Is Proximal Triangular Fixation Better than the Conventional Method in Adult Spinal Deformity Surgery?

In adult spinal deformity (ASD) surgery, one of the key factors working to prevent proximal junctional kyphosis is the proximal anchor. The aim of this study was to compare clinical and radiographic outcomes of triangular fixation with conventional fixation as proximal anchoring techniques in ASD surgery. We retrospectively evaluated 54 patients who underwent corrective spinal fusion for ASD. Fourteen patients underwent proximal triangular fixation (Group T; average 74.6 years), and 40 patients underwent the conventional method (Group C; average 70.5 years). Clinical and radiographic outcomes were assessed using visual analogue scale (VAS) values for back pain and the Oswestry disability index (ODI). Radiographic evaluation was also collected preoperatively and postoperatively. Surgical times and intraoperative blood loss of the two groups were not significantly different (493 vs 490 min, 1,260 vs 1,173 mL). Clinical outcomes such as VAS and ODI were comparable in the two groups. Proximal junctional kyphosis in group T was slightly lower than that of group C (28.5% vs 47.5%, p=0.491). However, based on radiology, proximal screw pullout occurred significantly less frequently in the triangular fixation group than the conventional group (0.0% vs 22.5%, p=0.049). Clinical outcomes in the two groups were not significantly different.

Minimal Clinically Important Differences in Gait and Balance Ability in Patients Who Underwent Corrective Long Spinal Fusion for Adult Spinal Deformity.

STUDY DESIGN: Retrospective observational study. BACKGROUND: The risk of a femoral neck fracture due to a fall after adult spinal deformity surgery has been reported. One of the most significant factors among walking and balance tests in post-operative ASD patients was the timed up-and-go test (TUG). This study aims to calculate the minimal clinically important difference (MCID) in balance tests after ASD surgery. METHODS: Forty-eight patients, 4 males and 44 females, were included by exclusion criteria in 66 consecutive patients who underwent corrective surgery as a treatment for ASD at our institution from June 2017 to February 2022. The inclusion criteria for this study were age ≥50 years; and no history of high-energy trauma. The exclusion criteria were dementia, severe deformity of the lower extremities, severe knee or hip osteoarthritis, history of central nervous system disorders, cancer, and motor severe paralysis leading to gait disorders. The surgeries were performed in two stages, first, the oblique lumber interbody fusion (OLIF) L1 to L5 (or S1), and second, the posterior corrective fusion basically from T10 to pelvis. For outcome assessment, 10 m walk velocity, TUG, ODI, and spinopelvic parameters were used. RESULTS: Ten meter walk velocity of pre-operation and post-operation were 1.0 ± 0.3 m/s and 1.2 ± 0.2 m/s, respectively (p < 0.01). The TUG of pre-operation and post-operation were 12.1 ± 3.7 s and 9.7 ± 2.2 s, respectively (p < 0.01). The ODI improved from 38.6 ± 12.8% to 24.2 ± 15.9% after surgery (p < 0.01). All post-operative parameters except PI obtained statistically significant improvement after surgery. CONCLUSIONS: This is the first report of MCID of the 10 m walk velocity and TUG after ASD surgery. Ten meter walk velocity and the TUG improved after surgery; their improvement values were correlated with the ODI. MCID using the anchor-based approach for 10 m walk velocity and the TUG were 0.10 m/s and 2.0 s, respectively. These MCID values may be useful for rehabilitation after ASD surgery.

Ten-Segment Classification has Lowest Inter/Intra-Observer Reliability as Compared to Schatzker, Three-Column and AO Systems for Tibial Plateau Fractures: A Comparison Based on Surgeons' Experience.

Objectives: The primary aim of this study was to assess the reliability of the ten-segment classification system proposed (TSC) by Krause et al. and see how it compares with the traditionally used Schatzker classification, AO classification system, and Luo's "Three columns" classification (ThCC) system. The second aim of this study was to assess the inter-observer reliability of the above classifications based on professional experience by comparing the entry level of residents (1 year into postgraduation), senior residents (1 year after postgraduation completion), and faculty (>10 years after postgraduation completion). Methods: 50 TPFs were classified by a 10-segment classification system, and its intra-observer (at 1-month interval) and inter-observer reproducibility was checked using k values by three different groups with varying levels of experience (Group I, II, and III comprised of 2 juniors residents, senior residents and consultants each), and the same was compared for three other common classification systems (Schatzker, AO and 3 -column). Results: 10-segment classification showed least k for both inter-observer (0.08) and intra-observer (0.03) reliability. Highest individual inter-observer (k= 0.52) and intra-observer reliability (k= 0.31) was for Schatzker classification in Group I. Lowest individual inter-observer and intra-observer reliability was seen for 10-segment classification (k= 0.07) and AO classification system (k= -0.03) respectively. Conclusion: 10-segment classification showed the lowest k for both inter-observer and intra-observer reliability. The inter-observer reliability for the Schatzker, AO, and 3- column classifications reduced with increasing experience of the observer (JR>SR>Consultant). A possible reason could be a more critical evaluation of the fractures with increasing seniority.

Comparison of C-Arm-Free Oblique Lumbar Interbody Fusion L5-S1 (OLIF51) with Transforaminal Lumbar Interbody Fusion L5-S1 (TLIF51) for Adult Spinal Deformity.

Background and Objectives: Adult spinal deformity (ASD) surgery, L5-S1 lordosis is very important factor. The main objective of the research is to retrospectively compare symptomatic presentation and radiological presentation in the sequelae of oblique lumbar inter-body spinal fusion at L5-S1 (OLIF51) and transforaminal lumbar interbody fusion (TLIF) for ASD. Materials and Methods: We retrospectively evaluated 54 patients who underwent corrective spinal fusion for ASD between October 2019 and January 2021. Thirteen patients underwent OLIF51 (average 74.6 years old, group O) and 41 patients underwent TLIF51 (average 70.5 years old, group T). Mean follow-up period was 23.9 months for group O and 28.9 months for group T, ranging from 12 to 43 months. Clinical and radiographic outcomes are assessed using values including visual analogue scale (VAS) for back pain and Oswestry disability index (ODI). Radiographic evaluation was also collected preoperatively and at 6, 12, and 24 months postoperatively. Results: Surgical time in group O was less than that in group T (356 min vs. 492 min, p = 0.003). However, intraoperative blood loss of both groups were not significantly different (1016 mL vs. 1252 mL, p = 0.274). Changes in VAS and ODI were similar in both groups. L5-S1 angle gain and L5-S1 height gain in group O were significantly better than those of group T (9.4° vs. 1.6°, p = 0.0001, 4.2 mm vs. 0.8 mm, p = 0.0002). Conclusions: Clinical outcomes were not significantly different in both groups, but surgical time in OLIF51 was significantly less than that in TLIF51. The radiographic outcomes showed that OLIF51 created more L5-S1 lordosis and L5-S1 disc height compared with TLIF 51.

RCC (reinforced criss-cross construct): an easy and effective multi-rod thoraco-lumbar posterior reconstruction technique.

STUDY DESIGN: Surgical technical note and literature review. OBJECTIVES: To describe a technique that uses 4 rod constructs in cases of complex thoracolumbar spinal deformity correction or revision surgeries based on the hybrid use of two different types of purchase points by a staggered pedicle screw fixation. It utilizes two rods on either side of the spine using a lateral and medial entry point of pedicle screws in the vertebral body. METHODS: Pedicle screws using extra-pedicular technique are more converging screws and are inserted alternately in the vertebral body and connected by rods. The left-out alternate vertebral bodies are fixed by a relatively straighter pedicle entry screw and connected to each other by a separate rod. So, two trajectories are independently used for a four-rod construct. This reconstruction has been named RCC (reinforced criss-cross construct). The screws in the index case were placed by free hand method, but we have increasingly utilized navigation guidance for placement of screws in recent times. RESULTS: We present a surgical technical note in a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV-AIDS). He was diagnosed to have multi-drug-resistant (MDR) tuberculous spondylodiscitis, complicated with Immune reconstitution inflammatory syndrome (IRIS) and implant failure resulting in kyphosis and thoracic myelopathy. RCC with pharmacological management achieved healing and union, which was maintained at 4 years follow-up. Our method of four-rod construct provides a strong and lasting construct in the management of spinal deformities and three-column osteotomies. It provides good structural support to the spine till bony union is achieved. CONCLUSION: Hybrid multi-rod construct like RCC provides a rigid mechanical support to the instrumentation and reduces the chances of rod failure especially in complex thoraco-lumbar spinal deformity correction surgeries.

Treatment of acetabular fractures with quadrilateral plate injury - a comparison of two commonly used methods.

BACKGROUND: Acetabular fractures with quadrilateral plate (QLP) involvement have traditionally been treated by buttress plates applied through an Ilio-inguinal approach. Recently, many surgeons prefer the application of infra-pectineal plates through the modified Stoppa approach for this purpose. Whether one method can be preferred over the other is a matter of investigation. HYPOTHESIS: The research question was whether an infra pectineal plate applied through the modified Stoppa approach for acetabular fractures with QLP involvement would result in an equivalent or better outcome than a buttress plate applied through an ilioinguinal approach. PATIENTS AND METHODS: This was a retrospective study of patients with QLP fractures operated by either of the two methods and who had completed at least one year follow up. Demographic and surgical details and the radiological and clinical outcomes at the last follow-up visit were obtained from patient records. RESULTS: A total of 41 patients were treated with a buttress plate applied through an ilioinguinal approach (group A), and 49 patients were treated with an infra-pectineal plate by the modified Stoppa approach (group B). Duration of surgery and intra-operative blood loss was significantly less in group B patients. Radiological and clinical outcomes were better in group B patients than group A patients. Implant loosening was more frequent in group A patients. Injury to the obturator vessels were more common in group B patients. CONCLUSION: With a comparatively lesser surgical duration and blood loss, better clinical and radiological outcomes at least one year after the surgery, an infra-pectineal plate applied through the modified Stoppa approach can be considered the preferred treatment for most acetabular fractures with QLP involvement. LEVEL OF EVIDENCE: III.

Sagittal Balance, Pulmonary Function, and Spinopelvic Parameters in Severe Post-Tubercular Thoracic Kyphosis.

STUDY DESIGN: Cross-sectional study. PURPOSE: To evaluate sagittal balance, pulmonary function, and spinopelvic parameters in patients with healed spinal tuberculosis with severe thoracic kyphosis. OVERVIEW OF LITERATURE: Deterioration of neurological function is an absolute indication of surgical intervention in severe post-tubercular kyphosis, but the relationship of compromise in lung function and spinal alignment with severity of kyphosis is still unclear. METHODS: Twenty patients (age, 14-60 years) with healed spinal tuberculosis with thoracic kyphosis >50° were included. Lateral-view radiography of the whole spine, including both hips, was performed for assessment of kyphotic angle (K angle), sagittal balance, lumbar lordosis, and spinopelvic parameters. Pulmonary function was assessed by measuring the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and their ratio (FEV1/FVC) by spirometry. RESULTS: A positive correlation between severity of kyphosis and sagittal imbalance was noted, with compensatory mechanisms maintaining the sagittal balance in only up to 80° of dorsal kyphosis. In >80° of kyphosis, FVC was found to be markedly decreased (mean FVC=50.6%). The mean K angle was lower in subjects with lower thoracic kyphosis. In lower thoracic kyphosis, due to short lordotic and long kyphotic curves, both lumbar lordosis and pelvic retroversion worked at compensation, whereas, in middle thoracic kyphosis, due to long lordotic curve, only lumbar lordosis was required. Normal pulmonary function (mean FVC, 83.0%) and lesser kyphotic deformity (mean K angle in adolescents, 69.8°; in adults, 94.4°) were found in adolescents. CONCLUSIONS: In >80° of thoracic kyphosis, there is sagittal imbalance and a markedly affected pulmonary function. Such patients should be offered corrective surgery if they are symptomatic and medically fit to undergo the procedure. However, whether the surgical procedure would result in improved pulmonary function and sagittal balance needs to be evaluated by a follow-up study.

Concomitant ipsilateral acetabular and femoral fractures - an appraisal of outcomes and complications in 34 patients.

Concomitant ipsilateral femoral and acetabular fractures are complex injuries which result from high-velocity trauma. Surgical treatment is the accepted management of such injuries. The objectives of this study were to evaluate the outcomes and study the complications in patients treated for concomitant ipsilateral acetabular and femoral fractures (type 'B' floating hip injuries). This retrospective study was conducted at a tertiary care teaching hospital on patients operated for type B floating hip injuries, who had completed a minimum of one-year follow-up after the surgery and whose complete records were available. Those with floating hip injuries with pelvic fractures were excluded. All patients were operated on the femoral side first, followed by the acetabular side. 34 patients were included ; most of them were young males. A road traffic accident was the most common mode, with a dashboard injury being the most common mechanism of injury. No association between the type of acetabular and femoral fractures was found. The clinical (measured with Harris hip score) and radiological (Matta's method) outcomes at the latest follow-up were excellent or good in >60% cases and had a significant association with the quality of reduction on the post-operative radiographs. Complications were seen in 12 out of the 34 patients. Type B floating hips injuries can be managed well with acceptable short-term results by following a femur first strategy. However, patients must be informed of the possible complications and the probabilities of poorer outcomes when compared to isolated acetabular or femoral fractures.

Dislodgement of Telescopic Nail from the Epiphysis: A Case Report with an Analysis of Probable Mechanism.

Telescopic nails such as Fassier-Duval (FD) nails have become the standard treatment for stabilizing long bones and correcting deformities in osteogenesis imperfecta (OI). These nails do not require repeat surgery for their replacement when the bones outgrow them. However, they are not completely free from complications. The prohibitive costs of the original implants have led to design modifications being introduced in locally manufactured telescopic nails. While these low-cost devices work well in most cases, they can lead to complications resulting from their design flaws. We present here the complication observed in a locally manufactured telescopic nail with a design similar to the FD nail. The male component of the nail got dislodged from the distal tibial epiphysis, resulting in its proximal migration. We discuss the probable mechanism of this complication and propose possible design changes that can bring down the rates of such incidences.

Can patients with complex acetabular fractures be operated by combined anterior and posterior approaches in a single anesthetic sitting?

INTRODUCTION: While there is a consensus that complex acetabular fractures require anatomical reduction and stable fixation for their management, there is no agreement on the surgical approaches to be used for achieving that goal. Invariably two surgical approaches are needed for management of such fractures. Whether these approaches should be performed in different anesthetic sittings or in the same sitting, sequentially or simultaneously, is debatable. MATERIALS AND METHODS: 41 patients with complex acetabular fractures were operated in floppy lateral position by combined anterior and posterior approaches during the same anesthetic sitting and were followed for a minimum of one year. Patient related parameters as well as the details of their clinical outcome assessed by Merle D' Aubigne (MD'A) score, radiological outcome by Matta's method, Harris Hip score and complications encountered were recorded. Correlations of the clinical outcomes with other parameters were analyzed along with other statistical details. RESULTS: The mean surgical duration was 3.5 h. Anatomical reduction was achieved in 17 patients, congruent reduction in 19 and incongruent reduction in 5 patients. MD'A scores were excellent in 8 cases, good in 18 cases, fair in 5 cases and poor in 10 cases. Radiological outcome was excellent in 5, good in 16, fair in 13 and poor in 7 patients. Statistically significant correlation was noted between the MD'A score with reduction quality, cartilage damage and radiological outcome. Delay in surgery and choice of surgical approach had no correlation with the clinical outcome. CONCLUSION: Combined approaches in the same anesthetic sitting can be used for satisfactory management of complex acetabular fractures. These offer the ease of assessing reduction during surgery, can potentially save time and expenses without unduly affecting the clinical and radiological outcomes and without increasing the rate of complications when compared to approaches performed sequentially.

Sternoclavicular joint tuberculosis: A series of 9 cases.

Tuberculosis (TB) is a chronic disease that may affect any part of the human body. Though the osteoarticular TB is not uncommonly seen, TB of the sternoclavicular joint (SC joint) is an infrequently reported condition. The very fact that many physicians have never seen a single case of SC joint TB in their entire career makes them never think of this condition in cases of chronic swellings of the medial end of clavicle. We are reporting here our experience with nine cases of SC joint TB that were treated by us. Delay in diagnosis in each of the case was a common feature, and they had been treated in line of inflammation elsewhere. Diagnosis was arrived at by clinical, radiological, and microscopic examinations. Six of the reported cases responded well to antitubercular chemotherapy, and in one of the cases, chemotherapy was combined with debridement, which was actually done during biopsy and primarily for tissue diagnosis; in another two cases, immunomodulation therapy for HIV was given along with antitubercular therapy. Tuberculous etiology should be considered for patients presenting with atypical sites of skeletal inflammation, and a high index of suspicion by the treating physician is necessary to make early diagnosis and appropriate treatment.

Tubercular dactylitis in children.

Tubercular dactylitis is a rare manifestation of skeletal tuberculosis in the paediatric population. Its clinical diagnosis is often delayed as local symptoms may easily be missed in children and constitutional features such as loss of weight, loss of appetite, night sweats, evening rise of temperature and history of close contact with a patient of tuberculosis may not always be present. Parents seek treatment only when they notice significant swelling or tenderness of fingers or hand in their children. Radiology and fine-needle aspiration cytology may help in establishing an early diagnosis. Astute multidrug antitubercular therapy is curative.

Ingenious method of external fixator use to maintain alignment for nailing a proximal tibial shaft fracture.

Fractures of the tibia are one of the most commonly seen orthopedic injuries. Most of them result from a high velocity trauma. While intramedullary nailing of tibial diaphyseal fractures is considered as the golden standard form of treatment for such cases, many metaphyseal and metaphyseal-diaphyseal junction fractures can also be managed by nailing. Maintenance of alignment of such fractures during surgical procedure is often challenging as the pull of patellar tendon tends to extend the proximal fragment as soon as one flexes the knee for the surgical procedure. Numerous technical modifications have been described in the literature for successfully nailing such fractures including semi extended nailing, use of medial plates and external fixators among others. In this study, it was aimed to report two cases in which we used our ingenious method of applying external fixator for maintaining alignment of the fracture and aiding in the entire process of closed intramedullary nailing of metaphyseal tibial fractures by the conventional method. We were able to get good alignment during and after the closed surgery as observed on post-operative radiographs and believe that further evaluation of this technique may be of help to surgeons who want to avoid other techniques.

WHOQOL-BREF Hindi questionnaire: Quality of life assessment in acetabular fracture patients.

BACKGROUND: The incidence of acetabular fractures in India has increased over the past years but so has the operating skills of pelvi-acetabular trauma surgeons. The outcomes of surgical management need to be assessed so as to be able to devise proper treatment plan and execute the same during and after surgery, which in turn requires assessment of quality of life indices as well as functional scores. While there are studies assessing Harris Hip scores (HHS) and world health organization quality of life BREF (WHOQOL BREF) in the western population there is no study which assesses the same in Indian population. We designed this study to evaluate and define reference values for use of WHOQOL BREF Hindi scores in QOL Assessment in patients with acetabular fractures and to assess the relationship between it and HHS. MATERIALS AND METHODS: 118 patients with acetabular fractures who were treated surgically were included in this retrospective study. Assessment of reduction quality (Matta's radiological criteria), clinical outcome (HHS) and functional outcome (WHOQOL-BREF score) were done. The affect of age, gender, fracture displacement, hip dislocation, delay in surgery and associated injury on the clinical and functional outcome was evaluated. RESULTS: The mean HHS was 90.65 (42-100) which showed an overall good to excellent outcome in 78.8% cases. WHOQOL-BREF Hindi score of domain-one was 63.06 ± 20.31 (13-94), of domain-two was 58.22 ± 19.57 (13-100), of domain-three was 70.49 ± 17.92 (13-100) and of domain-four was 64.48 ± 18.46 (13-100), which showed significant functional deficit in domain-one (P = 0.0001) and domain-two (P = 0.0001) but not in domain-three (P = 0.458) and domain-four (P = 0.722) when compared to score of general healthy population. The domain scores of general population norms were achieved in 59.3%, 61.9%, 69.5% and 66.1% cases in domain one, two, three and four respectively. CONCLUSIONS: Based on these results one can conclude that WHOQOL-Hindi questionnaire is good enough for assessment of QOL in addition to clinical measures in acetabular fracture patients.

Iatrogenic brachial artery injury during anterolateral plating of humeral shaft fracture.

There are several well defined indications for surgical management of humeral shaft fractures. Operative procedures on the humerus are associated with their own complications. Iatrogenic brachial artery injury as a complication of humeral shaft plating has not been reported previously. We report a case of a 48 years old female, who received operation at a district hospital and was referred to us when the surgeon could not palpate the pulse. CT angiogram showed that there was segmental non-opacification of the brachial artery. There was distal reformation and the thrombosis was decided to be managed conservatively. We believe that the arterial injury was a result of improper surgical technique and the segmental block might be due to improper use of plate holding forceps. This case report makes us aware of a rare complication of operative management of humeral shaft fractures and that basic principles of surgery must be always followed to prevent such injuries.