Medium Term Outcomes in Palliative Transpedicular Corpectomy with Cement Based Anterior Vertebral Reconstruction Performed for Patients with Spinal Metastasis.

STUDY DESIGN: Retrospective. OBJECTIVE: Assess the outcomes of single stage posterior transpedicular corpectomy with cement-based anterior column support for spinal metastasis at longer follow-ups. SUMMARY OF BACKGROUND DATA: Life expectancy of cancer patients is constantly increasing. Reliable anterior column reconstruction after posterior corpectomy becomes necessary. METHODS: In this retrospective monocentric study, patients who underwent posterior transpedicular corpectomy and cement-based anterior reconstruction, with a minimum 6 months follow-up, were included. Ambulatory status and pain visual analog score(PVAS), complication rates and Local Sagittal Cobb angle (LSA) were evaluated preoperatively, postoperatively and at the latest follow-up. RESULTS: In total, 253 patients were included, with a mean follow-up of 21 months [6-132] and a median survival of 9 months. Pre-operatively, 202 patients(81%) were ambulant while 47 patients (19%) weren't. At the latest follow-up, 241 patients (95%) were ambulant while 12 patients(5%) weren't (P<0.001). Dorsal/lumbar PVAS went from 8.2±2.2 pre-operatively to 5.2(±1.7) post-operatively reaching 3.4±1.9 at the latest follow-up (P<0.001). Mean LSA decreased from 13.2°(±5.78) pre-operatively to 6.11°(±8.51)(P<0.001) post-operatively and reached 7.56°(±7.55) at the latest follow-up(P=0.59). Complications occurred in 39(15.4%) patients. One-third of those were mechanical(rod/screw fracture, cement displacement) needing re-intervention in 4 patients(1.6%). CONCLUSIONS: The mechanical stability offered by the cement-based anterior reconstruction is maintained during the lifespan of patients operated for the spinal metastasis. Satisfying functional and radiological outcomes observed at the last follow-up show that this lasting, cost sparing, and relatively simple reconstruction technique, is a valid alternative for the costly and more complicated cage-based reconstruction.

Bone Allograft Pedicle Screw Augmentation: A Biomechanical Study.

STUDY DESIGN: We performed a comprehensive cadaveric biomechanical study to compare the fixation strength of primary screws, screws augmented with bone allograft, and screws augmented with polymethylmethacrylate cement. OBJECTIVE: To evaluate a novel technique for screw augmentation using morselized cortico-cancellous bone allograft to fill the widened screw track of failed pedicle screws. BACKGROUND: To date, there are no known biological methods available for failed pedicle screw augmentation or fixation. MATERIALS AND METHODS: Biomechanical tests were performed using 2 different testing modalities to quantify fixation strength including axial screw pullout and progressive cyclic displacement tests. RESULTS: Fifty vertebrae were instrumented with pedicle screws. Our study showed that bone allograft augmentation using the same diameter screw was noninferior to the fixation strength of the initial screw. In the axial pullout test, screws undergoing bone allograft repair failed at 25% lower loads compared with native screws, and screws augmented with cement showed approximately twice as much strength compared with native screws. In the cyclic displacement test, screws fixed with cement resisted loosening the best of all the groups tested. However, screws augmented with bone graft were found to have an equal strength to native screw purchase. our study did not find a correlation with bone mineral density as a predictor for failure in axial pullout or cyclic displacement tests. CONCLUSION: Bone allograft augmentation for pedicle screw fixation was noninferior to the initial screw purchase in this biomechanical study. This bone allograft technique is a viable option for screw fixation in the revision setting when there is significant bone loss in the screw track.

The Saint-Joseph Acetabular score: a reproducible and accurate prediction of the outcome of open reduction and internal fixation of acetabular fractures.

PURPOSE: Acetabular fractures are associated to an increased risk of subsequent hip osteoarthritis. The only available score for post-operative reduction assessment in acetabular fractures (Matta's score) is x-ray based. CT-scan was shown superior to X-rays in post-operative reduction assessment. We aim to describe a CT-scan-based post-operative reduction score in acetabular fractures and evaluate its accuracy and reproducibility. METHODS: This is a retrospective study that includes 138 patients who underwent surgery for an acetabular fracture in our tertiary referral centre with a mean follow-up of 104.39±42.2 months. The post-operative CT-scan was reviewed and residual displacement (maximum gap and step) measured by three independent observers. The association between the occurrence of THA and the CT-scan measurements was evaluated. This led to a new prognostic score. The interobserver reliability and accuracy of this score were calculated. RESULTS: Interobserver reproducibility for the residual maximal gap was 0.82 (95% CI [0.70-0.89]) and 0.61 (95% CI [0.52-0.70]) for the residual maximal step displacement measurements. We created a score from a logistic regression model, attributing 1 point for every 1 mm of residual maximal step displacement and 1 point for every 2 mm of residual maximal gap displacement. The interobserver reproducibility of this score was 0.78 (95% CI [0.71-0.84]), and its AUC was 0.79 (95% CI [0.69-0.88]). CONCLUSION: This is the first CT-scan-based score for the assessment of residual displacement of a surgically treated acetabular fracture. It shows good interobserver reproducibility and accuracy in predicting the risk for secondary THA. It should be regularly used per-operatively (if per-operative 3D imaging is available) and post-operatively to predict the prognosis.

Primary Sarcomas of the Spine: A Systematic Review and Pooled Data Analysis.

STUDY DESIGN: A systematic review of the literature and pooled data analysis of treatment outcomes of primary sarcomas of the spine. OBJECTIVE: To examine the current literature and treatment options for primary sarcomas of the spine. SUMMARY OF BACKGROUND DATA: A paucity of literature exists on treatment outcomes of primary sarcomas of the spine. MATERIALS AND METHODS: Two authors searched PubMed to identify articles for review, and a pooled data analysis was performed to determine overall survival for each type of surgical resection on spine sarcomas. RESULTS: In total, 1776 articles were identified, and 11 met our inclusion criteria for review. In chondrosarcoma, overall survival was significantly higher with en bloc excision when compared with piecemeal resection (HR for piecemeal resection: 4.11; 95% CI: 2.08-8.15). Subgroup analysis showed that the addition of radiation therapy after piecemeal excision increased overall survival to 60 months from 48 months with piecemeal excision alone. In osteosarcoma, there was no significant difference in overall survival between en bloc and piecemeal resection (HR for piecemeal resection: 1.76; 95% CI: 0.776-3.99). In Ewing's sarcoma, overall survival was significantly higher when a successful en bloc resection was achieved and coupled with chemotherapy and radiation therapy for local control (HR for piecemeal resection: 7.96; 95% CI: 2.12-20.1). Interestingly, when a successful en bloc resection could not be achieved, chemotherapy and radiation therapy alone had significantly higher survival than piecemeal resection (HR for piecemeal resection: 2.63; 95% CI: 1.01-6.84). A significantly higher number of local recurrences were associated with the piecemeal resection group in all types of spine sarcomas. CONCLUSION: This review and pooled data seem to favor en bloc excision for local control as the treatment of choice in primary sarcomas of the spine.

LUMiC® endoprosthesis for pelvic reconstruction: A Canadian experience.

BACKGROUND AND OBJECTIVES: The LUMiC® prosthesis was introduced to reduce the mechanical complications encountered with periacetabular reconstruction after pelvic tumor resection. Few have evaluated the outcomes associated with its use. METHODS: A retrospective study from five Orthopedic Oncology Canadian centers was conducted. All patients with a LUMiC® endoprosthesis were included. Their charts were reviewed for surgical and functional outcomes. RESULTS: A total of 16 patients were followed for 28 months (3-60). A total of 12 patients (75%) had a LUMiC® after a resection of a primary sarcoma. Mean surgical time was 555 min. Four patients (25%) had a two-stages procedure. MSTS score was 60.3 preoperatively and 54.3 postoperatively. Patients got a dual mobility bearing and the silver coated implant was used in 7 patients (43.7%). Five patients (31.3%) underwent capsular reconstruction using a fabric. Silver-coating was not found to reduce infection risk (p = 0.61) and capsuloplasty did not prevent dislocation (p = 0.6). Five patients had peroperative complications (31.3%). Eight patients (50%) had an infection including all four with two-stages surgery. Dislocation occurred in five patients (31.3%) whereas no cases of aseptic loosening were reported. A total of 10 patients (62.5%) needed a reoperation. CONCLUSION: LUMiC® endoprosthesis provides low rates of aseptic loosening on medium-term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and silver-coated implants.

Outcomes After Abductor Reattachment to Proximal Femur Endoprosthesis After Tumor Resection.

INTRODUCTION: Resection of the proximal femur raises several challenges including restoration of the abductor mechanism. Few evaluated the outcomes of different techniques of abductor fixation to the proximal femur endoprosthesis. METHODS: A retrospective review of patients who underwent proximal femoral arthroplasty with a minimum follow-up of 12 months was conducted. Patients were divided into two groups: (1) those with preserved greater trochanter (GT) reattached to the implant and (2) those with direct abductor muscle reattachment. Both groups were compared for surgical and functional outcomes. Group 1 patients were subdivided into those who received GT reinsertion using grip and cables and those reattached using sutures. RESULTS: Fifty-three patients were included with a mean follow-up of 49 months. There were 22 patients with reinserted GT and 31 patients with soft-tissue repair. The endoprosthesis revision rate was comparable between groups (P = 0.27); however, the incidence of dislocations was higher in group 2 (0/22 versus 6/31; P = 0.035). Trendelenburg gait (77% versus 74%), use of walking aids (68% versus 81%), and abductor muscle strength were comparable between both groups (P > 0.05). In group 1, 15 patients had GT reinsertion with grip and cables. Of those, five patients (33%) had cable rupture within 13 months of follow-up. GT displacement reached 12 mm at 12 months of follow-up in patients with grip and cables compared with 26 mm in patients with GT suture reinsertion (P < 0.05). DISCUSSION: Although GT preservation did not improve functional outcomes, it was associated with a lower dislocation rate despite frequent cable failure. Less displacement was observed when GT reattachment used grip and cables.

Joint-sparing reconstruction for extensive periacetabular metastases: Literature review and a novel minimally invasive surgical technique.

Classically, patients with advanced lytic disease of the acetabulum secondary to metastatic bone disease are treated with complex arthroplasty reconstruction techniques. Advancements in percutaneous techniques have extended the indications for safer, minimally invasive procedures for patients with periacetabular metastasis without the need for complex hip replacement and the complications that follow it. The purpose of this report is to revisit the management of this group of patients and provide indications for an alternative minimally invasive joint-sparing technique. We describe a novel technique using a combination of percutaneous cryoablation, cementoplasty and two-screw fixation. With careful consideration of indications, excellent functional and oncologic outcomes one year after surgery is possible without the need for additional procedures.

Clinical impact of intraoperative cone beam tomography and navigation for displaced acetabular fractures: a comparative study at medium-term follow-up.

INTRODUCTION: The use of per-operative cone beam tomography imaging for displaced acetabular fractures yields increased post-operative articular reduction accuracy. This study evaluates the need for total hip replacement (THR) and hip-related functional outcomes in patients with displaced acetabular fractures treated with O-ARM guidance compared to those treated under C-ARM guidance. MATERIALS AND METHODS: This is a prospective matched cohort study. Adult patients (35) with acetabular fractures operated under O-ARM guidance were included. These were matched (age, fracture type) to classically treated patients (35) from our data base. The primary outcome was the need for THR during three year follow-up period. Secondary outcomes were functional scores [Harris Hip score (HHS), Postel-Merle d'Aubigné (PMA)] and hip osteoarthritis grade at three year follow-up. Correlation between reduction gap and THR was evaluated. RESULTS: At three years, five patients were lost to follow-up in O-ARM group and four in control group. Two patients (6.66%) in the O-ARM group needed THR compared to eight patients in controls (25.80%) (p = 0.046). Hip X-ray osteoarthritis grade averaged 0.00 in patients without THR in O-ARM group compared to 0.22 in patients without THR in controls (p = 0.008). HHS averaged 95.79 in patients without THR in O-ARM group, compared to 93.82 in patients without THR in the control group (p = 0.41%). PMA averaged 17.25 in patients without THR in the O-ARM group compared to 17.04 in patients without THR in group 2 (p = 0.37). Evaluation of correlation between reduction gap and THR rate yielded OR = 1.22 (1.06-1.45). DISCUSSION: Increased accuracy in articular reduction, with per-operative three-dimensional control of impaction, in acetabular fractures led to significantly less need for THR in patients treated under O-ARM. Patients in both groups are comparable for functional outcomes because those with the lowest scores were offered THR. Per-operative cone beam guidance and navigation use are recommended in tertiary referral centres for acetabular trauma.

Modified Stoppa Approach: Beyond Acetabular Fractures: A Report of 2 Cases.

CASES: We used the modified Stoppa approach in a 17-year-old man with a retained bullet in his acetabular fossa. The acetabular hole was used to irrigate the hip joint. We also used this approach in a 29-year-old woman with right hip pain and limping to remove an isolated tenosynovial giant cell tumor ("localized pigmented villonodular synovitis") in the acetabular fossa expanding through the acetabulum. DISCUSSION: We believe that this approach should become more familiar because it offers a simple alternative for treating acetabular pathologies mainly involving the acetabular fossa, sparing patients the hazards of capsulotomy, trochanteric osteotomy, dislocation, and traction and fluid pressure in hip arthroscopy.

Knee injuries concomitant to posterior acetabular fractures: an association to look for.

PURPOSE: Acetabular fractures are frequently associated with other skeletal injuries, particularly knee injuries. This study aims to evaluate the relationship between posterior acetabular fractures and knee injury, analyzing its patterns and association with other injuries. METHODS: This is a retrospective monocentric study in a tertiary referral centre. We reviewed the data (age, sex, type of fracture, and concomitant injury) of patients hospitalized for a posterior acetabular fracture. We recorded concomitant knee injury diagnosed up to one year following acetabular fracture. RESULTS: Two-hundred-seventeen patients (177 males/40 females) were included. The mean age was 40.5 years. Eighty-five patients (39%) had a concomitant hip dislocation, nine (4.1%) had sciatic nerve palsy, 17 (7.8%) had upper extremity injury, and 18 (8.3%) had lower extremity injury (other than the knee). Eight (3.7%) patients had spine injury, 11 (5.1%) had severe thoracic injury, nine (4.1%) had an abdominal injury, and four (1.8%) had a head injury. There were 33 (15.21%, 95% CI 10.80-20.8%) patients (30 M/3 F) (group 1) with a concomitant knee injury and 184 patients without a concomitant knee injury(group 2). The mean age in group 1 was 34.3 compared to 45.4 in group 2(p = 0.021). The pattern analysis revealed five fractures, 14 ligamentous injuries (PCL injuries = 68%), and 14 soft tissue injuries. Sixteen (48.48%) injuries were identified during hospitalization and 17 (51.51%) during follow-up. There were an association between knee injury and upper extremity injury (OR = 3.49 95% CI 1.12-10.00,p = 0.022) and other lower extremity injury (OR = 3.18 95% CI 1.03-8.95,p = 0.032). DISCUSSION: Knee injury is the second most frequent lesion associated with posterior acetabular fractures. Being missed in half of cases, we recommend a systematic examination of ipsilateral knees under general anaesthesia, keeping a high index of suspicion and a low threshold for complementary knee imaging. Knee injury should be mainly looked for in patients younger than 60 years and in those with upper and/or lower extremities injuries.

Is There Still a Place for Convex Hemiepiphysiodesis in Congenital Scoliosis in Young Children? A Long-Term Follow-up.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To evaluate the long-term effect of convex growth arrest (CGA) on coronal deformity correction in congenital scoliosis. METHODS: Twenty-two patients with congenital scoliosis operated by 1-staged double approach hemiephysiodesis by bone grafting of the convex side without instrumentation are included. Eighteen curves had an isolated hemivertebra while 4 curves had congenital bar. Subgroup analysis was performed according to age at surgery (3 years cutoff), type of malformation (hemivertebra vs congenital bar), and severity of curve (35° cutoff). RESULTS: Patients' mean age at surgery was 3 years (range 0.5-8 years), with a mean frontal Cobb angle of 40.59°. Mean follow-up is 10.7 years (range 5.5-25 years). Overall results showed mean frontal Cobb angle reduction of 35.47% (40.59° to 27.41°). Detailed analysis showed that 15 curves had a mean correction of 51.8%, 5 stabilized and 2 had a mean aggravation of 25.11%. Subgroup analysis revealed that patients operated ≤3 years of age had mean cobb angle correction of 43.1% versus 21.49% in patients operated >3 years (P = .140). Mean correction of 44.5% was gained in curves with isolated hemivertebra compared with 1.3% in curves with congenital bar (P = .004). A 58.17% mean correction was reached in curves ≤35° versus 23.68% in curves >35° (P = .032). CONCLUSIONS: A limited convex hemiepiphysiodesis still has a place in congenital scoliosis care when it is performed in patients ≤3 years old, with curves ≤35°, and with isolated hemivertebra. It spares patients the risks of vertebral resection and instrumentation, while fusing the same number of levels.

Does the induced membrane have antibacterial properties? An experimental rat model of a chronic infected nonunion.

INTRODUCTION: The Masquelet procedure proved its efficiency in treating infected nonunion filling bony gaps up to 25 cm. Yet the use of local antibiotics is still questionable in the daily practice with lack of evidence regarding its usefulness in controlling infection. An experimental rat model is put in place to study the antibacterial properties of the induced membrane produced during the first stage of Masquelet. METHOD: Twenty-three-month-old wistar male rats are inoculated with a 0.5 mL solution of 10^8 CFU/mL MRSA over a critical fracture done on the right femur. Six weeks later, remaining 11 rats exhibiting signs of a chronic infection with a sinus tract and oozing pus along with radiological nonunion are used for a first stage Masquelet procedure. They are randomly divided into two groups with six rats having no local antibiotic in the cement mixture and five rats having 3 g of vancomycin mixed with gentamycin loaded cement. Six weeks later (twelve weeks from baseline), all eleven rats are euthanized and blood samples for C-reactive protein are withdrawn. The induced membrane is identified and resected along with bone fragments and sent for cultures and pathology. RESULTS: MRSA is isolated in the cultures of all six rats in the first group where no local antibiotic was added. Altered polymorphonuclears with abscess and pus are noted on four of six pathology samples. However in the second group where local antibiotics were added, three out of five rats exhibited eradication of MRSA (p = 0.034) and all samples did not exhibit clear infection signs on pathology. A pyo-epithelioid over a foreign body reaction is seen predominantly in this group demonstrating a regenerative process. DISCUSSION: The induced membrane does not have antimicrobial properties capable of overcoming an infected nonunion on its own. When local antibiotics were added during the first stage of the Masquelet procedure, new bone formation occurred indicating the need to control an infection in order for bone union to occur. CONCLUSION: Local antibiotics use in adjunction to extensive debridement is advisable during the first stage of a Masquelet procedure for an infected nonunion.

Femoral head fracture in an adult patient with isolated posterior labrum avulsion recognized through the 'fleck' sign: technical tips.

Femoral head fractures in adults are known to be frequently associated with femoral neck fractures, acetabular fractures and sciatic nerve neurapraxia. Here, we report for the first time in the English medical literature the case of a 30-year-old patient having a Pipkin Type II comminuted femoral head fracture associated to an isolated acetabular labral osteochondral avulsion. This entity was diagnosed preoperatively through the presence of the acetabular 'fleck' sign recently described in adolescents with hip dislocation. This was of paramount importance knowing the key role of the acetabular labrum in physiological hip functioning. Therefore, a high index of suspicion of complete posterior acetabular labrum avulsion should be raised in front of a hip computed tomography scan showing the acetabular fleck sign even in an adult patient. This finding is important in posing the surgical indication and in completing the preoperative surgical planning in cases of femoral head fractures and dislocations.

Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome.

The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients' clinical history (observing "red flags"), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.

Proximal junctional kyphosis in adult scoliosis: comparison of four radiological predictor models.

OBJECTIVE: The objective of this retrospective study is to identify the best immediate postoperative radiological predictors for the occurrence of proximal junctional kyphosis (PJK). Four proposed methods will be explored. METHODS: A homogeneous database of adult scoliosis from multiple centers was used. Patients with whole spine X-rays at the required follow-up (FU) periods were included. Spinal and pelvic parameters were measured and calculated to compare four predictive methods: Method 1: assessment of the global sagittal alignment (GSA); Method 2: restoration of the theoretical values of lumbar lordosis (LL) and thoracic kyphosis (TK) according to pelvic incidence (PI); Method 3: evaluation of TK + LL, and Method 4: restoration of the apex of sagittal LL to its theoretical values according to various spine shapes in Roussouly Classification. PJK occurrence was assessed at the last FU radiograph. RESULTS: 250 patients were included; mean age was 56.67 years and mean FU was 2.5 years. PJK occurred in 25.6% of cases. PJK occurred in 19.9% in patients with a GSA <45° and in 29.9% where GSA >45° (p = 0.04, OR = 1.71). Restoring the sagittal apex of the LL to its theoretical values according to PI deceased PJK to 13.5% compared to 38.9% in the other cases (p = 0.01, OR = 4.6). The two other described methods (2 and 3) were not significant predictors. DISCUSSION: The comparison between the four predictive methods showed that a GSA >45° and restoration of sagittal apex of lordosis according to PI, were the most predictive methods for PJK in ASD. The latter had a higher predictive value. Our findings could prove useful in effective preoperative planning in ASD surgery to reduce PJK rates. LEVEL OF EVIDENCE: Level IV.

A Large Rice Body-Containing Cyst Mimicking Infection following Total Hip Arthroplasty: A Case Report.

INTRODUCTION: Soft tissue mass following total hip arthroplasty raises several differential diagnoses not limited to infection, hematoma, wear debris, malignancy, and bursitis. Rice body formation in the hip region is an uncommon process denoting a chronic inflammation. We report here the second case of its kind in the medical literature of a wide symptomatic rice-like body cyst complicating a total hip arthroplasty. CASE PRESENTATION: This is the case of an 82-year-old white female, presenting with a warm, red, and inflated groin five years after revision of right total hip arthroplasty. Surgical intervention reveals a large well circumscribed cyst containing well-organized rice-like bodies. This eventuality was never reported in differential diagnosis of hip periprosthetic soft tissue masses before. CONCLUSION: This case report helps widening the array of the differential diagnosis in patients presenting with a slow growing soft tissue mass following total hip arthroplasty, making rice-like bodies cyst a valid one to consider.