Effect of Severity of Deformity on Clinical Outcomes of Scarf Osteotomies.

BACKGROUND: Literature is sparse on whether severity of hallux valgus affects outcomes of surgery. We thus aimed to evaluate the impact of hallux valgus severity on the clinical outcomes of surgery. METHODS: 83 consecutive scarf osteotomies performed by a single surgeon for symptomatic hallux valgus between 2007 and 2011 were divided into 3 groups (mild, moderate, and severe) based on severity of their preoperative hallux valgus using the hallux valgus and intermetatarsal angles. Outcomes were assessed using the visual analog scale (VAS) for pain, 36-Item Short Form Health Survey physical functioning (SFPF) and mental health (SFMH) subscales, and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores. These were assessed preoperatively and at 6 months and 2 years postoperatively. Patient satisfaction was assessed at 6 months and 2 years postoperatively. Eleven (13.2%), 54 (65.1%), and 18 (21.7%) feet were in the mild, moderate, and severe groups, respectively. RESULTS: There was no difference in preoperative VAS, SFPF, SFMH and AOFAS scores between the groups except for AOFAS scores for the second toe, which were poorer with increasing hallux valgus. Postoperatively, there was improvement across all outcome scores. VAS and AOFAS showed excellent scores, and patient satisfaction was high across all 3 groups (88.9%, 89.4%, and 86.7%). The severe group had slightly lower SFPF scores at 6 months (mild, 81.1; moderate, 84.0; severe, 74.3; P = .031) and 2 years postoperatively (mild, 93.4; moderate, 89.7; severe, 76.4; P = .005), and slightly poorer second toe scores for VAS (mild, 0.0; moderate, 0.1; severe, 1.2; P = .017) and AOFAS (mild, 94.7; moderate, 93.5; severe, 83.4; P = .043) at 2 years postoperatively. All other scores including patient satisfaction showed no between-group differences. Complication and revision rates between the groups were similar. CONCLUSION: Surgery for symptomatic hallux valgus lead to excellent outcomes and high patient satisfaction regardless of severity of deformity. LEVEL OF EVIDENCE: Level III, comparative series.

Enoxaparin: A cause of postoperative fever?

Enoxaparin (clexane) is a low-molecular-weight heparin commonly prescribed for the chemoprophylaxis of venous thromboembolism in postoperative hip or knee replacement or abdominal surgery patients. We herein report a case of persistent postoperative fever in a patient, likely due to enoxaparin use. Prompt resolution of the patient's fever was observed after discontinuation of subcutaneous enoxaparin for chemical thromboprophylaxis. Reliable incidence data are lacking. A comprehensive search of PubMed, MEDLINE and EMBASE databases, as well as grey literature, found only two prior single case reports on enoxaparin-related fever. The mechanism responsible for the febrile reaction is likely an idiosyncratic response. Enoxaparin is typically derived from bovine or porcine intestines and lungs, hence its potential to cause hypersensitivity reactions is perhaps unsurprising. Clinicians should be alert to this possibility.

Preoperative Anemia, Functional Outcomes, and Quality of Life After Hip Fracture Surgery.

OBJECTIVES: To determine whether preoperative anemia, perioperative blood transfusion, and predischarge anemia affect function and health-related quality of life (HRQoL) after hip fracture surgery. DESIGN: Retrospective single-center cohort study PARTICIPANTS: Individuals undergoing traumatic hip fracture surgery from 2012 to 2016 (N=973). MEASUREMENTS: Demographic data, Charlson Comorbidity Index, preoperative hemoglobin level, perioperative blood transfusion, predischarge hemoglobin level, type of surgery (replacement or fixation). Anemia was divided into quintiles at 10.0, 11.0, 12.0, and 13.0 g/dL. Baseline, 6-week, and 6-month Harris Hip Scale (HHS), Parker Mobility Scale (PMS), and Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) scores were obtained. PMS; HHS and SF-36 role physical (RP), physical function (PF), and social functioning (SF) domains had more than 20% change from baseline to 6 weeks and from 6 weeks to 6 months. Univariate and multivariate analyses were conducted to examine the association between preoperative anemia, transfusion and predischarge anemia on 6-month scores. RESULTS: On univariate analysis, preoperative hemoglobin less than 10.0 g/dL was associated with lower baseline prefall PMS, PF, RP, and SF scores. Predischarge anemia did not affect 6-month scores. On multivariate analysis, preoperative anemia (hemoglobin <10.0 g/dL) was associated with lower 6-month HHS, PMS, PF, and RP scores, whereas transfusion was not significant. CONCLUSION: Preoperative anemia (hemoglobin <10.0 g/dL) is associated with poorer physical function and HRQoL after hip fracture surgery. Perioperative blood transfusion and predischarge anemia had no effect.

Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years.

BACKGROUND: A previously published study found positive outcomes for a novel technique for ultrasound-guided percutaneous ultrasonic tenotomy, showing good tolerability, safety, and early efficacy within an office setting. PURPOSE: In this follow-up study, all 20 members of the original cohort were contacted after 3 years to explore the sustainability of symptomatic relief, functional improvement, and sonographic soft tissue response for percutaneous ultrasonic tenotomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All 20 subjects of the clinical trial that was performed from June to November 2011 were further assessed at 36 months after the procedure in terms of visual analog scale for pain, Disabilities of the Arm, Shoulder and Hand (DASH)-Compulsory/Work scores, need for adjunct procedures, and overall satisfaction. Importantly, all 20 were reassessed with ultrasound imaging at 36 months, and evidence of the common extensor tendon response was assessed in terms of tendon hypervascularity, tendon thickness, and the progress of the hypoechoic scar tissue. RESULTS: A 100% clinical follow-up was achieved, inclusive of ultrasonographic assessment. None of the subjects required further treatment procedures, and 100% expressed satisfaction. Previous improvements in visual analog scale (current median ± SD, 0 ± 0.9; range, 0-3) and DASH-Work scores (current median, 0 ± 0) were sustained with conformity to a linear pattern on polynomial measures. There was further reduction in DASH-Compulsory scores to a median of 0 ± 0.644 (range, 0-2) with a significant decrease on repeated measures (P = .008). Tendon hypervascularity was resolved in 94% of patients, and 100% had reduction in tendon thickness. Overall reduction in the hypoechoic scar tissue was observed in all subjects, with a 90% response achieved by 6 months. Between 6 and 36 months, further reduction in the scar was observed in around 60% of patients, with 20% of patients having complete resolution of the hypoechoic scar. CONCLUSION: Minimally invasive percutaneous ultrasonic tenotomy provided sustained pain relief and functional improvement for recalcitrant tennis elbow at 3-year follow-up. It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy.

Spontaneous disruption of the bilateral knee extensor mechanism: a report of two cases.

Spontaneous disruption of the knee extensor mechanism is associated with systemic diseases, steroid usage, and repeated microtrauma. Early repair or reconstruction is imperative for optimal outcome. We report 2 cases of spontaneous disruption of the bilateral knee extensor mechanism. The first patient had connective tissue disease and long-term steroid use. She had acute-on-chronic spontaneous bilateral patellar tendon rupture. She underwent reconstruction with an allograft and defunctioning wire. The second patient had end-stage renal failure with tertiary hyperparathyroidism and was on haemodialysis. He had a right patellar tendon rupture and a left quadriceps tendon rupture. He underwent primary repair of both tendons. Postoperatively, both patients followed a strict physiotherapy regimen and achieved good functional outcome.

Restoring Sesamoid Position in Scarf Osteotomy: A Learning Curve.

Incomplete reduction of the sesamoid is a known risk factor for recurrence of the deformity after scarf osteotomy for correction of hallux valgus. The purpose of the present study was to determine whether a learning curve exists for successfully restoring the sesamoid position in scarf osteotomy. We reviewed 71 consecutive cases (71 feet) of scarf osteotomy performed on female patients during a 2.5-year period by the same surgeon. The cases were divided into 3 groups according to the date of surgery, with the first 24 cases assigned to group 1, the next 24 to group 2, and the last 23 to group 3. We compared the median sesamoid position of the 3 groups at 6 weeks postoperatively and patient reported satisfaction at 6 months postoperatively. The sesamoid position ranged from 1 to 7, using the Hardy and Clapham classification system. The median sesamoid position for all patients had improved from 7 preoperatively to 2 postoperatively. The postoperative sesamoid position was significantly better for the second and third groups than for the first (p < .05), and 92% of the patients were satisfied with the procedure. We have concluded that a learning curve to optimally restoring the position of the sesamoid in scarf osteotomy is present and that this has a direct effect on reducing the risk of recurrence of the deformity.

Does Navigation Improve Accuracy of Placement of Pedicle Screws in Single-level Lumbar Degenerative Spondylolisthesis?: A Comparison Between Free-hand and Three-dimensional O-Arm Navigation Techniques.

STUDY DESIGN: This was a prospective, nonrandomized study. OBJECTIVES: To assess the accuracy of O-arm navigation-based pedicle screw insertion in lumbar degenerative spondylolisthesis and to compare it with free-hand pedicle screw insertion technique in matched population. SUMMARY OF BACKGROUND DATA: O-arm navigation is latest in navigation technology that can provide real-time intraoperative images in 3 dimensions while placing the pedicle screws to improve intraoperative pedicle screw accuracy. Degenerative lumbar spondylolisthesis is a locally unstable pathology and placement of pedicle screws can cause increased rotation and translation of the vertebral body. However, is this motion detected by the tracker placed across the unstable segment, is a matter of debate. Inability to detect these positional changes can lead to pedicle perforation while inserting screws using navigation. No study has evaluated the role of O-arm navigation in this patient population. MATERIALS AND METHODS: The study population was divided into 2 groups with 19 patients each, one comprising patients who underwent O-arm navigation-based pedicle screw insertion (group 1) and the other comprising patients who underwent free-hand pedicle screw insertion technique (group 2). A total of 152 pedicle screws were implanted in 38 patients for 1-level instrumented fusion for degenerative lumbar spondylolisthesis. Intraoperative 3-dimensional computed tomography scans using the O-arm were obtained for all patients after insertion of pedicle screws. The images were reviewed intraoperatively and postoperatively for the analysis of pedicle breaches. Assessments in either of the group included (i) accuracy of placement of screws; (ii) the rate and direction of perforation; and (iii) the number of segments the perforated screw was away from the navigation tracker. RESULTS: Mean age of patients in group 1 (O-arm navigation-assisted) was 60 years (SD 11.25; range, 37-73 y), whereas in group 2 (free-hand pedicle screw) was 62 years (SD 18.07; range, 36-90 y). Overall anatomic perforation rate was 12.5% (19/152). Individually, group 1 had 14.47% (11/76) of perforations in comparison with 10.53% (8/76) observed in group 2. The difference was not statistically significant. The lateral margin was the most common site of perforation in both group 1 (64%, 7/11) and group 2 (62.5%, 5/8). Functional perforation rate for the series was 3.3% (5/152), with group 1 having 2.63% (2/76) and group 2 having 3.95% (3/76). The rate of perforation (PR) was significantly higher statistically when the tracker was placed 3 or more [PR 37.5% (6/16)] spinal segments away from instrumented segment compared with when it was placed 1 (0%) or 2 [PR 13.89% (5/36)] spinal segments away. Overall, 11 screws (11/152, 7.24%) had grade 2 perforations and had to be revised. No neurological complications were observed in the series. CONCLUSIONS: O-arm navigation does not provide any significant advantage over conventional free-hand pedicle screw insertion technique in patients with single-level degenerative spondylolisthesis. The accuracy is dependent on the distance of the tracker from the level of instrumentation. Lateral perforations are more common because of instability at the instrumented level leading to translation and rotation of the vertebral body while placing pedicle screws leading to preferential lateral trajectory. These lateral perforations could not be prevented by using navigation. However, no significant complications were noted in either technique.

Risk factors for recurrence of giant cell tumours of bone.

PURPOSE: To determine the risk factors for recurrence of giant cell tumours (GCTs) of bone. METHODS: Medical records of 29 men and 29 women (mean age, 34 years) treated for primary (n=53) or recurrent (n=5) GCTs of bone and followed up for a mean of 40.2 months were reviewed. The tumours were located in the distal femur (n=18), proximal tibia (n=10), proximal femur (n=8), distal radius (n=7), proximal fibula (n=4), distal ulna (n=3), calcaneum (n=3), sacrum (n=2), vertebra (n=1), metatarsal (n=1), and distal humerus (n=1). 26 patients had pathological fractures, 12 had cortical break, and 20 had neither. The Campanacci grades of the tumours were I (n=1), II (n=18), and III (n=33); the grades of the remaining 6 tumours were unknown because radiographs were unavailable. The Enneking stages of the tumours were 1 (n=51), 2 (n=6), and 3 (n=1). Treatment included curettage and cementation (n=29), curettage, cementation, and adjuvant treatment with distilled water or liquid nitrogen for bones without fracture (n=18), wide resection for extensive soft tissue involvement (n=9), and amputation (n=2) for a recurrent GCT of the distal femur and a primary GCT of the calcaneus. Reconstruction included cementation (n=27), bone grafting (n=7), cementation/bone grafting with internal fixation (n=14), reconstruction with endoprosthesis (n=3), and none (n=7). RESULTS: 19 patients had recurrence after a mean of 23.1 months. The overall recurrence-free survival at years 1, 2, and 3 were 86%, 79%, and 72%, respectively. Recurrence did not correlate with patient age (p=0.20), primary or recurrent tumour at presentation (p=0.12), Campanacci grade (p=0.10), Enneking stage (p=0.54), or presence of pathological fracture (p=0.28). Compared to GCTs at other locations, GCTs in the proximal tibia were more likely to recur (27% vs. 60%, p=0.04). CONCLUSION: GCTs of the proximal tibia are more likely to recur than those at other locations.

Five-year outcomes of minimally invasive versus open transforaminal lumbar interbody fusion: a matched-pair comparison study.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To compare midterm clinical and radiological outcomes of minimally invasive surgery (MIS) versus open transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA: Open TLIF is a proven technique to achieve fusion in symptomatic spinal deformities and instabilities. The possible advantages of MIS TLIF include reduced blood loss, less pain, and shorter hospitalization. To date, there is no published data comparing their midterm outcomes. METHODS: From 2004-2007, 40 cases of open TLIF were matched paired with 40 cases of MIS TLIF for age, sex, body mass index, and the levels on which the spine was operated. Oswestry Disability Index, neurogenic symptom score, the 36-Item Short Form Health Survey, and visual analogue scale scores for back and leg pain were obtained before surgery, 6 months, 2 years, and 5 years after surgery. Fusion rates were assessed using Bridwell classification. RESULTS: Fluoroscopic time (MIS: 55.2 s, open: 16.4 s, P < 0.001) was longer in MIS cases. Operative time (MIS: 185 min, open: 166 min, P = 0.085) was not significantly longer in MIS cases. MIS had less blood loss (127 mL) versus open (405 mL, P < 0.001) procedures. Morphine use for MIS cases (8.5 mg) was less compared with open (24.2 mg, P = 0.006). Patients who underwent MIS (1.5 d) ambulated earlier than those who underwent open fusion (3 d, P < 0.001). Patients who underwent MIS (3.6 d) had shorter hospitalization than those who underwent open fusion (5.9 d, P < 0.001). Both groups showed significant improvement in Oswestry Disability Index, neurogenic symptom score, back and leg pain, SF-36 scores at 6 months until 5 years with no significant differences between them. Grade 1 fusion was achieved in 97.5% of both groups at 5 years. The overall complication rate was 20% for the open group and 15% for MIS group (P = 0.774), including 4 cases of adjacent segment disease for each group. CONCLUSION: MIS TLIF is comparable with open TLIF in terms of midterm clinical outcomes and fusion rates with the additional benefits of less initial postoperative pain, less blood loss, earlier rehabilitation, and shorter hospitalization.

Accuracy of core needle biopsy for musculoskeletal tumours.

PURPOSE: To evaluate the sensitivity and specificity of core needle biopsy in determining musculoskeletal tumours in our hospital. METHODS: Records of 134 patients who underwent core needle biopsy followed by definitive surgery were retrospectively reviewed. Results of the core needle biopsy were compared with those of the final histology. Histology was classified into benign versus malignant, and bony versus soft-tissue lesions. The sensitivity and specificity of core needle biopsy were calculated. RESULTS: Based on final histology, there were 33 bone tumours (3 benign and 30 malignant), 74 soft-tissue tumours (6 benign and 68 malignant), 11 schwannomas (7 benign and 4 malignant), and 16 inflammatory/necrotic (benign) lesions. For 118 (88%) tumours, the biopsy results matched the final histological results. For 7 tumours, biopsy results were non-diagnostic, as the amount of tissue obtained was insufficient. For 9 tumours, biopsy results did not match the final histological results; 5 considered benign but turned out to be malignant, one considered malignant but turned out to be benign, and 3 were correctly identified as malignant but incorrectly subtyped. The sensitivity and specificity of core needle biopsy were 95% (97/102) and 97% (31/32), respectively, assuming that the 7 non-diagnostic tumours were correctly diagnosed. CONCLUSION: Core needle biopsy is an accurate and reliable diagnostic tool for musculoskeletal tumours if performed by skilled persons and adequate tissue is obtained.

Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty.

BACKGROUND CONTEXT: Multilevel cervical myelopathy can be treated with anterior cervical discectomy and fusion (ACDF) or corpectomy via the anterior approach and laminoplasty via the posterior approach. Till date, there is no proven superior approach. PURPOSE: To elucidate any potential advantage of one approach over the other with regard to clinical midterm outcomes in this study. STUDY DESIGN: A prospective, 2-year follow-up of patients with cervical myelopathy treated with multilevel anterior cervical decompression fusion and plating and posterior laminoplasty. PATIENT SAMPLE: In total, 116 patients were studied. Sixty-four patients underwent ACDF two levels and above or anterior cervical corpectomy and fusion one level and above. Fifty-two patients underwent posterior cervical surgery (laminoplasty C3-C6 and C3-C7). OUTCOME MEASURES: Self-report measures: Japan Orthopedic Association (JOA) score, JOA recovery rate, visual analog scale for neck pain (VASNP), neck disability index (NDI), and American Academy of Orthopaedic Surgeons (AAOS) neurogenic symptom score (AAOS-NSS). Physiologic measures: range of motion (ROM) flexion and extension of neck. Functional measures: short-form 36 (SF-36) score comprising physical functioning, physical role function, bodily pain, general health, vitality, social role function, emotional role function, and mental health scales. METHODS: Comparison of the JOA scores, JOA recovery rates, NDI scores, SF-36 scores, VASNP, and ROM preoperatively to 2 years. Chi-square and two-sided Student t tests were used to analyze the variables. RESULTS: Posterior surgery took an hour shorter (p<.05) and had better improvement in JOA scores at early follow-up of 6 months (p=.025). Anterior surgery group had better improvement of NDI scores at early follow-up of 6 months (p=.024) and was associated with less blood loss intraoperatively compared with posterior surgery. There was no statistical difference between the two groups for JOA scores, JOA recovery rates, SF-36 quality-of-life scores, NDI, AAOS-NSS, VAS neck pain, and ROM at 2 years. Complications were higher for anterior surgery group: two hematoma postoperation, one vocal cord paresis, and one new onset C6/C7 dermatome numbness versus one dura leak in posterior surgery group. CONCLUSIONS: Our study showed that patients with multilevel disease treated with laminoplasty do well and compare favorably with patients treated with an anterior approach. Notably, posterior surgery was associated with shorter operating time, better improvement in JOA scores at 6 months, and a tendency toward lesser complications. Posterior surgery was not associated with increased neck disability and neck pain at 2 years. Anterior surgery had better NDI improvement at early follow-up. There is a need for a larger study that is prospectively randomized with long-term follow-up before we can confidently advocate one approach over the other in the management of cervical myelopathy.

Two-year outcome of erectile dysfunction in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression: a prospective study.

STUDY DESIGN: This is a prospective study. OBJECTIVE: A 2-year outcome of erectile dysfunction (ED) in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression for ED is evaluated. Risk factors for ED were also evaluated. SUMMARY OF BACKGROUND DATA: There is no literature documenting 2-year follow-up of ED status in young patients with atraumatic lumbar spine disease. METHODS: All male patients younger than 50 years who underwent lumbar spine surgery between June 2006 and November 2007 without risk factors for ED were included. Patient demographics, neurological dysfunction, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index, North American Spine Society score for neurogenic symptoms, and the international index of erectile function-5 scores were recorded preoperatively and at 2 years. Patients who did not complete a 2-year follow-up were excluded. RESULTS.: A total of 75 patients were eligible for the study. Nineteen patients did not complete a 2-year follow-up giving a response rate of 75%. There were 56 patients in the study with a mean age of 38.4 (SD, 7.2; range, 20-49). The most common diagnosis was prolapsed intervertebral disc (77%) for which patients underwent discectomy. Preoperatively, 21 of 56 (37.5%) patients had ED. Despite significant improvement in mean VAS scores for back pain and leg pain, Oswestry Disability Index, and North American Spine Society score for neurogenic symptoms at 2 years (P < 0.01), the mean international index of erectile function-5 scores remained stable. Patients with ED at 2 years had greater back pain (mean VAS score 3.4) compared with patients without back pain (mean VAS score, 1.6; P ≤ 0.01). CONCLUSION: Despite excellent outcome in most spine scores postoperatively after lumbar spine surgery, one has to be less optimistic about any improvement in the ED status of patients after surgery. ED is still a problem 2 years after surgery. Back pain reduction may have a significant role in dealing with ED at 2 years postoperatively. LEVEL OF EVIDENCE: 2.

Improved clinical outcomes after high-flexion total knee arthroplasty: a 5-year follow-up study.

The purpose of this study was to determine if high-flexion total knee arthroplasty resulted in improved outcomes compared with conventional total knee arthroplasty. This was a prospective, double-blind, randomized controlled trial involving 76 patients over 5 years. We compared the postoperative flexion range, Knee Society scores, Oxford knee scores, and SF-36 scores between 2 groups. The high-flexion group was able to achieve a significant sustainable increase in postoperative knee flexion angle; and this correlated to a significant improvement in the General Health, Vitality, and Physical Functioning scales of SF-36 at 5 years postoperatively. Our results signify that high-flexion total knee arthroplasty has additional benefits to the quality of life in patients who require higher degrees of knee flexion in their activities of daily living.