No difference in postoperative complications,pain, and functional outcomes up to 2 years after incidental durotomy in lumbar spinal fusion: a prospective,multi-institutional,propensity-matched analysis of 1,741 patients

BackgroundIncidental durotomies occur in up to 17% of spinal operations. Controversy exists regarding the short- and long-term consequences of durotomies.PurposeThe primary aim of this study was to assess the effect of incidental durotomies on the immediate postoperative complications and patient-reported outcome measures.Study designProspective study.Patient sampleA total of 1,741 patients undergoing index lumbar spine fusion were selected from a multi-institutional prospective data registry.Outcome measuresPatient-reported outcome measures used in this study included back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), and Oswestry Disability Index.MethodsA total of 1,741 patients were selected from a multi-institutional prospective data registry, who underwent primary lumbar fusion for low back pain and/or radiculopathy between January 2003 and December 2010. We collected and analyzed data on patient demographics, postoperative complications, back pain, leg pain, and functional disability over 2 years, with risk-adjusted propensity score modeling.ResultsIncidental durotomies occurred in 70 patients (4%). Compared with the control group (n=1,671), there was no significant difference in postoperative infection (p=.32), need for reoperation (p=.85), or symptomatic neurologic damage (p=.66). At 1- and 2-year follow-up, there was no difference in patient-reported outcomes of back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), or functional disability (Oswestry Disability Index) (p>.3), with results remaining consistent in the propensity-matched cohort analysis (p>.4).ConclusionWithin the context of an on-going debate on the consequences of incidental durotomy, we found no difference in neurologic symptoms, infection, reoperation, back pain, leg pain, or functional disability over a 2-year follow-up period.     

Clinical and radiological outcomes between biportal endoscopic decompression and microscopic decompression in lumbar spinal stenosis

Background contextNumerous minimal invasive techniques treating lumbar spinal stenosis have been introduced. Clinical results using biportal endoscopic spinal surgery has recently been introduced as a treatment option for lumbar spinal stenosis. The purpose of this study was to compare the clinical and radiologic outcome between microscopic unilateral laminotomy bilateral decompression and biportal endoscopic unilateral laminotomy bilateral decompression in patients with degenerative lumbar spinal stenosis.MethodA total of 89 patients were evaluated for this study. Only single-level patients were enrolled for accurate comparison. Patients that underwent biportal endoscopic surgery were assigned to Group A, and patients that underwent microscopic surgery were designated Group B. Clinical outcomes were evaluated using modified Macnab criteria, Oswestry Disability Index, and Visual Analog Scale. Postoperative complications were checked until final follow up. Plain radiographs before and after surgery were compared to analyze the change of alignment.ResultThere was a significant difference between Group A and B in VAS of back on postoperative 2 months. Other clinical measurements except for postoperative 2 months VAS of back showed no significant difference. There were no significant differences between Group A and Group B regarding preoperative and postoperative radiological findings.ConclusionTwo different decompression techniques preserve the spinal structure and exhibit a favorable clinical outcome and have the advantage of not causing postoperative instability in the short term follow up. Biportal endoscopic surgery may leads to less postoperative back pain than microscopic surgery, which may allow early ambulation and shorter hospitalization period.     

Comparing rates of early pedicle screw loosening in posterolateral lumbar fusion with and without transforaminal lumbar interbody fusion

BACKGROUND CONTEXTAddition of interbody fusion via a transforaminal approach (TLIF) has become a popular surgical option for treatment of degenerative lumbar conditions. Although technically more complicated than posterolateral fusion surgery (PLF), it has been suggested that TLIF provides superior immediate stability and protects against early pedicle screw loosening. This theory has never been formally examined in a clinical study.PURPOSETo determine the impact of TLIF on early pedicle screw loosening and radiographic fusion rates compared with PLF using pedicle screws alone in the treatment of single level lumbar degenerative conditions.STUDY DESIGNRetrospective computed tomography (CT) based review.PATIENT SAMPLEOne hundred ninety-three patients underwent TLIF+PLF with local autograft bone or PLF alone with local autograft bone.OUTCOME MEASURESRadiographic fusion rates and screw loosening were measured at 6 and 12 months using strict CT criteria. Patient self-reported outcome measures included Visual Analog Scale for low back pain and leg pain and Oswestry Disability Index.METHODSPostoperative thin-cut CTs were examined for pedicle screw loosening and radiographic fusion status. Early screw loosening rates were determined using 6-month postoperative CT, whereas radiographic fusion rates were determined using 12-month postoperative CT. One-way analysis of variance was used to determine significant differences in mean outcome scores and other continuous measures between groups at baseline and follow-up. Chi-square test of independence or Fisher's exact test was used to compare proportions between groups on categorical measures.RESULTSEighty-three patients underwent TLIF+PLF (Group A) and 115 patients underwent PLF alone (Group B). At 6-month follow-up, loosening was observed in 49 of 792 total screws (6.19%). Of Group A, 7.23% of patients demonstrated loosening of one or more screws compared with 18.3% of Group B (Chi-Square value 4.98; p=.0256). Six-month radiographic fusion rates were 36.1% in Group A versus 44.3% in Group B. Twelve-month radiographic fusion rates increased to 58.6% in Group A versus 73.1% in Group B. Among Group A patients not yet fused at 6 months, screw loosening was associated with a 0% rate of radiographic fusion at 12 months versus 41.2% without screw loosening. Rates for Group B were 6.25% and 70.3%, respectively. Patient age was a significant independent predictor of loosening (p=.0336).CONCLUSIONSTLIF appears to have a protective effect, reducing rates of early screw loosening by approximately 60% versus PLF. However, this effect appears independent of actual overall radiographic fusion rates which may be approximately 20% lower with TLIF at 12 months. TLIF may have advantages in patients where early loosening is a particular concern, for example, in the setting of increased patient age.     

Is the likelihood of dysphagia different in patients undergoing one-level versus two-level anterior cervical discectomy and fusion?

BACKGROUND CONTEXTDysphagia following anterior cervical discectomy and fusion (ACDF) is a common complication, the etiology of which has not been established. Given that one potential mechanism for dysphagia is local tissue edema, it is thought that a greater number of operative levels may result in higher dysphagia rates. However, prior reports comparing one-level to two-level ACDF have shown varying results.PURPOSETo determine if there is a difference in dysphagia between one-level and two-level ACDF.STUDY DESIGN/SETTINGRetrospective review of prospectively collected data.PATIENT SAMPLEPatients who underwent one- or two-level ACDF with a plate-graft construct by a single-surgeon at a high-volume academic medical center.OUTCOME MEASURESNeck Disability Index, Visual Analog Scale for neck pain and arm pain, Short Form-12 physical and mental health components, and Swallowing Quality of Life (SWAL-QOL) Questionnaire.METHODSPatient demographics, operative data, and patient-reported outcome measures (PROMs; Neck Disability Index, Visual Analog Scale, Short Form-12, and SWAL-QOL) of patients undergoing one- and two-level ACDF were compared using Fisher exact test for categorical variables and Student's t test for continuous variables. Regression analyses were conducted to identify factors associated with 6- and 12-week SWAL-QOL scores in order to determine whether the number of surgical levels impacts these outcomes.RESULTSFifty-eight patients (22 one-level and 36 two-level ACDF) were included. Patients undergoing two-level fusions were older (54.17+8.67 vs 48.06+10.68 years, p=.02) and had longer operative times (69.08+10.51 vs 53.5+14.35 minutes, p<.0001). There were no other significant differences in demographics or operative data. Both groups showed a statistically significant improvement in PROMs from preoperatively to 12 weeks. There was no difference in PROMs or dysphagia rates between groups at any time-point. Younger age (p=.023), male sex (p=.021), longer operative times (p=.068), and worse preoperative SWAL-QOL (p<.0001) were associated with dysphagia at 6 weeks. Preoperative SWAL-QOL was the only variable associated with dysphagia at 12 weeks (p=.003). Operative time of >61.5 minutes had a sensitivity and specificity of 62.1% for worse dysphagia scores at 6 weeks compared with baseline.CONCLUSIONSThe results of our study indicate that there is no difference in the degree of postoperative dysphagia in one- versus two-level ACDF. However, other variables associated with increased postoperative dysphagia in our population included younger age, male sex, procedural time >61.5 minutes, and worse preoperative dysphagia. Larger studies are required to confirm these findings and identify additional risk factors for postoperative dysphagia.     

Interposition arthroplasty with bovine collagenous membrane for hallux rigidus: A long-term results retrospective study

BackgroundHallux rigidus (HR) is a degenerative arthritis of the first metatarsophalangeal joint (MTP1) with progressive loss of range of movement (ROM). Interposition arthroplasty (IA) is a technique widely used for the treatment of HR;however, few studies reported long-term clinical results. This study aims to report the clinical results of IA using a bovine pericardium collagen matrix for HR with a minimum 10-years follow-up.MethodsThirty patients (31 feet) who underwent IA using a bovine pericardium collagen matrix from 2001 to 2009 were retrospectively evaluated with a mean follow up of 154.1 ± 28.6 (range 124–218) months. All HR ranged from grade II to grade III, according to Regnauld classification. All patients were clinically assessed with the American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal- Interphalangeal Scale, a pain Visual Analog Scale, and the Foot and Ankle Disability Index. Scores before and after treatment, respectively achieved from clinical records and clinical evaluation at final follow-up were compared.ResultsAt final follow-up, an improvement of all the considered scores (p < 0.01) was recorded. The overall rate of unsatisfying results was 16.1 %. Two (6.4 %) patients complained discomfort due to first ray shortening and 3 (9.7 %) cases of persistent metatarsal pain. There was one (3.2 %) case of Complex Regional Pain Syndrome (CPRS). No revision surgeries, infection, or other adverse events were reported.Conclusion: Interposition arthroplasty using bovine collagenous membrane is a reliable solution for high-grade HR with durable results over 10 years in more than 80 % of patients.     

Functional outcomes and quality of life in patients with subtalar arthrodesis for posttraumatic arthritis

IntroductionSubtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis, a condition frequently seen in patients who suffered major trauma. Functional outcomes in trauma patients may be influenced by concomitant injuries and the severity of the initial trauma. The aim of this study was to evaluate quality of life and functional outcomes of subtalar arthrodesis for posttraumatic arthritis in patients with severe or complex foot injuries.Materials and methodsThis is a retrospective single center study with prospective follow-up. Patients who underwent subtalar arthrodesis for posttraumatic arthritis between 2000 and 2016 were included and invited to complete a Maryland Foot Score (MFS), a EuroQol five-dimensional (EQ-5D™) and Visual Analog Scale (EQ-VAS™) questionnaire, and four additional questions.ResultsForty patients were included in the study, functional outcome scores were available for 30 patients (response rate 75%). Additional surgery of the fused foot was performed in 29 patients and 15 suffered multiple lower extremity injuries. Six patients were polytraumatized. Ninety percent of all patients would recommend the procedure to others, walking abilities improved in 69% and less pain was experienced in 76%. Median MFS score was 61 (IQR 53–72). Quality of life was significantly lower when compared to a reference population (p < 0.001).ConclusionSatisfaction was high, as 90% of all patients would recommend subtalar fusion to others, even though the relatively poor outcome measures would suggest differently. Existing functional outcomes measures were influenced by concomitant injuries and additional procedures. This demands development of instruments suitable for severely injured patients with multiple or complex injuries.     

Does obesity affect long-term outcomes of extreme lateral interbody fusion with posterior stabilization?

Background ContextObese patients can pose significant challenges to spine surgeons in lumbar fusion procedures. The increased risk of complications has led surgeons to be wary in pursing operative interventions in these patients. Since the advent of minimally-invasive techniques in lumbar fusion, surgeons are turning to these procedures in an attempt to minimize operative time, blood loss and overall cost. With an increased proportion of obese patients in the population, it is imperative to understand the long-term outcomes in these minimally-invasive approaches.PurposeThe purpose of this study was to evaluate the long-term safety and efficacy of extreme lateral interbody fusion (XLIF) in the obese.Study Design/SettingRetrospective cohort study.Patient SampleA total of 115 patients (53 nonobese and 62 obese) who underwent XLIF with a minimum of 5-year follow-up.Outcome Measures(1) Patient reported outcome scores: Visual Analog Scale (VAS) for back pain, Oswestry Disability Index (ODI), (2) Reoperation rate, (3) Pelvic incidence (PI)- Lumbar lordosis (LL) mismatch correction, (4) Graft subsidence and fusion rateMethodsA retrospective review was performed to identify patients who underwent XLIF with percutaneous posterior stabilization since 2007 with a minimum follow-up of 5 years. Demographics including BMI were recorded and patients were subdivided into 2 cohorts: nonobese (BMI <30 kg/m²) and obese (BMI ≥30 kg/m²). Functional outcomes were assessed by comparing pre- and postoperative VAS and ODI scores. Reoperation rates were compared between cohorts. PI-LL mismatch was calculated from both pre- and postoperative radiographs. Rates of graft subsidence and fusion were measured at final follow-up.ResultsA total of 115 consecutive patients were included (53 nonobese and 62 obese) with a mean follow up of 95.3 months. Mean BMI was 25.3 in the nonobese group and 35.3 in the obese group (p<.001). There were more females in nonobese cohort. VAS scores decreased by a mean of 5.7 in the nonobese cohort, and 5.4 in the obese cohort (p=.213). ODI improvement was also similar between the groups. 5.6% of nonobese patients required reoperation compared to 9.6% of obese patients (p=.503). Graft subsidence rates at final follow-up were 5.66% and 8.06% for the nonobese and obese groups, respectively (p=.613). Rates of successful fusion were 96.23% and 98.39% for the nonobese and obese groups, respectively (p=.469). Both cohorts achieved a similar proportion of PI-LL mismatch correction, 85% in obese versus 78% in nonobese patients (p=.526).ConclusionObese patients have similar surgical outcomes to nonobese patients with respect to functional outcome scores, reoperation rates, graft subsidence and correction of PI-LL mismatch after long-term follow-up. With similar outcome and reoperation profiles, minimally-invasive approaches to the spine, such as XLIF, may be an acceptable alternative to traditional open procedures in obese patients.     

Clinical outcomes of upper extremity ambulators post-reverse total shoulder arthroplasty

BackgroundPatients requiring upper extremity assist devices such as canes, walkers, and wheelchairs have shown an increased incidence of rotator cuff tears (RCTs), distal clavicle osteolysis, and osteoarthritis. The frequent combination of glenohumeral arthritis and rotator cuff arthropathy makes reverse total shoulder arthroplasty (rTSA) an attractive option in treating the shoulder pathology in these patients. The objective of this study is to determine the effectiveness of the rTSA procedure for treatment of shoulder pathology in the upper extremity ambulator population, and what role preoperative functional status plays on outcomes.MethodsThe study involved a retrospective analysis of 30 upper extremity ambulator patients (ages 48-88, average = 72.54 years) who underwent a rTSA procedure performed by the senior author (S.G.) in Milwaukee, WI, USA. Of these 30, 5 patients received bilateral rTSAs, for a total of 35 procedures. Average follow-up for these patients was 32 months, (range 24-84 months). The following preoperative and postoperative characteristics were recorded for each patient: range of motion, Visual Analog Scale scores, American Shoulder and Elbow Surgeons scores, Constant Murley scores, and Simple Shoulder Test scores. Data were analyzed using ANCOVA analysis.ResultsAverage Visual Analog Scale scores improved from 6.40 to 2.08 (gain = 4.362; P< .0001). Average forward flexion improved from 70.32° to 127.74° (gain = 57.42°; P < .0001), while average abduction improved from 41.79° to 110.18° (gain = 68.69°; P = .0002). Average Murley scores improved from 25.68 to 63.32 (gain = 37.64; P = .030). American Shoulder and Elbow Surgeons and Simple Shoulder Test scores were not shown to be statistically significant, though patients showed a trend toward gains in these metrics. A patient's preoperative status was highly correlated with their expected gain in function postoperatively, with lower baseline preoperative function correlating to larger gains postoperatively. Patients showed statistically significant gains in the metrics listed above, regardless of preoperative diabetic status, opioid use, or the type of ambulatory assistive device used.ConclusionThis study shows that rTSA reliably leads to significant postoperative improvements in range of motion, function, and pain relief in the upper extremity ambulator population. Patients with lower preoperative scores showed overall higher gains in both pain and function postoperatively, ultimately leading to similar postoperative outcomes to those who started at a high baseline function. These gains were irrespective of a patient's other preoperative characteristics, including diagnosis of diabetes, preoperative opioid use, and the type of upper extremity assist device used.Level of evidenceLevel III.     

Avaliação da qualidade da recuperação e do estado de saúde no pós‐operatório de cirurgias eletivas

Purpose

Postoperative recovery is a complex process with physiologic, functional, and psychologic dimensions. Postoperative quality of recovery is considered as a crucial outcome following surgery and anesthesia. The objective of this study was to assess and compare the quality of postoperative recovery and health status before and after surgery, in patients undergoing elective surgery.

The correlation between preoperative disc space height and clinical outcomes after anterior lumbar interbody fusion

OBJECTIVE: To determine whether preoperative disc space height (DSH) influences the clinical outcomes of patients diagnosed with single-level symptomatic discogenic disease and treated with a stand-alone anterior lumbar interbody fusion with two tapered threaded fusion cages, we performed a retrospective analysis of 392 patients. METHODS: Preoperative radiographs were used to establish four study groups based on the patients' DSH: the tall disc group: DSH >15 mm; the intermediate tall group: DSH ranging from 10 to 15 mm; the intermediate collapsed group: DSH ranging from 5 to 10 mm; and the collapsed disc group: DSH <5 mm. RESULTS: All of the patient groups exhibited improvement in their clinical outcomes. However, patients in the collapsed disc group (DSH of <5 mm) tended to have earlier and greater improvement in Oswestry Disability Index scores, Physical Component Summary scores of the Short Form-36, and Visual Analog Scale scores for low back pain. CONCLUSION: Symptomatic disc degeneration can be readily identified with plain radiographic findings, and patients' symptoms can often be relieved predictably with a stand-alone interbody fusion procedure.     

"开窗技术"治疗退行性腰椎管狭窄症融合指征

目的 探讨初次"开窗技术"治疗退行性腰椎管狭窄症融合的指征.方法 对1999年12月至2005年12月收治的145例退行性腰椎管狭窄症患者进行回顾性研究.按术前腰椎条件及手术方法分三组:A组39例,术前合并腰椎失稳运动、退变性滑脱或侧弯,行融合术;B组31例,术前合并腰椎失稳运动、退变性滑脱或侧弯,行非融合术;c组75例,术前无腰椎失稳运动、退变性滑脱或侧 弯,行非融合术.对患者住院天数、手术时间、估计出血量复发、再手术及并发症情况等进行统计分析;采用Oswestry 功能障碍指数(ODI)和疼痛视觉模拟评分(VAS)及满意率等进行疗效评估,并进行统计学分析.结果 所有患者随访时间均在3年以上.C组的住院时间少于A组和B组(P<0.05);A组的手术时间和估计出血量均大于B组和c组,差异均有统计学意义(P<0.05);A、C组长 期疗效优于B组(P<0.05),而A、c两组间差异无统计学意义;三组间的复发或残余症状恶化、再手术及并发症等方面差异没有统计学意义.结论 对于术前合并腰椎失稳、滑脱或侧凸的退变性腰椎管狭窄症患者,即使初次行"开窗技术"减压,也应融合;单纯狭窄患者初次手术则无需融合.     

Treatment of lateral ankle sprain with platelet-rich plasma: A randomized clinical study

BackgroundWe aimed to clinically evaluate the effect of platelet-rich plasma (PRP) therapy in patients with acute lateral ankle sprain treated with rigid immobilization.MethodsPatients with first-time grade II lateral ankle sprain clinically diagnosed were evaluated (n = 21). A rigid immobilization was placed in all patients for ten days; previously, an application of PRP over the anterior talofibular ligament was performed in patients from the experimental group. The Visual Analogue Scale, the American Orthopedic Foot and Ankle Score, and the Foot and Ankle Disability Index were applied at 3, 5, 8 and 24 weeks of follow-up period.ResultsThe experimental group presented the highest reduction in pain and better functional scores than the control group at 8 weeks. At the end of follow-up period the results of both groups were similar.ConclusionsA similar evolution was observed in patients treated with rigid immobilization with or without PRP after 24 weeks.Trial registrationClinical Trials.gov with ID NCT02609308.     

Prospective assessment of bone texture parameters at the hand in rheumatoid arthritis

ObjectiveFractal bone analysis (Hmean) is a texture parameter reflecting bone microarchitecture. The BMA device (D3A? Medical Systems, Orléans, France) is a high-resolution X-ray device that allows assessment of bone texture analysis. We aimed to measure Hmean in rheumatoid arthritis patients at the second and third metacarpal bones, at baseline and after 1 year of follow-up, and to assess the relationship of Hmean and rheumatoid arthritis disease parameters.MethodsPatients with rheumatoid arthritis according to ACR criteria were included. They were assessed over 1 year, in the context of a prospective study conducted in Maastricht. For this substudy, activity of the disease was assessed by erythrocyte sedimentation rate, C-reactive protein and Disease Activity Score 28 performed at each visit. Radiographic bone damage was assessed using hand and feet radiographs at baseline and on a 1-year basis. The bone texture parameters were evaluated on the second and third metacarpal heads of the left hand using BMA device.ResultsOne hundred and sixty-five rheumatoid arthritis patients were included in this study. At baseline, Hmean was negatively correlated with age [r = ?0.22 (P = 0.013)] and erythrocyte sedimentation rate [r = ?0.16 (P = 0.039)]. No significant correlation was found between Hmean and Disease Activity Score, disease activity Visual Analog Scale, daily corticosteroid dose and C-reactive protein. There was a significant increase in Hmean of second and third metacarpal bones over 1 year (1.6% and 1.3%, P < 0.01) except in patients with local second and third metacarpal bones erosion.ConclusionThe bone texture parameter Hmean is influenced by age, inflammation and local erosions in rheumatoid arthritis.     

Predictors of clinical outcomes after non-operative management of symptomatic full-thickness rotator cuff tears

BACKGROUNDPrevious studies have shown that non-surgical management can be an effective treatment strategy for many patients with rotator cuff tears. Despite the prevalence of rotator cuff disease, few studies have examined the patient and tear related factors that predict outcomes of nonsurgical management in this cohort of patients.AIMTo identify factors that are associated with changes in patient reported outcomes over time in individuals with full-thickness rotator cuff tears treated without surgery. METHODSA cohort of 59 patients who underwent non-surgical management of full thickness rotator cuff tears with a minimum of 1-year follow-up were identified from our institutional registry. Patient demographics, comorbidities and tear characteristics were collected at initial presentation. Outcome measures were collected at baseline and at each clinical follow-up, which included Western Ontario Rotator Cuff (WORC) index, American Shoulder and Elbow Surgeons score, Visual Analog Scale for pain and Single Assessment Numerical Evaluation. Multi- and univariate regression analyses were used to determine the impact of each patient and tear related variable on final WORC scores and change in WORC scores throughout the study. RESULTSIn this non-surgical cohort, all patient-reported outcome measures significantly improved compared to baseline at 1 and 2-year follow-up. There was no significant difference in outcomes between 1 and 2 years. The average improvement surpassed the published minimal clinically important differences values for WORC, American Shoulder and Elbow Surgeons, Visual Analog Scale pain and Single Assessment Numerical Evaluation scores. Regression analysis identified female gender (β = - 19.88, P = 0.003), smoking (β = -29.98, P = 0.014) and significant subscapularis fatty infiltration (β = -15.35, P = 0.024) as predictors of less favorable WORC scores at 1 year, and female gender (β = -19.09, P = 0.015) alone as a predictor of lower WORC scores at 2 years. Patients with symptom duration greater than 1 year at presentation reported less improvement in WORC scores at 1-year follow-up (β = -14.63, P = 0.052) and patients with traumatic tears reported greater improvements in WORC scores at 2-year follow-up (β = 17.37, P = 0.031). CONCLUSIONPatients with full thickness rotator cuff tears can achieve and maintain clinically meaningful benefit from non-surgical management through 2-year follow-up. Female patients, smokers, and those with significant subscapularis fatty infiltration tend to have lower overall WORC scores at 1-year follow-up, and females also have lower WORC scores at 2-year follow-up. Patients presenting with symptoms greater than 1 year had less clinical improvement at 1-year follow-up, and those with traumatic tears had greater clinical improvement at 2-year follow-up.     

Comparison of Expectations and Outcomes in Rheumatoid Arthritis Versus Osteoarthritis Patients Undergoing Total Knee Arthroplasty

BackgroundWe hypothesized that patients undergoing primary total knee arthroplasty (TKA) for rheumatoid arthritis (RA) would have different preoperative expectations compared to osteoarthritis (OA) patients, and that postoperative satisfaction would correlate with specific postoperative pain and functional domains.MethodsThis is a retrospective cohort study of RA patients matched based on age, gender, American Society of Anesthesiologists score, and Charlson Comorbidity Index score 1:2 with OA patients (76 RA, 152 OA) who underwent primary TKA. The Hospital for Special Surgery Knee Replacement Expectations Survey, Visual Analogue Scale for Pain (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), and the Short Form-12 (SF-12) were compared at baseline and at 2 years postoperatively. Minimum clinically important differences (MCIDs) were calculated for KOOS and SF-12 subdomains.ResultsPreoperatively, RA patients had lower expectations, worse VAS Pain, and worse KOOS Pain, Symptoms, and Activities of Daily Living (P < .05). However, at 2 years, RA patients had significantly larger improvements in VAS (P = .01) and these 3 KOOS subdomains (P < .05), achieving comparable absolute scores to OA patients. Overall, 86.1% of RA and 87.1% of OA patients were either somewhat or very satisfied with their TKA. Patient satisfaction correlated with VAS Pain and KOOS outcome scores in both groups. RA and OA patients had high rates of achieving MCID in SF-12 physical component scores and all 5 KOOS subdomains. A higher proportion of RA patients achieved MCID in KOOS Symptoms (98.4% vs 77.2%, P < .001).ConclusionRA patients had lower baseline expectations compared to OA patients. However, RA patients had greater improvements in KOOS and SF-12 subdomains, and there was no difference in satisfaction compared to OA patients after TKA.     

Impact of iliac crest bone graft harvesting on fusion rates and postoperative pain during instrumented posterolateral lumbar fusion

This study aims to evaluate the influence of bone harvesting on postoperative pain and fusion rates. Group 1 patients received iliac crest bone graft (ICBG) either alone or augmented with local bone. Group 2 received only local bone. No statistical significance was found in radiological union or in the Oswestry Disability Index scores. Visual Analogue Scale scores showed less pain in group 2. Logistic regression showed no correlation between residual pain and occurrence of fusion. Harvesting ICBG did not appear to increase fusion rates and no relation was found between radiological non-union and pain.     

Lumbar spine arthroplasty: early results using the ProDisc II: a prospective randomized trial of arthroplasty versus fusion

This study represents the first 39 patients with at least 6-month follow-up enrolled in a prospective randomized Food and Drug Administration study evaluating the safety and efficacy of the ProDisc II versus the control, a 360 degrees lumbar spinal fusion. Data were collected preoperatively and at 6 weeks, 3 months, and 6 months postoperatively. Visual Analog Scale (VAS), Oswestry Low Back Pain Disability Questionnaire (ODQ), and patient satisfaction rates were evaluated at these intervals, as well as range of motion, return to work, and recreational and ambulatory status. There were 28 ProDisc patients and 11 who underwent fusion. Six patients had two-level surgery. Estimated blood loss (ProDisc = 69 mL versus fusion = 175 mL) and operative time (ProDisc = 75 minutes versus fusion = 219 minutes) were significantly different (P < 0.01). Hospital stays were shorter (ProDisc = 2.1 days versus fusion = 3.5 days [P < 0.01]) for ProDisc patients. There was a significantly greater reduction in the ODQ scores at 3 months in the ProDisc group compared with the fusion group (P < 0.05). No difference was noted in VAS. A trend was identified at 6 months in patient satisfaction rates favoring ProDisc versus fusion (P = 0.08), and motion was significantly improved in ProDisc patients compared with the fusion group (P = 0.02). Ambulatory status as well as recreational activity improved faster in the ProDisc group. The data suggest that total disc arthroplasty may be an attractive option as opposed to lumbar fusion for the surgical treatment of disabling mechanical low back pain secondary to lumbar disc disease.     

Interlaminar stabilization for spinal stenosis in the Medicare population

BACKGROUND CONTEXTThe number of complex fusions performed on Medicare beneficiaries, defined as ≥age 65, with lumbar spinal stenosis with or without spondylolisthesis has been increasing. Typically, these procedures are longer, more invasive and pose a greater risk for complications. Interlaminar stabilization (ILS) serves as an intermediary between decompression alone and decompression with fusion.PURPOSEThe purpose of this study was to prospectively examine the efficacy of ILS in patients ≥age 65 through comparison to fusion in the same age group and ILS in younger patients.STUDY DESIGN/SETTINGA prospective, multicentered, randomized controlled trial comparing decompression with ILS to decompression with posterolateral fusion with bilateral pedicle screw instrumentation.PATIENT SAMPLEPatients from 21 sites in the United States underwent surgery for moderate stenosis with up to a grade 1 degenerative spondylolisthesis and failure of conservative treatment with low back pain at 1 or 2 contiguous levels from L1–L5. Preoperatively, patient-reported assessment had to meet the criteria of significant pain and disability (Visual Analog Scale [VAS back pain] ≥50 mm on a 100 mm scale; Oswestry Disability Index [ODI] of ≥20/50).OUTCOME MEASURESThe primary outcome was overall Composite Clinical Success (CCS) as determined by ODI scores, incidence of postoperative epidural injections and/or reoperations, incidence of device-related complications, and persistent or progressive neurological deficit. Secondary outcomes included patient satisfaction as measured by VAS for back and worse leg pain and Zurich Claudication Questionnaire scores. Narcotic usage data and radiographic assessment of changes in postoperative posterior disc height and foraminal height were also evaluated.METHODSAt 1- or 2-levels, 84 patients ≥age 65 underwent decompression with ILS, 57 patients ≥age 65 underwent decompression with fusion, and 131 patients <age 65 underwent decompression with ILS. Comparisons were made between ≥age 65 ILS patients and ≥age 65 fusion patients and between <age 65 and ≥age 65 ILS patients. The patients were assessed before and after surgery at 6 weeks and 3, 6, 12, 18, 24, 48, and 60 months.RESULTSAt 24 and 60 months, there were no statistically significant differences in CCS or any of the individual components of CCS between the ≥ age 65 ILS and fusion groups or between the < age 65 and ≥ age 65 ILS groups. ILS Medicare patients experienced significantly shorter surgeries (p<.001), less blood loss (p<.001), and a shorter hospital stay (p<.001) than fusion patients. There were no significant differences radiographically or with regards to postoperative narcotic usage.CONCLUSIONSClinically, ILS patients ≥age 65 performed as well as both those receiving fusion and those <age 65 who received ILS. Importantly, however, for this older population, ILS Medicare patients experienced less blood loss, a shorter operation and shorter hospital stay than fusion Medicare patients.     

加速康复外科理念在老年骨质疏松性腰椎压缩性骨折椎体成形术和后凸成形术后康复中的应用

目的：探讨按照加速康复外科（enhanced recovery after surgery,ERAS）理念指导术后规律性核心肌力训练对老年骨质疏松腰椎压缩性骨折椎体成形术（percutaneous vertebroplasty,PVP）和椎体后凸成形术（percutaneous kyphoplasty,PKP）术后康复的作用。方法：将2016年1月至2018年1月期间94例符合纳入、排除标准的因骨质疏松性腰椎压缩骨折而行PKP或PVP手术的老年患者分成观察组和对照组,术后均常规抗骨质疏松治疗。观察组47例,男18例,女29例,年龄（62.62±3.21）岁;对照组47例,男17例,女30例,年龄（62.38±2.84）岁。对照组按照传统的方式训练,观察组按ERAS理念指导患者规律性核心肌力训练。术后1、3、6个月随访,根据患者的Barthel量表、日本骨科协会（Japanese Orthopaedic Association,JOA）腰痛评分,Oswestry功能障碍指数对患者病情进行量化评估,统计分析。比较两组治疗效果的差异性。结果：94例完成随访,术后1、3个月观察组的Barthel量表、JOA腰痛评分、Oswestry功能障碍指数均优于对照组（P<0.05）。术后6个月观察组的Oswestry功能障碍指数优于对照组（P<0.05）,但两组JOA腰痛评分、Barthel量表差异无统计学意义（P>0.05）。两组患者术后1、3、6个月的Barthel量表、JOA腰痛评分、Oswestry功能障碍指数均明显好转（P<0.05）。结论：早期规律性核心力量训练在老年骨质疏松性腰椎压缩骨折PKP或PVP术后早期功能恢复及改善生活能力方面具有积极的作用,符合加速康复外科理念。     

Analysis of the incidence and clinical effect of the heterotopic ossification in a single-level cervical artificial disc replacement

Background contextHeterotopic ossification (HO) is a well-known phenomenon occurring after joint arthroplasty. However, its incidence and clinical effects have not yet been clearly identified with cervical disc replacement.PurposeThe first aim of this study was to evaluate the incidence of HO in single-level cervical disc replacement. The second aim was to identify the relationship of HO with clinical outcomes and radiological findings.Study designA retrospective study of 48 patients who underwent single-level artificial disc replacement in one of our clinics.Patient sampleBetween November 2004 and December 2008, 48 consecutive patients underwent single-level cervical artificial disc replacement in Seoul Wooridul Hospital, Seoul, Korea.Outcomes measuresClinical outcomes were graded using visual analog scale (VAS) scores (score range, 0–10, with 0 reflecting no pain). Functional outcomes were measured using Oswestry Disability Index (ODI) scores. Radiological outcomes were evaluated with follow-up dynamic X-ray.MethodsOccurrence of HO was investigated with the McAfee classification on the follow-up cervical dynamic X-ray. We also measured cervical range of motion (ROM) to identify HO's biomechanical effects. For the clinical effects, the VAS and the ODI were evaluated in correlation with the occurrence of HO.ResultsIn 48 treated patients, a total of 13 HOs were detectable. Grade 1 and 2 HO occurred in 11 patients and Grade 3 HO in two patients. Mean occurrence of HO was observed on the 11th month after the surgery. HO that led to the restriction of the ROM was not present in any patients. The clinical outcome was not significantly correlated with the occurrence of HO.ConclusionsThe overall incidence of HO after cervical artificial disc replacement was relatively high. However, Grade 3 and 4 HO that limit the ROM rarely occurred. Moreover, the occurrence of HO did not affect the clinical symptoms and biomechanical dynamics. A longer follow-up with a larger group of patients should be undertaken, which may demonstrate a higher rate of HO and long-term effects on the ROM.