Intraoperative two-stage evaluation of muscle contractures in Crowe type IV hips in total hip arthroplasty (a new surgical technique).

BACKGROUND: It is important to maintain soft-tissue balance and prevent muscle contractures after hip reduction during total hip arthroplasty (THA) in patients with Crowe type IV developmental dysplasia of the hip (DDH). To make such hips functional and durable, the techniques to achieve soft-tissue balance were studied to create an algorithm for intraoperative 2-stage evaluation of muscle contractures, specifying the optimal order for contracture release. METHODS: Between February 2011 and March 2015, we evaluated 64 patients (75 hips) with DDH for muscle contractures as they underwent THA. Following acetabular implantation, femoral osteotomy was applied of various lengths according to limb-length discrepancy. First, the distal part of the femur was prepared by broaching, and the hip was then reduced. The tensor fascia lata, rectus femoris, sartorius, hamstrings, and adductor muscles were evaluated, and any contractures were released. A trial conjoining of the distal and proximal parts of the femur was made, and the hip was reduced again. Finally, the iliopsoas and abductor muscles were evaluated, and contractures were released. RESULTS: The mean follow-up duration was 4.6 years. Preoperative and postoperative Harris Hip Scores were 52 and 87, respectively. Limb-length discrepancy was mean 4.2 cm preoperatively, and <1 cm postoperatively. All contractures were released according to our newly developed algorithm. CONCLUSIONS: It is challenging to pinpoint the main muscle causing contractures, because other muscles acting on the hip joint have similar secondary functions. The method we describe here may provide better and more specific restoration of muscle function in a hypoplastic hemipelvis in DDH.

Short-term outcomes of outpatient surgery for total knee arthroplasty.

INTRODUCTION: We developed an accelerated clinical pathway involving outpatient surgery for patients undergoing total knee arthroplasty (TKA) who are healthy enough for early discharge. METHODS: Between March 2014 and April 2015, 89 TKAs were performed at a single institution by a single orthopaedic surgeon. 31 patients met the inclusion criteria for the study. All patients received 2 g tranexamic acid and 750 mg cefuroxime sodium intravenously 30 minutes prior to surgery. A multimodal protocol for perioperative pain management was used for all patients. RESULTS: 31 patients (three male, 28 female), with a mean age of 67 (range 49-78) years, who underwent TKA were enrolled in this study. The mean length of hospital stay was 28.7 (range 16-49) hours and mean duration of surgery was 92 (range 75-128) minutes. Combined spinal epidural anaesthesia was performed for 23 (74.2%) patients and general anaesthesia was used in 8 (25.8%) patients. Among the 31 patients, 23 (74.2%) patients were discharged within 23 hours of surgery. CONCLUSION: Early discharge of patients following outpatient surgery for TKA was not associated with any procedure-related complications among the selected patients up to three months postoperatively.

Results of Posterior Vertebral Column Resection: Surgical Modification of Suk Technique.

STUDY DESIGN: Consecutive, retrospective review. OBJECTIVES: To evaluate and report a modified posterior vertebral column technique. METHODS: We present a retrospective analysis of 20 patients. Patients having severe 3-dimensional deformity with flexibility less than 20% and managed by posterior vertebral body resection (PVCR) between 2011 and 2014 were included in this study. There were 12 female and 8 male patients, with a mean age of 18 year (range = 3-63 years). RESULTS: The average follow-up was 3.5 years (2-5 years). The preoperative coronal plane deformity was 84° (70° to 120°) and corrected to 42° (28° to 68°), showing 60% scoliosis correction. Average preoperative local kyphotic angle was 92° (82° to 110°). Correction rate for kyphosis was 62%. All patients after surgery showed their baseline neurological status, and no complications were encountered. The mean estimated blood loss was 1072 mL (350-2000 mL). Thirty-nine percent (33% to 50%) of total blood loss occurred after vertebral body resection, and 61% (50% to 67%) blood loss occurred after the removal of posterior elements. The ratio of estimated blood loss to estimated body blood volume was 26% (range = 19% to 52%). CONCLUSION: We found that 60% of total bleeding occurs during and after posterior bone resection. Spinal cord is open to possible iatrogenic direct spinal cord injury with surgical instruments for a much shorter period of time compared with the original technique.

Does the Addition of a Dynamic Pedicle Screw to a Fusion Segment Prevent Adjacent Segment Pathology in the Lumbar Spine?

STUDY DESIGN: Retrospective clinical cohort study. PURPOSE: To investigate whether the combined use of dynamic pedicle screws and polyaxial pedicle screws was effective on adjacent segment pathology (ASP). OVERVIEW OF LITERATURE: Various screw and rod models have been recently developed for preventing adjacent segment disease, and hybrid systems have been described along with posterior instrumentation in the fusion segment. In the literature, although the success of dynamic systems has been demonstrated in non-fusion posterior instrumentation, it remains unclear whether the addition of a screw-based dynamic system to a fusion segment would successfully prevent ASP in the long term. METHODS: The study included 101 patients who underwent surgery for degenerative spine diseases between 2007 and 2014 with lumbar stabilization that used either polyaxial pedicle screws alone or polyaxial pedicle screws plus dynamic stabilization screws (with hinged screw heads). These two patient groups were compared using retrospectively obtained postoperative new clinical findings, Oswestry disability index (ODI) scores, visual analog scale (VAS) scores, and radiological data. RESULTS: The proportion of patients with ASP who were radiologically assessed was low (p <0.01) in the group that underwent lumbar stabilization along with dynamic screws. Treatment outcomes were clinically successful in both groups according to ODI and VAS scores, and no significant difference was determined between the groups in terms of clinical ASP (p >0.05). CONCLUSIONS: Although the combined use of dynamic screws and the static system was radiologically found to be effective for preventing ASP in patients who underwent lumbar fusion with posterior instrumentation, it did not completely eliminate ASP or result in a significant improvement in clinical ASP.

Validation of the Turkish version of the visual analog scale spine score in patients with spinal fractures.

OBJECTIVE: The visual analog scale spine score (VASSS) is a valid and reliable instrument for outcome assessment of patients with thoracic and lumbar spine fractures. The aim of this study was to prepare a Turkish version of the VASSS and to validate its use for assessing treatment outcomes in Turkish patients with spinal trauma. METHODS: The German version of the VASSS was blindly and independently translated into Turkish by three translators and modified by a team. Fifty patients who had been surgically treated for thoracic or lumbar fracture and a group of 50 healthy controls were evaluated using the VASSS, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), and Short Form 36 (SF-36). The Cronbach's alpha was performed to test the internal consistency of the score. RESULTS: The Cronbach's alpha coefficient was calculated as 0.965 in the overall assessment of the scale. Criterion validity measured by comparing the VASSS responses with the results of ODI, RMDQ, and SF-36 physical component (for ODI r=0.881, p<0.001; for RMDQ r=0.882, p<0.001; for SF-36 r=0.824, p<0.001). Construct validity tested by factor analysis yielded a factorial structure of the questionnaire with 64.7% of cumulative percentage of explained variance, and Turkish version of the VASSS showed a similar structure than the original version. CONCLUSION: The Turkish version of the VASSS is a reliable and valid instrument to assess the outcome in patients with thoracic or lumbar spinal fractures in the Turkish population.

Long-term outcome after surgical treatment of thoracolumbar fractures versus a control group of healthy volunteers.

The authors conducted a retrospective study on the long term outcome (+/- 9 years) after instrumentation for thoracolumbar fractures. This study is probably unique in that it compares the surgical group with a control group of healthy volunteers, rather than with a group of conservatively treated patients. All classical outcome measures were used: ODI, RMDQ, VASSS, VAS, Denis Pain scale, SF-36 Bodily Pain, SF-12 Bodily Pain, the remaining SF-36 and SF-12 scores, and the Denis Work Scale. As expected, the large majority of the scores was better in the healthy group. The difference was significant, except as far as the SF-tests were concerned.

[Treatment of intertrochanteric femur fractures in high-risk geriatric patients (≥65 years) with external fixation]. / Ileri yasli (≥65 yas) yüksek riskli olgularda gelisen intertrokanterik femur kiriklarinin eksternal fiksatörle tedavisi.

BACKGROUND: We evaluated the results of intertrochanteric hip fractures treated with closed reduction and external fixation (minimally invasive and biological osteosynthesis) in patients with high surgical risk. METHODS: Twenty-three patients (14 females, 9 males; mean age 74 [65-88]) with intertrochanteric hip fracture classified as group III and IV according to American Society of Anesthesiologists (ASA) criteria were treated with closed reduction and unilateral external fixation under short-term anesthesia. Fourteen fractures were stable (60.8%) and nine were unstable (39.2%). The mean follow-up was 23.8 months (4-58). We evaluated the operation time, hospitalization time, union time, mobilization capacity, complications, and mortality rates. RESULTS: The mean duration of operation was 25 minutes (15-40), mean duration of hospital stay 4 days (2-9) and average union time 13 weeks. Five patients (21.7%) died due to additional health problems in the first six months after surgery. Superficial pin tract infection occurred in 11 cases (47.8%). There was no implant failure. In the last follow up, an average 5° varus (range: 0-8°) and 1 cm shortening (range: 0-3) in stable fractures and an average 15° varus (range: 8-20°) and 3 cm shortening (range: 2-5) in unstable fractures were determined. CONCLUSION: The treatment of intertrochanteric hip fractures with closed reduction and external fixation is an easy, effective and safe biological fixation method with minimal damage to surrounding tissues, especially in patients with high surgical risk.