Regeneration: Bone-Marrow Stimulation of the Talus-Limits and Goals.

Bone Marrow Stimulation of osteochondral lesions of the talus has been shown to be a successful way to treat cartilage injuries. Newer data suggest that Bone Marrow Stimulation is best reserved for osteochondral lesions of the talus Sizes Less Than 107.4 mm2 in area. Additionally, newer smaller and deeper techniques to perform bone marrow stimulation have resulted in less subchondral bone damage, less cancellous compaction, and superior bone marrow access with multiple trabecular access channels. Biologic adjuvants such as platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow aspirate concentrate (BMAC) may lead to better functional outcomes when used concomitant to bone marrow stimulation.

Patients With Intact Shoulder Superior Capsular Reconstruction Grafts on Ultrasound Show Significant Improvement in Functional Outcomes at Minimum 2-Year Follow-up.

Purpose: To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up. Methods: A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound. Results: We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores. Conclusions: SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months. Level of Evidence: Level IV, therapeutic case series.

Well-Leg Compartment Syndrome Due to Hemilithotomy Positioning after Arthroscopic Reconstruction of the PCL.

Introduction: Acute compartment syndrome (ACS) occurs due to decreased perfusion of an osseofascial space due to increased compartmental pressure. Due to its potentially devastating sequelae, emphasis is placed on its prompt diagnosis. While fractures continue to be the most common cause of ACS, mechanisms such as crush injuries and even surgical positioning are described etiologies of compartment syndrome. ACS of the well-leg from hemilithotomy positioning has been previously depicted in medical literature; however, there have been no illustrations of this complication after elective arthroscopic-assisted posterior cruciate ligament (PCL) reconstruction. Case Report: This report discusses a patient undergoing PCL reconstruction who developed an ACS in the non-operative extremity that was positioned in hemilithotomy in a leg positioner. Conclusion: ACS is an uncommon but serious complication that can occur from hemilithotomy positioning. Surgeons should be mindful of risk factors that can place a patient at higher risk, including length of the case, body habitus, height of elevation of the leg, and method of leg support. The prompt recognition and surgical management of ACS can prevent the devastating long-term complications.

Anterior Hip Heterotopic Ossification after Traumatic Anterior Hip Dislocation in a Non-head Injured Pediatric Patient: A Case Report.

Introduction: Traumatic hip dislocation in pediatric patients is uncommon, with anterior dislocation being particularly rare. Heterotopic ossification (HO) is a rare complication, especially in the absence of concomitant head trauma. There are no reported cases of symptomatic anterior hip HO, after closed anterior dislocation, in the pediatric population. Case Report: We present a case of symptomatic anterior hip HO in a 14-year-old female after traumatic anterior hip dislocation without associated head trauma. After closed reduction, anterior hip HO matured over the course of 1 year and resulted in a near complete ankylosis of the hip joint. Surgical excision and prophylactic radiation therapy resulted in a satisfactory clinical outcome. Conclusion: Pediatric anterior hip dislocation, even in the absence of head trauma, can cause symptomatic HO to the extent of near ankylosis of the hip joint. This can be managed with surgical excision and prophylactic radiation, with satisfactory clinical results.

Cement augmentation of suture anchors in the proximal humerus during rotator cuff repair improves pullout strength: a systematic review.

IMPORTANCE: Rotator cuff pathology is a growing concern in the ageing population. If cement augmentation of suture anchors improves pullout strength, its application can potentially be applied in cases of poor bone quality to prevent anchor failure. OBJECTIVE: To evaluate the biomechanical benefits and fixation strength of cement-augmented versus non-augmented suture anchors in the proximal humerus during rotator cuff repair (RCR). EVIDENCE REVIEW: A systematic review of PubMed, Embase and Cochrane Library was performed to identify all published articles reporting on biomechanical analysis of suture anchors in the shoulder in a cadaveric model. Inclusion criteria required fresh-frozen specimens, placement in the footprint of the proximal humerus, and comparative assessment of fixation constructs with or without polymethylmethacrylate (PMMA) or bioabsorbable composite cement augmentation. Biomechanical testing procedure, cement augmentation method and pullout force were assessed. FINDINGS: After review of 105 abstracts, seven full manuscripts met inclusion criteria. Six of seven studies reported statistically significant differences in mean pullout force between augmented (three PMMAs, three composites, one PMMA vs composite) and non-augmented anchors. Of two studies evaluating cycles to failure, both found a significant increase in the augmented versus non-augmented anchors. Of two studies stratifying by anchor position, both investigations identified significant differences in mean pullout strength between augmented and non-augmented anchors at the posteromedial and anterolateral anchor positions. CONCLUSIONS AND RELEVANCE: Cement augmentation of suture anchors in cadaveric humeri for RCR improves pullout strength regardless of cement type used or anchor position. Cement augmentation may provide a viable option for future clinical application. LEVEL OF EVIDENCE: IV, systematic review.

Oxidative Stress and Osteoporosis.

➤: Oxidative stress has been implicated as a causative factor in many disease states, possibly including the diminished bone mineral density in osteoporosis. ➤: Understanding the effects of oxidative stress on the development of osteoporosis may lead to further research improving preventative and therapeutic measures that can combat this important contributor to morbidity and mortality worldwide. ➤: A diet rich in whole plant foods with high antioxidant content along with antioxidant-preserving lifestyle changes may improve bone mineral density and reduce the risk of fragility-related fractures. While it is not explicitly clear if antioxidant activity is the effector of this change, the current evidence supports this possibility. ➤: Supplementation with isolated antioxidants may also provide some osteoprotective benefits, but whole plant food-derived antioxidants potentially have more overall benefits. Larger-scale clinical trials are needed to give credence to definitive clinical recommendations.

Anatomic Analysis of a Percutaneous Fixation Technique for the Posterior Malleolus Using Posterior-to-Anterior-Directed Cannulated Screws: A Cadaveric Study and Technique Description.

BACKGROUND: Posterior malleolus fractures are traditionally managed with open reduction and internal fixation or percutaneous anterior-to-posterior screws. We present a third option using a percutaneous technique for the placement of posterior-to-anterior-directed screws. An anatomic safety analysis is done using cadaveric specimens. METHODS: Using 15 embalmed specimens (10 F and 5 M), a guidewire was placed using the described technique. The posterolateral ankle was dissected to evaluate for damage to vulnerable structures including the sural nerve, peroneal artery, and flexor hallucis longus/flexor digitorum longus/peroneal/Achilles tendons. The distance from the sural nerve and peroneal artery was measured to the guidewire at its nearest point. The tendons were evaluated for traumatic piercings. RESULTS: The sural nerve had a mean distance to wire of 5.3 mm (range 0 to 12) and the peroneal artery had a mean distance to wire of 5.7 mm (range 2 to 13 mm) with no traumatic piercings of either structure. The flexor hallucis longus/flexor digitorum longus/peroneal/Achilles tendons had no traumatic piercings. CONCLUSION: This percutaneous technique provides a safe alternative to the standard open and traditional percutaneous techniques. It has limited application and is suitable for noncomminuted minimally displaced posterior malleolus fractures and those with fragile tissues where the morbidity of the soft tissue exposure outweighs the benefit of an open reduction.

Outcomes of patients with syringomyelia undergoing spine deformity surgery: do large syrinxes behave differently from small?

BACKGROUND CONTEXT: A paucity of data exists studying outcomes of patients with syringomyelia undergoing spinal deformity correction. The literature does not stratify patients by syrinx size, which is likely a major contributor to outcomes. PURPOSE: The study aimed to compare differences in outcomes between patients with large (≥4 mm) and small syrinxes (<4 mm) undergoing spinal deformity correction. DESIGN: This is a retrospective review. PATIENT SAMPLE: The sample included 28 patients (11 with large syrinx [LS, >4 mm] and 17 with small syrinx [SS, <4 mm]). OUTCOME MEASURES: The outcome measures were radiographic, operative, and neurophysiological measures. METHODS: We retrospectively reviewed 28 patients with syringomyelia who underwent spine deformity surgery with 2-year follow-up. Demographic, surgical, and radiographic data were collected and compared preoperatively and at 2 years. RESULTS: The LS group (11 patients) trended toward more left-sided thoracic curves (36% vs. 18%, p=.38) and was more likely to have had a Chiari decompression (45% vs. 12%, p=.08). The LS patients had larger preoperative major curves (LS=66° vs. SS=57°, p=.05), more thoracic kyphosis (LS=42°, SS=24°, p<.01), and greater rib prominences (LS=16°, SS=13°, p=.04). The LS patients had more levels fused (LS=12.2, SS=11.2, p=.05), higher estimated blood loss (EBL) (LS=1068 cc, SS=832 cc, p=.04), and a trend toward less percent correction of the major curve (LS=57%, SS=65%, p=.18). Four of 11 LS patients (36%) did not have somatosensory evoked potentials, and one of these also did not have motor evoked potentials. Neuromonitoring changes occurred in 3 of 11 (27%) LS patients and in none of the SS patients, with no postoperative deficits. CONCLUSIONS: Outcomes of patients with syringomyelia undergoing spine deformity surgery are dependent on the size of the syrinx. Those with large syringomyelia are fused longer with more EBL and less correction. Spine surgeons should be aware that these patients are more likely to have less reliable neuromonitoring, with a higher chance of experiencing a change.

Management of spinal cord injury-related scoliosis using pedicle screw-only constructs.

OBJECT: Almost all pediatric patients who incur a spinal cord injury (SCI) will develop scoliosis, and younger patients are at highest risk for curve progression requiring surgical intervention. Although the use of pedicle screws is increasing in popularity, their impact on SCI-related scoliosis has not been described. The authors retrospectively reviewed the radiographic outcomes of pedicle screw-only constructs in all patients who had undergone SCI-related scoliosis correction at a single institution. METHODS: Medical records and radiographs from Shriner's Hospital for Children-Philadelphia for the period between November 2004 and February 2011 were retrospectively reviewed. RESULTS: Thirty-seven patients, whose mean age at the index surgery was 14.91±3.29 years, were identified. The cohort had a mean follow-up of 33.2±22.8 months. The mean preoperative coronal Cobb angle was 65.5°±25.7°, which corrected to 20.3°±14.4°, translating into a 69% correction (p<0.05). The preoperative coronal balance was 24.4±22.6 mm, with a postoperative measurement of 21.6±20.7 mm (p=1.00). Preoperative pelvic obliquity was 12.7°±8.7°, which corrected to 4.1°±3.8°, translating into a 68% correction (p<0.05). Preoperative shoulder balance, as measured by the clavicle angle, was 8.2°±8.4°, which corrected to 2.7°±3.1° (67% correction, p<0.05). Preoperatively, thoracic kyphosis measured 44.2°±23.7° and was 33.8°±11.5° postoperatively. Thoracolumbar kyphosis was 18.7°±12.1° preoperatively, reduced to 8.1°±7.7° postoperatively, and measured 26.8°±20.2° at the last follow-up (p<0.05). Preoperatively, lumbar lordosis was 35.3°±22.0°, which remained stable at 35.6°±15.0° postoperatively. CONCLUSIONS: Pedicle screw constructs appear to provide better correction of coronal parameters than historically reported and provide significant improvement of sagittal kyphosis as well. Although pedicle screws appear to provide good radiographic results, correlation with clinical outcomes is necessary to determine the true impact of pedicle screw constructs on SCI-related scoliosis correction.

Anterior vertebral body tethering for immature adolescent idiopathic scoliosis: one-year results on the first 32 patients.

PURPOSE: This retrospective chart review evaluates the clinical and radiographic outcomes of anterior vertebral body tethering (VBT) at 1-year follow-up. Anterior VBT offers a fusionless treatment option for skeletally immature patients with adolescent idiopathic scoliosis. It is a growth-modulation technique, which utilizes patients' growth to attain progressive scoliosis correction. Numerous animal models support its promise; however, clinical data remain sparse. METHODS: Clinical and radiographic data were retrospectively analyzed. We reviewed 32 patients who underwent thoracic VBT with a minimum one-year follow-up. Pertinent clinical and radiographic data were collected. ANOVA, Student's t test and Fisher's exact test were utilized to compare different time points. RESULTS: 32 patients with thoracic idiopathic scoliosis (72 % female) with a minimum one-year follow-up were identified; mean age at surgery was 12 years. All patients were considered skeletally immature pre-operatively; mean Risser score 0.42, mean Sanders score 3.2. Patients underwent tethering of an average of 7.7 levels (range 7-11). Median blood loss was 100 cc. The mean pre-operative thoracic curve magnitude was 42.8° ± 8.0° which corrected to 21.0° ± 8.5° on first erect and 17.9° ± 11.4° at most recent. The pre-operative lumbar curve of 25.2° ± 7.3° demonstrated progressive correction (first erect = 18.0° ± 7.1°, 1 year = 12.6° ± 9.4°, p < 0.00001). Thoracic axial rotation measured 13.4° pre-operatively and 7.4° at the most recent measurement (p < 0.00001). One patient experienced prolonged atelectasis which required a bronchoscopy; otherwise, no major complications were observed. CONCLUSIONS: Our early results indicate that anterior VBT is a safe and potentially effective treatment option for skeletally immature patients with idiopathic scoliosis. These patients experienced an improvement of their scoliosis with minimal major complications. However, longer term follow-up of this cohort will reveal the true benefits of this promising technique. LEVEL OF EVIDENCE: IV.

Anterior vertebral body tethering for idiopathic scoliosis: two-year results.

STUDY DESIGN: Retrospective review. OBJECTIVE: To report the 2-year results of the initial cohort undergoing anterior vertebral body tethering (VBT). SUMMARY OF BACKGROUND DATA: Anterior VBT is a promising new technique with abundant preclinical studies but very few clinical results. It is a growth modulation technique, which utilizes patients' growth to attain progressive correction of their scoliosis. We report 2-year results of the initial cohort undergoing this procedure. METHODS: After obtaining institutional review board approval, we retrospectively reviewed our first 11 consecutive patients who underwent anterior VBT with 2-year follow-up. We collected pertinent preoperative, intraoperative, and most recent clinical and radiographical data. Student t test and Fisher exact test were utilized to compare different time points. RESULTS: Eleven patients with thoracic idiopathic scoliosis (8 females) were identified, with a mean age of 12.3 ± 1.6 years. Preoperatively, all were skeletally immature (Sanders mean = 3.4 ± 1.1; Risser mean = 0.6 ± 1.1). All underwent tethering of an average of 7.8 ± 0.9 (range: 7-9) levels, with the most proximal being T5 and the most distal L2. Preoperative thoracic Cobb angle averaged 44.2 ± 9.0° and corrected to 20.3 ± 11.0° on first erect, with progressive improvement at 2 years (Cobb angle = 13.5 ± 11.6°, % correction = 70%; P < 0.00002). Similarly, the preoperative lumbar curve of 25.1 ± 8.7° demonstrated progressive correction (first erect = 14.9 ± 4.9°, 2 yr = 7.2 ± 5.1°, % correction = 71%; P < 0.0002). Thoracic axial rotation as measured by a scoliometer went from 12.4 ± 3.3° preoperatively to 6.9 ± 3.4° at the most recent measurement (P < 0.01). No major complications were observed. As anticipated, 2 patients returned to the operating room at 2 years postoperatively for loosening of the tether to prevent overcorrection. CONCLUSION: Anterior VBT is a promising technique for skeletally immature patients with idiopathic scoliosis. This technique can be performed safely and can result in progressive correction. LEVEL OF EVIDENCE: 4.

The posterior pedicle screw construct: 5-year results for thoracolumbar and lumbar curves.

OBJECT: Several studies of the outcomes of patients with adolescent idiopathic scoliosis (AIS) with thoracolumbar and lumbar curves after treatment with posterior pedicle screws have been reported, but most of these studies reported only 2-year follow-up. The authors analyzed the radiographic and clinical outcomes of patients with thoracolumbar and lumbar curves treated with posterior pedicle screws after 5 years of follow-up. METHODS: A multicenter database was retrospectively queried to identify patients with AIS who underwent spinal fusion for Lenke 3C, 5C, and 6C curves. Radiographs from the following times were compared: preoperative, first follow-up visit, 1-year follow-up visit, 2-year follow-up visit, and 5-year follow-up visit. Chart review included scoliometer measurements, Scoliosis Research Society (SRS)-22 questionnaires, and complications requiring return to the operating room. RESULTS: Among 26 patients with Lenke 3C, 5C, and 6C curves, the mean (± SD) age was 14.6 ± 2.1 years. From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal lumbar Cobb angles (p < 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the lumbar curve remained stable (p = 0.14). From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal thoracic Cobb angles (p < 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the thoracic curve remained stable (p = 0.10). From the first postoperative visit to the 5-year follow-up visit, the thoracic kyphosis (T5-12) remained stable (p = 0.10), and from the time of the preoperative radiographs to the 5-year follow-up radiographs, the lumbar lordosis (T-12 to top of sacrum) remained stable (p = 0.44). From the preoperative visit to the 5-year follow-up visit, the coronal balance improved significantly (p < 0.05) and remained stable from the first postoperative visit to the 5-year follow-up visit (p = 0.20). The SRS-22 total scores improved significantly from before surgery to 5 years after surgery (p < 0.0001). No patients required reoperation because of complications. CONCLUSIONS: Correction of the coronal, sagittal, and axial planes in this cohort of patients was maintained from the first follow-up measurements to 5 years after surgery. In addition, at 5 years after surgery total SRS-22 scores and inclinometer readings were improved from preoperative scores and measurements.

The impact of direct vertebral body derotation on the lumbar prominence in Lenke Type 5C curves.

OBJECT: The thoracic rib hump, caused by axial rotation of the spine, is one of the most dissatisfying cosmetic features associated with adolescent idiopathic scoliosis (AIS). However, advances in instrumentation and surgical techniques, such as direct vertebral body derotation (DVBD), have allowed improved correction in the axial plane and the rib hump. In cases of thoracolumbar/lumbar curves (Lenke Type 5), the lumbar prominence can be equally disfiguring and is often associated with waist asymmetry, another cosmetic concern. Although DVBD has been evaluated in the thoracic spine, little is known about its impact on the lumbar spine. The authors investigated the outcomes of DVBD on the lumbar prominence. METHODS: A prospectively collected multicenter database was queried for pediatric patients with AIS and Lenke Type 5 curves. All patients who underwent thoracoplasty procedures were excluded. A total of 34 patients underwent surgical correction via a posterior-only approach using pedicle screw constructs. Nineteen patients underwent concurrent DVBD, and the remaining 15 patients served as a control group and did not undergo DVBD. All patients had a minimum of 2 years of follow-up. RESULTS: The mean age of the entire cohort was 14.9 ± 2.3 years, and the majority of patients were female (88%). All patients had Lenke Type 5C curves with a mean major curve of 46.0° ± 8.7°, which corrected to 13.7° ± 7.2° (70% correction). A mean of 10.7 ± 3.0 levels were fused. Only thoracic kyphosis was significantly different between the groups preoperatively. Similarly, postoperative radiographic parameters were comparable between the groups, with equivalent percentages of correction. Although improvement in the thoracic rib hump was comparable between the groups, the DVBD group had 56.2% correction of the lumbar prominence, and the control group had 76% improvement (p = 0.05). CONCLUSIONS: Although DVBD has been a valuable tool in the management of AIS, the authors' results suggest that its application for thoracolumbar curves may be limited. Further analysis with a larger cohort is required to better ascertain the impact of DVBD on thoracolumbar curves.

Comparison of 5-year outcomes between pedicle screw and hybrid constructs in adolescent idiopathic scoliosis.

OBJECT: Pedicle screw fixation has been theorized to provide better correction of scoliotic deformity, but controversy over the benefits of pedicle screw-only constructs remains, and the longer-term impact of pedicle screw fixation as compared with hybrid constructs is unclear. In this study, a retrospective review of a prospectively collected database was conducted to determine the longer-term impact of pedicle screw fixation as compared with hybrid constructs in patients with adolescent idiopathic scoliosis (AIS). METHODS: The authors retrospectively reviewed a multicenter database of pediatric patients (ages ≤ 18) from 1995 to 2006 and identified 127 patients with Lenke Type 1-4 AIS curves with a minimum 5 years of follow-up. Patients were divided into 2 cohorts based on whether they had undergone pedicle screw fixation or fixation with hybrid constructs. RESULTS: The mean main thoracic curvature of 56.1° ± 13.0°, which corrected to 14.9° ± 9.3°, translated into a mean correction of 73% (p < 0.01). The curve was 19.4° ± 10.6° at 2-year follow-up and 20.5° ± 10.4° at 5 years. When comparing preoperative parameters between the groups, differences were noted in the magnitude of the main thoracic curve (p = 0.04), flexibility of the main thoracic curve (p = 0.02), coronal balance (p = 0.04), T2-12 kyphosis (p = 0.02), and sex (p = 0.02). The pedicle screw cohort had fewer spinal segments instrumented (p < 0.01), fewer anterior releases performed (p = 0.02), and fewer thoracoplasties performed (p < 0.01). By 5 years of follow-up, significant differences were apparent between the two cohorts with respect to upper thoracic curvature (p = 0.01), T2-12 (p = 0.02) and T5-12 (p = 0.02) kyphosis, lumbar lordosis (p < 0.01), and sagittal balance (p = 0.01). CONCLUSIONS: Although some preoperative differences did exist, outcomes were comparable between hybrid and screw constructs at 2 and 5 years. However, hybrid constructs required more concurrent anterior releases and thoracoplasties to achieve similar results.