Bilateral Simultaneous Asymmetrical Anterior Shoulder Dislocation With a Fracture.

In this case report, we present the case of a 19-year-old male who presented to the emergency department with bilateral shoulder pain and significantly decreased range of motion. His X-rays showed a bilateral dislocation of the glenohumeral joints, along with a proximal humeral fracture. Shoulder dislocations were manipulated, while the proximal humeral fracture was conservatively managed. Bilateral simultaneous asymmetric anterior shoulder dislocations are uncommon in such a young age group, especially when associated with a sports injury.

The Incidence of Venous Thromboembolism in Patients Undergoing Anterior Lumbar Interbody Fusion: A Proposed Thromboprophylactic Regime.

OBJECTIVE: To determine the safety and efficacy of the proposed venous thromboembolism (VTE) prophylaxis regime in patients undergoing anterior lumbar interbody fusion (ALIF) surgery. BACKGROUND: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are recognized complications after spine surgery, with rates in the literature ranging from 0% to 14% with some form of prophylaxis. Pharmacological thromboprophylaxis can cause postoperative bleeding and hematomas, which can result in significant neural compromise or permanent injury, and wound complications. ALIF surgery involves the handling and compression of major abdominal vessels during surgery and this adds to the risk of both arterial thrombosis and VTE. METHODS: A retrospective review of data, which were prospectively collected to evaluate the incidence of VTE in 200 consecutive patients undergoing ALIF following our VTE prophylaxis protocol. All patients had low molecular weight heparin, tinzaparin 4500 units subcutaneously on the evening before surgery, then daily for 3 to 5 days, then aspirin (acetylsalicylic acid) 150 mg daily plus lansoprazole 30 mg daily for 4 weeks after surgery. All patients had intermittent pneumatic compression of their calves and thighs intraoperatively and for 24 hours postoperatively then had early mobilization and thromboembolic deterrent stockings for 6 weeks. RESULTS: There was no incidence of any symptomatic VTE in the any of the 200 patients and no loss to follow-up. There was a 0% incidence of injury to the iliac vessels, symptomatic arterial occlusion, wound hematoma, major intraoperative bleeding, need for transfusion, symptomatic GI bleed, or retroperitoneal hematoma requiring intervention. CONCLUSIONS: The proposed VTE prophylactic regime is safe and efficacious and may decrease the incidence of symptomatic VTE in patients undergoing an ALIF procedure, and despite the use of chemical thromboprophylaxis, there is no evidence of bleeding complications as a result of using this regime. LEVEL OF EVIDENCE: 4.

Novel bone grafting technique in stand-alone ALIF procedure combining allograft and autograft ('Northumbria Technique')-Fusion rate and functional outcomes in 100 consecutive patients.

INTRODUCTION: Successful ALIF surgery depends upon achieving solid fusion, whilst avoiding significant complications. Herein, we present the 'Northumbria Technique' of combining allograft with autograft in order to achieve solid interbody fusion. MATERIALS AND METHODS: A single-surgeon series of 100 consecutive patients undergoing stand-alone ALIF from 2016 to 2019 was studied. All had percutaneously harvested iliac crest bone graft (ICBG) dowels inserted into blocks of fresh frozen femoral head (FFFH) allograft, which were then inserted into the ALIF cages. Patients had dynamic radiographs at 4 months, CT at 6 months, and patient reported outcome measure scores (PROMS) throughout. RESULTS: One hundred patients (average age 44.8 years) were followed-up for an average of 29.1 months. Ninety-four (94%) patients were assessed as having fused on both CT and radiographs by an independent Radiologist. Three (3%) patients had abolition of movement on radiographs, but either lacked a CT scan or failed to meet Williams criteria for fusion. Two patients failed to attend for any imaging, so were considered not fused, and one patient had no evidence of fusion in either modality. There was a significant improvement in all PROMS. There were no intra-operative complications, and one patient had transient donor-site pain. CONCLUSIONS: The newly described 'Northumbria Technique' utilises the osteoconductive characteristics of the FFFH allograft, as well as the osteoinductive and osteogenic properties of the ICBG autograft. It gives high fusion rates (94-97%) and statistically significant improvements in PROMS, whilst avoiding the complications of harvesting a large amount of autograft and the huge costs of using synthetic agents.

Does symptom duration correlate negatively with outcome after posterior lumbar interbody fusion for chronic low back pain?

STUDY DESIGN: Original report. OBJECTIVE: To investigate the putative negative correlation between the duration of symptoms (DOS) and outcome after surgery for chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: Posterior lumbar interbody fusion (PLIF) is a well established treatment for CLBP. Anecdotally, a prolonged DOS is associated with a poor prognosis for recovery of CLBP. In one recent study, a DOS greater than 3 years predicted a poor prognosis for subsequent clinical improvement with CLBP. METHODS: Patients (n = 209) underwent PLIF for CLBP who had proven unresponsive to nonoperative management for at least 6 months. A wide variety of physical and mental outcome scores were simultaneously assessed pre- and after surgery: i.e., the Oswestry Disability Index (ODI), SF-36 body score, SF-36 mental score, Visual Analogue Score (VAS) for back pain, VAS for leg pain, Hospital Anxiety Score (HAS), and Hospital Depression Score. RESULTS: Despite a prolonged mean DOS of 84.3 ± 6.6 months, there was a significant postoperative improvement in all 7 outcome scores after PLIF. Significant improvement occurred in 181 patients (i.e., 86.6%) and was sustained at 51.6 ± 12.0 months follow-up. No significant correlation was found between DOS and any outcome score (ODI: rs = 0.013, P = 0.877; SF-36 bodily pain: rs = 0.013, P = 0.87; VAS for back pain: rs = 0.038, P = 0.656; VAS for leg pain: rs = 0.086, P = 0.310; HAS: rs = 0.511, P = 0.056; Hospital Depression Score: rs = 0.056, P = 0.509, or SF-36 mental score rs = 0.007, P = 0.935). No arbitrary DOS "cut-off" was found for which significantly different outcomes were recorded either side of the cut-off; or for which a significant correlation was revealed either side of the cut-off. Finally, no significant partial correlation was found between DOS and any outcome score after controlling for pain severity (VAS(back pain)) before surgery. There were no significant differences in terms of age, sex, or DOS between those with improved ODI scores less than 10 compared with those with improved ODI scores greater than 10. CONCLUSION: The putative negative correlation between DOS and outcome was not observed under any analysis in our study. PLIF procured a rapid and sustained improvement in CLBP, even where the DOS was excessively prolonged; and even after having allowed for pain severity. Symptom chronicity, therefore, does not represent a poor prognostic indicator for CLBP outcome after PLIF: PLIF should be considered irrespective of DOS. Because DOS and pain severity are likely mediators of "central sensitization," the hypothesis that central sensitization may be prevalent in CLBP patients selected for PLIF is therefore questioned.

Minimizing ferromagnetic artefact with metallic lumbar total disc arthroplasty devices at adjacent segments: technical note.

STUDY DESIGN: Technical report. OBJECTIVE: To minimize the gross artefact associated with a conventional metallic lumbar total disc arthroplasty (TDA) device on a conventional high field-strength (1.5 Tesla [T]) magnetic resonance imaging (MRI) scanner. SUMMARY OF BACKGROUND DATA: Gross artefact is often apparent with ferromagnetic metallic TDA devices on conventional high field-strength MRI scanners. Such artefact completely obliterates MRI assessment at the operated level, and usually obscures visualization of adjacent segments. Because adjacent segment preservation is a raison d'être of spinal TDA, clarity of imaging at this latter level is imperative. A failure to image adjacent segments may presage investigations, which are either invasive (e.g., myelography) or associated with significant radiation hazard (e.g., computed tomography), both with significantly less diagnostic sensitivity. This could negatively direct TDA choice with certain TDAs. METHODS: Progressive modifications to specific imaging parameter settings were sought on a conventional high field-strength (1.5T) closed-bore scanner to match the minimal artefact previously observed on a lower field-strength (0.3T) open scanner. Direct comparisons were made between each modified protocol image obtained initially using a phantom; however, routine postoperative MRIs were subsequently obtained in n = 40 patients following lumbar TDA insertion. RESULTS: Key parameter modifications were required in the receive bandwidth, the strength of the frequency encoding gradient, as well as in the echo train length. The use of higher specification "focused gradients" was also avoided. The overall effect was to reduce the slew rate of the gradients, which limited artefact due to a decrease in phase dispersion. Such appearances effectively matched with those previously obtained on the low field-strength (0.3T) open scanner in n = 40 patients. CONCLUSION: Relatively simple modifications to MRI parameter settings can be made on conventional high field-strength (1.5T) closed-bore scanners, which minimize metal artefact and enhance imaging of adjacent segments with ferromagnetic TDA devices. Such modifications effectively match appearances to those obtained with outmoded low field-strength (0.3T) open-bore scanners.

Significantly improved outcomes with a less invasive posterior lumbar interbody fusion incorporating total facetectomy.

STUDY DESIGN: Original study. OBJECTIVE: Prospective comparison of clinical outcomes after a standard posterior lumbar interbody fusion (ST-PLIF) and after a limited exposure PLIF incorporating total facetectomy (LI-PLIF). SUMMARY OF BACKGROUND DATA: Most groups have reported significantly improved clinical outcomes after ST-PLIF. To our knowledge, however, a comparison of outcomes between ST-PLIF and the LI-PLIF that we herein describe has not been reported before. METHODS: Patients were included who had suffered chronic low back pain for a minimum of 2 years that was unresponsive to conservative treatment. N = 114 consecutive patients underwent ST-PLIF, whereas n = 209 underwent LI-PLIF. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). The minimum follow-up for either group was 2 years. RESULTS: There was a significant improvement in the ODI (22.5 +/- 1.0, P < 0.001), VAS for back pain (3.8 +/- 0.1, P = 0.003), VAS for leg pain (4.0 +/- 0.2, P = 0.002), and SF-36 for bodily pain (14.7 +/- 0.9, P = 0.012) after ST-PLIF. However, there was a significantly greater improvement in all scores after LI-PLIF: ODI (28.8 +/- 1.4 vs. 22.5 +/- 1.0, P < 0.001), VAS for back pain (5.4 +/- 0.2 vs. 3.8 +/- 0.1, P = 0.001), VAS for leg pain (5.1 +/- 0.2 vs. 4.0 +/- 0.2, P < 0.001), and SF-36 for bodily pain (18.5 +/- 0.8 vs. 14.7 +/- 0.9, P = 0.003). There was a significantly shorter duration of hospital stay after LI-PLIF (2.24 +/- 0.057 days) than after ST-PLIF (4.04 +/- 0.13 days) (P = 0.005). Operative complications occurred in 19.3% of ST-PLIF and in 6.7% of LI-PLIF. CONCLUSION: Clinical outcomes were significantly improved after both ST-PLIF and LI-PLIF. However, outcomes were significantly better after LI-PLIF than after ST-PLIF. Significantly shortened hospital stay with LI-PLIF probably reflected the "less invasive" technique per se. Significantly better clinical outcomes with fewer complications after LI-PLIF, however, potentially reflected maneuvers singular to LI-PLIF: (1) preservation of posterior elements, (2) avoidance of far lateral dissection over the transverse processes, (3) bilateral total facetectomy, (4) fewer neurologic complications, and (5) avoidance of iliac crest autograft. LI-PLIF is therefore recommended over ST-PLIF.

External fixator-assisted acute shortening with internal fixation for leg length discrepancy after total hip replacement.

We report a case of a 51-year-old lady, who underwent a femoral shortening using a fixator assisted blade plate after total hip replacement. The patient had a total hip replacement on the other side with previous revisions, which resulted in a leg length discrepancy. We used the above technique to control the shortening and preserve the mechanical and anatomical axis of the femur.

A radiographic technique for the assessment of ankle and midfoot equinus.

BACKGROUND: Both clinical and radiographic techniques have been used to evaluate foot and ankle position and orientation. Clinical measurements have been shown to be less reliable than radiographic measurements. Because midfoot equinus deformity may coexist with ankle joint equinus deformity, a radiographic method of separating and measuring these two components is desirable. The purpose of this study was to evaluate a new radiographic technique, the Lateral Mid-Tibia to Toes (LMTT), weightbearing view of the foot and ankle. METHOD: Twenty LMTT images were randomly selected from the study population of patients treated in our center for lower limb equinus deformity. Validation was achieved by a study involving three observers, assessing 20 images on two consecutive occasions, 4 weeks apart. Analysis was performed using Kappa statistics. RESULTS: The plantigrade and midfoot equinus angles provided substantial (p = 0.000) and moderate (p = 0.005) agreement, respectively. CONCLUSIONS: Awareness of midfoot equinus and its correction may avoid residual deformity when surgery is performed to correct equinus deformity of the ankle.

The precision and accuracy of templating the size of unicondylar knee arthroplasty.

In trauma and joint arthroplasty, preoperative templating is an important step that can help in the selection of implant size, position and alignment. Although the precision (reproducibility) of templating in unicondylar knee arthroplasty has been assessed previously, the accuracy has never been studied. Our aim is to assess the precision and accuracy of using the templating system for one commonly used unicondylar knee arthroplasty, ALPHANORM design (Alphanorm Medizintechnik, Germany). Eight observers used the templating system to estimate the size of the unicondylar knee prosthesis ALPHANORM in 29 randomly selected patients with osteoarthritis. The observers, who all were orthopaedic surgeons with two different levels of experience, worked independently and repeated their measurements 2 weeks later. All the patients subsequently underwent unicondylar knee replacements, and the actual size of the femur and tibia was assessed intra-operatively without any knowledge of the template sizes. Our results revealed a high level of intra-observer reproducibility. However, the inter-observer reproducibility and the accuracy all were poor.