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PubMed1994

[Prosthetic treatment of mandibular pseudarthrosis using an articulated prosthesis].

Two cases with complete loss of the tooth-bearing portion of the mandible were repaired with a prosthesis. This type of defect can involve the loss of a large number of teeth and aggression to the remaining teeth must be limited as much as possible. A two-part "articulated" prosthesis with two rings appears to be the best adapted system. This method takes into account the requirements of for additional conventional prostheses and thus makes it possible to save the remaining teeth.

Aged↗

PubMed1994

[The Seidel humeral nail in limited indications: pathological fractures, delayed union, pseudarthrosis and reconstruction].

The authors report 10 cases of Seidel locked intramedullary nailing of the humeral shaft for borderline indications (5 delayed unions, 2 complex nonunions, 2 reconstructions for tumor and a panmetastatic humerus). All delayed unions went to union in spite of unscrewing of the expanding screw in 2 cases. In cases of segmental reconstruction, union never occurred due to unlocking of the distal bolt by bone incompetence. Diaphyseal straightening was obtained, but not rotational stability. These elderly patients, in whom the osteoporotic bone is inadequate for plate osteosynthesis, were pleased with the result in comparison with their preoperative status. For pathological fracture, a painfree status is obtained. No subacromial impingement was observed.

Adult↗

PubMed2005

Defining pseudoarthrosis in the cervical spine with differing motion thresholds.

STUDY DESIGN: Calculate the apparent pseudarthrosis rate for anteriorly plated cervical spine fusions using different threshold levels of intervertebral rotation. OBJECTIVES: Determine whether the apparent pseudarthrosis rate depends on the amount of intervertebral rotation used to characterize a fusion as a pseudarthrosis. SUMMARY OF BACKGROUND DATA: Intervertebral motion at a spine fusion site is an important outcome measure in most spine fusion research studies. Intervertebral motion measures are used to determine if a device can be sold for use in spine fusion surgery. There is no consensus on how much motion is too much motion at a spine fusion site, and the intervertebral motion threshold that is used to define a pseudarthrosis is arbitrary. There are only limited data on the dependence of the pseudarthrosis rate on the threshold used to define a pseudarthrosis. METHODS: Intervertebral motion at the fusion site was measured from flexion extension radiographs taken 1 year after cervical spine fusion using anterior plates and allograft in 200 patients. The number of cases where intervertebral motion at the fusion site exceeded thresholds between 1 degrees and 4 degrees were calculated. RESULTS.: The apparent pseudarthrosis rate varied from 6% when the intervertebral motion threshold was 4 degrees to 44% when the intervertebral motion threshold was 1 degrees . CONCLUSIONS: The apparent pseudarthrosis rate was highly dependent on the threshold of motion used to define a pseudarthrosis.

Bone Plates↗

PubMed2000

Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion.

STUDY DESIGN: A retrospective review of all patients surgically treated with a two-level anterior cervical discectomy and fusion with and without anterior plate fixation by a single surgeon. OBJECTIVES: To compare the clinical and radiographic success of two-level discectomy and the effect of anterior cervical plate fixation. SUMMARY OF BACKGROUND DATA: Prior studies of multisegment fusions have shown decreased fusion rates correlating with the number of increased levels. The use of anterior plates for single-level cervical fusions is controversial. However, their use in multilevel fusions may be warranted because of the increased pseudarthrosis rates. METHODS: Over a 6-year period, 60 patients were treated surgically with a two-level anterior cervical discectomy and fusion by the senior author. Thirty-two patients had cervical plates, and 28 underwent fusions without plates. These patients were followed for an average of 2.7 years. Clinical and radiographic follow-up evaluations were performed. RESULTS: Of the 60 patients, 7 had a pseudarthrosis. The pseudarthrosis rates were 0% for patients with plating and 25% for those with no plating. This difference was statistically significant (P = 0.003). No correlation of pseudarthrosis with gender, age, level of surgery, history of tobacco use, or the presence of prior anterior surgery was found. There was significantly less graft collapse (P = 0.0001) in the patients without plates in whom pseudarthrosis developed (1.4 mm) than in those who had fusions with plates (0.3 mm). The amount of kyphotic deformity of the fused segment was 0.4 degree in patients with plating compared with 4.9 degrees in those without plating who developed a pseudarthrosis (P = 0.0001). CONCLUSIONS: The addition of plate fixation for two-level anterior cervical discectomy and fusion is a safe procedure with no significant increase in complication rates. The pseudarthrosis rates are significantly higher in patients treated without plate fixation. No nonunions occurred in the patients treated with plate fixation. There was significantly less disc space collapse and kyphotic deformity with the plated fusions than with the nonplated fusions, in which a pseudarthrosis developed. The complication rates for plated fusions are extremely low and do not differ from those for nonplated fusions.

Adult↗

PubMed2003

Pseudoarthrosis of the cervical spine: a comparison of radiographic diagnostic measures.

STUDY DESIGN: A retrospective review was conducted. OBJECTIVE: To compare the accuracy of two objective radiographic techniques in identifying nonunion after anterior cervical discectomy and fusion. SUMMARY OF BACKGROUND DATA: The accuracy of diagnostic methods for detecting pseudarthrosis has been poorly documented. Radiographic criteria mentioned in the literature include perceived motion or change in the Cobb angles between the involved segments on flexion-extension views. METHODS: The participants in this study were 27 patients with 29 cervical fusions ranging from one to three levels. Patients were examined and radiographs obtained. The mean follow-up period was 39 months. Two measurements were obtained from lateral flexion-extension radiographs: Cobb angle and the distance between the tips of the spinous processes of the surgically managed levels. The measurements were obtained independently by three physicians in a blinded fashion. RESULTS: The reliability among the observers, as measured by Cronbach's alpha, was 0.95 for the spinous process method and 0.74 for the Cobb angle method. A measurement of more than 2 mm between spinous processes was noted in patients with a known pseudarthrosis. The Pearson correlation between pseudarthrosis and use of the spinous process method was 0.77 ( < 0.001). The Pearson correlation between pseudarthrosis and use of the Cobb angle method was 0.28 ( > 0.10). The area under the receiver operating characteristic curve for the spinous process method was found to be 0.980, as compared with 0.662 for the Cobb angle method, for the measurement of pseudarthrosis. CONCLUSIONS: Measurement of the change in distance between spinous processes is more reproducible and accurate than the Cobb method for making the diagnosis of pseudarthrosis. The authors believe that the measurement of distances between spinous processes on lateral flexion-extension radiographs should be used as a method for evaluating radiographic fusion in patients with pseudarthrosis.

Adult↗

PubMed1988

Osteoarthritis of the wrist secondary to non-union of the scaphoid.

The surgical treatment of osteoarthritis of the wrist secondary to pseudarthrosis of the scaphoid is presented in the light of twenty years experience, and with improved knowledge of the pathological anatomy of this problem. The condition is difficult to treat owing to the varied pathology, the different needs of the patients and the alternative treatments available. Where a pseudarthrosis exists with involvement of the scaphoid-radius joint only, we recommend radial styloidectomy and repair of the pseudarthrosis. Where the pseudarthrosis is associated with carpal collapse which can be corrected, and osteoarthritis is confined to the joint between the capitate and lunate bones, we recommend correction of the carpal collapse and an arthrodesis between the lunate, capitate, hamate and triquetrum, with either anatomical repair of the scaphoid or eventual replacement with a Silastic implant. Where there is irredicable carpal collapse or lunate dislocation, proximal row carpectomy is recommended as an alternative to arthrodesis. Pseudarthrosis of the proximal pole of the scaphoid is best treated by replacement of the small bone fragment with a Silicone rubber implant. For pseudarthrosis with a painful arthritic joint of radius, scaphoid and lunate without involvement of the other periscaphoid joints, we recommend arthrodesis of the affected joints only. Finally, in cases of pseudarthrosis with advanced degenerative changes in the radiocarpal and intercarpal joints with associated collapse and deformity, or following unsuccessful resection, we recommend arthrodesis of the wrist.

Arthrodesis↗

PubMed2001

Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion.

STUDY DESIGN: A retrospective review of all patients surgically treated by a single surgeon with a three-level anterior cervical discectomy and fusion with and without anterior plate fixation. OBJECTIVES: To compare the clinical and radiographic success of anterior three-level discectomy and fusion performed with and without anterior cervical plate fixation. SUMMARY OF BACKGROUND DATA: Previous studies of multilevel cervical discectomies and fusions have shown fusion rates to decrease as the number of surgical levels increases. Anterior cervical plate stabilization can provide more stability and may increase fusion rates for multilevel fusions. METHODS: Over a 7-year period, 59 patients were treated surgically with a three-level anterior cervical discectomy and fusion by the senior author. Forty patients had cervical plates, whereas 19 had fusions with no plates. These patients were observed for an average of 3.2 years. Clinical and radiographic follow-up data were obtained. RESULTS: Of the 59 patients, 14 had a pseudarthrosis (7 in each group). The pseudarthrosis rates were 18% (7 of 40) for patients with plating and 37% (7 of 19) for patients with no plating. Although the nonunion rate for unplated fusions was double that of plated fusions, this difference was not statistically significant. There was no statistically significant correlation between pseudarthrosis and gender, age, level of surgery, history of tobacco use, or previous anterior surgery. The fusion rates were improved with the use of a cervical plate. Inferior clinical results were demonstrated in patients with a pseudarthrosis, regardless of the use of a cervical plate. CONCLUSIONS: The addition of plate fixation for three-level anterior cervical discectomy and fusion is a safe procedure and does not result in higher complication rates. In this study, the pseudarthrosis rate was lower for patients with a cervical plate. However, this difference was not statistically significant. Patients treated with cervical plating had overall better results when compared with those of patients treated without cervical plates. Although the use of cervical plates decreased the pseudarthrosis rate, a three-level procedure is still associated with a high nonunion rate, and other strategies to increase fusion rates should be explored.

Bone Plates↗

PubMed2006

Posterior correction and fixation without anterior fusion for pseudoarthrosis with kyphotic deformity in ankylosing spondylitis.

STUDY DESIGN: Retrospective review. OBJECTIVE: To assess the effectiveness of posterior correction and fixation without anterior fusion for pseudarthrosis with kyphosis in patients with ankylosing spondylitis. SUMMARY OF BACKGROUND DATA: Anterior fusion is the current surgical treatment for pseudarthrosis with kyphosis in ankylosing spondylitis. The unique characteristic in ankylosing spondylitis is the superior ability to bridge and fuse the large anterior opening-wedge gap created by posterior osteotomy to correct the kyphosis without anterior fusion after the osteotomy site is adequately fixed. This ability may persist even if pseudarthrosis is present. METHODS: A total of 30 consecutive patients with ankylosing spondylitis (mean age 41.7 years, range 29-55) underwent posterior correction and fixation without anterior fusion to treat pseudarthrosis with kyphosis. Mean follow-up was 4.7 years (range 2.2-9.1). Radiographic and clinical results and complications were assessed. RESULTS: Local kyphosis was substantially corrected from 45.5 degrees (range 37 degrees-68 degrees) to 7.5 degrees (0 degrees-14 degrees), with a mean correction of 38 degrees. All patients had no evidence of nonunion on x-ray at the level of the pseudarthrosis at final follow-up. None had a notable loss of correction. No major complication occurred. There were 3 patients with neurologic deficits who had postoperative improvement. CONCLUSION: Posterior correction and fixation is effective for treating pseudarthrosis with kyphosis in ankylosing spondylitis. No anterior fusion procedure was necessary.

Adult↗

PubMed1997

Revision of anterior cervical pseudoarthrosis with anterior allograft fusion and plating.

Anterior cervical discectomy and fusion is an efficacious procedure used to treat a variety of cervical spinal disorders, including spondylosis, myelopathy, herniated discs, trauma, and degenerative disc disease. Pseudarthrosis, or failure of fusion, may be the most common complication of spinal fusion procedures. Nineteen consecutive patients with symptomatic pseudarthrosis following failed anterior cervical fusions were treated with anterior cervical revision using iliac crest allografts and either the Cervical Spine Locking Plate system (10 patients) or the Trapezial Osteosynthetic Plate system (nine patients). The mean age of the nine men and 10 women undergoing treatment was 49.1 years (range 25-72 years). Eleven patients (57.9%) exhibited pseudarthrosis at one level, six (31.5%) at two levels, and two (10.5%) at three levels. The indications for revision were intractable neck pain with radiculopathy (17 patients) or myelopathy (two patients), with evidence of pseudarthrosis on plain cervical radiography as well as computerized tomography (CT) or single-photon emission computerized tomography (SPECT) scanning, or both. All eight patients evaluated with SPECT showed increased focal uptake consistent with pseudarthrosis, which was subsequently confirmed intraoperatively in all eight. The average follow-up period was 22.4 months (range 12-42 months). Solid osseous fusion was achieved over all 28 levels in all 18 patients available for follow-up review (100%). One patient died 4 months postoperatively from myocardial infarction related to preexisting coronary artery disease. There were no intraoperative complications; postoperatively, two patients (10.5%) experienced transient hoarseness. Anterior revision of failed cervical fusions using allograft interbody fusion material and anterior plating is a safe and efficacious procedure. In this series, the use of allografts avoided donor site morbidity without adversely affecting fusion rates. Rigid internal fixation was achieved by means of anterior plating without increasing surgical morbidity rates. The SPECT imaging technique has the potential to reliably confirm the diagnosis of pseudarthrosis.

Adult↗

PubMed1998

Evaluation and treatment of clinical instability associated with pseudoarthrosis after anterior cervical surgery for ossification of the posterior longitudinal ligament.

BACKGROUND: Between 1989 to 1993, clinical instability associated with pseudarthrosis was evaluated in 76 patients with cervical ossification of the posterior longitudinal ligament (OPLL). Average 2.5 level extended anterior diskectomy and fusion and average 3.0 level anterior corpectomy and fusion were performed without anterior plate instrumentation using iliac crest or fibular strut autografts. METHODS: Fusion versus pseudarthrosis resulting in clinical instability, as defined by White and Panjabi, was assessed using flexion and extension X-rays 3 and 6 months post-operatively. Radiographic instability was defined by > 3.5 mm. of sagittal plane translation (or 20%) and > 20 degrees of sagittal plane rotation on dynamic X-rays. Two and 3 dimensional (D) computed tomography (CT) scans, also obtained 3 months postoperatively, either confirmed fusion or indicated failed bony union. The average clinical follow up period was 3 years (range, 25-52 months). RESULTS: Three months postoperatively, dynamic X-rays in 20 patients demonstrated radiographic instability consistent with pseudarthrosis, whereas 2 and 3D CT studies indicated a lack of fusion. At 6 months, flexion and extension X-rays revealed that 10 patients were fused and that another 7 were clinically stable despite persistent, irregular, linear lucencies at graft/body interfaces. Three (4%) patients with clinical instability associated with pseudarthrosis required secondary posterior wiring and fusion. CONCLUSION: Only 4% of patients undergoing average 2.75 level anterior OPLL surgery without anterior plate instrumentation required secondary posterior wiring and fusion for clinical instability associated with pseudarthrosis.

Aged↗

PubMed2000

Anterior cervical diskectomy and fusion without plate instrumentation in 178 patients.

Between 1989 and 1996, fusion, pseudarthrosis, repeated operation rates, and outcomes were studied in 178 patients undergoing one- to four-level (average, 2.2 levels) anterior cervical diskectomy and fusion (ADF) without plating. Dynamic radiographs taken 3 and 6 months after operation showed fusion or pseudarthrosis without motion in 99% of patients after one-level ADF (78 patients), in 90% after two-level ADF (84 patients), and in 100% after three-level ADF (12 patients) and four-level ADF (4 patients). Pseudarthrosis with motion was noted in 1% after one-level ADF and in 10% after two-level ADF (statistically significant with a lower pseudarthrosis rate in the 1-level; by Fisher's exact test, p = 0.0351). Three patients required secondary posterior wiring and fusion. Good or excellent outcomes (by Odom's criteria) were achieved in 96% of patients within an average of 82 months. Although fusion rates for one-level ADF without plates appear adequate, high pseudarthrosis rates after two-level ADF warrant that plating be considered.

Adult↗

PubMed1995

Surgical revision for failed anterior cervical fusions. Articular pillar plating or anterior revision?

STUDY DESIGN: This retrospective study reviewed one surgeon's experience in treating symptomatic anterior cervical pseudarthrosis by three methods: anterior revisions, posterior revisions, and circumferential procedures. OBJECTIVES: To determine whether anterior revision and plating achieves a higher probability of radiographic fusion and better clinical outcomes compared with posterior fusion and articular pillar plating. The role of circumferential procedures was evaluated. SUMMARY OF BACKGROUND DATA: Management of cervical pseudarthrosis by a repeat anterior procedure requires a difficult dissection in a previously operated area, resection of a nonunion site, and regrafting. Because the incidence of failure is reported to be high, posterior cervical fusion has been proposed as a treatment for anterior pseudarthrosis. METHODS: The second author has performed 44 surgical revisions for symptomatic anterior cervical pseudarthrosis. Before this surgical revision, all patients had pain and a radiographic nonunion that was confirmed during surgery. The average follow-up period after the secondary procedure was 28 months with a range of 12-60 months. All patients (100%) were available for follow-up evaluation. Twenty patients had anterior pseudarthrosis repair and anterior plating. Seventeen patients underwent posterior cervical fusion and articular pillar plating. Seven patients had a circumferential repair with anterior revision and posterior articular pillar plating. RESULTS: All seven patients (100%) who had circumferential procedures achieved a solid radiographic fusion. Clinically, five patients felt better than before surgery, and two patients felt the same. Sixteen of 17 patients (94%) with posterior repairs achieved a solid fusion. Fourteen patients felt better; two patients felt the same, and one patient with a nonunion felt worse than before surgery. A solid fusion was obtained in only 45% of the patients after anterior repair alone. CONCLUSIONS: Posterior cervical articular pillar plating and fusion result in a higher probability of fusion than repeat anterior procedures, even with the addition of anterior plate stabilization. Posterior fusion and articular pillar plating, whether alone or part of a circumferential procedure, provides the added fixation required to successfully repair failed anterior cervical fusions.

Adolescent↗

PubMed2002

Effect of grafting technique on the maintenance of coronal and sagittal correction in anterior treatment of scoliosis.

STUDY DESIGN: A retrospective radiographic study was conducted to analyze 50 consecutive adolescents with thoracolumbar-lumbar scoliosis treated with single solid-rod anterior instrumentation and either rib strut or morsellized interbody bone grafting technique. OBJECTIVES: To evaluate the effect of grafting technique on the maintenance of coronal and sagittal plane correction and alignment and the incidence of pseudarthrosis. SUMMARY OF BACKGROUND DATA: Loss of scoliosis correction and progressive kyphosis in the instrumented segment associated with radiographic pseudarthrosis have historically been disadvantages of the anterior technique used to correct thoracolumbar-lumbar scoliosis. METHODS: All the patients underwent anterior discectomy, spinal fusion, and correction with Texas Scottish Rite Hospital instrumentation, with rib strut grafts used in 18 patients to "prop open" disc spaces below L1 and simple morsellized bone graft used in 32 patients. Most of the patients were instrumented from T11-L3 or T10-L2. Maintenance of coronal and sagittal plane correction and alignment was determined from the preoperative, immediate postoperative, and final follow-up radiographs. RESULTS: Scoliosis correction was 72% immediately after surgery, but with an average 6 degrees loss of correction, it was 61% at follow-up evaluation. Final correction of apical vertebral translation was 69%, and trunk shift was 86%. Ten patients lost more than 10 degrees of scoliosis correction. In the sagittal plane, the instrumented segment was corrected initially from a mean of 3 degrees kyphosis to -1 degrees lordosis, but then had settled to 7 degrees kyphosis at follow-up evaluation. Progressive kyphosis exceeding 10 degrees in the instrumented segment was found in 19 patients. The technique of grafting had no effect on the maintenance of correction or sagittal alignment. Rib strut grafting did demonstrate a decreased incidence of pseudarthrosis, as compared with morsellized grafting (P = 0.029). Not unexpectedly, patients with pseudarthrosis had an increased incidence of correction loss, progressive kyphosis in the instrumented segment, instrumentation failure, and revision surgery, which was required in three cases. CONCLUSIONS: Although the rib strut grafting technique improves the pseudarthrosis rate, as compared with morsellized graft, it did not affect the maintenance of correction or sagittal alignment. Adjunctive measures to provide truly structural interbody support (fusion cages, allograft rings, two-rod construct) appear to be required to address the shortcomings of anterior single-rod instrumentation.

Adolescent↗

PubMed1999

Complications associated with pedicle screws.

BACKGROUND: The safety and the effectiveness of pedicle-screw instrumentation in the spine have been questioned despite its use worldwide to enhance stabilization of the spine. This review was performed to answer questions about the technique of insertion and the nature and etiology of complications directly attributable to the screws. METHODS: We performed a retrospective review of all of the pedicle-screw procedures that were done by us from January 1, 1984, to December 31, 1993. We inserted 4790 screws during 915 operative procedures on 875 patients; 668 (76.3 percent) of the patients had a lumbosacral arthrodesis. The mean duration of follow-up was three years (range, two to five years). The accuracy of screw placement was assessed on intraoperative, immediate postoperative, and follow-up radiographs with use of a technique that was developed by one of us (F. D.); this technique has yet to be validated to determine the prevalence of various types of error. RESULTS: Of the 4790 screws, 4548 (94.9 percent) had been inserted within the pedicle and the vertebral body. One hundred and thirty-four (2.8 percent) of the screws had perforated the anterior cortex, and this was the most common type of perforation. One hundred and fifteen (2.4 percent) of the screws were associated with complications that could be ascribed to the use of pedicle screws. The most common problem was late-onset discomfort or pain related to a pseudarthrosis or perhaps to the screws; this problem was associated with 1102 (23.0 percent) of the screws, used in 222 (24.3 percent) of the procedures. The symptoms necessitated removal of the instrumentation with or without repair of the pseudarthrosis. A pseudarthrosis was found during forty-six (20.7 percent) of the 222 procedures. Irritation of a nerve root occurred after nine procedures (1.0 percent) and was caused by eleven screws (0.2 percent); it was more commonly caused by medially placed screws. Three patients had residual neurological weakness despite removal of the screws. Twenty-five screws (0.5 percent), used in twenty procedures (2.2 percent), broke. The screws that broke were of an early design. A pseudarthrosis was found in thirteen of twenty patients who had broken screws. Sixteen of the twenty patients had an exploration; three of them were found to have a solid fusion, and thirteen were found to have a pseudarthrosis. The remaining four patients had evidence of a solid fusion on radiographs and had no pain. CONCLUSIONS: There are few problems associated with the insertion of screws, provided that the surgeon is experienced and adheres to the principles and details of the operative technique. Our review revealed a low rate of postoperative complications related to pedicle screws. The problem of late-onset pain may be related to the implants or to the stiffness of the construct; however, it is difficult to accurately identify its exact etiology.

Adolescent↗

PubMed2000

The safety and efficacy of Isola-Galveston instrumentation and arthrodesis in the treatment of neuromuscular spinal deformities.

BACKGROUND: Implant systems that realign and stabilize a deformed spine continue to evolve. The purpose of the study of this case series was to determine the safety and effectiveness of a system designed to integrate hook, wire, screw, and post anchors for the treatment of a wide spectrum of neuromuscular disorders associated with pelvic deformity or the potential for deformity. METHODS: Forty-seven consecutive patients who had a spinal deformity that was due to cerebral palsy or an upper motor-neuron cerebral palsy-like disease (thirty-one patients), myelomeningocele (nine), Duchenne muscular dystrophy (four), or other disorders (three) were managed with Isola-Galveston instrumentation and arthrodesis. The average age at the time of the operation was fourteen years and three months (range, five years and four months to twenty-three years and nine months). Eight patients (17 percent) had an additional anterior discectomy and arthrodesis without instrumentation, and three (6 percent) had an additional decancellation egg-shell osteotomy. The forty-seven patients were followed for an average of forty-seven months (range, twenty-four to 100 months). The complications were tabulated to assess the safety of the procedure, and the correction of each deformity was calculated to determine the efficacy. RESULTS: There were no deaths, acute wound infections, or serious neurological problems. Reoperation was necessary in five patients (11 percent). One reoperation was performed because of a delayed deep wound infection; one, because of delayed sterile drainage; and one, for a pseudarthrosis repair. The remaining two reoperations were done for removal of an implant because the cephalad portion had become prominent. In addition to the pseudarthrosis that required a reoperation, there were three possible pseudarthroses that did not require a reoperation (overall prevalence of pseudarthrosis, 9 percent). Postoperative bracing was used for eleven patients (23 percent); it did not influence the rate of pseudarthrosis or possible pseudarthrosis. The average preoperative scoliosis of 70 degrees was corrected to 24 degrees (a 66 percent correction) at the time of the latest follow-up, and the average preoperative pelvic obliquity of 27 degrees was corrected to 5 degrees (an 81 percent correction). A survey of the patients, parents, and caregivers indicated that 96 percent of them were satisfied or very satisfied with the result of the operation. CONCLUSIONS: Isola-Galveston instrumentation seems as safe and effective as other types of instrumentation that have been studied in comparable series in the literature. Isola-Galveston instrumentation is probably more effective for the correction of pelvic obliquity and the maintenance of correction. Only a posterior procedure is used, and the instrumentation appears to decrease the need for an additional anterior approach. Spinal hook, wire, screw, and post anchors have been successfully integrated into one posterior spinal implant system.

Adolescent↗

PubMed1985

Closed loop instrumentation of the lumbar spine.

A review of 40 consecutive nonreported multilevel lumbar fusions revealed an unacceptable pseudarthrosis rate of 32.5%. In an attempt to reduce this complication, a modification of segmental spinal instrumentation with use of a closed loop was performed on 50 consecutive patients treated by multilevel lumbar stabilizations. The primary diagnoses were degenerative disc and/or facet disease in 32, spondylolisthesis in 14, and pseudarthrosis in four. Thirty-eight percent had three or more levels to be fused. Thirty-two percent had had previous spinal surgery. Follow-up study was a minimum of one year. Seventy-three percent had posterior facet fusions. Twenty-seven percent had bilateral transverse process fusions. A pseudarthrosis occurred early in six patients, an incidence of 12%; three of the six occurred in patients with spondylolisthesis. Four of the six pseudarthroses occurred following posterior fusions. Subjective symptoms were improved in 80%. Working capacity was the same or better in 56%. Closed loop instrumentation (CLI) decreased the overall incidence of pseudarthrosis. When combined with transverse process fusion, CLI produced a slightly higher rate of success (90%) than did posterior fusion alone (87%) but did not reduce the incidence of pseudarthrosis in patients with spondylolisthesis.

Adolescent↗

PubMed1994

The fate of anterior vertebral bone grafts in patients irradiated for neoplasm.

Perioperative irradiation is often used with anterior decompression and vertebral interbody fusion for the treatment of spinal neoplasms, yet little is known regarding the healing potential of these grafts. This review of 25 patients with neoplasm who had anterior vertebrectomy, bone strut insertion, and perioperative irradiation was performed to look specifically for evidence of radiographic fusion as determined by plain radiographs, tomograms, or computed tomography reconstruction. Four of 25 patients (16%) were judged to have a pseudarthrosis. All four pseudarthrosis patients but only four of 21 fusion patients had 4000 cg or more of irradiation, a statistically significant difference. There was a trend for lumbar lesions to have a higher risk for nonunion. Concomitant posterior stabilization did not necessarily prevent pseudarthrosis. Two iliac strut grafts with a pseudoarthrosis developed late fracture and one went on to collapse into kyphosis. The pseudarthrosis rate of anterior vertebral strut grafts in the face of irradiation for tumor is relatively high, and late graft fracture can occur if pseudarthrosis develops. Probable risk factors include irradiation greater than 4000 cg and lumbar lesions. Posterior stabilization to protect the graft may be warranted in the highest-risk patients.

Bone Transplantation↗

PubMed1995

Comparison between allograft plus demineralized bone matrix versus autograft in anterior cervical fusion. A prospective multicenter study.

STUDY DESIGN: This study analyzed the fusion results of an allograft-demineralized bone matrix composite versus autograft in a prospective series of patients undergoing surgery for cervical disc disease. OBJECTIVES: To determine the fusion rates of allograft-demineralized bone matrix composite in anterior cervical fusion as compared with the gold standard autograft. SUMMARY OF BACKGROUND DATA: For the anterior cervical fusion, the use of freeze-dried allograft is well documented in the literature, citing its effectiveness and inferior fusion rates. The use of demineralized bone matrix in conjunction with freeze-dried allograft in anterior cervical fusion has not been reported. METHODS: This study was done in a prospective fashion in two medical centers. One group received autograft from the anterior iliac crest, whereas others received freeze-dried allograft augmented with demineralized bone matrix (Grafton, Osteotech, Inc., Shrewsbury, New Jersey). For the autograft group, the standard Smith-Robinson grafting technique was used. For the allograft composite group, demineralized bone matrix was pasted onto the freeze-dried allograft and into the disc space before graft insertion. The autograft group consisted of 38 patients with age ranging 26-71 years (mean, 46.1 years) and follow-up periods of 12-33 months (mean, 18.4 months). There were 19 one-level, 17 two-level, and two three-level fusions. Similarly, the allograft group consisted of 39 patients with age ranging 28-80 years (mean, 48.0 years) with follow-up period of 12-31 months (mean, 17.5 months). There were 19 one-level, 16 two-level, and four three-level fusions. Clinical and radiographic follow-up evaluations were completed at 3-month intervals. Radiographs taken 12 months after surgery were analyzed blindly. RESULTS: Pseudarthrosis developed in 46.2% of patients (33.3% of levels) in the allograft-demineralized bone matrix group compared with 26.3% (22% of levels) in the autograft group (P = 0.11 for patients, P = 0.23 for levels). For patients undergoing two-level fusions, 37.5% of allograft-demineralized bone matrix failed compared with 23.5% of autografts. For single-level fusions, 47.4% of allograft patients developed a pseudarthrosis compared with 26.3% in the autograft group. Graft collapse of > or = 3 mm was noted in 11% of the autograft group versus 19% in the allograft-demineralized bone matrix group (P = 0.32). Graft collapse of > or = 2 mm occurred in 24.4% of autograft patients compared with 39.7% of the allograft-demineralized bone matrix group (P = 0.09). Smokers had an increased rate of pseudarthrosis (47.1%) compared with nonsmokers (27.9%, P = 0.13). CONCLUSIONS: The study revealed that the allograft-demineralized bone matrix construct gives a higher rate of graft collapse and pseudarthrosis when compared with autograft in a prospective series, although the differences were not statistically significant. The pseudarthrosis rate in the series may be high because of the large percentage of smokers and radiographic evaluation techniques. For the purpose of solid radiographic fusion, the use of autograft is recommended in anterior cervical surgery until other acceptable osteoinductive materials are developed.

Adult↗