Proximal and distal mechanical repercussions of instrumentation by double rods and interbody grafts in adult scoliosis.

INTRODUCTION: Correction of adult scoliosis by instrumentation with double rods and interbody grafts aims to reduce the risk of pseudarthrosis with rod fracture. An increase in instrumentation rigidity can lead to an increase in stresses at the proximal and distal ends of the construct. The aim of this study was to analyze the incidence and clinical repercussions of proximal junctional kyphosis (PJK), proximal junctional failure (PJF) and iliac screw loosening. MATERIEL AND METHODS: An analysis of patients operated on for adult scoliosis with instrumentation to the pelvis using 4 rods and interbody cages was carried out from a prospective register. The Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Scoliosis Research Society 22 (SRS-22) clinical scores and radiological parameters were collected preoperatively, postoperatively at 3 months, 1 year and 2 years. The appearance of PJK, PJF or distal screw loosening was sought; the clinical impact and the risk factors were analyzed by Bayesian inference. RESULTS: Fifty-one patients with a mean age of 64.5 years were included. The clinical scores improved significantly (Pr>0.95) at 2 years: VAS back 6.9 versus 2.6, VAS leg 4.9 versus 2.5, ODI 48.2 versus 25.4, SRS-22 2.4 versus 3.5. The radiological parameters were corrected (Pr>0.95): Cobb angle 63.9° versus 22.8°, spinosacral angle (SSA) 112.4° versus 118.8°, T1-pelvic angle (TPA) 24, 8° versus 20.8°, lumbar lordosis 43.8° versus 51.0°, thoracic kyphosis 45.2° versus 53.6°. Thirteen patients (25.5%) presented with PJK and 11 (21.6%) with PJF. Seven patients (13.7%) presented with iliac screw loosening. None of these complications was associated with a significant deterioration in clinical scores. Cranial migration of the lumbar apex increased the risk of distal screw loosening: Odds-Ratio 10.31 (Pr>0.999). Two patients were re-operated on for PJF and one patient for iliac screw loosening (5.9%). No rod fracture with pseudarthrosis was found. CONCLUSION: Instrumentation with double rods and interbody grafts was associated with a rate of 47.1% of mechanical repercussions at the extremity of the construct. However, these complications were not associated with a significant deterioration in clinical scores. LEVEL OF EVIDENCE: III.

Midshaft clavicle fracture synthesis with twisted one-third tubular plate with anterior-inferior approach.

BACKGROUND: Fractures of the clavicle are common and usually treated as minor injuries. The middle-third fractures account for 80% of all clavicle fractures. For many years, these fractures have been treated conservatively. After recent studies, this traditional approach has been reconsidered pointing the need to operate in some cases. AIM: To describe functional and radiological outcome of midclavicular fractures fixation using one-third tubular molded plate through an anterior inferior incision and to compare it to the outcome in the literature. METHODS: It was a retrospective study, using data gathered in 40 months from 38 cases of mid-shaft clavicle fractures treated operatively using one-third tubular molded plate with minimum perspective of 12 months. RESULTS: The mean age of the patients was 27 years with a sex ratio of 4.42. 8% of patients were suffering from diabetes. 58% were manual workers. 89% of fractures occurred on the side of the dominant limb, mostly after a domestic accident. In ⅔ of cases, the fracture occurred on the right side after an indirect injury. No vascular or neurological complications were reported. Fractures were most frequently classified Allman type I, AO type A1 and A2 and Edinburgh type 2A2 and 2B1. The mean operative time was 55 minutes. Immobilization with a sling were recommended for 24 hours. The mean consolidation time was 53 days. There was no postoperative complications and none of our patients underwent plate removal for infection. The mean Constant score at last follow up was 90. CONCLUSION: Operative treatment of mid-shaft clavicle fractures using one-third tubular molded plate allows avoiding neurovascular and skin complications with a low financial cost and helps patients, especially manual workers and young athletics, recover a normal shoulder function and return sooner to their usual activities.