Allografts use in orthopedic surgery: trend change over the past 11 years from a regional tissue bank.

Allografts are the second most transplanted tissue in medicine after blood and are now increasingly used for both primary and revision surgery. Allografts have the advantages of lower donor site morbidity, availability of multiple grafts, and shorter operative time. The Banks represents the bridge between Donor and Recipient and guarantees the quality and safety of the distributed allografts Given the increasing interest in these tissues, a retrospective analysis of data collected from the Regional Musculoskeletal Tissue Bank registry over an 11-year period (2009-2019) was conducted. The statistical analyses used were the Shapiro-Wilk normality test and a Poisson regression model. From January 2009 to December 2019, a total of 14,199 musculoskeletal tissues stored in the Regional Musculoskeletal Tissue Bank were provided for surgical allograft procedures. In 2009, the number of allografts performed was 925; this figure has steadily increased to 1599 in 2019. Epiphyses were taken as the reference tissue with an almost constant trend over the period, while a significant increase was denoted for extensor mechanism allograft, ligaments, tendons and long bone corticals (p < 0.001), processed bone tissues had no change in trend (p = 0.841). There was also a gradual decrease in the rate of microbiological positivity, as determined by bacteriological and serological tests performed on the collected tissues. This phenomenon is due to improved sampling techniques and the training of a dedicated team. Thus, we have seen how the use of allografts in orthopedic surgery has increased over the past 11 years, uniformly in terms of tissue type, except for the noticeable increase in ligamentous tissue.

Transforaminal lumbar interbody fusion with a tantalum cage: lumbar lordosis redistribution and sacral slope restoration with a modified posterior technique.

BACKGROUND: Transforaminal lumbar interbody fusion (TLIF), a commonly used procedure in spine surgery, has the advantage of a lower incidence of nerve lesions compared to the posterior lumbar interbody fusion (PLIF) technique. The intersomatic arthrodesis has always been carried out with a single tantalum cage normally used for PLIF. Tantalum is a metal that is particularly used in orthopedic surgery. It has a modulus of elasticity similar to marrow and leads to high primary stability of the implant. MATERIALS AND METHODS: Our study was a retrospective monocentric observational study evaluating clinical and radiological outcomes of tantalum cages in a modified TLIF technique with posterior instrumentation and autologous and/or homologous posterolateral bone grafting. The aim of the study was to evaluate clinical outcomes and the increase in or redistribution of lumbar lordosis. The intersomatic arthrodesis was always carried out with a single tantalum cage normally used for PLIF to reduce the neurological risk. We retrospectively studied 105 patients who were treated with a modified unilateral TLIF approach by two surgeons between 2013 and 2018. We evaluated the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back pain, global lumbar lordosis, lordosis of L4-sacrum, segmental lordosis of functional motion units that underwent arthrodesis, pelvic tilt, pelvic incidence, and the sacral slope in 77 patients. All patients were suffering from grade III or IV Pfirrmann, instability, or foraminal post-laminectomy stenosis and/or grade I-II degenerative spondylolisthesis or low-grade isthmic spondylolisthesis. They had no significant sagittal imbalance, with a sagittal vertical axis (SVA) of < 5 mm. The average follow-up duration was 30 months. RESULTS: We achieved excellent clinical results, with only four cases of failure (5.2%). Moreover, we noticed a statistically significant redistribution of lumbar lordosis, with an average percentage increase in L4-S1 lordosis equal to 19.9% (P < 0.001), an average increase in the L4-S1/Lumbar lordosis (LL) ratio from 0.53 to 0.63 (P < 0.001), and a mean percentage increase in sacral slope equal to 7.6% (P < 0.001). CONCLUSION: Thanks to the properties of tantalum, our modified single-portal TLIF technique is a valid surgical solution to obtain a solid arthrodesis and restore the correct lumbar lordosis distribution while reducing neurological complications and the number of failures. LEVEL OF EVIDENCE: 4 Trial registration statement: retrospective observational study, no trial registration.

What Is the Role of Traction Test Radiographs in the Preoperative Planning of Adolescent Idiopathic Scoliosis?

Lower instrumented vertebra (LIV) selection is critical to avoid complications like adding-on. This study aims to determine the usefulness of the traction test (TR) in selecting the LIV during surgery for adolescent idiopathic scoliosis (AIS). We analyzed 42 AIS patients with Lenke 1 curves who had preoperative, postoperative, and at least 12-month follow-up X-rays, as well as preoperative side bending (SB) and TR radiograms. Neutral vertebra (NV), stable vertebra (SV), lower instrumented vertebra (LIV), and Cobb angles were identified and compared on all radiographic images. In 23 cases, the TR resulted in SV proximalization compared to the preoperative X-rays, while in 8 cases, SV-TR was more distal. This distalization occurred in 50% of Lenke 1C curves, where a greater correction of the distal curve was found. NV-TR was proximal to NV-preop in 9 cases, while NV-SB was proximal in 22 cases. LIV was proximal to SV-TR in 8 cases, while it was proximal to SV-preop in 22. One patient with LIV proximal to SV-TR developed adding-on. In conclusion, the TR is crucial in AIS preoperative planning as it provides information distinct from that of standard X-rays and SB: (1) it better assesses gravitational stability than rotational stability; and (2) choosing LIV equal to or proximal to SV-TR may prevent adding-on, except in 'flexible' Lenke 1C curves where LIV should be equal or distal to SV-preop.

Paraparesis and congenital severe hyperkyphosis in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: A rare deformity management during the Sars-Cov-2 pandemic.

Introduction: Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) syndrome can be classified into two types: type I (isolated) without extragenital abnormalities; type II (associated) with the presence of extragenital dimorphisms. Skeletal abnormalities are the second most frequent extragenital manifestations. Research question: Association between MRKH and congenital scoliosis has been described; on the contrary, hyperkyphosis is very rare and sparsely described in the medical literature. Here we report our experience in the management of thoracolumbar hyperkyphosis in 16-year-old patient diagnosed with MRKH syndrome with an acute neurological impairment due to T11-T12 disc herniation. Material and methods: Clinical and radiological images of the case were retrieved from the medical notes, operative records and imaging system. Results: Posterior surgical correction was proposed to treat the severe spinal deformity; however, surgery was delayed because of SARS-CoV2 pandemic outbreak. During the pandemic, the patient had a major clinical and radiological deterioration with development of paraparesis. Complete clinical resolution of the paraparesis and restoration of balance was achieved with a two stage surgical approach, with a first anterior stage followed by a delayed posterior approach aimed at deformity correction. Discussion: Congenital kyphosis are rare deformities that can progress rapidly leading to severe neurological deficits and worsening of the deformity. When patient has neurological deficit the surgical strategy to address the neurological problem first and plan the more complex and demanding corrective surgery remains a valid strategy that must be consider. Conclusion: This is the first reported case of hyperkyphosis in Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) syndrome surgically treated.

Is posteromedial translation with sublaminar bands effective in correcting axial rotation in adolescent idiopathic scoliosis surgery? A 3D reconstruction study.

PURPOSE: Hybrid constructs with sublaminar bands have recently regained popularity as an alternative to all-screw construct for correction of adolescent idiopathic scoliosis (AIS). The aim of this study is to evaluate the ability of hybrid constructs with sublaminar bands to achieve a tridimensional correction of the scoliotic deformity. Our hypothesis is that hybrid construct with sublaminar bands are able to achieve a substantial derotation of the apical vertebrae, while preserving the thoracic kyphosis. METHODS: A prospective evaluation of 50 consecutive cases (41 F, 9 M, mean age 14.7 ± 2 years) of AIS correction with hybrid construct was performed. In all cases, sublaminar bands were used at the apex of the main curve on concave side. All patients underwent pre and postoperative X-rays with EOS System, with full 3D reconstruction. Spinopelvic parameters and axial rotation of the vertebrae were measured pre and postoperatively. RESULTS: 2.7 ± 0.9 mean sublaminar bands were used per patient. Mean correction of deformity was 50 ± 9.5%. on the coronal plane. The mean axial rotation of the apical vertebra went from 18° ± 11.5° preoperatively to 9.4° ± 7.2° postoperatively (p < 0.001) with a mean derotation of 47.7%. Thoracic kyphosis went from 32.1° ± 18° preoperatively to 37.3° ± 13.1° postoperatively (p < 0.05). No intraoperative complications due to sublaminar bands were recorded. CONCLUSIONS: Hybrid construct with sublaminar band have been showed to be safe and effective in deformity correction and in maintaining or restoring thoracic kyphosis. This study showed that with sublaminar bands applied at the curve apex a substantial derotation of the apical vertebrae can be achieved.

Indications for the monosegmental stabilization of thoraco-lumbar spine fractures.

PURPOSE: To evaluate the efficacy and to underline the right indications of the posterior monosegmental stabilization for the treatment of thoraco-lumbar spine fractures. METHOD: Twenty patients underwent a monosegmental stabilization at our Institution and were retrospectively reviewed with a minimum follow-up of two years. All the patients had a clinical and radiological assessment before, after the surgery and at final follow-up. All data were evaluated by one independent observer. Data collected were Denis pain and work scale, somatic kyphosis (SK), somatic height (SH), and compression percentage (CP). RESULTS: The mean pre-operative SK angle measured between the upper and lower end plate of the fractured vertebra was 23.6°. The mean SK immediately after surgery was 12.8° and at final follow-up was 13.9°. The mean pre-operative SH was 21.9 mm, the mean value after surgery was 26.5 mm, and at final follow-up was 24.8 mm. The mean pre-operative CP was 66.7%, the mean value after surgery was 80.9%, and at final follow-up was 75.3%. At final follow-up, 75% of the patients had no pain or moderate pain and 95% of the patients returned to a full time work. CONCLUSIONS: Monosegmental stabilization with fusion is a safe and effective method to treat well selected thoracolumbar spine fractures. The right indications are type A1, type B2, and type A3 with a load sharing of less than 7 points and some very well selected type C fractures in which there is not lateral and rotatory displacement.

Apical vertebral derotation and translation (AVDT) for adolescent idiopathic scoliosis using screws and sublaminar bands: a safer concept for deformity correction.

PURPOSE: To assess the efficacy and safety of a new deformity correction philosophy treatment for AIS called apical vertebral derotation and translation (AVDT). METHODS: It is a retrospective study of prospectively collected data concerning two different scoliosis correction techniques used in our department. A total of 81 patients (22M, 59F) with a mean age of 15.5 years and minimum follow-up of 2 years were reviewed. Patients were divided into two groups according to the correction technique: 36 patients underwent single-rod derotation using all screws construct (AS), while 45 patients underwent apical vertebral derotation and translation using screws and sublaminar bands (SB). RESULTS: The mean improvement of the MT curve was 70% in the AS group and 60.6% in the SB group, while the mean improvement of the TL/L curve was 65.5 and 72.4%, respectively. PT increased in both groups after surgery with a mean amount of 2.5° in the AS group and only 1° in the SB group. We observed also a greater amount of cervical lordosis reduction in the AS group (4.5°) compared with the SB group (only 1°). The SB group had less operative time and less blood loss. CONCLUSION: There was no significant difference between the two groups at the final follow-up and both techniques led to an excellent correction in the frontal plane; in the sagittal plane, the AVDT technique seemed to give less sagittal imbalance with better cervical profile; the surgical procedure is easy with less operative time, less blood loss and less risk of potential complications. These slides can be retrieved under Electronic Supplementary Material.

Long-term Radiological and Clinical Outcomes After Using Bone Marrow Mesenchymal Stem Cells Concentrate Obtained With Selective Retention Cell Technology in Posterolateral Spinal Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study was to evaluate the long-term clinical and radiological outcomes of the use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect with a particular collagen scaffold, Healos for posterolateral spinal fusion. SUMMARY OF BACKGROUND DATA: With the increasing rate of spinal fusion, the problem of pseudarthrosis, which contributes to recurrent pain with patient disability, is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being carried out to develop an alternative source of bone grafting and improve the spinal fusion rate. METHODS: A retrospective review of hospital records was performed. Identified patients were contacted to have a clinical and radiological evaluation follow-up. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing dynamic flexion/extension lateral views and calculation of segmental Cobb angle. Any implant-associated complication was reported. Computed tomography (CT) scans were also performed. RESULTS: Twenty-one patients were included and all patients achieved successful fusion. The mean difference of the segmental Cobb angle was 0.48° (range 0.3°-0.7°). Computed tomography scans showed solid bilateral fusion with bridging bone (Grade I) in all patients, but solid unilateral fusion with bridging bone (Grade II) was detected for one patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.1 ±â€Š2.1, whereas the ODI was 10.5 ±â€Š5.6 points, and the mean disability index was 21.1%. CONCLUSION: The use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology could be considered as an effective means for augmenting spinal fusion. LEVEL OF EVIDENCE: 3.

Complication rate in adult deformity surgical treatment: safety of the posterior osteotomies.

PURPOSE: The treatment of adult scoliosis is a challenge especially in patients over 50 years old with severe, rigid curves in whom the use of vertebral osteotomies may be necessary to correct the deformity. The aim the study was to analyse the perioperative complications related to vertebral osteotomies in elderly treated for spinal deformity. METHODS: We analysed 72 consecutive cases of kyphoscoliosis, we classify them according to Berjano-Lamartina classification. We divided patients into two groups: we only practised SPO and/or PO in patients that composed group A; we practised also PSO in patients that composed group B. We retrospectively analysed the perioperative complications and radiographical results. Average follow-up was 30 months. RESULTS: We had 50 cases of degenerative segment diseases (DSD) Type III, 13 Type IVa DSD and 9 Type IVb DSD. Mean age was 60.7 years old. Overall complication rate was 22.2 %. In group A, the complication rate was 16.9 % while in group B it was 46.2 %. Mean Cobb primary curve angle was 41.75° with average C7 plumb line (C7PL) of 4.49 cm, residual scoliosis after surgery was 15.41° and average C7PL of 2.08 cm, with statistically significant differences. CONCLUSIONS: Previous studies have shown increased complication rates with vertebral osteotomies in elderly patients, our experience support this evidence. Our study demonstrates a high incidence of intraoperative complication rate in elderly patients underwent a PSO. PSO is a demanding technique to be considered in very selected and motivated patients who must be carefully informed about the risks of the procedure.

Sagittal balance in adolescent idiopathic scoliosis: radiographic study of spino-pelvic compensation after surgery.

STUDY DESIGN: Radiographic retrospective study of a consecutive series of 76 patients with adolescent idiopathic scoliosis (AIS) undergoing posterior only surgical correction and fusion. OBJECTIVE: To evaluate the sagittal profile changes in a population of adolescent idiopathic scoliosis after posterior only surgical correction. Although the relationship between pelvic indexes and sagittal profile is well known, little has been published about the sagittal profile changes after posterior surgery in adolescent idiopathic scoliosis. METHODS: Radiological data of 76 AIS patients were analyzed by an independent observer to compare pelvic indexes and spino-pelvic parameters before and at the last follow-up after surgical posterior correction. All patients underwent a posterior only surgical correction by using different anchor techniques (all screws or hybrid construct), but the same derotation correction maneuver (C-D technique). The collected data were analyzed, on AP and LL radiographic views of the entire spine in the upright position, from the same independent observer and using the same Impax software analysis. We collected for each patient on latero-lateral X-rays the following data: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), C7 plumb line (C7PL) and spino-sacral angle (SSA). All data were analyzed using a D'Agostino-Pearson normality test and the comparison between the groups was performed with a student's t test. RESULTS: The mean pelvic incidence (PI) of the cohort was 48.89° (± 11.24), with a mean Cobb angle for the main curve of 60.13° (± 13.6). The mean value of residual scoliosis after surgery was 28.18° (± 13.22) with an average improvement of the curve in the frontal plane of 53.2 %. The amount of curve correction of the primary scoliosis curve was statistically significant (p < 0.0001). In the evaluation of the whole group after surgery, we observed an increasing amount of PT (average delta value 2.38°) with a statistical significance (p = 0.0034). If we compare the mean ideal PT value (11.09°) with the pre- and post-operative mean true PT values, we found statistical significance only for the post-operative difference (p = 0.0014). In the general assessment, C7PL seems to remain stable after surgery, and in particular it remains negative. In Lenke 1 group, there was a mean PI value of 50.54° (± 11.45) which is higher than the one reported in the global assessment. Also in this subgroup, we observed a reduction in the mean SS values, with consequent increase in the PT values, as in the general assessment. The C7PL tends to move posteriorly after surgery and this difference is statistically significant. In Lenke 1 group we found a strong statistical significance between pre- and post-surgery data for the Cobb primary curve and for the C7PL, which continues to remain negative. The C7PL remains relatively stable only in the normokyphotic group, while it tends to move behind in the other three groups (Lenke 3, hyperkyphosis and hypokyphosis). CONCLUSIONS: In our series of 76 adolescent affected by AIS, we reported mean PI values of 48.9° with a mean pre-operative PT of 11.51°. After surgery we observed an increase in the PT mean value, about three degrees higher than the ideal value, meaning that there was some compensatory mechanism. Patients affected by AIS showed a slight posterior imbalance and the intervention of scoliosis correction seems to cause a slight further posterior imbalance, especially in Lenke 1 type curves and in patients with hypokyphosis. The clinical significance of this slight imbalance must be carefully evaluated. Further studies are necessary to better establish which could be the best surgical strategy to obtain an optimal spinal sagittal balance.

Cement leakage: safety of minimally invasive surgical techniques in the treatment of multiple myeloma vertebral lesions.

PURPOSE: To evaluate and address the safety of vertebroplasty (VP) and kyphoplasty (KP) in terms of rate and type of cement leakage in the treatment of Multiple Myeloma (MM) vertebral fractures. METHODS: A total number of 37 treated vertebrae were evaluated post-operatively by using standard X-rays and CT scan looking for a cement leakage. VP was done using a monoportal approach in all cases (18 treated levels, group A), while KP was done using a monopedicular approach in 9 levels (group B1) and using a bipedicular approach in the remaining 10 levels (group B2). A computed tomography was used to establish the presence of any cement leakage and to determine its localization. RESULTS: Vertebral augmentation through VP and KP provides immediate pain relief and an improvement of the quality of life of patients affected by MM but it is gravated by high risk of cement leakage. Cement extravasation occurred in 27.7% of total VP procedures and in 21.05% of total KP procedures, but considering the whole number of treated levels, it was more common in multi-level VP and in bipedicular KP, in which a higher quantity of cement was employed. CONCLUSIONS: KP procedure in these patients is slightly less risky but we suggest doing it with a monopedicular approach. It's mandatory to use an high viscosity cement and we suggest not to use an amount of PMMA over 2 cc and a previous treatment with bone marrow transplant is related to a lower risk of cement leakage.

Efficacy of unipedicular baloon kyphoplasty for treatment of multiple myeloma vertebral lesions.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To analyze differences in between the unipedicular vs. bipedicular balloon kyphoplasty for the treatment of multiple myeloma lesions. OVERVIEW OF LITERATURE: Both vertebroplasty and kyphoplasty are reported to be effective for the treatment of vertebral compression fractures in multiple myeloma patients. Kyphoplasty is often performed with a bipedicular approach while vertebroplasty with a monopedicular approach. Monopedicular kyphoplasty is investigated as a viable surgical technique alternatively in comparison with the bipedicular method. METHODS: We performed 37 vertebral body augmentation procedures, 18 vertebroplasty (group A) and 19 kyphoplasty, 9 unipedicular approaches (group B1) and 10 bipedicular approaches (group B2), on 14 patients affected by multiple myeloma with a mean clinical and radiographic follow up of more than 12 months. RESULTS: Both kyphoplasty techniques lead to a better postoperative improvement of the vertebral height and kyphotic deformity if compared with the vertebroplasty, with a statistical significance for the body height restoration only (p = 0.0066). The unipedicular and the bipedicular kyphoplasty have similar results in term of kyphotic deformity correction and height restoration. The 85.7% (12/14) of the patients had an immediate improvement of the pain and no difference between the vertebroplasty and kyphoplasty groups were observed regarding the pain. We observed a 24.3% of cement leakage in all groups with no clinical symptoms and noticed that the risk of extravasations was higher in multilevel treatment, in bipedicular kyphoplasty procedures and in patients not treated previously with a bone marrow transplant. CONCLUSIONS: Both vertebroplasty and kyphoplasty are effective in treating vertebral compression fracture due to multiple myeloma. Unipedicular kyphoplasty could give equivalent results as with bipedicular kyphoplasty in multilevel disease, aiming only to restore the sagittal alignment of the spine and the height of the vertebral body especially at the thoracolumbar spinal segment.

Alternative fixation method for open femoral fractures from a damage control orthopaedics perspective.

A decision for immediate versus delayed fixation in a polytrauma patient mainly in cases of open femoral fracture depends upon time elapsed since injury, duration of stay in intensive care, soft tissue status, probable intra-operative difficulties and presence of systemic complication. We studied the outcome of the Taylor Spatial Frame (TSF) as a solution in the role of primary and definitive fixator for patients in whom definitive osteosynthesis with intramedullary nailing (IMN) can be associated with higher rate of complications. In view of damage control orthopaedics (DCO), we found that TSF is an effective technique compared to internal nails and earlier external fixator devices, attributable to its advantages such as continuity of frame till union, preventing any second-hit phenomenon, early mobilisation and restoration of primary defect due to bone loss by differential distraction osteogenesis without additional surgery. According to the Paley and Maar's evaluation criteria, 11 patients had an excellent result with clinical and radiological union; the functional result was excellent in three patients, good in five, fair in two and poor in one.