Halm-Zielke instrumentation for primary stable anterior scoliosis surgery: operative technique and 2-year results in ten consecutive adolescent idiopathic scoliosis patients within a prospective clinical trial.

Halm-Zielke instrumentation (HZI) was developed to eliminate the disadvantages of Zielke instrumentation (VDS) in terms of lack of primary stability and a kyphogenic effect. HZI is an anterior double-rod system. The system is composed of a lid-plate, which is fixed at the lateral aspect of the vertebral body with two screws, a sunk screw anteriorly and a VDS screw posteriorly. The lid-plate design provides the lowest possible implant profile. The longitudinal components consist of a threaded VDS rod and a solid, fluted rod. Correction is performed with the threaded rod and the solid rod. The solid rod allows internal derotation and relordosation, eliminates the Zielke three-point lever system and augments the system. The fluted design of the rod provides rotatory stability. This is a report of the first ten consecutive adolescent idiopathic scoliosis patients in a prospective clinical trial using HZI with a minimum follow-up of 2 years. Curves ranged from 36 degrees to 77 degrees. Correction of the frontal plane averaged 77.5% and 72.2% postoperatively and at follow-up, respectively. Thoracolumbar kyphosis was present in three patients and corrected in all from an average of +18 degrees to +1.7 degrees at follow-up. Implant-related complications were not observed. All patients were treated without any additional external immobilization. In our opinion, HZI is a major improvement on the original Zielke VDS. It eliminates the kyphogenic effect and provides primary stability.

[Halm-Zielke instrumentation (Munster Anterior Double Rod System) as an improvement over Zielke-VDS. Surgical method and preliminary results]. / Halm-Zielke Instrumentation (Münsteraner Anteriores Doppelstab System) als Weiterentwicklung der Zielke-VDS. Operationsmethode und vorläufige Ergebnisse.

INTRODUCTION AND AIM OF THE STUDY: Halm-Zielke Instrumentation (HZI), in german speaking countries also named the Münster Anterior Doublerod System, was developed to eliminate the disadvantage of VDS-Zielke in terms of lack of primary stability. Additionally sagittal plane control should be improved. Within a prospective clinical trial it was examined, if HZI fulfilled these demands. METHODS: HZI is an anterior doublerod system with a two screw per vertebral body fixation. The longitudinal components consist of a threaded VDS-rod and a solid rod. 12 consecutive patients with idiopathic scoliosis and curves ranging from 36 degrees to 77 degrees were treated with HZI. RESULTS: Correction of the frontal plane averaged 75% and 73.8% postoperatively and at follow-up, respectively. Derotation averaged 49.3%. Thoracolumbar kyphosis was present in four patients and always completely corrected. Implant related complications were not noted. All patients were treated without any additional external immobilisation. CONCLUSION: The aim of improvement of VDS in terms of primary stability and control or improvement of the sagittal plane was completely achieved.

Results of surgical correction of kyphotic deformities of the spine in ankylosing spondylitis on the basis of the modified arthritis impact measurement scales.

STUDY DESIGN: This is a retrospective study of patient outcome in ankylosing spondylitis patients with fixed kyphotic deformities of the spine who underwent reconstructive surgery. OBJECTIVES: To measure the multidimensional effects of reconstructive spinal osteotomy in this patient group with a questionnaire-based instrument. SUMMARY OF BACKGROUND DATA: Between 1979 and 1988, 175 ankylosing spondylitis patients underwent operative treatment for fixed flexion deformities of the spine. One hundred forty-eight of these patients answered the questionnaire correctly and were included in the study. The others either died or were lost to follow-up. METHODS: The modified Arthritis Impact Measurement Scales with eight scales and 60 items plus six additional summative questions were administered at a mean follow-up period of 4.8 years (range, 2-10 years). The modified Arthritis Impact Measurement Scale measures eight scales--mobility, physical, household, daily, social activity, pain, anxiety, and depression. The Wilcoxon and chi-square test were used for analysis. RESULTS: Forty-seven of 60 items showed significant improvement of activity levels or status. Only two items showed a significant impairment of function. Of the patients, 88.4% were very satisfied with the result of the operation; 60.9% were able to return to work. Age, sex, and type of surgical technique did not influence the results. CONCLUSIONS: The modified Arthritis Impact Measurement Scales approach shows excellent overall improvement of health status after surgery, proving the worth of reconstructive surgery in ankylosing spondylitis patients with fixed kyphotic deformities of the spine.

Effects of the combined VDS-Zielke and Harrington operation on the frontal rib cage deformity of double major curves in idiopathic scoliosis.

STUDY DESIGN: This study analyzed the changes in the frontal plane of the deformed lower rib cage and the scoliosis-related alterations on the spine in patients with double major curve-pattern idiopathic scoliosis. OBJECTIVES: The results obtained preoperatively, after the Zielke operation, postoperatively after the Harrington instrumentation, and at the follow-up evaluation were compared to investigate which changes of the elements of the rib cage deformity are caused by each of the two instrumentations. SUMMARY OF BACKGROUND DATA: Previously, Wojcik reported on the effects of a Zielke operation on the lower rib in mild S-shaped idiopathic scoliosis. No previous data exist regarding the lower rib cage deformities in severe idiopathic double major-pattern scoliosis and their changes after combined VDS-Zielke and Harrington instrumentation. METHODS: Fifteen patients who underwent the staged Zielke operation followed by Harrington rod instrumentation were followed-up for an average period of 31.1 months. The methods used in our study included Cobb angle and a segmental analysis (T7-T12) of each of convex and concave rib-vertebra angles, rib-vertebra angle differences, vertebral rotation, and vertebral tilt. RESULTS: In this series, the apical convex ribs showed an increased droop preoperatively compared with the concave apical ribs. The VDS-Zielke operation corrected the lumbar scoliosis in an average of 63% of patients, whereas the thoracic scoliosis showed an immediate spontaneous correction of 30%. The VDS-Zielke operation also produced a significant correlation of the scoliosis-related vertebral tilt (T10-T12), derotated the lumbar vertebrae and the T12 vertebra significantly, elevated the "mobile" concave ribs, and increased the droop of the lower (T11, T12) "mobile" convex ribs. The Harrington instrumentation did not change the vertebral rotation, the vertebral tilt, the convex rib-vertebra angle, or the L4 obliquity, but significantly changed the apical concave rib-vertebra angle. The combined Zielke-Harrington instrumentation reduced the thoracic kyphosis and the thoracolumbar junction-kyphosis significantly, whereas the lumbar lordosis remained practically unchanged. CONCLUSIONS: Only the anterior VDS-Zielke instrumentation significantly corrects severe spinal deformities, elevates the three lower ribs on the concavity, and increases the droop of the two lower ribs on the convexity in the severe idiopathic double major curve-pattern scoliosis combined operated (Zielke-Harrington). Therefore, the Harrington instrumentation should have only limited use in cosmetic scoliosis surgery and should be replaced with posterior multi-hook instrumentation with a derotation effect.

[Surgical treatment of kyphotic spinal deformities in ankylosing spondylitis using the Harrington compression system: long-term results based on the MOPO scales in the framework of a retrospective questionnaire]. / Operative Behandlung kyphotischer Wirbelsäulendeformitäten bei der Spondylitis ankylosans mit dem Harrington-Kompressionssystem: Langzeitergebnisse auf der Basis der MOPO-Skalen im Rahmen einer retrospektiven Fragebogenerhebung.

INTRODUCTION: Meanwhile a lot of papers have been published concerning the operative treatment of kyphotic deformities of the spine in ankylosing spondylitis. Long term results from the patient's view-point on the basis of standardized parameters are not available. This was the intention of this study. MATERIAL AND METHODS: From 1979 to 1982 34 patients underwent surgical correction of a flexion deformity of the spine in ankylosing spondylitis. Correction was achieved with four v-shaped lumbar osteotomies using Harrington's compression system. Seven to ten years postoperatively the patients were asked to answer a questionnaire containing the Mopo-scales and a few additional questions in order to compare the patients pre- and postoperative status and evaluate the long-term quality of the operative procedure. The Mopo-scales exist of the 8 subscales mobility, physical-, daily-, household-, social activity, pain, depression, anxiety with 60 questions (items). The statistical analysis was carried out with the Wilcoxon- and Chi-Square-test using a level of significance of p < 0.01. RESULTS: Within all Mopo-subscales most items (n = 47) demonstrated significant improvement of function (p < 0.01). Whereas 11 times no significant changes could be proved, twice a significant impairment was noticed. The latter mentioned 13 items tested activities that would have been performed better in inclination, so that the results do not amaze. Visual analog scales for pain and general health status indicated significant improvement of both. 85.7% of the patients were very satisfied with the result of the operation. CONCLUSION: The results prove the long term value of the operative treatment of kyphotic deformities of the spine in ankylosing spondylitis using Harrington's compression system, although meanwhile transpedicular screw fixation instead of hooks is used, as it is well known. It can now be said in detail, which long term influences vertebral osteotomies of the spine for correction have on specific activities and health conditions in these patients.

Does the combined ventral derotation system (VDS) followed by Harrington instrumentation improve the vital capacity in patients with idiopathic double major curve pattern scoliosis? An analysis of 33 cases and review of the literature.

A young, homogenous population of 33 patients with idiopathic scoliosis of double major curve pattern (DMC), a mean thoracic curve of 70.6 degrees (standard deviation [SD] = 20.6), and a mean lumbar curve of 72.9 degrees (SD = 15), had a measurement of the vital capacity (VC) at rest before and at a minimum of one year after combined ventral derotation system (VDS). This was followed by Harrington instrumentation and fusion to evaluate the effect of scoliosis, kyphosis, and their surgical correction on VC at rest. A regression analysis showed that the VC was significantly lowered before operation to 69.6% of predicted value, whereas individuals with thoracic curvatures greater than 70 degrees had a lower VC. The surgical correction of the thoracic curve of 50.8% and the lumbar curve of 68.4% was permanent in the follow-up evaluation, and the functional improvement in postoperative VC was 4.36%, statistically not very significant. The time between the two evaluations did have a significant statistical correlation with the observed improvement of the VC. The longer the interval between the two evaluations, the better the improvement of the VC. The age of the patient at the time of the first (VDS) operation influences the changes of the observed VC, significantly favoring the younger patients. The number of the functional vertebral segments included by the spinal instrumentation and fusion does not improve the VC.(ABSTRACT TRUNCATED AT 250 WORDS)

Correction of the sagittal plane in idiopathic scoliosis using the Zielke procedure (VDS).

This paper reports a retrospective review of 91 patients with idiopathic thoracic scoliosis corrected by Zielke VDS instrumentation. The results were analysed to demonstrate the correction in all three planes. Satisfactory correction was obtained, and was particularly good in the sagittal and horizontal planes. There were no disadvantages from the thoracotomy.

Stabilization of the lumbosacral spine in postlaminectomy syndromes. Technique and 2-year results.

A 2-year follow-up study is presented using transpedicular stabilization with USIS (Universal Spinal Instrumentation System) and dorsoventral fusion for failed back syndrome. Eighty-four % excellent and good results at 3 to 6 months have decreased to 56% at 1 to 2 years. Complications are few if the anatomic landmarks are respected. Many psychological and social factors also modify the final outcome of salvage surgical procedures. Only the relief of pain determined our subjective evaluation by the patient himself, without regard to sensory or motor deficiencies.

Correction and stabilization of angular kyphosis.

Reconstruction of normal geometric relationships, regardless of original pathology, has to be the goal when treating angular kyphosis. Since anterior and posterior spinal structures are involved, successful decompression, correction, and stabilization require both dorsal and ventral surgery. By using segmental transpedicled and ventrolateral Instrumentation System implants, permanent fixation can be achieved. As a result, the length of the compression spondylodesis and fusion time are short. pedicular anchorage and implant design leave the joints and ligamentum flavum of healthy neighboring segments untouched. In the last five years, over 570 kyphotic deformities, including congenital kyphosis, spondylitis, tumors, and acute and neglected fractures, have been treated with this method. During a three- to five-year follow-up period of 40 patients with posttraumatic kyphoses, no additional neurologic damage, pseudarthrosis, or substantial loss of correction occurred.

Polysegmental lumbar osteotomies and transpedicled fixation for correction of long-curved kyphotic deformities in ankylosing spondylitis. Report on 177 cases.

Despite conservative therapy in ankylosing spondylitis, kyphotic deformities are common. Mono-segmental lumbar osteotomy had a high complication rate. Therefore, a poly-segmental lordosis osteotomy of the lumbar spine was introduced in four to six segments using trans-pedicled screws and threaded rods in eight to ten segments (isolated correction is possible for each segment). Instead of dangerous short kinking, a poly-segmental lordosis osteotomy results in harmonious lordosis with a correction per segment of about 10 degrees, and complications are decreased. Of 177 patients undergoing the operation, there was a 2.3% mortality rate with cardiopulmonary problems, 2.3% with irreversible complications, and 18.1% with reversible complications, mostly small root lesions, of which 7% were reoperated. The 173 surviving patients had a correction of 43%, and improvement in body height of 9 cm, and improvement of flexion by 57%. Fifty-three patients have been followed for more tha 18 months. the visual axis in all cases was horizontal. No pseudoarthrosis occurred. After correction, the frequent spondylodiscitis healed. Ninety-two percent were pain free compared with 15% before the operation. Loss of correction of body height was 20%, of flexion 4%, and of the lordosis 7%, which was 18% in 37 patients after three years.

[Spondylodiscitis in kyphotic deformity of ankylosing spondylitis and its healing affected by dorsal correction osteotomies. Report of 33 patients]. / Die Spondylodiszitis bei kyphotischer Deformität der Spondylitis ankylosans und ihre Ausheilung durch dorsale Korrekturosteotomien. Bericht über 33 patienten.

Out of 144 patients with kyphotic deformities in Ankylosing spondylitis 33 (23%) had 45 disco-vertebral lesions of the spondylodiscitic type. They were characterized by osteolyses, scleroses and absence of syndesmophytes. 5 had additional arch fractures. All were localized in or below the apical vertebra in the lumber or the lower thoracic spine. Compared with the total collective strong pain, high sedimentation rates and extravertebral manifestations were more frequent, osteoporosis rare, and the degree of kyphosis and the types of ossification same. The radiology showed the lesions as inflammatory etiology. Functionally, however, they are pseudarthroses. All spines were lordosed by dorsal osteotomies and therewith statically corrected and for one year externally immobilized. The spondylodeses fusioned in this time. Complications did not occur on account of the spondylodiscites. The therapy of kyphosis had an influence on the spondylodiscites. They all healed except for one. After a follow up of two years 98% were completely fused, also those with non-identical levels of correction and lesion. The loss of correction in the segments of lesion was negligibly more than in the total collective. 91% of the patients were pain-free compared to 12% preoperatively. The spondylodiscites were no hindrance for dorsal lordosing osteotomies and can be treated successfully by means of this static correction and the immobilisation.

[10-year results following surgery of idiopathic scoliosis using the Harrington technique (work by the "Conference of German-language Spinal Surgeons)]. / 10-Jahresresultate bei nach Harrington operierten idiopathischen Skoliosen (Arbeit der "Konferenz deutschsprachiger Wirbelsäulen-Chirurgen").

From 1972 through 1976 90 patients with idiopathic scoliosis underwent posterior spine fusion using Harrington instrumentation. Follow up was 10 years or more with an average of 12 years. The most frequent and most serious complications occurred in adults with scoliotic deformities of more than 90 degrees. Vital capacity of adults improved more than 20 percent. In young patients with low grade scoliotic spines a better immediate postoperative correction was achieved. There was also a higher loss of correction later on in this group. Thus in the long term follow up there was no correlation between magnitude of the preoperative curve and postoperative correction.

[The natural history of scoliosis]. / Der natürliche Verlauf (natural history) der Skoliose.

Adequate treatment of scoliosis requires from the managing doctor a detailed knowledge about the natural history of the disease for correct indication of the various possibilities for treatment and favourable influence of the spontaneous history. Essential prognostic factors of idiopathic scoliotic forms and congenital or neuromuscular scolioses will be demonstrated.

[A 10-year follow-up of the Harrington operation in congenital scoliosis and scoliosis due to poliomyelitis and neurofibromatosis]. / 10-Jahresverläufe nach Harrington-Operation bei kongenitalen, Poliomyelitis- und Neurofibromatose-Skoliosen.

From 1972 through 1976 40 patients with congenital scoliosis, scoliosis in neurofibromatosis and scoliosis following poliomyelitis underwent posterior spine fusion using Harrington instrumentation. Follow up was 10 years or more with an average of 12 years. 63 percent of all patients showed a curve of more than 90 degrees before operation. The different types of scolioses revealed characteristical results according to their etiology during long time follow up. Concerning long time reduction of curve the best results were obtained in patients following poliomyelitis. Patients with congenital and neurofibromatous scoliosis showed loss of correction 2 and 5 years postoperatively.

[Long-term follow-up of lung function and standing height following scoliosis surgery in children and adolescents]. / Langzeitverläufe von Lungenfunktion und Stehgrösse nach Skolioseoperationen bei Kindern und Jugendlichen.

Previous investigations have reported conflicting results on the development of lung function and body height after operative correction of scoliosis at young age. Partly the number of patients or the duration of observation were relatively small. 120 patients were followed for at least 10 years (10-14, average 12 years) after surgical correction of scoliosis at the age of 18.2 +/- 6.8 years. Standing height and vital capacity were measured 1, 2, 5 and 10 years after operation. Height was expressed as percentile for age and vital capacity as % expected for actual height. The primary diagnoses were idiopathic scoliosis (n = 84, average Cobb angle 90 degrees), congenital scoliosis (n = 20, 83 degrees), poliomyelitis (n = 10, 128 degrees), neurofibromatosis (n = 6, 101 degrees). We found an initial decrease in lung function after 1 year, which was probably due to post-operative immobilization and increased by the gain in body height achieved by the operation. During the rest of the observation period a significant (p less than 0.05) increase of vital capacity (% of expected for actual height) was observed. The gain was maximal for idiopathic scoliosis (+6%). In congenital scoliosis body height %ile and relative vital capacity appeared fixed at the preoperative level. Interestingly patients with an initial vital capacity below 50% expected (n = 29) or preoperative Cobb angle above 90 degrees showed the best results. They also lacked the initial deterioration of lung function in the first postoperative year and had a significant gain of vital capacity (+14%) over 10 years.(ABSTRACT TRUNCATED AT 250 WORDS)

[Zielke ventral derotation spondylodesis]. / Die ventrale Derotationsspondylodese nach Zielke.

There are several procedures in the operative treatment of scoliosis. Zielke-instrumentation has proven to be a safe and effective method for many years. Biomechanics, the operative technique, indications and complications are presented as well as long-term results after 5-10 years. VDS really proves a superior correction of all the three dimensions of a curve, major complications are very rare. Special regard is given to rotation correction, the cosmetic improvement and to the behavior of compensatory curves: a full correction is not an ideal result.

[Correction of Bechterew kyphosis]. / Die Korrektur der Bechterew-Kyphose.

The derangement of posture in advanced flexion deformity due to ankylosing spondylitis, as well as operative correction procedures are analysed. The "Dorsal Lordosating Spondylodesis", DLS, according to Zielke is introduced. This method of polysegmental correction and transpedicular fixation via USIS implants allows the recreation of a balanced upright posture by restoration of smooth lumbar lordosis. We present results of 173 patients corrected by DLS. Since the total amount of correction is split into 5-7 osteotomy sites, complication rates are substantially lower than in the monosegmental methods. Besides the gain of body height and immediate pain relief, the restoration of a horizontal axis of vision could be achieved. The latter, for all patients the most important feature, was maintained as up to 5 years follow-up's show.

[Comments on the contribution: initial results of surgical treatment of scoliosis with the Cotrel and Dubousset CD instruments by Ch. Hopf, H. H. Matthiass and J. Heine. Z. Orthop. 125 (1987) 347]. / Stellungnahme zu dem Beitrag: Erste Ergebnisse der operativen Behandlung der Skoliose mit dem CD-Instrumentarium nach Cotrel und Dubousset von Ch. Hopf, H. H. Matthiass und J. Heine. Z. Orthop. 125 (1987) 347.

It really must be appreciated that in the above mentioned publication of Hopf, Heine and Matthiass the authors were brave enough-against normal habits-to publish their bad results. In demonstrating their cases they render the CD system a destructive rebuff. Not in one of their demonstrated cases they were able to show that there are convincing advantages of this surgery compared to other already wellknown and sufficiently proven methods. We still have to acknowledge the opinion of Nachemson (1986) that the CD method is yet in the experimental stage. The authors show in their selective cases how it should not be done. They sacrifice in favor of a primary stability functionally important segments of the spine cranially as well as caudally and thus mutilate young human beings to an irresponsible extent. Of course it is astonishing when the authors in spite of their actually crushing experiments with this system in summary arrive at positive results without reasons indeed. For example they comment positively on the attained derotation, although they had shown with their results that no derotation could be achieved at all. Remarks about diminishing the rib hump, which should after all be a result of a good derotation are missing. Exact measurements in CT scans of the apical vertebra, as demonstrated in an extraordinary way by Giehl, have not yet been made in Münster. Otherwise the authors would have clearly recognized that a derotation with resection of the discs is not possible using the CD method. The authors present the system-in spite of their very bad results-as a universal spinal system for correction and stabilization and at the same time they doubt the value and extent of anterior surgical methods according to Dwyer or Zielke, even though these methods have internationally shown how the optimal corrections have resulted in fewer mutilations by using shorter fusion areas on the spine provided that the surgeon knows how to use the instruments. We spine surgeons should always be aware that we can cause an irreversible condition on the spine of the human being with our spinal fusion operation this could have grave results for the patient for his whole life. No doubt, there are advantages in the CD method, but they rather result in better stability than in better corrections.(ABSTRACT TRUNCATED AT 400 WORDS)

[Stabilization of the lumbosacral segment by distracting posterolateral spondylodesis using the Zielke divided sacral strut. Analysis of 400 cases based on indications, results and cause of errors]. / Stabilisierung des lumbosakralen Abschnittes durch distrahierende posterolaterale Spondylodese über den geteilten Sakralstabaufbau nach Zielke. Analyse von 400 Fällen hinsichtlich der Indikation, der Ergebnisse und der Ursache von Fehlergebnissen.

Out of 400 patients who underwent posterolateral or purely dorsal spondylodesis of the lumbosacral joint with a divided sacral strut or sacral knee using distracting Harrington struts, a total of 68.5% were free of complaints--100% in cases of fractures and destruction, spondylarthroses and osteochrondroses, 73% in cases of spondylolyses with and without spondylolistheses, and only 49% among the so-called "failed-back" patients who had already undergone one or more previous operations. Where results were poor, particularly in the group of failed-back patients, when surgical error, pseudarthroses, or inadequacies of instruments were ruled out, it could be assumed in approximately 80% of the cases that these patients simultaneously had a pension claim under review or had attempted to institute proceedings at a social insurance tribunal. In such cases the goal of treatment desired by the surgeon, i.e., pain-free stability, cannot be the aim of the patients. Freedom from pain means ability to work, and loss of the pension or the pension litigation. It is almost endemic among these patients to put the blame on the same exogenous mechanisms, as far as both time and cause are concerned, in order to obtain certification of their inability to work. The suspicion that they use the operation to prove the severity of their disability is in many cases justified. The high incidence of psychosocial problems is at least a partial explanation of why the measures we took in our efforts to improve the results of surgery failed. We changed the position of the patient, extended the duration of hospitalization, revised our implantation method, verified plasters and braces. To no avail. Essentially, the result of surgery was influenced by four factors: the number of previous operations, drug and alcohol abuse, pseudarthrosis, and simultaneous pension claims. In 1983 and 1984 the number of patients without pain soared. Basically, this is probably due to the fact that in the light of the results of this investigation, more stringent criteria were applied with regard to the selection of patients. If the patient has a claim against a social insurance institution, a private insurer, or physicians who have treated him/her previously (!!!) we refuse to operate. It is unlikely that these patients will be pain-free before the proceedings in question are terminated. This much we have learned from this analysis.(ABSTRACT TRUNCATED AT 400 WORDS)

Chylothorax--a rare complication after anterior and posterior spinal correction. Report on six cases.

The authors observed six cases of chylothorax of 2,000 operations for spinal deformities performed in the past 5 years: in one case of VDS, two Harrington operations, and three anterior strut graft operations. Chylothorax resulted from direct injury to the lymphatic system in four cases of anterior spinal surgery. One of the Harrington cases had a previous history of spontaneous chylothorax that had been managed surgically. The other cases of chylothorax observed after a Harrington operation was bilateral and probably caused by the central venous catheter. All cases were treated conservatively, and the duration of the chylothorax varied from 1 to 18 days.