Vertical Relationship Ratio (VRR): A High Reliability and Accuracy Radiographic Measurement for Basilar Invagination in Rheumatoid Arthritis.

BACKGROUND Previous radiographic measurements for diagnosis of a basilar invagination or impression (BI) in rheumatoid arthritis (RA) were used as reference values based on anatomical reference distances. Due to the obscured anatomical landmarks, our group proposed a new radiographic measurement based on anatomic ratios to identify BI. MATERIAL AND METHODS The vertical relationship ratio (VRR) was developed and evaluated. The VRR is the relationship between the distance obtained with the modified Ranawat method and the C3 vertebral body height. VRR was used to assess its ability to distinguish BI in 3 patient groups (28 RA with BI, 37 RA without BI, and 56 non-RA patients). The intra- and inter-observer reliability, the sensitivities, and specificities of all measurements were analyzed. The cutoff value of VRR measurement was calculated by using the receiver operating characteristic (ROC) curve. RESULTS The VRR measurement showed excellent intra- and inter-observer reliabilities. The VRR could significantly distinguish RA patients with BI from RA patients without BI. The mean VRR of RA patients with BI (1.82±0.20) was less than for the non-RA patients (2.26±0.19) and the RA patients without BI (2.24±0.19). The cutoff value of VRR from the ROC curve was below 2.025. Its sensitivity was 92.85%, specificity was 97.85%, positive predictive value was 92.86%, and negative predictive value was 97.84%. CONCLUSIONS VRR has excellent intra-/inter-observer reliability and can distinguished BI in RA patients. We recommend using VRR in preference to the other available methods for assessment and screening BI in rheumatoid arthritis.

Surgical outcome of scoliosis in patients with Marfan syndrome.

PURPOSE: To evaluate clinical and radiographic outcomes after surgical scoliosis correction and posterior instrumented fusion in SMF patients. METHODS: A single-center medical database was reviewed to identify MF patients who presented with scoliosis from 2000 to 2015. Patients who underwent spinal fusion surgery were included. Demographic, operative and clinical data were reviewed, and the preoperative, postoperative, and latest follow-up radiographic parameters were compared. RESULTS: Twelve patients were identified (2 males, 10 females) with an average age at surgery of 14.4 ± 2.6 years. Comorbidities were found in 84.6%. Most patients (90.9%) presented with a right thoracic curve. The average preoperative Cobb angle was 75.6 ± 15.5 degrees. Posterior instrumented spinal fusion was performed in all patients (1 hook/pedicular screw and 11 pedicle screws only). The average follow-up period was 6.8 ± 3.1 years. The mean postoperative Cobb angle after surgery and at the final follow-up was 33.4 ± 18.0 degrees and 35.5 ± 18.4 degrees, respectively. There was a statistically significant difference among the preoperative and postoperative Cobb angles (p < 0.001), but no significant difference among the sagittal angles. Two perioperative complications including superficial wound infection and broken rods were observed. CONCLUSIONS: Posterior scoliosis correction and instrumented spinal fusion resulted in a satisfactory outcome in MF patients. Perioperative complications are not uncommon; however, no neurological complication or spinal decompensation was observed in this study. LEVEL OF EVIDENCE: IV.

Evaluation of the Effectiveness of Preoperative Blood Ordering Guideline in Elective Spine, Knee Replacement, and Hip Replacement Surgery.

Background: Preoperative blood ordering is necessary in most of the major orthopedic operations. However, over-crossmatching 200 units/day results in technician workload and compromises blood stock for other patients at Siriraj Hospital. Objective: To evaluate the effectiveness of a new blood ordering guideline in spine and arthroplasty surgery at Siriraj Hospital by comparing the quantity of blood ordering between pre-guideline and guideline groups. Material and Method: The guideline was developed from data of 456 patients who underwent spine or arthroplasty surgery between January 2013 and December 2013 at Siriraj Hospital. To evaluate the effectiveness of the guideline, blood order, and use in 89 patients who received specific orthopedic surgical procedures between December 2014 and March 2015 were compared to blood order and use in pre-guideline patients. Results: Five hundred forty five patients were included. Mean age of subjects was 58 years and 71.49% were females. Mean cross-matched units between the pre-guideline group (1.81 units; 95% CI 1.70 to 1.92) and the guideline group (1.34 units; 95% CI 1.13 to 1.55) was significantly different (p<0.001). Conclusion: The blood ordering guideline does increase effectiveness of preoperative blood reservation, reduce unnecessary cost, and does not compromise patient safety. Consistent use and frequent evaluation of this guideline are encouraged.

The outcomes of combined posterior instrumentation and anterior radical debridement with fusion for multilevel spinal tuberculosis.

BACKGROUND: Aside from antituberculous drugs, anterior radical debridement with fusion has been recommended to eradicate the infectious foci and promote early bone healing in spinal tubercular patients. The addition of spinal instrumentation to stabilize the spine and restore physiologic alignment has also been proposed. OBJECTIVE: This study was undertaken to evaluate the effectiveness of the combined posterior instrumentation and anterior spinal fusion procedure. MATERIAL AND METHOD: Eleven consecutive patients who were diagnosed with tubercular spondylosis involving more than one vertebral level and who received combined posterior instrumentation and anterior spinal fusion were reviewed. The number of vertebrae involved was three levels in four patients and two levels in seven patients. There were 8 one-stage and 3 two-stage procedures. The mean follow-up time was 16 months (range 7-33). Patients were evaluated before and after surgery for kyphotic correction, fusion formation, and neurological status. RESULTS: The average pre-operative, immediate postoperative, and last follow-up kyphotic angles were 40, 19, and 23 degrees, respectively. All patients obtained solid bony fusion, except for one who had partial graft dislodgment. There was no serious complication, such as neurological injury or deep wound infection. CONCLUSION: Posterior instrumentation and anterior interbody fusion was effective in the management of multilevel spinal tuberculosis, as this procedure can effectively eradicate disease, provide bony fusion, correct deformity and prevent the progression of kyphosis.

Incidence of symptomatic pulmonary embolism in spinal surgery.

BACKGROUND: Pulmonary embolism (PE) is a serious condition in orthopedic surgery. The incidence of PE, which is a sequelae of VTE in spinal surgery, is quite low. In the limited available published data, incidence rates of PE in spinal surgery are comparable to that of hip or knee arthroplasty surgery. The role of pharmacologic thomboprophylaxis remains controversial in spinal surgery. OBJECTIVE: The present study was designed to evaluate the incidence of symptomatic pulmonary embolism in spinal surgery at a single tertiary care institute. MATERIAL AND METHOD: A retrospective study of the medical records of patients that were diagnosed with symptomatic pulmonary embolism in spinal surgery from 2002-2012. The reviewed data were retrieved from the database of the Faculty of Medicine Siriraj Hospital, Mahidol University in Bangkok, Thailand. RESULTS: Three cases of symptomatic pulmonary embolism were found from 9,184 spinal surgery cases. The incidence rate was 0.033%. There were two patients with lumbar spine surgery and one case with thoracolumnbar surgery. All three cases had different underlying conditions, operations, and clinical course. One case of fatal pulmonary embolism was found in our study. CONCLUSION: Although there is a very low incidence of symptomatic pulmonary embolism, this is a catastrophic condition for affected patients and their families. PE can occur in spinal surgery cases at all levels of severity and complexity, even with no apparent risk factors.

Atlantoaxial transarticular screw fixation and posterior fusion using polyester cable: a 10-year experience.

PURPOSE: To retrospective review the clinical outcomes of the modified operative technique using a polyester suture material (Ethibond* Excel) for atlantoaxial transarticular screw fixation and posterior fusion. METHODS: The retrospective reviews were conducted from 2002 to 2012. The patient's medical record reviews included demographic data, cause of atlantoaxial instability, orthopedic and surgical history, clinical presentation, radiographic finding including plain radiography, complications, operative detail, and outcome of treatment. Fusion of C1-C2 was defined as either graft consolidation or absence of C1-C2 movement on lateral flexion-extension radiograph. RESULTS: Twenty-three patients demonstrated clinical and radiographic evidence of atlantoaxial instability (13 men and 10 women, with a mean age of 42 years). Majority of atlantoaxial instability was caused by trauma. Most common clinical symptom was neck pain with or without cervical myelopathy. Bilateral screws were placed in 18 of the 23 patients. Five patients underwent placement of unilateral screws. The 13 patients were inserted by screws with diameter 4.0 mm. The means screw length was 40.33 mm. The means of operative time and estimated blood loss were 3.6 h and 234 ml, respectively. The mean of follow-up duration was 18 months. All 41 screws were positioned satisfactorily in C1 lateral mass. All 23 patients achieved fusion (100% fusion rate). After a period of follow-up, 9 of the 10 neurological deficit patients had completely recovered. CONCLUSIONS: We concluded that the atlantoaxial transarticular screw fixation and posterior fusion using polyester cable can be used for C1-2 fusion with a high fusion rate and less complications in various cases.

The surgical treatment of the osteoporotic vertebral compression fracture in the elderly patients with the spinal instrumentation.

The study was to present the results of the surgical treatment using the spinal instrumentation toe resolve the osteoporotic vertebral compression fracture in the elderly patients having the clinical symptoms of pain and the neurological compromise. Sixty elderly patients who underwent the surgical treatment of the osteoporotic vertebral compression fracture were retrospectively reviewed. Their average age was 72 years; the range was 60-90. The average follow-up period for these patients was 4.2 years; the range was 3-7. Twenty-four patients were performed by the posterior stabilization enhanced by the pedicle screws and rods with the transpedicular bone grafting. Thirty-two patients were performed by the anterior corpectomy with the interbody fusion and the anterior spinal instrumentation. Four patients were performed by two-step surgical treatment: firstly the posterior stabilization enhanced by pedicle screws and rods, and finally, the anterior corpectomy with the interbody fusion. The sagittal Cobb angle and the back pain were improved in all patients. The neurological deficits were improved in 14 patients out of the 16 patients. Twelve patients had the post operative complications: late implants loosening in 5 patients, subcutaneous wound infections in 4 patients, painful neuromas at thoracic cage in 2 patients and incisional hernia in one patient. Although the surgical treatment with spinal implants in the osteoporotic compression fracture was performed in the selected patients, the complication rate was still high, i.e. twenty percent. All of them, nevertheless, were not the mortal complications. The anterior column support could maintain the sagittal alignment better than the posterior spinal fusion alone in the long-term follow up period while the VAS of pain was improved in the similar results.

Repair of full-thickness cartilage defects in rabbit knees with free periosteal graft preincubated with transforming growth factor.

This study compared different concentrations of transforming growth factor-beta 1 (TGF-beta1) used for short-term preincubation in vitro of large periosteal explants to determine the effect of chondrogenesis and the fate of repair cartilage over time. Eighty-two rabbits were divided into four groups: group A, non-grafted; group B, non-incubated grafted; group C, 100 ng/mL recombinant human (rh) TGF-beta1 preincubated grafted; and group D, 20 ng/mL rhTGF-beta1 preincubated grafted. Rabbits from each group were sacrificed at intervals between 2 and 24 weeks. Histologic slides were stained with safranin O and were scored based on a subjective scoring system. Group A healed with non-cartilaginous material. Group B healed with hyaline cartilage-like material with progressive thinning of this regenerated layer; at 24 weeks, this layer was fibrous tissue. Group C enhanced repair with hyaline cartilage-like material but accelerated early degeneration and osteophyte formation; the cartilage became fibrous tissue at 24 weeks. Group D did not enhance cartilaginous repair. At 24 weeks, all groups had the same result. The 100 ng/mL rhTGF-beta1 preincubation in vitro with periosteum enhanced early osteochondral repair but did not show prolonged durability. Clinical application of this growth factor necessitates further study.