What Constitutes Shoulder Imbalance in Adolescent Idiopathic Scoliosis? Aesthetic Threshold for Surgical Correction.

OBJECTIVE: To determine what constitutes clinical shoulder imbalance and the aesthetic unsightliness of the torso region in patients with scoliosis. How can it be measured? Shoulder imbalance is one of the most perplexing problems in scoliosis. There are no standard clinical or radiologic criteria for diagnosing shoulder imbalance, and hence its impact and prevention are poorly understood. This prospective cohort study aims to determine the clinical parameters in the torso region that are most aesthetically disfiguring in scoliosis, and the measures with their threshold values that can define shoulder imbalance. METHODS: Twenty-six consecutive patients with adolescent idiopathic scoliosis formed the patient cohort. Only preoperative clinical photographs (not x-rays) of these patients were used for the study. Forty random observers were asked to rate the shoulder disfigurement in these patients as acceptable or unacceptable. An independent researcher plotted and measured 10 different deformity markers on these photographs. Three regions of the torso, the neck, shoulder, and axillary region, were studied separately. Receiver operating characteristic analysis was used to determine significance of each measure. RESULTS: The patients with unacceptable deformation had statistically significant values in each of the 3 regions. The patients with acceptable appearance also had several measures that proved significant. Threshold values for each of these parameters were established from the analysis. CONCLUSIONS: Shoulder imbalance in scoliosis is defined based on 3 regions: the neck, shoulder, and axillary region. Each has a specific threshold for producing cosmetically unacceptable deformation and they can be measured on clinical photographs. Measurement of the shoulder level alone is less representative.

Single-stage deformity correction in children with neurogenic kyphoscoliosis: nuances and a proposal for risk stratification.

OBJECTIVE Neurogenic kyphoscoliosis in pediatric patients has varied causes and diverse management options. The most common management strategy is to stage the orthopedic and neurosurgical aspects of the correction at an interval of 3-6 months from each other. The aim of this study was to report the authors' experience with correction of deformity in children with associated neurological abnormalities requiring intervention as a single-stage surgical treatment. METHODS Of 591 pediatric patients with scoliosis treated at the Amrita Institute of Medical Sciences and Research Centre between January 2001 and January 2011, the authors identified all patients with neurogenic kyphoscoliosis who underwent deformity correction and a neurosurgical procedure in the same surgical session when they were younger than 15 years. Data regarding the demographic details, preoperative Cobb angle/kyphotic angle, surgical details, postoperative complications, cost of the procedure, and long-term neurological outcome were collected for each case and analyzed. Based on the results of this analysis, the authors propose a 2-category risk stratification system for the timing of deformity correction depending on the primary neurogenic etiology. RESULTS Ten cases involving patients with neurogenic kyphoscoliosis requiring both deformity correction and neurosurgical procedure met the criteria and were included in the analysis. All 10 patients were younger than 15 years; their mean age was 10.8 years. The average Cobb angle was 59.5°. Five patients underwent foramen magnum decompression, 5 patients underwent spinal cord detethering, and 1 patient had intraspinal intradural tumor excision. The mean estimated blood loss was 1177 ml (range 700-1550 ml), and the mean operative time was 4.4 hours (range 3-5.5 hours). There were no intraoperative complications. None of the patients had any new postoperative neurological deficits. The mean postoperative Cobb angle of the main thoracic curve was 12.6°. CONCLUSIONS Simultaneous deformity correction along with a definitive neurosurgical procedure in patients with neurogenic kyphoscoliosis can be performed without added morbidity and avoids both the added costs and the risk of complications associated with a second surgery. The risk stratification system proposed in this paper may serve as a guideline for case selection and help to optimize outcome.

Axial Plane Deformity of the Shoulder in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To study axial plane deformation of the shoulder in adolescent idiopathic scoliosis (AIS) and try to correlate it with curve type and surgical correction. SUMMARY OF BACKGROUND DATA: It is established that AIS is a 3-dimensional deformity. The rib hump is the most common manifestation of axial plane deformations; the least common manifestation seems to be upper trunk and shoulder rotation, which has been hitherto undescribed. METHODS: Fourteen consecutive, operated cases of AIS were analyzed prospectively. Preoperative and postoperative x-rays of the spine and clinical photographs were studied. Clinical photographs (top view) were taken with patients in the sitting position, to show shoulder level in relation to the axis of the head and pelvis. Chest computed tomography scans were also studied to determine the direction of apical vertebra and trunk torsion. RESULTS: All 14 patients in this series had their right shoulders anteriorly rotated preoperatively (anticlockwise). The direction of rotation seemed unrelated to the curve type and shoulder elevation, although most had rib humps on the right. This shoulder rotation was corrected postoperatively by routine maneuvers done for scoliosis correction. Minor residual rotation was seen in 6 patients who also had minimal persisting rib hump. In 1 case the axial plane rotation worsened, although the shoulder level and trunk symmetry improved significantly. The apical vertebral rotation on computed tomography had little bearing on the direction of shoulder rotation. CONCLUSIONS: Axial plane rotation of the shoulder is a hitherto un-described dimension of AIS deformity complex. Much of it corrects spontaneously with correction of the thoracic spinal deformity.

Post-operative shoulder imbalance in adolescent idiopathic scoliosis: a study of clinical photographs.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To assess what features determine post-operative shoulder asymmetry in Adolescent Idiopathic Scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Shoulder balance is one of the major determinants of the cosmetic outcomes of AIS surgery. Yet, other than level of the shoulders we are not clear what parameters are to be measured to assess torso symmetry. This study looks at the various features that might affect the appearance of the shoulder region. METHODS: The records of 157 operated cases of AIS were retrospectively reviewed. Eight patients with documented post-operative shoulder asymmetry and were dissatisfied with their cosmetic outcomes were selected for the study. Their clinical photographs alone were studied. Three regions- the base of the neck, the shoulder and upper arm region- were analysed separately. Four measures each for the neck and shoulder and two for the arms were documented. No statistical tools were employed since the numbers were quite small but consensus was obtained between two Consultant Orthopaedic surgeons regarding the cosmetic impact of each parameter. RESULTS: The neck and the shoulder appeared independent determinants of cosmesis of the proximal trunk. The base of neck symmetry seemed to be dependent on four features viz. centralization of the neck, neck tilt, trapezius angle and base of neck angle. The appearance of the shoulder itself depended on its level, axillary fold level, scapular level and the scapular prominence. The upper arm parameters appeared less critical in determining the cosmetic impact. CONCLUSIONS: Proximal trunk symmetry in AIS depends on the symmetry of the base of the neck and shoulder regions. The level of the shoulders, axillary folds along with the base of neck angle, Trapezius angle appear to be key determinants of symmetry.

Patterns of shoulder imbalance in adolescent idiopathic scoliosis: a retrospective observational study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To study the relationship between the proximal spine and shoulder levels in adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: It has been frequently observed that the shoulder levels do not correspond to the spinal curve direction in AIS. MATERIALS AND METHODS: Eighty-five operated cases of AIS were analyzed retrospectively of which 69 were Lenke type I and II curves. Preoperative anteroposterior standing x-rays of the spine and clinical photographs were studied. T1 tilt and intercoracoid line (ICL) tilt and their mutual relationship were documented. The curve type (Lenke), magnitude, and direction of the proximal and main thoracic (PT and MT) curves were also noted. RESULTS: The shoulder level as depicted by the ICL showed 3 patterns-horizontal, left side elevated, or right side elevated. The T1-ICL relationship was either concordant or discordant. In the concordant case the T1 was tilted to the same side as the ICL; and vice versa in the discordant. The shoulder level was dependent on the MT curve if the ICL tilted to the same side as the MT curve and it was dependent on the PT curve if it tilted to the same side as the PT curve. This relationship appeared unrelated to curve type. CONCLUSIONS: Preoperative shoulder levels in AIS may be concordant with the T1 or discordant-each can have left or right shoulder elevation or balanced shoulders. Further, the shoulder might be MT dependent or PT dependent. Theoretically therefore, surgical balancing of the shoulder and upper instrumented vertebra placement should not depend only on the magnitude and stiffness of the PT curve.

Bilateral pathological dislocation of the hip secondary to tuberculous arthritis following disseminated tuberculosis: a case report and review of the literature.

Pathological dislocation of the hip has been reported as a complication in various hip disorders. Several pathomechanisms including capsular laxity, synovial hypertrophy, and acetabular and proximal femur destruction have been described. We report a case of bilateral pathological dislocation of the hip in a 6-year-old girl secondary to tuberculous arthritis following disseminated tuberculosis, which we managed operatively. At the 18-month follow-up, the child had a clinically stable left hip despite radiological subluxation. Bilateral pathological dislocation of the hip associated with tuberculous arthritis is a rare condition and has never been reported in the literature.

Role of ultrasonography and magnetic resonance imaging in the diagnosis of intramuscular cysticercosis.

OBJECTIVES: Nonspecific clinical presentations often lead to misdiagnosis of focal cysticercal myositis. This report emphasizes the role of ultrasonography and magnetic resonance imaging (MRI) in the diagnosis of solitary intramuscular cysticercosis. MATERIALS AND METHODS: Six patients with persistent post-traumatic isolated muscular swelling were treated with analgesic and antibiotics, but the swelling did not subside. Radiographs showed soft tissue swelling with no bony abnormalities. Laboratory markers were inconclusive. Ultrasonographic and magnetic resonance images (MRI) showed typical features of intramuscular cysticercosis. Clinical, radiological, and fundoscopic evaluation of brain and eyes could not isolate any cysticercosis focus in these organs. Patients were treated with 3 weeks albendazole therapy. RESULTS: The identifying sonographic features of intramuscular cysticercosis, as evident from this case series, included an intramuscular elliptical or oval anechoic lesion with echogenic intralesional focus likely to be scolex. Magnetic resonance images showed orientation of the cyst along the direction of muscle fibers with T2W hyperintense signal and post-contrast perilesional enhancement. All patients responded to medical treatment. CONCLUSION: Cysticercosis may manifest as isolated muscular swelling without neurological or ocular involvement. Clinicians should be aware of this clinical condition to avoid misdiagnosis. Ultrasonography and magnetic resonance imaging are good diagnostic aids to establish soft tissue cysticercosis.

Osteosynthesis of femoral-neck nonunion with angle blade plate and autogenous fibular graft.

PURPOSE: Revision internal fixation for femoral-neck nonunion is a challenging procedure. Treatment options are osteotomy, osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularised or nonvascularised fibular graft) or arthroplasty. The objective of this article is to report the outcome of revision internal fixation using an angle blade plate and autogenous fibular graft in symptomatic aseptic femoral-neck nonunion. METHODS: Twenty-two patients who had been treated previously with cannulated screws or dynamic hip screw for femoral-neck fracture and progressed to nonunion were treated with revision internal fixation using an angle blade plate and autogenous nonvascularised fibular graft. Mean patient age was 38 (range 21-52) years, with average duration between injury and revision surgery 11.2m (range 8-16 months). RESULTS: Other than one nonunion, we achieved union in all patients (21 patients, 91%) after an average period of 4.4 months. The functional outcome after 3.2 years as per scoring system given by Nagi et al.. showed excellent results in four, good in ten, fair in six and poor in two patients. Patients with poor results included one with nonunion and other with avascular necrosis with collapse of the femoral head. Average limb shortening was 1.5 cm, and mean femoral-neck-shaft angle was 116°. There was no instance of fibular graft fracture, slippage or implant cut-through. CONCLUSION: Angle blade plate provides rigid stability and offloads any shearing force over the fibular graft when used for revision internal fixation in aseptic femoral-neck nonunion. Thus, the fibular graft only serves the purpose of osteogenesis and stimulates the surrounding host cells to promote healing at the nonunion site. We recommend the angle blade plate and autogenous fibular graft as a viable option for hip-joint salvage in revision internal fixation of aseptic femoral-neck nonunion.

Giant osteochondroma of axis in a child with multiple hereditary exostoses: case report and review of literature.

Though osteochondromas are the most common benign bone tumour, their spinal involvement is less frequent. We report a case of osteochondroma in a 5-year-old female child with multiple hereditary exostoses that originated from posterior elements of C2 vertebra, not involving spinal canal and caused restriction of neck movement. It was excised from its base without disturbing the continuity of lamina. Two years later she had normal neck movements without any recurrence. The rarity of this tumour at this location, with such a large size at an early age, makes this article unique.

Simultaneous bilateral anterior shoulder dislocation: report of two cases and review of the literature.

Bilateral shoulder dislocations are rare and almost always occur in the posterior direction. Simultaneous bilateral anterior shoulder dislocation is even rarer and only a few cases are stated in the literature. The most interesting part of a bilateral shoulder dislocation is about its injury mechanism as a synchronous and simultaneous force is needed to result in it. In cases of epilepsy or electrocution, the mechanism is different and the forceful contractions of the selective group of muscles result in the dislocation. This article reports two cases of bilateral simultaneous anterior shoulder joint dislocation that occurred after a road side accident and after an episode of convulsion in an epileptic patient. The dislocations were diagnosed early and reduced immediately with a proper postreduction rehabilitation. During their follow-up, both patients had sa-tisfactory functional outcome. This article emphasizes on the importance of shoulder examination in road side accident victims and epileptic patients. All orthopedic surgeons and emergency physicians should be aware of such unusual possibilities to have an early diagnosis and treatment. An early reduction and appropriate rehabilitation can provide satisfactory functional outcome. This article also briefly discusses the injury mechanisms, diagnoses and treatments of bilateral shoulder dislocation as reported in the literature.

Ewing's sarcoma as second malignancy following a short latency in unilateral retinoblastoma.

Second malignancies, mostly in the form of bone sarcomas, are known to occur in hereditary retinoblastomas, which usually present with bilateral disease. Only 2 cases of Ewing's sarcoma have been reported in the literature following sporadic unilateral retinoblastoma. A 5-year-old boy presented to our hospital with Ewing's sarcoma of the right humerus (proven by biopsy and immunohistochemistry) following successful treatment of retinoblastoma of the left eye with enucleation and chemotherapy 2 years previously. He was treated with 2 cycles of chemotherapy followed by radiation therapy. At 15 months follow-up, the tumor had reduced in size and the child had a good functional outcome. The cumulative risk of second malignancies in retinoblastoma survivors is 32%. Ninety-eight percent of second malignancies occur in patients with bilateral retinoblastoma. Germ line mutations have been considered in sporadic tumors occurring bilaterally and multifocal unilateral sporadic tumors. Bone and soft tissue sarcomas are the most common second malignancies. Radiation therapy increases the risk of developing a second malignancy in the irradiated field. Unilateral retinoblastomas, which comprise the majority of retinoblastomas, are not immune from the development of second malignancies. Close follow-up of all retinoblastomas--even in the early period--can improve the outcome by facilitating the early detection and aggressive treatment of second malignancies.

Outcome of spinal decompression in Cauda Equina syndrome presenting late in developing countries: case series of 50 cases.

The purpose of this study is to find the clinical outcome of decompression of Cauda Equina presenting late in the course of disease. There were 33 males and 17 females with average age of 48 years, ranging from 25 to 85 years. All patients presented to us with a fully developed Cauda Equina syndrome (CES). All of them presented late with mean delay of 12.2 days. Time interval between bladder and bowel dysfunction and admission to hospital varied from 1 to 35 days. The average follow-up was 34.5 months, ranging from 12 to 60 months. There was no statistically significant difference in time of delay in surgery between the recovered and non-recovered group as tested by Student's t test. But there was a statistically significant positive correlation between duration taken for total recovery and delay in surgery. Anal wink as a predictor of bladder and bowel recovery also showed statistical significance, as patients with an absence had a poorer prognosis for bladder recovery. The result of surgery in CES is not as dramatic and fast as seen after routine disc surgery. Some improvement can be expected with decompression even in those patients presenting late and results are not universally poor as previously thought. The treating physicians of such patients should be aware that the recovery in this group of patients can take an exceptionally long time and hence should involve in constant reassurance and rehabilitation of the patient. Presence of anal wink is a very good predictor of bladder and bowel recovery.

Broken Kirschner or guide-wire retrieval: a report of 4 cases.

Migration of a broken wire into the hip joint or pelvis during surgery is rare, but it can cause significant complications. Retrieval can be extremely difficult and hazardous. We report 4 cases of broken Kirschner or guide wire removal around the hip joint. Two wires were inside the hip joint and two had protruded into the pelvis. The problems encountered and techniques used for retrieval are discussed.