Long-term outcome after surgical treatment of Scheuermann's Kyphosis (SK).

STUDY DESIGN: A retrospective observational cohort study with a minimum follow-up of 10 years of patients who underwent surgery for Scheurmann Kyphosis (SK). OBJECTIVE: Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior-posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature. METHODS: 51 patients (30 M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed. RESULTS: The mean age at surgery for 51 patients was 20.6 years who were followed up for a minimum of 10 years (mean: 14 years; range 10-16 years). The mean age was 18.5 ± 2.2 years and 21.9 ± 4.8 years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p < 0.0001) and 30.7 ± 11.7 and 6.4 ± 5.7, respectively, in group 2 (p < 0.0001). The final SRS-22 scores in group 1 and 2 were 4.1 ± 0.4 and 4.0 ± 0.35, respectively (p = 0.88). The preoperative flexibility index was 49.2 ± 4.2 and 43 ± 5.6 in groups 1 and 2, respectively (p < 0.0001). The mean TKs were 81.4° ± 3.8° and 86.1° ± 6.0° for groups 1 and 2, respectively, which corrected to 45.1° ± 2.6° and 47.3° ± 4.8°, respectively, at final follow-up (p < 0.0001). The mean pre-operative LL angle was 60.0° ± 5.0° and 62.4° ± 7.6° in groups 1 and 2, respectively, which at final follow-up was 45.1° ± 4.4° and 48.1° ± 4.8°, respectively (p < 0.0001). The mean pre-operative and final follow-up Voustinas index (VI) in group 1 were 22.9 ± 2.9 and 11.2 ± 1.2, respectively, and in group 2 was 25.9 ± 3.5 and 14.0 ± 2.3, respectively. The mean pre-operative and final follow-up SI angle were 43.6° ± 3.3° and 31.2° ± 2.5° in group 1, respectively, and 44.3° ± 3.5° and 32.1° ± 3.5° in group 2, respectively (p < 0.0001). The pre-operative and final follow-up SVA in group 1 were - 3.3 ± 1.0 cms and - 1.3 ± 0.5 cms, respectively, and in group 2 was - 4.0 ± 1.3cms and - 1.9 ± 1.1cms, respectively (p < 0.0001). Though the magnitude of curve correction in the groups 1 and 2 was significant 36° vs 39° (p = 0.05), there was no significant difference in correction between the two groups. Proximal JK was seen in seven and distal JK in five patients were observed in the whole cohort. CONCLUSION: The long-term clinical outcomes for both PSF and AF/PSF are comparable with reproducible results. No difference was noted in loss of correction and outcome scores between the two groups. The correction of thoracic kyphosis (TK) had a good correlation with ODI. AF/PSF had much higher complications than PSF group. The objective of correcting the sagittal profile and balancing the whole spinal segment on the pelvis can be achieved through single posterior approach with fewer complications.

Lumbar spondylolysis - Current concepts review.

Lumbar pars interarticularis (PI) injury or spondylolysis occurs only in humans. This represents a stress fracture of the PI. Excessive loading in repetitive hyperextension is a significant risk factor and occurs most commonly at L5 followed by L4. It is bilateral in 80% of symptomatic cases but can be unilateral defect as well which runs a more benign course. Symptoms of low back pain relating to this lesion are more common in young athletes involved in trunk twisting sports. Like other stress fractures, the pain may come on abruptly or more insidiously over time and only related to certain activities. The pathologic progression starts with a stress reaction in the pars, progressing to an incomplete stress fracture, and then a complete pars fracture. Diagnosis is dependent on clinical examination and radiological imaging studies (plain radiography, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans). Treatment is dependent on symptoms as well as radiographic stage of the lesion. Conservative management is the mainstay of treating early lesions. A comprehensive rehabilitation program incorporates core spinal stabilization exercises. Athletes should not return to sports until pain free. Professional sporting individuals are at increased risk of failure of resolution of symptoms that may require early surgical repair of the PI defect. Modified Buck's technique & pedicle screw-hook constructs for direct repair has a high success rate in patients who have persistent low back pain. Minimally invasive lumbar pars defect repair has given similar successful outcome with added advantage of minimizing muscle injury, preserving the adjacent joint and reduced hospital stay. Functional outcome is evaluated using the Visual Analogue Scale (VAS) for back pain, Oswestry Disability Index (ODI) and 36-Item Short-Form Health Survey (SF-36). Preoperative ODI and SF-36 physical component scores (PCS) are significant predictor of a good functional outcome.

Single-Stage Combined Anterior Corpectomy and Posterior Instrumented Fusion in Tuberculous Spondylitis With Varying Degrees of Neurological Deficit.

BACKGROUND: A combined anterior decompression and stabilization followed by posterior instrumented fusion promotes fusion of the affected segment of spine and prevents further progression of deformity. The objective of this study is to report on outcome of patients with tuberculous spondylitis, progressive neurologic deficit, and kyphotic deformity who underwent single-stage anterior corpectomy and fusion and posterior decompression with instrumented fusion. METHODS: A total of 49 patients (29 males, 20 females) with varying grades of neurological deficit due to tuberculosis of the spine (thoracic, thoracolumbar, and lumbar) were included in this prospective study. The diagnosis of tubercular infection was established after clinical, hematological, radiological, and histological specimens taken at surgery. All were treated with combined anterior and posterior decompression, debridement, and stabilization with direct autologous bone grafting or wrapped bone graft in mesh or expandable cages. Neurological status and visual analog scale (VAS) pain score were recorded at each visit. X-rays, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver function were evaluated at 3, 6, and 12 months after surgery and then once a year thereafter. Results were analyzed in terms of neurological recovery (Frankel grade), bony union time, and correction of kyphotic deformity. RESULTS: The mean age was 37.8 years (range, 2-65 years). Mean preoperative VAS scores improved from 5.6 to 1.5. The average ESR and CRP returned to normal within 6 months in all patients. The mean time to fusion was 8.4 months for the whole group. The neurological deficit in 42 of 49 patients had excellent or good clinical outcome (P < .0001). A total of 10 of 17 patients improved from Frankel A and B to Frankel E (normal activity). Three patients each in the thoracic and thoracolumbar groups improved to Frankel D. Radiological measurements showed the mean kyphotic correction was 61%, 66%, and 67% in the thoracic, thoracolumbar, and lumbar/lumbosacral spine, respectively. CONCLUSIONS: Combined single-stage anterior decompression and stabilization followed by posterior instrumented fusion is safe and effective in the treatment of tuberculous spondylitis with neurological deficit in the thoracic and lumbar spine. This procedure helps to correct and maintain the deformity, abscess clearance, spinal-cord decompression, and pain relief as well as return to normal motor function. Bony fusion prevents further progression of deformity. LEVEL OF EVIDENCE: 2.

Mesenchymal Stem Cell Therapy in Chondral Defects of Knee: Current Concept Review.

PURPOSE: Full-thickness cartilage defects if left alone would increase the risk of osteoarthritis (OA) with severe associated pain and functional disability. Articular cartilage defect may result from direct trauma or chronic degeneration. The capability of the mesenchymal stem cells (MSCs) to repair and regenerate cartilage has been widely investigated. This review describes current trends in MSC biology, the sourcing, expansion, application and role of MSCs in chondral defects of human knees. METHODS: The studies referencing MSCs and knee osteoarthritis were searched (from1998 to 2020) using PubMed, EMBASE, Cochrane Library, Web of Science and the ClinicalTrials.gov with keywords (MSCs, chondral defects or cartilage degeneration of knee, cartilage regeneration, chondrogenesis, tissue engineering, efficacy and safety). The inclusion criteria were based on use of MSCs for treatment of chondral defects and osteoarthritis of the knee, English language and human studies. RESULTS: The history of MSC research from the initial discovery of their multipotency to the more recent recognition of their role in cartilage defects of knee is elucidated. Several studies have demonstrated promising results in the clinical application for repair of chondral defects as an adjuvant or independent procedure. Intra-articular MSCs provide improvements in pain and function in knee osteoarthritis at short-term follow-up in many studies. The tendency of MSCs to differentiate into fibrocartilage affecting the outcome is a common issue faced by researchers. CONCLUSION: Some efficacy has been shown of MSCs for cartilage repair in osteoarthritis; however, the evidence of efficacy of intra-articular MSCs on both clinical outcomes and cartilage repair remains limited. Despite the high quality of evidence to support, MSC therapy has emerged but further refinement of methodology will be necessary to support its routine clinical use.

A prospective study of two methods of analgesia in shoulder arthroscopic procedures as day case surgery.

BACKGROUND & PURPOSE: The recent advances in anaesthesia and analgesia have significantly improved the early recovery and effective post-operative pain control in day care surgery e.g. shoulder arthroscopic procedures. Adequate analgesia improves the early rehabilitation for a better outcome. We prospectively evaluated the post-operative pain relief following the two methods of analgesia i.e. regional Inter-scalene block (ISB) vs Intra-articular (IA) injection using 0.5% Chirocaine in various therapeutic arthroscopic shoulder procedures. METHODS: A prospective comparative study was performed on a group of 105 patients (ASA grade I or II) who underwent the following procedures at two different hospitals: diagnostic arthroscopy, subacromial decompression (SAD) alone, SAD in combination with mini open cuff repairs or distal clavicle excision, anterior stabilization (Bankart's repair) and inferior capsular shift. A successful Inter-scalene block (0.5% Chirocaine-30mls) preceded the general anaesthesia (Group 1-52 patients). Local intra-articular infiltration (0.5% Chirocaine - 20 mls) was given postoperatively (Group 2-53 patients). Post operatively visual analogue scores (VAS) from 0 (no pain) to 10 (severe pain) were assessed in post-anaesthesia care unit (PACU), at 4hrs, at 24hrs and at 48 h. The amount of morphine consumption for the first 2 days after surgery was recorded. RESULTS: Patient characteristics were similar in both groups at both the hospitals. The median postoperative pain score of VAS <3 was observed in both groups. Significant difference (p < 0.0001) was observed in the VAS scores between the two groups at all the time intervals. The mean length of adequate sensory block in group 1 was significantly higher than in group 2 [20.5 h: 4.2 h] (p < 0.001). The mean analgesic (morphine) consumption was lower in Group 1 as compared to Group 2 [4.6 mg/24 h: 18.8mg/24 h](p < 0.0001). Bone shaving procedures e.g. SAD, SAD + Rotator Cuff repair, SAD + Lateral clavicular excision required significantly higher analgesia in both groups compared to the soft tissue procedures. CONCLUSION: Single dose ISB provided longer and effective postoperative analgesia. The bone shaving procedures required more analgesia in IA Group as compared to ISB Group.

Predictive Factors for the Outcome of Surgical Treatment of Lumbar Spondylolysis in Young Sporting Individuals.

STUDY DESIGN: Retrospective consecutive case series. OBJECTIVES: Only few sporting individuals with symptomatic lumbar pars injuries require surgical repair and it is often difficult to predict the outcome following surgery. The factors that predict the outcome after direct repair of lumbar pars defect was evaluated clinically and statistically. The preoperative background variables both subjective and objective as well as radiological evaluation were used in a multiple regression model to find the strong predictors of postoperative outcome as measured by VAS (visual analogue scores), ODI (Oswestry Disability Index) and SF-36 (Short Form). METHODS: Fifty-two consecutive young sporting individuals with a mean age of 19 years (range 8-30 years) were treated surgically for lumbar pars defect confirmed on imaging studies (ie, single-photon emission computed tomography, computed tomography, and magnetic resonance imaging). Fifty patients completed the VAS, ODI, and SF-36 questionnaires as a part of their assessment. Preoperative background variables were used in a multiple regression model to find the strongest predictor of postoperative outcome as measured by ODI. Ethical approval was taken by the institutional review board. RESULTS: Buck's screw repair of the pars defect was carried out in 44 patients (33 males, 11 female): unilateral in 8 patients (7 males, 1 female) and bilateral in 36 patients (26 males, 10 females). Although age at surgery showed linear colinearity (ρ = 0.32, P < .05), it was not significant in the model. The most consistent association with the preoperative VAS score were the pre- and postoperative ODI scores, that is, ρ = 0.51 (P < .01) and ρ = 0.33 (P < .05), respectively. In the bilateral group, with Buck's repair at a single level, that is, 33 of 36 (93%) patients had returned to sports at a mean time of 7.5 months (range 6-12 months). Overall, 44 of 52 (84%) individuals had returned to their sports with posttreatment ODI score of <10. The stepwise regression modeling suggested 6 independent factors (preoperative ODI, preoperative SF-36 physical component summary (PCS), Buck's repair, multiple operations, professionalism, and pars defect at L3), as the determinants of the outcome (ie, postoperative ODI) in 80.9% patients (R2 = 0.809). CONCLUSIONS: The outcome after direct repair of pars defect in those younger than 25 years runs a predictable course. Professionalism in sports has a high impact on the outcome. Preoperative ODI and SF-36 PCS scores are significant predictors of good functional outcome. The regression equation can predict the outcome in 80.9% sporting individuals undergoing Buck's repair.

Interbody Fusion in Low Grade Lumbar Spondylolsithesis: Clinical Outcome Does Not Correalte with Slip Reduction and Neural Foraminal Dimension.

STUDY DESIGN: Prospective nonrandomized study. PURPOSE: To find a possible correlation between clinical outcome and extent of lumbar spondylolisthesis reduction. OVERVIEW OF LITERATURE: There is no consensus in the literature concerning whether a beneficial effect of reduction on outcome can be expected following reduction and surgical fusion for low grade lumbar spondylolisthesis. METHODS: Forty six patients with a mean age of 37.5 years (age, 17-48 years) with isthmic spondylolisthesis underwent interbody fusion with cages with posterior instrumentation (TLIF). Clinical outcome was measured using visual analogue score (VAS) and Oswestry disability index (ODI). Foraminal dimensions and disc heights were measured in standard digital radiographs. These were analyzed at baseline and 1 year after surgery and changes were compared. Radiographic fusion was judged with computed tomography scans at 1 year. RESULTS: Ninety percent of the patients had good or very good clinical results with fusion and instrumentation. Baseline and one-year postoperative mean VAS score was 6.33 (range, 5-8) and 0.76 (range, 0-3), respectively (p=0.004). Baseline and one-year postoperative, mean ODI score was 48 (range, 32-62) and 10 (range, 6-16), respectively (p<0.001). A mean spondylolisthesis slip of 32.1% was reduced to 6.7% at 1 year. Average anterior disc height, posterior disc height, vertical foraminal dimension), and foraminal) diameter improved from 9.8 to 11.7 mm (p=0.005), 4.5 to 5.8 mm (p=0.004), 11.3 to 12.6 mm (p=0.002), and 18.6 to 20.0 mm (p<0.001), respectively. The fusion rate was 75% with TLIF. There is no significant correlation between the improvements of ODI scores and the extent of slip reduction. CONCLUSIONS: Neural decompression and interbody fusion can significantly improve pain and disability but the clinical outcome does not correlate with radiological improvement in the neural foraminal dimension.

Distal forearm fractures in children: Cast index as predictor of re-manipulation.

BACKGROUND: Displaced distal forearm fractures in children have been treated in above-elbow plaster casts since the last century. Cast index (CI) has been proposed as a measure to indicate how well the cast is molded to the contours of the forearm. In this study the CI in post-manipulation radiographs were analyzed to evaluate its relevance to re-angulation of distal forearm fractures in children in different age-groups. MATERIALS AND METHODS: Out of 174 consecutive cases treated during the study period, 156 patients (114 male and 42 female) with a mean age of 9.8 years (range: 2-15 years) were included in this retrospective radiographic analysis; 18 patients were excluded for various reasons. All patients were manipulated in the operation theater under general anesthesia and a molded above-elbow cast was applied. The CI was measured on immediate post-manipulation radiographs. Children were divided into three groups according to age: group 1: <5 years, group 2: 5-10 years, and group 3: >10 years. RESULTS: Angulation of the fracture within the original plaster cast occurred in 30 patients (19.2%): 22/114 males and 8/42 females. The mean CI in these 30 patients who required a second procedure was 0.92±0.08, which was significantly more than the mean CI in the other children (0.77±0.07) (P<.001). The mean CI in children who underwent re-manipulation in the group 1 was 0.96, which was significantly higher than that of the other two groups, i.e., 0.90 in group 2 and 0.88 in group 3 (P<.05). A receiver operating characteristics (ROC) curve estimated the cutoff point for intraoperative CI of 0.84 when both the sensitivity and specificity of CI was high to predict re-manipulation for re-displaced fractures of the distal forearm in children in any age-group. CONCLUSION: The CI is a valuable tool to assess the quality of molding of the cast following closed manipulation of forearm fractures in children. A high CI (≥0.84) in post-manipulation radiographs indicates increased risk of re-displacement of the fracture in children, especially in those under the age of 5 years and over the age of 10 years.

Congenital scoliosis - Quo vadis?

Congenital spinal vertebral anomalies can present as scoliosis or kyphosis or both. The worldwide prevalence of the vertebral anomalies is 0.5-1 per 1000 live births. Vertebral anomalies can range from hemi vertebrae (HV) which may be single or multiple, vertebral bar with or without HV, block vertebrae, wedge shaped or butterfly vertebrae. Seventy per cent of congenital vertebral anomalies result in progressive deformities. The risk factors for progression include: type of defect, site of defect (junctional regions) and patient's age at the time of diagnosis. The key to success in managing these spinal deformities is early diagnosis and anticipation of progression. One must intervene surgically to halt the progression of deformity and prevent further complications associated with progressive deformity. Planning for surgery includes a preoperative MRI scan to rule out spinal anomalies such as diastematomyelia. The goals of surgical treatment for congenital spinal deformity are to achieve a straight growing spine, a normal standing sagittal profile, and a short fusion segment. The options of surgery include in situ fusion, convex hemi epiphysiodesis and hemi vertebra excision. These basic surgical procedures can be combined with curve correction, instrumentation and short segment fusion. Most surgeons prefer posterior (only) surgery for uncomplicated HV excision and short segment fusion. These surgical procedures can be performed through posterior, anterior or combined approaches. The advocates of combined approaches suggest greater deformity correction possibilities with reduced incidence of pseudoarthrosis and minimize crankshaft phenomenon. We recommend posterior surgery for curves involving only an element of kyphosis or modest deformity, whereas combined anterior and posterior approach is indicated for large or lordotic deformities. In the last decade, the use of growing rods and vertebral expandable prosthetic titanium rib has improved the armamentarium of the spinal surgeon in dealing with certain difficult congenital spinal deformities. The goal of growing rod treatment is to provide simultaneous deformity correction and allow for continued spinal growth. Once maximal spinal growth has been achieved, definitive fusion and instrumentation is performed.

Compartment syndrome of leg following total lumbar disc replacement via anterior retroperitoneal approach: a rare complication of anterior spinal surgery.

STUDY DESIGN: Observational study of a case with a rare complication of lower limb compartment syndrome following total lumbar disc replacement via anterior retroperitoneal approach. OBJECTIVE: To describe a patient with lower limb compartment syndrome, following total lumbar disc replacement via anterior retroperitoneal approach. SUMMARY OF BACKGROUND DATA: Compartment syndrome is a rare complication of spinal surgery. Previously, there were very few reported cases of compartment syndrome following posterior approach through a knee chest position. We are reporting the first case of lower limb compartment syndrome following total lumbar disc replacement through anterior retroperitoneal approach. METHODS: Case report and literature review. RESULT: Total lumbar disc replacement through anterior retroperitoneal approach led to a vascular complication (left iliac vein injury) with failed attempt at surgical repair. At 48 hours, the patient developed left lower limb compartment syndrome. Surgical decompression of the compartment prevented serious sequel with a successful outcome. CONCLUSION: Total disc replacement in the lumbar spine complicated with an acute compartment syndrome due to the left common iliac vein injury is reported for the first time. A vigilant postoperative work-up in an unconscious patient resulted in the diagnosis and decompression with a successful outcome.

Pituitary apoplexy after joint arthroplasty.

Pituitary apoplexy is a rare but potentially life-threatening condition caused by the sudden enlargement of a pituitary adenoma secondary to infarction and hemorrhage. The clinical syndrome is characterized by sudden onset of headache, ocular palsies, visual disturbances, and altered state of consciousness. We report 2 patients who had postoperative pituitary apoplexy after total hip and total knee arthroplasty. Asymptomatic pituitary adenomas are difficult to diagnose preoperatively. Its existence is an unlikely suspect until the clinical symptoms develop after surgery. This is the first reported case following total hip arthroplasty.

Coeliac axis thrombosis after surgical correction of spinal deformity in type VI Ehlers-Danlos syndrome: a case report and review of the literature.

STUDY DESIGN: An unusual case of postoperative thrombosis of celiac artery in a patient of Type VI Ehlers-Danlos syndrome (EDS) with severe kyphotic deformity is reported. OBJECTIVE: To describe an unusual complication of celiac artery thrombosis following surgical correction of kyphotic deformity in Type VI EDS. SUMMARY OF BACKGROUND DATA: Neurologic deficit following surgical correction for kyphoscoliotic deformities in patients with Type VI has been reported in 4 cases previously. There has been no previous report of combined celiac artery thrombosis leading to infarction of major abdominal organs along with quadriparesis below C7-C8. METHODS: Case report and literature review. RESULTS: Subsequent to a 2-stage surgical correction with posterior instrumentation and fusion of spine, this patient with Type VI EDS developed celiac artery thrombosis leading to infarction of major abdominal organs. At laparotomy, he required hemihepatectomy, splenectomy, cholecystectomy, and a repair of gastric perforation. Following his abdominal catastrophe, he developed quadriparesis possibly due to anterior spinal artery ischemia. CONCLUSION: Spine surgeons treating Type VI EDS with progressive kyphoscoliosis should be aware of such an unusual complication of celiac artery occlusion in late postoperative period. Preoperative antithrombotic medication should be monitored carefully to avoid such catastrophic complication. The prognosis remains poor following anterior spinal artery ischemia due to infarction or thrombosis.

Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis.

STUDY DESIGN: A prospective case-series study. OBJECTIVE: To evaluate the results of nonoperative and operative treatment of symptomatic unilateral lumbar pars stress injuries or spondylolysis. SUMMARY OF BACKGROUND DATA: Most patients become asymptomatic following nonoperative treatment for unilateral lumbar pars stress injuries or spondylolysis. Surgery, however, is indicated when symptoms persist beyond a reasonable time affecting the quality of life in young patients, particularly the athletic population. METHODS: We treated 42 patients (31 male, 11 female) with unilateral lumbar pars stress injuries or spondylolysis. Thirty-two patients were actively involved in sports at various levels. Patients with a positive stress reaction on single photon emission computerized tomography imaging underwent a strict protocol of activity restriction, bracing, and physical therapy for 6 months. At the end of 6 months, patients who remained symptomatic underwent a computed tomography (CT) scan to confirm the persistence of a spondylolysis. Eight patients subsequently underwent a direct repair of the defect using the modified Buck's Technique. Baseline Oswestry Disability Index (ODI) and Short-Form-36 (SF-36) scores were compared with 2-year ODI and SF-36 scores for all patients. RESULTS: Eight of nine fast bowlers in cricket were right-handed. The spondylolytic defect appeared on the left side of their lumbar spine. In the nonoperated group, the mean pretreatment ODI was 36 (SD = 10.5), improving to 6.2 (SD = 8.2) at 2 years. In SF-36 scores, the mean score for physical component of health (PCS) improved from 30.7 (SD = 3.2) to 53.5 (SD = 6.5) (P < 0.001), and the mean score for the mental component of health (MCS) improved from 39 (SD = 4.1) and 56.5 (SD = 3.9) (P < 0.001) at 2 years. Twenty of 32 patients resumed their sporting career within 6 months of onset of treatment, and a further 4 of 32 patients returned to sports within 1 year. The 8 patients who remained symptomatic at 6 months underwent a unilateral modified Buck's repair. The most common level of repair was L5 (n = 5). One patient with spina bifida and a right-sided L5 pars defect remained symptomatic following direct repair. The mean preoperative ODI was 39.4 (SD = 3.6), improving to 6.4 (SD = 5.2) at the latest follow-up. The mean score of PCS (SF-36) improved from 29.6 (SD = 4.4) to 49.2 (SD = 6.2) (P < 0.001), and the mean score of MCS (SF-36) improved from 38.7 (SD = 1.9) to 54.5 (SD = 6.4) (P < 0.001). CONCLUSIONS: The increased incidence of the unilateral lumbar pars stress injuries or frank defect on the contralateral side in a throwing sports, e.g., cricket (fast bowling), may be related to the hand dominance of the individual. Nonoperative treatment for patients with a unilateral lumbar pars stress injuries or spondylolysis resulted in a high rate of success, with 81% (34/42) of patients avoiding surgery. If symptoms persist beyond a reasonable period, i.e., 6 months, and reverse gantry CT scan confirms a nonhealing defect of the pars interarticularis, one may consider a unilateral direct repair of the defect with good functional outcome. Direct repair in patients with spina bifida at the same lumbar level as the unilateral defect may be complicated by nonunion.

Rotational dislocation of the thoracolumbar spine. Case report and review of the literature.

The authors report a rare case of rotational dislocation of the thoracolumbar spine in a 12-year-old girl with neurofibromatosis Type 1. The patient had progressive spinal kyphoscoliosis with acute-onset paraplegia. She was treated with corrective traction preoperatively, followed by spinal decompression and circumferential spinal fusion without instrumentation. She had complete neurological recovery after a solid fusion of her spine.

Operative management of ankle fractures in patients with diabetes mellitus.

BACKGROUND: Multiple studies have documented increased risks associated with treatment of ankle fractures in patients with diabetes mellitus. We reviewed our results in the largest series to date of this complex patient group to determine the frequency of complications. METHODS: Eighty-four patients with diabetes had open reduction and internal fixation using standard fixation techniques for acute, closed ankle fractures. The 51 men and 33 women had an average age was 49.3 (22 to 77) years. The average followup was 4.1 years (11 to 97 months). Seventy-five fractures were closed and nine were open. Thirty-nine patients used insulin and 45 used oral hypoglycemics or diet for control of their diabetes. Diabetic complications, including nephropathy, hypertension, peripheral vascular disease, and neuropathy were evaluated. The management of diabetes, fracture classification, and presence of diabetic complications were assessed with chi-square, ANOVA, and univariate logistic regression to determine the presence of statistical significance for these factors. RESULTS: Twelve of the 84 patients developed postoperative complications. Ten patients developed infections (eight deep and two superficial). Four of 12 patients with preoperative evidence of peripheral neuropathy developed Charcot arthropathy. Ten of 12 patients who had absent pedal pulses preoperatively developed complications (p<0.0001) and 11 of 12 patients with peripheral neuropathy had complications (p<0.0001). A trend towards complications was noted with nephropathy (two of five patients) and hypertension (nine of 12 patients). Open fractures, insulin dependence, patient age, and fracture classification had no significant effect on outcome. CONCLUSIONS: Most patients with diabetes can undergo open reduction and internal fixation of acute ankle fractures without complications. Patients with absent pedal pulses or peripheral neuropathy are at increased risk for complications.

Candida albicans osteomyelitis of the spine: progressive clinical and radiological features and surgical management in three cases.

Candida albicans vertebral osteomyelitis is rare. Three cases are presented. Without antifungal treatment, they developed spinal collapse and neurological deterioration within 3-6 months from the onset of symptoms. There was a delay of 4.5 and 7.5 months between the onset of symptoms and surgery. All patients were managed with surgical debridement and reconstruction and 12-week fluconazole treatment. The neurological deficits resolved completely. The infection has not recurred clinically or radiologically at 5-6 years follow-up. Although rare, Candida should be suspected as a causative pathogen in cases of spinal osteomyelitis. Without treatment the disease is progressive. As soon as osteomyelitis is suspected, investigations with MRI and percutaneous biopsy should be performed followed by medical therapy. This may prevent the need for surgery. However, if vertebral collapse and spinal cord compression occurs, surgical debridement, fusion and stabilisation combined with antifungal medications can successfully eradicate the infection and resolve the neurological deficits.

A prospective randomized comparison of coralline hydroxyapatite with autograft in cervical interbody fusion.

STUDY DESIGN: A prospective randomized trial with independent clinical and radiographic outcome review of patients receiving either hydroxyapatite or tricortical iliac crest graft for cervical interbody fusion was conducted. OBJECTIVE: To determine whether coralline-derived hydroxyapatite is a suitable bone graft substitute in cervical interbody fusion. SUMMARY OF BACKGROUND DATA: Tricortical iliac crest bone is the "gold standard" graft material for cervical interbody fusion. Various bone substitutes have been used for this procedure to avoid potential donor site morbidity. ProOsteon 200 is a coralline-derived hydroxyapatite product, the use of which remains unclear for cervical interbody fusion. METHODS: In this study, 29 patients undergoing anterior cervical fusion and plating were randomized to receive either ProOsteon 200 or iliac crest grafts. The SF-36 and Oswestry Disability Index were used to measure clinical outcome. Postoperative radiographs were analyzed for graft fragmentation, loss of height, angular alignment, and hardware failure to assess structural integrity of the graft material. Plain radiographs and computed tomography scans were used to evaluate fusion. RESULTS: Both the ProOsteon 200 and iliac crest groups demonstrated significant improvement in clinical outcome scores. There was no significant difference in clinical outcome or fusion rates between the two groups. Graft fragmentation occurred in 89% of the hydroxyapatite grafts and 11% of the autografts (P = 0.001). Significant graft settling occurred in 50% of the hydroxyapatite grafts, as compared with 11% of the autografts (P = 0. 009). One patient in the ProOsteon 200 group required revision surgery for graft failure. CONCLUSIONS: ProOsteon 200 does not possess adequate structural integrity to resist axial loading and maintain disc height or segmental lordosis during cervical interbody fusion.