Degenerative lumbar spondylolisthesis: cohort of 670 patients, and proposal of a new classification.

Degenerative spondylolisthesis is common in adults. No consensus is available about the analysis or surgical treatment of degenerative spondylolisthesis. In 2013, the French Society for Spine Surgery (Societe francaise de chirurgie du rachis) held a round table discussion to develop a classification system and assess the outcomes of the main surgical treatments. A multicentre study was conducted in nine centres located throughout France and Luxembourg. We established a database on a prospective cohort of 260 patients included between July 2011 and July 2012 and a retrospective cohort of 410 patients included in personal databases between 2009 and 2013. For patients in the prospective cohort clinical assessments were performed before and after surgery using the self-administered functional impact questionnaire AQS, SF12, and Oswestry Disability Index (ODI). Type of treatment and complications were recorded. Antero-posterior and lateral full-length radiographs were used to measure lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence (PI), pelvic tilt (PT), sagittal vertical axis (SVA), and percentage of vertebral slippage. Mean follow-up was 10 months. We started a randomised clinical trial comparing posterior fusion of degenerative spondylolisthesis with versus without an inter-body cage. 60 patients were included, 30 underwent 180° fusion and 30 underwent 360° fusion using an inter-body cage implanted via a transforaminal approach. We evaluated the quality of neural decompression achieved by minimally invasive fusion technique. In a subgroup of 24 patients computed tomography (CT) was performed before and after the procedure and then compared. Mean age was 67 years and 73% of degenerative spondylolisthesis were located at L4-L5 level. The many surgical procedures performed in the prospective cohort were posterior fusion (39%), posterior fusion combined with inter-body fusion (36%), dynamic stabilization (15%), anterior lumbar fusion (8%), and postero-lateral fusion without exogenous material (2%). Peri-operative complications of any severity occurred in 17% of patients. The AQS, ODI and SF12 scores were improved significantly at follow-up. We found no differences in clinical improvements across surgical procedure types. Circumferential fusion (360°) was associated with greater relief of nerve root pain and better lordosis recovery after 1 year compared to postero-lateral fusion (180°). Post-operative CT images showed effective decompression of nervous structures after minimally invasive fusion. Longer follow-up of our patients is needed to assess the stability of the results of the various surgical procedures. Based on a radiological analysis, the authors propose a new classification with five types of degenerative spondylolisthesis: type 1, SL>5° and LL>PI-10°; type 2, SL<5° and LL>PI-10°; type 3, LL25°; and type 5, sagittal imbalance with SVA>4 cm. PROOF LEVEL: IV Observational cohort study. Retrospective review of prospectively collected outcome data.

Management of massive traumatic compound defects of the foot.

The management of high-energy trauma to the foot often requires multiple tissues reconstructive procedures with various technical options. The authors report the case of a patient presenting an extensive defect of the medioplantar region of the right foot involving an almost complete (90%) medial cuneiform bone loss. A deferred operation with saphenous cross-leg flap and interposition of a cement spacer was first performed. Reconstruction of the bone defect with corticocancellous iliac bone graft was subsequently carried out at two months post-trauma. At four months follow-up, the bone and soft tissues healing were good. At 24 months follow-up, the patient could return to normal professional and sports activities. The saphenous cross-leg flap has proven to be a reliable reconstructive procedure. The use of the modified Masquelet technique ensured an anatomical reconstruction and a satisfying final functional outcome.