Orthopaedics

Rising to the challenge: Spinal ailments in India Harvinder Singh Chhabra Indian Journal of Orthopaedics 2019 53(4):489-492

A comparison of clinical and functional outcomes following anterior, posterior, and combined approaches for the management of cervical spondylotic myelopathy Gautam R Zaveri, Nitin Parmeshwarlal Jaiswal Indian Journal of Orthopaedics 2019 53(4):493-501 Background: The key determinants when planning surgery in patients with CSM are the direction of compression, number of levels, sagittal alignment and instability. However there is no literature that compares the clinical and functional outcomes following different approaches in patients selected for surgery. Aims: Prospective non-randomized study that aims to compare the clinical and functional outcomes following surgical approaches with the goal of planning the optimal surgical strategy. Material and Methods: 75 patients- 61 males and 14 females (mean age: 64.2 years) with CSM underwent spinal decompression using an anterior (30), posterior (35) or combined approach (10).The surgical approach was selected based on the above mentioned key determinants. Functional disability was measured using the modified Japanese Orthopaedic Association score for myelopathy. Based on this the recovery rate was calculated. The mean followup duration was 21 months (range 6-72 months). Results: The preoperative mJOA score was 11.01 and the functional disability was graded as mild in 15, moderate in 50 and severe in 10. Postoperatively, the mJOA score improved to 16.41.The overall recovery rate was 77.25%.Patients with mild deficits/disability preoperatively had a significantly better recovery (<0.01) than those with more severe disability. There was comparable improvement in the functional status within the groups with the recovery rates were 83.37%, 76.6% and 64.13%.The blood loss, operative time and peri-operative complication rate were significantly higher with a combined surgery (33%) as compared to anterior (13.3%) or posterior approaches 14.8%. Conclusions: Outcomes are excellent following surgery for CSM. The best recovery is seen in patients with mild to moderate functional disability at the time of surgery.

The radiologic and clinical outcomes of oblique lateral interbody fusion for correction of adult degenerative lumbar deformity Ravish Shammi Patel, Seung Woo Suh, Seong Hyun Kang, Ki-Youl Nam, Shiblee Sabir Siddiqui, Dong-Gune Chang, Jae Hyuk Yang Indian Journal of Orthopaedics 2019 53(4):502-509 Background: Osteotomies aimed at correcting adult spinal deformity are associated with higher complications and perioperative morbidity. Recently, oblique lumbar interbody fusion (OLIF) was introduced for degenerative lumbar diseases. The aim of our study is to demonstrate the effectiveness of OLIF on the management of adult degenerative lumbar deformity (ADLD). Materials and Methods: Patients with ADLD who underwent deformity correction and decompression using OLIF and posterior instrumentation were enrolled. For radiologic evaluation, Cobb's angle (CA), sagittal vertical axis (SVA), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI) were evaluated. Visual analog scale (VAS), Oswestry disability index (ODI), and perioperative parameters were recorded for clinical evaluation. Results: Fifteen patients with a mean age of 67 years (63–74 years) were enrolled prospectively and an average of 3 OLIFs (range 1–4) was performed. Posterior instrumentations were done at average of six levels (range 4–8). The mean operative blood loss was 863 ml (range 500–1400 ml) with a mean surgical duration of 7 h (range 3–11 h). SVA, TK, LL, CA, PT, and SS showed significant correction (P < 0.05) in immediate postoperative period and all parameters except TK were maintained at final followup. At the end of 24 months of average followup, 86% (13/15) showed fusion. VAS (leg pain), VAS (back pain), and ODI improved by 74% (range 40–100), 58% (range 20%–80%), and 69.5% (range 4%–90%), respectively. There were two major complications requiring revision (1 infection and 1 adjacent vertebral body fracture). Transient hip weakness present in two patients (13%) recovered within 6 weeks. Conclusions: OLIF gives favorable short term clinical and radiological outcomes in patients of ADLD. It could potentially reduce the need for morbid pelvic fixation and posterior osteotomies in patients with degenerative lumbar deformity.

Outcome evaluation of modified uninstrumented open-door cervical laminoplasty for ossified posterior longitudinal ligament with cervical myelopathy Charanjit Singh Dhillon, Shrikant Rajeshwari Ega, Raviraj Tantry, Narendra Reddy Medagam, Nilay Chhasatia, Chetan Pophale, Anand Khatavi Indian Journal of Orthopaedics 2019 53(4):510-517 Study Design: This was a retrospective study. Purpose: To evaluate the short term outcomes of a novel self-developed technique of performing uninstrumented open-door cervical laminoplasty (ODCL) in patients with cervical myelopathy secondary to ossified posterior longitudinal ligament (OPLL). Review of Literature: Published literature on cervical laminoplasties largely focuses on the outcomes of instrumented variants. Materials and Methods: Retrospective data were collected from 54 patients who underwent uninstrumented ODCL for cervical OPLL at a single institution from January 2010 to February 2017. The preoperative and postoperative modified Japanese Orthopaedic Association score (mJOA) and Nurick grading were documented. Cervical lordotic angle at C2–C7 and range of motion (ROM) were obtained from the preoperative and postoperative lateral cervical radiographs in neutral and flexion extension views, respectively. Descriptive and analytical statistics were generated by SAS 9.4 University Edition (SAS Institute, Cary. North Carolina, USA). Results: The average age was 58.6 ± 7.8 years. The average time of presentation from the onset of symptoms was 7.6 ± 3 months. Of the 54 patients who were included in the study, majority (48.14%) had segmental type of OPLL while C3–C6 was the most commonly operated level (66.67%). The mean operating time was 115 ± 31 min with a mean blood loss of 165.9 ± 75 ml. There was a significant improvement in the mJOA scores (9.2 ± 1.1–13.7 ± 0.9, P < 0.0001) and Nurick grading (3.4 ± 0.8–1.6 ± 0.5, P < 0.0001) at 24-month followup. Preoperative C2–C7 angle had an average decrease of 4.5° at 24-month followup (19.3 ± 7.2–14.8 ± 8.8, P < 0.0001). There was a mean reduction of 4.3° ± 3.78° noted in the C2–C7 ROM between the preoperative and final followup. Conclusion: Uninstrumented ODCL is an easily reproducible and economical alternative to the standard instrumented laminoplasty with equivalent short term outcomes. This technique is a valuable option in the treatment of cervical OPLL, especially in regions with scarce resources.

Management of combined atlas fracture with type II odontoid fracture: A review of 21 cases Zhong-Sheng Zhao, Guang-Wen Wu, Jie Lin, Ying-Sheng Zhang, Yan-Feng Huang, Zhi-Da Chen, Bin Lin, Chun-Song Zheng Indian Journal of Orthopaedics 2019 53(4):518-524 Purpose: To evaluate the therapeutic effects of combined atlas fracture with type II (C1-type II) odontoid fractures and to outline a management strategy for it. Patients and Methods: Twenty three patients with C1-type II odontoid fractures were treated according to our management strategy. Nonoperative external immobilization in the form of cervical collar and halo vest was used in 13 patients with stable atlantoaxial joint. Surgical treatment was early performed in 10 patients whose fractures with traumatic transverse atlantal ligament disruption or atlantoaxial instability. The visual analog scale (VAS), neck disability index (NDI) scale, and American Spinal Injury Association (ASIA) scale at each stage of followup were then collected and compared. Results: Compared to pretreatment, the VAS score, NDI score, and ASIA scale were improved among both groups at followup evaluation after treatment. However, in the nonsurgical group, one patient (1/11) developed nonunion which required surgical treatment in later stage and one patient (1/13) with halo vest immobilization had happened pin site infection. Two patients of the surgical group (2/11) had appeared minor complications: occipital cervical pain in one case and cerebrospinal fluid leakage in one case. Two patients (2/23) were excluded from nonsurgical treatment group because their followup period was less than 12 months. Twenty one patients were followed up regularly with an average of 23.9 months (range 15–45 months). Conclusions: We outlined our concluding management principle for the treatment of C1-type II odontoid fractures based on the nature of C1 fracture and atlantoaxial stability. The treatment principle can obtain satisfactory results for the management of C1-type II odontoid fractures.

A prospective study of clinicoradiologic-urodynamic correlation in patients with tuberculosis of the spine Roop Singh, Milind Tanwar, Santosh Singh, Rajesh Kumar Rohilla Indian Journal of Orthopaedics 2019 53(4):525-532 Introduction: Involvement of spinal cord in spinal tuberculosis (TB) has been associated with bladder disturbances on which literature is scarce. The present study aimed at evaluating the urodynamic profile, its correlation with clinical and radiological features, and the prognosis with treatment in these patients. Materials and Methods: Thirty patients of spinal TB were prospectively evaluated clinically, radiologically, and urodynamically in this single center prospective study. All patients underwent urodynamic assessment at presentation; and those with bladder dysfunction on initial urodynamics were followed with sequential testing at 3, 6, and 12 months. Results: Patients were divided into two groups on the basis of the absence (Group 1, n = 14) or presence (Group 2, n = 16) of bladder dysfunction. The magnitude of deformity (P = 0.011), sensory deficit (P = 0.025), and tenderness (P = 0.030) at presentation was found to be significantly more in Group 2 and involvement of posterior elements, reduction in disc height, endplate erosion, and nerve root were significantly higher. The initial urodynamic assessment showed delayed sensations in 23.3% and early sensations in 13.3%, respectively; decreased bladder compliance in 3.33%; underactive detrusor in 16.6%, and overactive in 13.3% of cases. The sphincter was dyssynergic in 13.3% of cases. Statistically significant (P < 0.001) improvement in sensory parameters of bladder, detrusor contractility, and compliance with treatment was observed. Thirteen (81.3%) patients of Group 2 showed overall improvement on serial urodynamics after chemotherapy. Patients with bladder disturbances had poorer functional recovery at 6 and 12 months. Conclusion: Significant bladder comorbidity is associated with spinal TB and its presence can be recognized as a poor prognostic factor. Urological morbidity is strongly linked to the nerve root and posterior element involvement; reduction in disc height; and end plate erosion. Clinical/neurological improvement correlates with marked radiological and urological improvement.

Therapeutic impact of percutaneous pedicle screw fixation on palliative surgery for metastatic spine tumors Hiroshi Uei, Yasuaki Tokuhashi Indian Journal of Orthopaedics 2019 53(4):533-541 Background: Percutaneous pedicle screw (PPS) fixation has been introduced into palliative surgery for metastatic spine tumors; however, the therapeutic effects of PPS on the outcomes of multidisciplinary treatment for such tumors are unclear. Therefore, the therapeutic impact of PPS was investigated among patients with metastatic spine tumors and with revised Tokuhashi scores of ≤8. Materials and Methods: A total of 47 patients who underwent conventional palliative surgery (posterior decompression and stabilization, 33; posterior stabilization alone, 14) before the introduction of PPS and 38 patients who underwent PPS (posterior decompression and stabilization, 19; posterior stabilization alone, 19) were included. Surgical stress (operative time, blood loss, complications, etc.) and treatment outcomes (postoperative survival time, visual analog scale scores, Frankel classification, and the Barthel index at the final followup) were compared between the conventional and PPS groups. Results: The age of the indicated patients significantly increased after the introduction of PPS (P < 0.05). Regarding posterior decompression and stabilization, there were no significant intergroup differences in surgical stress or treatment outcomes. As for posterior stabilization alone, there were significant preoperative differences in various parameters between the conventional and PPS groups (P < 0.01) and also significant postoperative intergroup differences between surgical stress and treatment outcomes (P < 0.01). Conclusions: For patients with early-stage metastatic spine tumors, the use of PPS-based posterior stabilization combined with multidisciplinary adjuvant therapy has changed the age range of the patients indicated for surgery and caused significant improvements in surgical stress, postoperative survival time, and Barthel index.

A comparison study of three posterior fixation strategies in transforaminal lumbar interbody fusion lumbar for the treatment of degenerative diseases Yong Hu, Bing-Ke Zhu, Christopher K Kepler, Zhen-Shan Yuan, Wei-Xin Dong, Xiao-Yang Sun Indian Journal of Orthopaedics 2019 53(4):542-547 Background: There are various posterior fixations utilized with transforaminal lumbar interbody fusion (TLIF). Previous studies have focused on the comparison of two fixation techniques. Materials and Methods: Sixty five patients with single-level lumbar disease were included in this retrospective study. Group A was treated by TLIF with bilateral pedicle screw (BPS), Group B treated by TLIF with unilateral pedicle screw (UPS), and Group C treated by TLIF with UPS plus contralateral translaminar facet screw (UPSFS). The operative time, blood loss, Oswestry disability index (ODI), Japanese Orthopaedic Association Scores (JOA), and visual analog scores (VAS) were recorded. Radiographic examination was used to assess fusion rates and incidence of screw failure. Results: The blood loss and operative times were 188.69 ± 37.69 ml and 132.96.5 ± 8.69 min in BPS group, 117.27 ± 27.11 ml and 99.32 ± 12.94 min in UPS group, and 121.50 ± 22.54 ml and 112.55 ± 9.42 min in UPSFS group; UPS and UPSFS were better than BPS (P < 0.05). The mean followup time was 38.2 months. Fusion rates were – BPS group: 95.6%, UPS group: 90%, UPSFS: 95% (P > 0.05). Screw and/or rod failures were found in three groups (BPS group: 1, UPS group: 2 and UPSFS: 1, P > 0.05). The average postoperative VAS, ODI, and JOA scores of BPS, UPS, and UPSFS were improved significantly in each group compared to preoperative scores (P < 0.05); there were no significant differences between any two groups at each followup time point (P > 0.05). Conclusion: UPSFS with TLIF is a viable treatment option that provides satisfactory clinical results; the clinical outcome and the complication rate were comparable to BPS. In addition, the invasive of UPSFS cases was comparable to UPS and better than BPS cases. For UPS, it could be used in suitable patients.

Greater trochanter apophysiodesis in Legg–Calve–Perthes disease: Which implant to choose? Evren Akpinar, Osman Nuri Ozyalvac, Ilhan Avni Bayhan, Kubilay Beng, Ahmet Kocabiyik, Mehmet Firat Yagmurlu Indian Journal of Orthopaedics 2019 53(4):548-553 Background: Greater trochanter apophysiodesis (GTA) is relatively minimal invasive technique for the treatment of trochanteric overgrowth. Various types of implants can be used in each procedure. The purpose of this study was to compare outcomes of three different types of implants that were used in treatment of trochanteric overgrowth in Legg–Calve–Perthes disease. Materials and Methods: We retrospectively studied radiological results of three implants (screw, screw washer, and EP) on inhibiting trochanteric growth in 32 patients. Articulo-trochanteric and trochanter-trochanter distances (TTDs) were measured on radiographs. Embedding of implant evaluated on final radiographs. Results: The mean of age at the surgery was 10 ± 2.3 years, and the mean of follow up period was 50.0 ± 16.7 months. In all groups, articulo-trochanteric distance was decreased on final radiographs. In screw and screw washer group, increase of TTD was not statistically significant (P < 0.05). Twelve, one, and two implants were embedded, respectively, in screw, screw washer, and EP groups. Two patients in EP group had revision surgery due to loosening. Conclusions: In this study group, GTA using screw and screw washer methods could slow down but did not restore trochanteric overgrowth. We suggest using washer to reduce embedding of the screw.

Results of rodding and impact on ambulation and refracture in osteogenesis imperfecta: Study of 21 children Atul R Bhaskar, Deepak Khurana Indian Journal of Orthopaedics 2019 53(4):554-559 Introduction: Delay in presentation and surgical intervention is quite usual in osteogenesis imperfecta (OI) because of various local and cultural beliefs. The purpose of this study is to review the results of 21 children who had intramedullary rodding and its effect on ambulation and refracture. Methods: We reviewed 21 children with a clinical diagnosis of OI. The mean age of children at presentation was 8.74 years (3–21 years). All children had recurrent fractures of long bones. Twenty eight femurs and 21 tibiae were stabilized with intramedullary rodding. Ambulatory status was assessed by the Hoffers and Bullock's (H and B) grading, and muscle power was recorded using the Medical Research Council, U. K., grade. Ten children had received intravenous bisphosphonates preoperatively. Postoperatively, the children were assessed for ambulatory status, pain, and ability for independent self-care. Results: The mean followup period was 34 months (24–48 months). Rush rods were used in 20 femurs, the Fassier–Duval (FD) rods in 6 femurs, and in two cases, with narrow intramedullary canals, Kirshner (K) wires were used. For the tibiae, 15 children received rush rods and in 6 cases, an FD rod was used. The mean time to fracture union was 8 weeks (6–12 weeks). Before surgery, 13 children were in H and B Grade 4 (wheel-chair independent or carried by parents usually in a developing country), four were able to ambulate with a walking aid (H and B Grade 3b), and four children were able to walk about in the house without aids (H & B Grade 2). After the rodding procedure, the ambulatoty status improved in 11 (50%) children. Seven children (33%) became household physiologic walkers (H & B Grade 3b), three achieved independent ambulation with orthosis (H & B Grade 1b), and one child with mild OI could walk unaided (H & B Grade 1a). No child had deterioration in ambulatory status. Only two children had refractures at the distal end of the rod due to continual growth of bones. Conclusions: Intramedullary rodding treatment for recurrent fractures in children with OI improves their mobility potential. It also and prevents repeated cast application, disuse wasting, and osteopenia which can lead to deterioration in the quality of the long bones.

Alexandros Sfakianakis
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