Stability of One-Step Spray-on Splint for Lower Extremity Fractures During Splinting, MEDEVAC, and Impact.

INTRODUCTION: Military transport can induce whole-body vibrations, and combat almost always involves high impact between lower extremities and the ground. Therefore, robust splinting technology is necessary for lower extremity fractures in these settings. Our team compared a novel one-step spray-on foam splint (FastCast) to the current military standard structured aluminum malleable (SAM) splint. MATERIALS AND METHODS: Ten cadaveric specimens were subjected to complete tibia/fibula osteotomy. Specimens were fitted with custom accelerometer and gyroscope sensors superior and inferior to the fracture line. Each specimen underwent fracture and splinting from a standard of care SAM splint and an experimental FastCast spray foam splint in a randomized order. Each specimen was manually transported to an ambulance and then released from a 1 meter height to simulate impact. The custom sensors recorded accelerations and rotations throughout each event. Repeated-measures Friedman tests were used to assess differences between splint method within each event and between sensors within each splint method. RESULTS: During splinting, overall summation of change and difference of change between sensors for accelerations and rotations were greater for SAM splints than FastCast across all axes (P ≤ 0.03). During transport, the range of acceleration along the linear superior/inferior axis was greater for SAM splint than FastCast (P = 0.02), as was the range of rotation along the transverse plane (P < 0.01). On impact, the summation of change observed was greater for SAM splint than FastCast with respect to acceleration and rotation on the posterior/anterior and superior/inferior axes (P ≤ 0.03), and the cumulative difference between superior and inferior sensors was greater for SAM than FastCast with respect to anterior-axis rotation (P < 0.05). CONCLUSION: FastCast maintains stabilization of fractured lower extremities during transport and impacts to a significantly greater extent than SAM splints. Therefore, FastCast can potentially reduce the risk of fracture complications following physical stressors associated with combat and extraction.

Cervical Spinal Immobilization: A Head-to-Head Comparison of a One-Step Spray-on Foam Splint Versus Structural Aluminum Malleable Splint Immobilization.

INTRODUCTION: Cervical spine immobilization in a low-resource environment is difficult secondary to limited equipment, prolonged transportation, and secondary complications. A structural aluminum malleable (SAM) splint is commonly utilized because of its availability and multipurpose intention. A one-step spray-on foam immobilization technique (Fast Cast) has been shown to be effective in lower-extremity splinting. The aim of this study was to demonstrate the ability of the Fast Cast to effectively immobilize the cervical spine in a head-to-head comparison against the SAM splint. We hypothesized that there would be no difference in surgeon scoring between Fast Cast and SAM splints for the immobilization of the cervical spine. METHODS: This was a cadaveric experimental comparative study that compared a SAM splint versus Fast Cast for the immobilization of an unstable cervical spine. Each of the three cadaveric specimens had a corpectomy without fixation performed. A board-certified emergency medicine physician specialized in disaster medicine performed all SAM immobilizations. An orthopedic surgeon performed Fast Cast immobilizations. Each method of immobilization was done on each cadaver. Lateral fluoroscopic imaging was taken before and after immobilization and after log roll/gravity stress. Five board-certified orthopedic surgeons served as graders to independently score each splint. A 5-point Likert scale based on 10 splinting criteria (50 total points possible) was utilized to evaluate cervical spine immobilization. The lead statistical analyst was blinded to the immobilization groups. The statistical significance was assessed via a Wilcoxon signed-rank test and chi-square Fisher's exact test with significance between groups set at α < .05. Inter-rater reliability of the Likert scale results was assessed with the interclass correlation coefficient. RESULTS: Inter-rater reliability for the current Likert scale in the evaluation of cervical spine stabilization was good (interclass correlation coefficient = 0.76). For the cumulative Likert scale score, Fast Cast (32 [28-34]) exhibited a higher total score than SAM (44 [42-47]; P < .01). Likewise, Fast Cast exhibited a greater likelihood of higher Likert scores within each individual question as compared to SAM (P ≤ 0.04). In 100% of cases, raters indicated that Fast Cast passed the gravity stress examination without intrinsic loss of reduction or splinting material, whereas 33% of SAM passed (P < .01). In 100% of cases, raters indicated that Fast Cast passed the initial radiographic alignment following immobilization, whereas 66% of SAM passed (P = .04). In 100% of cases, raters indicated that Fast Cast passed radiographic alignment after the gravity stress examination, whereas 47% of SAM passed (P < .01). CONCLUSION: The Fast Cast exceeded our expectations and was shown to be rated not equivalent but superior to SAM splint immobilization for the cervical spine. This has significant clinical implications as the single-step spray-on foam is easy to transport and has multifaceted applications. It also eliminates pressure points and circumferential wrapping and obstruction to airway/vascular access while immobilizing the cervical spine and allowing for radiographic examination. Further studies are needed for human use and application.

Arthroscopic Releases and Hindfoot Fusion for Spastic Equinovarus Foot Deformities, An All-Inside Technique.

Neurologic foot contractures pose a challenging situation for orthopaedic surgeons. These deformities are long-standing problems for patients with acute brain injuries, ultimately affecting their quality of life. We report our experience with using arthroscopic assisted, minimally invasive contracture tenotomies paired with a tibio-talo-calcaneal arthrodesis to achieve improved alignment and functional reconstruction of spastic equinovarus foot deformities.

Lower Extremity Splinting: A Head-to-Head Comparison of A Novel One-Step Spray-on Splint Versus Standard Splinting.

INTRODUCTION: Splinting is an essential component of treating many lower extremity musculoskeletal injuries; however, little development has been made in splinting technology. The purpose of this study is to evaluate the efficacy of current immobilization equipment for lower extremity fractures by testing a novel one-step spray-on foam splint (Fast Cast) against structural aluminum malleable (SAM) lower extremity musculoskeletal injuries and 6-inch ACE (3M Corp., Minneapolis, MN, USA) bandage splints. MATERIALS AND METHODS: Six orthopedic surgical residents and two medical students participated in a prospective analysis of austere splinting techniques and equipment that utilized a cadaveric model with a distal third tibia-fibula shaft fracture. Each participant was observed and scored by three fellowship trained attending orthopedic surgeons. All scoring was independent using a 5-point Likert scale based on 10 splinting criteria (50 total points possible), including quality of radiographic reduction, time to completion, safety, and sustain longitudinal traction. The Likert scale is a set of questions that reflects the respondent's degree of agreement or disagreement with a statement. Each of the 10 questions has a range of 1-5. A score of 50 means the splint performed perfectly. The lowest possible score is a 10. The participants utilized standard equipment that included SAM splints and 6-inch ACE wraps (3M Corp., Minneapolis, MN, USA) in their first attempt. A second immobilization attempt was done with a one-step spray-on foam splint (Fast Cast). After each splinting attempt, the reduction was verified with radiographic imaging. Data analysis was performed using standard descriptive statistics, Student's t-tests, and inter-rater reliability was calculated using Cronbach's alpha scores. This project is Institutional Review Board (IRB) exempt. RESULTS: The one-step spray-on foam splinting technique was superior (P < .05) in all parameters of the Likert scale, yielding a mean overall score of 45.1 points (±3.8), safety 4.7 points, longitudinal traction 4.5 points, and time 136 seconds (±23). The SAM resulted in a mean overall score of 33.8 points (±7.3), safety 2.8 points, longitudinal traction 4.1 points, and time 170 seconds (±52). Radiographic rating was 4.1 points (±0.7) for the SAM splint and 4.5 (±0.6) for Fast Cast. The differences in time to completion and radiograph rating did not reach statistical significance (P = .12 and P = .07, respectively). CONCLUSION: A one-step spray-on foam splinting technique demonstrated consistent superiority in reducing fracture motion, potential soft-tissue damage, and sustained longitudinal traction as compared to the standard technique.

Discharge to a Non-Home Destination Following Total Ankle Arthroplasty (TAA): An Analysis of the ACS-NSQIP Database.

Despite an increasing trend in the number of total ankle arthroplasties (TAAs) being done globally, current evidence remains limited with regards to factors influencing a non-home discharge to a facility following the procedure. The 2012-2016 American College of Surgeons - National Surgical Quality Improvement Program database was queried using Current Procedural Terminology code 27702 for patients undergoing TAA. Discharge to a destination was categorized into home and non-home. Multivariate analysis using logistic regression models were used to evaluate independent risk factors associated with non-home discharge disposition. As a secondary objective, we also evaluated risk factors associated with a prolonged length of stay (LOS) >2 days. A total of 722 TAAs were retrieved for final analysis. A total of 68 (9.4%) patients experienced a non-home discharge following the surgery. Independent factors for a non-home discharge were a LOS >2 days (odds ratio [OR] 10.51), age ≥65 years (OR 4.52), female (OR 2.90), hypertension (OR 2.63), and American Society of Anesthesiologists >II (OR 2.01). A total of 174 (24.1%) patients stayed in the hospital for more than 2 days. Significant risk factors for LOS >2 days were age ≥65 years (OR 1.62), female (OR 1.53), operative time >150 minutes (OR 1.91), and an inpatient admission status (OR 4.74). With limited literature revolving around outcomes following TAA, the current study identifies significant predictors associated with a non-home discharge. Providers should consider preoperatively risk-stratifying and expediting discharge in these patients to reduce the costs associated with a prolonged hospital length of stay.

Validation of 9-Grid Scheme for Localizing Osteochondral Lesions of the Talus.

BACKGROUND: A 9-grid scheme has been integrated into the foot and ankle literature to help clinicians and researchers localize osteochondral lesions of the talus (OLTs). We hypothesized that fellowship-trained orthopedic foot and ankle surgeons would have a high rate of intra/inter-observer reliability when localizing OLTs, therefore validating the scheme. METHODS: We queried our institution's foot and ankle radiographic database for magnetic resonance images with OLTs. Each MRI was reviewed by the senior author, and 2 key images (widest OLT diameter) from each tangential view were copied and combined onto one slide. Fifty consecutive deidentified images of ankles were then sent to 4 practicing fellowship-trained foot and ankle surgeons. Each was asked to identify which zone the OLT was localized within. A radiologist's report served as the control. Statistical analyses were performed using Cohen and Fleiss kappa tests. RESULTS: The reviewers demonstrated majority consensus on 45/50 images with substantial agreement for zones 4 and 6. The interobserver reliability was moderate with a κ = 0.55. The mean intraobserver reliability was substantial, with a κ = 0.79. A musculoskeletal radiologist determined there were 3 lesions in zone 7, 18 lesions in zone 4, and 29 lesions in zone 6. CONCLUSION: This study is the first to critically evaluate the 9-grid scheme and its reliability among orthopedic foot and ankle surgeons. Our study found that the 9-grid scheme is an accurate method of localization for OLTs with high intra- and moderate interobserver reliability between surgeons. LEVEL OF EVIDENCE: Level IV, retrospective diagnostic study.

Early vs Delayed Weightbearing After Microfracture of Osteochondral Lesions of the Talus: A Prospective Randomized Trial.

BACKGROUND: Osteochondral lesions of the talus (OLTs) are common injuries in young, active patients. Microfracture is an effective treatment for lesions less than 150 mm2 in size. Most commonly employed postoperative protocols involve delaying weightbearing for 6 to 8 weeks (DWB), though one study suggests that early weightbearing (EWB) may not be detrimental to patient outcomes. The goal of this research is to compare outcomes following EWB and DWB protocols after microfracture for OLTs. METHODS: We performed a prospective, randomized, multicenter clinical trial of subjects with unilateral, primary, unifocal OLTs treated with microfracture. Thirty-eight subjects were randomized into EWB (18 subjects) and DWB (20 subjects) at their first postsurgical visit. The EWB group began unrestricted WB at that time, whereas the DWB group were instructed to remain strictly nonweightbearing for an additional 4 weeks. Primary outcome measures were the American Academy of Orthopaedic Surgery (AAOS) Foot and Ankle score and numeric rating scale (NRS) pain score. RESULTS: The EWB group demonstrated significant improvement in AAOS Foot and Ankle Questionnaire scores at the 6-week follow-up appointment as compared to the DWB group (83.1 ± 13.5 vs 68.7 ± 15.8, P = .017). Following this point, there were no significant differences in AAOS scores between groups. At no point were NRS pain scores significantly different between the groups. CONCLUSIONS: EWB after microfracture for OLTs was associated with improved AAOS scores in the short term. Thereafter and through 2 years' follow-up, no statistically significant differences were seen between EWB and DWB groups. LEVEL OF EVIDENCE: Level II, prospective randomized trial.

Comparative Outcomes for the Treatment of Articular Cartilage Lesions in the Ankle With a DeNovo NT Natural Tissue Graft: Open Versus Arthroscopic Treatment.

BACKGROUND: The treatment of osteochondral lesions of the talus (OLTs) with a juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large OLTs, the potential advantage of a particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach, nor have any compared an arthroscopic technique with an open approach. PURPOSE: To compare the outcomes of an arthroscopic transfer technique with the previously published open technique. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 34 patients (mean age, 33 years) underwent treatment of talar cartilage lesions with a DeNovo NT Natural Tissue Graft. Of these treatments, 20 were performed arthroscopically and 14 were performed with open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. The mean lesion area was 107 mm2. The scores from 6 different validated outcome measures were recorded for patients in each group preoperatively and subsequently at 6 months, 1 year, 18 months, and 2 years. RESULTS: Comparing outcome scores at each time point to baseline, there were no statistically significant postoperative differences found between open and arthroscopic approaches with regard to the visual analog scale (VAS) for pain (P = .09), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (P = .17), Foot and Ankle Ability Measure (FAAM)-sports subscale (P = .73), Short Form-12 (SF-12) physical health summary (P = .85), SF-12 mental health summary (P = .91), or FAAM-activities of daily living subscale (P = .76). CONCLUSION: The treatment of talar articular cartilage lesions with a DeNovo NT Natural Tissue Graft demonstrated no significant differences in outcome at 2 years regardless of whether the graft was inserted with an arthroscopic or open technique. CLINICAL RELEVANCE: Our analysis demonstrated no significant difference between an arthroscopic versus open approach at any time point for the first 2 years after implantation of a juvenile particulated cartilage allograft for large OLTs. With that said, both groups demonstrated improvement from baseline. These findings indicate that surgeons with different levels of comfort utilizing arthroscopic techniques can offer this treatment modality to their patients without altering their planned surgical approach. In addition, this will be particularly helpful in counseling patients for surgery when the extent of the defect will be evaluated intraoperatively. Patients can be counseled that they will likely have the same incisions regardless of whether they require debridement, microfracture, or implantation of a particulated allograft.

Implementing an Electronic Patient-Based Orthopaedic Outcomes System: Factors Affecting Patient Participation Compliance.

INTRODUCTION: Few studies have reported on the optimization of patient compliance within outcome registries and no studies exist on orthopaedic outcome registries in the military to date. Our aim is to report on the compliance rate of an electronic, web-based, patient-reported outcomes program, with particular emphasis on the effect of variables in data acquisition on survey compliance at a single military installation. METHODS: 1,814 patients were entered into the database allowing patients to complete subjective preoperative validated scores. Patient compliance and completeness was calculated. Furthermore, we compared compliance rates for paper vs. electronic platforms and length of survey. RESULTS: 40% complied without staff intervention. This increased to 73% with staff intervention. The electronic platform had a higher compliance rate (67%) and lower incompletion rate (3%) than paper (59%, p = 0.044). Short form compliance was 89% compared to standard form of 70% (p = 0.006). CONCLUSIONS: This is the first report of an orthopaedic registry in a U.S. military population. Self-prompted compliance occurred in 40% of patients and can be increased to over 70% with staff intervention. Electronic platforms are logistically simpler, and result in higher patient compliance, as do shorter survey lengths. Further study on longer term compliance is warranted.

Genome Sequences of Six Paenibacillus larvae Siphoviridae Phages.

Six sequenced and annotated genomes of Paenibacillus larvae phages isolated from the combs of American foulbrood-diseased beehives are 37 to 45 kbp and have approximately 42% G+C content and 60 to 74 protein-coding genes. Phage Lily is most divergent from Diva, Rani, Redbud, Shelly, and Sitara.

The Effect of Syndesmosis Screw Removal on the Reduction of the Distal Tibiofibular Joint: A Prospective Radiographic Study.

BACKGROUND: Injury to the tibiofibular syndesmosis is frequent with rotational ankle injuries. Multiple studies have shown a high rate of syndesmotic malreduction with the placement of syndesmotic screws. There are no studies evaluating the reduction or malreduction of the syndesmosis after syndesmotic screw removal. The purpose of this study was to prospectively evaluate syndesmotic reduction with CT scans and to determine the effect of screw removal on the malreduced syndesmosis. METHODS: This was an IRB-approved prospective radiographic study. Patients over 18 years of age treated at 1 institution between August 2008 and December 2011 with intraoperative evidence of syndesmotic disruption were enrolled. Postoperative CT scans were obtained of bilateral ankles within 2 weeks of operative fixation. Syndesmotic screws were removed after 3 months, and a second CT scan was then obtained 30 days after screw removal. Using axial CT images, syndesmotic reduction was evaluated compared to the contralateral uninjured ankle. Twenty-five patients were enrolled in this prospective study. The average age was 25.7 (range, 19 to 35), with 3 females and 22 males. RESULTS: Nine patients (36%) had evidence of tibiofibular syndesmosis malreduction on their initial postoperative axial CT scans. In the postsyndesmosis screw removal CT scan, 8 of 9 or 89% of malreductions showed adequate reduction of the tibiofibular syndesmosis. There was a statistically significant reduction in syndesmotic malreductions ( t = 3.333, P < .001) between the initial rate of malreduction after screw placement of 36% (9/25) and the rate of malreduction after all screws were removed of 4% (1/25). CONCLUSIONS: Despite a high rate of initial malreduction (36%) after syndesmosis screw placement, 89% of the malreduced syndesmoses spontaneously reduced after screw removal. Syndesmotic screw removal may be advantageous to achieve final anatomic reduction of the distal tibiofibular joint, and we recommend it for the malreduced syndesmosis. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Computed tomography analysis of third webspace injections for interdigital neuroma.

BACKGROUND: Injection for interdigital neuroma (IDN) may not selectively target the common digital nerve. We investigated the anatomical localization and extent of extravasation with injection for IDN. METHODS: Two fellowship-trained foot and ankle surgeons injected radiopaque contrast into the third webspace of 49 cadaveric specimens (29 with 2 mL and 20 with 1 mL). Computed tomography scan of each specimen was obtained. An independent blinded foot and ankle surgeon analyzed the scans. RESULTS: All injections were accurate. Contrast was found in the second (greater than 70%) and fourth (greater than 30%) webspaces in both injection volume groups. No contrast was found within the third metatarsophalangeal joint. Extravasation extent was significantly greater with 2 mL versus 1 mL of solution in the medial to lateral (27.9 [7.8] mm vs 23.7 [6.0] mm; P = .05) and distal to proximal (52.1 [13.7] mm vs 40.4 [16.1] mm; P = .01) planes. No differences were observed in extravasation extent between surgeons. CONCLUSION: Injection for IDN was accurate, and extravasation extended into adjacent webspaces in a large percentage of specimens with both solution volumes. Lower extent of extravasation with 1 mL of solution did not indicate better selectivity of injection. CLINICAL RELEVANCE: Steroid injections for interdigital neuroma were accurate for therapeutic purposes but not diagnostic, except potentially for distinguishing webspace pain from joint pain.

Treatment of open proximal femoral fractures sustained in combat.

BACKGROUND: Open proximal femoral fractures are rare injuries that often result from wartime high-energy causes. Limited data exist regarding the treatment and complications of these injuries. METHODS: We retrospectively reviewed the records of combat casualties treated at two institutions between March 2003 and March 2008. The casualty patient databases, medical records, radiographs, and laboratory data were reviewed to determine time to union, complication rates, and patient outcomes. RESULTS: Forty-one patients (thirty-nine men and two women) with a mean age of 25.7 years were identified as receiving treatment for open proximal femoral fractures. The mechanisms of injury for these forty-one patients were blast (twenty-nine patients [71%]), gunshot wound (eight patients [20%]), motor vehicle crash (three patients [7%]), and helicopter crash (one patient [2%]). There were thirty Type-IIIA, six Type-IIIB, and five Type-IIIC open fractures. The predominant method of definitive fixation was a cephalomedullary or reconstruction nail in thirty-four patients (83%). Thirty-nine patients had at least two years of follow-up data available for assessment of complications and radiographic union. The mean time to union was 5.1 months (range, 2.8 to 16.0 months). Complications requiring reoperation occurred in twenty-two (56%) of thirty-nine patients. Wound infection (twelve patients [31%]) and symptomatic heterotopic ossification (ten patients [26%]) were the most common complications. CONCLUSIONS: Cephalomedullary nail fixation of open Type-III wartime subtrochanteric and pertrochanteric femoral fractures can be reliably used to effect fracture union in a timely manner. The most frequent complications of treatment are wound infection and symptomatic heterotopic ossification.

Soft tissue management of war wounds to the foot and ankle.

This article details the experiences of United States military reconstructive surgeons in the soft tissue management of war wounds of the foot and ankle resulting from the conflicts in Iraq and Afghanistan. War wounds from this conflict are commonly caused by blast and fragmentation, and are characteristically extensive, heterogeneous, and severe. Multiple serial débridement episodes are routinely necessary because of deterioration of the wounds over time, which is in contrast to civilian trauma wherein fewer débridement episodes are generally required. Wound therapy adjuncts, such as subatmospheric wound dressing and synthetic dermal replacement, have been used extensively with favorable results. Pedicled flaps, such as the distally based sural neurofasciocutaneous flap, are reliable, and avoid the risks and technical demands associated with microsurgery. Free tissue transfer, such as the anterolateral thigh flap, the latissimus dorsi muscle flap, and the rectus abdominis muscle flap, are powerful reconstructive tools, and have been extensively used in the reconstruction of war wounds of the foot and ankle.

Treatment of open periarticular shoulder fractures sustained in combat-related injuries.

Open periarticular shoulder fractures present a tremendous challenge for orthopedic surgeons. These injuries, albeit rare, are typically caused by high-energy mechanisms and are associated with insult to multiple organ systems resulting in high morbidity and mortality. Although the civilian trauma literature includes several articles on outcomes of closed periarticular shoulder fractures, only 1 peer-reviewed article has focused on this specific open injury pattern. No standard management technique has been adopted for these injuries, and treatment patterns have anecdotally evolved from war to war. In this article, we review evacuation of patients, management of combat-related open periarticular shoulder injuries, and the pertinent literature; we supplement this review with a description of the recent experience of Drs. HMF and WCD. All cases of combat-related open fractures treated at our institution between March 2003 and January 2007 were reviewed. We identified 44 patients with open periarticular shoulder fractures (33 IIIA, 1 IIIB, 10 IIIC). Inpatient and outpatient medical records, x-rays, laboratory culture data, and photographic documentation records were reviewed. Mean follow-up was 34 months (range, 12-49 months). Rates of associated neurologic and vascular injury were 41% (18/44 patients), and 23% (10/44 patients), respectively. Other associated significant injuries occurred in 38/44 patients (86%). Internal fixation was used as definitive treatment in 26/44 patients (59%). Radiographic union occurred by a mean of 4.5 months (range, 3-9 months) after surgery. Postoperative deep infection/osteomyelitis occurred in 5/35 patients (14%) with more than 1-year follow-up data available. The overall amputation rate was 9%. Open combat-related periarticular shoulder fractures are complicated injuries, often associated with several traumatic comorbidities that together present difficult challenges to treatment. Meticulous surgical débridement is essential in managing these severely comminuted and contaminated open fractures. In cases in which internal fixation is used, careful timing and patient selection are required to minimize risk for osteomyelitis. Data collection is being continued in this patient cohort to allow for eventual reporting of functional outcomes.

Comparison of sagittal contour and posterior disc height following interbody fusion: threaded cylindrical cages versus structural allograft versus vertical cages.

OBJECTIVE: Segmental restoration of sagittal contour is recognized as critical for improved long-term success following instrumented lumbar fusions. As such, the use of wedged implants has become more popular. Few studies exist to assess the postoperative lordotic and disc height changes following these varied techniques in spinal fusion. An observational radiographic study examining lumbar sagittal contour and posterior intervertebral disc space height following posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) was conducted using vertical cages (VCs), wedged structural allograft (WSA), and threaded cylindrical cages (TCCs). METHODS: Forty-nine consecutive patients (59 spinal segments) were evaluated following single- or two-level interbody fusion with either stand-alone TCCs (n = 18 levels), WSA with posterior transpedicular compression instrumentation (n = 25 levels), or VCs with posterior transpedicular compression instrumentation (n = 16 levels). Standing lumbar radiographs were measured by two independent observers preoperatively, immediately postoperatively (within 1 week), at 6-week follow-up (range 4-8 weeks), and postoperatively (at 1-year follow-up) for segmental lordosis at each level undergoing posterior interbody arthrodesis and posterior intervertebral disc space height to assess indirect nerve root decompression. RESULTS: At the 1-year follow-up, postoperative lordosis was improved in the VC group (+5.3 degrees ; P < 0.005), whereas it decreased in the WSA group (-0.9 degrees ; P = 0.407) and TCC group (-3.5 degrees ; P < 0.005). The posterior disc space height decreased in the VC group (-0.5 mm; P = 0.109), whereas it increased for both the WSA group (+1.2 mm; P = 0.05) and the TCC group (+0.8 mm; P = 0.219). CONCLUSIONS: PLIF with stand-alone TCC and PLIF (or TLIF) with WSA and posterior transpedicular instrumentation results in an increased posterior disc height and thus improved indirect nerve root decompression. PLIF (or TLIF) with VC and posterior transpedicular instrumentation results in an overall decrease in posterior disc height. However, TCC and WSA resulted in a loss of lumbar lordosis, whereas VC resulted in an increase in lumbar lordosis.