Occiput-to-Pelvis Spinal Arthrodesis: A Case Series.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To describe the indications, operative course, and outcomes in eight pediatric patients who underwent occiput-to-pelvis (O-P) spinal arthrodesis. SUMMARY: Spinal arthrodesis from the occiput to pelvis is needed for some children with extensive spine deformity. There are few reports of patients with O-P arthrodesis. METHODS: We reviewed records of pediatric patients who underwent spinal arthrodesis to treat spine deformity between 1987 and 2017 at one institution. Eight patients (six girls) who underwent staged O-P arthrodesis were identified. Underlying conditions, indications for surgery, medical comorbidities, operative courses, complications, and imaging of these patients were recorded. RESULTS: Diagnoses were neuromuscular disorders in five patients and syndromic disorders in three patients. Mean ages were 9.7 ± 4.1 years at index surgery and 16.8 ± 4.6 years at completion of O-P arthrodesis. Patients underwent a mean of three operations (range, two to five). Occipitocervical arthrodesis was the final operation in six of eight patients (all but the two patients with Loeys-Dietz syndrome). Mean follow-up after the last procedure was 8.5 ± 7.1 years. Two patients underwent revision for protruding occipital implants, and one patient underwent revision for thoracic pseudarthrosis. No patients developed postoperative infections or new neurologic deficits. At final follow-up, Scoliosis Research Society-22r questionnaire scores were lowest for Function (2.6 ± 1.0 of 5 possible points) and highest for Satisfaction (4.1 ± 1.4). CONCLUSIONS: O-P arthrodesis can benefit patients with extensive spine deformity from neuromuscular or syndromic causes. Patients were young at first operation, which may suggest that younger patients are at higher risk than older patients of major progression of deformity in other spinal regions after deformity correction. Health-related quality of life and radiographic outcomes suggest that patients who underwent O-P arthrodesis had satisfactory outcomes and maintenance of correction during a mean of 8.5 years of follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Systemic lidocaine fails to improve postoperative morphine consumption, postoperative recovery and quality of life in patients undergoing posterior spinal arthrodesis. A double-blind, randomized, placebo-controlled trial.

BACKGROUND.: It is inconclusive whether the perioperative administration of systemic lidocaine provides effective postoperative analgesia and enhances recovery in major orthopaedic surgery. We hypothesised that in adolescent and adult patients undergoing posterior spinal arthrodesis, a perioperative lidocaine infusion would reduce opioid requirements during the first 24 postoperative h. METHODS.: 70 patients undergoing posterior arthrodesis were enrolled in this prospective, randomised, double-blind, placebo-controlled clinical trial. Patients received total i.v. anaesthesia with propofol and remifentanil and were randomized to an adjuvant therapy with either lidocaine [i.v.-bolus injection of 1.5 mg kg -1 at induction of anaesthesia, followed by an infusion of 1.5 mg kg -1 h -1 which was continued until six h after arrival at the post-anaesthesia care unit] or placebo (equal volumes of saline). Postoperative pain was treated with patient-controlled i.v. morphine. Primary endpoints of this study were morphine requirements in the first postoperative 24 h. RESULTS.: Systemic lidocaine did not decrease morphine requirements in the first 24 postoperative h [lidocaine-group: 48 (23) mg (mean( sd )) vs placebo-group: 51(19) mg, P = 0.22]. Likewise, groups were not different with respect to the severity of postoperative pain, morphine consumption after 48 and 72 h, incidence of postoperative nausea and vomiting, perioperative inflammation, time to recovery of intestinal function, hospital length of stay, and quality of life (assessed preoperatively and one month postoperatively using the SF-12 physical and mental composite scores). CONCLUSIONS.: In our study, systemic lidocaine had no analgesic benefits in posterior arthrodesis when added to an opioid-based anaesthetic regimen. CLINICAL TRIAL REGISTRATION.: Eudra CT 2012-005264-98.

Patient satisfaction and function after bilateral ankle arthrodeses.

BACKGROUND: The optimum way to manage patients with bilateral ankle arthritis (AA) is unclear. METHODS: This review was performed to report the midterm satisfaction and functional outcome of a series of patients who have undergone bilateral staged ankle arthrodesis. RESULTS: Eight patients, median age 68.5 yrs (range 59-80) were followed-up for a median of 58.5 months (range 24-100). All fusions united in a median time of 12.8 weeks (range 10-19) Their median AOFAS hindfoot score was 79.5 (range 71-90). Six patients (75%) were very satisfied, one was satisfied, and the other neither satisfied nor dissatisfied. Two patients developed symptomatic subtalar arthritis requiring subtalar fusion. CONCLUSIONS: This is the first study to report the outcome of bilateral AA independent to that of unilateral AA. Bilateral AA appears to give patients a good functional result with high patient reported satisfaction into the medium term.

[Clinical functional assessment of various surgical hand arthrodesis techniques]. / Klinisch-funktionelle Nachuntersuchung verschiedener handchirurgischer Versteifungsmethoden.

BACKGROUND: Total and partial arthrodesis of the wrist are currently sophisticated treatment options for many advanced pathological changes of the wrist. This retrospective study analyzed the subjective and objective outcome of different wrist arthrodesis techniques, e.g. total wrist arthrodesis, scaphotrapeziotrapezoid (STT) bone fusion and midcarpal arthrodesis. MATERIALS AND METHODS: Subjective physical and mental quality of life of 98 patients (total wrist arthrodesis n = 43, STT fusion n = 30 and midcarpal arthrodesis n = 25) was measured using the DASH questionnaire. The range of motion and grip strength were analyzed in 48 patients (total wrist arthrodesis n = 21, STT fusion n = 17 and midcarpal arthrodesis n = 10). RESULTS: Patients with partial wrist arthrodesis achieved a significantly better DASH score than patients with total wrist arthrodesis. Grip strength did not show any statistically significant differences between the two groups. Patients with STT fusion showed the best range of motion of the wrist. CONCLUSION: Partial arthrodesis seems to be superior to total wrist arthrodesis. Patients profit from a higher physical and mental quality of life.

Comparative study of the quality of life between arthrodesis and total arthroplasty substitution of the ankle.

Our goal was to compare the health status of patients with primary and secondary arthrosis of the ankle before and after arthrodesis or total substitution arthroplasty, and to determine the improvement in quality of life and whether there is any difference between these techniques. A prospective comparative study of clinical-functional evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) scale and quality of life with the short form (SF)-36 questionnaire in patients who underwent arthrodesis (16 cases) or total substitution arthroplasty of the ankle (14 cases) after 2 years (mean, 25.2 months) of follow-up after surgery, in comparison with the baseline preoperative status. In this series of comparable patients, both techniques showed a statistically significant improvement with regard to the clinical evaluation and quality of life after 2 years of follow-up; the arthrodesis group increased from mean AOFAS values of 37.12 to 45.62 (P = .055) and mean SF-36 values of 32.96 to 46.25 (P = .008), whereas in the arthroplasty group the mean values of AOFAS increased from 33 to 62 (P = .024) and SF-36 from 33.62 to 59.84 (P = .001). Nevertheless, in all cases the improvement was statistically greater in patients who underwent arthroplasty than in those who underwent arthrodesis (P = .048 for AOFAS, and P = .026 for SF-36). In conclusion, arthrodesis and arthroplasty represent good options in the surgical treatment of ankle arthrosis, providing both a significant improvement in function and in the health perception and quality of life of the patient. New-generation total ankle substitution arthroplasty provides an improvement in the quality of life and perception of general health of the patient with arthrosis of this joint, when this technique is compared with surgical fusion.

Health-related quality of life after posterolateral lumbar arthrodesis in patients seventy-five years of age and older.

STUDY DESIGN: Retrospective cohort analysis of prospectively collected data. OBJECTIVE: The purpose of this study is to report health-related quality of life (HRQOL) outcomes in patients 75 years of age and older who underwent one- to two-level instrumented posterolateral lumbar arthrodesis. SUMMARY OF BACKGROUND DATA: HRQOL measures are increasingly used to measure clinical success after spinal surgery. There is limited data available to guide the clinician caring for the growing geriatric population with degenerative lumbar spine conditions. METHODS: From a database of prospectively collected HRQOL measures in patients undergoing instrumented lumbar arthrodesis, we identified 35 patients 75 years of age and older who underwent one- or two-level instrumented posterolateral lumbar arthrodesis who had complete preoperative and 2-year postoperative data. HRQOL measures included the Oswestry Disability Index (ODI), Short Form-36 Physical Component Score (PCS) and Mental Component Score (MCS), and back and leg pain numerical rating scales. Paired sample t tests were used to compare preoperative and 2-year postoperative scores. The percentage of patients reaching previously established thresholds for Minimum Clinically Important Difference (MCID) and Substantial Clinical Benefit (SCB) were calculated. RESULTS: There were 11 men and 24 women with a mean age of 78.3 years (range 75-85). Diagnoses included stenosis (20), spondylolisthesis (12), instability (1), disc pathology (1), and scoliosis (1). Twelve patients (34%) had complications, 8 (23%) major and 4 (11%) minor. There was a statistically significant improvement in all of the HRQOL measures from preoperative to 2-years postoperative. Sixty percent (21 of 35) of the patients reached the MCID threshold for ODI, PCS, and leg pain, whereas 83% (29 of 35) reached the MCID for back pain. More than half of the patients reached the SCB threshold for leg pain (19 of 35, 54%), back pain (21 of 35, 60%), ODI (19 of 35, 54%), and PCS (21 of 35, 60%). CONCLUSIONS: Properly selected patients 75 years of age and older can achieve substantial clinical improvements, based on patient reported HRQOL measures, 2 years after one- and two-level instrumented posterolateral lumbar arthrodesis.

Trial pinning prior to wrist arthrodesis in children.

The purpose of this investigation was to assess the utility of trial wrist pinning as an assessment tool prior to wrist arthrodesis in the paediatric patient. Ten paediatric patients who were unable to decide if a wrist arthrodesis would be beneficial to them underwent a trial wrist pinning (using temporary K-wires) in neutral posture for an average of 28 days. The etiology of wrist pathology varied. The utility of the trial pining in decision-making was assessed through chart review and telephone conversation. All patients felt the trial pinning facilitated their decision. Two of the 10 patients declined wrist arthrodesis secondary to difficulty with daily activities. Eight patients who underwent wrist arthrodesis were satisfied with wrist position and function. Temporary wrist pinning is an effective informational tool for patients, families and physicians, allowing a true assessment of wrist function prior to definitive wrist arthrodesis.

Role of first ray hypermobility in the outcome of the Hohmann and the Lapidus procedure. A prospective, randomized trial involving one hundred and one feet.

BACKGROUND: The role of hypermobility of the first tarsometatarsal joint in the etiology of hallux valgus deformity is controversial. Consequently, the need to include an arthrodesis of this joint in the surgical treatment of hallux valgus has been questioned. We designed a study to evaluate the role of arthrodesis of the first tarsometatarsal joint on the outcome of surgical treatment of hallux valgus. METHODS: A prospective, blinded, randomized study was performed to compare the results of a distal osteotomy of the first metatarsal (the Hohmann procedure) with those of an arthrodesis of the first tarsometatarsal joint combined with a soft-tissue procedure of the first metatarsophalangeal joint (the Lapidus procedure) for correction of a symptomatic hallux valgus deformity. One hundred and one feet of eighty-seven patients were included in the study. Fifty feet had a Hohmann procedure, and fifty-one had a Lapidus procedure. The mobility of the first tarsometatarsal joint was assessed in the preoperative clinical examination. On the basis of this examination, two subgroups were identified: sixty-eight feet with a hypermobile first tarsometatarsal joint and thirty-three feet with a nonhypermobile first tarsometatarsal joint. The patients were assessed clinically and radiographically at two years after the operation. RESULTS: There was a significant improvement in the score on the great toe metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and Ankle Society and in the pain score following both procedures (p < 0.001). With the numbers available, no significant difference between the two procedures or between the subgroups of feet with a hypermobile first tarsometatarsal joint and those with a nonhypermobile joint could be identified. The patient satisfaction rating did not differ either between the two procedures or between the two subgroups. The radiographic results of the two methods were also similar, except for shortening of the first metatarsal, which was significantly greater (p < 0.001) in the Hohmann group, and plantar flexion of the first metatarsal, which was greater in the Lapidus group. CONCLUSIONS: These short-term results were satisfactory and were comparable with those in previous isolated reports on these two procedures. As no significant differences between the two procedures or between the two subgroups (feet with a hypermobile first tarsometatarsal joint and those with a nonhypermobile joint) were found on clinical assessment, the theory that patients with hallux valgus and a hypermobile first tarsometatarsal joint should be managed with a Lapidus procedure was not supported. LEVEL OF EVIDENCE: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

Midfoot and hindfoot arthrodeses in diabetic Charcot arthropathy.

OBJECTIVES: To review the clinical outcome of arthrodesis of the foot in patients with diabetic Charcot arthropathy and to review the pathophysiology, clinical and radiographic features of Charcot arthropathy. DESIGN: A retrospective review and clinical follow-up of a series of patients. SETTING: St. Michael's Hospital, Toronto, a tertiary care teaching hospital. PATIENTS: Ten diabetic patients treated between 1996 and 1998 who required an arthrodesis of the midfoot or hindfoot secondary to deformity of diabetic neuropathic joints. INTERVENTIONS: Three midfoot (Lisfranc) and 7 hindfoot arthrodeses with autogenous iliac-crest bone grafting and internal fixation. OUTCOME MEASURES: Patient satisfaction, maintenance of the correction of the deformity and avoidance of amputation. Western Ontario/McMaster University score and midfoot/hindfoot American Orthopaedic Foot and Ankle Society foot ratios. Clinical examination including E-MED pedographic examination. Correction and evidence of bony or fibrous union assessed radiologically. RESULTS: The postoperative correction was maintained, no further skin ulceration occurred and amputation was avoided in 9 of 10 patients. Because this is a salvage procedure and there was often significant concomitant illness, the results of clinical rating systems were poor. Five of 9 patients had clinical and radiographic evidence of a solid bony arthrodesis; 4 had a stable fibrous union. CONCLUSIONS: With careful surgical technique, a reasonable number of feet can be salvaged by an arthrodesis of a diabetic neuropathic joint when nonoperative measures fail. Patient selection is important because there is a significant complication rate.

Rigid internal fixation for shoulder arthrodesis.

Fifteen patients underwent a shoulder arthrodesis utilizing standard dynamic compression plate fixation, but with limited postoperative immobilization with only an abduction pillow. In each case, the position of the extremity relative to the scapula and trunk was recorded immediately postoperatively, at regular intervals until fusion, and at follow-up evaluations. Thirteen of 15 shoulders fused without change of intraoperative position after an average postoperative period of 4 months. One patient lost position in the early postoperative period secondary to inadequate fixation, but subsequently fused. Another who demonstrated a persistent non-union at 2 1/2 years was subsequently explored and underwent a bone graft. Four patients complained of residual symptomatic hardware, with two requiring surgical removal of the plate and screws. All but one patient were satisfied with the clinical result at follow up. Only two patients were within 5 degrees of the preoperatively determined position of 30 degrees abduction, 30 degrees forward flexion, and 30 degrees internal rotation. However, almost all were able to function satisfactorily. The authors concluded that shoulder arthrodesis utilizing rigid internal fixation without postoperative cast or brace immobilization maximizes patient comfort without compromising the success of arthrodesis. However, control of arm position remains inexact and additional modifications are needed to ensure fusion position and to minimize disability.

Function after amputation, arthrodesis, or arthroplasty for tumors about the knee.

We studied the function of twenty-two patients who had had a malignant skeletal tumor adjacent to the knee. An above-the-knee amputation was done in seven; a resection arthrodesis, in nine; and a replacement arthroplasty, in six. The patients all walked at a similar speed (sixty-one to sixty-six meters per minute), which is slower than normal (eighty meters per minute). They all walked with comparable efficiency at three velocities: the mean consumption of oxygen was 0.210 milliliter per kilogram of body weight per meter at free velocity, 0.215 milliliter per kilogram of body weight per meter when they walked 25 per cent faster, and 0.211 to 0.240 milliliter per kilogram of body weight per meter when they walked 50 per cent faster. The three groups of patients and a normal control group consumed oxygen at similar rates. The patients who had had an amputation were very active, and they were the least worried about damaging the affected limb, but they had difficulty walking on steep, rough, or slippery surfaces. The patients who had had an arthrodesis had a more stable limb and performed the most demanding physical work and recreational activities, but they had difficulty sitting. The patients who had had an arthroplasty led sedentary lives and were the most protective of the limb, but they were the least self-conscious about the limb.

[Arthrodesis of the wrist in cases of hand paralysis (personal technique)]. / L'arthrodèse du poignet dans les paralysies de la main (technique personnelle).

Arthrodesis of the wrist in cases of paralysis of the upper limb, although rejected by certain authors, is a valid operation provided it is confined to certain indications such as paralyses requiring minimal muscle transfers. Arthrodesis of the wrist is particularly useful in the sequelae of brachial plexus lesions with dissociated paralysis and in total paralysis of the radial nerve with hand drop and preservation of the wrist flexors. Numerous techniques of arthrodesis have been proposed. Over the last 27 years, the authors use a technique with a direct dorsal incision. The first row of carpal bones and the radius are roughened with chisel. A cortico-cancellus graft is then raised from the dorsal surface of the radius, leaving a distal cortical bridge. The graft is slid under this bridge, placed onto the roughened surface of the carpus and pushed under the operculum raised at the base of the 2nd and 3rd metacarpals. The arthrodesis is fixed with two Kirschner pins and a plaster for 3 months. We have used this technique in 31 patients with nerve paralyses since 1971 and have obtained complete consolidation with total patient satisfaction in all but one case.