Reliability of Modified Pauwels Angle in Preoperative Plain X-ray and Intraoperative Fluoroscope in Young Femoral Neck Fracture Fixation.

Purpose: This research aims to evaluate the reliability of modified Pauwels angle in preoperative plain X-ray and intraoperative fluoroscope. Method: This study included 48 male and 18 female patients with an average age of 36.95 years. Seven observers contributed to this study by measuring the modified Pauwels types and angles on 66 anterior-posterior (AP) views from preoperative radiographs and intraoperative fluorography. Intra-observer and inter-observer reliability was calculated using Fleiss's kappa and intraclass correlation coefficient (ICC). Results: The results showed that the intra-observer reliability for the modified Pauwels type using Kappa coefficient in preoperative and intraoperative assessments was 0.584 and 0.823, respectively. The inter-observer reliability for preoperative and intraoperative evaluations was 0.467 and 0.753 for all observers, 0.647 and 0.783 for specialized trauma orthopedists, and 0.41 and 0.752 for the residents. The modified Pauwels angle assessment in intra-observers using ICC was 0.804 preoperatively and 0.943 intraoperatively. The inter-observer for preoperative and intraoperative assessments was 0.675 and 0.834 for all observers, 0.977 and 0.982 for specialized trauma orthopedists, and 0.622 and 0.823 for residents. The difference between preoperative and intraoperative modified Pauwels angles was 9.75 ± 6.76 (p < 0.05). Eleven patients had their modified Pauwels type changed, which altered the implant selection in 8 patients. Conclusion: The modified Pauwels angle together with type assessment has excellent reliability for implant selection when implemented intraoperatively, and at least two specialized trauma orthopedists should evaluate the fracture lines.

Factors Affecting Neurological Deficits in Thoracic Tuberculous Spondylodiscitis.

BACKGROUND: Thoracic spinal tuberculosis (TB) causes destruction of the spine and compression of the adjacent spinal cord. This study aimed to identify the risk factors for neurological deterioration in patients with thoracic spinal TB to guide decision-making regarding immediate surgery before the onset of weakness. METHODS: Demographic, clinical, laboratory, and radiologic (x-ray and magnetic resonance imaging) data of 115 patients with active thoracic spinal TB were retrospectively analyzed. Patients with neurological status categorized as Frankel grades A, B, or C (n = 71) were classified as the neurological deficit group, while those with neurological status categorized as Frankel grades D and E (n = 44) constituted the control group. Univariate and multivariate logistic regression analyses were used to predict the risk factors for neurological deficits. RESULTS: The mean patient age was 57.2 years. The most common lesion location was the distal thoracic region (T9-L1; 62.6%). Paradiscal involvement was the most common form of involvement (73%). In the univariate analysis, the significant risk factors associated with neurological worsening were overweight (body mass index [BMI] >25), C-reactive protein level > 20 mg/L, panvertebral involvement, loss of cerebrospinal fluid posterior to the cord, cord signal changes, and canal compromise. The multivariate analysis revealed that only BMI >25 (adjusted OR = 16.18; 95% CI 1.60-163.64; P = 0.018), cord signal changes (adjusted OR = 7.42; 95% CI 1.85-29.74; P = 0.005), and canal encroachment >50% ( adjusted OR = 51.86; 95% CI 5.53-486.24; P = 0.001) were independent risk factors for predicting the risk of neurological deficits. CONCLUSIONS: Overweight (BMI >25), cord signal changes, and canal compromise >50% significantly predicted neurological deficits in patients with thoracic spinal TB. Prompt spinal surgery should be considered before progressive worsening of the neurological condition in patients with all of these risk factors. CLINICAL RELEVANCE: Predictive factors for neurological deficits in thoracic spinal TB were determined. Overweight, cord signal changes, and canal compromise >50% showed predictive value. These factors can help identify patients who require early surgical intervention.

IgG4-Related Spinal Hypertrophic Pachymeningitis With Neurological Deficit: A Report of 2 Cases.

CASE: Immunoglobulin G4 (IgG4)-related spinal hypertrophic pachymeningitis (IgG4-RHP) is a rare disease characterized by diffuse inflammatory fibrosis of the spinal dura mater that can cause myelopathy and neurological deficits. Here, we report 2 cases in which both patients presented with myelopathy and paraplegia. They underwent decompressive laminectomy, and the diagnoses were confirmed through histopathologic examination. Both patients received prednisolone postoperatively, which was subsequently switched to methotrexate for maintenance. CONCLUSION: Two cases of IgG4-RHP were successfully treated with decompressive laminectomy and combined therapy with steroids and other immunosuppressive agents.

Cost-utility Analysis of Anterior Cervical Discectomy and Fusion for Cervical Spondylosis Patients Comparing Polyetheretherketone Versus Tricortical Iliac Crest Bone Graft.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To perform a cost-utility analysis and to investigate the clinical outcomes and patient's quality of life after anterior cervical discectomy and fusion (ACDF) to treat cervical spondylosis compared between fusion with polyetheretherketone (PEEK) and fusion with tricortical iliac bone graft (IBG) in Thailand. SUMMARY OF BACKGROUND DATA: ACDF is one of the standard treatments for cervical spondylosis. The fusion material options include PEEK and tricortical IBG. No previous studies have compared the cost-utility between these 2 fusion material options. PATIENTS AND METHODS: Patients with cervical spondylosis who were scheduled for ACDF at Siriraj Hospital (Bangkok, Thailand) during 2019-2020 were prospectively enrolled. Patients were allocated to the PEEK or IBG fusion material group according to the patient's choice of fusion material. EuroQol-5 dimensions 5 levels and relevant costs were collected during the operative and postoperative periods. A cost-utility analysis was performed using a societal perspective. All costs were converted to 2020 United States dollars (USD), and a 3% discount rate was used. The outcome was expressed as the incremental cost-effectiveness ratio. RESULTS: Thirty-six patients (18 ACDF-PEEK and 18 ACDF-IBG) were enrolled. Except for Nurick grading, there was no significant difference in patient baseline characteristics between groups. The average utility at 1 year after ACDF-PEEK and ACDF-IBG were 0.939 ± 0.061 and 0.798 ± 0.081, respectively ( P < 0.001). The total lifetime cost of ACDF-PEEK and ACDF-IBG was 83,572 USD and 73,329 USD, respectively. The incremental cost-effectiveness ratio of ACDF-PEEK when compared with that of ACDF-IBG showed a gain of 4468.52 USD/quality-adjusted life-years, which is considered cost-effective at the Thailand willingness-to-pay threshold of 5115 USD/quality-adjusted life-year gained. CONCLUSIONS: ACDF-PEEK was found to be more cost-effective than ACDF-IBG for treating cervical spondylosis in Thailand. LEVEL OF EVIDENCE: Level II.

Incidence and Associated Factors for Kyphosis Progression in Short-Segment Fixation Thoracolumbar Spine Fractures.

BACKGROUND: The thoracolumbar spine is the most frequently affected portion of the spine during fractures. In surgical management, short-segment fixation is the treatment of choice because of preserved spine motion and fewer complications. However, this technique causes concerns of kyphosis progression compared with long-segment fixation. The widely used load-sharing classification was of limited value for predicting kyphosis progression in recent literature. The goal of this study was to identify the incidence and explore the factors associated with kyphosis progression in short-segment fixation in thoracolumbar spine fractures. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with thoracolumbar spine fractures and no known neurological deficits treated by short-segment fixation and followed up for at least 12 months during January 2015 to October 2019 were included in this study. Demographic and radiographic data parameters were collected from the hospital database. Incidence of kyphosis progression was collected, and multivariable logistic regression analysis was used to explore associated factors. RESULTS: A total of 91 patients were included in this study. The most common fractures were AO-type A3 in 57.7% of patients, followed by A4 in 31.9%, A2 in 9.9%, and B in 6.6%. Posterior ligamentous complex (PLC) injuries were found in 51.7%. The incidence of kyphosis progression was 35.2%. The PLC was found to be significantly associated with kyphosis progression (OR 3.14, P = 0.040). Intermediate screw insertion was a preventive factor (OR 0.11, P = 0.043). Age, body mass index, and type of fracture were not significant associated factors. CONCLUSION: The incidence of kyphosis progression was 35.2%. The PLC injury and intermediate screw insertion were significant associated factors. Long-segment fixation in a patient who had PLC injury or intermediate screw insertion should be considered to prevent kyphosis progression. CLINICAL RELEVANCE: PLC injury was significantly associated with kyphosis progression in short segment thoracolumbar fracture fixation. Therefore, the surgeon should carefully select treatment options for these groups of patients.

Cup Alignment Change after Screw Fixation in Total Hip Arthroplasty.

BACKGROUND: Cup malalignment increase impingement, dislocation, cup migration, and polyethylene wear. Screw fixation for enhanced stability is the preferred option in cases of doubtful primary cup stability. There have been few studies about alignment changes after screw fixation, which may be another cause of cup malalignment. This study aimed to evaluate cup alignment change after screw fixation. MATERIALS AND METHODS: Patients undergoing imageless navigation total hip arthroplasty using screws fixation for acetabular cup were corrected. After the press-fit cup was fully seated, the cup orientation was recorded. After screws were inserted, the cup orientation was recorded again to calculate the alignment change. RESULTS: There were 99 cases with a mean age 63.7 years (25-93). Alignment change after screw fixation was found in 73 cases (73.7%). There were 56 cases (56.6%) with inclination angle change and the mean change was 2.21° (0°-8°). The inclination angle increased in 47 cases (47.5%) with 9 cases (9.1%) increased by 5° or more and decreased in 9 cases (9.1%). There was statistically significant difference between patients using one screw and patients using two or more screws in inclination angle change, 1.56° (0°-5°) and 3.4° (0°-8°), respectively (P = 0.0039). There was statistically significant correlation between inclination angle change and number of screws (r = 0.5401, P < 0.01). There were 49 cases (49.5%) with anteversion angle change and the mean change was 1.67° (0°-5°). The anteversion angle increased in 31 cases (31.3%), decreased in 18 cases (18.2%) with two cases (2%) decreased by 5° or more. There was significant difference between patients using one screw and patients using two or more screws in anteversion angle change, 1.46° (0°-5°) and 2.21° (0°-5°), respectively (P = 0.009). There was significant correlation between anteversion angle change and number of screws (r = 0.284, P = 0.048). CONCLUSIONS: Changes in cup alignment after screw fixation were detected in most cases. It is one possible cause of cup malalignment.

A Randomized Controlled Trial of Topical Application of Tranexamic Acid in Patients with Thoracolumbar Spine Trauma Undergoing Long-Segment Instrumented Posterior Spinal Fusion.

STUDY DESIGN: Prospective, randomized controlled trial. PURPOSE: To evaluate the effect of topically applied tranexamic acid (TXA) on postoperative blood loss of neurologically intact patients with thoracolumbar spine trauma. OVERVIEW OF LITERATURE: Few articles exist regarding the use of topical TXA for postoperative bleeding and blood transfusion in spinal surgery. METHODS: A total of 57 patients were operated on with long-segment instrumented fusion without decompression. In 29 patients, a solution containing 1 g of TXA (20 mL) was applied to the site of surgery via a drain tube after the spinal fascia was closed, and then the drain was clamped for 2 hours. The 28 patients in the control group received the same volume of normal saline, and clamping was performed using the same technique. The groups were compared for postoperative packed red cells (PRC) transfusion rate and drainage volume. RESULTS: The rate of postoperative PRC transfusion was significantly lower in the topical TXA group than in the control group (13.8% vs. 39.3%; relative risk, 0.35; 95% confidence interval, 0.13 to 0.97; p=0.03). The mean total drainage volume was significantly lower in the topical TXA group than in the control group (246.7±125 mL vs. 445.7±211.1 mL, p<0.01). No adverse events or complications were recorded in any patient during treatment over a mean follow-up period of 27.5 months. CONCLUSIONS: The use of topically administered 1 g TXA in thoracic and lumbar spinal trauma cases effectively decreased postoperative transfusion requirements and minimized postoperative blood loss, as determined by the total drainage volume.

Deviation of cup alignment from target angle during press-fit insertion.

BACKGROUND: Several factors lead to cup malalignment including preoperative pelvic tilt, inaccurate pelvic position on the operating table, pelvic movement during the operation and alignment change after screw fixation of the cup. There are few studies about the deviation of cup alignment from target angle during press-fit insertion, which may be the other cause of cup malalignment. The purpose of this study was to evaluate the deviation of cup alignment from target angle during press-fit insertion by using imageless navigation and to define any influential factors, including gender, age and side of operation. METHODS: Between February 2016 and March 2017, patients undergoing total hip arthroplasty (THA) with imageless navigation were included in the present single-center study. Cup inclination angle was set at 40 degrees in all cases but the anteversion angle varied depending on the stem anteversion in each case using a combined anteversion technique. The final cup was aligned at target angles in both inclination and anteversion, the tracker was detached from the insertion handle and the surgeon inserted the cup until it was seated completely. The tracker was attached again to display both inclination and anteversion angles and these angles were recorded. Deviated Inclination Angles (DIA) and Deviated Anteversion Angles (DAA) in each case were calculated. RESULTS: There were 124 cases in the present study. The mean age of the patients was 60.2 years (25-93). There were equal numbers of right-sided and left-sided operations, 62 cases each. There were 114 cases (91.9%) with DIA. The mean DIA was 2.65° (0°-8°, SD 1.66). The DIA decreased in 107 cases (86.3%) with 12 cases (9.7%) showing a decrease of 5° or more. The DIA increased in 7 cases (5.6%) with 2 cases (1.6%) showing an increase of 5° or more. There were 103 cases (83.1%) with DAA. The mean DAA was 2.3° (0°-14°, SD 2.3). The DAA increased in 78 cases (62.9%) with 11 cases (8.3%) increasing by 5° or more. The DAA decreased in 25 cases (20.2%) with 4 cases (3.2%) decreasing by 5° or more. The DIA was significantly higher in males than in females (p = .012). There was significant correlation between DAA and patient's age (p = .037). There was no significant difference between DIA or DAA and side of operation. CONCLUSION: Changes in cup orientation were observed in most cases during cup insertion with hammer blows detected by imageless navigation. Deviation of cup alignment from target angle during press-fit insertion was a possible cause of cup malalignment, male gender and patient's age were influential factors.

Impact on Neurological Recovery of Transforaminal Debridement and Interbody Fusion versus Transpedicular Decompression in Combination with Pedicle Screw Instrumentation for Treating Thoracic and Lumbar Spinal Tuberculosis.

STUDY DESIGN: Retrospective study. PURPOSE: To compare the neurological outcome of transforaminal debridement and interbody fusion with transpedicular decompression for treatment of thoracic and lumbar spinal tuberculosis. OVERVIEW OF LITERATURE: Few articles have addressed the impact of neurological recovery in patients with tuberculosis who were treated by two different operative methods via the posterior-only approach. METHODS: Clinical and radiographic results of one-stage posterior instrumented spinal fusion for treatment of tuberculous spondylodiscitis with neurological deficits were reviewed and analyzed from 2009 to 2013. The extensive (E) group consisted of patients who received transforaminal debridement and interbody fusion, whereas transpedicular decompression was performed on limited (L) group. Rapid recovery was improvement of at least one Frankel grade within 6 weeks after operation. Otherwise, it was slow recovery. RESULTS: All 39 patients had improved neurological signs. The median follow-up period was 24 months. Proportionately younger patients (under 65 years of age) received extensive surgery (15 of 18, 83.3% vs. 11 of 21, 52.4%; p=0.04). The mean operative time and blood loss in the group E were higher than in the group L (both p<0.01). With regard to type of procedure, especially at thoracic and thoracolumbar spine, patients who underwent extensive surgery had rapid neurological recovery significantly different from those of limited surgery (p=0.01; Relative Risk, 3.06; 95% Confidence Interval, 1.13 to 8.29). CONCLUSIONS: Transforaminal debridement and interbody fusion provides more rapid neurological recovery in patients with thoracic and thoracolumbar spinal tuberculosis compared to transpedicular decompression.

Neurological Recovery Determined by C-Reactive Protein, Erythrocyte Sedimentation Rate and Two Different Posterior Decompressive Surgical Procedures: A Retrospective Clinical Study of Patients with Spinal Tuberculosis.

BACKGROUND: C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) not only are useful in the diagnosis but also are reliable parameters in evaluating the response to treatment and prognosis of tuberculous spondylodiscitis. OBJECTIVE: To analyze the correlation between neurological recovery and declination of CRP or ESR after two different posterior spinal procedures. MATERIAL AND METHOD: The patients who had neurological deficit due to spinal tuberculosis and undergone spinal surgery between January 2009 and June 2013 were analyzed retrospectively. Posterior transforaminal decompression and interbody fusion were done in group I, whereas posterior transpedicular decompression and posterolateralfusion were performed on group II. Both groups were stabilized with pedicle screw instrumentation. Rapid recovery represented by improvement of at least one Frankel grade within 6 weeks after operation, otherwise it was slow recovery. Inflammatory markers were evaluated at initial diagnosis and at 6-week, 3-month, 6-month, and 1-year post-operation. RESULTS: There were 31 patients. Group I included 14 cases and group II consisted of 17 cases. The median CRP and ESR at diagnosis were 80.4 mg/L and 78.0 mm/hour respectively. Rapid neurological recovery significantly related to the earlier declination of CRP within the first 6 weeks (p < 0.001). Considering the type of spinal procedures especially at thoracic and thoracolumbar level, neurological recovery in group I was significantly faster than in group II (p = 0.02; relative risk, 2.67; 95% confidence interval, 1.02 to 6.91). CONCLUSION: Earlier declination of CRP within six weeks post-operation could determine rapid neurological recovery. Posterior transforaminal decompression and interbody fusion with instrumentation may be a suitable optionfor thoracic and thoracolumbar lesions.

Effectiveness of Mom-made Pavlik harness for maintaining reduction of the hip in DDH.

BACKGROUND: Co-operation of the parent is a major factor for successful treatment of developmental dysplasia of the hip (DDH). The commercial Pavlik harness is too expensive and the parent may not understand or refuse its use. Regarding the function of the Pavlik harness and awareness of complications, a Mom-made Pavlik harness was developed. OBJECTIVE: To evaluate the effectiveness of Mom-made Pavlik harness in maintaining the reduction ofDDH MATERIAL AND METHOD: Infants with Ortolani positive DDH, ages up to five months, treated at Maharat Nakhon Ratchasima Hospital between October 2003 and September 2012, were analyzed, retrospectively. Irreducible DDH, neuromuscular DDH and hyperlaxity syndrome were excluded. A Mom-made Pavlik harness was used to maintain reduction after the initial two weeks of a hip spica cast. The success of treatment was evaluated by ultrasound of the hip. The center edge (CE) angle was measured from AP film at age one and four years. RESULTS: There were 24 infants, 35 hips with 11 bilateral, seven left and six right sides DDH. Thirty-two hips were successfully reduced (91.4%). Three hips had recurrent dislocation. Two of these were further managed by adductor tenotomy and closed reduction under general anesthesia and hip spica cast, followed by hip abduction brace. Another was treated by open reduction and Salter's innominate osteotomy. The average CE angle at age one and four years was 16.5 and 25.9 degree, respectively. CONCLUSION: Treatment of the infants with DDH requires a long period of care not only in hospital but also at home. Therefore, it needs the diligence, intention and regularity by their parents to achieve a successful outcome. The Mom-made Pavlik harness represents the spirit of this resolution.