Complications of the Use Allograft in 1- or 2-Level Anterior Cervical Discectomy and Fusion: A Systematic Review.

Study Design: Systematic literature reviewObjective: To critically analyze the literature and describe the complications associated with the use of allograft in 1- or 2- level anterior cervical discectomy and fusion (ACDF)Methods: A systematic search of PubMed/MEDLINE, EMBASE, and ClinicalTrials.gov databases was conducted for literature published between January 2000 and August 2020 reporting complications associated with the use of allograft in 1- or 2- level ACDF.Results: From 584 potentially relevant citations, 21 met the inclusion criteria (4 randomized controlled trials (RCT), 4 prospective, and 13 retrospective studies). The patient number varied between 26 and 463 in comparative studies (RCT and non-RCT) and between 29 and 345 in non-comparative studies. Fusion rate was reported in 14 studies and ranged between 68.5-100%. The most frequently reported complication was post-operative dysphagia or dysphonia, with incidences ranging between .5% and 14.4%. Revision surgery was the second most reported complication (14 studies) and ranged between 0% and 10.3%. Wound-related complications were reported in 6 studies and ranged between 0% and 22.8%.Conclusion: The overall reporting of complications was low with very few comparative studies. Reported complications with allografts are within the range of other osteobiologics and autografts and in most cases may not attributable to the use of osteobiologics and may be complications of the procedure itself. Comparative studies with a more robust methodology analyzing complications with allograft and other osteobiologics are needed to inform current practice with strong recommendations.

What Is the Evidence Supporting Osteobiologic Use in Revision Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: Systematic literature review. OBJECTIVE: To analyze the literature and describe the evidence supporting osteobiologic use in revision anterior cervical discectomy and fusion (ACDF) surgery. METHODS: A systematic search of PubMed/MEDLINE, EMBASE, Cochrane library, and ClinicalTrials.gov databases was conducted for literature reporting the use of osteobiologics in revision ACDF. We searched for studies reporting outcomes of using any osteobiologic use in revision ACDF surgeries (independently of the number of levels) in the above databases. RESULTS: There are currently no studies in the literature describing the outcome and comparative efficacy of diverse osteobiologic agents in the context of revision ACDF surgery. A majority of the current evidence is based only upon studies involving primary ACDF surgery. CONCLUSION: The current study highlights the paucity of literature evidence on the role of diverse osteobiologics in revision ACDF, and foregrounds the need for high-quality evidence on this subject.

Encasement Of Popliteal Vascular Bundle Due Local Osteosarcoma Recurrence Treated With Wide Resection And Vascular Reconstruction.

Osteosarcoma is the most common primary bone malignancy. The prognosis of patients after local recurrence is generally poor and management of the locally recurrent disease is not well defined, especially in patients who have undergone limb-sparing surgery. A 20-year-old male presented a local recurrence of conventional osteosarcoma at the popliteal fossa with encasement of popliteal vascular bundle after previous tumor-wide resection and reconstruction with proximal tibia endoprosthesis. A wide resection "en bloc" of the lesion included part of the popliteal vessel. A bypass of both popliteal vessels, the vein with polytetrafluoroethylene (PTFE) prosthesis, and the artery with contralateral saphenous vein were performed to allow a limb salvage surgery. Local management of recurrent osteosarcoma in a previously reconstructed limb is highly individualized. This case confirms that preservation of lower limb function is possible using reconstruction techniques of bone and vessels in the sarcoma of the musculoskeletal system.

Total knee arthroplasty coronal alignment and tibial base stress-a new numerical evaluation.

Background: Total knee arthroplasty (TKA) is one of the most frequently performed orthopedic procedures. The correct positioning and alignment of the components significantly affects prosthesis survival. Considering the current controversy regarding the target of postoperative alignment of TKA, this study evaluated the tension at tibial component interface using two numerical methods. Methods: The stress of the prosthesis/bone interface of the proximal tibial component was evaluated using two numerical methods: the finite element method (FEM) and the new meshless method: natural neighbor radial point interpolation method (NNRPIM). The construction of the model was based on Zimmers NexGen LPS-Flex Mobile® prosthesis and simulated the forces by using a free-body diagram. Results: Tibiofemoral mechanical axis (TFMA) for which a higher number of nodes are under optimal mechanical tension is between 1° valgus 2° varus. For values outside the interval, there are regions under the tibial plate at risk of bone absorption. At the extremities of the tibial plate of the prosthesis, both medial and lateral, independent of the alignment, are under a low stress. In all nodes evaluated for all TFMA, the values of the effective stresses were higher in the NNRPIM when compared with the FEM. Conclusion: Through this study, we can corroborate that the optimal postoperative alignment is within the values that are currently considered of 0 ± 3° varus. It was verified that the meshless methods obtain smoother and more conservative results, which may make them safer when transposed to the clinical practice.

Simple and inexpensive synovial fluid biomarkers for the diagnosis of prosthetic joint infection according to the new EBJIS definition.

Introduction: diagnosis of periprosthetic joint infection (PJI) is challenging, as no single test has absolute accuracy. The purpose of this study was to assess the utility of different simple synovial biomarkers in the diagnosis of PJI as defined by the European Bone and Joint Infection Society (EBJIS). Methods: we retrospectively identified all patients undergoing revision hip or knee arthroplasty from 2013 to 2019 on our prospectively maintained database. Only patients with minimum required infection diagnostic workup were included in the study. Patients with comorbidities that may influence the accuracy of synovial biomarkers were excluded. Receiver operator characteristic (ROC) curves were utilised to assess the diagnostic utility of synovial fluid white blood cell (WBC) count, polymorphonuclear leukocyte percentage (PMN %), C-reactive protein (CRP), adenosine deaminase (ADA), and alpha-2-microglobulin (A2M). Results: in total, 102 patients met the inclusion criteria. Of these, 58 were classified as infection unlikely, 8 as infection likely, and 36 as infection confirmed. Synovial WBC count (area under the curve (AUC) 0.94) demonstrated the best utility for the diagnosis of PJI, followed by PMN % (AUC 0.91), synovial CRP (AUC 0.90), ADA (AUC 0.82), and A2M (AUC 0.76). We found added value in the combined interpretation of different biomarkers. We calculated high sensitivity and negative predictive value if at least two of them are negative and high specificity and positive predictive value if at least two are elevated. Conclusion: current results show that synovial fluid investigation is a useful tool for the diagnosis of PJI, and the combined interpretation of simple and inexpensive biomarkers demonstrated improved diagnostic accuracy.

Postoperative impact of rod bending in the lumbar spine fusion surgery with polyaxial screws - Validation of a study.

Introduction: In 2019, Moufid and Gille published a study in which they proposed certain radiological parameters that may justify the mismatch between the lordosis of the lumbar segment and the lordosis of the rod bar using polyaxial screws. The aim of this study is to reproduce the measurements performed by Moufid and Gille and try to validate their findings. Material and methods: A retrospective study was performed including patients submitted to L3-L5 posterior fusion with or without interbody devices using polyaxial screws and titanium rods, for degenerative disease. Radiological parameters were analysed:the distance between the posterior wall and the rod for each vertebra(the standard deviation of the three distances was called Alpha); the angle between the screw and the rod for each screw(mean of the three was called Theta); the angle between screws and superior endplate for each instrumented vertebra(mean of the three was called Lambda). The difference between post-operative segmental lordosis and the lordosis of the rod was called DiffL. Results: A total of 58 cases were included. The most frequent fusion surgery was posterolateral fusion(77.6%). The mean value of lumbar lordosis, fused segmental lordosis, pelvic incidence, Alpha, Theta, Lambda and DiffL were 48.7 ± 12.7°, 28.4 ± 9.2°, 60.7 ± 11.9°, 3.4 ± 1.6 mm, 90.5 ± 1.8°, 3.9 ± 1.8° e 9.9 ± 9.5° respectively. The mean value of rod lordosis was 20.5 ± 8.1°. DiffL varied between 0.1° (practically no mismatch) and 30.5° of mismatch. DiffL didn't correlate with gender, fusion type, age, PI and Alpha, Theta or Lambda. There was a significant positive correlation between lumbar lordosis and DiffL(ρ = 0.28; p = 0.03). No correlation was found between the radiological parameters for the cut-off point proposed by Moufid and Gille(Alpha 4.7 mm, Theta 86°, Lambda 2.8°) and the DiffL value. Conclusion: No significant factors were identified in this study to aid in achieving an ideal match between rod and segmental spine lordosis, therefore not validating the study by Moufid and Gille.

Shoulder Arthroplasty Options for Glenohumeral Osteoarthritis in Young and Active Patients (<60 Years Old): A Systematic Review.

Aim: This study aims to describe the shoulder arthroplasty options for young and active patients (<60 years old) with glenohumeral osteoarthritis. Methods: A systematic review of the literature was conducted by searching on Pubmed database. Studies that reported outcomes of patients with glenohumeral arthritis, younger than 60 years, that underwent shoulder arthroplasty [(Hemiarthroplasty (HA), Hemiarthroplasty with biological resurfacing (HABR), Total shoulder arthroplasty (TSA), Reversed total shoulder arthroplasty (RSA)] were included. Data include patient characteristics, surgical technique, range of motion, pain relief, outcome scores, functional improvement, complications, need for and time to revision. Results: A total of 1591 shoulders met the inclusion criteria. Shoulder arthroplasty provided improvements in terms of ROM on the 3 plains, forward flexion (FF), abduction (Abd) and external rotation (ER), in different proportions for each type of implant. Patients submitted to RSA had lower preoperative FF (p = 0.011), and the highest improvement (Δ) in Abd, but the worst in terms of ER (vsTSA, p = 0.05). HA had better ER postoperative values (vsRSA p = 0.049). Pain scores improved in all groups but no difference between them (p = 0.642). TSA and RSA groups had the best CS Δ (p = 0.012). HA group had higher complication rates (21.7%), RSA (19.4%, p = 0.034) and TSA (19.4%, p = 0.629) groups the lowest, and HABR had the highest rate of revisions (34.5%). Conclusions: HA had the highest rate of complications and HABR unacceptable rates of revision. These implants have been replaced by modern TSAs, with RSA reserved for complex cases. Surgeons should be aware of the common pitfalls of each option.

Surgical Treatment of Acetabular Posterior Wall Fracture with Hip Arthroscopy: A Case Report.

Posterior wall fractures are the most common type of acetabular fractures. Treatment can be conservative or surgical. Operative treatment is indicated for acetabular fractures that result in hip joint instability and/or incongruity, as well injuries with incarceration of fragments of bone or soft tissue within the hip joint. Surgical treatment can range from open reduction and osteosynthesis to hip arthroplasty. Arthroscopy has recently been used as the main surgical technique or as a reduction aid. In this case a 26-year-old male with a fracture of the posterior wall who underwent a posterior miniinvasive approach, followed by hip arthroscopy. This allowed joint wash, removal of the loose body, confirmation of reduction and absence of intra-articular hardware. Excellent clinical and radiological results were obtained. This case demonstrates the advantage of using hip arthroscopy in assessment of fracture reduction, the absence of intra-articular hardware or fragments, as well as a less invasive approach.

Comparison of short-stem versus conventional stem for hip arthroplasty in patients younger than 60 years: 7-14 years follow-up.

PURPOSE: Short-stem prostheses in hip arthroplasty have emerged as an alternative to conventional stems, especially in younger patients. The purpose of this study was to compare functional and radiological results of a short metaphyseal fitting cementless stem versus a conventional stem implant, in patients younger than 60 years. METHODS: All patients operated from January 2006 to April 2013 were included, obtaining a minimum follow-up of 7 years. Harris Hip Score (HHS) and SF-36 (quality of life) questionnaires were applied and the presence of "thigh pain" was specifically assessed. We also compared complication rate, revision rate and average prosthesis survival. Femoral stress shielding (Gruen scale), stem subsidence, varus-valgus tilt and implant stability (Engh scale) were also compared. RESULTS: A total of 101 short-stem and 74 conventional arthroplasties were included, with an average follow-up of 9.82 (7-14) years. HHS functional score and SF-36 were excellent in both implants and no significant difference between them (p > 0.05) was found. However, "thigh pain" was present in 7 patients with conventional stems and none with short-stems (p < 0.001). The survival rate at 13 years was 99%, for both implants, and no significant differences were found between them (χ2(2) = 0.178; p = 0.673). Conventional stems had stress shielding at the greater trochanter in 72% of the cases and 43% at the calcar, being statistically superior (p < 0.001) to the stress shielding observed in the short stems. CONCLUSION: According to our results, this short-stem seems to allow preservation of bone stock, with decreased stress shielding and also a lower incidence of thigh pain compared to conventional stems. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Asymmetric Bilateral Chronic Shoulder Dislocation in a Young Patient - A Rare Case Report.

Introduction: Chronic shoulder dislocations are infrequent and can be easily overlooked unless a carefully clinical history, physical examination, and radiographic evaluation are undertaken. Bilateral simultaneous instability is almost pathognomonic for a convulsive disorder. To the best of our knowledge, we describe the first case of asymmetric bilateral chronic dislocation. Case Report: A 34-year-old male patient with a history of epilepsy and schizophrenia and multiple seizure episodes, suffered a bilateral asymmetric shoulder dislocation. Radiological examination revealed a posterior shoulder dislocation of the right shoulder with a severe reverse Hill-Sachs lesion comprising more than 50% of the humeral head surface, while on the left shoulder, a chronic anterior shoulder dislocation with a Hill-Sachs lesion of moderate dimension. On the right shoulder, a hemiarthroplasty was performed, and on the left, a stabilization with Remplissage Technique, subscapularis plication, and temporary trans-articular Steinmann pin fixation was done. After bilateral rehabilitation, the patient showed residual pain in the left shoulder and slight range of motion limitation. There were no new episodes of shoulder instability. Conclusion: Our aim is to emphasize the importance of being alert to flag patients and make a prompt and accurate diagnosis of acute shoulder instability episodes, to avoid unnecessary morbidity, as well as of a high index of suspicion when a history of seizures is present. Despite the uncertain prognosis of a bilateral chronic shoulder dislocation functional results, the surgeon must take into consideration the patient's age, functional demand, and expectations to define the best treatment strategy.

Septic arthritis of the lumbar facet joint presenting as spontaneous bacterial peritonitis: a rare case requiring surgical intervention.

PURPOSE: To report and discuss a rare case of septic arthritis of a lumbar facet joint presenting as septic bacterial peritonitis and requiring surgical debridement. METHODS: A 55-year-old man, with a history of intravenous drug usage and hepatitis C, presented to the emergency department with fever, abdominal and lumbar pain. Examination showed ascites. Erythrocyte sedimentation rate and C-reactive protein were elevated. A paracentesis was performed, and a diagnosis of spontaneous bacterial peritonitis was assumed as acute on chronic liver failure. The patient was admitted for antibiotic treatment with cefotaxime. Staphylococcus aureus was isolated in blood cultures. Despite directed treatment, there were persistent fever, back pain and continuous elevation of serum inflammatory markers. An MRI of the lumbar spine was performed 14 days after presentation and identified septic arthritis of the left L4-L5 facet joint. In the absence of a response to the medical treatment, surgical debridement of the facet joint was performed. After surgery, back pain resolved and inflammatory markers started to decline. One year after surgery, the patient is asymptomatic and has normalization of the inflammatory markers of infection. Follow-up MRI shows complete resolution of the infection. CONCLUSIONS: Septic arthritis of the lumbar facet joints is a rare condition with no more than 50 cases reported in the literature. This infection, which can cause significant morbidity, can result from local or systemic inoculation. MRI is the diagnostic method of choice. While antibiotic therapy is the first line of treatment, when it fails, surgical debridement may be necessary.