ICA agenesis with transcavernous anastomosis: a systematic review.

PURPOSE: To present two cases of Internal Carotid Artery (ICA) agenesis and conduct a systematic review to assess for associations with other anomalies and intracranial aneurysms. METHODOLOGY: We performed a retrospective review of published cases of patients with ICA agenesis with intercavernous anastomosis in MEDLINE database on August 2022 using search terms "internal carotid artery", "agenesis" and "transcavernous anastomosis". We also included two cases of ICA agenesis with type D collateral that we encountered. RESULTS: Total of 46 studies that included 48 patients and two of our cases resulted in 50 patients. Only 70% of studies reported the location of a collateral vessel of which more than two-thirds were on the floor of sella. More than half of the vessels connected cavernous segments of ICA. A1 segment ipsilateral to the side of ICA agenesis was absent in most of the cases but was not true for all cases. Aneurysm was seen in more than one-quarter of the patients. It can also mimic microadenoma as in prior reported cases as well as in one of our cases. CONCLUSION: ICA agenesis with type D collateral is a rare anomaly but clinically relevant due to the increased risk of an aneurysm or mimic microadenoma or false alarm for occlusion of ICA but knowledge of this rare variant can help in better management of these patients.

Tonsillar Metastasis From Colon Cancer Detected on 18F-FDG PET/CT Imaging.

A 54-year-old woman with smoking history who was diagnosed with invasive adenocarcinoma of the rectosigmoid colon with subsequent surgical resection and chemotherapy was presented. The patient developed local recurrence and pulmonary metastases that required further chemotherapy and surgical resection. During follow-up, the patient had F-FDG PET/CT scan showing asymmetric hypermetabolic tonsils with activity greater on the right compared with the left. The patient underwent bilateral tonsillectomy, and pathology revealed moderately to poorly differentiated adenocarcinoma in the right tonsil, consistent with metastasis from known colonic primary.

Clinical Utility of 18F-FDG PET/CT in Staging Localized Breast Cancer Before Initiating Preoperative Systemic Therapy.

BACKGROUND: 18F-fluorodeoxyglucose PET/CT is recommended as an optional study in the current NCCN Clinical Practice Guidelines in Oncology for Breast Cancer after CT of the chest, abdomen, and pelvis with contrast and bone scan (CTBS) in stage IIA-IIIC breast cancer. We evaluated our experience with the use of PET/CT in this setting before beginning primary systemic therapy (PST) prior to planned surgery. METHODS: We performed medical record abstractions of all adult female patients with clinical stage IIA-IIIC breast cancer diagnosed at Montefiore Medical Center from January 1, 2014, through January 1, 2019, who underwent PET/CT before PST. We calculated the proportion of patients upstaged after PET/CT and examined the cost and radiation exposure associated with PET/CT compared with CTBS. RESULTS: A total of 195 patients with 196 breast cancers (bilateral disease in 1 patient) met the study inclusion criteria and had PET/CT as the first imaging study before PST. The overall upstaging rate for regional nodal metastasis and/or distant metastasis was 37% (73/196), including 24% for stage IIA (9/38), 39% for stage IIB (31/79), 54% for stage IIIA (22/41), 27% for stage IIIB (8/30), and 37% for stage IIIC (3/8). The overall upstaging rate for distant metastasis was 14% (27/196), including 0% for stage IIA, 13% for stage IIB (10/79), 22% for stage IIIA (9/41), 17% for stage IIIB (5/30), and 37% for stage IIIC (3/8). Medicare reimbursement rates were $1,604.37 for PET/CT and $1,679.94 for CTBS. The radiation dose for PET/CT was 14 mSv versus 21 mSv for CTBS. CONCLUSIONS: Approximately 37% of patients with clinical stage IIA-IIIC breast cancer who underwent PET/CT before PST showed more extensive disease, including 23% with more extensive nodal metastasis and 14% with distant metastasis. Given its high detection rate, comparable cost, lower radiation dose, and greater convenience, PET/CT should be considered as an alternative to CTBS rather than "optional" after CTBS, especially in patients who require an efficient and expeditious workup before initiating PST.

Unilateral Absence of the Basal Ganglia on 123I-Ioflupane DaTScan.

This 33-year-old man presented with hemorrhagic stroke manifesting with left hemiparesis and right ptosis. Angiography revealed no patent carotids. The anterior and middle cerebral arteries were filling collaterally through the posterior vertebrobasilar pathway. The presumptive diagnosis was moyamoya disease. The etiology of the bleeding was right basilar tip aneurysm that subsequently had partial coil placement. Months later, the neck of the aneurysm perforated and second coiling was performed. Later on follow-up, patient developed left hand tremor. A radionuclide DATscan revealed total absence of right-sided basal ganglia activity. A possible etiology was occlusion of the middle cerebral artery's lenticulostriate branches.

Minimum 20-Year Health-Related Quality of Life and Surgical Rates After the Treatment of Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Longitudinal cohort. OBJECTIVES: To determine the patient-reported functional outcomes and need for related surgical procedures in a US cohort of adolescent idiopathic scoliosis (AIS) patients with minimum 20-year follow-up. SUMMARY OF BACKGROUND DATA: There is limited information regarding the long-term outcomes of scoliosis treatment in the US population. METHODS: A novel population of patients who underwent pediatric treatment for AIS with minimum 20-year follow-up was identified. Search of a single-center diagnostic registry generated 337 patients who fulfilled the inclusion criteria (AIS, curve magnitude >35°, and childhood treatment with bracing, surgery, or observation from 1975 to 1992). Any additional spine surgery as well as EQ5D, ODI, SRS 22, SAQ were determined. A total of 180 patients were included (mean of 30-year follow-up, range 20-37). Childhood treatment entailed bracing (41 patients), surgery (103 patients), and observation (36 patients). RESULTS: During the study period, only 1 of the 41 bracing patients underwent additional scoliosis-related spine surgery, whereas 5 of the 36 patients in the observation cohort underwent scoliosis surgery as adults. Seven of 103 childhood surgical patients required additional revision surgery as adults. Fifteen patients (4 braced, 7 fusion, and 4 observed) underwent chest wall surgery as adults. SRS scores were around 10% worse compared to population-based controls, with the exception of SRS mental health scores, which were similar to controls. Overall, 5.6% of patients were on disability, with no difference between operative and nonoperative groups. CONCLUSION: We found a low rate of adult scoliosis surgery in the braced population, and a low rate of revision surgery at the 30-year follow-up in patients undergoing spine fusion for AIS between 1975 and 1992. No detected differences in patient-reported outcomes were found between the braced, surgical, and observed populations at a mean of 30 years' follow-up. LEVEL OF EVIDENCE: Level III, therapeutic.

Sternoclavicular joint allograft reconstruction using the sternal docking technique.

BACKGROUND: The sternoclavicular joint may become unstable as a result of trauma or medial clavicle resection for arthritis. Allograft reconstruction with the figure-of-8 configuration is commonly used. This study was conducted to determine the outcome of sternoclavicular joint reconstruction using an alternative graft configuration. METHODS: Between 2005 and 2013, 19 sternoclavicular joint reconstructions were performed using a semitendinous allograft in a sternal docking configuration. The median age at surgery was 44 years (range, 15-79 years). Indications included instability in 16 (anterior, 13; posterior, 3) or medial clavicle resection for osteoarthritis in 3. The median follow-up time was 3 years (range, 1-9 years). RESULTS: Two reconstructions (10.5%) underwent revision surgery, 1 additional patient had occasional subjective instability, and the remaining 16 (84%) were considered stable. Sternoclavicular joint reconstruction led to improved pain (visual analog scale for pain subsided from 5 to 1 point, P < .01), with pain being rated as mild or none for 15 shoulders. At the most recent follow-up, the median 11-item version of the Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 11 (interquartile range [IQR], 0-41) and 88 (IQR, 62-100) respectively. The cosmetic aspect of the shoulder was satisfactory in 16 reconstructions (84%), with a median of 10 points (IQR, 9-10 points) on the visual analog scale for overall satisfaction. CONCLUSION: Reconstruction of the sternoclavicular joint with a semitendinous allograft in a sternal docking fashion restores stability in most patients requiring surgery for instability of the sternoclavicular joint or medial clavicle resection for osteoarthritis.

Two-stage reimplantation for the treatment of deep infection after shoulder arthroplasty.

BACKGROUND: Two-stage reimplantation is the most common treatment modality considered for periprosthetic shoulder infection (PSI). Most studies to date have reported on a relatively small number of shoulders. The purpose of this study was to determine the outcome of 2-stage reimplantation for PSI in terms of both eradication of infection and restoration of function. METHODS: Between 1980 and 2010, 40 shoulders (39 patients) underwent a 2-stage reimplantation for PSI; 35 shoulders (34 patients) met inclusion criteria (10 hemiarthroplasties, 24 anatomic total shoulder arthroplasties, 1 reverse total shoulder arthroplasty). Outcome data included pain, motion, Neer rating, and complications. RESULTS: At most recent follow-up (4.1 years), 2-stage reimplantation had resulted in significant improvements in pain (from 4.4 to 2 on a 5-point scale; P < .0001), mean forward elevation (64°-118°; P < .0001), and mean external rotation (14°-41°; P < .0001). Preoperative testing showed leukocytosis in 1 patient, elevated C-reactive protein concentration in 67%, elevated erythrocyte sedimentation rate in 61%, and positive preoperative aspiration in 69%. Persistent infection, defined as positive cultures in samples obtained at the time of reimplantation, was identified in 5 shoulders (15%); 50% of persistent infections grew Propionibacterium acnes. Reoperations for infection included irrigation and débridement (1), a second 2-stage reimplantation (2), and resection arthroplasty (1); 2 additional patients were treated with chronic suppression. Reoperation for aseptic glenoid loosening was performed in 2 additional shoulders. Results were graded excellent in 10 (28%), satisfactory in 12 (33%), and unsatisfactory in 13 (39%) shoulders. CONCLUSION: Two-stage reimplantation eradicated PSI in 85% of the shoulders. Pain relief and good arcs of motion were achieved in many patients, but there was an overall rate of unsatisfactory results approaching 40%. Preoperative testing was not always reliable for the diagnosis of PSI.

The hospital cost of two-stage reimplantation for deep infection after shoulder arthroplasty.

BACKGROUND: The cost of treating infection after hip and knee arthroplasty is well documented in the literature. The purpose of this study was to determine the cost of two-stage reimplantation for deep infection after shoulder arthroplasty. METHODS: Between 2003 and 2012, 57 shoulders (56 patients) underwent a two-stage reimplantation for deep periprosthetic shoulder infection; implants placed at reimplantation included anatomic total shoulder arthroplasty (a-TSA) in 58%, reverse total shoulder arthroplasty (r-TSA) in 40%, and hemiarthroplasty (HA) in 2%. During the same timeframe, 2953 primary shoulder arthroplasties (2589 patients) were performed at the same institution (a-TSA in 55%, r-TSA in 28%, and HA in 17%). Total direct medical costs were calculated by using standardized, inflation-adjusted costs for services and procedures billed during hospitalization and were adjusted to nationally representative unit costs in 2013 inflation-adjusted dollars. RESULTS: The mean hospital cost (per shoulder) for two-stage reimplantation was $35,824 (95% CI: 33,363 to 38,285) and was significantly higher than for primary procedures (mean: $16,068; 95% CI: 15,823 to 16,314). Both Part A and Part B costs were significantly higher in two-stage reimplantation (p < 0.001). For part A (hospital services), the mean cost for two-stage reimplantation was $29,851 (95% CI: 27,741 to 31,960), compared to $13,508 (95% CI: 13,302 to 13,715) for primaries. For part B (professional costs), mean costs were $5973 (95% CI: 5493 to 6453) versus 2560 (95% CI: 2512 to 2608) respectively. CONCLUSIONS: The hospital cost of two-stage reimplantation for the treatment of an infected shoulder arthroplasty is about two times higher than the cost of a primary shoulder arthroplasty.

Primary Linked Semiconstrained Total Elbow Arthroplasty for Rheumatoid Arthritis: A Single-Institution Experience with 461 Elbows Over Three Decades.

BACKGROUND: Elbow arthroplasty is the treatment of choice for end-stage rheumatoid arthritis (RA). The purpose of this study was to determine the long-term outcome of a linked semiconstrained elbow arthroplasty implant design in patients with RA. METHODS: Between 1982 and 2006, 461 primary total elbow arthroplasties using the Coonrad-Morrey prosthesis were performed in 387 patients with RA. Fifty-five of the arthroplasties were performed to treat concurrent traumatic or posttraumatic conditions. There were 305 women (365 elbows, 79%) and 82 men (96 elbows, 21%). Ten patients (10 elbows) were lost to follow-up, 9 patients (10 elbows) died, and 6 patients (6 elbows) underwent revision surgery within the first 2 years. For the 435 elbows (362 patients, 94%) with a minimum of 2 years of follow-up, the median follow-up was 10 years (range, 2 to 30 years). RESULTS: At the most recent follow-up, 49 (11%) of the elbows had undergone component revision or removal (deep infection, 10 elbows; and mechanical failure, 39 elbows). Eight additional elbows were considered to have radiographic evidence of loosening. For surviving implants followed for a minimum of 2 years, the median Mayo Elbow Performance Score (MEPS) was 90 points. Bushing wear was identified in 71 (23%) of the surviving elbows with a minimum of 2 years of radiographic follow-up; however, only 2% of the elbows had been revised for isolated bushing wear. The rate of survivorship free of implant revision or removal for any reason was 92% (95% confidence interval [CI] = 88% to 94%) at 10 years, 83% (95% CI = 77% to 88%) at 15 years, and 68% (95% CI = 56% to 78%) at 20 years. The survivorship at 20 years was 88% (95% CI = 83% to 92%) with revision due to aseptic loosening as the end point and 89% (95% CI = 77% to 95%) with isolated bushing exchange as the end point. Risk factors for implant revision for any cause included male sex, a history of concomitant traumatic pathology, and implantation of an ulnar component with a polymethylmethacrylate surface finish. CONCLUSIONS: Elbow arthroplasty using a cemented linked semiconstrained elbow arthroplasty provides satisfactory clinical results in the treatment of RA with a reasonable rate of survivorship free of mechanical failure at 20 years. Although bushing wear was identified on radiographs in approximately one-fourth of the patients, revision for isolated bushing wear was uncommon. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Validation of the anatomic severity score developed by the American Association for the Surgery of Trauma in small bowel obstruction.

BACKGROUND: The anatomic severity schema for small bowel obstruction (SBO) has been described by the American Association for the Surgery of Trauma (AAST). Although acknowledging the importance of physiological and comorbid parameters, these factors were not included in the developed system. Thus, we sought to validate the AAST-SBO scoring system and evaluate the effect of adding patient's physiology and comorbidity on the prediction for the proposed system. METHODS: Patients aged ≥18 y who were treated for SBO at our institution between 2009 and 2012 were identified. The physiology and comorbidity as well as the AAST anatomic scores were determined, squared, and added to calculate the score that we termed Acute General Emergency Surgical Severity-Small Bowel Obstruction (AGESS-SBO). The area under the receiver operating characteristic (AUROC) curve analyses were performed for the AAST anatomic score and compared with the AGESS-SBO score as a predictor for inhospital mortality, extended hospital stay, and inhospital complications. RESULTS: A total of 351 patients with mean age of 66 ± 17 years were identified, of whom 145 (41%) underwent operation to treat bowel obstruction. Extended hospital stay (>9 d) occurred in 86 patients (25%), inhospital complications in 73 (21%), and inhospital mortality in eight patients (2%). The median (interquartile range [IQR]) AAST anatomic score was 1 point (IQR: 1-2), physiology score was 0 point (IQR: 0-1), and comorbidity score was 1 point (IQR: 1-3); for overall median AGESS-SBO score of 5 points (IQR: 3-13). The AUROC curve analyses demonstrated that the AGESS-SBO system with measures of presenting physiology, comorbidities in addition to AAST anatomic criteria could be beneficial in predicting key outcomes including inhospital mortality (AUROC curve: 0.80 versus 0.54, P = 0.03). CONCLUSIONS: The AAST anatomic score is a reliable system, which assists care providers to categorize SBO. Adding physiology and comorbidity parameters to the described anatomic criteria can be helpful in predicting the outcomes including mortality. Further studies evaluating its usefulness in research and quality improvement purposes across institutions are still required.

Lumbar Spinous Process-Splitting Laminoplasty: A Novel Technique for Minimally Invasive Lumbar Decompression.

Minimally invasive posterior spinous process-splitting laminoplasty preserving the paraspinal musculature has been introduced to treat patients with lumbar spinal stenosis. Despite its theoretical advantage of limiting muscular trauma, additional efforts are required to evaluate patients' clinical and functional results following this procedure. Between 2010 and 2012, 37 patients underwent spinous process-splitting laminoplasty for lumbar stenosis at a mean age of 68 years (range, 36-87 years) and were followed for minimum of 1 year (mean, 1.3 years). There were 22 (59%) men and 15 (41%) women. Mean number of levels treated with a spinous process-splitting laminoplasty was 2.2 (range, 1-6 levels). Patients had statistically significant improvements in their scores for all self-reported outcomes, including visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Short Form 36 (SF-36) components. Mean VAS significantly decreased by 4.4±3.2 points for back pain and 3.9±3.7 points for leg pain (P<.0001). Mean ODI significantly decreased by 17.5±19.1 points (P<.0001), and mean SF-36 significantly increased by 29±30.4 points (P=.0017) for the physical component and 21.8±25.6 points (P=.0062) for the mental health component. Four (10.8%) patients had a dural tear requiring repair (3 were intraoperative), 3 (8%) had an epidural hematoma requiring evacuation, 1 (2.7%) had an infection requiring irrigation and debridement, and 2 (5%) had additional decompression for symptom recurrence secondary to instability. Lumbar spinous process-splitting laminoplasty is a novel minimally invasive technique that provides adequate decompression for the neuronal elements and may avoid extensive paraspinal muscular damage associated with conventional laminectomy. Patients demonstrated significant improvements in pain and overall heath and function scores at a minimum 1-year follow-up. [Orthopedics.2016; 39(5):e950-e956.].

Long-term outcomes of gastrografin in small bowel obstruction.

BACKGROUND: The gastrografin (GG) challenge is a diagnostic and therapeutic tool used to treat patients with small bowel obstruction (SBO); however, long-term data on SBO recurrence after the GG challenge remain limited. We hypothesized that patients treated with GG would have the same long-term recurrence as those treated before the implementation of the GG challenge protocol. METHODS: Patients ≥18 years who were treated for SBO between July 2009 and December 2012 were identified. We excluded patients with contraindications to the GG challenge (i.e., signs of strangulation), patients having SBO within 6-wk of previous abdominal or pelvic surgery and patients with malignant SBO. All patients had been followed a minimum of 1 y or until death. Kaplan-Meier method and Cox regression models were used to describe the time-dependent outcomes. RESULTS: A total of 202 patients were identified of whom 114 (56%) received the challenge. Mean patients age was 66 y (range, 19-99 y) with 110 being female (54%). A total of 184 patients (91%) were followed minimum of 1 year or death (18 patients lost to follow-up). Median follow-up of living patients was 3 y (range, 1-5 y). During follow-up, 50 patients (25%) experienced SBO recurrences, and 24 (12%) had exploration for SBO recurrence. The 3-year cumulative rate of SBO recurrence in patients who received the GG was 30% (95% confidence interval [CI], 21%-42%) compared to 27% (95% CI, 18%-38%) for those who did not (P = 0.4). The 3-year cumulative rate of exploration for SBO recurrence in patients who received the GG was 15% (95% CI, 8%-26%) compared to 12 % (95% CI, 6%-22%) for those who did not (P = 0.6). CONCLUSIONS: The GG challenge is a clinically useful tool in treating SBO patients with comparable long-term recurrence rates compared to traditional management of SBO.

Readability of discharge summaries: with what level of information are we dismissing our patients?

BACKGROUND: We assessed the health literacy of trauma discharge summaries and hypothesize that they are written at higher-than-recommended grade levels. METHODS: The Flesch-Kincaid grade level (FKGL) and Flesch reading ease scores (FRES), 2 universally accepted scales for evaluating readability of medical information, were used. RESULTS: A total of 497 patients were included. The mean patient age was 56 ± 22 years. Average FKGL and FRES were 10 ± 1 and 44 ± 7, including 132 summaries classified as very or fairly difficult to read. A total of 204 (65%) patients had functional reading skills at grade levels below the FKGL of their dismissal note; only 74 patients (24%) had the reading skills to adequately comprehend their dismissal summary. Total 30-day readmissions were 40, 65% of whom were patients with inadequate literacy for dismissal summary comprehension. CONCLUSIONS: Patient discharge notes are written at too advanced of an educational level. To ensure patient comprehension, dismissal notes should be rewritten to a 6th-grade level.

Pylephlebitis: a Review of 95 Cases.

Pylephlebitis, or suppurative thrombophlebitis of the portal mesenteric venous system occurring in the setting of abdominal inflammatory processes, is a rare but deadly disease commonly associated with diverticulitis. We review our institutional experience in the management of patients with this condition. A retrospective review of medical records from 2002 to 2012 was performed. Patients with a portal mesenteric vein thrombosis (PMVT) within 30 days of an intra-abdominal inflammatory process were identified and evaluated. Ninety-five patients were included. The mean patient age at presentation was 57 years (range, 24-88). The most common associated processes were pancreatitis (31 %), followed by diverticulitis (19 %). Bacteremia was noted in 34 (44 %) patients. The most common organism cultured was Streptococcus viridans. Antibiotic and anticoagulation therapy was given in 86 (91 %) and 78 (82 %) patients, respectively. Overall, we report an 11 % mortality rate. Albeit rare, pylephlebitis most commonly was manifested in the setting of pancreatitis. Treatment should be individualized to culture results and extent of thrombosis. If diagnosed early and managed appropriately, a favorable outcome is possible.

Implant distribution in surgically instrumented Lenke 1 adolescent idiopathic scoliosis: does it affect curve correction?

STUDY DESIGN: Retrospective review of prospective multicenter database of patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion. OBJECTIVE: To analyze implant distribution in surgically instrumented Lenke 1 patients and evaluate how it impacts curve correction. SUMMARY OF BACKGROUND DATA: Although pedicle screw constructs have demonstrated successful surgical results, the optimal pedicle screw density and configuration remain unclear. METHODS: A total of 279 patients with adolescent idiopathic scoliosis treated with pedicle screws were reviewed. Implant density was computed for each side of the instrumented segment, which was divided into 5 regions: distal and proximal ends (upper/lower instrumented vertebra +1 adjacent vertebra), apical region (apex ± 1 vertebra), and the 2 regions in between (upper/lower periapical). Centralized measurement of Cobb angle and thoracic kyphosis was performed on preoperative and at 1-year postoperative radiographs as well as percent curve flexibility. RESULTS: The mean implant density was 1.66 implants per level fused (1.08 to 2) with greater available pedicles filled on the concavity (92%, 53%-100%) compared with the convex side (73%, 23%-100%, P < 0.01). The concave distal end region had the highest density with 99% of pedicles filled (P < 0.01), followed by the other concave regions and the convex distal end region (88%-94%) (P > 0.05). Other convex regions of the construct had less instrumentation, with only 54% to 78% of pedicles instrumented (P < 0.01). Implant density in the concave apical region (69%, 23%-100%) had a positive effect on curve correction (P = 0.002, R = 0.19). CONCLUSION: Significant variability exists in implant distribution with the greatest variation on the convex side and lowest implant density used in the periapical convex regions. Only instrumentation at the concave side, particularly at the apical region, was associated with curve correction. This suggests that for a low implant density construct, the best regions for planned screw dropout may be in the periapical convexity. LEVEL OF EVIDENCE: 3.

At What Levels Are Freehand Pedicle Screws More Frequently Malpositioned in Children?

STUDY DESIGN: Retrospective case series. BACKGROUND: Previous studies report that 5% to 17% of pedicle screws placed in children are malpositioned. Knowledge of the long-term effects of malpositioned screws is limited. We sought to further characterize risk factors for malpositioned pedicle screws in order to establish a more proactive role in limiting future complications. OBJECTIVE: We undertook this study to answer the following: 1) Is the rate of freehand pedicle screw malpositioning higher in children with spinal deformity, particularly at the apical concavity? 2) At what vertebral levels do freehand pedicle screws have the highest rates of malpositioning? 3) In which direction (medial or lateral) do freehand pedicle wall violations occur most often? METHODS: Incidental postoperative computed tomographic (CT) exams were retrospectively reviewed in 85 pediatric patients (605 screws) treated with posterior spinal fusion using freehand pedicle screw technique. Of the screws imaged, 355 were in patients without deformity and 250 in patients with deformity. Breaches were categorized as mild (<2 mm), moderate (2-4 mm), or severe (>4 mm). RESULTS: Screws in pediatric deformity patients were more frequently malpositioned by 2 mm or more than were screws in patients without deformity (26% vs. 19%, p = .02). In patients with deformity, no higher rate of screw malposition was detected at the apical region. Overall, the highest rates of severe screw malposition were between T3 and T8. Pedicle breaches were more commonly in a medial direction compared with lateral (74% vs. 26%, p < .0001). However, severe breaches within the T3-T8 region were more often directed lateral than medial (92% vs. 8%, p ≤ .0001). CONCLUSIONS: The clinical significance of asymptomatic pedicle screw breaches in children has not yet been determined. In this study, screws at the apical concavity were no more likely to be malpositioned than those at other sites. Efforts to reduce pedicle screw malposition would likely be most effective at the T3-T8 levels. LEVEL OF EVIDENCE: Level IV, Therapeutic Study. See the Guidelines for Authors for a complete description of the levels of evidence.

Long-term results of the uncemented acetabular component in a primary total hip arthroplasty performed for protrusio acetabuli: a fifteen year median follow-up.

PURPOSE: Protrusio acetabuli is an uncommon finding that can be seen in patients undergoing primary total hip arthroplasty for arthritis. Uncemented fixation of the acetabular component and bone grafting of the protrusio defect is commonly used as a reconstruction method and has shown good mid-term results. The long-term outcome of these reconstructions warrants further study. The objective of this study was to determine the results of primary total hip arthroplasty (THA) with use of an uncemented acetabular component for protrusio acetabuli in patients followed for a minimum of ten years. METHODS: Sixty-five hips in 53 patients had a primary THA with uncemented acetabular component for the protrusio acetabuli between 1984 and 2001. There were 53 procedures performed in females (82%) and 12 in males (18%). The mean age at the procedure was 66 years. Acetabular floor reconstruction with use of bone graft was performed in 58 hips (89%). Four patients (five hips) were lost to follow-up less than ten years after the procedure and 25 patients (31 hips) had died during the follow-up period. The median follow-up of living patients that did not have revisions for acetabular component was 15.4 years (range, ten to 24 years). RESULTS: During the study duration, six hips underwent acetabular component revision: aseptic loosening (three hips), polyethylene wear (two hips), and recurrent instability (one hip). The median Harris hip score for the living patients who did not have an acetabular component revision improved from 55 points pre-operatively to 82 points at the latest follow-up. At 15 years, the estimated survival rate from revision was 70% for the THA: 85.4% for the acetabular component, and 83% for the femoral component. Five unrevised acetabular components had evidence of non-progressive radiolucency. CONCLUSIONS: In patients undergoing THA with acetabular protrusio, fixation of an uncemented hemispherical shell and use of bone graft as necessary provided satisfactory clinical and radiographic results as well as satisfactory survivorship rates at a median follow-up of 15 years.