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PubMedDate not supplied

Achievement of normal sagittal plane alignment using a wedged carbon fiber reinforced polymer fusion cage in treatment of spondylolisthesis.

BACKGROUND CONTEXT: Previous clinical studies of interbody fusion cages have generally failed to report sagittal plane alignment. In some cases, parallel-sided cages have contributed to loss of lumbar lordosis. A wedged-shaped carbon-fiber-reinforced polymer (CFRP) cage implant filled with autologous bone was designed to allow surgeons to more easily achieve normal sagittal plane alignment in posterior lumbar interbody fusion (PLIF). PURPOSE: This study was conducted to test the safety and efficacy of the wedged CFRP cage and the ability of surgeons to achieve normal anatomic alignment using an implant of this shape. STUDY DESIGN/SETTING: The wedged CFRP cage with pedicle screw fixation was evaluated in the treatment of patients with spondylolisthesis in a 2-year prospective study performed at 12 centers under a Food and Drug Administration (FDA)-approved protocol PATIENT SAMPLE: Inclusion criteria included patients with isthmic or degenerative spondylolisthesis at a single level below L4 with a translational malalignment of 3 mm or greater. Exclusion criteria included patients with more than 90% translation, previous surgery or abnormalities at more than two levels. OUTCOME MEASURES: Traditional outcome measures have included clinical success (improvement in pain and function) and fusion success (proof of living bone bridging the fusion area). This study adds a more complete analysis of anatomic success (restoration or maintenance of normal disc space height and sagittal plane alignment). METHODS: A clinical study of PLIF with pedicle screw fixation included a prospective group of 46 patients treated for spondylolisthesis. This article presents the data from the FDA-approval protocol. RESULTS: Fusion success was achieved in 35 of 36 patients (97.2%) reaching the 2-year follow-up interval. Clinical success was achieved in 35 of 37 (94.6%), and overall success was achieved in 33 of 36 (91.2%). Disc space height averaged 8.3 mm preoperatively, was increased to 10.2 mm at surgery and was maintained at 9.8 mm at 2 years. L4-S1 sagittal plane alignment was maintained within normal range, averaging 30.6 degrees after surgery. Clinical and fusion success rates trended higher than previous results with the rectangular cage but were not statistically different. Fusion success was significantly better than prior literature for treatment of spondylolisthesis (p=.0160). Complications of the surgery trended lower but were not statistically different from the study of the rectangular cage. CONCLUSIONS: The wedged CFRP cage with pedicle screw fixation allows surgeons to maintain normal sagittal plane alignment. These devices are safe and effective for treatment of spondylolisthesis and are FDA approved in the United States.

Adult↗

PubMed2005

An evaluation of image-guided technologies in the placement of anterior thoracic vertebral body screws in spinal trauma: a cadaver study.

BACKGROUND: Image guidance provides additional anatomic information to the surgeon, which may allow more accurate insertion of spinal implants. Imprecise placement of anterior thoracic screws places the spinal cord and paraspinal structures at risk for injury. Image guidance may afford a safety benefit to patients when anterior thoracic screws are required in the setting of spinal stabilization after trauma. OBJECTIVES: To compare the accuracy of anterior thoracic screw placement using standard fluoroscopy, computer-assisted fluoroscopic image guidance, Iso-C3D image guidance, and electromagnetic fluoroscopic image guidance. STUDY DESIGN: A surgical simulation study in human cadaver spine specimens. METHODS: After an open thoracotomy approach, anterior thoracic screws were placed by experienced spine surgeons using 4 different image-guided techniques in 4 human cadaver thoracic spines. Screws were placed in the 9th, 10th, and 11th thoracic vertebrae of each specimen. The specimens were then examined with thin-cut computed tomography (CT) scans, and with sagittal and coronal reconstructions. Measurements included the distance of the screw from the spinal canal, the angle of the screw path in relation to a perpendicular to a line that bisects the spinous process, and the angle of screw divergence from the superior endplate. RESULTS: There was no evidence of spinal canal penetrance with any of the image-guided techniques used to place anterior thoracic vertebral body screws. Screws inserted with standard fluoroscopy tended to aim anterolaterally by 18 degrees. The image-guidance systems allowed more accurate placement of anterior thoracic screws in the transverse plane compared with standard fluoroscopy. There was no statistically significant difference in coronal plane screw angulation (angle of divergence with the superior endplate) between any of the imaging methods. CONCLUSIONS: Spinal image-guidance systems may allow spine surgeons to place anterior thoracic screws more precisely, particularly in the axial plane. The improved accuracy of spinal implant insertion could ultimately provide a benefit to patient safety, especially in the setting of malaligned vertebral bodies after trauma.

Aged↗

PubMed1992

The long-term success of fresh, small fragment osteochondral allografts used for intraarticular post-traumatic defects in the knee joint.

Ninety-two fresh osteochondral allografts were implanted in 91 patients with posttraumatic osteoarticular defects of the knee joint. These patients have been prospectively followed since 1972. An analysis of long-term survival of these grafts has been performed to determine their success rates: 75% at 5 years, 64% at 10 years, and 63% at 14 years. An evaluation was made between unipolar grafts, which involve only one surface of the compartment, and bipolar grafts, which involve both surfaces. The unipolar grafts had a lower failure rate at all time periods compared to bipolar grafts, with 76% survival at 5 years, 69% at 10 years, and 67% at 14 years. While investigating other factors that might affect the survival of the fresh osteochondral allografts, we calculated the influence of the anatomical location of the graft, patient sex, and patient age. There was no meaningful impact on allograft survival by either the location of the allograft or the sex of the patient. However, there was a significant effect on allograft longevity in terms of patient age, with patients under age 60 doing better. The best indication for the use of unipolar fresh osteochondral allografts is for posttraumatic defects in relatively young, active patients. Joint malalignment should be corrected to achieve best results.

Adult↗

PubMed1987

Torsion-transmitting properties of the hind foot.

The torsion-transmitting capacity of the hind foot was studied experimentally in ten cadaver specimens. An average of 0.44 degrees of outward rotation of the tibia occurred for every degree of supination of the foot. The relationship was linear. There was less transmission of torsion during dorsal extension than during plantar flexion of the ankle. The joint complex of the hind foot somewhat resembles a universal joint except that the distal fork of the universal joint changes its configuration through its range of motion. This distal fork, consisting of the calcaneus, the cuboid, and the navicular, together with the central piece, the talus, constitutes a three-arm link system, which explains the configurational change. The process of balance when standing on one leg and when walking on uneven surfaces, when the torsion-transmitting effect plays a central role, can be controlled as rotations in the hip joint. This torsion-transmitting model helps to elucidate the trauma mechanisms of various ankle fractures. It also may explain why anterior knee pain due to malalignment can be relieved with supinating foot supports.

Ankle Joint↗

PubMed1997

Complex nonunion of fractures of the femoral shaft treated by wave-plate osteosynthesis.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation. Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.

Adolescent↗

PubMed1990

Sequelae and reconstruction after septic arthritis of the hip in infants.

We evaluated the residual deformity and late treatment of thirty-four hips of thirty-one children who had had septic arthritis when they were less than one year old. The hips were classified into four groups on the basis of radiographic changes. Type-I deformity (five hips) involved transient ischemia of the epiphysis, with or without mild coxa magna, and these hips did not need reconstruction. Type-II deformity (eleven hips) included deformity of the epiphysis, physis, and metaphysis, and these hips needed an operation to prevent subluxation; the goals of the operation included improvement in acetabular coverage, improvement in abductor efficiency by epiphyseodesis or transfer of the greater trochanter, and equalization of limb-length discrepancy by epiphyseodesis of the contralateral limb. Type-III deformity (five hips) involved malalignment of the femoral neck, with extreme anteversion or retroversion or with a pseudarthrosis of the femoral neck that necessitated a realignment osteotomy of the proximal part of the femur or bone-grafting of the pseudarthrosis. Type-IV deformity (thirteen hips) included destruction of the femoral head and neck, with persistence of only a remnant of the medial base of the femoral neck. In the hips that had a Type-IV deformity, the complex clinical problems, which included severe limb-length discrepancy and incompetent articulation of the hip, necessitated operations such as Pemberton osteotomy, trochanteric arthroplasty, arthrodesis, epiphyseodesis of the contralateral limb, and lengthening of the ipsilateral tibia. The functional result was satisfactory in all five hips that had a Type-I deformity, in seven of eleven that had a Type-II deformity, in three of four that had a Type-III deformity, and in only four of thirteen that had a Type-IV deformity.

Arthritis, Infectious↗

PubMed2000

Sport related proximal femoral fractures: a retrospective review of 31 cases treated in an eight year period.

In an eight year period, 31 patients with proximal femoral fractures resulting from sports accidents were treated by implantation of either a Gamma nail or a dynamic hip screw. Return to work or sports and the time to bone healing did not differ very much between the treatments. Gamma nailing was clearly the best with regard to stability and time to full mobilisation (4.5 days), but required 39 minutes to perform compared with insertion of a dynamic hip screw (27 minutes). The incidence of complications and malalignments did not differ very much between the two, although, when Gamma nailing was first used in the authors' clinic, more intraoperative complications occurred than with the dynamic hip screw. Stable pertrochanteric fractures may be treated with a dynamic hip screw. Unstable pertrochanteric or subtrochanteric fractures are treated with a Gamma nail at the authors' institution.

Adult↗

PubMed2001

Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing.

OBJECTIVE: To observe and report the clinical results of indirect plating techniques in the treatment of femoral shaft nonunions originally treated with intramedullary nailing. DESIGN: Prospective consecutive. SETTING: Regional trauma center. PATIENTS: A consecutive series of twenty-three patients with nonunion of femoral shaft fractures previously treated with intramedullary nailing. INTERVENTION: Surgical treatment with indirect plating techniques using the AO 95-degree condylar blade plate in nonunions of the distal and proximal one thirds and broad large-fragment dynamic compression plating in nonunions of the middle one third, with selective autologous cancellous bone grafting. Emphasis was placed on preoperative planning, intraoperative attention to soft tissue sparing and selection of the appropriately applied implant to correct deformity and obtain union. MAIN OUTCOME MEASUREMENTS: Healing rate and time, operative blood loss and time, and incidence of complications, including hardware failure, loss of fixation, infection, and postoperative malalignment. RESULTS: Twenty-one of the twenty-three nonunions healed without further intervention at an average of twelve weeks (range 10 to 16 weeks) postoperatively. The two remaining patients (9 percent) had early breakage of their hardware, requiring repeat plating. Union in both of these cases occurred within sixteen weeks of the revision (12 and 16 weeks). Including the two patients requiring reoperation, all twenty-three nonunions healed at an average of seventeen weeks (range 10 to 24 weeks) from the initial plating procedure. There were no intraoperative complications. Average operative time was 164 minutes (range 120 to 240 minutes), and blood loss was 340 milliliters (range 200 to 700 milliliters). There were no cases of significant postoperative axial or rotational malalignment (more than 5 degrees), limb length discrepancy (more than 1 centimeter), or deep infections. CONCLUSIONS: Modern plating techniques are effective in the treatment of femoral shaft nonunions after intramedullary fracture fixation. The authors consider this method particularly valuable in the presence of deformity. Union occurred reliably with few complications.

Adult↗

PubMed2003

[Intramedullary nailing in tibiotalocalcaneal arthrodesis].

Tibiotalcalcaneal arthrodesis is still the treatment of choice for disabling arthrosis of the upper and lower ankle joint, although replacement of the upper ankle joint is widely accepted. Numerous techniques have been described, with increasing use of internal fixation and compression. In 20 patients tibiotalocalcaneal arthrodesis was performed using a retrograde femur nail inserted through the heel, whereas in 20 patients combined arthrodesis of the upper and lower ankle joint was performed using a distal tibia nail through an anterograde approach. Patients were evaluated in a standardized examination using criteria of SF 36 focussing on approach, osseous consolidation, and quality of life.Both techniques demonstrated good results: bony consolidation was achieved after follow-up time of 19 months in 85% of the anterograde group and 95% of the retrograde group. In 78% pain was reduced effectively using the intramedullary nail arthrodesis and quality of life improved drastically. In four cases pseudarthrosis occurred, two implant failures were reported, and there were two infections. Using the anterograde as well as the plantar approach, tibiotalocalcaneal intramedullary nail arthrodesis is an appropriate technique. In this study both groups demonstrated good results regarding bony consolidation, reduction of pain, and improved quality of life. Advantage of the retrograde technique is the noninvasiveness of the proximal tibia. Heel pain or plantar infections were not observed. We see limits of the presented technique in severe malalignment and septic history of the patient.

Adult↗

PubMed2006

MRI and non-cartilaginous structures in knee osteoarthritis.

Magnetic resonance imaging (MRI) provides a sensitive tool for examining all the structures involved in the osteoarthritis (OA) process. While much of the MRI literature previously focussed on cartilage, there is increasing research on whole-organ evaluation and including features such as synovitis, bone marrow edema, and meniscal and ligamentous pathology. The aim of this session at the Outcome Measures in Rheumatology Clinical Trials (OMERACT)-Osteoarthritis Research Society International (OARSI) Workshop for Consensus in Osteoarthritis Imaging was to describe the current MRI methods for identifying and quantifying non-cartilaginous structures and review their associations with both OA symptoms and structural progression. Although there is much experience in measuring synovitis (derived from the rheumatoid arthritis literature), only one study has reported an association of MRI-detected synovitis and effusions with OA pain. Bone marrow edema lesions, which may represent areas of trabecular remodelling, have been associated with pain and compartment-specific structural deterioration. MRI studies have confirmed the frequency and importance of meniscal damage in progressive cartilage loss, but not related such damage to symptoms. Osteophytes have been associated with cartilage loss and malalignment to the side of the osteophyte. Ligament damage, including anterior cruciate ligament tears, has been found more commonly than expected in painful OA knees. Improvements in quantitative and semi-quantitative assessments of non-cartilage features will greatly assist understanding of the OA process and its response to therapy.

Bone Marrow↗

PubMed1984

Failure of total condylar knee replacement. Correlation of radiographic, clinical, and surgical findings.

The authors reviewed 55 failed total condylar knee replacements, correlating the radiographic and surgical findings at removal or revision. Failure was due to infection in 20 cases, mechanical loosening in 18, instability without loosening in 10, malalignment without loosening in 4, a supracondylar fracture in 2, and unknown causes in 1. In infection with loosening or chronic infection, radiographs usually showed a wide, extensive radiolucent region at the cement-bone interface around one or more components without shifting, while in acute infection without loosening the radiographs were normal. In mechanical loosening, in addition to a similar lucent region, the prosthesis became tilted in 16 out of 18 cases. Most loosening involved tilting of the tibial component into the varus position with subsidence into the medial tibial plateau, collapse of the cancellous bone, and plastic deformation. Radiographs can be helpful in determining the reason for failure of a total knee replacement, which is important in planning surgery.

Adult↗

PubMed2004

Peripheral talar fractures.

Peripheral fractures of the talus are uncommon and often overlooked. CT scanning has become the imaging modality of choice and is necessary for decision making on treatment. Displaced peripheral fractures have to be managed with open reduction and internal fixation. Precise anatomical reduction is necessary to achieve a good result. A rigid internal fixation with interfragmentary lag screws is the method of choice in almost all fractures, which allows early postoperative mobilization. The outcome is related to the degree of the chondral lesion and the degree of instability of the subtalar joint, but it may be poor due to the treatment. Early diagnosis and proper treatment achieve the best possible results and prevent long-term complications. Typical complications of the fracture are nonunion and malalignment with slight subtalar instability or osseous overgrowth with secondary impingement and posttraumatic subtalar arthritis.

Arthroscopy↗

PubMed2004

Calcification of the patellar tendon after ACL reconstruction. A case report with long-term follow-up.

Extensive calcification of the patellar tendon following ACL reconstruction with central-third bone-patellar tendon-bone autograft is a rarely seen complication. A 45-year-old male patient underwent combined intraarticular reconstruction of ACL with 1/3 central patellar bone-tendon-bone graft and extraarticular reconstruction with modified MacIntosh technique. Two cm of calcification of the patellar tendon was observed incidentally when he underwent a high tibial osteotomy due to medial compartment degeneration, secondary to varus malalignment, 18 months after the ACL surgery. The calcification, being painless, was left untouched during the surgery. At the final examination, 136 months postoperatively, the patient still had no complaint relating to the patellar tendon.

Anterior Cruciate Ligament↗

PubMed1992

Angled bearing inserts in total knee arthroplasty. A brief technical note.

Malalignment of total knee prosthetic components may lead to premature wear, loosening of components, or patellar instability. Unfortunately, removal of securely cemented or ingrown components is difficult and may be extremely destructive to the available bone stock. Angled bearing inserts provide a means to compensate for malpositioned components and should be considered an alternative to component removal in certain cases.

Aged↗

PubMed2004

A supernumerary maxillary tooth: its topographical anatomy and its clinical implications.

A supernumerary tooth was detected in the left maxilla during an osteology teaching session with undergraduate medical students. Supernumerary teeth have previously been detected in individuals who have approached a dental surgeon with a complaint and who have then been diagnosed by X-ray. Asymptomatic cases are frequently not diagnosed in time and it is only the malalignment or delayed eruption of the tooth which raises the suspicion that this type of dental anomaly is present. The present paper highlights the anatomico-radiological study of a supernumerary maxillary tooth in a bone specimen and describes its clinical implications. Precise anatomical details of the supernumerary maxillary tooth might be of significant clinical interest to dental and maxillofacial surgeons in drawing up a plan for orthodontic treatment and may thus minimise the possible complications involved.

Humans↗

PubMed1990

[Stabilization of open tibial fracture by an external fixator. Advantages through supplemental screw osteosynthesis].

One hundred thirty-two open tibial shaft fractures were treated by unilateral external fixation. In order to evaluate the usefulness of supplemental lag screw fixation, we compared forty-four reexamined fractures in which only external fixation was utilized with fifty-five reexamined fractures, stabilized with supplemental lag screws and external fixation. We did not find significant differences in time to full-weight bearing (17.1 vs. 15.6 weeks), time to union (18.7 vs 18.0 weeks), incidence of delayed union [as defined by time to union over 32 weeks (10.9% vs. 11.4%)], incidence of osteomyelitis (5.4% vs. 4.5%), or incidence of malunion [axial malalignment greater than 5 degrees (12.7% vs. 11.4%)]. Clinically significant differences were found demonstrating a twofold increase in refracture rate in the group with supplemental lag screws (10.9% vs. 4.5%) and requiring twice as many bone grafting procedures to achieve union (65.5% vs. 29.5) than did the group treated by external fixation alone. Therefore we do not recommend the routine use of supplemental lag screw fixation.

Adolescent↗

PubMedDate not supplied

Anteromedial tibial tubercle transfer without bone graft.

We followed 30 patients for more than 2 years after anteromedial tibial tubercle transfer for persistent patellofemoral pain associated with patellar articular degeneration. Twelve of these patients were followed more than 5 years. We report 93% good and excellent results subjectively and 89% good and excellent results objectively. The quality of improvement was sustained in all 12 of the patients who were evaluated again after more than 5 years from surgery. When examined separately, 75% of those patients with advanced patellar arthrosis achieved a good result; none of these patients achieved an excellent result. Postoperative continuous passive motion has markedly reduced the incidence of stiffness. Serious complications such as compartment syndrome, infection, and skin slough were avoided completely in 51 consecutive cases. Patellofemoral contact pressure studies in five cadaver knees have shown that anteromedial tibial tubercle transfer can provide substantial reduction of patellofemoral contact stress while helping to balance medial and lateral facet pressures. This surgical procedure is mechanically and clinically successful for alleviating intractable pain related to patellar malalignment and articular degeneration. This procedure enables the majority of appropriately selected patients with malalignment and patellar articular degeneration to resume increased levels of activity with substantially diminished pain.

Adolescent↗

PubMed2005

Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft.

BACKGROUND: The quadriceps tendon is a viable graft source for revision anterior cruciate ligament reconstruction. PURPOSE: To determine the functional results and graft failure rates in knees in which the patellar tendon had been previously harvested or was unavailable, expanded tunnels precluded the use of a semitendinosus-gracilis graft, or patients requested autogenous tissues instead of allografts for revision reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors observed 21 patients for a mean of 49 months postoperatively after revision anterior cruciate ligament reconstruction with a quadriceps tendon graft. The results were determined by KT-2000 arthrometer testing, the Cincinnati Knee Rating System, and the International Knee Documentation Committee Rating System. Fifteen knees required a concurrent procedure, including reconstruction of posterolateral structures in 5 knees, meniscal repairs in 5 knees, and high tibial osteotomy in 2 knees. RESULTS: Significant improvements occurred in symptoms (P < .0001), daily activities (P < .05), sports activities (P < .01), and the overall rating scores (P < .0001). Eighteen patients rated their knee condition as improved. Total mean anterior-posterior displacements decreased from 8.4 +/- 3.1 mm preoperatively to 2.0 +/- 2.3 mm at follow-up (P < .001). On the International Knee Documentation Committee knee ligament rating, 17 knees were graded as normal or nearly normal, 3 were graded as abnormal, and 1 was graded as severely abnormal. CONCLUSION: The revision operation provided reasonable results in this group of complex knees. However, the functional and overall results were inferior to those reported for primary anterior cruciate ligament reconstruction. Many knees (90%) had compounding problems of articular cartilage damage, meniscectomy, varus malalignment, or additional ligamentous injury that most likely affected the results.

Adolescent↗