Current Progress and Future Perspectives in Contact and Releasing-Type Antimicrobial Coatings of Orthopaedic Implants: A Systematic Review Analysis Emanated from In Vitro and In Vivo Models.

Background: Despite the expanding use of orthopedic devices and the application of strict pre- and postoperative protocols, the elimination of postoperative implant-related infections remains a challenge. Objectives: To identify and assess the in vitro and in vivo properties of antimicrobial-, silver- and iodine-based implants, as well as to present novel approaches to surface modifications of orthopedic implants. Methods: A systematic computer-based review on the development of these implants, on PubMed and Web of Science databases, was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Overall, 31 in vitro and 40 in vivo entries were evaluated. Regarding the in vitro studies, antimicrobial-based coatings were assessed in 12 entries, silver-based coatings in 10, iodine-based in 1, and novel-applied coating technologies in 8 entries. Regarding the in vivo studies, antimicrobial coatings were evaluated in 23 entries, silver-coated implants in 12, and iodine-coated in 1 entry, respectively. The application of novel coatings was studied in the rest of the cases (4). Antimicrobial efficacy was examined using different bacterial strains, and osseointegration ability and biocompatibility were examined in eukaryotic cells and different animal models, including rats, rabbits, and sheep. Conclusions: Assessment of both in vivo and in vitro studies revealed a wide antimicrobial spectrum of the coated implants, related to reduced bacterial growth, inhibition of biofilm formation, and unaffected or enhanced osseointegration, emphasizing the importance of the application of surface modification techniques as an alternative for the treatment of orthopedic implant infections in the clinical settings.

3D-printed glenoid implant reconstruction, after partial scapulectomy for malignant tumors: a case series.

PURPOSE: Glenoid tumors are extremely rare, and reconstruction remains very challenging. The aim of this study is to present the clinical and functional outcomes, of a new glenoid reconstruction method using 3-dimensional-printed implant. METHODS: Four patients with primary glenoid tumors underwent reconstruction using 3-dimensional-printed glenoid implant linked with reverse shoulder arthroplasty. We retrospectively reviewed the clinical and functional outcome, using MSTS and DASH score, as well as complications' rate. RESULTS: Wide excision was achieved in all patients. No local recurrence or distant metastasis was diagnosed at the follow-up period. The mean MSTS score was 80.5%, and DASH score was 15.2%. According to Hendersons' classification, there were no postoperative complications. CONCLUSION: The use of 3-dimensional-printed implants, can be a very reliable solution with satisfying clinical and functional outcomes for reconstruction, in patients with musculoskeletal malignancies of the glenoid. Level of evidence IV Treatment Study.

Bone mineral density, vitamin D and osseous metabolism indices in neurofibromatosis type 1: A systematic review and meta-analysis.

BACKGROUND: Neurofibromatosis type 1 (NF1) is a genetic autosomal neurocutaneous syndrome correlated with skeletal dysplasia and defects in the osseous microarchitecture. The physiological mechanism for the development of NF1-related bone abnormal turnover is still unclear. OBJECTIVES: A meta-analysis was performed to investigate the effects of NF1 on bone mineral density (BMD) and osseous metabolic indices in order to provide clinical evidence for the pathogenesis of the associated skeletal deformities. METHODS: A systematic literature review search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the PubMed/Medline and Web of Science databases from the date of inception of each database through to 10 September 2023. Specific inclusion and exclusion criteria were applied for the identification of studies examining the effects of NF1 on bone strength and metabolism. The Newcastle-Ottawa and Jadad scales were applied to assess the quality of the included studies. RevMan 5.3 software was used for the analysis of the data, and MedCalc was applied to examine publication bias. RESULTS: Overall, 13 studies met the inclusion criteria comprised of 5 cross-sectional, 6 case-control and 2 retrospective studies. 703 patients and 973 healthy subjects formed the NF1 and control group, respectively. The results of the meta-analysis displayed that lumbar (SMD = -3.85, 95%CI = -7.53 to -0.18, Z = 2.05, p = 0.04) and femoral (SMD = -4.78, 95%CI = -8.86 to -0.69, Z = 2.29, p = 0.02) BMD was reduced in the NF1 group. Both in children and adults the serum levels of 25 hydroxyvitamin D3 were also decreased in NF1 group, but without any statistical significance (SMD = -0.62, 95%CI = -1.34 to -0.11, Z = 1.66, p = 0.10). Serum Parathyroid hormone (PTH) (SMD = 0.73, 95%CI = 0.31 to 1.15, Z = 3.43, p = 0.0006) and C-telopeptide of type 1 collagen (CTX) (SMD = 0.82, 95%CI = 0.33 to 1.30, Z = 3.29, p = 0.001) were elevated in NF1 patients, while serum calcium (SMD = -0.10, 95%CI = -0.74 to 0.53, Z = 0.32, p = 0.75) phosphorous (SMD = 0.33, 95%CI = -0.38 to 1.05, Z = 0.92, p = 0.36), alkaline phosphatase (ALP) (SMD = -0.36, 95%CI = -0.77 to 0.05, Z = 1.71, p = 0.09), osteocalcin (SMD = 1.81, 95%CI = -0.37 to -3.98, Z = 1.63, p = 0.10) and bone formation markers (SMD = 0.28, 95%CI = -0.37 to -0.94, Z = 0.85, p = 0.39) were not. CONCLUSION: NF1 is associated with decreased BMD at the lumbar spine and femur. Taking into account that the serum levels of PTH, CTX were increased whereas the concentrations of vitamin D, calcium, phosphorous, ALP, osteocalcin and bone formation markers were not altered significantly in the NF1 patients compared with the healthy subjects, a vitamin D independent dysregulated bone cellular activity could be considered. STUDY REGISTRATION: Registered on PROSPERO (CRD42023424751).

Erector Spinae Plane Block Reduces Immediate Postoperative Pain and Opioid Demand After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Matched cohort comparison. OBJECTIVE: To determine perioperative outcomes of erector spinae plane (ESP) block for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). SUMMARY OF BACKGROUND DATA: There is a paucity of data on the impact of lumbar ESP block on perioperative outcomes and its safety in MI-TLIF. MATERIALS AND METHODS: Patients who underwent 1-level MI-TLIF and received the ESP block (group E ) were included. An age and sex-matched control group was selected from a historical cohort that received the standard-of-care (group NE). The primary outcome of this study was 24-hour opioid consumption in morphine milligram equivalents. Secondary outcomes were pain severity measured by a numeric rating scale, opioid-related side effects, and hospital length of stay. Outcomes were compared between the two groups. RESULTS: Ninety-eight and 55 patients were included in the E and NE groups, respectively. There were no significant differences between the two cohorts in patient demographics. Group E had lower 24-hour postoperative opioid consumption ( P = 0.117, not significant), reduced opioid consumption on a postoperative day (POD) 0 ( P = 0.016), and lower first pain scores postsurgery ( P < 0.001). Group E had lower intraoperative opioid requirements ( P < 0.001), and significantly lower average numeric rating scale pain scores on POD 0 ( P = 0.034). Group E reported fewer opioid-related side effects as compared with group NE, although this was not statistically significant. The average highest postoperative pain score within 3 hours postprocedurally was 6.9 and 7.7 in the E and NE cohorts, respectively ( P = 0.029). The median length of stay was comparable between groups with the majority of patients in both groups being discharged on POD 1. CONCLUSIONS: In our retrospective matched cohort, ESP blocks resulted in reduced opioid consumption and decreased pain scores on POD 0 in patients undergoing MI-TLIF. LEVEL OF EVIDENCE: Level 3.

Floor-Mounted Robotic Pedicle Screw Placement in Lumbar Spine Surgery: An Analysis of 1,050 Screws.

OBJECTIVE: To analyze the usage of floor-mounted robot in minimally invasive lumbar fusion. METHODS: Patients who underwent minimally invasive lumbar fusion for degenerative pathology using floor-mounted robot (ExcelsiusGPS) were included. Pedicle screw accuracy, proximal level violation rate, pedicle screw size, screw-related complications, and robot abandonment rate were analyzed. RESULTS: Two hundred twenty-nine patients were included. Most surgeries were primary single-level fusion. Sixty-five percent of surgeries had intraoperative computed tomography (CT) workflow, 35% had preoperative CT workflow. Sixty-six percent were transforaminal lumbar interbody fusion, 16% were lateral, 8% were anterior, and 10% were a combined approach. A total of 1,050 screws were placed with robotic assistance (85% in prone position, 15% in lateral position). Postoperative CT scan was available for 80 patients (419 screws). Overall pedicle screw accuracy rate was 96.4% (prone, 96.7%; lateral, 94.2%; primary, 96.7%; revision, 95.3%). Overall poor screw placement rate was 2.8% (prone, 2.7%; lateral, 3.8%; primary, 2.7%; revision, 3.5%). Overall proximal facet and endplate violation rates were 0.4% and 0.9%. Average diameter and length of pedicle screws were 7.1 mm and 47.7 mm. Screw revision had to be done for 1 screw (0.1%). Use of the robot had to be aborted in 2 cases (0.8%). CONCLUSION: Usage of floor-mounted robotics for the placement of lumbar pedicle screws leads to excellent accuracy, large screw size, and negligible screw-related complications. It does so for screw placement in prone/lateral position and primary/revision surgery alike with negligible robot abandonment rates.

NDI <21 Denotes Patient Acceptable Symptom State After Degenerative Cervical Spine Surgery.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the Neck Disability Index (NDI) cut-off for achieving patient acceptable symptom state (PASS) at six months following degenerative cervical spine surgery. SUMMARY OF BACKGROUND DATA: An absolute score denoting PASS might be a better marker to assess clinical outcomes than a change score denoting minimal clinically important difference. MATERIALS AND METHODS: Patients who underwent primary anterior cervical decompression and fusion, cervical disk replacement, or laminectomy were included. The outcome measure was NDI. The anchor used to assess PASS achievement at six months was the response on the Global Rating Change: "Compared with preoperative, you feel (1) much better, (2) slightly better, (3) same, (4) slightly worse, or (5) much worse." It was converted to a dichotomous outcome variable (acceptable=response of 1 or 2, unacceptable=response of 3, 4, or 5) for analyses. The overall cohort and subgroups based on age (65 yr and below, above 65 yr), sex, myelopathy, and preoperative NDI (≤40, >40) were analyzed for the proportion of patients achieving PASS and the NDI cut-off using receiver operator curve. RESULTS: Seventy-five patients (42 anterior cervical decompression and fusion, 23 cervical disc replacement, 10 laminectomy) were included. 79% of patients achieved PASS. Males, patients with age 65 years and below, preoperative NDI ≤40, and absence of myelopathy were more likely to achieve PASS. The receiver operator curve analysis revealed an Oswestry Disability Index cut-off of 21 to achieve PASS (area under the curve, AUC: 0.829, sensitivity: 81%, specificity: 80%). The subgroup analyses based on age, sex, myelopathy, and preoperative NDI revealed AUCs >0.7 and NDI threshold values consistent between 17 and 23. CONCLUSIONS: With an AUC of 0.829, NDI showed an excellent discriminative ability. Patients with NDI ≤21 are expected to achieve PASS following degenerative cervical spine surgery.

Knee Arthrodesis with a Modular Silver-Coated Endoprosthesis for Infected Total Knee Arthroplasty with Extensive Bone Loss: A Retrospective Case-Series Study.

INTRODUCTION: Knee arthrodesis is a limb salvage intervention for persistent periprosthetic joint infection (PJI) when revision total knee arthroplasty fails. Conventional arthrodesis techniques are associated with the increased rate of complications, especially in patients with extensive bone loss and extensor tendon deficiency. METHODS: Eight patients with a modular silver-coated arthrodesis implant after failed exchange arthroplasty for infection, were retrospectively reviewed. All patients had significant bone loss, while 5 displayed extensor tendon deficiency. Survivorship, complications, leg length discrepancy, median Visual Analogue Scale (VAS) and Oxford Knee score (OKS) were evaluated. RESULTS: The median follow up was 32 months (range 24-59 months). The survivorship rate of the prosthesis was 86% during the minimum time of follow up of 24 months. In one patient recurrence of the infection was observed and above-knee amputation was performed. The median postoperative leg length discrepancy was 2.07 ± 0.67 cm. Patients were able to ambulate with mild or no pain. The median VAS and OKS was 2.14 ± 0.9 and 34.7 ± 9.3, respectively. CONCLUSIONS: The results of our study demonstrated that knee arthrodesis with a silver coated arthrodesis implant, performed for persistent PJI in patients with significant bone loss and extensor tendon deficit, provided a stable construct, allowed eradication of infection and was associated with good functional outcome.

Step-by-step guide to robotic-guided minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

Robotics in spinal surgery offers a promising potential to refine and improve the minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) technique. Suitable surgeons for this technique include those who are already familiar with robotic-guided lumbar pedicle screw placement and want to advance their skillset by incorporating posterior-based interbody fusion. We provide a step-by-step guide for robotic-guided MI-TLIF. The procedure is divided into 7 practical and detailed techniques. The steps in sequential order include: (I) planning trajectories for pedicle screws and the tubular retractor; (II) robotic-guided pedicle screw placement; (III) placement of tubular retractor; (IV) unilateral facetectomy using the surgical microscope; (V) discectomy & disc preparation; (VI) interbody implant insertion; and (VII) percutaneous rod placement. We standardize surgeon training in robotic MI-TLIF by teaching our spine surgery fellows these 7 key technical steps highlighted in this guide. Current-generation robotics offers integrated navigation capability, K-wireless placement of pedicle screws through a rigid robotic arm, compatibility with tubular retractor systems to perform facetectomy, and allows for placement of interbody devices. We have found robotic-guided MI-TLIF to be a safe procedure that allows for accurate and reliable pedicle screw placement, less collateral damage to the soft tissues of the low back, and decreased radiation exposure.

Neuromuscular activity of the lower-extremities during running, landing and changing-of-direction movements in individuals with anterior cruciate ligament reconstruction: a review of electromyographic studies.

PURPOSE: Running, jumping/landing and cutting/change of direction (CoD) are critical components of return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR), however the electromyographic (EMG) activity patterns of the operated leg during the execution of these tasks are not clear. METHODS: A systematic review was conducted to retrieve EMG studies during running, jumping/landing and cutting/(CoD) in ACLR patients. MEDLINE, PubMed, SPORTDiscus and Web of Science databases were searched from 2000 to May, 2022 using a combination of keywords and their variations: "anterior cruciate ligament reconstruction" OR "ACLR", "electromyography" OR "EMG", "running", "jumping" OR "landing", "cutting" OR "change-of-direction" OR "CoD". The search identified studies comparing EMG data during running, landing and cutting/(CoD) between the involved limb and contralateral or control limbs. Risk of bias was assessed and quantitative analyses using effect sizes were performed. RESULTS: Thirty two studies met the inclusion criteria. Seventy five percent (24/32) of the studies reported altered EMG activity pattern of the ACLR leg during running, jumping/landing and cutting/(CoD) when compared with either the healthy control leg or the contra-lateral leg. Twelve studies showed decreased, delayed or earlier onset and delayed peak in quadriceps EMG activity with small to large effect sizes and 9 studies showed increased, delayed or earlier onset and delayed peak in hamstrings EMG activity with small to large effect sizes. Four studies showed a "hamstrings-dominant" strategy i.e. decreased quadriceps coupled with increased hamstrings EMG activity in both running and jumping/landing irrespective of graft type. One study reported that on the grounds of decreased quadriceps activity, lower hamstrings EMG activity was predictive of ipsilateral re-injury in ACLR patients. CONCLUSION: This systematic review of Level III evidence showed that the ACLR leg displays decreased quadriceps or increased hamstrings EMG activity or both despite RTS. Simultaneous decreased quadriceps and increased hamstrings EMG activity was shown for both running and jumping/landing. From a clinical perspective this "hamstrings dominant" strategy can serve as a protective mechanism against graft re-injury. LEVEL OF EVIDENCE: III.

Subchondral Bone Cyst Development in Osteoarthritis: From Pathophysiology to Bone Microarchitecture Changes and Clinical Implementations.

Osteoarthritis is a degenerative joint disease affecting middle-aged and elderly patients. It mainly involves weight-bearing joints such as the hip, knee and spine as well as the basilar joint of the thumb, causing dysfunction and painful symptoms. Often, joint arthritis is accompanied by cartilage defects, joint space narrowing, osteophytes, bone sclerosis and subchondral bone cysts (SBC). The aim of the present study was to explore the pathophysiology responsible for the development of SBCs as well as the association between SBCs and disease progress, the level of clinical symptoms and their impact on postoperative outcomes and risk of possible complications following joint replacements if left untreated. A literature review on PubMed articles was conducted to retrieve and evaluate all available evidence related to the main objective mentioned above. A few theories have been put forth to explain the formation process of SBCs. These involve MMPs secretion, angiogenesis, and enhanced bone turnover as a biological response to abnormal mechanical loads causing repeated injuries on cartilage and subchondral tissue during the development of arthritis. However, the application of novel therapeutics, celecoxib-coated microspheres, local administration of IGF-1 and activated chondrocytes following surgical debridement of SBCs hinders the expansion of SBCs and prevents the progression of osteoarthritis.

Female Sex and Supine Proximal Lumbar Lordosis Are Associated With the Size of the LLIF "Safe Zone" at L4-L5.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: Identify demographic and sagittal alignment parameters that are independently associated with femoral nerve position at the L4-L5 disk space. SUMMARY OF BACKGROUND DATA: Iatrogenic femoral nerve or lumbar plexus injury during lateral lumbar interbody fusion (LLIF) can result in neurological complications. The LLIF "safe zone" is the anterior half to two third of the disk space. However, femoral nerve position varies and is inconsistently identifiable on magnetic resonance imaging. The safe zone is also narrowest at L4-L5. METHODS: An analysis of patients with symptomatic lumbar spine pathology and magnetic resonance imaging with a visibly identifiable femoral nerve evaluated at a single large academic spine center from January 1, 2017, to January 8, 2020, was performed. Exclusion criteria were transitional anatomy, severe hip osteoarthritis, coronal deformity with cobb >10 degrees, > grade 1 spondylolisthesis at L4-L5 and anterior migration of the psoas.Standing and supine lumbar lordosis (LL) and its proximal (L1-L4) and distal (L4-S1) components were measured. Femoral nerve position on sagittal imaging was then measured as a percentage of the L4 inferior endplate. A stepwise multivariate linear regression of sagittal alignment and LL parameters was then performed. Data are written as estimate, 95% CI. RESULTS: Mean patient age was 58.2±14.7 years, 25 (34.2%) were female and 26 (35.6%) had a grade 1 spondylolisthesis. Mean femoral nerve position was 26.6±10.3% from the posterior border of L4. Female sex (-6.6, -11.1 to -2.1) and supine proximal lumbar lordosis (0.4, 0.1-0.7) were independently associated with femoral nerve position. CONCLUSIONS: Patient sex and proximal LL can serve as early indicators of the size of the femoral nerve safe zone during a transpsoas LLIF approach at L4-L5.

Improvement following minimally invasive transforaminal lumbar interbody fusion in patients aged 70 years or older compared with younger age groups.

OBJECTIVE: The goal of this study was to assess the outcomes of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) in patients ≥ 70 years old and compare them to younger age groups. METHODS: This was a retrospective study of data that were collected prospectively. Patients who underwent primary single-level MI-TLIF were included and divided into 3 groups: age < 60, 60-69, and ≥ 70 years. The outcome measures were as follows: 1) patient-reported outcome measures (PROMs) (i.e., visual analog scale [VAS] for back and leg pain, Oswestry Disability Index [ODI], 12-Item Short-Form Health Survey Physical Component Summary [SF-12 PCS]); 2) minimum clinically important difference (MCID) achievement; 3) return to activities; 4) opioid discontinuation; 5) fusion rates; and 6) complications/reoperations. RESULTS: A total of 147 patients (age < 60 years, 62; 60-69 years, 47; ≥ 70 years, 38) were included. All the groups showed significant improvements in all PROMs at the early (< 6 months) and late (≥ 6 months) time points and there was no significant difference between the groups. Although MCID achievement rates for VAS leg and ODI were similar, they were lower in the ≥ 70-year-old patient group for VAS back and SF-12 PCS. Although the time to MCID achievement for ODI and SF-12 PCS was similar, it was greater in the ≥ 70-year-old patient group for VAS back and leg. There was no significant difference between the groups in terms of return to activities, opioid discontinuation, fusion rates, and complication/reoperation rates. CONCLUSIONS: Although patients > 70 years of age may be less likely and/or take longer to achieve MCID compared to their younger counterparts, they show an overall significant improvement in PROMs, a similar likelihood of returning to activities and discontinuing opioids, and comparable fusion and complication/reoperation rates following MI-TLIF.

Practical answers to frequently asked questions in minimally invasive lumbar spine surgery.

BACKGROUND CONTEXT: Surgical counseling enables shared decision-making (SDM) by improving patients' understanding. PURPOSE: To provide answers to frequently asked questions (FAQs) in minimally invasive lumbar spine surgery. STUDY DESIGN: Retrospective review of prospectively collected data. PATIENT SAMPLE: Patients who underwent primary tubular minimally invasive lumbar spine surgery in form of transforaminal lumbar interbody fusion (MI-TLIF), decompression alone, or microdiscectomy and had a minimum of 1-year follow-up. OUTCOME MEASURES: (1) Surgical (radiation exposure and intraoperative complications) (2)Immediate postoperative (length of stay [LOS] and complications) (3) Clinical outcomes (Visual Analog Scale- back and leg, VAS; Oswestry Disability Index, ODI; 12-Item Short Form Survey Physical Component Score, SF-12 PCS; Patient-Reported Outcomes Measurement Information System Physical Function, PROMIS PF; Global Rating Change, GRC; return to activities; complications/reoperations) METHODS: The outcome measures were analyzed to provide answers to ten FAQs that were compiled based on the authors' experience and a review of literature. Changes in VAS back, VAS leg, ODI, and SF-12 PCS from preoperative values to the early (<6 months) and late (>6 months) postoperative time points were analyzed with Wilcoxon Signed Rank Tests. % of patients achieving minimal clinically important difference (MCID) for these patient-reported outcome measures (PROMs) at the two time points was evaluated. Changes in PROs from preoperative values too early (<6 months) and late (≥6 months) postoperative time points were analyzed within each of the three groups. Percentage of patients achieving MCID was also evaluated. RESULTS: Three hundred sixty-six patients (104 TLIF, 147 decompression, 115 microdiscectomy) were included. The following FAQs were answered: (1) Will my back pain improve? Most patients report improvement by >50%. About 60% of TLIF, decompression, and microdiscectomy patients achieved MCID at ≥6 months. (2) Will my leg pain improve? Most patients report improvement by >50%. 56% of TLIF, 67% of decompression, and 70% of microdiscectomy patients achieved MCID at ≥6 months. (3) Will my activity level improve? Most patients report significant improvement. Sixty-six percent of TLIF, 55% of decompression, and 75% of microdiscectomy patients achieved MCID for SF-12 PCS. (4) Is there a chance I will get worse? Six percent after TLIF, 14% after decompression, and 5% after microdiscectomy. (5) Will I receive a significant amount of radiation? The radiation exposure is likely to be acceptable and nearly insignificant in terms of radiation-related risks. (6) What is the likelihood that I will have a complication? 17.3% (15.4% minor, 1.9% major) for TLIF, 10% (9.3% minor and 0.7% major) for decompression, and 1.7% (all minor) for microdiscectomy (7) Will I need another surgery? Six percent after TLIF, 16.3% after decompression, 13% after microdiscectomy. (8) How long will I stay in the hospital? Most patients get discharged on postoperative day one after TLIF and on the same day after decompression and microdiscectomy. (9) When will I be able to return to work? >80% of patients return to work (average: 25 days after TLIF, 14 days after decompression, 11 days after microdiscectomy). (10) Will I be able to drive again? >90% of patients return to driving (average: 22 days after TLIF, 11 days after decompression, 14 days after microdiscectomy). CONCLUSIONS: These concise answers to the FAQs in minimally invasive lumbar spine surgery can be used by physicians as a reference to enable patient education.

ODI <25 Denotes Patient Acceptable Symptom State After Minimally Invasive Lumbar Spine Surgery.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the Oswestry Disability Index (ODI) cutoff for achieving Patient Acceptable Symptom State (PASS) at one year following minimally invasive lumbar spine surgery. SUMMARY OF BACKGROUND DATA: An absolute score denoting PASS, rather than a change score denoting minimal clinically important difference (MCID), might be a better metric to assess clinical outcomes. MATERIALS AND METHODS: Patients who underwent primary minimally invasive transforaminal lumbar interbody fusion or decompression were included. The outcome measure was ODI. The anchor question was the Global Rating Change: "Compared with preoperative, you feel (1) much better, (2) slightly better, (3) same, (4) slightly worse, or (5) much worse." For analysis, it was collapsed to a dichotomous outcome variable (acceptable=response of 1 or 2, unacceptable=response of 3, 4, or 5). Proportion of patients achieving PASS and the ODI cutoff using receiver operating characteristic curve analyses were assessed for the overall cohort as well as subgroups based on age, sex, type of surgery, and preoperative ODI. Differences between the PASS and MCID metrics were analyzed. RESULTS: A total of 137 patients were included. In all, 87% of patients achieved PASS. Patients less than or equal to 65 years and those undergoing fusion were more likely to achieve PASS. The receiver operating characteristic curve analysis revealed an ODI cutoff of 25.2 to achieve PASS (area under the curve: 0.872, sensitivity: 82%, specificity: 83%). The subgroup analyses based on age, sex, and preoperative ODI revealed area under the curve >0.8 and ODI threshold values consistent between 25.2 and 25.5 (except 28.4 in patients with preoperative ODI >40). PASS was found to have significantly higher sensitivity compared with MCID (82% vs. 69%, P =0.01). CONCLUSIONS: Patients with ODI <25 are expected to achieve PASS, irrespective of age, sex, and preoperative disability. PASS was found to have significantly higher sensitivity than MCID. LEVEL OF EVIDENCE: 3.

Hypophosphatemic osteomalacia in neurofibromatosis 1 associated with intracranial gliomas and congenital renal agenesis: A rare case report and review of the literature.

Introduction: Neurofibromatosis Type 1 (Nf1), also termed von Recklinghausen disease, is a rare autosomal dominant genetic disorder accompanied by several osseous and skeletal manifestations. In NF, hypophosphatemia linked to secondary hyperparathyroidism due to Vitamin D deficiency and low calcium intake has been reported as a risk factor for low bone mass density (BMD), but reports of NF1 associated oncogenic hypophosphatemic osteomalacia (HO) are extremely rare. Case Report: We report a patient with NF1 associated with intracranial low-grade gliomas and congenital renal agenesis suffering from HO. Bone defects and deformities such as generalized bone pains located in feet, ankles and lower limbs, thoracic scoliosis, mild bowing of long bones of lower limbs, stress fractures, and old fractures as well as with altered bone metabolic serum markers were present. After 8 weeks of follow-up, it was observed that the combination of oral administration of phosphate and Vitamin D improved her medical symptoms without significant changes in phosphate levels or BMD. Conclusion: Although renal agenesis is not correlated with hypophosphatemia, the coexistence of NF1, renal congenital deformities, and low-grade gliomas may contribute to disease severity. Conventional treatment with high doses of oral calcitriol associated with phosphate is efficient to improve the clinical and laboratory symptoms of the disease.

Epithelioid Hemangioma of Bone: A Rare Vascular Neoplasm. A Case Report and Literature Review.

Epithelioid hemangioma (EH) of bone is a rare benign, albeit locally aggressive vascular neoplasm. It is usually solitary and involves the metaphysis or diaphysis of long tubular bones, especially in the lower extremities. Rarely it may present as multifocal lesions. The differential diagnosis includes malignant vascular bone tumors such as epithelioid hemangioendothelioma and epithelioid angiosarcoma. Clinical presentation and radiographic and histological findings are not specific and diagnosis is based mostly on immunohistochemical and molecular studies. There is no consensus regarding the optimal treatment. Curettage and bone grafting or en bloc resection are the current treatment options, however local recurrence have been reported. We present a case of multifocal EH of the distal tibia, distal fibula and hindfoot in a 38 year-old male managed with curettage, radiofrequency ablation and cement osteoplasty. The imaging features, histological findings and treatment options of this rare vascular tumor are discussed.

Robotics Reduces Radiation Exposure in Minimally Invasive Lumbar Fusion Compared With Navigation.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To compare robotics and navigation for minimally invasive elective lumbar fusion in terms of radiation exposure and time demand. SUMMARY OF BACKGROUND DATA: Although various studies have been conducted to demonstrate the benefits of both navigation and robotics over fluoroscopy in terms of radiation exposure, literature is lacking in studies comparing robotics versus navigation. MATERIALS AND METHODS: Patients who underwent elective one-level or two-level minimally invasive transforaminal lumbar interbody fusion (TLIF) by a single surgeon using navigation (Stryker SpineMask) or robotics (ExcelsiusGPS) were included (navigation 2017-2019, robotics 2019-2021, resulting in prospective cohorts of consecutive patients for each modality). All surgeries had the intraoperative computed tomography workflow. The two cohorts were compared for radiation exposure [fluoroscopy time and radiation dose: image capture, surgical procedure, and overall) and time demand (time for setup and image capture, operative time, and total operating room (OR) time]. RESULTS: A total of 244 patients (robotics 111, navigation 133) were included. The two cohorts were similar in terms of baseline demographics, primary/revision surgeries, and fusion levels. For one-level TLIF, total fluoroscopy time, total radiation dose, and % of radiation for surgical procedure were significantly less with robotics compared with navigation (20 vs. 25 s, P <0.001; 38 vs. 42 mGy, P =0.05; 58% vs. 65%, P =0.021). Although time for setup and image capture was significantly less with robotics (22 vs. 25 min, P <0.001) and operative time was significantly greater with robotics (103 vs. 93 min, P <0.001), there was no significant difference in the total OR time (145 vs. 141 min, P =0.25). Similar findings were seen for two-level TLIF as well. CONCLUSION: Robotics for minimally invasive TLIF, compared with navigation, leads to a significant reduction in radiation exposure both to the surgeon and patient, with no significant difference in the total OR time.

Factors Causing Delay in Discharge in Patients Eligible for Ambulatory Lumbar Fusion Surgery.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF). SUMMARY OF BACKGROUND DATA: Assessing postoperative inefficiencies is vital to increase the feasibility of ALF. MATERIALS AND METHODS: Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge. RESULTS: Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS. CONCLUSIONS: Unavailability of PT, surgery after 1  pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge. LEVEL OF EVIDENCE: 4.

Three-dimensional Printed Endoprosthesis for Reconstruction of the Distal Tibia and Ankle Joint After Tumor Resection.

Below-knee amputation is the treatment of choice for distal tibia malignancies, considering the specific anatomic features of the distal leg and ankle. However, advances in imaging modalities and adjuvant therapies and improved surgical techniques have made limb salvage surgery increasingly possible. The distal tibia is an uncommon location for malignant bone tumors, and there is limited information about limb salvage and reconstruction. Currently, 3-dimensional printed implants may successfully address reconstruction challenges after tumor resection. We present a patient with high-grade osteosarcoma of the distal tibia who underwent limb salvage and distal tibia and ankle joint replacement with a 3-dimensional printed endoprosthesis. [Orthopedics. 2022;45(6):e348-e352.].

Recovery Kinetics After Commonly Performed Minimally Invasive Spine Surgery Procedures.

STUDY DESIGN: Single-center, multisurgeon, retrospective review. OBJECTIVE: To evaluate the timing of return to commonly performed activities following minimally invasive spine surgery. Identify preoperative factors associated with these outcomes. SUMMARY OF BACKGROUND DATA: Studies have reported return to activities with open techniques, but the precise timing of when patients return to these activities after minimally invasive surgery remains uncertain. MATERIALS AND METHODS: Patients who underwent either minimally invasive lumbar laminectomy (MI-L) or minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) were included. Patient-reported outcome measures, return to drive, return to work, and discontinuation of opioids data were reviewed. Regression was conducted to identify factors associated with return to driving by 15 days, return to work by 30 days, and for discontinuing opioids by 15 days. A composite group analysis was also performed for patients who returned to all three activities by 30 days. RESULTS: In total, 123 MI-L patients and 107 MI-TLIF patients were included. Overall, 88.8% of MI-L patients and 96.4% of MI-TLIF patients returned to driving in 11 and 18.5 days, respectively. In all, 91.9% of MI-L patients and 85.7% of MI-TLIF patients returned to work in 14 and 25 days. In all, 88.7% of MI-L patients and 92.6% of MI-TLIF patients discontinued opioids in a median of seven and 11 days. Overall, 96.2% of MI-L patients and 100% of MI-TLIF patients returned to all three activities, with a median of 27 and 31 days, respectively. Male sex [odds ratio (OR)=3.57] and preoperative 12-Item Short Form Physical Component Score (OR=1.08) are associated with return to driving by 15 days. Male sex (OR=3.23) and preoperative 12-Item Short Form Physical Component Score (OR=1.07) are associated with return to work by 30 days. Preoperative Visual Analog Scale back was associated with decreased odds of discontinuing opioids by 15 days (OR=0.84). CONCLUSION: Most patients return to activity following MI-L and MI-TLIF. These findings serve as an important compass for preoperative counseling.