Factores influyentes en el desarrollo de competencias en Ortopedia y Traumatología durante el internado médico / Influential Factors in The Development of Competencies in Orthopedics and Traumatology During the Medical Internship

RESUMEN Introducción: Actualmente la salud es concebida como un derecho fundamental y para garantizarlo se debe propender por una adecuada formación de los profesionales de la salud. El internado rotatorio es la última etapa y la más importante del pregrado en Medicina. Objetivo: Explorar los factores desde la perspectiva de estudiantes y docentes, que influyen en el desarrollo de competencias en la rotación de Ortopedia y Traumatología durante el internado médico. Métodos: Estudio cualitativo con enfoque en teoría fundamentada. Para la recolección de datos se realizó un cuestionario semiestructurado a una muestra aleatoria de 14 participantes, 7 estudiantes y 7 docentes, que cumplían los criterios de inclusión. El análisis se basó en la codificación y categorización de los datos que posteriormente fueron sometidos a un proceso de triangulación para lograr la teorización final. Resultados: Los factores que favorecen el desarrollo de competencias están relacionados con la motivación intrínseca del estudiante, la flexibilidad y disponibilidad de recursos académicos, las características del programa de la rotación y el ambiente de práctica. Se identificaron como factores limitantes aquellos asociados a una formación deficiente en ciencias básicas médicas, la priorización del componente asistencial sobre el académico, la disponibilidad limitada de espacios y recursos de aprendizaje y los métodos de enseñanza tradicionales. Conclusiones: Es de vital importancia la identificación de los factores que favorecen y limitan el desarrollo de las competencias de los estudiantes de medicina en su última etapa de formación en ortopedia.

ABSTRACT Introduction: Few areas of orthopedic surgery have had such important technical changes in recent decades as in corrective spinal surgery. Fundamental changes have come with the new spinal instrumentation systems, which have been substantially modified and improved to facilitate three-dimensional correction of the deformity and provide secure spinal fixation, correction and stability. Objective: To evaluate the results achieved with the spinal instrumentation systems used in the correction of thoracolumbar kyphosis due to ankylosing spondylitis. Methods: A descriptive, retrospective and longitudinal study was carried out on 16 patients with thoracolumbar kyphosis due to ankylosing spondylitis operated on with the pedicle subtraction osteotomy technique and instrumented with Luque-type pedicle and sublaminar systems, in the Orthopedics service at Hermanos Ameijeiras Surgical Clinical Hospital, from March 2001 to March 2021. Results: All the patients were male, white skin color and average age of 39 years. More than 80% correction was achieved in the sagittal profile and an average of 34.3° per osteotomy, without major neurological complications. Good functional results were obtained, with high degree of patient satisfaction and improvement in their quality of life. Conclusions: The use of both spinal instrumentation systems is effective in maintaining the correction of thoracolumbar kyphosis due to ankylosing spondylitis.

Sistemas de instrumentación espinal en la corrección de la cifosis toracolumbar por espondilitisanquilopoyética / Spinal Instrumentation Systems in The Correction of Thoracolumbar Kyphosis Due to AnkylosingSpondylitis

Introducción: En pocas áreas de la cirugía ortopédica se han producido cambios técnicos tan importantes en las últimas décadas como en la cirugía correctora espinal. Los cambios fundamentales han sobrevenido con los nuevos sistemas de instrumentación espinal, que se han modificado y mejorado sustancialmente para facilitar la corrección tridimensional de la deformidad y aportar fijación segura de la columna, corrección y estabilidad. Objetivo: Evaluar los resultados alcanzados con los sistemas de instrumentación espinal utilizados en la corrección de la cifosis toracolumbar por espondilitis anquilopoyética. Método: Se realizó un estudio tipo descriptivo, retrospectivo y longitudinal a 16 pacientes con cifosis toracolumbar por espondilitis anquilopoyética intervenidos con la técnica de osteotomía de sustracción pedicular e instrumentados con sistemas pediculares y sublaminar tipo Luque, en el servicio de Ortopedia del Hospital Clínico Quirúrgico Hermanos Ameijeiras, durante el período comprendido entre marzo de 2001 y marzo de 2021. Resultados: La totalidad de los pacientes correspondieron al sexo masculino, color de la piel blanca y edad promedio de 39 años. Se logró más del 80 por ciento de corrección en el perfil sagital y un promedio de 34,3° por osteotomía, sin complicaciones neurológicas mayores. Se obtuvo un buen resultado funcional, con un alto grado de satisfacción de los pacientes y mejora de su calidad de vida. Conclusiones: La utilización de ambos sistemas instrumentación espinal es eficaz para mantener la corrección de la cifosis toracolumbar por espondilitis anquilopoyética(AU)

Introduction: Few areas of orthopedic surgery have had such important technical changes in recent decades as in corrective spinal surgery. Fundamental changes have come with the new spinal instrumentation systems, which have been substantially modified and improved to facilitate three-dimensional correction of the deformity and provide secure spinal fixation, correction and stability. Objective: To evaluate the results achieved with the spinal instrumentation systems used in the correction of thoracolumbar kyphosis due to ankylosing spondylitis. Methods: A descriptive, retrospective and longitudinal study was carried out on 16 patients with thoracolumbar kyphosis due to ankylosing spondylitis operated on with the pedicle subtraction osteotomy technique and instrumented with Luque-type pedicle and sublaminar systems, in the Orthopedics service at Hermanos Ameijeiras Surgical Clinical Hospital, from March 2001 to March 2021. Results: All the patients were male, white skin color and average age of 39 years. More than 80 percent correction was achieved in the sagittal profile and an average of 34.3° per osteotomy, without major neurological complications. Good functional results were obtained, with high degree of patient satisfaction and improvement in their quality of life. Conclusions: The use of both spinal instrumentation systems is effective in maintaining the correction of thoracolumbar kyphosis due to ankylosing spondylitis(AU)

Surgical choice of posterior osteotomy way for senile osteoporotic thoracolumbar fracture with kyphosis / 中国骨伤

OBJECTIVE@#To investigate the surgical choice of posterior osteotomy way by the observation of clinical outcome of Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO) and vertebral column re-section (VCR) for senile osteoporotic thoracolumbar fracture with kyphosis.@*METHODS@#From June 2015 to August 2017, an amount of 8 elderly patients with thoracolumbar kyphosis caused by osteoporotic vertebral fracture underwent osteotomy approach for posterior osteotomy. All patients were old osteoporotic vertebral fracture more than 6 months and received invalid conservative treatment for 3 months including nonsteroidal anti-inflammatory and analgesic drugs, anti-osteoporosis drugs and acupuncture, etc. There were 3 males and 5 females, with an average age of 73.4 years (66 to 83 years), with an average course of the disease of 34.6 months (8 to 60 months). Eight patients had a total of 8 vertebral fractures, and fracture segment was in T of 1 case, T of 1 case, T of 3 cases, L of 2 cases, L of 1 case. Eight patients showed kyphosis caused by wedge deformation of single segmental vertebral fractures. The thoracolumbar kyphosis and symptoms were progressively developing into central sagittal imbalance. SPO osteotomy was performed in 3 cases, PSO osteotomy in 3 cases, and VCR osteotomy in 2 cases. Orthopaedic effects were analyzed by imaging measurements, including pre- and post-operative kyphosis Cobb angle, localized kyphosis (LK), thoracic kyphosis (TK), lumbar lordosis (LL), sacral tilt angle (ST) and sagittal vertical axis (SVA). Visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the pain and lumbar function.@*RESULTS@#All the eight patients were followed up from 8 to 24 months with an average of 13.5 months and all the symptoms of low back pain have significantly reduced or disappeared. The VAS score decreased from 5-8 points (mean 6.5 points) before surgery to 1-4 points (mean 1.88 points) at the final follow-up, and the score was significantly improved. The ODI score decreased from 36-78 points (mean 60.25 points) before surgery to 10-32 points (mean 20.38 points) at the final follow-up, and the functional score improved significantly. During the follow-up period, X-ray examination showed that some patients had a slight decrease in the height of the intervertebral fusion, and the bone graft was healed. There was no obvious corrected degree loss and internal fixation loosening, and the thoracolumbar kyphosis was significantly improved. The mean Cobb angle of T-L was reduced from 25.3° to 2.8° with corrected rate of 89.3% ; LK was reduced from 43.4° to 7.1° with corrected rate of 86.2% ; TK was reduced from 49.9° to 30.6°, LL was reduced from 43.6° to 30.8°, and ST was changed from 24.0° to 32.1°, SVA was changed from 6.23 cm to 2.40 cm.@*CONCLUSION@#For the different pathological features and deformities of senile osteoporotic thoracolumbar fracture combined with kyphosis, SPO, PSO or VCR can achieve good orthopedic effect and clinical efficacy.

Four-rod Technique Stabilization after Pedicle Subtraction Osteotomy (PSO) for the Treatment of Thoracolumbar Hyperkyphosis Secondary to Pott Disease: A Two-Year Follow-Up Case Report

Pedicle subtraction osteotomy (PSO) is a powerful tool for themanagement of sagittal misalignment. However, this procedure has a high rate of implant failure, particularly rod breakages. The four-rod technique diminishes this complication in the lumbar spine. The aim of the present study is to provide a case report regarding PSO and fourrod technique stabilization in the treatment of short-angle hyperkyphosis in the thoracolumbar (TL) junction. The authors describe the case of a patient with TL hyperkyphosis secondary to spinal tuberculosis treated with L1 PSO and fixation with a four-rod technique. There were no major surgical complications. The self-reported quality of life questionnaires (the Short-Form Health Survey 36 [SF-36] and the Oswestry disability index) and radiological parameters were assessed preoperatively, as well as 6, 12 and 24 months after surgery, and they showed considerable and sustained improvements in pain control and quality of life. No hardware failure was observed at the two-year follow-up.

A Review of Complications and Outcomes following Vertebral Column Resection in Adults

The correction of rigid spinal deformities in adult patients can require a three-column osteotomy (pedicle subtraction osteotomy [PSO] or vertebral column resection [VCR]) to obtain spinal balance. Unfortunately, the existing adult deformity literature frequently reports the outcomes and complications of these procedures together even though VCR is a more extensive procedure with potentially higher rates of complications. We sought to address this shortcoming and provide clinicians with an overview of the existing literature regarding VCR in adult patients. The goals of this review are: to determine the rate of overall and neurologic complications following VCR, the rate of complications with VCR compared to PSO, and the impact of VCR on clinical and radiographic outcomes. An electronic literature search was used to identify studies reporting outcomes or complications following VCR in adult patients. Raw data on patient demographics, case information, radiographic outcomes, complications and clinical outcomes were extracted. Data were pooled to report a rate of overall complications and neurologic complications. A pooled relative risk of complications following PSO vs. VCR was also calculated. Eleven retrospective studies (Level IV) met our inclusion criteria. The overall rate of complications was 69.2%. The reoperation rate was 9.6%. The rate of neurologic complications was 13.3% (range, 6.3% to 15.8%) with most cases being transient. The rate of permanent neurologic deficits was 2.0%. We found a significantly higher rate of all complications with VCR compared to PSO (relative risk, 1.36; 95% confidence interval, 1.24-1.49; p<0.001). All studies reporting clinical outcomes showed significant improvements in functional outcome postoperatively.

Surgical Outcomes of Post-Fusion Lumbar Flatback Deformity with Sagittal Imbalance

OBJECTIVES: To review surgical results of post-fusion lumbar flatback treated with pedicle subtraction osteotomy (PSO) or Smith-Petersen osteotomies (SPOs). METHODS: Twenty-eight patients underwent osteotomies. Radiological outcomes by sagittal vertical axis (SVA), and pelvic tilt (PT), T1 pelvic angle (T1PA), and pelvic incidence (PI)-lumbar lordosis (LL) at preoperative, postoperative 1 month, and final were evaluated. Oswestry Disability Index (ODI), visual analog scale (VAS) score of back pain/leg pain, and Scoliosis Research Society-22 score (SRS-22r) were analyzed and compared. Patients were divided into 2 groups (SVA ≤5 cm : normal, SVA >5 cm : positive) at final and compared outcomes. RESULTS: Nineteen patients (68%) had PSO and the other 9 patients had SPOs with anterior lumbar interbody fusions (ALIFs) (Mean age : 65 years, follow-up : 31 months). The PT, PI-LL, SVA, T1PA were significantly improved at 1 month and at final (p0.05). Common reoperations were early 4 proximal junctional failures (14%) and late four rod fractures. CONCLUSION: Our results demonstrate that PSO and SPOs with ALIFs at the lower lumbar are significantly improves sagittal balance. For maintenance of normal SVA, PI-LL might be made negative value and T1PA might be less than 11° even though positive SVA group was also significantly improved clinical outcomes.

PEDICLE SUBTRACTION OSTEOTOMY ASSISTED WITH ANTERIOR COLUMN RECONSTRUCTION FOR TREATMENT OF CHRONIC OSTEOPOROTIC VERTEBRAL COMPRESSION FRACTURE / 中国修复重建外科杂志

OBJECTIVE: To evaluate the effectiveness of pedicle subtraction osteotomy (PSO) assisted with anterior column reconstruction in the treatment of chronic osteoporotic vertebral compression fracture (OVCF). METHODS: Between January 2008 and October 2014, 11 cases of chronic OVCF were treated. There were 2 males and 9 females, aged 65-76 years (mean, 72.3 years). The vertebral compression fracture segment involved T11 in 2 cases, T12 in 2 cases, L1 in 4 cases, L2 in 2 cases, and L3 in 1 case. At preoperation, the Oswestry disability index (ODI) score was 31.1±10.2; kyphosis Cobb angle of fractured vertebrae was (36.5±10.2)° on the lateral X-ray films of the spine; and distance between C7 plumb vertical line (C7 PL) and sagittal vertical axis (SVA) of the S1 superior border was (5.2±2.5) cm. Six cases had spinal cord injury (SCI), including 4 cases of Frankel grade C and 2 cases of grade D. At last follow-up, ODI score, kyphosis Cobb angle of fractured vertebrae, and distance between C7 PL and SVA were recorded and compared with preoperative values. Postoperative Frankle scores were recorded in SCI cases. X-ray film and CT scan were taken to evaluate bone fusion at 12 months after operation. RESULTS: The operation was completed successfully without serious complications. Nerve root radiation symptoms occurred in 2 cases undergoing lumbar PSO, which was relieved after conservative treatment. Cerebrospinal fluid leakage occurred in 1 case and was cured after 2 weeks. All cases were followed up 12-24 months (mean, 15.6 months). No internal fixation failure or pseudarthrosis was found postoperatively.Screw loosening was found in 1 case (2 screws of the upper level) and titanium Cage cutting vertebral body was found in 1 case. Bone fusion was obtained in all cases at 12 months after operation. At last follow-up, ODI score was significantly improved to 13.7±5.7(t=4.417, P=0.018), kyphosis Cobb angle of fractured vertebrae to (7.0±15.2)° (t=5.113, P=0.009), and the distance between C7 PL and SVA to (2.8±2.2) cm (t=3.285, P=0.032). In 6 SCI cases, Frankle grade was recovered to E (1 case), to D (1 case), and no improvement (2 cases) from C, and to E from D (2 cases). CONCLUSIONS: PSO assisted anterior column reconstruction was an effective method in treatment of chronic OVCF.

Clinical Outcomes and Complications after Pedicle Subtraction Osteotomy for Fixed Sagittal Imbalance Patients : A Long-Term Follow-Up Data

OBJECTIVE: Clinical, radiographic, and outcomes assessments, focusing on complications, were performed in patients who underwent pedicle subtraction osteotomy (PSO) to assess correction effectiveness, fusion stability, procedural safety, neurological outcomes, complication rates, and overall patient outcomes. METHODS: We analyzed data obtained from 13 consecutive PSO-treated patients presenting with fixed sagittal imbalances from 1999 to 2006. A single spine surgeon performed all operations. The median follow-up period was 73 months (range 41-114 months). Events during perioperative course and complications were closely monitored and carefully reviewed. Radiographs were obtained and measurements were done before surgery, immediately after surgery, and at the most recent follow-up examinations. Clinical outcomes were assessed using the Oswestry Disability Index and subjective satisfaction evaluation. RESULTS: Following surgery, lumbar lordosis increased from -14.1degrees +/- 20.5degrees to -46.3degrees +/- 12.8degrees (p < 0.0001), and the C7 plumb line improved from 115 +/- 43 mm to 32 +/- 38 mm (p < 0.0001). There were 16 surgery-related complications in 8 patients; 3 intraoperative, 3 perioperative, and 10 late-onset postoperative. The prevalence of proximal junctional kyphosis (PJK) was 23% (3 of 13 patients). However, clinical outcomes were not adversely affected by PJK. Intraoperative blood loss averaged 2,984 mL. The C7 plumb line values and postoperative complications were closely correlated with clinical results. CONCLUSION: Intraoperative or postoperative complications are relatively common following PSO. Most late-onset complications in PSO patients were related to PJK and instrumentation failure. Correcting the C7 plumb line value with minimal operative complications seemed to lead to better clinical results.

Osteotomy of the Spine to Correct the Spinal Deformity

There are a number of reports on Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR). However, there are few systematic reviews of all three kinds of osteotomies. Literature review and author's experience of SPO, PSO and VCR osteotomy will be described. Various surgical techniques can be applied according to the disease entity and magnitude of the deformity. The most appropriate methods for deformity correction should be chosen and the potential complications should be considered. Before attempting an osteotomy of the spine for a spinal deformity, sufficient surgical experience and a thorough understanding of the anatomy of the spine and adjacent structures are needed. In addition, a well-organized team with the other departments is essential.

Lumbar spinal pedicle subtraction osteotomy on single segment for correction of kyphosis in ankylosing spondylitis / 中国矫形外科杂志

[Objective] To assess the outcomes of lumbar spinal pedicle subtraction osteotomy on single segment for correction of kyphosis in ankylosing spindylitis.[Methods]15 patients were treated with L2 or L3 pedicle subtraction osteotomy and internal fixation by pedicle screw system.All the patients underwent X-ray examinations in standing position before and after the operations.The angles in different part of the sagittal planes were measured and the preoperative and postoperative differences were compared.[Results]All the operations were well complete.The mean time of operations was 3h and the mean bleeding was 840 ml.The lumbar lordosis angle increase from(14.5?15.5)?to(48.4?11.9)?,the total spinal kyphosis angle and the thoracolumbar kyphosis angle improve from(36.1?14.7)?and(30.7?9.3)?to(0.2?14.2)?and(23.7?12.3)? respectively,the sacral slope increase from(12.0?12.7)?to(28.9?8.8)?,whereas thoracic kyphosis angle remained relative stable.[Conclusion]Lumbar spinal pedicle subtraction osteotomy on single segment is a satisfactory and reliable technique for correction of kyphosis in ankylosing spindylitis and the average correction of lumbar lordosis was 33.9?.

Analysis of Correction Loss after Pedicle Subtraction Osteotomy in Patients with Sagittal Imbalance: Radiologic Aspects / 대한정형외과학회잡지

PURPOSE: To validate the surgical principles by analyzing the cause of a correction loss after pedicle subtraction osteotomy in patients with a sagittal imbalance in the radiological aspects, retrospectively. MATERIALS AND METHODS: Forty cases were analyzed radiographycally according to the presence (Group A) or absence (Group B) of the lower mobile segment and anterior column support performed (Group A2) or not (Group A1), respectively. RESULTS: The overall correction loss of the total fused part appeared to increase in group A (p=0.025) and the degree of lordosis of the osteotomy site showed an almost zero correction loss in group A and B. No statistic difference of the correction loss of the upper segment of the osteotomy site between the two groups was found (p=0.138). The correction loss of the lower segment of osteotomy site increased statistically more in goup A (p=0.014). The correction loss in group A occurred more in the lower segment than in the upper segment and the correction loss of the lower segment in group A1 appeared to have a better correlation than group A2 (p=0.012). CONCLUSION: Correction loss occurs at the intervertebral disc of the mobile segment. It is considered desirable to have anterior column support to all lower segment of the osteotomy site, because the correction loss increases more in the lower segment than in the upper segment.

Comparison of Smith-Petersen Osteotomy versus Pedicle Subtraction Osteotomy for the Correction of Fixed Sagittal Imbalance / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: The purpose of this study was to compare the results between Smith-Petersen and pedicle subtraction osteotomies for fixed sagittal imbalance, and to determine the specific indications for each. LITERATURE REVIEW SUMMARY: Smith-Petersen (SPO) and pedicle subtraction osteotomies (PSO) are the techniques most commonly used to correct fixed sagittal imbalance of the spine, but there are no reports regarding the superiority of either technique. A Smith-Petersen osteotomy is an anterior opening wedge osteotomy, which hinges on the posterior edge of the intervertebral disc, while a pedicle subtraction osteotomy is a posterior closing wedge osteotomy, without distracting the anterior column, with the hinge on the anterior aspect of the vertebral body. MATERIALS AND METHODS: Thirty patients (mean age 40.1 years, range 20 ~64 years), who underwent a SPO, were compared with forty-one patients (mean age 54.5 years, range 21 ~73 years) who underwent a PSO. The SPO was carried out in more than three segments (3 SPOs) in fourteen of the SPO group. The average follow-up periods were 4.6 years, ranging from 2 to 11.5 years, and 3.8 years, ranging from 2 to 7.1 years, for the SPO and PSO groups, respectively. Patients were evaluated by standing radiographs, chart review and outcome questionnaires. RESULTS: The mean correction of the kyphotic angle at the osteotomy sites for the SPOs was 10.7 per segment, and for those with 3 SPOs and the PSO group the average total corrections were 33.0+/-9.2 and 31.7+/-9.0, respectively. However, the improvement in sagittal balance was less statistically significantly with 3 SPOs (5.5+/-4.5 cm) than with a PSO (11.2+/-7.2 cm; p<0.01). Comparing 3 SPOs to one PSO, the SPO group decompensated the patients more substantially to the concavity (p<0.02). The mean estimated blood loss (adding up all anterior and posterior surgeries) for the procedures were 1398+/-738 (1392+/-664 mL in the 3 SPO group), and 2617+/-1645 mL in the SPO and PSO groups, respectively (p<0.001; p<0.01). The total operative times for the SPO versus the PSO groups were similar, with no statistical difference. There were substantial complications in both groups, with 13 in the 30 SPO and 30 in the 41 PSO patients. In the SPO group, 1 patient had a non-union at an osteotomy site; in the PSO group, 2 patients had a non-union at an osteotomy site. The mean Oswestry score improved from 42.3+/-14.2 to 21.3+/-14.8 postoperatively at the last visit for the SPO group and, it improved from 47.9+/-15.8 preoperatively to 29.7+/-18.3 at the last visit in PSO group (p=0.35). CONCLUSIONS: When comparing 3 Smith-Petersen osteotomies to one pedicle subtraction osteotomy, the corrections of kyphosis were almost identical, but the improvement in the C7 plumb was significantly better in the PSO group. There was a significantly greater likelihood of decompensating the patient to the concavity with the 3 SPOs than with a single PSO (p<0.02). The total operative time for the SPO versus the PSO groups showed no statistical difference. However, the blood loss was substantially greater in the PSO group (p<0.001).

Comparison of Smith-Petersen Osteotomy versus Pedicle Subtraction Osteotomy for the Correction of Fixed Sagittal Imbalance / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: The purpose of this study was to compare the results between Smith-Petersen and pedicle subtraction osteotomies for fixed sagittal imbalance, and to determine the specific indications for each. LITERATURE REVIEW SUMMARY: Smith-Petersen (SPO) and pedicle subtraction osteotomies (PSO) are the techniques most commonly used to correct fixed sagittal imbalance of the spine, but there are no reports regarding the superiority of either technique. A Smith-Petersen osteotomy is an anterior opening wedge osteotomy, which hinges on the posterior edge of the intervertebral disc, while a pedicle subtraction osteotomy is a posterior closing wedge osteotomy, without distracting the anterior column, with the hinge on the anterior aspect of the vertebral body. MATERIALS AND METHODS: Thirty patients (mean age 40.1 years, range 20 ~64 years), who underwent a SPO, were compared with forty-one patients (mean age 54.5 years, range 21 ~73 years) who underwent a PSO. The SPO was carried out in more than three segments (3 SPOs) in fourteen of the SPO group. The average follow-up periods were 4.6 years, ranging from 2 to 11.5 years, and 3.8 years, ranging from 2 to 7.1 years, for the SPO and PSO groups, respectively. Patients were evaluated by standing radiographs, chart review and outcome questionnaires. RESULTS: The mean correction of the kyphotic angle at the osteotomy sites for the SPOs was 10.7 per segment, and for those with 3 SPOs and the PSO group the average total corrections were 33.0+/-9.2 and 31.7+/-9.0, respectively. However, the improvement in sagittal balance was less statistically significantly with 3 SPOs (5.5+/-4.5 cm) than with a PSO (11.2+/-7.2 cm; p<0.01). Comparing 3 SPOs to one PSO, the SPO group decompensated the patients more substantially to the concavity (p<0.02). The mean estimated blood loss (adding up all anterior and posterior surgeries) for the procedures were 1398+/-738 (1392+/-664 mL in the 3 SPO group), and 2617+/-1645 mL in the SPO and PSO groups, respectively (p<0.001; p<0.01). The total operative times for the SPO versus the PSO groups were similar, with no statistical difference. There were substantial complications in both groups, with 13 in the 30 SPO and 30 in the 41 PSO patients. In the SPO group, 1 patient had a non-union at an osteotomy site; in the PSO group, 2 patients had a non-union at an osteotomy site. The mean Oswestry score improved from 42.3+/-14.2 to 21.3+/-14.8 postoperatively at the last visit for the SPO group and, it improved from 47.9+/-15.8 preoperatively to 29.7+/-18.3 at the last visit in PSO group (p=0.35). CONCLUSIONS: When comparing 3 Smith-Petersen osteotomies to one pedicle subtraction osteotomy, the corrections of kyphosis were almost identical, but the improvement in the C7 plumb was significantly better in the PSO group. There was a significantly greater likelihood of decompensating the patient to the concavity with the 3 SPOs than with a single PSO (p<0.02). The total operative time for the SPO versus the PSO groups showed no statistical difference. However, the blood loss was substantially greater in the PSO group (p<0.001).

The Results of Pedicle Subtraction Osteotomy in Iatrogenic Flat Back Syndrome / 대한정형외과학회잡지

PURPOSE: To analyze the results of radiologic and clinical outcomes after pedicle subtraction osteotomy in iatrogenic flat back syndrome. MATERIALS AND METHODS: We reviewed 12 surgical cases of iatrogenic flat back syndrome from January 1998 to July 2001 with a follow-up of more than 12 months. All cases were females and an average age was 59.8 years (48-66 years). An average follow-up period was20.4 months (12-37 months). Initial diagnosis were as follows: lumbar degenerative kyphosis, in 5 cases; spinal stenosis, in 5 cases; spondylolisthesis, in 2 cases. For clinical evaluation, 10-point pain scale and 5-point scale for activity level, cosmesis and subjective satisfaction were used. Lumbar lordotic angles and sagittal vertical axis (SVA) were measured. RESULTS: In radiologic results, an average lumbar lordotic angle at preoperative, postoperative and the last follow-up were 5.13+/-21.69 degree, -31.33+/-16.32 degree, -27.50+/-16.73 degree respectively. And average SVA at preoperative, postoperative and the last follow-up were 8.46+/-6.04 cm, 0.62+/-2.24 cm, 2.82+/-2.81 cm respectively. In clinical results, preoperative pain (6), activity (2) and cosmesis (1.8) were improved to 3.2, 3 and 3.2respectively at the last follow-up. Subjective satisfaction was 3.9. CONCLUSION: Pedicle subtraction osteotomy seemed to be very useful surgical option for improvement of clinical results through recovering of lumbar lordotic angle and sagittal balance in cases of iatrogenic flat back syndrome.