The Effect of Distal Fusion Level on Functional and Radiographic Parameters in Degenerative Spine Following Long Posterior Instrumentation and Fusion.

AIM: To investigate the effect of distal fusion level on radiographic parameters and functional outcome in patients with degenerative spine disease who undergo long posterior fusion with instrumentation. MATERIAL AND METHODS: This study included 78 adult patients aged > 60 years who underwent long posterior fusion ( > 6 levels) for spinal deformity with a minimum 2-year follow-up. The patients were divided into two groups based on distal fusion level (L5 group and iliac group). Spinopelvic parameters, including lumbar lordosis (LL) and sagittal vertical axis (SVA), were evaluated. Functional outcome was evaluated with the pain visual analog scale (VAS) and the Oswestry Disability Index (ODI) questionnaire. Correlations between clinical and radiographic parameters were calculated statistically. RESULTS: In the L5 group, the mean SVA and LL significantly improved after surgery (p=0.025 and 0.008, respectively). Similarly, the SVA and LL also improved significantly in the iliac group (p=0.002 and 0.001, respectively). In both groups, lumbar VAS, leg VAS and ODI scores significantly improved (p < 0.001). The change in ODI score was significantly greater in the iliac group than the L5 group (p=0.013). CONCLUSION: Although patients did not achieve the desired optimal spinal saggital balance, both L5 and iliac groups showed significant improvement in VAS and ODI scores. The iliac group showed slightly better improvement in ODI score.

Efficiency of an implant: new criterion of objective assessment of implants for osteosynthesis of femoral neck fracture.

PURPOSE: In line with several designs for osteosynthesis of femoral neck fracture (FNF), their effectiveness is still estimated by the results of biomechanical and clinical trials, finite element method (FE). But surgeons require the criteria which would define their properties in advance and allow improve the results of treatment. METHODS: When new implant (NI) is being designed, we developed such criterion - index efficiency of an implant (IEI) - and performed mathematical comparative researches of properties of NI with the known designs. We analyzed the results of comparative clinical trials on treatment of FNF with various implants considering their IEI. RESULTS: Analysis showed that results of comparative clinical trials with the use of various implants for osteosynthesis FNF completely correlated to their IEI; IEI of the NI two to three times exceeds IEI of all known designs, and the destruction percentage of a bone tissue is two to three times less when it is applied. CONCLUSION: The offered IEI can be used for designing new implants and allows improving the results of treatment of patients with FNF by optimizing the choice of implant for osteosynthesis.

Perforated H-beam implant can be used in femoral neck fracture.

This biomechanical study evaluated comparison osteosynthesis of the femoral neck fracture model by 3 cannulated screw implants and new perforated H beam implants under different loading conditions with 45 third generation right proximal femur bones. A standardized Pauwels Type 3 of the femoral neck fracture was performed in the femur models. For assessing the rigidity and strength of fixation methods, the proximal femur bones after their osteosynthesis were then mechanically tested in axial compression, and torsional and dynamic axial compression loading. To determine the structural advantage of the new implant system, perforated and nonperforated new implant systems were comparing about pull out performance. When loading the samples, photographs were taken continuously. The reference parameters were described and measured from unloaded and loaded photographs of the static and dynamic tests. There was no significant difference between stiffness values of two fixation methods under static and rotational loading. Under dynamic loading, the displacement of the superior point of femoral head at the fracture line showed a significant decrease between the new implant system and cannulated screws. Comparing the relative motion at the mid line of the fracture in femoral neck between groups, a significant increase was found in H Beam implant group. Perforated H beam implants have similar static and torsion properties with golden standard. Although there was significant difference under dynamic loading which simulate movement early after surgery, the patient was not allowed to move early after surgery in the clinical practice. Therefore, the differences due to the perforated "H" beam implant would not cause clinical insecurity. Therefore, it is assumed that the perforated "H" beam implant can be used for internal fixation as an alternative to cannulated screws in the treatment of instable femoral neck fracture.

Treatment of post-traumatic elbow deformities in children with the Ilizarov distraction osteogenesis technique.

OBJECTIVE: The present study assessed functional and radiographic outcomes of distraction osteogenesis treatment of post-traumatic elbow deformities in children. METHODS: Eight children were treated between 2008 and 2013 for post-traumatic elbow deformities using distraction osteogenesis. Mean age at time of operation was 10.9 years. Six patients had varus and 2 had valgus deformity. Magnitude of correction, fixator index, complications, carrying angle, and elbow range of motion were assessed. Functional results were graded according to protocol of Bellemore et al. RESULTS: Mean follow-up was 43 months. Mean preoperative varus deformity in 6 patients was 29.2° and valgus deformity in 2 patients was 28.5°. Preoperative flexion and extension of elbow were 123.8° and -10.6°, respectively. Mean carrying angle was 9° valgus at last follow-up. Mean flexion and extension were 134.4° and -6.0°, respectively. Change in carrying angle was statistically significant (p = 0.002). There were 2 grade 1 pin tract infections and 1 diaphyseal fracture of humerus. Functional outcome was rated excellent in 7 patients and good in 1 patient. CONCLUSION: Ilizarov distraction osteogenesis is a valuable alternative in treatment of elbow deformities in children. The surgical technique is simple and correction is adjustable. Gradual correction prevents possible neurovascular complications and minimally invasive surgery produces less scarring. Compliance of patient and family is key factor in the success of the outcome. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Can we use intraoperative femoral tunnel length measurement as a clue for proper femoral tunnel placement on coronal plane during ACL reconstruction?

INTRODUCTION: Successful anterior cruciate ligament (ACL) reconstruction is dependent on correct placement of both tibial and femoral tunnels. The purpose of this study is to investigate whether we can use intraoperative femoral tunnel length measurement to estimate the correct femoral tunnel placement on coronal plane. METHODS: This prospective study comprised 164 consecutive patients who underwent ACL reconstruction surgery. Transtibial or anteromedial portal technique is used for drilling the femoral tunnels. The length of the femoral tunnel was measured during the operation. The femoral tunnel coronal plane angle was calculated on the postoperative tunnel radiographs. A statistical comparison was made of the lengths of the tunnel, the techniques used drilling and the femoral tunnel angles. RESULTS: The far anteromedial portal was used in 81 (49%) cases and the transtibial technique in 83 (51%) cases. The mean femoral tunnel length was 42 ± 6.4 mm and the mean femoral tunnel coronal angle was 41.1° ± 11.6. The tunnel angle in the transtibial technique was determined as significantly low compared to the far anteromedial portal technique (32.6°:49.8°) and the tunnel length was significantly longer (45.8:38.1 mm) (p < 0.001). In the statistical analysis, it was found that a patient with a tunnel length of 41 mm and above had a 92.1% likelihood of femoral tunnel angle below 45°. CONCLUSION: Femoral tunnel length can be used as a clue for intraoperative evaluation of the femoral tunnel position. If the femoral tunnel length is greater than 41 mm, the coronal plane orientation of the femoral tunnel will be improper and not at a desired position.

Pigmented villonodular synovitis of the thoracic vertebra presenting with progressive spastic paraparesis.

Pigmented villonodular synovitis (PVNS) is a proliferative benign lesion originating from the synovium and commonly affects large joints of the extremities. PVNS can arise from any synovium in the whole body and rarely affects the zygapophyseal joints of the spine. Spinal PVNS is diagnosed mostly after resection of the mass. In our case we present a 22-year-old male patient showing progressive spastic paraparesis with insidious onset of back pain and difficulty of walking in a relatively short period of 1 month. After gross excision of the mass, diagnosis was established through histopathology. Two years of follow-up period reveals complete resolution of the patient's complaints and no recurrence on radiologic images.

A new technique of subtrochanteric shortening in total hip replacement for Crowe type 3 to 4 dysplasia of the hip.

A new technique of femoral fixation that uses a transverse osteotomy for subtrochanteric shortening and derotation in total hip arthroplasty for Crowe type 3 to 4 dysplasia of the hip is described. This series included 21 cases in 12 women and 2 men, with a mean age of 42.3 years. Follow-up averaged 41.2 months. Bone pegs prepared from the resected femoral segment were seated in the medullary canal around the stem for femoral fixation. Merle d'Aubigné scores for pain, motion, and walking improved from 2.9, 4.4, and 3.7 to 5.2, 5.4, and 5.5, respectively. Radiographic union was detected within 12 +/- 3.4 (range, 6-24) weeks in all cases. Complications were early dislocation in 2 cases. This technique allows correction of anteversion, provides excellent rotational stability, and eliminates the need for additional osteosynthesis regardless of the stem design.

Results of using Ilizarov distraction osteogenesis technique for the treatment of cubitus varus deformities in adults.

INTRODUCTION: Five adult patients, with posttraumatic cubitus varus deformity underwent corrective surgery by the Ilizarov method of distraction osteogenesis. METHOD: A standard technique was applied in all patients. The average follow-up was 28 (range, 24-38) months. Preoperative carrying angle ranged from 12 degrees to 22 degrees of varus (average 16.6 degrees ) and postoperative carrying angle ranged from 10 degrees to 14 degrees of valgus (average, 11.6 degrees ) equalized to the contralateral side. RESULT: The outcome was rated as excellent in all patients. No complication was observed, except a grade-2 pin-tract infection in two patients. CONCLUSION: Rigid fixation, early rehabilitation, precise correction, satisfactory cosmetic scars and functionally excellent results can be obtained with this method.

The effect of anterior spinal fusion on spinal canal development in an immature porcine model.

STUDY DESIGN: Experimental study. OBJECTIVE: To investigate whether anterior spine fusion in the immature porcine spine has an adverse effect on the development of spinal canal. SUMMARY OF BACKGROUND DATA: Neurocentral cartilage (NCC) is located in the posterior vertebral body and responsible for the development of posterior aspect of the spinal canal. Injury to the NCC interferes with the development of the spinal canal. METHODS: Twelve 8-week-old domestic pigs were used to develop an anterior fusion model. A standard procedure as L3-L4, L4-L5 discectomy, and L3-L5 anterior instrumented spine fusion was performed. To evaluate the development of the spinal canal, all subjects had computed tomography scans before the procedure and at the final follow-up. The spinal canal area was measured at the control level (CL) (L2), arthrodesis level (AL) (L4), superior (L3), and inferior (L5) instrumented level (SIL and IIL). Percent change in spinal canal area from before surgery to final follow-up was also calculated. RESULTS.: Eleven subjects were available for the study. All subjects developed local kyphosis over the fused segments. The average area of L2 (CL) was 0.56 +/- 0.06 cm before surgery. The average areas of the L3 (SIL), L4 (AL), and L5 (IIL) were 0.62, 0.70, and 0.77 cm, respectively. At the final follow-up the average area of L2 was 1.20 cm. The average areas of the SIL, AL, and IIL were 1.16, 1.19, and 1.33 cm, respectively. The percent increase in spinal canal area at the CL was 116.6% whereas it was 85.8%, 71.0%, and 71.2% at SIL, AL, and IIL, respectively. CONCLUSION: Anterior spinal arthrodesis in the immature porcine spine results in iatrogenic retardation on spinal canal growth. This effect is most likely related to the tethering effect of the interbody fusion over the NCC. Although, it is difficult to directly extrapolate these findings to clinical practice, the spine surgeons operating on pediatric patients should be aware of this possibility.

Angular shortening and delayed gradual distraction for the treatment of asymmetrical bone and soft tissue defects of tibia: a case series.

BACKGROUND: Acute shortening is reported to be an effective method for the treatment of open fractures with bone and soft tissue defects. Little is known about primary skin closure with angulation to the side of the defect and distraction at the fracture site. METHODS: We present a series of three cases treated for defective fractures of tibia by angular shortening and delayed gradual distraction with hinged circular external fixator. Two cases were type IIIB open fractures and one case was an infected nonunion. Bone and soft tissue defects were managed by adaptation of edges and primary skin closure with angulation to the side of the defect. Axial alignment was restored by gradual distraction after a 2 to 3 weeks interval. Residual limb length discrepancy was lengthened through a separate corticotomy in two cases. RESULTS: Bone formation at both the fracture and corticotomy sites were sufficient to achieve union in all patients. Fixation time averaged 261 (182-392) days and average bone healing index was 42 days/cm. No further surgical intervention was necessary for soft tissue reconstruction after primary skin closure. Infection was eradicated in the case of infected nonunion. CONCLUSIONS: Angular compression to the side of the defect is a safe and reliable method of treatment for asymmetrical bone or soft tissue defects of tibia. It eliminates the need for complex soft tissue reconstruction procedures. Unnecessary debridement of bone is prevented by angular adaptation of edges. Definitive treatment of complex injuries is possible with a circular external fixator.

Arthroscopy of the knee in pre-adolescent children.

INTRODUCTION: Arthroscopic operations performed in the pediatric age group constitute less than 5% of all arthroscopies. Diagnostic accuracy is reported to be lower than the procedures in adult patients. The incidence of pathologies also varies in the literature. We aimed at assessing the diagnostic accuracy of arthroscopy and review the incidence of pathologies in pre-adolescent patients. MATERIALS AND METHODS: In the period April 1990-January 2002, 50 pre-adolescent patients underwent knee arthroscopy after clinical and radiological assessment. Average age was 10.24 (1-13) with a male-to-female ratio of 34:16. RESULTS: Discoid lateral meniscus was found to be the most common pathology encountered in 17 cases followed by infection and synovitis in 8 cases each. Diagnostic accuracy of arthroscopy correlated with preoperative clinical and radiologic evaluation was 90%. Arthroscopy findings were negative in two cases. Two cases of plica syndrome and one case of chondral injury were mistaken for medial meniscal tear. Final diagnosis was familial Mediterranean fever in one case of synovitis and knee fusion was performed at follow-up due to progressive degenerative changes. No other patient required reoperation. CONCLUSION: Arthroscopy is a safe procedure with minor morbidity allowing treatment of various intraarticular knee disorders. Diagnostic accuracy of the procedure may increase with careful preoperative work-up.

The effect of pedicle screw placement with or without application of compression across the neurocentral cartilage on the morphology of the spinal canal and pedicle in immature pigs.

STUDY DESIGN: Experimental study. OBJECTIVES: To investigate the effects of pedicle screw insertion on spinal canal and pedicle morphology in immature pigs, and, if transpedicular fixation has an effect, to document whether this occurs because of the inhabitance of the screw inside the growth plate (neurocentral cartilage [NCC]) or because of compression applied across the NCC. SUMMARY OF BACKGROUND DATA: Transpedicular fixation has been less commonly applied to the pediatric population, especially because of the risk of damage to the NCC. METHODS: Twelve newborn pigs (4-6 weeks of age) were operated on. Left sided pedicles from L1-L5 were studied, while right sides served as controls. Pigs were randomly assigned into 3 groups: (1) pedicles were probed only; (2) screws were inserted; and (3) after screw insertion, a washer and a nut were engaged at the pedicle entry point so that gradual compression across the NCC was achieved. After 4 months, spiral computerized tomography was used to measure the pedicle lengths and size of the halves of the spinal canal. RESULTS: In group 1, the operated hemi-canal area was not statistically different from the nonoperated side (P = 0.159). Pedicle screw insertion either with (P = 0.007) or without (P = 0.005) compression resulted in smaller hemi-canal area and shorter pedicles at the operated side, respectively (P = 0.008, P = 0.021). Approximately 4% to 9% shortening of the pedicle lengths and 20% to 26% narrowing of the hemi-canal areas on the instrumented side occurred with transpedicular instrumentation (groups 2, 3). CONCLUSION: Even without compression, pedicle screws passing through the NCC in immature pigs disturb spinal canal growth significantly. Clinical relevance for young children should be studied further.

Comparison of mechanical performance among different frame configurations of the Ilizarov external fixator: experimental study.

The circular frame of the Ilizarov fixator can be modified to reflect anatomic variations and treatment aims. However, these modifications in the frame system cannot always achieve the mechanical performance of the standard frame system. A standard system has two rings in each bone fragment connected by four longitudinal bars on each side of the ring. In this study, the mechanical performances of one standard and eight modified frame systems were compared. Each system was loaded on a material testing machine, with calculation of axial compression, four-point bending, and torsion. As a result, systems that were modified with drop wires and Schanz screws 45 degrees oblique to the wires on the proximal ring provided a mechanical performance closer to the standard system than systems with other modifications.

Fractures of the femoral neck in children: long-term follow-up in 62 hip fractures.

In this retrospective study, we evaluated the characteristics of 103 femoral neck fractures in 102 children seen our department between 1978 and 1994. In order to evaluate the correlation between the chosen procedure and complication risks, we further reviewed the late treatment results of 62 fractures in 61 children of the series whom we had followed for a minimum of 8 years. The ages of these children at the time of injury ranged from 2 to 14 years (average 10.2 years). Sixty-three hips were available for clinical and radiographic follow-up at a minimum of 8 years (mean 14 years). Overall, 67.2% radiologically good results were obtained. Complications were coxa vara in five (8%), avascular necrosis in nine (14.5%), premature epiphysis fusion in five (8%), coxa valga in two (3.2%), non-union in one (1.6%), limb shortening in seven (11.3%), and arthritic changes in two (3.2%). Our long-term follow-up revealed that the type of treatment influences the complication rate more than do the characteristics of the fracture itself, and that the end result cannot be satisfactorily determined until after physeal closure.

Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases.

OBJECTIVE: To evaluate the results of bifocal compression-distraction method for the acute treatment of open tibia fractures with bone and soft-tissue loss. DESIGN: Patients were selected for bifocal compression-distraction (shortening and lengthening) who had open tibia fractures with bone and soft-tissue loss and a Mangled Extremity Severe Score of 6 and below indicating good leg viability. PATIENTS: Bifocal compression-distraction osteogenesis using the Ilizarov type circular external fixator was applied to 24 patients with 14 grade IIIA and 10 grade IIIB open tibia fractures with bone and soft-tissue loss. Mean age of the patients was 30.6 years (range 18-53). The mean bone defect was 5 cm (range 3-8.5). The mean soft tissue defect was 2.5 x 3.5 (1 x 2-10 x 5) cm. INTERVENTIONS: Acute shortening at the fracture site was done for patients with bone defects up to 3 cm to achieve apposition of bone ends. Gradual shortening at a rate of 2 mm/d was done for patients who had bone defects more than 3 cm. Leg length discrepancy was overcome by lengthening at the same time through a corticotomy at a proximal or distal level depending on fracture localization, until there was equalization of leg lengths. RESULTS: Mean follow-up period was 30 months (range 18-60). Mean bone healing time was 7.5 months (range 4-11). The mean time in external fixation was 7.1 months (range 3-10), and the average external fixator index was 1.4 months/cm. Results were evaluated using the Paley bone and functional assessment scores. The bone assessment results were excellent in 21 and good in 3 patients. Functional assessment scores were excellent in 19, good in 4, and fair in 1 patient. Pin site infections were present in 10.7% of the pin sites. There were 52 complications in 24 patients, for a complication rate per patient of 2.08. Of the complications, 48.1% were problems (minor complications), 38.5% obstacles (major complications requiring a surgical solution), and 13.4% sequelae (true complications). Minor complications included soft tissue inflammation and infection, translation/angulation, and delayed maturation during distraction and transient knee contracture and loss of motion. All grade 1 and 2 soft tissue inflammations and infections healed with nonoperative therapy. Major complications included pin tract infection and reinfection, equinus deformity, frame failure, and premature consolidation, all of which required additional surgery to correct the problem. Sequelae included leg length discrepancy, loss of knee/ankle range of motion, knee flexion contracture, malalignment, and chronic osteomyelitis. CONCLUSION: Bifocal compression-distraction osteogenesis is a safe, reliable, and largely successful method for the acute treatment of open tibia fractures with bone and soft-tissue loss. Further nonoperative or operative treatment can correct most complications.