, and 25 ankles (31%) displayed evidence of lucency around a metallic component at the final radiographic follow-up. Outcome scores at a mean of 5.2 years revealed promising results for the cohort, with a mean VAS pain score of 17.7 and a mean FADI score of 79.1. Modern fixed-bearing total ankle arthroplasty had excellent implant survival, improved plantar flexion and total range of motion, and had good-to-excellent functional outcome at a mean follow-up of 5.2 years. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Primary Linked Semiconstrained Total Elbow Arthroplasty for Rheumatoid Arthritis: A Single-Institution Experience with 461 Elbows Over Three Decades.

Elbow arthroplasty is the treatment of choice for end-stage rheumatoid arthritis (RA). The purpose of this study was to determine the long-term outcome of a linked semiconstrained elbow arthroplasty implant design in patients with RA. Between 1982 and 2006, 461 primary total elbow arthroplasties using the Coonrad-Morrey prosthesis were performed in 387 patients with RA. Fifty-five of the arthroplasties were performed to treat concurrent traumatic or posttraumatic conditions. There were 305 women (365 elbows, 79%) and 82 men (96 elbows, 21%). Ten patients (10 elbows) were lost to follow-up, 9 patients (10 elbows) died, and 6 patients (6 elbows) underwent revision surgery within the first 2 years. For the 435 elbows (362 patients, 94%) with a minimum of 2 years of follow-up, the median follow-up was 10 years (range, 2 to 30 years). At the most recent follow-up, 49 (11%) of the elbows had undergone component revision or removal (deep infection, 10 elbows; and mechanical failure, 39 elbows). Eight additional elbows were considered to have radiographic evidence of loosening. For surviving implants followed for a minimum of 2 years, the median Mayo Elbow Performance Score (MEPS) was 90 points. Bushing wear was identified in 71 (23%) of the surviving elbows with a minimum of 2 years of radiographic follow-up; however, only 2% of the elbows had been revised for isolated bushing wear. The rate of survivorship free of implant revision or removal for any reason was 92% (95% confidence interval [CI] = 88% to 94%) at 10 years, 83% (95% CI = 77% to 88%) at 15 years, and 68% (95% CI = 56% to 78%) at 20 years. The survivorship at 20 years was 88% (95% CI = 83% to 92%) with revision due to aseptic loosening as the end point and 89% (95% CI = 77% to 95%) with isolated bushing exchange as the end point. Risk factors for implant revision for any cause included male sex, a history of concomitant traumatic pathology, and implantation of an ulnar component with a polymethylmethacrylate surface finish. Elbow arthroplasty using a cemented linked semiconstrained elbow arthroplasty provides satisfactory clinical results in the treatment of RA with a reasonable rate of survivorship free of mechanical failure at 20 years. Although bushing wear was identified on radiographs in approximately one-fourth of the patients, revision for isolated bushing wear was uncommon. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Posterior Spinal Fusion With Pedicle Screws in Patients With Idiopathic Scoliosis and Open Triradiate Cartilage: Does Deformity Progression Occur?

Anterior-posterior spinal fusion (APSF) is the traditional treatment for patients with idiopathic scoliosis and open triradiate cartilage (OTRC). Our goals were to assess whether posterior-only spinal fusion (PSF) with pedicle screws can halt deformity progression as effectively as APSF in patients with OTRC, and whether selection of the distal fusion level influences curve progression. We studied a prospective multicenter database to identify all children with 2-year radiographic and clinical follow-up who were 11 years or younger with Risser grade 0 and OTRC who were treated with (1) PSF (OTRC-PSF group, N=20); or (2) APSF (OTRC-APSF group, N=9). A reference group was constructed of 20 children who were 18 years or younger with Risser grade 4 or 5 and closed triradiate cartilage (CTRC) and who were treated with PSF (CTRC-PSF group) and matched in preoperative curve magnitude and type to the OTRC-PSF group. The 3 groups were compared with respect to operative time, blood loss, length of hospital stay, and radiographic and functional outcomes (significance, P<0.05). OTRC-APSF patients had significantly longer operative time (P<0.01), greater blood loss (P=0.02), and longer hospital stays (P<0.01) than OTRC-PSF patients. At 2 years, 7 (35%) OTRC-PSF patients had >10 degrees of curve progression compared with no patients in the OTRC-APSF group (P=0.042) and 1 patient in the CTRC-PSF group (P=0.018). The OTRC-PSF group had the highest number of patients fused to the stable vertebra. Of the 11 OTRC-PSF patients fused to 1 vertebra short of stable, 6 (55%) had >10 degrees of curve progression. Of the 9 OTRC-PSF patients fused to at least the stable vertebra or lower, only 1 (11%) had curve progression. There were no significant differences in Scoliosis Research Society outcome scores between OTRC-PSF patients who did and those who did not have >10 degrees of curve progression. PSF with pedicle screws was associated with curve progression in a significantly greater proportion of patients with OTRC compared with APSF. Not fusing to stable was also associated with curve progression in patients treated with PSF but not APSF. Level III-therapeutic.

Clinical Outcomes of Hip Arthroscopy in Radiographically Diagnosed Retroverted Acetabula

Background: Symptomatic global retroversion of the acetabulum, as diagnosed on plain radiographs of the pelvis, has traditionally been treated with reverse periacetabular osteotomy, which improves posterior undercoverage and eliminates the anterior pincer lesion. There is a paucity of literature on hip arthroscopy in this group, secondary to theoretical concern of iatrogenic dysplasia, subsequent instability, and arthritis. Purpose: To evaluate the outcomes of hip arthroscopy for patients with a radiographic diagnosis of acetabular retroversion, using patient-reported outcomes, visual analog scale (VAS), patient satisfaction, and pre- and postoperative Tönnis grades. Study Design: Case series; Level of evidence, 4. Methods: Pre- and postoperative data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy at 1 institution between June 2008 and February 2012. Data were analyzed for patients who had adequate radiographs of the pelvis that demonstrated global acetabular retroversion and who were treated with arthroscopic surgery. Complications were tracked in this institution’s database. The modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score (HOS)–activities of daily living subscale, and HOS–sport-specific subscale, and VAS were analyzed preoperatively and at latest follow-up. Level of postoperative satisfaction was assessed on a scale of 0 to 10. Pre- and postoperative alpha angle, lateral center-edge angle, anterior center-edge angle, crossover percentage, and Tönnis grade were recorded. Tönnis grade at latest follow-up was utilized to determine progression of osteoarthritis. Results: A total of 82 hips among 78 patients were identified who met the listed criteria. The mean age of the patients was 23 years, and the mean follow-up was 39 months. These patients showed statistically significant improvement in modified Harris Hip Score (preoperative to ≥2-year follow-up: 65 to 81), Nonarthritic Hip Score (65 to 86), HOS–activities of daily living subscale (69 to 88), HOS–sport-specific subscale (47 to 76), and VAS (5.9 to 2.5) (P < .0001). In terms of satisfaction with the surgery, they had an mean score of 7.4. There were 3 minor complications, none of which required reoperation. One patient underwent hip arthroplasty at 6 months after hip arthroscopy. Fifteen patients had >2-year radiographic follow-up; none of these patients had an increase in Tönnis grade as compared with the preoperative state. Conclusion: This study demonstrates that hip arthroscopy can successfully treat femoroacetabular impingement associated with a globally retroverted acetabulum at a minimum 2-year follow-up. Survivorship was 99% at 2 years, with 1 patient requiring further surgery in the form of hip arthroplasty. There was no noted progression of Tönnis grade at final follow-up. The procedure was extremely safe, with a minor complication rate of 3.6%.

The Natural History of Osteoarthritis: What Happens to the Other Hip?

Idiopathic osteoarthritis (OA) is a common diagnosis leading to hip arthroplasty. Patients undergoing unilateral hip arthroplasty often wonder whether their other hip will follow the same path as the one that was operated on, and if so, when? There also are limited data available to predict from AP radiographs which contralateral hips will have OA develop and which will not. We sought (1) to determine the incidence of contralateral osteoarthritic degeneration in a group of patients who were treated with unilateral hip arthroplasty; and (2) to identify clinical and radiographic features associated with the development of contralateral OA. Between 1998 and 2010, we performed 398 hip arthroplasties on patients with unilateral primary hip OA, who at the time of surgery did not have any symptoms in the contralateral hip. Of those, 367 (92%) had a minimum 2-year radiographic followup (mean, 11 years; range, 2-17 years). The 31 patients dropped from the study for lack of radiographic followup had comparable preoperative features as the study group. We performed a radiographic analysis on the baseline AP radiographs to see what factors were associated with arthritis progression, and we performed Kaplan-Meier survivorship analysis with contralateral hip pain and contralateral THA as the endpoints. Kaplan-Meier survival estimates indicated that 10 years after the baseline evaluation, 59% (95% CI, 53%-65%) of the patients remained free of symptoms on the contralateral hip and 81% (95% CI, 75%-85%) remained free of an arthroplasty on the contralateral hip. Sex, age, weight, or BMI were not associated with the development of OA on the contralateral hip with the numbers available. Reduced minimum joint space width (hazard ratio, 0.299; 95% CI, 0.237-0.378), low center-edge angle (hazard ratio, 0.941; 95% CI, 0.915-0.968), low head-to-neck ratio (hazard ratio, 1.555; 95% CI, 1.088-2.223), and the presence of osteophytes (hazard ratio, 1.453; 95% CI, 1.001-2.110) were associated with the development of contralateral OA. In hips with a center-edge angle greater than 25°, a head-to-neck ratio of 1.3 or less increased the chances of development of OA by 86% (hazard ratio, 1.857; 95% CI, 1.235-2.793). The variables we studied can easily be assessed from an AP pelvis radiograph so physicians can predict the occurrence of contralateral OA and the need for future hip arthroplasty in their patients needing unilateral arthroplasty. However, the data available might have led us to underestimate the need for contralateral arthroplasty. Future studies with a prospective design should aim at completing the list of radiographic features associated with the development of OA by adding a review of lateral radiographs. Level IV, prognostic study.

Maintenance of Derotation in Adolescent Idiopathic Scoliosis: a Novel Technique Measuring Postoperative Vertebral Rotation by Pedicle Screw Position.

Current methods of measuring vertebral rotation by plain radiographs rely on anatomic landmarks that are not present in the postoperative spine or require advanced imaging. Furthermore, there are few studies on the incidence of crankshaft with modern pedicle instrumentation. We sought to (1) describe and validate a method of vertebral rotation measurement using plain radiographs and (2) measure postoperative rotation in a series of patients treated for adolescent idiopathic scoliosis. Patients with adolescent idiopathic scoliosis treated with surgery over a 6-year period were reviewed. Patients with computed tomography (CT) scans and radiographs within 60days of another were included. Vertebral rotation was calculated by radiographic measurements and measured directly by CT scan. As an internal control, patients with two apical pedicle screws on all radiographs were analyzed. Rotation was measured for all patients with at least 1year of radiographic follow-up. Three thousand five hundred fifty-two instrumented spinal levels in 308 consecutive patients were reviewed. Ten patients with 93 screws were analyzed by CT and radiographs. The average discrepancy between computed tomography (CT) and radiographs was 3.3 ± 1.9°, with 81.7% (76/93) within 5°. Intra- and inter-rater reliabilities for measured axial rotation were excellent (intra-class correlation coefficient (ICC) = 0.879 and 0.900, respectively). One hundred swventy-eight patients were eligible with an average follow-up of 2.3 ± 1.2years; 84.8% (151/178) had screw(s) visible on all images at the major curve apex. The average postsurgical rotation was 3.5 ± 2.9°; 19.2% (29/151) were measured to have a rotation over 5°, and 4.0% (6/151) demonstrated a rotation over 10°. Only 4.6% (7/151) of patients demonstrated a postoperative Cobb angle change over 10°. Most major curves have apical pedicle screw instrumentation that can be followed by radiographs alone to measure rotation. Vertebral rotation measurement requires only plain radiographs and is a more sensitive determination for subtle postoperative crankshaft than change in Cobb angle.

Elderly Patients Older than 75 Years Undergoing Reconstructive Spinal Deformity Surgery Have Significantly Improved Health-Related Quality of Life Measures versus those Managed Nonoperatively Despite High Surgical Complication Rate

Introduction Elderly patients with adult spinal deformity (ASD) often report worse health-related quality of life (HRQOL) than younger patients. Increasing age is associated with increased surgical morbidity. The objective of this study was to compare the outcomes of patients with ASD older than 75 years managed operatively (OP) and nonoperatively (NONOP). Materials and Methods A retrospective review of a multicenter prospective ASD database was conducted. Inclusion criteria included age ≥ 75 years, ASD. Demographics, comorbidities, radiographs, complications, and HRQOL measures collected included pain with visual analog scale (VAS), Oswestry Disability Index (ODI), Short Form-36 (SF-36), and Scoliosis Research Society-22 (SRS22) at baseline, 1 and 2 years. Results A total of 32 patients met criteria (OP: 17, NONOP: 15), all had a minimum 2-year clinical and radiographic follow-up. Of the 32 patients, 13 were at least 80 years of age. There were no significant differences between OP and NONOP for age, BMI, and Charlson Comorbidity Index ( p &gt; 0.05 for all). OP had worse baseline ODI, PCS, SRS Activity, Appearance, and Total than NONOP ( p &lt; 0.05 for all). There were no significant differences in any baseline radiographic parameters. OP had significant improvement in LL, C7SVA, PI–LL, ODI, PCS, and all SRS subdomains except mental compared with pre-op ( p &lt; 0.05 for all). OP had significantly higher 2-year SRS appearance and satisfaction ( p &lt; 0.05) than NONOP. There were no significant differences between baseline and 2-year HRQOL for NONOP ( p &gt; 0.05). Of the 17 OP patients, 10 (58.8%) had at least one complication with a total of 27 complications including a 64.7% rate of PJK and a 35.3% rate of reoperation. Conclusion Elderly patients ≥ 75 years undergoing ASD surgery had significantly improved HRQOL and radiographic measures over baseline at 2 years compared with a similar nonoperative cohort, despite substantial operative morbidity. This data may be used for preoperative patient counseling in this high-risk elderly population.

Comparative Evaluation of in Vivo Radiographic Outcomes between Different Implants in Single-Level Cervical Disc Arthroplasty at Greater than 2 Years

Introduction Cervical fusion alters the biomechanics of the cervical spine. Adjacent levels compensate for motion lost at the fused levels. This may lead to or accelerate the development of symptomatic adjacent segment disease (ASD). Cervical disc arthroplasty (CDA) is a safe and effective alternative to fusion. It is postulated that by preserving motion at the operated level, the adjacent levels will be protected from ASD potentially related to fusion. ASD will develop over the long-term and therefore CDA implants must maintain motion and mimic the normal biomechanics of a native disc to have the protective effect. Implant design may influence a CDA implant's ability to do this. We aim to assess if the three implants with different designs do display different radiographic outcomes in vivo. Materials and Methods All one-level CDA patients with greater than 2-year radiographic follow-up were identified from hospital records. The C2 to C7 Cobb angle was measured on neutral lateral radiographs. The segmental Cobb angle was measured on lateral neutral, flexion, and extension radiographs with motion of the CDA calculated as the difference between the two later measurements. Any disc with &lt; 2 degrees motion was identified as not exhibiting motion. Results A total of 55 patients were included. Average follow-up was 145 weeks. Three different implants were used—Discocerv (Scient’x-Alphatec Spine, France), NuNec (Pioneer Surgical Technology, United States) and PRESTIGE LP (Medtronic Ltd., United States). The most common operated level was C5/6 with 40 implants. Other levels consisted of one C3/4, four C4/5, and ten C6/7. The number of implants, cervical alignment, segment alignment, and segmental motion (in degrees) is shown in Table 1. There was no statistically significant difference in any outcome between the implants. One PRESTIGE LP required revision after 2 years. Bony fusion was observed in 12.5% of Discocerv, 14.3% of NuNec, and 12.1% of PRESTIGE LP. Twenty-five percent of Discocerv cases had some degree of subsidence, while this was seen in 7.1% of NuNec and 6.1% of PRESTIGE LP implants. Conclusion Our results indicate that CDA implant type influences the alignment of the replaced segment and preservation of motion. This may be due to the different biomechanical designs of the implants. While statistically significant differences were not observed, differences may be clinically significant. We acknowledge that limited conclusions can be drawn from our results due to differing group sizes, but our study serves as a basis and highlights the need for further in vivo and in vitro studies. Disclosure of Interest A. Berg: None declared J. Tankel: None declared C. Jensen: None declared A. Irwin: None declared B. Purushothaman: None declared G. Reddy: None declared T. Friesem: Conflict with RTI Surgical, Globus Medical

A prospective multicenter clinical study of the Discovery elbow

Semiconstrained total elbow arthroplasty is used to improve elbow function and reduce pain. Although effective, high complication rates exist, with the polyethylene bushing especially susceptible to failure. The Discovery Elbow System (Biomet Inc, Warsaw, IN, USA) contains a spherical bearing designed to minimize polyethylene wear. This prospective, multicenter clinical study investigated the 4-year (mean) outcomes of this elbow. From 2002 to 2009, 92 patients (71 women, 21 men; mean age, 63.9 years; range, 33.4-88.7 years) received 99 Discovery elbows at 4 centers. The study cohort was limited to 46 elbows with complete preoperative and minimum 2-year clinical (modified American Shoulder and Elbow Surgeons elbow score) and radiographic follow-up. Mean follow-up was 4.1 years (range, 2-5.9 years). All American Shoulder and Elbow Surgeons elbow score components improved significantly (P < .001). Mean flexion-extension arcs increased from 81° to 121° and pronation-supination arcs from 134° to 163° (P < .001). Loose locking screws in 2 elbows (first-generation screws), a loose polyethylene bearing in 1 (history of falls), and a condyle/bearing in 1 (deep infection) were exchanged. Among the 46 elbows, gross survivorship was humeral/ulnar components, 100%; condyles, 97.8%; bearings, 95.7%; and screws, 95.7%. One humeral component (2.2%) was radiographically loose but not revised. An additional elbow (elbow 47) that did not meet the criteria for inclusion (<2 years of follow-up) was revised due to a loose humeral component and was reported separately. The Discovery elbow increased function and decreased pain with high survivorship at a mean of 4.1 years.

The posterior pedicle screw construct: 5-year results for thoracolumbar and lumbar curves

Object Several studies of the outcomes of patients with adolescent idiopathic scoliosis (AIS) with thoracolumbar and lumbar curves after treatment with posterior pedicle screws have been reported, but most of these studies reported only 2-year follow-up. The authors analyzed the radiographic and clinical outcomes of patients with thoracolumbar and lumbar curves treated with posterior pedicle screws after 5 years of follow-up. Methods A multicenter database was retrospectively queried to identify patients with AIS who underwent spinal fusion for Lenke 3C, 5C, and 6C curves. Radiographs from the following times were compared: preoperative, first follow-up visit, 1-year follow-up visit, 2-year follow-up visit, and 5-year follow-up visit. Chart review included scoliometer measurements, Scoliosis Research Society (SRS)–22 questionnaires, and complications requiring return to the operating room. Results Among 26 patients with Lenke 3C, 5C, and 6C curves, the mean (± SD) age was 14.6 ± 2.1 years. From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal lumbar Cobb angles (p &lt; 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the lumbar curve remained stable (p = 0.14). From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal thoracic Cobb angles (p &lt; 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the thoracic curve remained stable (p = 0.10). From the first postoperative visit to the 5-year follow-up visit, the thoracic kyphosis (T5–12) remained stable (p = 0.10), and from the time of the preoperative radiographs to the 5-year follow-up radiographs, the lumbar lordosis (T-12 to top of sacrum) remained stable (p = 0.44). From the preoperative visit to the 5-year follow-up visit, the coronal balance improved significantly (p &lt; 0.05) and remained stable from the first postoperative visit to the 5-year follow-up visit (p = 0.20). The SRS-22 total scores improved significantly from before surgery to 5 years after surgery (p &lt; 0.0001). No patients required reoperation because of complications. Conclusions Correction of the coronal, sagittal, and axial planes in this cohort of patients was maintained from the first follow-up measurements to 5 years after surgery. In addition, at 5 years after surgery total SRS-22 scores and inclinometer readings were improved from preoperative scores and measurements.

Clinical and radiographic outcomes with L4&amp;ndash;S1 axial lumbar interbody fusion (AxiaLIF) and posterior instrumentation: a multicenter study

IntroductionPrevious studies have confirmed the benefits and limitations of the presacral retroperitoneal approach for L5–S1 interbody fusion. The purpose of this study was to determine the safety and effectiveness of the minimally invasive axial lumbar interbody approach (AxiaLIF) for L4–S1 fusion.MethodsIn this retrospective series, 52 patients from four clinical sites underwent L4–S1 interbody fusion with the AxiaLIF two-level system with minimum 2-year clinical and radiographic follow-up (range: 24–51 months). Outcomes included back pain severity (on a 10-point scale), the Oswestry Disability Index (ODI), and Odom’s criteria. Flexion and extension radiographs, as well as computed tomography scans, were evaluated to determine fusion status. Longitudinal outcomes were assessed with repeated measures analysis of variance.ResultsMean subject age was 52 ± 11 years and the male:female ratio was 1:1. Patients sustained no intraoperative bowel or vascular injury, deep infection, or neurologic complication. Median procedural blood loss was 220 cc and median length of hospital stay was 3 days. At 2-year follow-up, mean back pain had improved 56%, from 7.7 ± 1.6 at baseline to 3.4 ± 2.7 (P < 0.001). Back pain clinical success (ie, ≥30% improvement from baseline) was achieved in 39 (75%) patients at 2 years. Mean ODI scores improved 42%, from 60% ± 16% at baseline to 35% ± 27% at 2 years (P < 0.001). ODI clinical success (ie, ≥30% improvement from baseline) was achieved in 26 (50%) patients. At final follow-up, 45 (87%) patients were rated as good or excellent, five as fair, and two as poor by Odom’s criteria. Interbody fusion observed on imaging was achieved in 97 (93%) of 104 treated interspaces. During follow-up, five patients underwent reoperation on the lumbar spine, including facet screw removal (two), laminectomy (two), and transforaminal lumbar interbody fusion (one).ConclusionThe AxiaLIF two-level device is a safe, effective treatment adjunct for patients with L4–S1 disc pathology resistant to conservative treatments.

Are Cementless Stems More Durable Than Cemented Stems in Two-stage Revisions of Infected Total Knee Arthroplasties?

The routine use of stems in revision TKA improves survival rates by enhancing the stability of the prosthesis. The ideal method of stem fixation (cemented or uncemented) in two-stage reimplantation remains controversial. The purpose of this study was to answer the following questions: (1) Are rerevision rates for aseptic loosening comparable between cemented stems and uncemented stems in two-stage reimplantation? (2) Is the reinfection rate comparable between antibiotic-impregnated cemented stems and uncemented stems for two-stage reimplantation? (3) Are there any differences in Knee Society radiographic scores between stem techniques? A retrospective analysis was performed in all patients who underwent two-stage reimplantation between 1990 and 2010 at Anderson Orthopaedic Research Institute (AORI) and OrthoCarolina (OC). One hundred fourteen patients with 228 stems met the inclusion criteria. Of these 228 stems, 102 stems were cemented and 126 stems were uncemented. The indication for stem fixation was largely institution specific; AORI used cementless stems 92% (118) of the time, whereas OC used a cemented stem 92% (92) of the time. A 2-year minimum radiographic and clinical followup was required for inclusion into the study. Radiographic evaluations were performed using a modification of the Knee Society radiographic score. Rerevision rates for aseptic loosening were comparable with three cemented and three cementless stem constructs. The reinfection rate was also comparable between cemented and cementless stems (p = 0.86). Using post hoc analysis, 32% of cemented stems were radiographically classified as loose or closely observe (33 of 102) compared with 17% of the cementless stem group (21 of 126; p = 0.006). Patients with good bone quality had a significantly lower rate of radiographic loosening compared with patients with poor bone quality (p = 0.01). There was no significant correlation with radiographic loosening and level of constraint (p = 0.90) or use of articulating versus static antibiotic spacer (p = 0.06). In this retrospective study, cementless diaphyseal-engaging stems had a lower rate of radiographic failure than did cemented stems in two-stage reimplantation. Reinfection rates remain similar despite the absence of antibiotic cement in the cementless constructs. At this time we believe the use of hybrid, cementless diaphyseal-engaging stems should be considered as a possible option at the time of reimplantation.

Type of Anchor at the Proximal Fusion Level Has a Significant Effect on the Incidence of Proximal Junctional Kyphosis and Outcome in Adults After Long Posterior Spinal Fusion

Study DesignRetrospective review. ObjectivesTo compare the incidence of proximal junctional kyphosis (PJK) and the clinical, radiographic, and functional outcomes in adults undergoing long posterior spinal fusion with transverse process hooks versus pedicle screws at the uppermost instrumented vertebrae. Summary of Background DataProximal junctional kyphosis often occurs after instrumented long spinal fusion. Although there have been numerous studies of PJK development in adolescents with idiopathic scoliosis, few studies have focused on adults. MethodsThis study reviewed data on 47 consecutive adult patients who underwent long spinal fusion (five or more levels) with hooks or screws at the uppermost instrumented vertebrae, from 2004 through 2009, and had 2-year radiographic and clinical follow-up. The hook group (20 patients) and screw group (27 patients) were similar in terms of age, gender, and levels fused. Proximal junctional kyphosis was defined as a sagittal Cobb angle of at least 10° between the lower end plate of the uppermost instrumented vertebrae and the upper end plate of the 2 immediately superior vertebrae, and at least 10° of progression from the previous measurement. The groups' radiographs, complications, and functional outcomes (Scoliosis Research Society–22 Patient Questionnaire and the Oswestry Disability Index) were compared using Hotelling's t2 test (significance, p < .05). ResultsComparing immediate postoperative and final follow-ups, none of the 20 patients in the hook group versus 8 of 27 patients in the screw group (29.6%) developed PJK (p = .01). There were no statistical differences between groups in major or minor complications rates. At final follow-up, patients with hooks had significantly higher functional scores than those with screws (p < .05), and patients with PJK had significantly lower functional scores in all Scoliosis Research Society–22 Patient Questionnaire domains except satisfaction. ConclusionsTransverse process hooks were associated with a lower incidence of PJK and higher functional scores than pedicle screws.

Benign Radiographic Coronal Synostosis After Sagittal Synostosis Repair

Whether cranial vault remodeling surgery for nonsyndromic, isolated sagittal suture synostosis affects the patency of initially normal, unaffected sutures is unknown. The influence of coronal and lambdoidal suture patency after cranial vault remodeling on the trajectory of subsequent cranial growth is also unknown. Disruption of normal sutural anatomy during cranial vault reconstruction could influence the incidence of secondary craniosynostosis and need for reoperation in a small proportion of these patients.We performed a retrospective review of patients younger than 1 year with nonsyndromic sagittal synostosis treated at a single tertiary referral pediatric hospital from September 2005 to January 2010 by an interdisciplinary team. Computed tomographic images obtained preoperatively, immediately postoperatively, and 2 years postoperatively were evaluated for the occurrence of secondary synostosis of initially nonsynostotic sutures. Craniofacial disorders clinic and ophthalmologic follow-up records were also analyzed for the occurrence of radiographic cranial restenosis, clinical or ophthalmologic signs of intracranial hypertension (ICH), and reoperation.Fifty-one patients younger than 1 year underwent primary surgical repair of isolated, nonsyndromic sagittal suture synostosis during the study period. Thirty-seven of these patients (71%) had completed 2-year clinical and radiographic follow-up by the time of analysis, constituting the study population. The average age at surgery was 5.4 months (range, 3.1-11.5 months). Thirty-three (89%) of the 37 study patients showed radiographic evidence of bilateral secondary coronal synostosis (SCS). Five patients (15%) additionally showed partial lambdoid synostosis. One patient with radiographic SCS (3%) required reoperation for radiographic cranial restenosis, clinical signs and symptoms of ICH, and papilledema first noted 1 year after primary cranial vault reconstruction.There is a high incidence of secondary coronal suture synostosis following cranial vault remodeling for isolated, nonsyndromic sagittal synostosis. Postoperative SCS was only rarely associated with secondary radiographic cranial stenosis, clinical or ophthalmologic signs of ICH, and the need for reoperation.

Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the treatment of thoracic aortic aneurysms

Thoracic endovascular aortic repair (TEVAR) has become a widely established treatment for a variety of thoracic aortic pathologic diseases despite limited long-term data to support its use. We compared the long-term outcomes of TEVAR with the 3 commercially available stents grafts for thoracic aortic aneurysms to results in control subjects undergoing open surgery. Demographic, clinical radiographic parameters were collected prospectively on patients enrolled in trials assessing the Gore TAG (55), Medtronic Talent (36) and Cook TX2 (15) devices. Outcomes were compared with 45 contemporaneous open controls. Detailed clinical and radiographic information was available for analysis. Standard univariate, survival, and regression methods were used. During the study period (1995-2007) 106 patients were enrolled in TEVAR trials and there were 45 open controls. TEVAR patients were older and had significantly more comorbidities including diabetes and renal failure. TEVAR patients had 2.3 ± 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P = .1), paralysis/paraparesis (3.9% TEVAR, 7.1% open; P = .2), and prolonged intubation more than 24 hours (9% TEVAR, 24% open; P = .02) tended to be more common in the open controls. Overall survival at 10 years was similar between groups (log rank P = .5). Multivariate predictors of late mortality included age, chronic obstructive pulmonary disease, diabetes, and chronic renal failure. Use of TEVAR versus open surgery did not influence mortality (hazard ratio, 0.9 95% confidence interval, 0.4-1.6). Over 5 years of radiographic follow-up in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention on the treated segment was 85% in TEVAR patients at 10 years. TEVAR is a safe and effective procedure to treat thoracic aortic aneurysms with improved perioperative and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysm diameters initially decrease and then stabilize over time.

Cementing Acetabular Liners Into Secure Cementless Shells for Polyethylene Wear Provides Durable Mid-term Fixation

In a previous experiment studying cementation of liners into cementless acetabular shells, placing grooves in the liner in a spider-web configuration created the greatest construct strength. Scoring shells without screw holes or other texturing helped prevent failure at the shell-cement interface. However, it was unclear whether these practices caused durable constructs in patients. We therefore determined (1) rerevision rates; (2) functional scores (Harris hip scores, WOMAC, and SF-36); (3) acetabular loosening rates; and (4) acetabular osteolysis rates in patients in whom we cemented nonconstrained liners into well-fixed and well-positioned acetabular shells. We prospectively followed 30 patients with 31 total hip arthroplasties in which a worn acetabular liner was revised by cementing a new liner into the existing shell that was stable and well positioned. Acetabular liners were prepared as determined by our previous study. Twenty-seven of the 30 patients (28 hips) were evaluated clinically. We recorded revisions and determined radiographic loosening and osteolysis. The minimum clinical followup was 2 years (mean, 5.3 years; range, 2-10 years). Twenty-six hips (87%) had minimum 2-year radiographic followup with an average length of 4.8 years. No hip required rerevision during the followup interval. Two hips (6%) dislocated once, both treated nonoperatively. Harris hip scores, WOMAC, and SF-36 scores increased over preoperatively at last followup. All acetabular shells and liners were radiographically stable without evidence of loosening or progressive acetabular osteolysis. Cementation of a liner into a well-fixed cementless shell after scoring in a spider-web configuration provided secure fixation with no failures of the construct at average 5.3 years followup. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Particulate vs. block bone grafts: Three-dimensional changes in graft volume after reconstruction of the atrophic maxilla, a 2-year radiographic follow-up

BackgroundExtensive alveolar bone resorption in the maxilla limits the possibility of successful placement and osseointegration of endosseous implants for future prosthetic rehabilitation. Autogenous bone from the iliac crest may be used as lateral onlays in the atrophic maxilla, both as block and particulate bone. To our knowledge, there is no three-dimensional 2-year follow-up study measuring the volumetric reduction of the augmented areas comparing particulate and block bone grafts. PurposeThe aim of this study was to conduct a radiographic 2-year follow-up study, using computed tomographic (CT) images in order to evaluate and compare the extent of bone graft resorption in the frontal maxillae augmented by particulate (test) and block bone (control). Material and methodsEleven patients treated with iliac bone grafts and oral implants in the maxilla were followed with CT examinations directly post grafting and after 2years. ResultThe volumetric changes after 6months were extensive. Additionally, the changes in particulate bone tended to be larger after 2years compared to block bone, using this protocol. However, the difference was not statistically significant. ConclusionThe present follow-up study showed that there is radiographically complete integration and embedding of implants installed in grafted bone despite extensive initial graft resorption. There was no significant difference in the amount of volumetric reduction between particulate bone and block bone grafts.