Clinical evaluation of ankle arthrodesis with Ilizarov fixation and internal fixation.

BACKGROUND: Ankle arthrodesis may have internal or external stabilization. We assessed whether the type of stabilization after ankle arthrodesis will affect: (1) functional outcome in Foot and Ankle Ability Measure (FAAM) scale, (2) pain level, (3) period of hospitalization, (4) rate of complications. METHODS: We retrospectively studied 47 individuals after ankle arthrodesis with Ilizarov fixation (group 1, n = 21) and internal stabilization (group 2, n = 26) at our institution in years 2007-2015. Clinical outcomes were measure by: (1) functional outcome in FAAM scale, (2) pain level, (3) period of hospitalization, (4) rate of complications. RESULTS: Total number of complications in Ilizarov group was 13, which corresponded to 0.62 complications per patient on average. In group 2 there were 15 complications, which corresponded to 0.58 complications per patient on average. The intergroup difference in rate of complications was not statistically significant (p = 0.066). In group 1 the mean VAS pain level before treatment was 4.69 and after treatment was 1.5 (p = 0.037). In group with internal stabilization the mean VAS pain level before treatment was 4.71 and after treatment was 2.9 (p = 0.044). In group 1 the mean period of hospitalization was 5.29 days, in group 2 was 5.71 days (p = 0.517). In group 1 the mean functional outcome in FAAM scale was 79.38, in group 2 was 70.11 (p = 0.458). CONCLUSIONS: Ankle arthrodesis with Ilizarov stabilization is associated with lower prevalence of VAS pain level after surgery than after internal screws stabilization. Rate of complications, FAAM functional score and period of hospitalization were not statistically significant between group 1 and 2. Clinical outcome was satisfactory in group 1 and 2, but outcomes in Ilizarov group were slightly better than after internal stabilization.

Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation.

BACKGROUND: A number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads. METHODS: Retrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform. RESULTS: In group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant. CONCLUSIONS: Balance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients' balance.

Increased Radiation but No Benefits in Pedicle Screw Accuracy With Navigation versus a Freehand Technique in Scoliosis Surgery.

BACKGROUND: The clinical value of pedicle screws in spinal deformity surgery is well known; however, screw insertion is demanding and sometimes associated with complications. Navigation systems based on intraoperatively obtained three-dimensional (3-D) images were developed to minimize pedicle screw misplacements. However, there is a lack of data confirming superiority of navigation above other techniques. There are also concerns regarding increased radiation used during the procedure. QUESTIONS/PURPOSES: The purposes of this study were (1) to compare accuracy of the two methods of pedicle screws placement: intraoperative 3-D image navigation versus a freehand technique in patients with idiopathic scoliosis; and (2) to assess the radiation dose received by patients with both methods. METHODS: Between 2014 and 2016, 49 patients underwent posterior spinal fusion with all pedicle screw constructs for idiopathic scoliosis performed by two surgeons. The study design involved alternating the use of the freehand technique and navigation to position pedicle screws in consecutive patients, forming groups of 27 patients with 451 navigated screws and 22 patients with 384 screws positioned freehand. The two groups did not differ in age, sex, or magnitude of deformity. Two observers not involved in the treatment evaluated the position of the screws. The pedicle breach was assessed on intraoperatively obtained 3-D O-arm® scans according to a grading system: Grade 0 = no pedicle wall violation; Grade 1 = perforation ≤ 2 mm; Grade 2 = 2 to 4 mm; and Grade 3 = perforation > 4 mm. Grades 0 and 1 were considered properly positioned and Grades 2 and 3 represented malposition. RESULTS: In terms of accuracy, we found no differences, with the numbers available, between the freehand and navigated groups in terms of the proportion of screws that were properly positioned (96% freehand and 96% in the navigation group, respectively; p = 0.518). Grade 3 pedicle screws were observed only in the freehand group and were all located in the upper thoracic spine. Patients undergoing navigated pedicle screw placement received a greater mean radiation dose than those whose screws were placed freehand (1071 ± 447 mGy-cm versus 391 ± 53 mGy-cm; mean difference, 680 mGy-cm; 95% confidence interval, 217-2053 mGy-cm; p < 0.001). CONCLUSIONS: In patients with moderate idiopathic scoliosis undergoing primary surgery, we did not observe benefits of pedicle screw placement with CT-based navigation, but the patients experienced greater exposure to radiation. LEVEL OF EVIDENCE: Level III, therapeutic study.

The impact of direct vertebral rotation (DVR) on radiographic outcome in surgical correction of idiopathic scoliosis.

INTRODUCTION: Recent developments of spinal instruments allow to address nearly all components of idiopathic scoliosis. Direct vertebral rotation (DVR) maneuver was introduced to correct apical axial vertebral rotation. It is however still not well established how efficiently DVR affects results of scoliosis correction. The object of the study was to evaluate en bloc apical vertebral rotation (DVR) and its impact on coronal and sagittal correction of the spine in patients undergoing surgical scoliosis treatment. MATERIALS AND METHODS: Thirty-six consecutive patients who underwent posterior spinal fusion with pedicle screws only constructs for idiopathic scoliosis. Fifteen patients (20 curves) were corrected by rod derotation only and 21 patients (26 curves) had both rod derotation and DVR. Curve measurements were performed on x-rays obtained before and postoperatively-coronal curves, kyphosis (T2-T12, T5-T12). Spine flexibility was assessed on prone bending x-rays. Apical axial rotation was determined on CT scans obtained intraoperatively and postoperatively. Rotation angle (RAsag) was measured according to Aaro and Dahlborn. RESULTS: We observed reduction of RAsag in all patients; however, in DVR group, decrease was greater, by 31.8% comparing to non-DVR group, by 8.6% (p = 0.0003). Mean coronal correction in DVR group was 68.8% and in rod derotation group without DVR 55% (p = 0.002). No significant correlation was found between degree of derotation obtained and coronal correction. In DVR group T2-T12 kyphosis has increased in 28 (65%) patients whereas in non-DVR group in 31 (69%) cases. Mean value of T2-T12 kyphosis growth was 16.7% in DVR and 22.1% in non-DVR group. These differences however did not occur statistically significant. CONCLUSIONS: Direct vertebral rotation (DVR) maneuver reduces significantly apical rotation of the spine, enhances ability of coronal correction, and it does not reduce thoracic kyphosis.

Micromorphological assessment of bone tissue remodeling in various hip degeneration conditions.

BACKGROUND: The reorganization of bone tissue is closely associated with its metabolism and changes in its internal structure. Metabolism of the bone, which results from the simultaneous processes of resorption and formation of new bone tissue, may depend on the presence and type of arthritis. OBJECTIVES: The objective of the study was to assess, based on the morphological features and mineral composition of bone tissue, changes in the femoral head in various types of hip joint degeneration. MATERIAL AND METHODS: The study group consisted of 21 patients surgically treated for hip joint degeneration. They included 17 women, aged 30-70 years (mean age 52.5 years), and 4 men, aged 38-51 (mean age 48.5 years). The assessment of the morphological condition of the bone and the mineral composition of bone tissue took into account quantitative and qualitative relationships among the mineral components and bone matrix. The structure of spongious bone tissue was analyzed in histological studies, with special attention paid to osteogenesis and osteoclastic processes and the advancement of degeneration. RESULTS: Three main types of degenerative changes in bone tissue of the examined femoral head were recognized: osteoporosis with a prevalence of coarse-fiber bone tissue and decreased osteogenic activity; osteolysis with few osteogenesis centers; and intensified reorganization of bone tissue. In more than half of the examined samples, coarse-fiber bone tissue was replaced by newly formed bone tissue. We observed bone resorption and osteogenesis, which indicate normal homeostasis of the bone tissue. Uneven saturation of spongious bone with mineral components was found. The content of organic and inorganic bone components measured with Ca : P and C : Ca + P ratios had similar values in all types of changes. Only the bone with intense osteolysis contained a smaller quantity of carbon (4.96-8.13%). CONCLUSIONS: Our observations indicate an intense adaptive reorganization of bone tissue depending on external and internal factors, including biomechanical condition.

The impact of configuration of the Ilizarov fixator on its stiffness and the degree of loading of distraction rods.

BACKGROUND: The mechanical parameters of the Ilizarov fixator are influenced by many factors related to its spatial configuration. The aim of this study was to experimentally evaluate the impact of the type of implant and the number of distraction rods on the uniformity of loading of distraction rods and stiffness coefficients of the Ilizarov fixator. METHODS: The tests were carried out on a physical model. The model was mounted in a universal loading station MTS 858 Mini Bionix. Forces in distraction rods are measured with the use of strain gauge force transducers. Displacements of bone fragments were measured by means of digital image correction. FINDINGS: In the case of a fixator with 3 distraction rods, configuration of implants has no statistically significant effect on the forces occurring in distraction rods. In the case of a fixator with 4 distraction rods, there are statistically significant differences in the forces in distraction rods. The highest transverse stiffness coefficients occurs in the system with 4 distraction rods and the configuration of 1K1S implants, while the smallest transverse stiffness coefficients occurs in the fixator with 4 distraction rods and the configuration of 0K1S implants. INTERPRETATION: Based on the results of experiments on the physical model, we observed an asymmetry in the distribution of forces transmitted through distraction rods. The configuration with 3 distraction rods provides more uniform distribution of forces in distraction rods and reduces the impact of the implant configuration on transverse stiffness coefficients. The use of a configurations with 4 rods may be advantageous when we want to obtain greater transverse stiffness coefficients of a system consisting of the fixator and fragments of the lengthened bone.

Assessment of the distribution of load on the lower limbs and balance before and after ankle arthrodesis with the Ilizarov method.

Ankle arthrodesis with the Ilizarov method is an accepted form of treatment of advanced degenerative changes of the ankle joint. Incorrect balance and load distribution on the lower limbs may result in pain and dysfunction. The aim of the study was to assess the change of balance and load distribution in lower extremities in patients before and after ankle arthrodesis with the Ilizarov method. Between 2013 and 2016, ankle arthrodesis using the Ilizarov method was performed on 21 patients. The evaluation of balance and percentage of load in each lower limb was performed before the surgery and during the follow-ups. The evaluation was performed using a Zebris pedobarographic platform. Before the surgery, the patients exhibited an average load of 41.9% of body weight in the affected limb, whereas the load in the healthy limb was 58.1%. The difference was statistically significant (p = 0,000031). In two years follow-up, the average load in the treated limbs was 48.19%, whereas the healthy limbs were subjected to an average load of 51.81%. In preoperative tests, the average path length of the center of gravity was 161.55 cm; postoperatively, the average path length of the center of gravity was 129.7 cm (p = 0.00003206). Preoperatively, the average area of the center of gravity was 18.85 cm2; it decreased to 6.19 cm2 (p = 0.000032) postoperatively. Arthrodesis of the ankle with the Ilizarov method improved the statics of the musculoskeletal system by improving the distribution of loads in the lower limbs as well as balance. However, it failed to restore the parameters of a healthy person. Advanced degenerative changes of the ankle disturb the biomechanics of the entire lower limb.

Balance and lower limb loads distribution after Ilizarov corticotomy.

INTRODUCTION: Normal balance and symmetric distribution of lower limb loads are associated with adequate muscle strength, joint mobility and proprioception. The aim of this study was to analyze the distribution of lower limb loads and balance prior to and after axis correction and lengthening with Ilizarov method. MATERIALS AND METHODS: The prospective analysis included 20 patients from our clinic, who have been subjected to distraction-corrective lower limb corticotomies with the Ilizarov method in 2014-2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform. RESULTS: Prior to the surgery, mean loads on affected and non-affected limbs corresponded to42%and58%of body weight, respectively. Mean loads on affected and non-affected limbs during the postoperative examination did not differ significantly. Mean path length of the center of gravity prior to and after the surgery amounted to143.27 cm and 125.11 cm, respectively. Mean area of the center of gravity was 7.81 cm2prior to the surgery and 5.81 cm2after the procedure. DISCUSSION: Our present study showed that distraction-corrective Ilizarov corticotomy may provide more symmetric distribution of lower limb loads and improvement of balance. This outcome should be considered satisfactory from the perspective of the locomotor system statics. Corticotomies with Ilizarov method provide symmetric distribution of loads between non-affected and operated limb.

Three-dimensional printing as a technology supporting the treatment of lower limb deformity and shortening with the Ilizarov method.

BACKGROUND: Treatment of multiplanar deformities, especially in younger children, requires construction of a complex Ilizarov fixator, frequently with small dimensions. The aim of this study is to verify clinical application of a3D-printed bone model in treatment with the Ilizarov method. METHODS: The study involved a 6-year-old child in whom clinical and radiological examination revealed multiplanar deformity of the right leg. Then, 3D models of individual bones were printed by means of additive manufacturing and were used as a scaffold to install the Ilizarov apparatus. To compare the expected and factual axial correction and lengthening, we measured spatial orientation of bone fragments three times. The factual axial correction and lengthening were determined with a photometric technique. RESULTS: Ilizarov fixator with a configuration developed using a 3D model of the treated bone was mounted on the patient's leg. Corticotomy was carried out at the proximal metaphysis of the right tibia, along with osteotomy of the right talus. The treatment resulted in a 3.5-cm lengthening of the limb and a 7° correction of valgus angle. The values of actual lengthening and axial correction were 4.1% lower than the expected values of these parameters. INTERPRETATION: Orthopedists should consider differences between the expected and actual lengthening and axial correction in planning treatment with the Ilizarov method. Three-dimensional printing is a useful technology that can be used to support treatment with the Ilizarov method.

Cytokine induction of sol-gel-derived TiO2 and SiO2 coatings on metallic substrates after implantation to rat femur.

Material surface is a key determinant of host response on implanted biomaterial. Therefore, modification of the implant surface may optimize implant-tissue reactions. Inflammatory reaction is inevitable after biomaterial implantation, but prolonged inflammation may lead to adverse reactions and subsequent implant failure. Proinflammatory activities of cytokines like interleukin (IL)-1, IL-6, and tumor necrosis factor-alpha (TNF-α) are attractive indicators of these processes and ultimately characterize biocompatibility. The objective of the study was to evaluate local cytokine production after implantation of stainless steel 316L (SS) and titanium alloy (Ti6Al4V) biomaterials coated with titanium dioxide (TiO2) and silica (SiO2) coatings prepared by sol-gel method. Biomaterials were implanted into rat femur and after 12 weeks, bones were harvested. Bone-implant tissue interface was evaluated; immunohistochemical staining was performed to identify IL-6, TNF-α, and Caspase-1. Histomorphometry (AxioVision Rel. 4.6.3 software) of tissue samples was performed in order to quantify the cytokine levels. Both the oxide coatings on SS and Ti6Al4V significantly reduced cytokine production. However, the lowest cytokine levels were observed in TiO2 groups. Cytokine content in uncoated groups was lower in Ti6Al4V than in SS, although coating of either metal reduced cytokine production to similar levels. Sol-gel TiO2 or SiO2 coatings reduced significantly the production of proinflammatory cytokines by local tissues, irrespective of the material used as a substrate, that is, either Ti6Al4V or SS. This suggests lower inflammatory response, which directly points out improvement of materials' biocompatibility.

Radiological evaluation of ankle arthrodesis with Ilizarov fixation compared to internal fixation.

INTRODUCTION: We asked whether the type of ankle joint arthrodesis stabilization will affect: (1) rate of union, (2) rate of adjacted-joint arthritis, (3) malalignment of the ankle joint. MATERIAL AND METHODS: We retrospectively radiological studied 62 patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization (group 1,n=29) or internal stabilization (group 2,n=33) from 2006 to 2015. Radiologic outcomes were mesure by: (1) rate of union, (2) rate of adjacent-joint arthritis, (3) malalignment of the ankle joint. The Levene's test,Mann-Whitney U test and Students t-test were used to the statistical analyses. RESULTS: Ankle fusion was achieved in 100% of patients treated with external fixation and in 88% with internal stabilization. Desired frontal plane alignment was achieved in 100% of patients with external fixation and 76% with internal stabilization. Desired sagittal plane alignment was achieved in 100% of external fixation and 85% of internal stabilization. A total of 14 (48.3%) patients from group 1 showed a radiographic evidence of pre-existing adjacent-joint OA. The radiographic evidence of pre-existing adjacent-joint OA was also found in 27(81.8%) subjects from group 2. Alterations of adjacent joints were also found on postoperative radiograms of 19 (65.5%) patients subjected to Ilizarov fixation and in all 33 patients from group 2. DISCUSION: Ilizarov fixation of ankle arthrodesis is associated with lower prevalence of adjacent-joint OA and ankle joint misalignment,and with higher fusion rates than after internal fixation.Although achieving a complex ankle fusion is generally challenging,radiological outcomes after fixation with the Ilizarov apparatus are better than after internal stabilization.

Evaluation of dynamic formation of cervical spine column based on functional radiological studies in patients after cervical spine injury.

The purpose of this study was to evaluate cervical spine function, based on our own functional method of roentgenometric analysis in patients who suffered from cervical spine sprain injury. Study involved 72 patients who suffered from cervical spine whiplash injury. Conventional plain radiographs in all patients included three lateral views: maximum flexion, neutral (resting) and maximum extension. All views allowed roentgenometric evaluation of ligament instability of the lower cervical spine C5-C7 according to the White and Panjabi criteria. Furthermore, based on literature analysis and their own clinical observations, the authors proposed new classification of dynamic formation of cervical spine column. The dynamic formation of cervical column is evaluated based on pathomechanical chain of being between normal and unstable. Authors' own evaluation system in flexion views can be useful in diagnosis and treatment of this type of injury.

Influence of whiplash injury on cervical spine stability.

The aim of this study was to define the influence of whiplash injury on cervical spine stability. The study involved 72 patients who had suffered from sprain injury to cervical spine of 0°-III° according to QTF. To verify the results the authors examined the control group whose representatives have never suffered from any cervical spine injury and met all the exclusion criteria. Conventional plain radiographs in both groups showed three lateral views: maximum flexion, neutral (resting) position and maximum extension view. The results of image studies were subjected to roentgenometric analysis to find mechanical symptoms of instability according to radiological criteria: AADI, anterior translation and regional angulation. The authors demonstrated that there was no influence of whiplash injury on mechanical stability of cervical spine measured on radiograms in static-functional lateral views.