The Extended Flexor Carpi Radialis Approach for Concurrent Carpal Tunnel Release and Volar Plate Osteosynthesis for Distal Radius Fracture.

PURPOSE: To determine the relative benefits of an extended flexor carpi radialis (FCR) (eFCR) approach with prophylactic carpal tunnel release at the time of volar plate osteosynthesis for distal radius fracture via a single incision into the traditional volar Henry (VH) approach. METHODS: This was a prospective cohort comparison of preoperative and postoperative median nerve function of 27 patients (15 eFCR and 12 VH) with unilateral, isolated distal radius fractures requiring open reduction internal fixation without preoperative acute carpal tunnel syndrome. Patients were operated on via either the eFCR or VH approach. The validated Levine-Katz Carpal Tunnel Questionnaire (symptom and functional severity scores) was administered and Semmes-Weinstein monofilament and 2-point discrimination testing were conducted preoperatively and at 6 weeks and 3 months postoperatively. Grip and pinch strength were measured at 6 weeks and 3 months. The groups were comparable in terms of age, sex, and fracture type and displacement. RESULTS: Comparing across groups, there were no statistically significant differences in any outcome measured preoperatively or postoperatively. The eFCR and VH groups demonstrated significant improvement in functional severity scores, symptom severity, and grip strength. The symptom severity score improved to statistical significance at 6 weeks in the eFCR group and at 3 months in the VH group. CONCLUSIONS: In this small comparative study, the eFCR approach was found to be safe and efficacious. There was no increased surgical morbidity, which suggests that this technique can be used safely for all patients undergoing volar plating and not just in cases of concurrent carpal tunnel syndrome. It allows easier retraction of carpal tunnel contents; therefore, it is our preferred approach.

Complex trauma to the shoulder girdle, including the proximal humerus, the clavicle, and the scapula: current concepts in diagnosis and treatment.

Fractures to the shoulder girdle are common injuries in an aging population. Many techniques and theories lie behind the treatment of such injuries. Knowledge and understanding of current concepts for diagnosing and treating proximal humeral, clavicular, and scapular fractures and the theory behind them will help surgeons make informed decisions with regard to patient care.

Results of closed management of acute dislocation after reverse shoulder arthroplasty.

BACKGROUND: Postoperative instability continues to be one of the most common complications limiting outcomes of reverse shoulder arthroplasty (RSA). The optimal management of this complication remains unknown. The purpose of this study was to evaluate the outcomes of patients with postoperative dislocation after RSA managed with closed reduction. METHODS: All patients who were treated with a closed reduction for dislocation after RSA in the period between May 2002 and September 2011 were identified and retrospectively reviewed. Final outcomes including recurrent instability, need for revision surgery, American Shoulder and Elbow Surgeons outcome score, and range of motion were evaluated. RESULTS: A total of 21 patients were identified. Nearly 50% of cases (10 of 21) had previous surgery, with 80% (8 of 10) of these being previous arthroplasty. The average time to first dislocation was 200 days, with 62% (13 of 21) occurring in the first 90 days. At average follow-up of 28 months, 62% of these shoulders remained stable (13 of 21), 29% required revision surgery (6 of 21), and 9% remained unstable (2 of 21). The average American Shoulder and Elbow Surgeons score was 68.0 for patients treated with closed reduction for instability and 62.7 for those treated with revision surgery (P = .64). DISCUSSION: This study shows that an initial dislocation episode after RSA with use of this implant can be successfully managed with closed reduction and temporary immobilization in more than half of cases. Given that outcomes after revision surgery are not different from those after closed treatment, we would continue to recommend an initial attempt at closed reduction in the office setting in all cases of postoperative RSA dislocation.

Scapholunate ligament injuries: a review of current concepts.

Injuries to the scapholunate ligament are common, especially among young active individuals. Surgeons are faced with a difficult problem because of imperfect surgical outcomes and the high demands of this patient population. Here, we review the current concepts and newest literature on scapholunate ligament injuries as well as the classification and treatment options for each stage of scapholunate instability. Emphasis is on stages in which reconstructive rather than salvage procedures can be performed. The natural history is poorly understood; it is unknown which and how many scapholunate injuries lead to wrist arthritis (SLAC wrist). Partial injuries are rare and in small studies did well with arthroscopic treatment. Complete injuries are graded based on the acuity of the injury, the presence and reducibility of scapholunate malalignment, and, finally, cartilage status. In acute injuries, anatomic repair usually leads to satisfactory results, and many authors augment the repair with a capsulodesis technique. In chronic injuries, the presence of static malalignment usually leads to inferior outcomes. Various techniques have been devised and improved over the years. These techniques appear to provide a more anatomic reconstruction, with less loss of motion; motion is 60-80 % of the contralateral side and grip strength averages 65-90 %. Once there is cartilage loss, the surgeon only has salvage procedures to choose from, tailored to the degree of arthritis.

Spontaneous posterior iliac crest regeneration enabling second bone graft harvest; a case report.

We present a case of a revision spinal fusion in which successful bone graft reharvesting was performed from the posterior iliac crest 4 years after initial intracortical harvesting. To date, only anterior iliac crest regeneration has been reported in orthopedic trauma patients. A 70-year-old man with a history of two prior instrumented lumbar fusion operations developed thoracolumbar kyphosis junctional to the lumbosacral fusion mass. His first operation was an instrumented posterolateral lumbar fusion L1 to L5, where bone graft was harvested from the right iliac crest using the intracortical harvesting technique. The second procedure was performed 18 months later and consisted of an extension of the fusion to the sacrum due to L5-S1 level derived symptoms. The bone graft for this procedure was taken with the same technique from the left iliac crest. The development of thoracolumbar junctional kyphosis necessitated the third operation, which consisted of a same-day anterior-posterior extension of the fusion to T10. Prior to this third procedure, a spinal computer tomography was performed that documented regeneration of the cancellous bone in the right iliac crest. This permitted reharvesting of almost 40 ml of cancellous bone using the intracortical bone harvesting technique from the right iliac crest. Histological analysis showed mature bone. Cancellous bone regeneration and restoration of the local anatomy of the ilium are possible after intracortical bone harvesting. This regeneration can provide autologous bone graft to assist fusion in subsequent operations.

Osteoporotic vertebral fractures and collapse with intravertebral vacuum sign (Kümmel's disease).

The intravertebral vacuum phenomenon was first described by Kümmel and is also known as delayed vertebral collapse or vertebral pseudarthrosis. Clinically, it occurs in approximately 10% of vertebral osteoporotic fractures, mainly in the thoracolumbar zone, is accentuated on extension views and associated with benign fractures. Most patients are neurologically intact, and continued pain is a common symptom that responds well to stabilization. Various theories exist in the literature about the pathogenesis; data support a combination of ischemia and psuedarthrosis. The ultimate treatment plan must be individualized and involve decompression of neurologic elements--when present--and sufficient stabilization, which varies according to surgeon preference and the patient's combordities.

Major vascular injury during anterior lumbar spinal surgery: incidence, risk factors, and management.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To examine the incidence of major vascular injury during anterior lumbar spinal surgery, attempt to identify predisposing risk factors, and to discuss management techniques. SUMMARY OF BACKGROUND DATA: Major vascular injury can be a catastrophic complication of anterior lumbar spinal surgery. METHODS: Current procedural terminology codes were used to identify the occurrence of major vascular injury, defined as injury to the iliac vessels, vena cava, and aorta. Once identified, the office record, hospital chart, operative note, and diagnostic test results were reviewed in detail. RESULTS: Three hundred forty-five operations were performed on 338 patients. Incidence of major vascular complication was 2.9% (10 of 345). There were 9 injuries of the common iliac vein and a single aortic injury. Risk factors identified in patients with major vascular injury were current or previous osteomyelitis or discogenic infection (n = 3), previous anterior spinal surgery (n = 2), spondylolisthesis (n = 2; 1 isthmic Grade II, 1 iatrogenic Grade II), large anterior osteophyte (n = 2), transitional lumbosacral vertebra (n = 1), and anterior migration of interbody device (n = 1). Lateral venorrhaphy by suture (n = 6) and hemoclip application (n = 2) was augmented by topical agents, which constituted the sole method of repair on 1 occasion. Magnetic resonance venography demonstrated iliac vein thrombosis in 1 patient. CONCLUSION: Current or previous osteomyelitis or discogenic infection, previous anterior spinal surgery, spondylolisthesis, osteophyte formation, transitional lumbosacral vertebra and anterior migration of interbody device point to an increased risk of vascular injury during anterior lumbar spinal surgery. Careful handling of the vascular structures and liberal use of topical hemostatic agents can lead to control of hemorrhage and preservation of vascular patency. Routine postoperative surveillance for proximal deep vein thrombosis, by magnetic resonance venography of the pelvic veins and inferior vena cava, should be performed after venorrhaphy.

Correlation of end plate shape on MRI and disc degeneration in surgically treated patients with degenerative disc disease and herniated nucleus pulposus.

BACKGROUND CONTEXT: The sagittal profile of the lumbar end plates on magnetic resonance imaging (MRI) has not been investigated in patients with degenerative disc disease (DDD) or herniated nucleus pulposus (HNP). PURPOSE: To examine the shape of the end plates in patients treated surgically for a) low back pain or b) radiculopathy with HNP. Furthermore, to investigate the correlation between end plate shape and disc degeneration on the one, and end plate shape and symptoms on the other. STUDY DESIGN/SETTING: Retrospective review of charts and radiographs. METHODS: The charts, operative reports, preoperative lateral plain radiographs, and MRI scans of 178 patients (85 with low back pain and 93 with HNP) were reviewed. End plate shape was determined on midsagittal MRI cuts, disc degeneration was graded on T2 sequences, and disc height was measured on lateral plain radiographs from L1 to S1 in all patients. Student t-test and chi(2) test were used to detect significant differences and associations. RESULTS: Flat and irregular levels were most common in the lower lumbar spine. The L5/S1 segment was flat in most cases, due to a flat sacral end plate. In DDD patients, disc degeneration on MRI and plain radiographs worsened from concave to flat, to irregular levels. In HNP patients, MRI demonstrated concave levels to be less degenerated, whereas no difference was detected between flat and irregular levels. Disc height of irregular levels was well preserved in HNP patients. Comparing the two groups, flat levels were more degenerated on MRI in HNP patients. Despite similar degrees of degeneration on MRI, concave and irregular levels in DDD patients had lower disc heights. A higher frequency of symptoms was found in flat and irregular levels for both patient groups. CONCLUSIONS: The sagittal profile of end plates in the lumbar spine was described for patients with DDD on the one and HNP on the other. A higher association with symptoms was observed for flat and irregular levels in both patient groups. In DDD patients, disck degeneration on both MRI and plain radiographs increased from concave to flat, to irregular levels. In HNP patients, MRI demonstrated concave levels to be less degenerated, whereas no difference was detected between flat and irregular levels. Disc height of irregular levels was well preserved in HNP patients. Comparing the two groups of patients, flat levels were more degenerated on MRI in HNP patients. Despite similar degrees of degeneration on MRI, concave and irregular levels in DDD patients had lower disc heights. The correlation of symptoms and disc degeneration with the end plate shapes is not definitive evidence of end plate remodeling around degenerated discs. It may simply represent the higher rate of disc degeneration in the lower lumbar levels. This analysis did not provide any hints as to which degenerated discs are more likely to herniated and cause leg symptoms or cause predominantly low back pain.

Lumbar microdiscectomy under epidural anesthesia: a comparison study.

BACKGROUND CONTEXT: Lumbar microdiscectomy is most commonly performed under general anesthesia, which can be associated with several perioperative morbidities including nausea, vomiting, atelectasis, pulmonary aspiration, and prolonged post-anesthesia recovery. It is possible that fewer complications may occur if the procedure is performed under epidural anesthesia. PURPOSE: To investigate the safety and efficacy of epidural anesthesia in elective lumbar microdiscectomies. STUDY DESIGN: A prospective study evaluating the relative morbidities associated with epidural anesthesia and general anesthesia for lumbar microdiscectomy. PATIENT SAMPLE: Forty-three patients scheduled for primary lumbar microdiscectomy. Two cohorts were formed and were studied separately; one observational of all the 43 patients, and a second cohort of 17 patients who agreed to enter in the randomized trial. OUTCOME MEASURES: The clinical outcome was determined by the presence of postoperative pain, the absence of anesthesia-related complications, and the overall postoperative recovery. METHODS: This was a prospective study. With institutional review board approval, 43 consecutive patients were enrolled in the study. However, only 17 patients agreed to be randomized to receive either general or epidural anesthesia for the procedure; the remaining 26 patients selected the type of anesthesia of their preference. Recorded data for all patients included: age; total surgical time; occurrence of nausea, vomiting, atelectasis, or cardiopulmonary complication; ability to arise out of bed on the day of surgery; and the total number of inpatient hospital days. Postoperative pain and satisfaction were assessed only in the randomized cohort. RESULTS: There were a total of 43 patients, with a mean age of 38.1 years. The patients undergoing epidural anesthesia were marginally older than those undergoing general anesthesia. The epidural and general anesthetic groups were not different with respect to surgical time, pain assessed with a linear visual analogue scale, hospital stay, or the likelihood of arising out of bed on the day of surgery. There were no major cardiopulmonary complications in either group. Patients with epidural anesthesia had significantly less nausea and vomiting. CONCLUSIONS: Epidural anesthesia as an alternative to general anesthesia has shown less postoperative nausea and vomiting in lumbar microdiscectomy. Nevertheless, given the small number of patients, this study should be considered as preliminary, showing small differences in minor potential complications.

Discordantly high spinal bone mineral density values in patients with adult lumbar scoliosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: The purposes of this study were: 1) to investigate the validity of bone mineral density measurements with DEXA in patients with adult lumbar scoliosis and 2) to investigate the association between osteoporosis and adult lumbar scoliosis. SUMMARY OF BACKGROUND DATA: Osteoporosis and lumbar degenerative scoliosis are phenomena encountered with increased frequency in aging, often concurrently. It has been suggested that scoliosis predisposes to osteoporosis, but degenerative scoliosis could falsely elevate spinal bone mineral density measurements. METHODS: The feasibility of measuring Cobb's angle in DEXA scans was established in 48 surgical candidates with standing anteroposterior lumbar radiographs and supine DEXA scans. Charts and radiographs of 454 consecutive adult patients evaluated at an osteoporosis center were reviewed thereafter. The association between age, lumbar curve, and various bone density measurements was investigated. Bone density measurements between nonscoliotic and scoliotic patients with and without a history of adolescent scoliosis were compared. RESULTS: Cobb's angle on DEXA scan was measured with an error of 4 degrees and correlated highly with the plain lumbar radiographs. The prevalence of scoliosis was 9.47% in this cohort of patients. Advancing age was associated with an increase in osteoporosis in both scoliotic and nonscoliotic patients. Scoliotic patients demonstrated increased spinal bone mineral density (BMD) measurements compared with nonscoliotic patients, resulting in discrepancies between hip and spine BMD values. This discrepancy correlated with aging and curve magnitude (up to 30% for curves of 43 degrees ). Scoliotic patients demonstrated significantly lower hip BMD values than nonscoliotic. Curve magnitude did not correlate with severity of osteoporosis. CONCLUSIONS: Cobb's angle measurements on DEXA scans are reliable and comparable to conventional radiographs. Spinal BMD values are less valuable for monitoring osteoporosis than hip values in scoliotic patients; an increasing discrepancy with age was noted. Scoliotic patients exhibited discordantly high spinal BMD values, despite significant hip osteoporosis. The discrepancy correlated with aging and curve magnitude. Scoliosis was common among the osteoporotic population (9.47%). Lumbar scoliosis is a useful clinical marker for osteoporosis, irrespective of scoliosis history and magnitude. Viable alternatives for osteoporosis evaluation of adult patients with lumbar scoliosis are hip DEXA values, in conjunction with other BMD measurements.

Chronic infections of the spine: surgical indications and treatments.

UNLABELLED: Chronic vertebral osteomyelitis is a disease of substantial morbidity. Although uncommon to most spinal surgeons, the incidence of pyogenic and granulomatous spondylitis worldwide is on the rise. Although antibiotic therapy remains the initial treatment for most patients, surgical debridement with or without stabilization may be required for effective eradication of the disease. Indications for surgery in pyogenic and granulomatous osteomyelitis include the need to obtain a bacteriologic diagnosis when other methods have failed, the presence of a clinically significant abscess, an infection refractory to prolonged nonoperative treatment, cord compression with considerable neurologic deficit, and substantial deformity or spinal instability. Currently, controversy remains regarding the timing of surgery, the approach used, and the use of instrumentation. We reviewed the contemporary literature available through the Medline database, focusing on larger case series and, when existing, prospective randomized trials. The rationale for surgical treatment of the most common pathogens (eg, Mycobacterium tuberculae and Staphylococcus aureus) is reviewed. Commonly, anterior debridement with or without posterior instrumentation is used for cases of advanced disease, but more limited approaches may have a role in less severe cases or patients unable to tolerate extensive surgery. LEVEL OF EVIDENCE: Therapeutic study, level III (systematic review of level III studies). Please see the Guidelines for Authors for a complete description of levels of evidence.

Postoperative infections in interbody fusion for degenerative spinal disease.

UNLABELLED: Scant literature exists on the treatment of infection after interbody fusion. Some authors advocate removal of the interbody grafts. Salvage of the grafts was possible in 92.3% (12 of 13) of the infections in a series of 326 consecutive patients with degenerative spinal diseases treated by three surgeons. Posterior interbody fusion and posterolateral instrumented fusion was performed in 267 patients and anterior interbody fusion was done in 59 patients. Eight infections in the first group (3%) and six in the second group (10.1%) were identified. Mean followup was 18 months (range, 12-38 months). All infections were early, presenting at a mean of 18 days (range, 11-28 months). All but one infection were in the posterior wound and deep. A high number of risk factors were present in these patients. Initial treatment included wound debridement and broad spectrum antibiotics, until culture results indicated the final antibiotic regimen. Infection recurred as osteomyelitis in one patient with multiple previous surgeries and anterior/posterior fusion. This was treated with removal of the posterior instrumentation and the interbody graft and extensive anterior/posterior reconstruction. Clinical outcomes were good in 10 patients, fair in two and poor in one using the Stauffer-Coventry scale. One pseudarthrosis was identified in a patient with anterior interbody fusion at final followup. Salvage of the interbody graft and retaining the instrumentation was safe in most cases in the presented series and did not adversely affect outcome. LEVEL OF EVIDENCE: Therapeutic study, level IV (case series). Please see the Guidelines for Authors for a complete description of levels of evidence.

Pott disease in the thoracolumbar spine with marked kyphosis and progressive paraplegia necessitating posterior vertebral column resection and anterior reconstruction with a cage.

STUDY DESIGN: Case report. OBJECTIVES: To report on a patient with Pott disease, progressive neurologic deficit, and severe kyphotic deformity, who had medical treatment fail and required posterior/anterior decompression with instrumented fusion. Treatment options will be discussed. SUMMARY OF BACKGROUND DATA: Tuberculous spondylitis is an increasingly common disease worldwide, with an estimated prevalence of 800,000 cases. METHODS: Surgical treatment consisting of extensive posterior decompression/instrumented fusion and 3-level posterior vertebral column resection, followed by anterior debridement/fusion with cage reconstruction. RESULTS: Neurologic improvement at 6-month follow-up (Frankel B to Frankel D), with evidence of radiographic fusion. CONCLUSIONS: A 70-year-old patient with progressive Pott paraplegia and severe kyphotic deformity, for whom medical treatment failed is presented. A posterior vertebral column resection, multiple level posterior decompression, and instrumented fusion, followed by an anterior interbody fusion with cage was used to decompress the spinal cord, restore sagittal alignment, and debride the infection. At 6-month follow-up, the patient obtained excellent pain relief, correction of deformity, elimination of the tuberculous foci, and significant recovery of neurologic function.