ABSTRACT
STUDY DESIGN: A retrospective study for clinical, radiographic assessment. OBJECTIVES: To determine the appropriate level of distal fusion for the posterior instrumentation and fusion for thoracic hyperkyphosis by investigating the relationship between the sagittal stable (the most proximal vertebra touched by the vertical line from the posterior-superior corner of the sacrum), first lordotic (just caudal to the first lordotic disc) and lowest instrumented vertebrae. LITERATURE REVIEW SUMMARY: It has been recommended that the distal level of fusion for thoracic hyperkyphosis should include not only the distal end vertebra of kyphosis, but also the first lordotic disc beyond the transitional zone, distally. However, distal junctional breakdown was noted, even when these rules have been followed. MATERIALS AND METHODS: Thirty-one patients, with a mean age of 18, ranging from 13 to 38 years, who underwent long posterior instrumentation and fusion for thoracic hyperkyphosis, with a minimum of 2 years of follow up, were reviewed. The preoperative diagnosis included: Scheuermann`s disease (n=29), posttraumatic kyphosis (n=1) and postlaminectomy kyphosis (n=1). According to the level of distal fusion, the patients were divided into two groups. Group I (n=24): lowest instrumented vertebra (LIV), including the sagittal stable vertebra (SSV), Group II (n=7): lowest instrumented vertebra proximal to the sagittal stable vertebra. Patients were evaluated utilizing both standing radiographs and chart reviews. RESULTS: The mean thoracic kyphosis was 86.6+/-8.5 before surgery, which had been corrected to 53.0+/-10.4 by the final follow-up, with a correction rate of 39%. The average sagittal balance was slightly negative (0.24+/-3.8 cm) before surgery, and became more negative (1.33+/-2.8 cm) by the final follow-up. There were no statistical differences in the thoracic kyphosis between the two groups. However, there was a statistically significant difference, with Group II having a more posterior translation of the center of the LIV from the posterior sacral vertical line, preoperatively, than at the final follow-up in Group I (p=0.003). In Group I, distal junctional problems developed in only 2 of the 24 (8%) patients, whereas in Group II, they occurred in 5 of the 7 (71%) patients (p<0.05). Despite extending the fusion to the first lordotic vertebra, distal junctional problems developed in 3 of the 8 (38%) patients. CONCLUSIONS: The distal end of the fusion for thoracic hyperkyphosis should include the sagittal stable vertebra. The levels of distal fusion that include the first lordotic vertebra, but not the sagittal stable vertebra, are not always appropriate for the prevention of postoperative distal junctional kyphosis.
Subject(s)
Humans , Diagnosis , Follow-Up Studies , Kyphosis , Retrospective Studies , SpineABSTRACT
STUDY DESIGN: A retrospective study for clinical, radiographic assessment. OBJECTIVES: To determine the appropriate level of distal fusion for the posterior instrumentation and fusion for thoracic hyperkyphosis by investigating the relationship between the sagittal stable (the most proximal vertebra touched by the vertical line from the posterior-superior corner of the sacrum), first lordotic (just caudal to the first lordotic disc) and lowest instrumented vertebrae. LITERATURE REVIEW SUMMARY: It has been recommended that the distal level of fusion for thoracic hyperkyphosis should include not only the distal end vertebra of kyphosis, but also the first lordotic disc beyond the transitional zone, distally. However, distal junctional breakdown was noted, even when these rules have been followed. MATERIALS AND METHODS: Thirty-one patients, with a mean age of 18, ranging from 13 to 38 years, who underwent long posterior instrumentation and fusion for thoracic hyperkyphosis, with a minimum of 2 years of follow up, were reviewed. The preoperative diagnosis included: Scheuermann`s disease (n=29), posttraumatic kyphosis (n=1) and postlaminectomy kyphosis (n=1). According to the level of distal fusion, the patients were divided into two groups. Group I (n=24): lowest instrumented vertebra (LIV), including the sagittal stable vertebra (SSV), Group II (n=7): lowest instrumented vertebra proximal to the sagittal stable vertebra. Patients were evaluated utilizing both standing radiographs and chart reviews. RESULTS: The mean thoracic kyphosis was 86.6+/-8.5 before surgery, which had been corrected to 53.0+/-10.4 by the final follow-up, with a correction rate of 39%. The average sagittal balance was slightly negative (0.24+/-3.8 cm) before surgery, and became more negative (1.33+/-2.8 cm) by the final follow-up. There were no statistical differences in the thoracic kyphosis between the two groups. However, there was a statistically significant difference, with Group II having a more posterior translation of the center of the LIV from the posterior sacral vertical line, preoperatively, than at the final follow-up in Group I (p=0.003). In Group I, distal junctional problems developed in only 2 of the 24 (8%) patients, whereas in Group II, they occurred in 5 of the 7 (71%) patients (p<0.05). Despite extending the fusion to the first lordotic vertebra, distal junctional problems developed in 3 of the 8 (38%) patients. CONCLUSIONS: The distal end of the fusion for thoracic hyperkyphosis should include the sagittal stable vertebra. The levels of distal fusion that include the first lordotic vertebra, but not the sagittal stable vertebra, are not always appropriate for the prevention of postoperative distal junctional kyphosis.
Subject(s)
Humans , Diagnosis , Follow-Up Studies , Kyphosis , Retrospective Studies , SpineABSTRACT
PURPOSE: In this study, we tried to develop the technique of osteotomy for hallux valgus. The new modified technique of osteotomy was accomplished with even more greater stability, accurate correction of the deformity and more effective than 'chevron' osteotomy in terms of correction of the deformity. MATERIALS AND METHODS: Between March 1998 and December 2001, 55 cases of new modified osteotomy for hallux valgus were performed for 39 patients, 16 of whom underwent operation of both feet. Operations were made for 34 women and 5 men whose average age was 46 years old (range, 20~71 years). Average follow up period was three years (range, 2~5 years), and during the follow up, the patients underwent physical examination and assessment with use of the American Orthpaedic Foot and Ankle Society's hallux-metatarso-phalangealinterphalangeal scale8) and standard foot radiographic measurements16). RESULTS: 37 patients (53 cases) out of 39 patients (55 cases) had no pain, good cosmesis, and all of the patients were satisfied with the results of the operation. Two had occasional mild discomfort. The average score according to the hallux-metatarso-phallangeal-interphalangeal scale8) was 93.2 points (range, 78~100 points). The average preoperative intermetatarsal angle was 14.4 degrees, which was decreased to 7.9 degrees after the osteotomy with an average correction of 6.5 degrees and The average preoperative hallux valgus angle was 34.1 degrees, which was decreased to 11.1 degrees after the osteotomy with an average correction of 23 degrees. This new modified technique would prevent the angulation or shortening at the osteotomy site and it was also even more stable at osteotomy site, and could do even more effective and accurate correction of the deformity than conventional Chevron osteotomy. CONCLUSION: New modified chevron osteotomy for the treatment of symptomatic hallux valgus was done in 55 cases, and the results were satisfactory in all cases. This method was more stable at the osteotomy site than conventional Chevron osteotomy and was also possible to do more accurate and more effective correction of the deformity. It was also easy to control the distal fragment of first metatarsal bone.