Sagittal endplate morphology of the lower lumbar spine.

SUMMARY OF BACKGROUND DATA: The sagittal profile of lumbar endplates is discrepant from current simplified disc replacement and fusion device design. Endplate concavity is symmetrical in the coronal plane but shows considerable variability in the sagittal plane, which may lead to implant-endplate mismatch. OBJECTIVE: The aim of this investigation is to provide further analysis of the sagittal endplate morphology of the mid to lower lumbar spine study (L3­S1), thereby identifying the presence of common endplate shape patterns across these levels and providing morphological reference values complementing the findings of previous studies. STUDY DESIGN: Observational study. METHODS: A total of 174 magnetic resonance imaging (MRI) scans of the adult lumbar spine from the digital archive of our centre, which met the inclusion criteria, were studied. Superior (SEP) and inferior (IEP) endplate shape was divided into flat (no concavity), oblong (homogeneous concavity) and ex-centric (inhomogeneous concavity). The concavity depth (ECD) and location of concavity apex (ECA) relative to endplate diameter of the vertebrae L3­S1 were determined. RESULTS: Flat endplates were only predominant at the sacrum SEP (84.5%). The L5 SEP was flat in 24.7% and all other endplates in less than 10%. The majority of endplates were concave with a clear trend of endplate shape becoming more ex-centric from L3 IEP (56.9% oblong vs. 37.4% ex-centric) to L5 IEP (4% oblong vs. 94.3% ex-centric). Ex-centric ECA were always found in the posterior half of the lumbar endplates. Both the oblong and ex-centric ECD was 2-3 mm on average with the IEP of a motion segment regularly possessing the greater depth. A sex- or age-related difference could not be found. CONCLUSION: The majority of lumbar endplates are concave, while the majority of sacral endplates are flat. An oblong and an ex-centric endplate shape can be distinguished, whereby the latter is more common at the lower lumbar levels. The apex of the concavity of ex-centric discs is located in the posterior half of the endplate and the concavity of the inferior endplate is deeper than that of the superior endplate. Based on the above, the current TDR and ALIF implant design does not sufficiently match the morphology of lumbar endplates in the sagittal plane.

Utility of telephone consultations during COVID-19 and beyond: a study of orthopedic spinal patients.

BACKGROUND: Due to the COVID-19 pandemic, hospital clinic lists have abruptly shifted towards remote appointments via telephone. This study investigated the views and experiences of telephone consultations in a population of orthopedic spinal patients. METHODS: A 10-item telephone questionnaire was completed by 202 orthopedic spinal patients. Questions addressed patient perceptions towards: confidence in telephone consultations; their impact on treatment outcome; their advantages and limitations and how satisfied they were with their telephone consultation. RESULTS: Ninety-four percent of patients were confident in their doctor providing effective care via telephone consultation. 81% of patients were confident that their treatment outcome would not have changed with a face-to-face appointment and 75% would consider choosing a telephone consultation in the postpandemic era. Key benefits of telephone consultations for patients are the convenience of not travelling and avoiding travel-related expenses. The most commonly reported limitation is the lack of a clinical examination. Satisfaction scores were consistently high with no significant differences between different treatment groups. CONCLUSIONS: This study demonstrates that telephone calls are a favorable method of consultation for patients requiring orthopedic spinal care. Satisfaction levels are consistently high, patient confidence in their clinician is nearly unanimous and a majority of patients would consider choosing this method for future follow-up appointments. Issues with telephone consultations appear to chiefly concern the lack of physical examination, difficulties with the communication and retention of clinical information, and brevity of the appointment. However, consistent satisfaction scores suggest broad utility across a comprehensive range of treatment outcomes for orthopedic spinal patients.

Extra-articular fixation for treatment of Lisfranc injury.

Lisfranc injuries are not very common. Surgical options available for treatment of Lisfranc injuries have produced chronic pain and disability due to the damage to the articular surface, leading to early arthritis. We describe the technique of extra-articular fixation using dorsal plates for Lisfranc injury, avoiding any damage to the articular surface.

An analysis of different types of surgical fixation for avulsion fractures of the anterior tibial spine.

This is a retrospective study of 25 patients, looking at the outcome of open reduction and fixation of displaced anterior tibial spine avulsion fractures with absorbable and non-absorbable materials. The mean period of follow-up was 44 months (range, 21 to 88 months). The results of surgery were assessed clinically and radiologically. Outcome was evaluated by using the Lysholm knee scoring system. Anterior cruciate ligament laxity was assessed by using a KT-1000 arthrometer and range of movements with a goniometer. Overall, children did better than adults, but age per se did not appear to affect the final outcome. There was no significant difference between children fixed with absorbable or non-absorbable materials. Adults fixed with non-absorbable material had significantly better results than those fixed with absorbable material. Herbert screws had a tendency to migrate into the bone substance, and are best avoided. Protected early mobilisation in a knee brace was found to be safe and helped to regain early range of movements in the knee joint.

Achieving the required medial offset and limb length in total hip arthroplasty.

The magnitude of the medial offset and limb length discrepancy after a total hip arthroplasty (THA) significantly affects the biomechanics of the hip. If both of these components are not properly restored, the rate of dislocation may increase. In addition limb length inequality can be a cause for legal problems. We have used a method of intraoperative assessment to restore both the length and the medial offset, and assessed this by comparing the medial offset and leg length in the pre- and post-operative radiographs in 39 consecutive THAs. The median medial offset was 93.9% (range: 85 to 100) preoperatively and 94.2% (range: 85 to 110) postoperatively, compared with the unaffected contralateral side. The median limb length discrepancy was improved from a preoperative -4.84 mm (range: 0 to -30) to a postoperative -0.06 mm (range: -9 to +16). In conclusion, this technique is a simple, accurate and reliable way of restoring the medial femoral offset and correcting the limb length inequality.

Total hip replacement for acute femoral neck fracture: a survey of National Joint Registries.

Joint registers audit the performance of different types of prosthesis. The data from these registers is invaluable, as the conclusions are evidence based and are not based on the results from a small clinical trial or a case series. The 3rd National Joint Registry Annual Clinical Report (2005) of England and Wales was compared with the latest available online report of other national joint registers, particularly with reference to the usage of total hip replacement performed for fracture of the neck of the femur. In Sweden, total hip replacement is performed for the management of a fracture of the neck of the femur six times more often than in England and Wales, four times more often than in Australia, twice more often than in Canada. Hip fracture registers could provide us with the much needed clinical evidence that could help us solve the last controversy of this unsolved fracture.

The low anterior cervical approach to the upper thoracic vertebrae: a decision by preoperative MR imaging.

PURPOSE: Surgical approaches to the upper thoracic spine are fraught with many problems as they involve thoracotomy or sternotomy. We analyzed 102 midsagittal MRI scans to evaluate the level of the sternal notch in relation to the upper thoracic spine, so that if the tangential line through the upper part of the sternal notch passed below the level of the involved vertebra, we could surgically access the involved vertebra by the low anterior cervical approach, which is familiar to most spinal surgeons. MATERIALS AND METHODS: Between January and June 2002, 102 consecutive mid-sagittal T2 weighted MRI scans were evaluated. The line as described above was then drawn on each MRI to assess the level of the involved vertebra. RESULTS: In 68.7% of the cases, the level of the sternal notch corresponded to T2 and T3. This method of assessing accessibility was used in a patient with a fractured T3 that yielded excellent surgical exposure. It was found that routine use of saturation bands is not needed in upper thoracic spine pathology as it obscured the visualization of the sternal notch in 20% of the cases. CONCLUSION: In patients with high thoracic fractures who require surgical decompression and stabilization, pre-operative MR scan and assessing the level of the vertebra in relation to the sternal notch can allow a low anterior cervical approach to be used thus decreasing the patient morbidity related to the surgical approach.

Sequestrated lumbar intervertebral disc in the posterior epidural space: a report on two cases and review of the literature.

BACKGROUND: Posterior epidural migration is an interesting but rare path taken by a prolapsed intervertebral disc fragment. There are only seven cases reported of a similar migration of the disc fragment in the lumbar spine. PURPOSE: To diagnose the unusual presentation and interpretation of the sequestrated disc in the posterior epidural space. STUDY DESIGN: Case report. METHODS: Two cases of migration of the sequestrated disc into the posterior epidural space are presented. In one patient there was weakness of the ankle dorsiflexors, foot invertors, and toe extensors of the left foot, with sensory loss over the back of the calf and over the lateral three toes. The left ankle jerk was also absent. However, in the other case, there was no objective evidence of neurological deficit distally. RESULTS: Gadolinium magnetic resonance imaging scans showed ring enhancement preoperatively. Biopsy of the specimen taken from surgery confirmed it to be sequestrated disc fragment. CONCLUSION: Diagnosis of posterior epidural migration of the sequestrated discs may be difficult. It may present with subtle clinical features even though the disc transgresses through numerous anatomic restraints including the nerve roots in such cases.

"Created" patella in total knee arthroplasty (TKA) after prior patellectomy.

Currently, total knee arthroplasty (TKA) is one of the most successful orthopaedic surgeries. However, the results are inferior in patients with previous patellectomy because of anteroposterior instability, residual pain, and loss of the mechanical advantage of the patella. The moment arm of the quadriceps can be restored by bone grafting the patellar tendon, and thus regaining the benefits of an intact patella that results in a better outcome after TKA. Usually it requires an additional procedure with its associated co-morbidities to harvest the bone graft. As the bone graft has to articulate with the femoral prosthesis, it has to be smooth at least on one side. The authors have described a new technique in this Chapter by which bone grafting of the patellar tendon can be achieved with use of the tibial plateau obtained from the routine tibial cut during TKA. Tibial eminence can be used as the interfacetal ridge of the "created" patella.

Management of an unusual intra- and extra-capsular subcapital femoral neck fracture.

Femoral neck fractures are common in the elderly after low-energy falls. They are broadly grouped into either intracapsular or extracapsular fractures. We report an unusual subcapital femoral neck intra-extracapsular fracture and discuss the management of such a case with its inherent problems.

Atlantoaxial rotatory subluxation as a cause of torticollis in a 5-year-old girl.

Many patients present to the emergency department complaining of a sore or stiff neck and lateral flexion of the neck with contralateral rotation. Under the pressure of the breaching time and busy shifts some of the patients are discharged to the care of their general practitioners without adequate investigations. While most of the cases are due to benign causes, torticollis can be due to many congenital and acquired pathologies, some of which may need further investigation and urgent management. Atlantoaxial subluxation (AAS), tumours of the base of the skull and infections are among these causes. Delayed diagnosis may lead to worsening neurology and complicate the management. We report a case of a 5-year-old girl who presented to our fracture clinic with a fractured clavicle and torticollis; her subsequent investigations confirmed the diagnosis of AAS. Our patient responded to non-operative treatment and improved with no neurological complications.

Impact of reinfusion drains on hemoglobin level in total knee arthroplasty.

We conducted this study to determine the effect of reinfusion drains on the difference in hemoglobin (Hb) levels before and after total knee arthroplasty. Of the 158 patients who underwent total knee arthroplasty on one side, 74 had autologous blood transfusion through reinfusion drains (group 1); the other 84 did not have autologous blood transfusion, but ordinary suction drains were used to drain the wound during the immediate postoperative period (group 2). Mean preoperative Hb levels were 13.6 g/dL for group 1 (SD, 1.4 g/dL; range, 10.4-18.1 g/dL) and 13.6 g/dL for group 2 (SD, 1.3 g/dL; range, 10.0-16.7 g/dL). Mean postoperative Hb levels were 10.7 g/dL for group 1 (SD, 1.5 g/dL; range, 7.9-16.5 g/dL) and 10.7 g/dL for group 2 (SD, 1.6 g/dL; range, 5.4-13.6 g/dL). The difference in Hb levels between the groups before and after the surgery was analyzed with t test and found to be not significant (P = .76). The reinfusion drain cost pound 36.43 ( approximately US$58.87) more than the suction drain. Autologous blood from reinfusion drains did not significantly improve postoperative Hb levels. Further use of reinfusion drain is not cost-beneficial.

Spondylodiscitis due to Prevotella associated with ovarian mass--a rare case report and review of literature.

BACKGROUND: Spondylodiscitis is commonly caused by aerobic bacteria. Of all the spinal infections, anaerobic organisms account for less than 3% and are usually seen in postoperative patients. CASE DESCRIPTION: We report a rare case of spontaneous onset of spondylodiscitis caused by anaerobe Prevotella that led to the diagnosis of serous cystadenofibroma of the ovaries. CONCLUSION: The finding of Prevotella species in musculoskeletal infection should prompt investigation of the genitourinary system.

Infection rate of percutaneous Kirschner wire fixation for distal radius fractures.

PURPOSE: To review the infection rate in 43 patients who underwent percutaneous Kirschner wire fixation for distal radius fractures. METHODS: Records of 13 men and 30 women aged 25 to 86 (mean, 49) years who underwent closed reduction and percutaneous Kirschner wire fixation for unstable distal radius fractures were reviewed. Each fracture was fixed with 2 to 3 wires of 1.6-mm diameter. Kirschner wires were left protruding through the skin for easy removal, with their ends bent outside the skin to prevent migration. Wounds were cleaned and dressed with gauze and a plaster-of-Paris cast was applied. The severity of the pin tract infection was graded according to the modified Oppenheim classification. RESULTS: Nine (21%) of the patients developed pin tract infection (3 grade 1, 3 grade 2, 2 grade 3, and one grade 4). Three patients underwent early removal of the Kirschner wires at week 3. CONCLUSION: The infection rate after percutaneous Kirschner wire fixation is unacceptable. Kirschner wires should be buried under the skin to decrease the infection rate.

Thoracic vertebral osteomyelitis secondary to chronic esophageal perforation.

BACKGROUND CONTEXT: Osteomyelitis secondary to perforation of the esophagus is a rare condition. Thoracic osteomyelitis after chronic esophageal perforation has never been described in the literature. PURPOSE: We report a case of vertebral osteomyelitis resulting from a chronic esophageal perforation. STUDY DESIGN/SETTING: Case report/University hospital. METHODS: A 52-year-old woman presented with dysphagia, severe mid back, and epigastric pain over a 6-week period. Endoscopic and radiological investigations revealed the presence of a paraspinal inflammatory mass protruding into the posterior esophageal wall. Two weeks after admission, the patient developed septic complications which required surgical intervention. This revealed the presence of an esophageal perforation and osteomyelitis of the T4-T5 and T7-T8 vertebrae. After T-tube closure of the esophageal perforation along with surgical debridement of the vertebrae and a 6-week course of antibiotics, the patient made a sound recovery. However, there was persistence of back pain with exaggerated thoracic spine kyphosis at T7-T8 which needed thoracic spine stabilization with pedicle screw instrumentation and fusion. RESULTS: This treatment led to complete recovery with no recurrence of symptoms at 8-months' follow-up. CONCLUSIONS: To date this is the first case of thoracic osteomyelitis secondary to a chronic esophageal perforation to be reported in the literature. A high index of suspicion of this diagnosis is warranted in patients who present with similar clinical and radiological findings to enable prompt diagnosis and avoid the high mortality of esophageal perforation.

Radiographic assessment of sternal notch level and its significance in approaching the upper thoracic spine.

In this retrospective study, we used anteroposterior plain radiographs of the neck to analyze sternal notch level in relation to the upper thoracic spine and to assess the usefulness of this relation in deciding how to approach the upper thoracic spine. We reviewed 53 patients' anteroposterior plain radiographs of the cervicothoracic spine and thoracic magnetic resonance imaging (MRI) scans. On the plain radiographs, we drew a horizontal line joining the lower-fifth edge of the medial end of the 2 clavicles; on the midsagittal thoracic MRI scans, we drew a tangential line to the sternal notch. Then we noted the vertebral level of the 2 lines. In all cases, the horizontal line on the plain radiographs and the tangential line on the MRI scans corresponded to each other without discrepancy. We evaluated this method in a patient with a fractured T3 vertebral body, in whom a satisfactory procedure was performed using low anterior cervical spine approach. As the level of sternal notch is found to be present below the level of T2 and T3 radiologically in most cases, a low cervical approach can be contemplated in most patients with upper thoracic spine pathology depending on their sternal level as determined by preoperative radiographs. MRI scans are not needed to decide the approach, as it can be assessed with plain radiographs alone, as shown in this study.

Transsacral screw fixation for high-grade spondylolisthesis.

BACKGROUND CONTEXT: Symptomatic high-grade spondylolisthesis (Meyerding III-V) is usually treated by surgery. Recent literature shows that in situ fusion is better than reduction of the slip and fusion in high-grade spondylolisthesis. Furthermore, the outcome is improved if circumferential fusion is performed in severe spondylolisthesis. We have performed a new technique of circumferential fusion in high-grade spondylolisthesis using two transsacral hollow modular anchorage (HMA) screws supplemented with pedicle screw fixation and posterolateral fusion. PURPOSE: The aim of the study is to analyze the results of circumferential fusion using transsacral HMA screws supplemented with posterolateral fusion and pedicle screw fixation. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Twelve patients with high-grade spondylolisthesis were reviewed. OUTCOME MEASURES: Outcome was measured using short form 36 (SF-36) and the ability to return to work at the most recent follow-up. METHODS: All patients had interbody fusion using transsacral HMA screws filled with cancellous bone graft and supplemented with pedicle screw instrumentation and posterolateral fusion. RESULTS: The male to female ratio was 2:1 with a mean age of 31 years (range 13-54 years). Eleven of 12 patients had disappearance of leg pain. There were no neurological complications in any of them. Circumferential fusion was achieved in all of them at a mean follow-up of 21 months. The average physical function score improved from 22.50+/-10.34 to 57.50+/-17.39 (p=.001, 95% confidence interval [CI] -44.48 to -25.52), whereas the average pain score improved from 22.22+/-13.40 to 61.11+/-15.35 (p=.001, 95% CI -51.12 to -26.66). CONCLUSIONS: HMA screws avoid the complications associated with autologous cortical fibular strut graft and also are useful to promote interbody fusion, as the hollowness in the screw can be filled with cancellous bone graft that helps in better fusion. Supplementary pedicle screw fixation is necessary to protect the HMA screws, and they together give a stable construct that can achieve a circumferential fusion in high-grade spondylolisthesis.

Recurrence of kyphosis and its functional implications after surgical stabilization of dorsolumbar unstable burst fractures.

BACKGROUND CONTEXT: Treatment of unstable burst fractures in the dorsolumbar spine still remains controversial. Surgical stabilization has been aimed to prevent long-term back pain and progression of deformity. PURPOSE: This study was aimed to analyze the degree of loss of correction of the angle of kyphosis with pedicle screw instrumentation in place and the components responsible for the recurrence of kyphosis after surgical stabilization of dorsolumbar A3 fractures and to assess the return of functional capacity in these patients. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: This study involves 26 patients who had dorsolumbar unstable burst fractures (Arbeitsgemeinschaft für Osteosynthesefragen type A3). OUTCOME MEASURES: Radiological assessment at injury, immediate postoperative period, and most recent follow-up along with functional assessment using short form 36 (SF-36) and return to work. METHODS: All the patients had posterior pedicle screw instrumentation without fusion for unstable dorsolumbar burst compression (A3) fractures. The mean follow-up period was 25.5 months. All of them had their fractures stabilized with Universal Spinal System (Synthes, Welwyn Garden City, UK) Fracture System. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The angle of kyphosis; the heights of the discs above and below the fractured vertebra; and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle, and posterior). The values were normalized to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up was computed. RESULTS: The mean angle of kyphosis was 6.3+/-8.9 in the immediate postoperative period and 15.7+/-6.7 at the most recent follow-up (p<.001). The mean patient function score from SF-36 was 52.3%, and the mean pain score was 44.9%. There was no relationship to the loss of correction angle of kyphosis to the patient function score (r=0.06, p=.76) and the pain score (r=0.11, p=.58). The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the angle of kyphosis showed positive correlation to the decrease in the anterior and middle segment heights at the fractured vertebral level. CONCLUSION: There is a progressive loss of correction of the angle of kyphosis after posterior stabilization with instrumentation even without implant removal that mainly corresponds to the decrease in the anterior segment height of the fractured vertebral body.