Are the additional grafts necessary?

The goals of surgery for spinal deformity are to correct or improve the deformity to get a stable, balanced and fused spine. The long-term success of any procedure for scoliosis depends on a solid arthrodesis. Getting fusion of the instrumented segment with the aid of copious autogenous iliac graft has been the most important goal of treatment. However, harvesting copious graft from teenage iliac bone has its limitation in the quantity of graft, surgical time, and other complications of graft sites. Bone substitute is a promising concept, but there is not ideal bone substitute with all the characteristics of an autogenous bone graft. Several alternative graft materials like tricalcium phosphate, hydroxyapatite, and demineralized bone matrix have osteoinductive properties. Bone morphogenic protein has osteoconductive properties. The limitations with bone substitutes are osteoinduction and osteoconduction properties, sterilization, chances of transmitting infective disease and cost. We consider that the introduction of segmental spinal instrumentation which enables strong and firm correction and fixation of the scoliotic deformity has enabled getting fusion with less graft. We can obtain that quantity of graft after laminae and spinous process decortication. This retrospective study has been done in our hospital from January 2002 to December 2004. A total of 188 patients underwent posterior corrections for adolescent idiopathic scoliosis using segmental fixation by Moss-Miami. No autogenous iliac crest graft was taken or graft substitutes. After meticulous decortication and destruction of facet joints, we used local graft taken from spinous process and laminae. All patients had minimum thirty months follow-up. We have excellent results. Out of these 188 patients, 177 patients have fused spine, no implant failure, no pain, no infection and no loss of correction. Eleven (5.8%) patients underwent re-operation; four among them because of infection, three for symptomatic implants and four due to pseudarthrosis. We consider that the use of local harvesting graft is enough for getting good spondylodesis.

[Treatment of occipitocervical instability by SUMMIT].

The occipitocervical junction with its complex anatomy and biomechanics represents unique anatomical structure difficult for operative treatment. Biomechanics forces in this region need to be resisted with rigid metallic construction to facilitate bone fusion. Surgeon must be careful about close relations of the bone, vascular and neurologic structures and must have good skills and knowledge to avoid serious complications during operations. Before 2004 for instability treatment in this region of spine wires and pin construction for fixation of bone grafts were used. In our Institute rod constructions with screws have been used to get more rigid construction since 2004. In this paper we will present our early results in occipitocervical instability treatment by SUMMIT instrumentation.

Low back pain--differential diagnosis, prognosis and treatment.

From January 2002 to February 2003, 137 patients complaining of low back pain were treated at the Institute for Orthopedic Surgery "Banjica", Belgrade, Serbia. There were 89 male and 48 female patients aged 13 to 77, mean age 42.2. Their condition was diagnosed through use of radiography, CT, MRI, EMNG, standard battery of neurological tests, and laboratory analyses (urine and blood analysis). Surgical treatment was performed on 39 patients; all other patients received some form of non-surgical care (physical therapy, medication or corset). Treatment efficacy was evaluated by use of the visual analog scales (VAS) and the Oswestry index, before and after treatment. The use Wilcoxon's pair test revealed statistically significant difference between before and after treatment data on VAS and Oswestry index for all patients.

[Paralytic hip dislocation in cerebral palsy--soft tissue surgical procedures].

Results of a combination of soft tissue procedures performed for the first time in treating paralytic dislocation of the hip in cerebral palsy are presented. All hip flexors and adductors release, along with possible transposition or elongation of knee flexors on the side of the dislocation (if knee contracture exceeded 20) were peformed. 75 hips in 57 patients were operated on. 54 patients were analyzed. The average age of the patients was 6.6 years, the average follow-up was 7 years. Excellent result was achieved in 33patients (61%), good in 10 (18,6%), fair in 4 (7,4%) poor in 7 patients (13%). Poor results were registered in patients over 10 years of age and in patients with athetosis. Results were assessed according to clinical finding, radiological finding (migrational percentage) and the ability of patients to walk. When based on radiological findings only, excellent results were achieved in 63 hips (84%). This combination of soft-tissue procedures which includes all muscles that take part in the dislocation proved to be very successful in achieving reposition. It can be recommended to patients suffering from the spastic form of cerebral palsy up to 10 years of age.

Combined salter innominate osteotomy with femoral shortening versus other methods of treatment for Legg-Calvé-Perthes disease.

The results of treatment of Legg-Calvé-Perthes disease in 357 patients at the Institute for Orthopaedic Surgery "Banjica," Belgrade, from January 1963 to December 1987 with > or = 10 years of follow-up are summarized. The advantages of combined Salter innominate osteotomy with femoral shortening, as a one-step operation, are emphasized. Male predominance was found in a ratio of 4.75:1, and bilateral involvement was present in 21% of the patients. Disease onset was usually between ages 4 and 7 years (mean 6.5 years). Catterall criteria for the classification of the disease were used; patients in groups I and II were treated nonsurgically and those in groups III and IV were treated surgically. Most of the surgically treated patients (64.4%) had one or more head risk factors. The most frequently used surgical procedure was a Salter innominate osteotomy with or without femoral shortening. Assessment of treatment was made by measuring the final center-edge angle and by using criteria developed by Catterall, Mose, Harrison, and Stulberg. Final functional status of the operated hips was recorded as well. The greatest final center-edge angle of 34.27 degrees was found in the patients treated with combined Salter innominate osteotomy and femoral shortening, showing improvement of 14.98 degrees. Surgical treatment, except for revascularization procedures, showed good and fair results in > 90% of patients. The range of hip motion was improved in most patients. The earliest weight-bearing allowance was found in patients who underwent Salter innominate osteotomy and femoral shortening; it averaged 3.1 months. The duration of immobilization was also the shortest in this group. The average femoral shortening was 1.38 cm (range 0.9-1.9 cm). The proposed combined Salter osteotomy with femoral shortening is recommended for the treatment of more severe cases of Legg-Calvé-Perthes disease, thus preventing establishment of early secondary hip arthrosis.