Prevention of post-traumatic osteoarthritis after intra-articular knee fractures using hyaluronic acid: a randomized prospective pilot study.

PURPOSE: Based on the irreversible destruction of hyaline cartilage, post-traumatic osteoarthritis (PTOA) is a notorious sequelae after intra-articular knee fractures. This study evaluates the clinical efficacy and applicability of immediate post-operative intra-articular injection of hyaluronic acid (IA HA) into the knee joint with an intra-articular fracture. METHODS: Prospective randomized case-control study involving 40 patients (20 in each group) with intra-articular knee fracture with an average follow-up of 23 months (range 18-24 months). Twenty patients with intra-articular distal femoral or intra-articular proximal tibial fractures who met our inclusion criteria received three intra-articular hyaluronic acid injections weekly starting immediately after ORIF. Another 20 patients serving as a control group received no injection after ORIF. Patients were assessed functionally with Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) score. Plain X-rays and when indicated CT scans were used to assess radiological union. RESULTS: The results showed patients treated with intra-articular hyaluronic acid injection after fixation had significantly less pain (KOOS) (p = 0.01). No significant difference was found between both groups in other KOOS-related outcome measures, complications, functional outcome, or quality of life. CONCLUSIONS: These preliminary results support a direct role for hyaluronic acid in the acute phase of the inflammatory process that follows articular injury and provides initial evidence for the efficacy of IA HA.

Repair of spondylolysis using a pedicle screw U-shaped rod construct: A preliminary study of 25 young patients with a mean follow-up of 24 months.

STUDY DESIGN: Prospective case series, therapeutic Level IV. OBJECTIVES: Functional and radiographic outcome evaluation of patients with spondylolysis treated with pars interarticularis defect repair with iliac bone grafting and application of a construct consisting of a pair of polyaxial pedicle screws connected by a U-shaped rod passing beneath the spinous process. METHODS: Twenty-five patients (27 operated lumbar levels) with an average of 20 months of follow-up (range 12-24 m) with spondylolysis who met our inclusion criteria were treated with the above-mentioned technique. Functional assessment was by the Visual Analog Score (VAS) for low back pain (LBP) and Oswestry Disability Index (ODI). Fusion was confirmed with plain x-rays and when indicated with computed tomography scan. Return to activities of daily living (ADL) was also assessed. RESULTS: There were 16 males (64%) and 9 females (36%), with a mean age of 18 ± 3 years at surgery, with a mean operating time of 79 ± 13 min and a mean blood loss of 186 ± 57 ml. ODI significantly improved from a mean of 63 ± 7 preoperatively to 10 ± 4 at 12 months postoperatively (P < 0.001). The mean preoperative LBP VAS score 8 ± 1 showed also a statistically significant decrease of values to 1 ± 1 at 12 months, (P < 0.001). At 12 m, all patients returned to unrestricted ADL. Pars healing was present in 19 patients (76%) at 6 months and in all patients at 12 months. CONCLUSIONS: Polyaxial pedicular screws with a U-shaped rod offer an effective and reproducible treatment for spondylolysis with an appropriate fusion rate, predictable return to daily activities, and good pain relief in young adults.

Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Surgical Management of Post-Discectomy Syndrome.

STUDY DESIGN: This was a prospective case series of 30 patients with post-discectomy syndrome with an average of 18 months of follow-up (level IV). PURPOSE: The efficacy of post-discectomy syndrome managed by minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) was evaluated. OVERVIEW OF LITERATURE: In post-discectomy syndrome wherein conservative treatment had failed, the best surgical treatment modality still remains controversial. METHODS: Patients were functionally assessed using the Visual Analog Scale (VAS) for low back pain (LBP) and leg pain (LP) and Oswestry Disability Index (ODI). Radiological fusion was confirmed with plain X-rays and when indicated with computed tomography scan at 12 months postoperatively. A total of 30 patients with 37 operated at lumbar levels with failed discectomy surgery who met our inclusion criteria were treated with MIS-TLIF. RESULTS: The ODI of all patients showed significant improvement from a mean of 73.78% preoperatively to 16.67% at 1 month and 14.13% at 12 months postoperatively. The preoperative LBP VAS score (mean, 4.37) showed a significant decrease (p <0.001) to 1.90 at 1 month and 1.10 at 12 months. Preoperative LP VAS score of limb pain averaged 7.53 and showed a significant (p <0.001) decrease to 3.47 at 1 month and 1.10 at 12 months. All patients attained radiological fusion at 12 months. CONCLUSIONS: MIS-TILF constitutes a valid and effective treatment option for patients with post-discectomy syndrome.

A comparative study between the Universal Spinal System® (USS) and the CD Horizon® Legacy™ (CDH) in the management of thoracolumbar fractures.

INTRODUCTION: For the treatment of unstable non-osteoporotic thoracolumbar fractures, the clinical and radiological outcome of short-segment fixation with the USS™ - Universal Spine System (DePuy Orthopedics, Inc., Warsaw, IN, USA) and the CD HORIZON® LEGACY™ 5.5 Spinal System, (Medtronic Sofamor Danek USA, Inc., Memphis, TN, USA) were compared. METHODS: From March 2015 to January 2016, 40 consecutive patients with unstable traumatic thoracolumbar fractures who met our inclusion criteria were treated with either the USS system or CDH Legacy system. Segmental kyphosis angle (SKA) and anterior body height (ABH) of fractured vertebrae, and ASIA Impairment Scale (AIS) were evaluated. Radiological fusion was confirmed with plain X-rays and when indicated with computerized tomography (CT). RESULTS: The mean immediate kyphotic angle correction was 16.6° for the Schanz and 6.4 for the Legacy system, and the immediate mean anterior vertebral body height correction was 0.92 cm for the Schanz and 0.51 cm for the Legacy system. Our study shows a significant statistical difference between Schanz and Legacy systems regarding post-operative segmental kyphosis and height correction immediately postoperatively, at 6 months and at one-year follow-up (p-value < 0.005). The degree of pain reduction and neurological improvement was not influenced by the screw system. CONCLUSION: Usage of USS in thoracolumbar fracture as a short-segment fixation led to a near anatomical reduction when compared to the Legacy system. However, there was no advantage regarding pain reduction and neurological outcome.

The use of anterior cervical interbody spacer with integrated fixation screws for management of cervical disc disease.

INTRODUCTION: Integrated cage and screw designs were introduced for anterior cervical discectomy and fusion (ACDF) and allegedly are superior to anterior plating due to their minimal anterior profile. METHODS: A descriptive study was designed as a prospective case series of 25 patients (30 operated discs) with cervical disc disease treated with a zero-profile cage, and followed up for an average of 16 months (range 12 -18 months). Functional assessment was done with the Neck Disability Index (NDI) and Visual analog scale (VAS) scores for arm and neck pain. Furthermore, Nurick's classification system for myelopathy based on gait abnormalities was documented. Radiological fusion was confirmed with plain X-rays and when indicated with a CT scan at 12 months postoperatively. Dysphagia was classified according to the Bazaz criteria. RESULTS: VAS for neck and arm pain, NDI, and Nurick Score immediately improved postoperatively and remained so at 12-month follow-up. Fusion was achieved in 19 patients (95%) at six months and in 20 patients (100%) of the single-level group at one year. At six months 80% (four patients) and at 12 months 100% (five patients) showed complete union in the double-level group. No evidence of cage subsidence was noted radiographically. DISCUSSION: The favorable lordosis and fusion rates of the low-profile integrated device are consistent with ACDF using anterior plating. Additionally, improved pain and an acceptable rate of dysphagia support the use of integrated interbody spacers for use in ACDF procedures.

The use of platelet-rich fibrin in lumbar interbody fusion in lytic spondylolisthesis.

STUDY DESIGN: This was a retrospective observational study. AIM: The aim of this study was to evaluate the effectiveness of applying the platelet-rich fibrin (PRF) with bone graft in accelerating the rate of lumbar interbody fusion. SETTINGS AND DESIGN: This was a retrospective study measuring the outcome of posterior lumbar interbody fusion (PLIF) combined with PRF versus PLIF alone in the management of lytic spondylolisthesis. SUBJECTS AND METHODS: Forty patients were treated with instrumented PLIF for low-grade lytic spondylolisthesis and divided into two equal groups: one with addition of PRF to the bone graft and the other without. The minimum follow-up was 2 years. Clinical outcome was measured by the Oswestry Disability Index (ODI) and Visual Analogue Pain Scale (VAS) at 3, 6, and 12 months postoperatively. Radiological outcome was measured by standing X-ray at 3, 6, 12, and 24 months and computed tomography at 6 and 12 months postoperatively. RESULTS: ODI for the PRF group improved by 60% and 79% at 6 and 12 months, respectively, whereas for the non-PRF group, it improved by 55% and 70%. Radiological outcome showed fusion in 15 of 20 cases in the PRF group (75%) by the 6th month and in 19 of 20 cases (95%) by 1 year and 100% at 2 years. In the control group, fusion was present in 12 of 20 cases (60%) by the 6th month and in 13 of 20 cases in the PRF group (65%) by 1 year and 90% at 2 years (P < 0.05). CONCLUSIONS: These preliminary results show that PRF accelerates the rate of fusion in low-grade lytic spondylolisthesis in short-term follow-up.

Augmentation of fenestrated pedicle screws with cement in patients with osteoporotic spine.

BACKGROUND: Backing out and failure of pedicle screws in patients with osteoporosis is becoming a big problem due to wide use of these screws nowadays. PURPOSE: The aim of this study is to evaluate the purchase of fenestrated pedicle screws augmented with cement in patients with osteoporosis. STUDY DESIGN: This was retrospective observational study. PATIENTS AND METHODS: From May 2015 to January 2016, 25 patients with a poor bone stock condition underwent posterior fixation by fenestrated pedicle screws and cement augmentation. Assessment of pain improvement was done by visual analogue score (VAS) score while the long-term clinical outcome was assessed using Oswestry low back disability questionnaire (Oswestry disability index [ODI]). Implant stability was evaluated by plain radiography. Complications were evaluated in all cases. RESULTS: All patients were followed up clinically and radiographically for a mean age of 24.84 months. There was a significant reduction in pain and improvement of the quality of life as detected using VAS scores and ODI questionnaire consecutively (P < 0.001). No radiological loosening or backing out of screws was observed. Cement leakage occurred in five cases. CONCLUSION: Augmentation of fenestrated screws with cement provided effective and lasting purchase in patients with osteoporosis. The only clinical complication strictly related to this technique was cement leakage.