Outcomes of Dorsolumbar and Lumbar Spinal Tuberculosis Treated by Minimally Invasive and Open Techniques: A Prospective Comparative Study.

Purpose of Study: To compare the outcomes of minimally invasive and open techniques in the surgical management of dorsolumbar and lumbar spinal tuberculosis (STB). Methods: Skeletally mature patients with active STB involving thoracolumbar and lumbar region confirmed by radiology (X-ray, MRI) and histopathological examination were included. Healed and mechanically stable STB, patients having severe hepatic and renal impairment, coexisting spinal conditions such as ankylosing spondylitis and rheumatoid arthritis, and patients unwilling to participate were excluded from the study. The patients were divided in to two groups, group A consisted of patients treated by MIS techniques and group B consisted of patients treated by open techniques. All the patients had a minimum follow-up of 24 months. Results: A total of 42 patients were included in the study. MIS techniques were used in 18 patients and open techniques were used in 24 patients. On comparison between the two groups, blood loss (234 ml vs 742 ml), and immediate post-operative VAS score (5.26 vs 7.08) were significantly better in group A, whereas kyphotic correction (16° vs 33.25°) was significantly better in group B. Rest of the parameters such as duration of surgery, VAS score, ODI score and number of instrumented levels did not show significant difference between the two groups. Conclusion: MIS stabilization when compared to open techniques is associated with significant improvement in immediate post-operative VAS scores. The MIS approaches at 2-year follow-up have functional results similar to open techniques. MIS is inferior to open techniques in kyphosis correction and may be associated with complications.

Pre-operative Anemia and Hyponatremia Increase the Risk of Mortality in Elderly Hip Fractures.

Objectives: Pre-operative assessment is routinely performed for all hip fractures, and include a thorough clinical examination and multiple pre-operative tests. While abnormalities are often detected in many tests, they have varied effect on mortality. The purpose of the study was to assess the prevalence and impact of these abnormal tests and comorbidities. Methods: This was a prospective study of 283 consecutive hip fracture patients aged above 50 years admitted in a major trauma hospital from February 2019 to December 2019. The prevalence of abnormalities in the following tests were assessed: chest x-ray, electrocardiogram, complete blood count, serum electrolytes, renal function test, prothrombin time/international normalized ratio, and serum bilirubin. Also, presence of comorbidities were recorded. Mortality within 90 days of admission was assessed. Results: 91.5% (N= 259/283) of the patients had at least one abnormal investigation. The most common abnormal investigation was anemia (70.3%, N= 199/283), followed by deranged sodium (36.4%, N= 103/283). 17.7% (N= 50/283) of the patients had at least one new comorbidity diagnosed after admission. The most common newly diagnosed comorbidity was hypertension (10.6%, N= 30/283). Anemia (p=0.044), deranged sodium (p=0.002), raised urea (p=0.018), raised creatinine (p=0.002), renal disease (p=0.015), neurological diseases (p=0.024), and charlson comorbidity index (p=0.004) were associated with increased mortality in multivariate analysis. Conclusion: Pre-operative hemoglobin, sodium, urea, and creatinine were the most important tests influencing mortality, and derangements of these should therefore be carefully evaluated and managed. Hip fracture care pathways should focus on correction of these abnormalities.

Healing Assessment of Spinal Tuberculosis: A Systematic Review.

OBJECTIVE: Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB. METHODS: A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study. RESULTS: Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing. CONCLUSIONS: Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

The Impact of Surgical Timing of Hip Fracture on Mortality: Do the Cause and Duration of Delay Matter?

Purpose: Delay in performance of hip fracture surgery can be caused by medical and/or administrative reasons. Although early surgery is recommended, it is unclear what constitutes a delayed surgery and whether the impact of delayed surgery can differ depending on the reason for the delay. Materials and Methods: A total of 269 consecutive hip fracture patients over 50 years of age who underwent surgery were prospectively enrolled. They were divided into two groups: early and delayed (time from reaching the hospital to surgery less than or more than 48 hours). Patients were also categorized as fit or unfit based on anesthetic fitness. One-year mortality was recorded, and regression analyses were performed to assess the impact of delay on mortality. Results: A total of 153 patients (56.9%) had delayed surgery with a mean time to surgery of 87±70 hours. A total of 115 patients (42.8%) were considered medically fit to undergo surgery. No difference in one-year mortality was observed between patients with early surgery and those with delayed surgery (P=0.854). However, when assessment of the time to surgery was performed in a continuous manner, mortality increased with prolonged time to surgery, particularly in unfit patients, and higher mortality was observed when the delay exceeded six days (fit: P=0.117; unfit: P=0.035). Conclusion: The effect of delay on mortality was predominantly observed in patients who were not considered medically fit, suggesting that surgical delays might have a greater impact on patients with medical reasons for delay.

Management of long bone fractures in patients with pycnodysostosis.

Pycnodysostosis is a rare genetic condition that leads to generalised bony sclerosis and increased fracture risk. Orthopaedic specialists play a crucial role in managing affected children due to their susceptibility to frequent fractures. We had a case of a middle childhood female patient with pycnodysostosis and a femur fracture. Initially, an attempt using the Titanium Elastic Nailing System was made, but the sclerotic metaphyseal bone made it challenging. So, we opted for a 4.5 mm locked compressive plate, with multiple drill bits as a backup due to potential drill breakage. Though elastic nailing is preferred for paediatric long bone fractures, surgeons must be prepared for extremely sclerotic cortices and a narrow medullary canal when dealing with patients with pycnodysostosis. Open fixation and multiple drill bits in the toolkit are essential to overcome the potential obstacles during the procedure.

Excess mortality in elderly hip fracture patients: An Indian experience.

PURPOSE: Hip fractures in elderly have a high mortality. However, there is limited literature on the excess mortality seen in hip fractures compared to the normal population. The purpose of this study was to compare the mortality of hip fractures with that of age and gender matched Indian population. METHODS: There are 283 patients with hip fractures aged above 50 years admitted at single centre prospectively enrolled in this study. Patients were followed up for 1 year and the follow-up record was available for 279 patients. Mortality was assessed during the follow-up from chart review and/or by telephonic interview. One-year mortality of Indian population was obtained from public databases. Standardized mortality ratio (SMR) (observed mortality divided by expected mortality) was calculated. Kaplan-Meir analysis was used. RESULTS: The overall 1-year mortality was 19.0% (53/279). Mortality increased with age (p < 0.001) and the highest mortality was seen in those above 80 years (aged 50 - 59 years: 5.0%, aged 60 - 69 years: 19.7%, aged 70 - 79 years: 15.8%, and aged over 80 years: 33.3%). Expected mortality of Indian population of similar age and gender profile was 3.7%, giving a SMR of 5.5. SMR for different age quintiles were: 3.9 (aged 50 - 59 years), 6.6 (aged 60 - 69 years), 2.2 (aged 70 - 79 years); and 2.0 (aged over 80 years). SMR in males and females were 5.7 and 5.3, respectively. CONCLUSIONS: Indian patients sustaining hip fractures were about 5 times more likely to die than the general population. Although mortality rates increased with age, the highest excess mortality was seen in relatively younger patients. Hip fracture mortality was even higher than that of myocardial infarction, breast cancer, and cervical cancer.

Intramedullary Femur Nailing in Intertrochanteric Fractures: Postoperatively Do Helical Blades Migrate More Than Lag Screws? A Randomized Controlled Trial.

Objectives: This was a prospective, randomized controlled trial to test functional outcomes between a single lag screw and helical blade nails in the treatment of intertrochanteric fractures. Methods: 72 patients with intertrochanteric fractures between March 2019 to November 2020 were randomized into two groups and treated with a lag screw or a helical blade nail. Intraoperative parameters such as operative time, blood loss, and radiation exposure were calculated. Postoperatively, tip apex distance, neck length, neck-shaft angle, lateral impingement of implant, union rate, and the functional outcomes were measured at the end of 6 month follow-up period. Results: There was a significant decrease in tip apex distance (p = 0.03) and neck length(p-0.04) with significant lateral impingement of the implant (p = 0.04) in the helical blade group compared to the lag screw group. The functional outcome calculated using the modified Harris Hip score & Parker and Palmer mobility score, at the end of 6 months, had no significant difference between the two groups. Conclusion: Both lag screw and helical blade devices can be used to successfully treat these fractures, although there is greater medial migration in the helical blade as compared to the lag screw.

Utility of clinicoradiological, microbiological, histopathological, and molecular methods in the diagnosis of spinal tuberculosis.

PURPOSE: The diagnosis of STB is mainly based on clinicoradiological observations substantiated by bacterial culture, staining, Gene Xpert, and histopathology. The purpose of the study was to correlate these methods to evaluate the effectiveness in the diagnosis of STB. METHODS: A total of 178 clinicoradiologically suspected cases of STB were included in the study. The specimens for diagnostic workup were collected either during surgery or by CT-guided biopsy. All these specimens were tested for tuberculosis through ZN staining, solid culture, histopathology, and PCR. The sensitivity, specificity, PPV, and NPV of each test were calculated using histopathology as a gold standard. RESULTS: Out of the 178 cases, a total of 15 cases were excluded from this study. Among the remaining 163 cases, TB was diagnosed in 143 [87.73%] on histopathology, 130 [79.75%] on Gene Xpert, 40 [24.53%] on culture, and 23 [14.11%] on ZN stain. The sensitivity, specificity, PPV, and NPV of Gene Xpert were 86.71, 70, 95.38, and 42.42%, respectively. The sensitivity, specificity, PPV, and NPV of AFB culture were 27.97, 100, 100, and 16.26%, respectively. The sensitivity, specificity, PPV, and NPV of AFB stain were 16.08, 100, 100, and 14.29%, respectively. Gene Xpert showed a moderate agreement [Ƙc = 0.4432] with histopathology. CONCLUSION: No single diagnostic modality can ascertain the diagnosis, and it is desirable to have a combination of diagnostic batteries for better results. A combination of Gene Xpert and histopathology aids in early and reliable diagnosis of STB.

3D mapping: has the mystery of proximal tibia fractures been solved?

PURPOSE: One of the major limitations of the 2D fracture evaluation (Schatzker classification) is its failure to adequately assess fracture lines in the frontal plane and fracture displacement in the antero-posterior direction. 3D fracture line mapping includes steric assessment which can aid decision making with regards to the surgical approach and fixation scheme. We hypothesized that there are consistent fracture patterns and zones of comminution for proximal tibial fractures. METHODS: Radiographic data of 228 proximal tibia fractures were retrospectively included in this study. Fracture lines and zones of comminution were graphically superimposed onto a 3D template of an intact tibia after virtual reduction and normalization to identify major patterns of fracture and comminution. RESULTS: Out of 206 male and 21 female patients, 89 had a fracture of the lateral condyle only (Schatzker I and II), 53 involved the medial plateau only (Schatzker IV) and 86 had a high-grade fracture involving both the condyles (Schatzker V and VI). 64.5% of the fracture lines involving the medial plateau alone were in the coronal plane, and this number was even lesser (44.2%) in medial plateau involvement of bicondylar fractures. In bicondylar fractures, lines were usually not seen to pass directly through the posteromedial region. CONCLUSIONS: Medial tibial plateau fractures have a mix of coronal or sagittal fracture alignment. A clearer understanding of the 3D orientations of fractures based on CT scans can aid in diagnosing the pattern of fracture and adequate positioning of plates can be done to eventually improve operative outcomes.

Biomechanical analysis of Instrumented decompression and Interbody fusion procedures in Lumbar spine: a finite element analysis study.

Interbody fusions have become increasingly popular to achieve good fusion rates. Also, unilateral instrumentation is favored to minimize soft tissue injury with limited hardware. Limited finite element studies are available in the literature to validate these clinical implications. A three-dimensional, non-linear ligamentous attachment finite element model of L3-L4 was created and validated. The intact L3-L4 model was modified to simulate procedures like laminectomy with bilateral pedicle screw Instrumentation, transforaminal, and posterior lumbar interbody fusion (TLIF and PLIF, respectively) with unilateral and bilateral pedicle screw instrumentation. Compared to instrumented laminectomy, interbody procedures showed a considerable reduction in range of motion (RoM) in extension and torsion (6% and 12% difference, respectively). Both TLIF and PLIF showed comparable RoM in all movements with < 5% difference in reduction of RoM between them. Bilateral instrumentation showed a more significant decrease in RoM (> 5% difference) in the entire range of motion except in torsion when compared to unilateral instrumentation. The maximum difference in reduction in RoM was noted in lateral bending (24% and 26% for PLIF and TLIF, respectively), while the least difference in Left torsion (0.6% and 3.6% for PLIF and TLIF, respectively) in comparing bilateral with unilateral instrumentation. Interbody fusion procedures were found to be biomechanically more stable in extension and torsion than the instrumented laminectomy. Single-level TLIF and PLIF achieved a similar reduction in RoM with a < 5% difference. Bilateral screw fixation proved biomechanically superior to unilateral fixation in the entire range of motion except in torsion.

Deformity Correction with Interbody Fusion Using Lateral versus Posterior Approach in Adult Degenerative Scoliosis: A Systematic Review and Observational Meta-analysis.

This study was designed to systematically review and meta-analyze the functional and radiological outcomes between lateral and posterior approaches in adult degenerative scoliosis (ADS). Both lateral (lumbar, extreme, and oblique) and posterior interbody fusion (posterior lumbar and transforaminal) are used for deformity correction in patients with ADS with unclear comparison in this cohort of patients in the existing literature. A literature search using three electronic databases was performed to identify studies that reported outcomes of lateral (group L) and posterior interbody fusion (group P) in patients with ADS with curves of 10°-40°. Group P was further subdivided into minimally invasive surgery (MIS-P) and open posterior (Op-P) subgroups. Data on functional, radiological, and operative outcomes, length of hospital stay (LOHS), fusion rates, and complications were extracted and meta-analyzed using the random-effects model. A total of 18 studies (732 patients) met the inclusion criteria. No significant difference was found in functional and radiological outcomes between the two groups on data pooling. Total operative time in the MIS-P subgroup was less than that of group L (233.86 minutes vs. 401 minutes, p <0.05). The total blood loss in group L was less than that in the Op-P subgroup(477 mL vs. 1,325.6 mL, p <0.05). Group L had significantly less LOHS than the Op-P subgroup (4.15 days vs. 13.5 days, p <0.05). No significant difference was seen in fusion rates, but complications were seen except for transient sensorimotor weakness (group L: 24.3%, group P: 5.6%; p <0.05). Complications, such as postoperative thigh pain (7.7%), visceral injuries (2%), and retrograde ejaculation (3.7%), were seen only in group L while adjacent segment degeneration was seen only in group P (8.6%). Lateral approach has an advantage in blood loss and LOHS over the Op-P subgroup. The MIS-P subgroup has less operative time than group L, but with comparable blood loss and LOHS. No significant difference was found in functional, radiological, fusion rates, pseudoarthrosis, and complications, except for transient sensorimotor deficits. Few complications were approach-specific in each group.

Correction to: Femoral Shaft Fracture in Post-polio Syndrome Patients: Case Series from a Level-I Trauma Center and Review of Literature.

[This corrects the article DOI: 10.1007/s43465-022-00683-8.].

Tricortical iliac crest graft as a salvageable option in the reconstruction of comminuted posterior wall acetabular fractures: our experience from a level 1 trauma centre.

BACKGROUND: Comminuted fractures of the posterior acetabular wall, pose a significant challenge in the reduction and fixation of the fracture fragments and usually result in dubious functional outcomes. Primary reconstruction of the severely comminuted posterior wall using the autologous tricortical iliac crest graft has shown promising results, especially in fractures not amenable for anatomical reduction and fixation. Thus, the present study analyses the functional and radiological outcomes of severely comminuted posterior wall acetabular fractures, primarily reconstructed with an autologous tricortical iliac crest graft. METHODOLOGY: This is a retrospective study, where all cases of comminuted posterior wall acetabulum fractures treated primarily with reconstruction using ipsilateral autologous tricortical iliac crest graft between January 2011 and November 2018 were included. The data of patients were retrieved from the hospital records and all the patients were assessed clinically and radiologically at the final follow-up. RESULTS: Fourteen patients (ten males and four females) were operated on with a mean operative time of 160 min (range 125 to 190 min) and a mean blood loss of 410 ml (range 320 ml to 830 ml). At 2 years of follow-up, 11 patients (78.57%) had good to excellent functional outcomes based on the modified Merle d'Aubigne and Postel scoring system. The radiological assessment using Matta's criteria indicated excellent outcomes in two patients (14.48%), good in six patients (42.85%), fair in six patients (42.85%). CONCLUSION: Primary reconstruction of the comminuted posterior wall acetabulum fractures is a potential alternative and salvageable option with favourable outcomes. However, it ought to be considered in severely comminuted fractures where anatomical reduction and internal fixation is not feasible.

Is it Safe to Save Levels and Choose the Lowest Instrumented Vertebra as Touched Vertebra While Selectively Fusing Lenke 1/2 Curves? A Proportional Meta-Analysis of Existing Evidence.

STUDY DESIGN: Meta-analysis. OBJECTIVE: To compare the clinical and radiological outcomes in patients with Adolescent Idiopathic scoliosis (AIS) treated by selective thoracic fusion (STF) with lowest instrumented vertebra (LIV) at touched vertebra (TV) vs stable vertebra (SV). METHODS: The databases PubMed, Embase and Google Scholar were searched until November 2020.Studies which had Lenke type 1 curves and Lenke type 2 curves in adolescent population treated by STF and which reported pre- and post-operative curve characteristics including correction percentage and complications were included. Studies which did not report the LIV selection, curve correction percentages and whose full text could not be acquired were excluded. RESULTS: Eight studies were included for analysis of which seven were found to be retrospective studies (level III evidence) and one was prospective study (level II evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, total srs-22 scores, and complication rates. CONCLUSION: The evaluation of SV group and TV group as LIV for selective thoracic fusions in AIS reveals a comparable outcome in terms of curve correction, patient satisfaction scores and complication rates. The TV can be chosen safely as the LIV especially in type A and B Lenke 1&2 curves, as it saves more motion segments when compared to SV.

Is Final Fusion Necessary for Growing-Rod Graduates: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: The need for definitive fusion for growing rod graduates is a controversial topic in the management of Early-onset scoliosis (EOS) patients. The authors performed a systematic review and meta-analysis on the available literature to evaluate the outcomes of growing rod graduates undergoing final fusion or observation with implants in-situ. METHODS: An extensive literature search was carried out aimed at identifying articles reporting outcomes in growing rod graduates. Apart from the study characteristics and demographic details, the extracted data included Cobb's correction, trunk height parameters, and revision rate. The extracted data was analyzed and forest plots were generated to draw comparisons between the observation and fusion groups. RESULTS: Of the 11 included studies, 6 were case-control and 5 were case series. The authors did not find any significant difference between the 2 groups with respect to the pre-index and final Cobb's correction, T1-T12 or T1-S1 height gain in either over-all, or sub-analysis with case-control studies. The meta-analysis showed a significantly higher revision rate in patients undergoing a definitive fusion procedure. CONCLUSION: The current analysis revealed comparable outcomes in terms of correction rate and gain in the trunk height but a lesser need of revisions in observation sub-group. The lack of good quality evidence and the need for prospective and randomized trials was also propounded by this review.

Ipsilateral femoral neck and shaft fractures: case series from a single Level-I trauma centre and review of literature.

INTRODUCTION: Uncommon but increasingly diagnosed, ipsilateral femoral neck and shaft fracture represents a complex injury pattern with challenging management. The conundrum involves optimal diagnostic modality, timing of surgery, sequence of fixation, and the choice of implant. METHODOLOGY: A retrospective review was conducted at a Level-I trauma centre to assess the outcome of concomitant femoral neck and shaft fractures managed with various implants and attempt to provide solutions to the aforementioned queries. The time between injury and definitive surgery, choice of implant, sequence of fixation, time to fracture union, and complications were documented and analyzed. RESULTS: A total of 46 patients were included in the study wherein associated neck fracture was identified preoperatively in 93.5% of patients. In patients with isolated limb fractures, the mean time to surgery was 16.7 ± 5 h whereas patients with polytrauma witnessed an average delay of 4.6 days before fracture fixation. 72% of patients were managed by dual implants and in the remaining both the fractures were addressed using a single implant with no union time difference amongst implants. The mean time to the union for neck fracture was 21.7 weeks and 24.2 weeks for shaft femur fracture. 21.7% patients developed delayed union of fracture shaft femur and infection complicated 11% shaft fractures. CONCLUSION: Although, 6% neck fractures were missed in the series, we advocate that careful pre/intra/post-operative fluoroscopic evaluation of the femoral neck along with a low threshold for a pre-operative CT scan remains the optimal diagnostic modality while avoiding universal employment of computed tomography (CT). With fracture union being unaffected by implant choice, authors suggest that anatomical fixation of the femoral neck is of paramount importance followed by restoration of the length, alignment and rotation of the femoral shaft, and the implant selection primarily depends on surgeon's experience and the pattern of injury.

Interest in curves: when the radius of curvature matters in femur fractures. A CT based morphometric study.

PURPOSE: In today's era, fractures of the femur are primarily managed with intramedullary devices. Keeping in mind the anatomical sagittal bow of the femur, intramedullary devices have been devised with an anterior bow, but this varies amongst various manufacturers - leading to complications such as anterior cortex impingement beyond the isthmus and posterior cortical opening at the fracture site. We intend to find the average radius of curvature (ROC) of the anatomical bow of the femur and the variation of the same. METHODS: Radiographic data of 150 normal femur scans done in 81 patients were loaded in the Mimics 21.0 software (Materialise, Leuven, Belgium). A centerline (of the medullary cavity) was created using the software. A best-fit circle was created in the sagittal plane involving a major part of the centerline, and ROC was calculated. RESULTS: We found the average ROC of our data was 1027.2, with a standard deviation of 241.55. ROC and length of the femur (an indirect measure of height) had a slight positive correlation (r = 0.36; p < 0.05); and a highly positive correlation in the ROC of the left and right femurs of the same individuals (r = 0.605; p < 0.05). CONCLUSIONS: The usual ROC of intramedullary nails is commonly > 1300 mm, much higher than the average ROC we identified in our population. Thus, we conclude that implants with smaller ROC in the range of 1100 mm are needed, leading to better implant placement in the canal and avoiding complications of anterior cortex impingement and preventing fracture gap widening in our setting.