Comparison of Functional Outcomes and Complications of Inlay and Onlay Reverse Shoulder Arthroplasty in Neer Type 4 Proximal Humerus Fractures and Cuff Tear Arthropathy: A Multicentric Study.

Background: This multicenter retrospective study was conducted with the objective of comparing the outcomes and complications between inlay and onlay reverse shoulder arthroplasty (RSA) in patients presenting Neer Type 4 proximal humerus fractures and cuff tear arthropathy. The primary aim of this investigation was to assess and juxtapose the clinical as well as functional outcomes of individuals who underwent onlay reverse shoulder arthroplasty with those who underwent inlay reverse shoulder arthroplasty. Methods: A retrospective cohort study was conducted, involving patients who had undergone reverse shoulder arthroplasty between the period of 2016 and 2022. The study divided the population into two groups: Group A received inlay humeral components, while Group B received onlay humeral components. Functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores. Range of motion, infection, periprosthetic fractures, and nerve injuries were also assessed. Results: The study included 67 patients in Group A and 62 patients in Group B. Group A had significantly better functional outcomes, as indicated by higher ASES and Constant scores (p < 0.05). Group A also had greater shoulder joint motion (p < 0.05). Periprosthetic fractures were significantly more common in Group B (p < 0.05). However, complication rates, including infection and instability, did not significantly differ between the groups (p > 0.05). Nerve injuries occurred in both groups, with slightly higher occurrence in Group B. Conclusion: Inlay humeral components in reverse shoulder arthroplasty for Neer Type 4 fractures and cuff tear arthropathy resulted in better functional outcomes, increased range of motion, and lower incidence of periprosthetic fractures compared to onlay components. Onlay components showed potential advantages in reducing instability rates. Further studies with larger samples and standardized protocols are needed to confirm these findings.

The Importance of Lumbar Curve Flexibility and Apical Vertebral Rotation for the Prediction of Spontaneous Lumbar Curve Correction in Selective Thoracic Fusion for Lenke Type 1 and 2 C Curves: Retrospective Cohort Study with a Mean Follow-Up of More than 10 years.

STUDY DESIGN: Retrospective analysis of a prospectively collected data. OBJECTIVE: Lumbar flexibility(LF) is generally defined with preoperative side bending films;it is not clear what percentage of LF predicts the spontaneous lumbar curve correction (SLCC) at long term follow up. Aim of this study was to find out cut-off value of preoperative LF,apical vertebra rotation(AVR) and apical vertebral translation(AVT);which may predict more than 50%SLCC. METHODS: Patients with Lenke 1C&2C curves,treated with posterior STF,with a minimum 10 years follow up were included.The patients who had more than 50% SLCC(Group A) or less than 50% (Group B) were compared in terms of LF,AVR and AVT to understand a cut-off value of those parameters.Statistically, Receiver Operating Characteristic(ROC) test was used. RESULTS: Fifty five AIS patients (54F, 1M) with mean age 14 (11-17) were included to study.Thoracic curve correction rate was 75%;lumbar curve correction rate was 59% at the latest follow up.Group A included 45(82%) patients at the latest follow up.Three patients (5%) showed coronal decompensation at early postop and 2 of them became compensated at f/up.ROC analyses showed 69% flexibility as the cut-off value for SLCC (P < .01).The difference between groups in terms of preop mean AVRs was significant (P = .029) (Group A = 1.9; Group B = 2.4). CONCLUSION: In Lenke 1C&2C curves,whenever LF on the preoperative bending x-ray is greater than 70% (P < .01)and AVR is equal or less than grade 2,STF provides satisfactory clinical and radiological SLCC with more than mean 10 years f/up.This flexibility rate and apical vertebral rotation can be helpful in decision making for successful STF.

Single-Stage Posterior Vertebral Column Resection With Circumferential Reconstruction for Thoracic/Thoracolumbar Burst Fractures With or Without Neurological Deficit: Clinical Neurological and Radiological Outcomes.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study is to evaluate the clinical, neurological, and radiological outcomes of posterior vertebral column resection (PVCR) technique for treatment of thoracic and thoracolumbar burst fractures. METHODS: Fifty-one patients (18 male, 33 female) with thoracic/thoracolumbar burst fractures who had been treated with PVCR technique were retrospectively reviewed. Preoperative and most recent radiographs were evaluated and local kyphosis angle (LKA), sagittal and coronal spinal parameters were measured. Neurological and functional results were assessed by the American Spinal Injury Association (ASIA) Impairment Scale, visual analogue scale score, Oswestry Disability Index, and Short Form 36 version 2. RESULTS: The mean age was 49 years (range 22-83 years). The mean follow-up period was 69 months (range 28-216 months). Fractures were thoracic in 16 and thoracolumbar in 35 of the patients. AO spine thoracolumbar injury morphological types were as follows: 1 type A3, 15 type A4, 4 type B1, 23 type B2, 8 type C injuries. PVCR was performed in a single level in 48 of the patients and in 2 levels in 3 patients. The mean operative time was 434 minutes (range 270-530 minutes) and mean intraoperative blood loss was 520 mL (range 360-1100 mL). The mean LKA improved from 34.7° to 4.9° (85.9%). For 27 patients, the initial neurological deficit (ASIA A in 8, ASIA B in 3, ASIA C in 5, and ASIA D in 11) improved at least 1 ASIA grade (1-3 grades) in 22 patients (81.5%). Solid fusion, assessed with computed tomography at the final follow-up, was achieved in all patients. CONCLUSION: Single-stage PVCR provides complete spinal canal decompression, ideal kyphosis correction with gradual lengthening of anterior column together with sequential posterior column compression. Anterior column support, avoidance of the morbidity of anterior approach and improvement of neurological deficit are the other advantages of the single stage PVCR technique in patients with thoracic/thoracolumbar burst fractures.

Clinical, radiological and HRQoL outcomes after selective thoracic fusion with minimum 15-year follow-up.

INTRODUCTION: The purpose of the study was to provide a 15-year natural history evaluation of the radiographic appearance of uninstrumented compensatory lumbar curves in patients who had undergone selective thoracic fusion (STF) for scoliosis, measure any changes in health-related quality of life scores (HRQoL) and compare them with controls matched for age, gender and body-mass index (BMI). METHODS: STF group included 43 female adolescent idiopathic scoliosis (AIS) patients who underwent STF with mean age 33(27-42) years and a mean follow-up of 18.7 (15-28) years, mean BMI 22(18-29). Preop, early postop and follow-up radiographs were reviewed for behavior of lumbar curves. Control group included a random selection of healthy volunteers with no history of back pain and with mean age 33(27-41), and mean BMI 22(17-33). HRQoL scores were compared between two groups in latest f/up. Radiographs including low dose biplanar imaging with EOS were used to measure disc heights and assess for radiographic evidence of degenerative changes. Various parameters were statistically compared. RESULTS: Posterior fusion was performed in all 43, with all pedicle screws used in 41 and all-hook constructs in 2. Main thoracic curve correction was improved from pre-op to early-post-op and maintained at latest f/up (55.6°-16.1°-16.9°). Spontaneous lumbar curve correction (SLCC) was also maintained beyond 15 years (39.9°-16.6°-17.1°). Two patients developed coronal decompensation following surgery, but improved with time and were well compensated at final follow-up. Mean HRQoL scores, self-image and mental health scores were higher in STF group than control group (p < 0.05). SRS-22r pain and function, Oswestry Disability Index and Numeric Rating Scale, marital status, number of children were similar between the groups(p > 0.05). All disc heights except L5-S1 were significantly lower in STF group (p < 0.05). There was no significant difference between the groups for degenerative changes in the latest radiographs. CONCLUSION: In this group of patients, the uninstrumented lumbar curve spontaneously corrected and the correction was maintained after 18 years following surgery using STF. Mild degenerative changes were seen radiographically and HRQoL scores suggest that the psychological-functional well-being are quite good in the long term in AIS patients who have undergone STF when compared with an age-gender-BMI-matched population.

Does low body mass index constitute a risk of damage to the soft tissues during reaming for proximal femoral nailing? a cadaveric study.

BACKGROUND: The purpose of this cadaveric study was to evaluate the damage to the gluteus medius muscle, tendon and superior gluteal nerve in low BMI patients during the reaming of the greater trochanter tip for proximal femoral nailing. MATERIALS AND METHODS: The study used 19 femurs of 10 fresh femur intact cadavers [mean BMI: 22.79 (17.60-28.70)]. A guidewire was placed in the tip of greater trochanter under C-arm fluoroscopy, and a 17-mm reamer was advanced over the wire. After the reaming was completed, the hips were dissected and the gluteus medius muscle, tendon and superior gluteal nerve were inspected to evaluate the amount of injury. RESULTS: BMI was < 18.50 in 3 cadavers. The gluteus medius muscle was injured in all hips. The superior gluteal nerve was intact in all hips, but the thickness of gluteus medius muscle mass that remained intact was thicker in the cadavers with a higher BMI (3.86 mm for low BMI, 9.08 mm for high BMI group). The percentage of the tendon insertion disrupted by the reamer was an average of 36.20% in the low BMI group and an average of 26.93% in the high BMI group. The percentage of the tendon insertion disrupted by the reamer showed a statistically significant difference between low and high BMI cadavers. CONCLUSION: The injury to the gluteus medius muscle and tendon after proximal femoral nailing through the greater trochanter tip may be higher in patients with low BMI. It must be kept in mind that gluteal muscle could be damaged during proximal femoral nailing and this could result in limping.

Effect of cementing on pulmonary arterial pressure in vertebroplasty: A comparison of two techniques.

BACKGROUND: Increase in intraosseous pressure and displacement of bone marrow contents leading to fat embolism and hypotension during cement injection in vertebroplasty (VP). We aimed to compare the effect of low and high viscosity cements during VP on pulmonary arterial pressure (PAP) with different cannula. MATERIALS AND METHODS: Fifty-two patients having multilevel VP due to osteoporotic vertebral compression fractures were randomly treated either by a high viscosity cement (group A, n = 27 patients) and 2.8 mm cannula or a low viscosity cement (group B, n = 25 patients) injected through 4.2 mm cannula. PAP was measured by standard echocardiography and blood d-dimer values were recorded preoperatively, 24 h and third day after operation. RESULTS: Mean age was 69 (62-87) years in group A and 70 (64-88) years in group B, and sex and comorbidities were similar. Average number of augmented levels was 5.4 in group A and 5.7 in group B. Preoperative mean PAP was 33 mm/Hg in group A, elevated to 41 mm/Hg on first day, and decreased to 36 mm/Hg on third day. The mean PAP in group B was 35 mm/Hg preoperatively, 51 mm/Hg on first day and 46 mm/Hg on third day (p < 0.05). The average blood d-dimer values in group A increased from 2.1 µg/mL to 2.3 µg/mL and in group B from 2.2 µg/mL to 4.2 µg/mL. CONCLUSION: The finding of this study showed that high viscosity cement injected through a narrower cannula results in lesser PAP increase and d-dimer levels when compared to low viscosity cement injected through a wider cannula. Higher PAP and d-dimer level may show possible thromboembolism. This finding may give spine surgeons to reconsider their choice of cement type and cannula size.

The ANK nail treatment of lateral malleolar fractures with syndesmosis injury: Clinical outcomes at 10 years of follow-up.

BACKGROUND: Lateral malleolar fractures associated with syndesmotic injuries are common. Various surgical implants may be used for the management of syndesmosis injury. One of these is ANK nail. The aim of the present study was to assess the clinical and radiological outcomes of patients treated with ANK nail. METHODS: Forty-eight patients who were followed up for a minimum of 10 years were reviewed retrospectively using American Orthopedic Foot and Ankle Society (AOFAS) score, radiological evaluation, and development of posttraumatic arthritis. Final data were collected at the last follow-up. RESULTS: The mean age of the patients was 37.3 (17-69) years. The mean follow-up was 129.9 (123-150) months. Twenty-two patients had Weber type B fracture, and their mean AOFAS score was 93.36 points. The remaining 26 patients had Weber type C fracture, and their mean AOFAS score was 97.66 points. There was no relationship between the type of fracture and the clinical outcome. There was a significant correlation between shortening of the fibula and posttraumatic arthritis. CONCLUSION: The ANK nail used for the management of ankle fractures may provide both fracture and syndesmosis stabilities in selected cases and is also a cost effective method as cheap as a cortical screw and a Kirschner wire.

Longitudinal Follow-Up of Two Patients with Dysspondyloenchondromatosis due to Novel Heterozygous Mutations in COL2A1.

Dysspondyloenchondromatosis (DSC) is a rare form of generalized enchondromatosis and characterized by short stature with unequal limb length, multiple enchondromas in metaphyseal and diaphyseal parts of the long tubular bones, and progressive kyphoscoliosis. Although the COL2A1 gene mutation was found to be responsible for DSC, a case of DSC with no pathogenic mutation in the COL2A1 gene has also been reported, suggesting that the condition is genetically heterogeneous. Here, we report 2 novel heterozygous mutations in COL2A1 in 2 patients with DSC. They had prenatal onset short stature with unequal limb length and generalized enchondroma-like lesions in metaphyseal and diaphyseal parts of the long tubular bones, and osteopenia. The first patient was diagnosed at 3 months of age and followed for 10.5 years. Severe lumbosacral scoliosis and recurrent fractures were observed. The second patient was diagnosed at the age of 4 years. Mild deterioration in scoliosis was observed during the 3-year-long follow-up period. However, skeletal radiography of both patients showed the improvement of enchondromatous lesions. In conclusion, we verified that the COL2A1 gene mutations are responsible for the DSC phenotype. We observed severe osteopenia and fractures which were not reported previously.

Pulmonary cement embolism following cement-augmented fenestrated pedicle screw fixation in adult spinal deformity patients with severe osteoporosis (analysis of 2978 fenestrated screws).

INTRODUCTION: There is very limited information about pulmonary cement embolism (PCE) following cement-augmented fenestrated pedicle screw (CAFPS) fixation in the literature. The aim of this study to report the incidence of PCE following CAFPS fixation in adult deformity patients with severe osteoporosis and to identify risk factors such as; the number of levels, number of screws, and the cement volume used. METHODS: 281 patients (204F, 77M) in whom CAFPS fixation was used during deformity surgery were included. All patients' routine postop 2 day chest X-rays and any available CT scans were reviewed by two radiologists. In patients with PCE, preop, early postop, and latest echocardiography studies were compared in terms of changes in pulmonary artery pressure (PAP) and right ventricular dilatation. Estimated cement volume used was calculated as: 2 cc (1 cc + 1 cc) per thoracic and 3 cc (1.5 cc + 1.5 cc) per lumbar levels, which are our routine protocol. Statistical analysis for risk factors was assessed with point biserial correlation test. RESULTS: Average age is 70.5 (51-89) and average follow-up is 3.2 years (2-5). A total of 2978 CAFPS were instrumented with a mean of 10.5 levels (2-16) in 281 patients. PCE was diagnosed radiologically in 46 patients (16.3%). Among these 46 patients, PCE was clinically symptomatic in only 4 patients. Overall incidence of symptomatic PCE was 1.4% (4 of 281). Symptomatic PCE was statistically significant: when CAFPS fixation was performed > 7 levels; > 14 screws were used, and > 20-25 cc cement was used for augmentation (r = 0.378). In PCE group, mean preop PAP values of 27.40 (20-37) mm/Hg increased to 32.34 (20-50) mm/Hg in early postop and decreased to 28.29 (18-49) mm/Hg at final follow-up. In symptomatic PCE patients, mean preop PAP values of 30.75 (28-36) mm/Hg increased to 45.74 (40-50) mm/Hg in early postop and decreased to 38.75 (37-40) mm/Hg at final follow-up. CONCLUSION: This study showed an overall 16.3% radiological PCE and 1.4% symptomatic PCE incidence when CAFPS were used due to severe osteoporosis. The symptomatic PCE risk was significant when CAFPS were > 7 levels; > 14 fenestrated screws; and > 20-25 cc cement volume is used and this may cause PAP increase and right ventricular dilatation.

The effect of mechanical aspiration of the vertebral body on pulmonary arterial pressure before cement injection in the vertebroplasty procedure.

PURPOSE: The aim of this study is to compare the efficacy of the mechanical aspiration technique just prior to cement application in the standard vertebroplasty (VP). METHODS: Forty patients were included in the study. In group A, mechanical aspiration of the cavity was done just before the cement injection and in group B aspiration of vertebral body did not perform, VP was done with the same size cannula, same injection force, same injection speed and same cement viscosity. Pulmonary arterial pressures (PAPs) and blood d-dimer values were recorded preoperatively, 24 h and 3 days after the procedure. The PAP and d-dimer data were statistically compared with Student's t-test. RESULTS: The mean age was 71 (62-87) in A and 70 (64-88) in B. The augmented level was 6.7 in A and 6.9 in B. Cement leakage was present in four in A and six in B. Acute hypotension was observed immediately after cement injection in one patient in A and four patients in B. The preoperative mean PAP in A was 35mm/Hg and elevated to 48 mm/Hg on the first postoperative day and decreased to 42 mm/Hg on the third postoperative day. The mean PAP in B was 36 mm/Hg preoperatively, 71 mm/Hg on the first day, and 58 mm/Hg on the third day ( p < 0.05). The d-dimer values revealed a difference between groups, the PAP values significantly changed between before and after the operation in both groups ( p < 0.005). CONCLUSION: Aspiration of the vertebral body can easily be used to decrease the risk of cement leakage and the migration of fatty particles into the pulmonary circulation.

Paper #21: Posterior Vertebral Column Resection (PVCR) for Congenital Thoracic Lordoscoliosis in children under age of 10 with minimum 5 years follow-up.

Congenital thoracic lordosis or lordoscoliosis are rare deformities which causes severe cardiopulmonary problems in early ages. PVCR is effective in restoring thoracal kyphosis in treatment of these rare deformities and avoids morbidity of combined surgeries.

Does It Make a Difference to Stop Fusion at L3 Versus L4 in Terms of Disc and Facet Joint Degeneration: An MRI Study With Minimum 5 Years Follow-up.

OBJECTIVES: To compare the functional outcomes of patients with idiopathic scoliosis who had surgical correction and fusion with all pedicle screw construct down to L3 or L4 and to evaluate whether saving a mobile lumbar motion segment distally would demonstrate any difference in terms of disc degeneration (DD) and facet joint degeneration (FJD) after minimum 5 years follow-up. SUMMARY OF BACKGROUND DATA: Selection of lowest instrumented vertebra (LIV) is often difficult when lumbar curve was included into the fusion (L3 vs L4). Saving L4 is believed to be beneficial for preserving motion and preventing degeneration of unfused lumbar spine. METHODS: The L3 group included 21 patients (mean age of 21.4) and L4 group included 16 patients (mean age 22.9). Control group included 30 healthy individuals with no spinal deformities (mean age of 23.8). Follow-up lumbar magnetic resonance images (MRIs) were evaluated for each patient in terms of DD and FJD. Clinical evaluation was done by using the Scoliosis Research Society-22r, Oswestry Disability Index, and Numeric Rating Scale. RESULTS: Mean follow-up period was 7.4 (5-10) years in the L3 group and 9 (5-17) years in L4 group. Average correction rates for lumbar curve magnitudes were 78% in the L3 group and 79% in the L4 group, with no significant correction loss at the final follow-up. There was no statistical difference for DD in all groups (p > .05). FJD was significantly greater in both L3 and L4 groups compared to the control group (p < .001). Clinical outcome scores were similar among all three groups (p > .05). CONCLUSION: Spinal balance and corrections remained stable, without showing any decompensation over time. This midterm MRI study demonstrated similar disc and facet degeneration rates for L3 and L4 groups. FJD at the upper two levels adjacent to the LIV was significant for both surgically treated groups. Clinical outcome scores were similar for all groups at minimum 5 years follow-up.

Does pedicle screw fixation under age 5 cause spinal canal narrowing? A CT study with minimum 5 years follow-up.

PURPOSE: The aim of this retrospective study was to evaluate the changes in the vertebral body and spinal canal area in a group of patients who had pedicle screw fixation under age 5 for the treatment of congenital spinal deformity at least 5 year follow-up. METHODS: 11 patients who had been operated due to spinal deformity under age 5 with who had a CT examination at least 5 years after the initial operation were included in the study. All patients underwent hemivertebrectomy and transpedicular fixation procedures at an average age of 3.18 years (range 2-5 years). All had preoperative CT to evaluate the congenital deformities. Measurements were done at the instrumented vertebrae as well as the un-instrumented ones above and below them to evaluate; vertebral body parameters, pedicle parameters and spinal canal area of upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), upper adjacent un-instrumented vertebra and lower adjacent un-instrumented vertebra. RESULTS: The average follow-up was 7.2 (range 5-12) years. Six of the patients were over age 10 during the final CT examination while 5 were at age 7. Female-to male ratio was 8-3. Measurement of all the parameters in 22 instrumented and 22 non-instrumented segments showed a proportional increase rather than a decrease at each segment. The percentage of canal area growth at UIV and LIV was 21 and 17.5 %, respectively. CONCLUSION: Pedicle screw instrumentation has no adverse effect on further spinal body, pedicle and canal growth and does not result in iatrogenic spinal canal stenosis.

Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study.

BACKGROUND: The aim of this retrospective study was to evaluate treatment effect and importance of posterior malleolus (PM) fixation in surgically treated trimalleolar fractures. METHODS: A total of 57 cases of ankle joint fracture involving PM and treated with open reduction and internal fixation technique between 2004 and 2011 were evaluated. PM fixation was performed with cannulated screws in 46 cases, and in 11 cases, PM plate was used. All patients were assessed using American Orthopaedic Foot and Ankle Society (AOFAS) score, American Academy of Orthopedic Surgeons (AAOS) foot and ankle questionnaire, and Visual Analog Score (VAS) pain scale. Ankle joint mobility was also compared with unaffected side. RESULTS: Mean follow-up period was 44.6 months (range: 24-108 months). There were 36 female patients and 21 male patients between 23 and 85 years of age (mean: 55.9 years). Average time to surgery was 1.1 day (range: 1-3 days). According to AOFAS assessment, result was excellent in 21 patients and good in 26 patients. AAOS score was 92.4 (range: 32-100). Mean VAS score when resting was 1.1, and mean score was 1.3 when walking (range: 0-10). When compared with uninjured side, there was no significant difference in plantar flexion of ankle (p=0.325) but there was significant difference in dorsiflexion of ankle joint (p<0.001). CONCLUSION: Anatomical reduction and rigid internal fixation of PM provide satisfactory clinical and functional outcomes even in elderly patients where bone quality may make adequate fixation difficult. Fixation of even small PM fragments can facilitate rehabilitation by creating more stable construction.

Selective Thoracic Fusion Provides Similar Health-Related Quality of Life but Can Cause More Lumbar Disc and Facet Joint Degeneration: A Comparison of Adolescent Idiopathic Scoliosis Patients With Normal Population 10 Years After Surgery.

OBJECTIVES: To evaluate the long-term behavior of the lumbar curve in patients with adolescent idiopathic scoliosis treated with selective thoracic fusion and to assess the clinical and radiologic outcomes in this fusion group compared with an age- and gender-matched group. SUMMARY OF BACKGROUND DATA: Selective thoracic fusion for the treatment of adolescent idiopathic scoliosis (AIS) preserves lumbar motion segments but leaves a residual deformity. By avoiding fusion of the lumbar spine, a greater mobility may be preserved, which may be an advantage in long-term follow-up in terms of degenerative changes in unfused segments. METHODS: Group A included 25 AIS patients with mean a age of 23.8 years and a mean 11.4 years of follow-up. Group B included 30 age- and gender-matched subjects without any deformity. Preoperative, postoperative, and follow-up radiographs were reviewed. All patients had MRIs taken at the final follow-up in order to evaluate disc degeneration (DD) and facet joint degeneration (FJD) at the unfused lumbar spine. Clinical evaluation was done by using Scoliosis Research Society-22R, Oswestry Disability Index, and numerical rating scale. RESULTS: Sagittal and coronal balance and lowest instrumented vertebra disc angulation were stable over time. Mean grading of lumbar DD was 2.16 (2-4) in Group A and 1.86 (1-3) in Group B. Lumbar FJDs were 2.05 (1-4) in Group A and 1.60 (1-3) in Group B. There was significant difference between the two groups for DD except for the L4-L5 level (p = .26). FJD was significantly higher in the L1-L2 and L2-L3 levels (L1-L2, p = .002, L2-L3, p = .002) but not for the other levels. Outcome scores were similar without significant differences between the two groups (p > .05). CONCLUSION: Selective thoracic fusion provides satisfactory outcomes at more than 10 years of follow-up. Our study demonstrated a moderate increase in the rate of disc degeneration in the unfused segments. Facet joint degeneration was significant at the upper two levels adjacent to the lowest instrumented vertebra.

Relationship between axillary nerve and percutaneously inserted proximal humeral locking plate: a cadaver study.

OBJECTIVE: The aim of this study was to investigate the relationship between the axillary nerve and the percutaneously inserted proximal humeral locking plate and to evaluate the risk of axillary nerve injury during percutaneous plate insertion. METHODS: The study included 50 shoulders of 25 fresh frozen cadavers. A 5 cm incision was made from the anterolateral border of the acromion to the arm and a 5-hole 3.5-mm proximal humeral plate was inserted. The axillary nerve was then dissected. Plate holes which crossed the axillary nerve were noted. The distance between the axillary nerve and the lateral edge of the acromion and the length of the arm were measured and their relations evaluated with a correlation test. RESULTS: The average arm length was 319 mm. The average distance between the axillary nerve and the lateral edge of the acromion was 60 mm. There was a significant correlation between the arm length and acromion-axillary nerve distance (p<0.05). The plate was inserted under the deltoid fascia in all shoulders except one. There were no axillary nerve lesions. In 1 case, the distal end of the plate was inserted in the deltoid muscle. No constant relationship between the plate holes and the axillary nerve was detected. CONCLUSION: There is a risk of axillary nerve injury during percutaneous plate insertion. It must be ensured that the plate is inserted under the deltoid fascia during the surgery. The axillary nerve must be visible during application of the screws due to the impossibility of knowing which holes cross the axillary nerve.

Apical and intermediate anchors without fusion improve Cobb angle and thoracic kyphosis in early-onset scoliosis.

BACKGROUND: The main goal of treatment in early-onset scoliosis is to obtain and maintain curve correction while simultaneously preserving spinal, trunk, and lung growth. This study introduces a new surgical strategy, called the modified growing rod technique, which allows spinal growth and lung development while controlling the main deformity with apical and intermediate anchors without fusion. The use of intraoperative traction at the initial procedure enables spontaneous correction of the deformity and decreases the need for forceful correction maneuvers on the immature spine and prevents possible implant failures. This study seeks to evaluate (1) curve correction; (2) spinal length; (3) number of procedures performed; and (4) complications with the new approach. DESCRIPTION OF TECHNIQUE: In the initial procedure, polyaxial pedicle screws were placed with a muscle-sparing technique. Rods were placed in situ after achieving correction with intraoperative skull-femoral traction. The most proximal and most distal screws were fixed and the rest of the screws were left with nonlocked set screws to allow vertical growth. The lengthening reoperations were performed every 6 months. METHODS: Between 2007 and 2011, we treated 19 patients surgically for early-onset scoliosis. Of those, 16 (29%) were treated with the modified growing rod technique by the senior author (AH); an additional three patients were treated using another technique that was being studied at the time by one of the coauthors (CO); those three were not included in this study. The 16 children included nine girls and seven boys (median, 5.5 years of age; range, 4-9 years), and all had progressive scoliosis (median, 64°; range, 38°-92°). All were available for followup at a minimum of 2 years (median, 4.5 years; range, 2-6 years). RESULTS: The initial curve Cobb angle of 64° (range, 38°-92°) improved to 21° (range, 4°-36°) and was maintained at 22° (range, 4°-36°) throughout followup. Preoperative thoracic kyphosis of 22° (range, 18°-46°) was maintained at 23° (range, 20°-39°) throughout followup without showing any substantial change. There was a 47 mm (range, 38-72 mm) increase in T1-S1 height throughout followup. The mean number of lengthening operations was 5.5 (range, 4-10). The mean T1-S1 length gain from the first lengthening was 1.18 cm (range, 1.03-2.24 cm) and decreased to 0.46 cm (range, 0,33-1.1 cm) after the fifth lengthening procedure (p = 0.009). The overall complication rate was 25% (four of 16 patients) and the procedural complication rate was 7% (seven of 102 procedures). We did not experience any rod breakages or other complications apart from two superficial wound infections managed without surgery during the treatment period. The only implant-related complications were loosening of two pedicle screws at the uppermost foundation in one patient. CONCLUSIONS: In this preliminary study, the modified growing rod technique with apical and intermediate anchors provided satisfactory curve control, prevented progression, maintained rotational stability, and allowed continuation of trunk growth with a low implant-related complication rate.

Osteotomies/spinal column resections in adult deformity.

Osteotomies may be life saving procedures for patients with rigid severe spinal deformity. Several different types of osteotomies have been defined by several authors. To correct and provide a balanced spine with reasonable amount of correction is the ultimate goal in deformity correction by osteotomies. Selection of osteotomy is decided by careful preoperative assessment of the patient and deformity and the amount of correction needed to have a balanced spine. Patient's general medical status and surgeon's experience levels are the other factors for determining the ideal osteotomy type. There are different osteotomy options for correcting deformities, including the Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), bone-disc-bone osteotomy (BDBO) and vertebral column resection (VCR) providing correction of the sagittal and multiplanar deformity. SPO refers to a posterior column osteotomy in which the posterior ligaments and facet joints are removed and a mobile anterior disc is required for correction. PSO is performed by removing the posterior elements and both pedicles, decancellating vertebral body, and closure of the osteotomy by hinging on the anterior cortex. BDBO is an osteotomy that aims to resect the disc with its adjacent endplate(s) in deformities with the disc space as the apex or center of rotational axis (CORA). VCR provides the greatest amount of correction among other osteotomy types with complete resection of one or more vertebral segments with posterior elements and entire vertebral body including adjacent discs. It is also important to understand sagittal imbalance and the surgeon must consider global spino-pelvic alignment for satisfactory long-term results. Vertebral osteotomies are technically challenging but effective procedures for the correction of severe adult deformity and should be performed by experienced surgeons to prevent catastrophic complications.

Pneumomediastinum, subcutaneous emphysema, and tracheal tear in the early postoperative period of spinal surgery in a paraplegic achondroplastic dwarf.

Achondroplasia was first described in 1878 and is the most common form of human skeletal dysplasia. Spinal manifestations include thoracolumbar kyphosis, foramen magnum, and spinal stenosis. Progressive kyphosis can result in spinal cord compression and paraplegia due to the reduced size of spinal canal. The deficits are typically progressive, presenting as an insidious onset of paresthesia, followed by the inability to walk and then by urinary incontinence. Paraplegia can be the result of direct pressure on the cord by bone or the injury to the anterior spinal vessels by a protruding bone. Surgical treatment consists of posterior instrumentation, fusion with total wide laminectomy at stenosis levels, and anterior interbody support. Pedicle screws are preferred for spinal instrumentation because wires and hooks may induce spinal cord injury due to the narrow spinal canal. Pedicle lengths are significantly shorter, and 20-25 mm long screws are appropriate for lower thoracic and lumbar pedicles in adult achondroplastic There is no information about the appropriate length of screws for the upper thoracic pedicles. Tracheal injury due to inappropriate pedicle screw length is a rare complication. We report an extremely rare case of tracheal tear due to posterior instrumentation and its management in the early postoperative period.