The timing of tether breakage influences clinical results after VBT.

INTRODUCTION: Tether breakage is a frequent mechanical complications after vertebral body tethering (VBT), but not all patients with a breakage show loss of correction. The reason of this clinical finding has not yet been clarified. We hypothesized that the integrity of the tether is relevant only in the early stages after VBT, when it drives growth modulation and tissue remodelling. After these mechanisms have taken place, the tether loses its function and a breakage will not alter the new shape of the spine. Thus, tether breakage would have a greater clinical relevance when occurring shortly after surgery. METHODS: All consecutive patients who underwent VBT and had a min. 2-year follow-up were included. The difference in curve magnitude between the 1st standing x-ray and the last follow-up was calculated (ΔCobb). For each curve, the presence and timing of tether breakage were recorded. The curves were grouped according to if and when the breakage was observed (no breakage, breakage at 0-6 months, 6-12 months, > 12 months). The ΔCobb was compared among these groups with the analysis of variance (ANOVA). RESULTS: Data from 152 curves were available: 68 with no breakage, 12 with a breakage at 0-6 months, 37 at 6-12 months and 35 > 12 months. The ANOVA found significant difference in the ΔCobb among the groups (Sum of square 2553.59; degree of freedom 3; mean of square 851.1; Fisher test 13.8; P < 0.0001). Patients with no breakage or breakage at > 12 months had similar ΔCobb (mean 4.8° and 7.8°, respectively, P = 0.3), smaller than the 0-6 or 6-12 groups (15.8° and 13.8°, respectively). CONCLUSION: Tether breakage leads to a consistent loss of correction when occurring within the first 12 months, while it has limited clinical relevance when occurring later on.

Analysis of the risk factors for early tether breakage following vertebral body tethering in adolescent idiopathic scoliosis.

INTRODUCTION: Tether breakage is a common mechanical complication after VBT. When this occurs shortly after surgery, patients may be at higher risk for loss of correction. Aim of this study was to analyze demographic and radiographic parameters that may potentially be risk factors for early tether breakage, as no data are yet available on this topic. MATERIALS AND METHODS: All skeletally immature patients who underwent VBT and for whom a 1-year follow-up was available were included in the study. Demographic, intraoperative and coronal and sagittal parameters from the preoperative and 1st standing X-rays were collected. Patients were divided in two groups according to the presence or absence of a breakage and the outcomes of interest were compared. RESULTS: Data from 105 patients were available (age 14.2 ± 1.5, 153 curves). Lumbar curves showed a higher risk of breakage than thoracic ones (71% vs. 29%, P < 0.0001). Overall, preoperative risk factors were a high curve magnitude (MD, mean difference - 4.1°, P = 0.03) and a limited flexibility (MD 8.9%, P = 0.006); postoperative risk factors were a large residual curve (MD - 6.4°, P = 0.0005) and a limited correction (MD 8.4%, P = 0.0005). The same risk factors were identified in thoracic curves, while in lumbar instrumentation only a higher preoperative Cobb angle represented a risk factor for breakage. Age and skeletal maturity did not represent risk factors. CONCLUSION: The main preoperative risk factors for early tether breakage after VBT are a high curve magnitude and a limited flexibility. A limited curve correction also represents a risk factor for this complication.

[Sagittal Balance of the Spine--Clinical Importance and Radiographic Assessment]. / Die sagittale Wirbelsäulenbalance--klinische Bedeutung und radiologische Bemessung.

Sagittal deformities of the spine frequently result in back pain, as patients have to expend much energy in compensation. The sagittal alignment of the spine is defined by its curvatures (lordosis and kyphosis) relative to the position of the pelvis. Diagnostic assessment is based on full spine a. p. and lateral X-rays. The sagittal balance is primarily described by different angles that can be measured, e.g. lumbar lordosis, pelvic incidence, pelvic tilt and thoracic kyphosis. The quality of life can best be estimated by subtracting lumbar lordosis from the pelvic incidence. However, initial evaluation of the sagittal balance can also be based on the sagittal vertical axis. The severity of imbalance can be described by the sagittal vertical axis and the pelvic tilt, but surgical therapy necessitates a more profound analysis, which can be based on the SRS-Schwab classification.

[Pedicle Subtraction Osteotomy in the Lumbar Spine for Correction of Sagittal Spinal Imbalance]. / Die Pedikelsubtraktionsosteotomie in der LWS zur Korrektur einer sagittalen spinalen Imbalance.

INTRODUCTION: A sagittal spinal deformity can lead to a significant reduction in quality of life. A loss of lumbar lordosis, which may be degenerative or iatrogenic, is usually identified as the main driver for a sagittal imbalance. Re-lordosing the lumbar spine has the potential to correct a global sagittal imbalance. Different surgical techniques are available. The present video describes the pedicle subtraction osteotomy, which represents a powerful option for rigid and severe deformities. INDICATION: The pedicle subtraction osteotomy is most suitable for rigid deformities due to a lack of lumbar lordosis in which re-lordosing of 30° or more is intended. This is often the case if the difference between lumbar lordosis and pelvic incidence exceeds 30°. METHOD: The osteotomy begins with a wide laminectomy. The facet joints above and the pars interarticulares below the pedicles are removed. The pedicle is osteotomised in a wedge-shaped technique and resected while the dura and the exiting nerve root are protected with retractors. After resection of the posterior wall of the vertebral body, the osteotomy can be closed using the anterior wall of the vertebral body as pivot. CONCLUSION: The pedicle subtraction osteotomy represents a powerful surgical technique for correction of a sagittal spinal imbalance.

Vertebral body replacement by posterior approach for metastatic disease in the thoracic spine--modified technique using an expandable cage.

OBJECTIVE: To describe the technique of all-posterior vertebral body replacement using an expandable cage and angled instruments. This method facilitates implant seating with limited posterior decompression useful in the setting of metastatic disease. INDICATIONS: Patients with metastatic disease of the thoracic spine with or without spinal cord compression. CONTRAINDICATIONS: Patients with a limited life expectancy of less than 6 months. Multiple foci of metastatic disease in the spine. SURGICAL TECHNIQUE: A hemilaminectomy was performed followed by nerve root sacrifice. The pleura was mobilized away from the vertebral body, after which decompression and tumor resection was performed from an all-posterior approach. An expandable vertebral body cage was inserted with a rotational manoeuvre and expanded in situ. POSTOPERATIVE MANAGEMENT: The patient was mobilized on postoperative day 1. A chest X-ray is also recommended to exclude incidental pneumothorax. RESULTS: Four patients were operated by an all-posterior vertebral body replacement during a 6-month period. The average length of surgical procedure was 187 min (range 165-220 min). No patient required a transthoracic approach. There were no intra- or postoperative complications and all patients could be discharged to home self-ambulating.

[Multisegmental posterior cervical fusion with en bloc laminectomy--surgical technique]. / Dorsale multisegmentale zervikale Spondylodese mit En-bloc-Laminektomie--operative Technik.

PURPOSE: In patients with cervical spinal stenosis, the posterior laminectomy represents a surgical alternative to anterior procedures. Whereas the majority of surgeons prefer anterior procedures to treat mono- to three-segmental pathologies, posterior procedures have several advantages if the pathology includes four or more segments. INDICATION: In general, the indications for a posterior laminectomy resemble those for anterior procedures. Specifically patients with multisegmental pathologies benefit from a shorter operative time as well as reduced perioperative morbidity. METHOD: A midline incision is made and followed by subperiostal exposure of the cervical spine. Facet decortication and screw hole preparation can be performed if a fusion is required. The lamina is now separated from the lateral mass using a high-speed burr and elevated en bloc from the dura. The fusion can now be completed. CONCLUSION: The posterior en bloc laminectomy with or without fusion represents a viable alternative to anterior procedures in patients with a cervical spinal canal stenosis. It often is the technique of choice for treating more than 3 levels.

[Simultaneous bilateral humeral head disclocation and acetabular fracture. A rare manifestation after hypoglycemia-induced seizures]. / Simultane beidseitige Humeruskopfluxations- und Acetabulumfraktur. Eine seltene Folge eines hypoglykämieinduzierten Krampfanfalls.

Seizures can cause severe musculoskeletal injuries and posterior shoulder dislocation is a typical result of a seizure. Bilateral posterior shoulder dislocation is rare and acetabular fractures caused by a seizure are also a rarity. We present the case of a 48-year-old man with simultaneous bilateral posterior shoulder fracture dislocations and bilateral acetabular fractures as a result of hypoglycemia-induced seizures.

[Patients with periprosthetic femur fractures and consecutive stem replacement. Analysis of survival, complications, and quality of life]. / Geriatrische Patienten mit proximalen periprothetischen Femurfrakturen nach Prothesenschaftwechsel. Letalität, Komplikationsrate und weiterer Lebensweg.

BACKGROUND: The goal of treating proximal periprosthetic femur fractures in geriatric patients is a timely postoperative mobilization. The purpose of this study is to analyze the results after treating our patients by femoral stem exchange irrespective of fixation status. The study included 32 patients (2001-2009; mean age 82 years; Vancouver classification: 12 type B1, 16 type B2, and 4 type C). METHOD: Ambulatory status and activities of daily living pre- and postoperatively were compared. Retrospective data collection was performed by reviewing patients' charts. By interviewing patients, family members, and family physicians missing information was collected. RESULTS: A total of 22 patients (69%) achieved their pre-traumatic mobilization level; 22 of 26 patients (85%) were reintegrated into their pre-traumatic environment. A 16% (n=5) complication rate and an 87% 12-month survival rate were calculated. CONCLUSION: The concept of primary stable periprosthetic fracture care by using a revision prosthetic device potentially reduces complications related to postoperative non-weight-bearing without increasing the complication rate related to a more complex surgical procedure.

[Sagittal balance and compensatory mechanism after segmental instrumentation for adolescent idiopathic scoliosis]. / Sagittale Balance und Kompensationsmechanismen nach operativer Versorgung bei idiopathischer Skoliose mittels segmentaler Pedikelschraubeninstrumentation.

PURPOSE: Previous studies have demonstrated good ability to improve the sagittal profile with the use of segmental instrumentation for adolescent idiopathic scoliosis (AIS) by analysing the sagittal vertical axis (SVA). However, several authors recommend analysing the spinopelvic relation in addition to the SVA. While compensatory mechanisms may neutralise a positive SVA, these mechanisms are energy consuming and may lead to unphysiological biomechanics, which can negatively influence the quality of life. The purpose of this radiographic analysis was to analyse global sagittal balance and to identify potential compensatory mechanisms after segmental instrumentation for AIS. METHODS: From a prospectively collected multicentre database, patients with segmental instrumentation for AIS and a minimum follow-up of 2 years were identified. An additional inclusion criterion was the ability to measure lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and SVA on each X-ray (preoperative, 1st erect, and the 2-year follow-up visits). LL was analysed in relation to PI in order to identify iatrogenic changes. Changes in LL were correlated to changes in PT and SVA. RESULTS: 91 patients were included. On the 1st erect X-ray, LL significantly decreased from pre-op but the SVA remained stable due to a significant increase of PT. At two years follow-up, PT recurred to preoperative values, accompanied by a significant increase of SVA despite a compensatory hyperlordosis below the instrumentation. The temporary increase of PT on the 1st erect was significantly correlated to an iatrogenic decrease of LL. An iatrogenic decrease of LL was significantly correlated to an increase of SVA on the 1st erect and at 2 years follow-up. CONCLUSION: An iatrogenic decrease of LL after segmental instrumentation for AIS is initially compensated for by pelvic retroversion and later by a hyperlordosis below the instrumentation.

[Non-operative treatment for severe forms of infantile idiopathic scoliosis]. / Therapieerfolg der konservativen Therapie bei schweren infantilen idiopathischen Skoliosen.

INTRODUCTION: Infantile idiopathic scoliosis (IIS) is a rare orthopaedic condition. Braces and casts are popular options in the treatment of IIS but there is a paucity of studies commenting on the outcome of non-operative treatment. The purpose of this study was to analyse failure and success after non-operative treatment for severe forms of IIS. METHODS: We retrospectively reviewed the data of all children who had been treated for IIS between 2003 and 2009 at a single institution. After calculating the failure and success rates, we additionally performed a risk factor analysis for patients who failed non-operative treatment. Chi (2) and T tests were used for statistical analysis with significance set at p < 0.05. RESULTS: 25 children with an average age of 11 months and an Cobb angle of 46 degrees at presentation were analysed. Seven (28 %) patients were considered as having failed non-operative treatment after an average follow-up of 28 months. The pretreatment Cobb angle was identified as single significant risk factor for failure (55 versus 42) while neither age, gender, nor RVAD seem to influence the outcome. In children who were considered as successfully treated, the Cobb angle decreased from 42 to 18 degrees. CONCLUSION: Non-operative treatment for IIS is successful in 3 out of 4 patients.

[Clinical characteristics of patients who are lost to follow-up after surgical treatment for adolescent idiopathic scoliosis]. / Klinische Eigenschaften von Patienten, die nach operativer Korrekturspondylodese bei idiopathischer Skoliose nicht mehr zur Nachuntersuchung zur Verfügung standen.

BACKGROUND: Low follow-up rates are a limitation of many long-term studies. Studies on patients after surgical treatment of adolescent idiopathic scoliosis (AIS) rarely have follow-up rates that reach 80% after 5 years or 70% after 10 years. While there is general consensus that a high patient drop-out rate will decrease the accuracy of a study, little is known about the characteristics of those patients who have dropped out. The purpose of the present study was to identify patients who were lost to follow-up after surgical correction of AIS and to compare their clinical characteristics to those of patients who were available for follow-up. PATIENTS AND METHODS: All members of a popular scoliosis-specific online community were asked to submit information about demographic, surgical, and clinical characteristics. Patients who had surgical treatment for AIS and a minimum of 12 months since surgery were grouped into "lost to follow-up - LTF" and "follow-up - FU" based on whether they had changed their orthopedist or not after surgery. Demographic, surgical, and clinical characteristics with the use of the SRS-22 instrument were then compared. RESULTS: 271 patients submitted information of whom 81 patients (39 FU, 42 LTF) fulfilled all inclusion criteria. No difference was found in terms of age at surgery, surgical approach, number of fused levels, or revision rate whereas major curve correction and time since surgery showed significant differences. A subanalysis that was done after matching patients for time since surgery revealed significant differences for the SRS-22 domains function, pain, mental health, and total score in favour of the FU group. CONCLUSION: We found significant clinical differences for patients who are lost to follow-up when compared to patients who are available for follow-up. While we are aware of the difficulties in obtaining high follow-up rates for a clinical study, care should be taken in analysing studies with low follow-up rates because results may be skewed.

Vertebral body stapling as an alternative in the treatment of idiopathic scoliosis.

OBJECTIVE: Unilateral vertebral body stapling as a fusionless alternative to control curvature progression in patients with idiopathic scoliosis (IS). INDICATIONS: Skeletally immature patients (Risser 0 or 1) with IS measuring 20-45° and correction of the curvature <20° on side-bending X-rays. CONTRAINDICATIONS: Congenital scoliosis, curvature above T4 or below L4, thoracic kyphosis >40°. SURGICAL TECHNIQUE: Unilateral disc-sparing staples are placed at the convex side. A thoracoscopic approach can be used for thoracic curves and a mini-open retroperitoneal approach for lumbar curves. POSTOPERATIVE MANAGEMENT: Early ambulation on postoperative day 1 is encouraged. There are no absolute activity restrictions, and no bracing beyond 4 weeks is required. RESULTS: A total of 28 patients (4 males, 24 females; average age at operation 9.4 years) met all inclusion criteria and had a minimum 2-year follow-up (range 2-5.3 years). The success rate (improvement or stabilization of the curvature) was 86% for thoracic curves <35° and all lumbar curves meeting the indications.

[The internet: an Orthopedist's boon or bane?]. / Das Internet: Des Orthopäden Freund oder Feind?

AIM: The Internet provides additional and nearly endless health-related information material for the patient. On the other hand, previous studies reported on the lack of quality for health-related websites, especially for message boards. A direct analysis of treatment recommendations from message board members and spine experts has not yet been published in the medical literature. The aim of this study is to evaluate the quality of information regarding treatment of scoliosis one can receive from message board members compared to experts in this field. METHOD: All members of one of Germany's biggest scoliosis-related message boards were invited to fill out an online questionnaire. This questionnaire included questions regarding demographic data, questions commenting on the influence of the Internet regarding their own decision finding, and six imaginary cases with four answer options each. The attendees were asked to provide the best treatment option. The answers of experts in the treatment of spinal disorders who commented on the same cases were used as control. RESULTS: 31 complete questionnaires from Internet patients were included in the analysis and compared to 36 answers from spine experts. In four of six cases an excellent agreement could be found. There was a good agreement in one case and a poor agreement in another. The disagreement would unlikely have led to harm for the patient. One third of the patients claimed that information received from the Internet has had a major impact on their own decision finding. CONCLUSION: The data show that treatment recommendations from members of a scoliosis-related message board have good to excellent agreement with treatment recommendations from experts in the majority of cases. The use of a message board can potentially be helpful in the care of scoliosis patients. Additional studies will evaluate whether or not the results of our study are representative for other message boards as well.

[Rupture of the quadriceps tendon after lateral retinaculum release by arthroscopy]. / Quadrizepssehnenruptur nach arthroskopischem lateralem Retinakulumrelease.

Complications after arthroscopic surgery of the knee joint are infrequent. Quadriceps tendon ruptures after knee arthroscopy are rarities. Only two cases have been published in the medical literature. This article presents a case of a quadriceps tendon rupture that occurred in a 19-year-old patient 5 weeks after lateral release of the retinaculum by arthroscopy. The late occurrence differentiates this case from the other previously published cases.