Meta-Analysis on Efficacy and Complications of Bone Morphogenetic Protein-2 for Posterior Fusion of Cervical Spine.

OBJECTIVE: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is effective for promoting robust fusion for long-level cervical deformity and revision surgeries. However, only a few studies have reported its efficacy and complications in posterior cervical fusion (PCF). METHODS: Therefore we evaluated the efficacy and complications of rhBMP-2 application in PCF surgery by searching 3 electronic databases (PubMed, Cochrane Database, and EMBASE) for studies that evaluated the use of rhBMP-2 in PCF. Five studies (1 prospective and 4 retrospective) were included in the meta-analysis. RESULTS: The quality of each study was assessed, and data on pseudarthrosis, wound infection, neurologic, and immediate medical complications were extracted and analyzed. We found that the use of rhBMP-2 in PCF showed significant benefits in terms of pseudarthrosis and no significant increases in the risk for neurologic and immediate medical complications regardless of the dose. However, high-dose (>2.1 mg/level) rhBMP-2 was a risk factor for wound infection after PCF. CONCLUSIONS: Our meta-analysis of the currently available literature suggests that patients with PCF may benefit from BMP-2 usage without increasing the risk of complications. However, dose control and containment are important to ensure a low risk of complications.

[Scaphoid fractures : Current diagnostic and treatment concepts]. / Skaphoidfrakturen : Aktuelle diagnostische und therapeutische Konzepte.

Scaphoid fractures are by far the most frequent fractures of the carpal bones of the hand and often lead to problematic healing processes if the diagnostics and treatment are inadequate. The main complication of a scaphoid fracture is pseudarthrosis, which leads to carpal collapse and degenerative arthritis of the wrist if left untreated. Early diagnosis and individualized differentiated treatment aim to achieve bony healing with restoration of the scaphoid shape and preservation of the function of the wrist. The anatomical and biomechanical characteristics of the scaphoid can impede bony healing after a fracture and, in contrast to the diagnostics and treatment, cannot be influenced. A history of trauma and typical clinical signs of a scaphoid fracture should lead to systematic imaging diagnostics with obligatory computed tomography. Only by determining the exact fracture morphology can an appropriate treatment concept be established. Conservative treatment should be restricted to stable fractures without relevant displacement. Fractures of the proximal scaphoid pole are considered unstable even if they are not displaced. Operative treatment is indicated for all unstable fractures. The favored surgical procedure is osteosynthesis with a cannulated double-threaded screw, which can be used in a retrograde or antegrade manner and in a minimally invasive or open technique, depending on the fracture type. Surgical treatment results in earlier bony healing and quicker restoration of function but can be associated with a higher complication rate. Posttraumatic osteoarthritis after healing in malalignment is usually asymptomatic.

360-degree Arthroscopic Management of Scaphoid Pseudarthrosis: Description of Technique and Indications.

Nonunion remains one of the main complications of scaphoid fractures, with no consensus being reached as to the best surgical technique for scaphoid pseudoarthrosis. Thus, different types of procedures for bone stability and biological stimulus for consolidation have been described. The use of arthroscopy for scaphoid pseudoarthrosis has advantages as it allows for treating associated injuries, preserving wrist proprioception by minimizing damage to the joint capsule and ligaments and not deteriorating the already fragile scaphoid vasculature, leading to a quick recovery. Arthroscopy was initially indicated for stable scaphoid pseudoarthroses, being used in all patterns of this condition, including unstable ones and those with flexion collapse. However, most scientific articles describe the use of arthroscopy only through the dorsal portals, creating technical difficulty in complete debridement of the site of pseudarthrosis and in placing bone graft. This study describes the 360-degree technique, which standardizes arthroscopy in scaphoid pseudoarthrosis treatment, allowing, with the use of dorsal, volar, and radial portals, direct approach to the entire circumference of the nonunion site, facilitating the debridement of the injury site, the correction of the scaphoid deformity, and the placement of a graft directly on the site of the defect, mainly in its volar region after correction of the flexion deformity. The 360-degree technique aims to help and standardize the arthroscopic procedure for scaphoid pseudarthrosis, creating a routine with defined surgery stages. Additional portals allow complete access to the entire nonunion site and better positioning of the bone graft under direct view.

Thoracic Outlet Syndrome Secondary to Vascular Insufficiency from Congenital Pseudarthrosis of the Clavicle: A Case Report.

CASE: An 18-year-old woman with a history of congenital pseudarthrosis of the clavicle (CPC) presented with episodes of right upper extremity ischemia. Vascular studies demonstrated an extensive thrombus with complete occlusion of the brachial artery. She underwent urgent thrombectomy. Subsequently, she underwent first rib resection and scalenectomy as well as pseudarthrosis takedown and fixation. Postoperatively, she returned to Division I collegiate soccer with complete symptomatic resolution. CONCLUSION: We report a case of arterial thoracic outlet syndrome secondary to CPC.

Put Down the Tin: Chewing Tobacco Use Is Associated With Worse Outcomes After Primary Lumbar Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVE: This study evaluated the impact of chewing tobacco on both medical and spine-related complication rates after spinal lumbar fusions in comparison to both a control cohort and a smoking cohort. SUMMARY OF BACKGROUND DATA: Smoking is a prevalent modifiable risk factor that has been demonstrated to be associated with increased complications after lumbar fusion. Although smoking rates have decreased in the United States, chewing tobacco use has not similarly reduced. Despite chewing tobacco delivering up to 4 times the dose of smoking, the impact of chewing tobacco is incompletely understood. METHODS: A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent lumbar spine fusion and used chewing tobacco were matched with a control cohort and a smoking cohort. Medical complications within 90 days after primary lumbar fusion were evaluated, including deep venous thrombosis, acute kidney injury, pulmonary embolism, transfusion, acute myocardial infarction, and inpatient readmission. Spine-related complications were evaluated at 2 years postoperatively, including pseudoarthrosis, incision and drainage (I&D), instrument failure, revision, and infection. RESULTS: After primary lumbar fusion, the chewing tobacco cohort demonstrated significantly higher rates of pseudoarthrosis [odds ratio (OR): 1.41], revision (OR: 1.57), and any spine-related complication (OR: 1.32) compared with controls. The smoking cohort demonstrated significantly higher rates of pseudoarthrosis (OR: 1.88), I&D (OR: 1.27), instrument failure (OR: 1.39), revision (OR: 1.54), infection (OR: 1.34), and any spine-related complication (OR: 1.77) compared with controls. The chewing tobacco cohort demonstrated significantly lower rates of pseudoarthrosis (OR: 0.84), I&D (OR: 0.49), infection (OR: 0.70), and any spine-related complication (OR: 0.81) compared with the smoking cohort. CONCLUSIONS: This study demonstrated that chewing tobacco is associated with higher rates of both spine-related and medical complications after primary lumbar fusion. However, chewing tobacco use is associated with less risk of complications compared with smoking. LEVEL OF EVIDENCE: Level III.

Spinal pseudoarthrosis following osteoporotic vertebral fracture: prevalence, risk factors, and influence on patients' activities of daily living 1 year after injury.

PURPOSE: To investigate the prevalence and risk factors and influence of pseudoarthrosis on activities of daily living (ADL) of patients with osteoporotic vertebral fracture (OVF). METHODS: Spinal pseudoarthrosis is defined as the presence of a cleft in the vertebral body on a lateral X-ray image in the sitting position at 1 year after admission. Of the total 684 patients treated for OVF between January 2012 and February 2019 at our institution, 551 patients (mean age, 81.9 years; a male-to-female ratio, 152:399) who could be followed up to 1 year were included in this study. Prevalence, risk factors, and influence of pseudoarthrosis on the ADL of patients as well as fracture type and location were investigated. Pseudoarthrosis was set as the objective variable. Total bone mineral density, skeletal muscle mass index, sex, age, history of osteoporosis treatment, presence of dementia, vertebral kyphosis angle, fracture type (presence of posterior wall injury), degree of independence before admission, history of steroid use, albumin level, renal function, presence of diabetes, and diffuse idiopathic skeletal hyperostosis were set as explanatory variables for multivariate analysis of the influence of pseudoarthrosis on the walking ability and ADL independence before and 1 year after OVF. RESULTS: In total, 54 (9.8%) patients were diagnosed with pseudarthrosis 1 year after injury (mean age, 81.3 ± 6.5 years; male-to-female ratio, 18:36). BKP was performed in nine patients who did not develop pseudoarthrosis after 1 year. In the multivariate analysis, only the presence of posterior wall injury was significantly correlated with the presence of pseudoarthrosis (OR = 2.059, p = 0.039). No significant difference was found between the pseudarthrosis group and the non-pseudarthrosis group in terms of walking ability and ADL independence at 1 year. CONCLUSIONS: The prevalence of pseudoarthrosis following OVF was 9.8%, and its risk factor was posterior wall injury. The BKP group was not included in the pseudoarthrosis group, which may have led to an underestimation of the prevalence of pseudoarthrosis. The prevalence, risk factors, and influence of spinal pseudoarthrosis on patients' ADL following osteoporotic vertebral fracture (OVF) were investigated. Pseudoarthrosis occurs in 9.8% 1 year after the injury in patients with OVF. Posterior wall injury was the risk factor of pseudoarthrosis.

[Revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis]. / Revizionnye khirurgicheskie vmeshatel'stva posle dekompressivno-stabiliziruyushchikh operatsii po povodu poyasnichnogo stenoza.

Nowadays, vertebral stenosis is the most common indication for surgical treatment in patients over 65 years old in spine surgery. According to the literature, there are conflicting data on the incidence and indications for revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis. OBJECTIVE: To evaluate the incidence and indications for revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis. MATERIAL AND METHODS: A retrospective single-center study enrolled 1233 patients with lumbar spine stenosis who underwent spinal decompression and fusion surgery between 2014 and 2018. The number and causes of readmission were evaluated. RESULTS: There were 164 readmissions. Revision surgery at the same level was performed in 63 patients (38.4%), at the higher level - 72 (43.9%), at the lower level - in 29 (17.7%) patients. The most common indication for readmission was spondyloarthrosis with facet joint syndrome (94 (57.3%) patients). The second common complication was pseudoarthrosis (26 (15.9%) patients). These ones comprised 2.1% of all patients with lumbar spine stenosis. CONCLUSION: The most common indication for readmission was adjacent segment degeneration. The most severe complications requiring complex and even multiple stage revision surgery were pseudoarthrosis and postoperative spondylodiscitis. Causes of readmission are significantly changing at different periods after surgery.

Proximal and distal mechanical repercussions of instrumentation by double rods and interbody grafts in adult scoliosis.

INTRODUCTION: Correction of adult scoliosis by instrumentation with double rods and interbody grafts aims to reduce the risk of pseudarthrosis with rod fracture. An increase in instrumentation rigidity can lead to an increase in stresses at the proximal and distal ends of the construct. The aim of this study was to analyze the incidence and clinical repercussions of proximal junctional kyphosis (PJK), proximal junctional failure (PJF) and iliac screw loosening. MATERIEL AND METHODS: An analysis of patients operated on for adult scoliosis with instrumentation to the pelvis using 4 rods and interbody cages was carried out from a prospective register. The Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Scoliosis Research Society 22 (SRS-22) clinical scores and radiological parameters were collected preoperatively, postoperatively at 3 months, 1 year and 2 years. The appearance of PJK, PJF or distal screw loosening was sought; the clinical impact and the risk factors were analyzed by Bayesian inference. RESULTS: Fifty-one patients with a mean age of 64.5 years were included. The clinical scores improved significantly (Pr>0.95) at 2 years: VAS back 6.9 versus 2.6, VAS leg 4.9 versus 2.5, ODI 48.2 versus 25.4, SRS-22 2.4 versus 3.5. The radiological parameters were corrected (Pr>0.95): Cobb angle 63.9° versus 22.8°, spinosacral angle (SSA) 112.4° versus 118.8°, T1-pelvic angle (TPA) 24, 8° versus 20.8°, lumbar lordosis 43.8° versus 51.0°, thoracic kyphosis 45.2° versus 53.6°. Thirteen patients (25.5%) presented with PJK and 11 (21.6%) with PJF. Seven patients (13.7%) presented with iliac screw loosening. None of these complications was associated with a significant deterioration in clinical scores. Cranial migration of the lumbar apex increased the risk of distal screw loosening: Odds-Ratio 10.31 (Pr>0.999). Two patients were re-operated on for PJF and one patient for iliac screw loosening (5.9%). No rod fracture with pseudarthrosis was found. CONCLUSION: Instrumentation with double rods and interbody grafts was associated with a rate of 47.1% of mechanical repercussions at the extremity of the construct. However, these complications were not associated with a significant deterioration in clinical scores. LEVEL OF EVIDENCE: III.

Comparison of Complications between Anterior Cervical Diskectomy and Fusion versus Anterior Cervical Corpectomy and Fusion in Two- and Three-Level Cervical Spondylotic Myelopathy: A Meta-analysis.

BACKGROUND: In this study, we systematically analyze the differences in complications between anterior cervical diskectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) in two- and three-level cervical spondylotic myelopathy (CSM). METHODS: We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wan Fang Data for all relevant studies. All statistical analyses were performed using Review Manager version 5.3. RESULTS: A total of 11 articles with 849 study subjects were included, with 474 patients in the ACDF group and 375 patients in the ACCF group. The results of the meta-analysis showed that in C5 palsy (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.16-1.06), pseudarthrosis (OR: 1.07; 95% CI: 0.23-5.07), dysphagia (OR: 1.06; 95% CI: 0.60-1.86), infection (OR: 0.41; 95% CI: 0.16-1.09), cerebrospinal fluid leakage (OR: 1.21; 95% CI: 0.39-3.73), graft dislodgment (OR: 0.28; 95% CI: 0.06-1.37), and hematoma (OR: 0.32; 95% CI: 0.06-1.83), there are no significant differences between the ACDF and ACCF groups, whereas total complication (OR: 0.50; 95% CI: 0.31-0.80) showed that the ACDF group had a significantly lower morbidity than the ACCF group. Furthermore, the three-level subgroup of ACDF had significantly better results in C5 palsy (OR: 0.31; 95% CI: 0.11-0.88), infection (OR: 0.22; 95% CI: 0.05-0.94), graft dislodgment (OR: 0.07; 95% CI: 0.01-0.40), and total complication (OR: 0.37; 95% CI: 0.23-0.60) compared with the ACCF subgroup. CONCLUSION: In general, postoperative pseudarthrosis, dysphagia, cerebrospinal fluid leakage, hematoma, C5 palsy, infection, and graft dislodgment did not differ significantly between the two groups. Total complication was significantly less in the ACDF group compared to the ACCF group. In the three-level subgroup, the morbidity of C5 palsy, infection, and graft dislodgment was significantly lower in ACDF than in ACCF.

Surgical management of high-grade paediatric spondylolisthesis: meta-analysis and systematic review.

PURPOSE: There is currently no consensus on the management of high-grade spondylolisthesis (HGS) in paediatric populations. The objective of this analysis is to compare the outcomes of reduction followed by fusion (RFF) or in situ fusion (ISF) in paediatric patients. METHODS: Using major databases, a systematic literature search was performed. Primary studies comparing ISF with RFF in paediatric and adolescent patients were identified. Study data including patient-reported outcomes, complications, and spinopelvic parameters were collected and analysed. RESULTS: Seven studies were included, comprising 97 ISF and 131 RFF. Average patient age was 14.4 ± 2.1 years and follow up was 8.2 ± 5.1 years. Patients undergoing RFF compared to patients undergoing ISF alone were less likely to develop pseudarthrosis (RR 0.51, 95% CI, [0.26, 0.99], p = 0.05). On average, RFF led to 11.97º more reduction in slip angle and 34.8% more reduction in sagittal translation (p < 0.00001) compared to ISF. There was no significant difference between patient satisfaction and pain at follow up. Neurologic complications and reoperation rates were not significantly different. CONCLUSIONS: Both RFF and ISF are effective techniques for managing HGS. Performing a reduction followed by fusion reduces the likelihood of pseudarthrosis in paediatric patients. The difference between risk of neurologic complications, need for reoperation, patient satisfaction, and pain outcomes did not reach statistical significance. Correlation with patient-reported outcomes still needs to be further explored. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

Treatment of Recalcitrant Isolated Congenital Fibular Pseudarthrosis: Fibular Segment Transfer and Tibiofibular Synostosis with Unilateral External Fixator.

Isolated congenital pseudarthrosis of the fibula is a rare entity with a limited number of cases reported in the literature. Treatment is challenging because of recalcitrant nonunion and because no consensus about the best treatment plan exists. We report a case of isolated congenital fibular pseudarthrosis with valgus deformity of the ankle. The patient had a history of two failed operations. We used a novel surgical plan that combined tibiofibular synostosis with fibular segment transfer through a unilateral external fixator. The patient showed good early results with fibular union. We advocate the combination of tibiofibular synostosis and fibular segment transfer to restore the integrity and stability of the ankle in recalcitrant isolated congenital fibular pseudarthrosis cases with a history of failed surgery.

Prospective Study to Identify the Clinical and Radiologic Factors Predictive of Pseudarthrosis Development in Patients with Osteoporotic Vertebral Fractures.

BACKGROUND: Although most osteoporotic vertebral fractures (OVFs) heal conservatively, the most crucial undesirable outcome of conservative treatment is the failure to unite. There is paucity of literature on prevalence and risk factors of pseudarthrosis. METHODS: A prospective study involving patients (aged ≥50 years) undergoing conservative treatment of osteoporotic thoracic/lumbar fractures without neurodeficits was performed. Patients were followed for a minimum of 6 months and classified into 3 groups based on fracture healing: group 1, healing without collapse; group 2, healing with collapse; and group 3, pseudarthrosis. An assessment of all clinicoradiologic parameters at the time of injury and at each follow-up was performed and compared among patients belonging to the groups. RESULTS: A total of 77 patients (90 fractures) were studied. Sixty-six (73.3%), 16 (17.8%), and 28 (8.9%) fractures were classified under groups 1, 2, and 3, respectively. Mean ages in groups 1, 2, and 3 were 67.9 ± 9.1, 70.4 ± 7.6 and 72.3 ± 7.9 years (P = 0.08). Sex distribution was 62:15 (female/male). Seventy-three fractures (81.1%) occurred at the thoracolumbar junction. Stiff spine, ambulatory status, comorbidities, bone mineral density, and injury level were not associated with pseudarthrosis/collapse (P > 0.05). Male sex was associated with pseudarthrosis (P = 0.03). Based on regression analysis, initial vertebral height loss (radiography; P = 0.028), segmental Cobb (radiography; P = 0.019), vertebral comminution (computed tomography; P = 0.032), posterior ligamentous complex injury (magnetic resonance imaging; P = 0.048), and marrow change pattern (T2-weighted magnetic resonance imaging, Kanchiku classification; P = 0.037) were correlated with poorer outcome. Patients with pseudarthrosis had higher visual analog scale score (P = 0.04; final follow-up). CONCLUSIONS: Of OVFs, 8.9% developed pseudarthrosis. Male sex, severity of postinjury vertebral deformation (vertebral loss, kyphosis, comminution, and marrow changes) and presence of posterior ligamentous complex injury are risk factors for pseudarthrosis.

Pseudarthrosis of the Cervical Spine.

Pseudarthrosis of the cervical spine represents a common and challenging problem for spine surgeons. Rates vary greatly from as low as 0%-20% to >60% and depend heavily on patient factors, approach, and number of levels. While some patients remain asymptomatic from pseudarthrosis, many require revision surgery due to instability, continued neck pain, or radiculopathy/myelopathy. We aimed to provide a practical, narrative review of cervical pseudarthrosis to address the following areas: (1) definitions, (2) incidence, (3) risk factors, (4) presentation and workup, (5) treatment decision-making, and (6) postoperative care. It is our hope the current review provides a concise summary for how to diagnose and treat challenging cervical nonunions.

Congenital Pseudarthrosis of the Tibia Associated With Cleidocranial Dysostosis: Case Report and Literature Review.

CASE: We describe a case of 2 individually rare diseases existing comorbidly in the form of congenital pseudarthrosis of the tibia (CPT) coincident with cleidocranial dysostosis and provide a review of the literature, including the sole preexisting documented coincidence. CONCLUSION: Understanding, treatment, and surgical protocol of CPT have changed considerably since this comorbidity was last reported. Updates include synostosis, periosteal grafting, the use of bone morphogenetic protein, and bisphosphonates. Our case varies from the previous in associated disorder and family history. The relationship between CBFA1 and RUNX2 genes may hold the key, but further study is needed.

Tratamiento de pseudoartrosis séptica de tibia secundaria a fractura expuesta. A propósito de un caso / Treatment of tibia septic pseudo arthritis secondary to exposed fracture. Apropos of a case

RESUMEN Las fracturas expuestas de tibia han sido uno de los problemas más importantes para los sistemas de atención en salud pública. Se caracterizan por tres factores de riesgo fundamentales: daño óseo y tejidos blandos, gran posibilidad de contaminación y dificultades para el tratamiento conservador y quirúrgico, debido al daño óseo y de partes blandas asociados, que implica un alto índice de complicaciones. El tratamiento de estas fracturas es un tema ampliamente discutido en cuanto a la técnica quirúrgica a utilizar. Debido la pobre vascularización y poca cantidad de tejidos blandos que cubren la tibia, este hueso es muy vulnerable a la pseudoartrosis y a la infección. El objetivo de este trabajo fue describir la técnica quirúrgica de transportación ósea con fijador externo Ilizarov y evaluar el resultado en defectos óseos de tibia de más de 6 cm, secundario a pseudoartrosis infectada. Como resultado, el paciente evolucionó con una pseudoartrosis séptica de tibia derecha secundaria a fractura expuesta. El seguimiento fue de 18 meses, la pérdida ósea de 6 cm, la velocidad de distracción de 1 mm/día, el período de transportación de 95 días, y el tiempo con fijador de 198 días. Fue necesario realizar un nuevo proceder quirúrgico en el sitio de contacto, con vistas a reavivar los extremos óseos. La transportación ósea con fijador Ilizarov es válida para el tratamiento de la pérdida ósea en fracturas expuestas de tibia o pseudoartrosis séptica (AU).

ABSTRACT Exposed tibia fractures have been one of the most important problems for public health care systems. They are characterized by three main risk factors: bone and soft tissue damage, high possibilities of contamination and difficulties for the surgical and conservative treatment, due to the associated bone and soft tissues damage implying a high rate of complications. The treatment of these fractures is a widely discussed topic regarding the surgical technique to be used. Due to poor vascularization and little quantity of soft tissue covering tibia, this bone is highly vulnerable to pseudoarthritis and infection. The aim of this work was to describe the surgical technique of bone transport with Ilizarov external fixator and to evaluate the result in tibial bone defects of more than 6 cm, secondary to infected pseudoarthritis. As a result, the patient evolved with septic pseudoarthritis of right tibia secondary to exposed fracture. The follow up lasted 18 months; the bone loss was 6 cm; the distraction speed was 1 mm/day; the transportation period was 95 days and the time with fixator was 198 days. It was necessary to perform a new surgical procedure at the contact site to recuperate the bone ends. Bone transport with Ilizarov fixator is valid for the bone loss treatment in tibia exposed fractures or septic pseudo arthritis (AU).

Acute Thoracic Outlet Syndrome Associated with Congenital Pseudarthrosis of the First Rib: A Case Report.

CASE: A 15-year-old right-hand-dominant adolescent girl presented with a nondisplaced first rib fracture and evidence of mesoacromion. She reported radiating numbness, pain, temperature change, and paresthesia in her left arm. An MRI revealed a first rib fracture along with brachial plexus and scalene musculature inflammation. Follow-up radiographs demonstrated bilateral rib anomalies during routine comparison views. CONCLUSION: Congenital pseudarthrosis of the first rib occurs but is not well documented in the literature. This case report describes a case of congenital bilateral first rib pseudarthrosis with associated thoracic outlet syndrome symptoms in a competitive female softball athlete.

The effect of bioactive glasses on spinal fusion: A cross-disciplinary systematic review and meta-analysis of the preclinical and clinical data.

Pseudarthrosis following spinal fusion is correlated with poorer patient outcomes and consequently is an area of continued interest within spinal research. Recently, bioactive glasses have been proposed as a means of augmenting fusion rates. Here, we present the first systematic review and meta-analysis of the existing preclinical and clinical literature on the effect of bioactive glasses on spinal fusion. Using the MEDLINE, Embase, and Web of Science databases, we queried all publications in the English-language literature examining the effect of bioactive glasses on spinal fusion. The primary endpoint was fusion rate at last follow-up and the secondary endpoint for clinical studies was the rate of deep wound infection. Random-effects meta-analyses were performed independently for the preclinical and clinical data. Twelve preclinical studies (267 animals) and 12 clinical studies (396 patients) evaluating a total of twelve unique bioactive glass formulations were included. Across clinical studies, fusion was seen in 84% treated with bioactive glass. On sub-analysis, fusion rates were similar for standalone autograft (91.6%) and bioactive glass-local autograft mixtures (89.6%). Standalone bioactive glass substrates produced inferior fusion rates relative to autograft alone (33.6% vs. 98.8%; OR 0.01, p < 0.02). Rates of deep wound infection did not differ between the bioactive glass and autograft groups (3.1%). The preclinical data similarly showed comparable rates of fusion between autograft and bioactive glass-treated animals. The available data suggest that bioactive glass-autograft mixtures confer similar rates of spinal fusion relative to standalone autograft without altering the risk of deep wound infection.

Congenital Pseudarthrosis of the Fibula: Controlling Ankle Valgus in a Heterogenous Condition.

BACKGROUND: Congenital pseudarthrosis of the fibula (CPF) is a rare disorder characterized by a deficiency in the continuity of the fibula and can lead to progressive ankle valgus malalignment. An existing classification system for CPF is imperfect and may contribute to heterogeneity in reporting and discrepancy of outcomes in the literature. METHODS: Fifteen patients with CPF treated at our institution between 1995 and 2017 were retrospectively identified. Only patients with dysplasia leading to spontaneous fracture or pseudarthrosis were included in this series. The median age at presentation was 2.5 years (range: 3 mo to 13.4 y). The median duration of follow-up from the initial presentation was 11.8 years (range: 2.0 to 24 y). Chart review and serial radiographs were analyzed to assess natural history and outcomes following surgery. RESULTS: The coexistence of tibial dysplasia in CPF is very common. Patients were classified into 3 groups based on the degree of tibial involvement-group 1: no evidence of tibial dysplasia, group 2: mild tibial dysplasia, and group 3: significant tibial dysplasia. Age at presentation and age at which fibular fracture occurred were progressively younger with a greater degree of tibial involvement (P<0.05). In the absence of surgical intervention, group 1 patients did not undergo progressive ankle valgus (defined as the valgus change in tibiotalar angle by ≥4 degrees), whereas all patients in groups 2 and 3 did (P<0.001). Fibular osteosynthesis was performed in 6 patients, with union seen only in group 1 patients. Ten patients underwent distal tibiofibular fusion, with no cases of nonunion seen. Distal tibiofibular fusion with or without medial distal tibial hemiepiphysiodesis halted the progression of ankle valgus in 8 of the 10 patients. Further progression of ankle valgus occurred only in patients who did not undergo concurrent medial distal tibial hemiepiphysiodesis and with considerable wedging of the distal tibial epiphysis at the time of fusion. CONCLUSIONS: Tibial dysplasia and CPF are intimately related. Grouping patients on this basis may help guide natural history and treatment and may explain discrepancies in findings in the literature. Fibular osteosynthesis, distal tibiofibular fusion, and medial distal tibial hemiepiphysiodesis may all have an important role in the treatment of CPF. LEVEL OF EVIDENCE: Level IV-case series.

Non-infectious thoracic discitis: A diagnostic and management dilemma. A report of two cases with review of the literature.

Discitis/ Osteomyelitis is an inflammatory process involving an intervertebral disc and the adjacent vertebral bodies. Infection is the most common cause of discitis, which is often spontaneous and hematogenous in origin. However, many noninfectious processes affecting the spine such as pseudarthrosis in ankylosing spondylitis, amyloidosis, destructive spondyloarthropathy of hemodialysis, Modic changes type 1, neuropathic arthropathy, calcium pyrophosphate dehydrate (CPPD) spondyloarthropathy and gout can mimic infectious discitis/ osteomyelitis. To determine whether a particular patient's spinal process is due to an infectious versus non-infectious cause can be challenging. Although clinical findings and laboratory studies including erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) can be helpful in the diagnosis of bacterial discitis/osteomyelitis due to their high sensitivity; however, their specificity is low. Moreover, both the infectious and non-infectious discitis can appear quite similar on the imaging studies. We present two cases of thoracic discitis with adjacent vertebral osteomyelitis of probable non-infectious etiology. Both were managed with instrumented fusion for stabilization. We also discuss a range of noninfectious causes of discitis/spondylitis and their radiological features which can help differentiate from infectious processes.

Metabolic and Endocrine Disorders in Pseudarthrosis.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: Establish 1-year patient-reported outcomes after spine surgery for symptomatic pseudarthrosis compared with other indications. In the subgroup of pseudarthrosis patients, describe preexisting metabolic and endocrine-related disorders, and identify any new diagnoses or treatments initiated by an endocrine specialist. SUMMARY OF BACKGROUND: Despite surgical advances in recent decades, pseudarthrosis remains among the most common complications and indications for revision after fusion spine surgery. A better understanding of the outcomes after revision surgery for pseudarthrosis and risk factors for pseudarthrosis are needed. METHODS: Using data from our institutional spine registry, we retrospectively reviewed patients undergoing elective spine surgery between October 2010 and November 2016. Patients were stratified by surgical indication (pseudarthrosis vs. not pseudarthrosis), and 1-year outcomes for satisfaction, disability, quality of life, and pain were compared. In a descriptive subgroup analysis of pseudarthrosis patients, we identified preexisting endocrine-related disorders, frequency of endocrinology referral, and any new diagnoses and treatments initiated through the referral. RESULTS: Of 2721 patients included, 169 patients underwent surgery for pseudarthrosis. No significant difference was found in 1-year satisfaction between pseudarthrosis and nonpseudarthrosis groups (77.5% vs. 83.6%, respectively). A preexisting endocrine-related disorder was identified in 82% of pseudarthrosis patients. Endocrinology referral resulted in a new diagnosis or treatment modification in 58 of 59 patients referred. The most common diagnoses identified included osteoporosis, vitamin D deficiency, diabetes, hyperlipidemia, sex-hormone deficiency, and hypothyroidism. The most common treatments initiated through endocrinology were anabolic agents (teriparatide and abaloparatide), calcium, and vitamin D supplementation. CONCLUSIONS: Patients undergoing revision spine surgery for pseudarthrosis had similar 1-year satisfaction rates to other surgical indications. In conjunction with a bone metabolic specialist, our descriptive analysis of endocrine-related disorders among patients with a pseudarthrosis can guide protocols for workup, indications for endocrine referral, and guide prospective studies in this field.